Triple vs. single uterine tourniquet to reduce hemorrhage at myomectomy: a randomized trial.

PURPOSE: This study aimed to compare the effect of triple uterine tourniquet and single tourniquet on intraoperative blood loss during open myomectomy. METHODS: Women were randomized to undergo open myomectomy with a triple (n = 30) or single uterine tourniquet (n = 30). All symptomatic women aged 18-48 who had three or more myomas or at least one myoma greater than 8 cm if there were less than three myomas were eligible for the study. The primary outcome variable was the volume of intraoperative blood loss. The sample size was set to detect a 240 ml difference in blood loss with 80% power at α = 0.05, with an effect size of 0.8. The rate of transfusions, change in hemoglobin, volume of drains, operation time, tourniquet time, and perioperative complications were secondary outcomes. RESULTS: We found no significant difference in intraoperative blood loss between triple and single uterine tourniquets (527 [102-2931]) ml vs. 508 [172-2764] ml, p = 0.238). Between the single and triple tourniquet groups, the median weight of myoma (379 [136-3850] vs. 330 [140-1636] g, p = 0.451) and median number (1 [1-18] vs. 2 (1-13), p = 0.214), total operation time (84 ± 31 min vs. 79 ± 27 min, p = 0.503), ischemia time (35 ± 21 min vs. 30 ± 14 min., p = 0.238), drain volume at 48th hour (196 ± 89)ml vs. 243 ± 148 ml, p = 0.144) and decrease in hemoglobin (2.3 ± 1.8 g/dl vs. 2.8 ± 1.4 g/dl, p = 0.437) were similar. Eight (27%) patients in the triple tourniquet group and 12 (40%) patients in the single tourniquet group were transfused (p = 0.273). One patient underwent hysterectomy 6-8 h after myomectomy in a single tourniquet group. CONCLUSION: There was no clinically significant difference in intraoperative blood loss between triple and single uterine tourniquets during open myomectomy. CLINICAL TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: ClinicalTrials.gov ID: NCT02392585, 03/13/2015.

The effects of metyrosine on ischemia-reperfusion-induced oxidative ovarian injury in rats: Biochemical and histopathological assessment.

The aim of this study is to investigate the effect of metyrosine on ischemia-reperfusion (I/R) induced ovarian injury in rats in terms of biochemistry and histopathology. Rats were divided into: ovarian I/R (OIR), ovarian I/R+50 mg/kg metyrosine (OIRM) and sham (SG) operations. OIRM group received 50 mg/kg metyrosine one hour before the application of the anesthetic agent, OIR and SG group rats received equal amount of distilled water to be used as a solvent orally through cannula. Following the application of the anesthetic agent, ovaries of OIRM and OIR group rats were subjected to ischemia and reperfusion, each of which took two hours. This biochemical experiment findings revealed high levels of malondialdehyde (MDA) and cyclo-oxygenase-2 (COX-2) and low levels of total glutathione (tGSH), superoxide dismutase (SOD) and cyclo-oxygenase-1 (COX-1) in the ovarian tissue of OIR group, with significant histopathological injury. In metyrosine group, MDA and COX-2 levels were lower than the OIR group whereas tGSH, SOD and COX-1 levels were higher, with slighter histopathological injury. Our experimental findings indicate that metyrosine inhibits oxidative and pro-inflammatory damage associated with ovarian I/R in rats. These findings suggest that metyrosine could be useful in the treatment of ovarian injury associated with I/R.

Fetus delivery time in extraperitoneal versus transperitoneal cesarean section: a randomized trial.

Objective: We compared the extraperitoneal cesarean section to transperitoneal cesarean on fetal delivery time.Material and methods: This randomized study included 210 pregnant women undergoing cesarean section for elective reasons, repeat cesarean (< four), or dystocia. Patients who required an urgent cesarean section, who were at high risk for obstetric or maternal bleeding, who had a uterine or adnexal mass, or who requested tubal ligation were excluded from the study. The primary outcome of the study was the skin incision-to-delivery time. The sample size was set to detect of 1-minute difference in fetal delivery time between groups (two-tailed hypothesis, α = 0.05, ß = 0.10). Secondary outcome measures were total operation time, intraoperative nausea, gag reflex, vomiting, pain and anxiety for those receiving regional anesthesia, postoperative pain, change in hemoglobin, postoperative analgesic requirements, nausea, vomiting and shoulder pain, urogenital distress, time until gas passage, and neonatal outcome.Results: No significant difference occurred between the two groups for skin incision-to- delivery time (extraperitoneal cesarean 3.9 minutes [2.1-7.3] versus transperitoneal cesarean 4.2 minutes [1.9-8.2], p = .065). Significant differences regarding intraoperative pain, total operation time, postoperative pain at the surgical site and shoulder pain, analgesic requirements, time until gas passage, and oral tolerability favored the extraperitoneal group. No significant differences between groups occurred regarding other seconder outcome parameters.Conclusions: There is no clinically significant difference between extraperitoneal cesarean section and transperitoneal cesarean on fetal delivery time. Extraperitoneal cesarean reduces postoperative pain, analgesic requirements, and improves oral tolerability.

A Randomized Trial Comparing Triple versus Single Uterine Tourniquet in Open Myomectomy.

BACKGROUND: Single and triple uterine tourniquet significantly reduces blood loss during myomectomy and both are highly effective. Triple tourniquet, however, blocks ovarian circulation and there is doubt that it causes ischemic damage to ovaries. These 2 methods have not been compared by a randomised controlled study yet. The purpose of this study was to compare triple uterine tourniquet with single tourniquet in terms of blood loss during open myomectomy. MATERIAL AND METHODS: Women were randomized to triple (n = 24) or to single tourniquet (n = 24) at open myomectomy. All women with a myomatous uterus greater than 12 weeks of gestation were eligible to be part of the study. The primary outcome of the study was the amount of blood loss during surgery. Sample size was set to detect a 250 mL difference in blood loss with 80% power at α = 0.05. We also compared the change in anti-Müllerian Hormone (AMH) levels before and after surgery. RESULTS: There was no significant difference in the outcome of blood loss between triple and single uterine tourniquet (322 ± 223 vs. 426 ± 355 mL, p = 0.230). Change in AMH was not different between the groups. CONCLUSIONS: There is no clinically significant difference between triple and single uterine tourniquets on blood loss at open myomectomy.

Vaginal Misoprostol Compared With Buccal Misoprostol for Termination of Second-Trimester Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: To compare the efficacy of vaginal misoprostol with buccal misoprostol for second-trimester termination of pregnancies. METHODS: In a randomized trial, we compared 400 micrograms vaginal and buccal misoprostol every 3 hours for up to six doses for induction of labor at 13-24 weeks of gestation with a live fetus and intact membranes. Women who had a uterine scar were excluded from the study. The primary outcome of the study was induction-to-abortion interval. Based on a two-tailed α of 0.05, we planned to include 65 patients per group to detect a 50% difference in the primary outcome with a power of 80%. RESULTS: From January 2014 to December 2014, 172 women were screened and 130 were randomized: 65 vaginal and 65 buccal misoprostol. Characteristics of patients were similar between groups. Patients administered vaginal misoprostol compared with buccal misoprostol had a shorter induction-to-abortion interval (25±17 hours compared with 40±29 hours, P=.001) and a higher abortion rate within both 24 hours (41 [63%] compared with 27 [42%] P=.014) and 48 hours (59 [91%] compared with 44 [68%], P=.001). Complete abortion rates were similar in both groups (vaginal 51 [78%] compared with buccal 54 [83%]). The incidence of side effects was similar for both groups. The perceived pain was higher in the buccal group, but the small difference did not appear to be clinically meaningful. CONCLUSION: Vaginal compared with buccal misoprostol administration has a shorter induction-to-abortion interval for second-trimester termination of viable pregnancies. However, both administration routes are equally effective for induction of termination. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT02048098. LEVEL OF EVIDENCE: I.

The effect of agomelatine on oxidative stress induced with ischemia/reperfusion in rat ovaries.

BACKGROUND: Ovarian ischemia and reperfusion can lead to serious and irreversible health problems. OBJECTIVES: The aim of this study is to investigate the protective effect of agomelatine against ovarian ischemia/ /reperfusion injury in rats using biochemical methods. MATERIAL AND METHODS: Thirty female rats were divided into three groups (the number of animals in each group = 10), a control group in which ischemia/reperfusion was established (IRC), an ischemia/reperfusion + agomelatine (IRA) group and a healthy group given a sham operation (SG). Total glutathione (tGSH) and malondialdehyde (MDA) levels and glutathione peroxidase. RESULTS: Biochemical results revealed MDA levels of 19.1 ± 2.03, 5.8 ± 1.5 and 5.5 ± 1.4 µmol/g protein in ovarian tissue in the IRC, IRA and SG groups, respectively. MPO activity in the IRC, IRA and SG groups was 7.87 ± 2.7, 4.0 ± 2.0 and 3.0 ± 1.0 U/g protein, respectively. tGSH levels were 1.87 ± 1.13, 4.37 ± 1.4 and 5.87 ± 1.64 nmol/g protein, respectively. GPx activity in the IRC, IRA and SG groups was 7.37 ± 1.68, 18.6 ± 3 and 17.75 ± 3.2 U/g protein, and SOD activity 31.1 ± 2.9, 45.3 ± 3.7 and 54 ± 4.2 U/g protein, respectively. The level of 8-OH/ /Gua, a product of DNA damage, was 2.18 ± 0.2 pmol/L in the IRC group, 1.28 ± 0.2 pmol/L in the IRA group and 0.93 ± 0.01 pmol/L in the SG group. CONCLUSIONS: Agomelatine prevented ovarian ischemia/reperfusion injury.

Use of thiamine pyrophosphate to prevent infertility developing in rats undergoing unilateral ovariectomy and with ischemia reperfusion induced in the contralateral ovary.

OBJECTIVE: To investigate whether thiamine pyrophosphate can prevent infertility developing in rats undergoing unilateral ovariectomy and with ischemia reperfusion induced in the contralateral ovary. Biochemical examinations of the ovaries were also performed. STUDY DESIGN: Rats were divided into two main groups of three subgroups each. An ischemia reperfusion model was established in the first main group, while surgical unilateral ovariectomy was performed in the second. Thiamine pyrophosphate and melatonin were administered to the subgroups. No additional procedure was performed in the control groups. The rats were then left in laboratory environments and their fertility levels were determined. Malondialdehyde, total glutathione and DNA damage products were measured in those rats from which ovarian tissue was collected. RESULTS: The results showed that thiamine pyrophosphate prevented ischemia/reperfusion injury-related infertility, but melatonin did not provide adequate prevention. However, reproduction in healthy animals receiving melatonin began earlier compared to those receiving thiamine pyrophosphate. Melatonin suppressed oxidative stress caused by ischemia/reperfusion in ovarian tissue significantly better than did thiamine pyrophosphate. CONCLUSIONS: We think that different mechanisms, in addition to antioxidant activity, are involved in the prevention of reperfusion-associated infertility after ischemia.

Ischemia-reperfusion damage.

Ischemia-reperfusion damage is a complex pathological process that begins with tissue anoxia and continues with the production of free oxygen radicals, expanding with the inflammatory response. The literature suggests the importance of antioxidant and anti-inflammatory treatment to treat ischemia-reperfusion-related tissue damage.