The effect of administering vaginal estrogen to clomiphene citrate stimulated cycles on endometrial thickness and pregnancy rates in unexplained infertility.

OBJECTIVE: Clomiphene citrate (CC) has some negative effects on the endometrium. We aimed to determine the effect of vaginally administered local estrogen (LE) on endometrial thickness (ET) and pregnancy rates in CC stimulated cycles. MATERIAL AND METHODS: This was a prospective randomized crossover study that took place in a university hospital. The patients had received CC due to unexplained infertility (UI). Two different treatment protocols were given sequentially as, either CC+LE or CC alone. Each protocol was planned for two cycles and there was a one-month wash-out period between protocols. The effects of LE on the 3(rd) and 9(th) day, the ovulation day (OD) and 7(th) postovulation day (POD7) were investigated. RESULTS: A total of 6 pregnancies were achieved with 3 patients from each protocol. The ET was 7.6±1.4 mm and 8.3±2.1 mm respectively and significantly different in the CC group and the CC+E2 groups on the OD (p=.039), while these values were 9.7±2.3 mm and 10.9±3.0 mm respectively and significantly different on the POD7 (p=.007). There was no significant difference between the groups for arterial PI values on the OD and POD7. The frequency of thin endometrium (<6 mm) was 15.2% and 12.2% respectively in the CC group and the CC+E2 group on the OD (p=.628) and 5.1% and 1.2% respectively on the POD7 (p=.182). CONCLUSION: Adding vaginal LE to CC stimulated cycles led to a significant increase in ET on the OD and POD7. However, this difference in thickness was not reflected in the pregnancy rates in this study.

Anthropometric, clinical and laboratory comparison of four phenotypes of polycystic ovary syndrome based on Rotterdam criteria.

AIM: To compare all phenotypes of polycystic ovary syndrome (PCOS) for anthropometrical, hormonal, and metabolic differences according to Rotterdam criteria. MATERIAL & METHODS: Women with PCOS (Rotterdam definition; n = 127) and women without PCOS used as controls (n = 44). There were four phenotypes of PCOS: 56/127 (44.09%) of the patients were polycystic ovaries on ultrasound (PCO) + oligo or anovulation (O) + biochemical and/or clinical hyperandrogenism (HA), 29/127 (22.84%) were HA+O, 24/127 (18.90%) were PCO+O and 18/127 (14.17%) were HA+PCO. And 42/127 (33.07%) patients represented the new phenotypes (PCO+O and HA+PCO). Phenotypical, hormonal and metabolic parameters were compared between the groups. RESULTS: Waist-to-hip ratio, luteinizing hormone-to-follicle stimulating hormone ratio, testosterone, androstenedione, dehydroepiandrostenedione were lower in women with PCO+O and controls than the other three phenotypes. The highest score regarding hirsutismus was found in the HA+O phenotype and the lowest score in the PCO+O phenotype. Prevalence of metabolic syndrome and degree of insulin resistance in PCO+O phenotype was closer to control subjects than the other three phenotypes. CONCLUSIONS: Anthropometrical, hormonal, and metabolic differences suggest that PCO+O phenotype is closer to control group than the other PCOS phenotypes.

Acute mesenteric venous thrombosis due to protein S deficiency in a pregnant woman.

Acute mesenteric venous thrombosis is a rare and potentially fatal disease, which often occurs in medically compromised elderly patients. Isolated mesenteric venous thrombosis may be encountered in young women who have underlying hypercoagulable disease. We report a case of mesenteric venous thrombosis in a young pregnant woman in whom protein S deficiency was diagnosed at a later stage. The patient underwent extensive bowel resection. On follow-up she had developed an obstruction on the intestinal anastomosis. The anastomosis was revised, but the patient died of intervening complications 3 months after the operation. Early management of acute mesenteric venous thrombosis relies on early diagnosis, which requires a high index of suspicion. The condition must be considered during evaluation of persistent abdominal pain in pregnant women with hypercoagulable disorder.

Right-sided lateralisation of ovarian cancer and right bias asymmetry for involved pelvic lymph nodes by ovarian cancer cells.

The aim of the present study was to investigate if there is a possible lateralisation for ovarian cancers, to re-examine left-right asymmetry in pelvic lymph nodes distribution in patients with ovarian cancer, and to investigate if pelvic lymph node involvement by metastatic invasion of ovarian cancer cells is ipsilateral or contralateral. There was right-sided lateralisation for ovarian cancer. The numbers of external iliac and hypogastric+obturator lymph nodes were higher on the right side in patients with ovarian cancer on the right side; but they were about equal for right and left sides in patients with ovarian cancer in their left side. The numbers of external iliac and hypogastric+obturator lymph nodes involved by metastatic cancer cells were higher on the right side in patients with ovarian cancer on the both right and left sides. This case may result from the stronger cell-mediated immune activity in the left sides of humans.

Difficulty of the surgical management of a case with placenta percreta invading towards parametrium.

A 37-year-old woman was admitted due to vaginal bleeding at 25 weeks of gestation to our gynecology unit. Placenta percreta, which stems from posterior wall of the uterus, forming a mass in Douglas cavity and invading towards right parametrium was clinically diagnosed by exploration. Bilateral internal iliac artery ligation and supracervical hysterectomy could not prevent bleeding. A right radical parametrectomy was necessary to remove invaded parametrium and to control bleeding. The placenta percreta invading parametrium may need an extended hysterectomy procedure. Excess bleeding may be prevented by leaving the placenta in situ during surgery if the placenta percreta is diagnosed before termination of pregnancy, A classical incision may help leaving placenta is situ during operation.

Effects of progesterone on FSH-stimulated indomethacin ulcers in rats.

OBJECTIVE: To investigate whether the balance between progesterone and FSH levels has a role in ulcer formation/inhibition. DESIGN: Animal study. SETTING: Ataturk University, Faculty of Medicine, Laboratory of Pharmacology Department. PATIENT(S): One hundred thirty-two female Albino Wistar rats. INTERVENTION(S): Ovariectomy. Chronic administration of progesterone and estrogen to ovariectomized rats. Acute administration of progesterone to ovariectomized rats. Acute administration of progesterone and FSH to intact rats. Combined administration of mifepristone with progesterone or FSH to intact rats. Indomethacin administration to all rats. MAIN OUTCOME MEASURE(S): Gastric ulcer areas as mm(2). RESULT(S): Indomethacin-induced ulcers were significantly higher in ovariectomized rats than in intact rats. Chronic progesterone (1 mg/kg) inhibited gastrointestinal system ulcers by 51.2%, whereas 2 and 5 mg/kg chronic progesterone and 1, 2, and 5 mg/kg chronic estrogen were not effective. Acute progesterone (5 mg/kg) increased indomethacin ulcers significantly in ovariectomized rats. FSH increased indomethacin ulcers significantly. In addition, progesterone increased indomethacin ulcers significantly in intact rats. Mifepristone antagonized the ulcerogenic effects of FSH and progesterone. CONCLUSION(S): Our data suggest that progesterone is not an antiulcer hormone, and produces ulcers via its own receptor. In addition, FSH may produce ulcerogenic effects via progesterone receptors. The low doses of progesterone (inhibits endogenous FSH) cannot stimulate its own receptors sufficiently for ulcer formation and prevent the ulcerogenic effects of FSH by decreasing FSH concentration.

Asymmetries in pelvic lymph nodes and their metastatic involvement by gynecologic cancer cells.

AIM: The aims of this study were to re-examine left-right asymmetry in pelvic lymph node distribution in patients with gynecologic malignancies, and to investigate if there is a left-right asymmetry in pelvic lymph node metastatic involvement by gynecologic cancer cells. METHODS: The oncologic database of our gynecologic department was reviewed to identify patients who had pelvic lymphadenectomy as part of treatment for a variety of gynecologic malignancies. Right and left lymph node counts with and without involvement of cancer cells were retrieved from the pathological reports. RESULTS: Three hundred and thirteen patients were included in the study. The numbers of external iliac, and hypogastric + obturator lymph nodes were higher on the right side than on the left in all gynecologic malignancies. The numbers of involved external iliac, and hypogastric + obturator lymph nodes by metastatic cancer cells were significantly higher on the right side than on the left in all gynecologic malignancies. CONCLUSION: The results suggest the existence of a left-right asymmetry in pelvic lymph node distribution and pelvic lymph node distribution involved by gynecologic cancer cells. This situation may be due to the asymmetry in the number of pelvic lymph nodes. In addition, stronger cell-mediated immune activity in the left side of humans may be associated with the blocking of metastatic invasion of cancer cells from gynecologic malignancies in the left side of the body.

Maternal serum interleukin-10, interleukin-2 and interleukin-6 in pre-eclampsia and eclampsia.

PROBLEM: The aim of the study was to investigate and compare the concentrations of interleukin (IL)-2, IL-6, and IL-10 in serum of women with mild pre-eclampsia, severe pre-eclampsia, eclampsia, and normotensive pregnancy. METHOD OF STUDY: A total of 69 consecutive cases, 38 mild pre-eclampsia, 20 severe pre-eclampsia, 11 eclampsia, and 20 normotensive controls were included in this study. Serum IL-2, IL-6, and IL-10 levels were determined using enzyme-linked immunosorbent assay method. RESULTS: Gestational age (P = 0.210) and body mass index (P = 0.214) between the groups were similar. The mean concentration of serum IL-2 and IL-6 were not different between the groups (P = 0.261, P = 0.141 respectively). The median concentrations of serum IL-10 in patients with mild and severe pre-eclampsia were similar (P < 0.282) and was significantly lower than those of controls (P < 0.001) and patients with eclampsia (P < 0.001). In patients with eclampsia, the median concentration of IL-10 was significantly higher than that of all other groups (P < 0.001 for each comparison). CONCLUSION: Pre-eclampsia is associated with a deficiency serum IL-10. High serum IL-10 is correlated with the presence of eclampsia.

Huge teratoma of the fallopian tube: a case report.

BACKGROUND: Primary mature solid teratomas of the fallopian tube are extremely rare and only 11 cases have been reported in the literature. A woman presented with a mature, solid teratoma of the fallopian tube, possibly the largest solid teratoma on record. CASE: A 24-year-old, nulliparous woman presented with abdominal distention, intermittent abdominal pain, nausea and vomiting for 4 weeks and was admitted to the hospital. Abdominal examination revealed a palpable, nontender mass. Computed tomography showed a hypodense lesion in the abdomen. Serum concentrations of carcinoembryonic antigen (2.6 ng/mL) and beta-human chorionic gonadotropin (0.1 mIU/mL) were within normal limits, while serum levels of CA-125 (130 U/mL) and CA-19.9 (237 U/mL) were elevated. A multilobulated, pedunculated, mature, solid teratoma of the fallopian tube measured 31 x 21 x 14 cm and weighed 2,400 g. At laparotomy, it was located in the fimbrial portion of the left fallopian tube, and a left salpingectomy was performed. The tumor consisted of bone, hair, and sebaceous and sweat glands. The cavity of the cyst was lined mainly with skin composed of keratinized squamous epithelium and contained abundant sebaceous and sweat glands. CONCLUSION: In cases of undetermined pelvic or abdominal masses, especially with calcification, a teratoma of the fallopian tube should be considered.

99mTc-HMPAO labelled leucocyte scintigraphy in the diagnosis of pelvic inflammatory disease.

BACKGROUND: Scintigraphy using leucocytes labelled with 99mTc hexamethylpropyleneamine oxime (99mTc-HMPAO) is widely used for the localization of inflammatory foci and abscesses in cases of acute pelvic inflammatory disease, which is one of the serious health problems of women of child-bearing age. Early diagnosis and effective management of this condition can preserve fertility and prevent serious complications, such as peritonitis and sepsis. AIM: To evaluate the importance of scintigraphy using 99mTc-HMPAO labelled leucocytes in the early diagnosis of patients with pelvic inflammatory disease. METHODS: Fifteen women (mean age 29.2+/-8 years, range 25-46 years) with suspicion of pyogenic pelvic inflammatory disease based on gynaecological examinations, clinical findings and blood tests were included in this study. The patients received 555 MBq 99mTc-HMPAO labelled leucocytes, by injection, and were scanned by scintigraphy 0.5-1, 3 and 24 h later in the anterior abdominal projection. Ten of the patients were then evaluated by abdominal or transvaginal ultrasonography, four by computed tomography and two by both ultrasound and computed tomography. The final diagnosis was made by surgical intervention. RESULTS: Scintigraphy detected pelvic inflammatory disease in five of the patients. In three of them the disease was apparent on the scans taken at 0.5-1 h, and in the other two it was apparent at 3 h. There were no false negative results, and one false positive result. The scan accurately reflected the absence of pelvic inflammatory disease in nine patients showing non-pathological tracer uptake in the lower abdominal region. CONCLUSION: We showed that scintigraphy with 99mTc-HMPAO labelled leucocytes had a sensitivity of 100%, specificity of 90%, overall accuracy of 93%, positive predictive value of 83%, and negative predictive value of 100%. Therefore, we conclude that 99mTc-HMPAO labelled leucocyte scans provide a rapid and highly accurate method for diagnosing pelvic inflammatory disease in women of child-bearing age. This adds an important contribution to the diagnosis of infection and helps determine further operative or conservative treatment.

Urinary calcium excretion in severe preeclampsia and eclampsia.

Urinary calcium levels in women with mild preeclampsia, severe preeclampsia and eclampsia were evaluated in this study. We collected 24-h urine samples from 35 mild preeclamptic (Group 1), 30 severe preeclamptic (Group 2), and 17 eclamptic patients (Group 3). The control group (Group 4) consisted of 35 healthy pregnant women. Serum levels of total calcium and creatinine, and urinary calcium were measured. These values were compared in the four groups. The mean maternal age and parity were similar in all groups. There were no statistically significant differences in the serum levels of total calcium and creatinine (p > 0.05). Urinary calcium excretion in patients with preeclampsia and eclampsia was significantly lower than in controls (p < 0.0001). Urinary calcium levels between mild preeclampsia and severe pre-eclampsia, and severe preeclampsia and eclampsia were similar (p > 0.05), but were lower in eclampsia than in mild preeclampsia (p < 0.05). In conclusion, urinary calcium excretion is reduced in patients with severe preeclampsia or eclampsia. However, the decrease in urinary calcium excretion cannot be used to identify the severity of preeclampsia, or to predict impending eclampsia.

Elevated plasma homocysteine concentrations in severe preeclampsia and eclampsia.

Homocysteine is an essential amino acid required for the growth of cells and tissues in the human body. Maternal hyperhomocysteinemia is associated with a number of placenta-mediated diseases such as preeclampsia. The aim of this study was to evaluate the plasma level of homocysteine and its association with severity of preeclampsia. A case-control study was performed with 32 mild preeclamptic patients, 25 severe preeclamptic patients, 16 eclamptic patients and 34 controls. Maternal plasma homocysteine concentration was measured prospectively at antenatal period by high-performance liquid chromatography. There were no significant differences in demographic characteristics between the study and control groups. Mean plasma levels of homocysteine in women with severe preeclampsia (16.7 +/- 10.1 micromol/l, mean +/- S.D., n = 25) and eclampsia (16.5 +/- 9.6 micromol/l, mean +/- S.D., n = 16) were significantly higher than those in mild preeclampsia (7.7 +/- 2.4 micromol/l, mean +/- S.D., n = 32) and controls (6.7 +/- 1.6 micromol/l, mean +/- S.D., n = 34) (p < 0.0001). It should be noted that plasma levels of homocysteine are not significantly different between mild preeclampsia and controls. In conclusion, plasma homocysteine concentrations are increased in severe preeclampsia and eclampsia, but not in mild preeclampsia.

Management of bilateral fallopian tube carcinoma coexistent with tuberculous salpingitis.

Primary carcinoma of the fallopian tube is a rare gynecologic malignancy. Chronic tubal inflammation is associated with primary carcinoma of the fallopian tube. There are only a few reports on primary carcinoma of the fallopian tube coexisting with tuberculous salpingitis. We are reporting a patient with both the primary carcinoma of the fallopian tube and tuberculous salpingitis, which were detected in bilateral fallopian tubes. The histologic type was serous adenocarcinoma. The patient was treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, and bilateral pelvic lymphadenectomy followed by chemotherapy consisting of paclitaxel and cisplatin. She has been alive without evidence of disease for 18 months.

Medical treatment of ruptured with hemodynamically stable and unruptured ectopic pregnancy patients.

OBJECTIVE: To determine the success rate of methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable and unruptured ectopic pregnancy patients. STUDY DESIGN: This prospective clinical study was carried out on 161 patients with suspected tubal ectopic pregnancy. Fourty-six patients have been accepted as ruptured ectopic pregnancy with hemodynamically stable and 115 patients have been accepted as unruptured ectopic pregnancy. All patients diagnosed with ectopic pregnancy were treated by single dose (50 mg/m2) methotrexate if they have stable hemodynamia and fulfill the criteria of methotrexate treatment. Weekly beta-hCG level was measured and if this level was under 10 IU/L, the treatment has been accepted as successful. Mann-Whitney and Fisher's exact tests were used (SPSS, 10.0) for statistical analysis. RESULTS: The success rates of methotrexate treatments in ruptured ectopic pregnancy patients with hemodynamically stable and in patients with unruptured ectopic pregnancy were observed as 62% and 81%, respectively (P < 0.001). The treatment was successfully completed in all expectant management patients. CONCLUSION: Although methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable patients is not as successful as in unruptured ectopic pregnancy group, 62% success rate in this group may promise a treatment choice before surgery application.

[Correlation of urinary tract infections with the vaginal colonization in postmenopausal women]. / Menopoz sonrasi dönemdeki kadinlarda üriner sistem enfeksiyonlari ile vajinal kolonizasyonun iliskisi.

Estrogen deficiency is a major contributor to the pathogenesis of urinary tract infections (UTI) in postmenopausal women. After menopause, the vaginal pH increases, lactobacilli disappear from the vaginal flora, and the vagina is predominantly colonized by Enterobacteriaceae, especially Escherichia coli. To better understand the associations between post-menopausal vaginal flora and the development of UTI, we conducted a prospective study among 87 postmenopausal women ages between 50-65 years. Vaginal samples were collected from lateral vaginal wall of women to perform a smear on a glass slide and placed on appropriate media. The smear was then stained with Gram stain. Urine samples were collected and cultured by standard bacteriologic techniques. Vaginal lactobacilli were present in 55.2%, and vaginal Enterobacteriaceae were present in 40.2% of the subjects. Heavy growth of lactobacilli was associated with a lower frequency of vaginal colonization with Enterobacteriaceae members (p<0.001), Streptococcus sp. (p<0.05) and Pseudomonas sp. (p<0.05). The most commonly isolated microorganism was E. coli. The frequency of asymptomatic bacteriuria and symptomatic UTI among postmenopausal women were found 17.5% (15/87) and 11.5% (10/87), respectively. As a result, Enterobacteriaceae colonization of the vagina in postmenopausal women increases the prevalence of asymptomatic bacteriuria and symptomatic UTI (p<0.01 and p<0.05, respectively).

Anthrax during pregnancy: case reports and review.

We review, in detail, 2 cases of anthrax during pregnancy, its maternal and perinatal complications, and its management. Patient 1 was a 33-year-old woman at 32 weeks of gestation. She had a submandibular eschar; extensive edema on her face, neck, and upper thorax that inhibited respiratory function; and fever. The patient was treated with penicillin G and prednisolone after the diagnosis of anthrax. She recovered within 10 days but delivered a preterm baby. Patient 2 was a 29-year-old woman at 33 weeks of gestation. Her anthrax lesion was on her right elbow, and therapy consisted of procaine penicillin. She also delivered a preterm baby. These 2 cases show that anthrax during pregnancy can be successfully managed, but preterm delivery could be a complication.