Maternal serum ischemia-modified albumin as an oxidative stress biomarker in preterm pre-labor rupture of membranes.

OBJECTIVES: To evaluate the maternal serum ischemia-modified albumin (IMA) concentration as an oxidative stress biomarker in pregnancies complicated by preterm pre-labor rupture of membranes (PPROM) without maternal clinical infection and compare these results with healthy pregnancies. MATERIAL AND METHODS: The present cohort study included 40 pregnancies complicated by PPROM and 49 similar gestational age healthy pregnancies in the third trimester of gestation. Maternal venous blood specimens were obtained at the day of first diagnosis. Maternal serum IMA level was assayed with an Albumin Cobalt Binding test. The subjects were followed up until delivery and perinatal outcomes were recorded. RESULTS: The maternal serum IMA concentrations were significantly higher in the study group (0.56 ± 0.05 absorbance units) as compared to controls (0.54 ± 0.03 absorbance units) (p = 0.020). The maternal serum IMA concentrations were not significantly correlated with the initial maternal white blood cell count (r: 0.118, p = 0.269) and C-reactive protein levels (r: 0.066, p = 0.541). The maternal serum IMA concentrations were negatively correlated with gestational age at delivery (r: -0.248, p = 0.019), birthweight (r: -0.247, p = 0.020) and Apgar scores (r: -0.200, p = 0.049; r: -0.245, p = 0.020). The threshold value of maternal serum IMA concentration above 0.55 absorbance units indicated the pregnancy complicated by PPROM by 57.5% sensitivity and 57.1% specificity (Area under curve 0.613, confidence interval 0.50-0.73). CONCLUSIONS: The current study supported for the first time that there is an association between increased maternal serum IMA levels and the development of PPROM in the third trimester of gestation without maternal clinical infection. Elevated maternal serum IMA levels may alert the obstetrician about poor ongoing perinatal outcomes in the early phase of PPROM before increased maternal C-reactive protein and white blood cell count.

Helicobacter Pylori Infection in Amniotic Fluid May Cause Hyperemesis Gravidarum.

Objectives: Limited data are available from recent trials involving pregnant women to guide Helicobacter pylori infection diagnosis. There are no data about the presence of H. pylori in the amniotic fluid as well. Furthermore, the relation between amniotic fluid H. pylori and hyperemesis gravidarum (HG) has not been characterized yet. Materials and Methods: This is a prospective study conducted after obtaining approval from the Ethics Committee. Pregnant women undergoing amniocentesis were enrolled in the study. The stool antigen test assessed the presence of H. pylori in amniotic fluid. A perinatologist independently performed an amniocentesis. The obtained amniotic liquid was sent to the laboratory to evaluate H. pylori infection by stool H. pylori antigen assay. We determined the rate of H. pylori in amniotic fluid and assessed relations between H. pylori infection and pregnancy outcome, including HG. Results: Between May and September 2017, we enrolled 48 pregnant women who underwent amniocentesis to detect possible fetal malformations. Patients were divided into two groups regarding the HG status. There were significant differences between the groups in terms of H. pylori infection presence. Among them, 28 (58.3%) were found to have a positive H. pylori test in their amniotic fluid. The rate of HG was significantly higher (71.4%) in patients who tested positive for H. pylori in amniocentesis than the H. pylori-negative group (20%), (p<0.001). Conclusions: The study's main new finding is that presence of H. pylori in the amniotic fluid is possible. Our data suggest that H. pylori-infected amniotic fluid is associated with the experience of past HG. The current study may have important implications for HG detection and help identify patients who would benefit from future preventive strategies.

Maternal and Fetal Outcomes of Pregnant Women with Hepatic Cirrhosis.

AIM: The reproductive hormone levels and systemic physiology of women with hepatic cirrhosis are altered. Existing data have indicated the adverse effects of cirrhosis on both the mother and the fetus. Pregnancy is successful in most of the patients with chronic liver disease. But maternal and fetal complication rates are still high for decompensated hepatic cirrhosis. In this study, we aimed to evaluate the clinical features, etiological factors, medications, morbidity, mortality, and obstetric outcomes of pregnant women with hepatic cirrhosis. METHODS: Pregnant women, who were diagnosed with maternal hepatic cirrhosis and followed up in our clinic between 2014 and 2017, were retrospectively evaluated. The pregnant women that had been followed up for hepatic cirrhosis were classified as compensated disease and decompensated disease. Eleven cases were included in this period. RESULTS: The mean age of cases was 33.5 ± 5.5 years. The mean gravida number was 3.2 ± 1.1, and the mean parity number was 1.7 ± 1. Six cases were in the compensated cirrhosis stage, and 5 cases were in the decompensated cirrhosis stage. A pregnancy with decompensated cirrhosis was terminated after the fetal heart sound was negative in the 9th week of pregnancy. Spontaneous abortus occurred in one case (<20 weeks). The mean gestational week of the 9 cases was 33.3 ± 6.2. Two of the 9 cases delivered birth vaginally. Seven cases delivered by cesarean section. The mean first- and fifth-minute APGAR scores were 6.6 ± 1.41 and 8.2 ± 1.56, respectively. The mean birth weight was 2303 ± 981 g. Among 9 cases with live birth, 6 had compensated cirrhosis and 3 had decompensated cirrhosis. In the second trimester, upper gastrointestinal endoscopy was performed to all patients in terms of esophageal varices. Endoscopic band ligation was performed in 3 cases with upper gastrointestinal bleeding. The postpartum mortality did not occur. Discussion. Pregnancy is not recommended for patients with hepatic cirrhosis due to high maternal and fetal morbidity and mortality. The pregnancy course of cases with cirrhosis changes according to the stage of liver injury and severity of disease. Although the delivery method is controversial, delivery by cesarean section is recommended for patients with esophageal varices by the reason of bleeding from varices after pushing during labor. The bleeding risk must be kept in mind as coagulopathy is common in hepatic diseases. The maternal-fetal morbidity and mortality rates have been decreased by the current developments in hepatology, prevention of bleeding from varices with drugs and/or band ligation, improvement in liver transplantation, and increasing experience in this issue.

Shear-wave elastography - virtual touch tissue quantification of fetal placentas with a single umbilical artery.

OBJECTIVE: In this study, we aimed to evaluate the elasticities of fetal placentas with a single umbilical artery using the Virtual Touch Tissue Quantification (VTTQ) technique. MATERIALS AND METHODS: Pregnant women with fetuses with a single umbilical artery (SUA) and pregnant women with fetuses having three vessel cord (3VC) at 18-22 weeks of gestation were enrolled in the research. The placentas were evaluated and divided into three equal parts as the inner 1/3 of the placenta (fetal edge), the outer 1/3 of the placenta (maternal edge) and the central 1/3 of the placenta (central part). Shear-wave velocity (SWV) measurements were used in the elastographic evaluation of placentas by VTTQ. RESULTS: Forty pregnant women were included in the study (n = 20 SUA, n = 20 three vessel cord pregnant women). The placental Acoustic Radiation Force Impulse (VTTQ) of the placenta regarding SWV measurement values of the fetal edge of the placenta in the fetuses with SUA and the control group were 0.876 and 0.957 m/sec, respectively. A significant statistical difference was found between the groups regarding the measurement of the stiffness of fetal placenta (p = 0.021). There was no significant difference between the measured stiffness values of the central or outer region of the placentas. CONCLUSIONS: In this study, we found lower SWV scores for the fetal edge of the placenta with SUA. This finding may reflect tissue elasticity level, and we hope that the use of the VTTQ technique may contribute to predicting the pregnancy-related morbidities of fetuses with SUA in the future.

Use of ARFI elastography in the prediction of placental invasion anomaly via a new Virtual Touch Quantification Technique.

We aimed to evaluate the efficiency of placental elasticity in predicting a placental invasion anomaly with the Virtual Touch Quantification (VTQ) technique. Pregnant women in the third trimester with suspected placental invasion anomaly were enrolled into the research (n = 58). The placenta was evaluated and divided into three equal parts as foetal edge (inner 1/3 of placenta), maternal edge (outer 1/3 of placenta) and the central part (central 1/3 of placenta). Shear wave velocity (SWV) measurements were used in the elastographic evaluation of placentas by VTQ. We performed the measurements at the different regions of placenta for sampling the variety areas of the placenta. Acoustic Radiation Force Impulse (ARFI) Elastography scores were significantly higher in the group in which an invasion was detected during the surgery of patients with preoperative placental invasion suspicion. A significant difference in the measurements of the inner, central and outer third of the placenta between the groups was found (p < .001). In this study, we have shown higher SWV scores of placental measurements of the patients with preoperative suspected anomalies and an invasion detected during their surgery. These findings may reflect an event at the tissue elasticity level and we hope that the use of the VTQ technique may contribute to an early prediction of placental invasions before surgery in the future via new research. Impact statement What is already known on this subject? Placenta invasion anomalies (PIA's) are characterized by haemorrhages which can threat the mother's life. Placental invasion anomalies are among the most important causes of maternal mortality and morbidity. Early diagnosis is very important condition in reducing the mortality and morbidity. Gray scale ultrasonography (US) is mostly used in early diagnosis of PIA's. Acoustic radiation force impulse elastography (ARFI) is a new elastographic ultrasonography technic. We aimed to evaluate a new method in the early diagnosis of PIA's using ARFI technique. There is no study in the diagnosis of PIA's by ARFI in the literature to our knowledge. We think that this original study will contribute to the literature. What do the results of this study add? We showed the accuracy of ARFI in determination of PIA's. ARFI scores were significantly higher in the group in which invasion was detected during surgery of patients with preoperative placental invasion suspicion. What are the implications are of these findings for clinical practice and/or further research? Our findings may reflect an event at the tissue elasticity level and we hope that the use of VTQ technique may contribute to early predict of placental invasions before surgery in the future via new researches. Early diagnosis of placental invasion anomalies may reduce mortality and morbidity.

Maternal serum calponin 1 level as a biomarker for the short-term prediction of preterm birth in women with threatened preterm labor.

PURPOSE: To assess the utility of maternal serum calponin 1 level in the prediction of delivery within 7 days among pregnancies complicated with threatened preterm labor. MATERIALS AND METHODS: Eligible women who presented at 24-34 weeks of gestation with threatened preterm labor underwent sampling for serum calponin 1 level and cervical length measurement. They were followed up until delivery prospectively and the perinatal outcomes of the patients were recorded. RESULTS: Of 73 women included in the study, 36 women delivered within 7 days and 37 women delivered beyond 7 days after admission. The maternal serum calponin 1 level was significantly high in women who delivered within 7 days (p: 0.031). The threshold value of 2 ng/mL for maternal serum calponin 1 predicted delivery within 7 days with 61.1% sensitivity and 62.2 specificity (area under curve, 0.658, confidence interval 0.53-0.79). The general accuracy values for maternal cervical length measurement (≤25 mm), serum calponin 1 level (>2 ng/mL) and the combination of two tests to predict delivery within 7 days was found to be 64.4%, 61.6% and 72.1%, respectively. CONCLUSIONS: The maternal serum calponin 1 level may be a useful biomarker in short-term prediction of preterm birth among pregnancies complicated with threatened preterm labor, in addition to cervical length measurement.

The maternal thiol/disulfide homeostasis does not change in pregnancies complicated by preterm prelabor rupture of membranes.

PURPOSE: To evaluate the maternal thiol/disulfide homeostasis in pregnant women complicated by preterm prelabor rupture of membranes (PPROM) and to compare the results with healthy pregnancies. MATERIALS AND METHODS: This cohort study consisted of thirty-nine pregnancies complicated by PPROM and 44 gestational age-matched healthy pregnancies in the third trimester of gestation. Maternal serum samples were obtained at the day of diagnosis, and thiol/disulfide profiles were measured by using an automated assay method. The patients were followed till delivery, and perinatal outcomes were noted. RESULTS: The maternal native thiol (319.9 ± 30.5 µmol/L versus 305.1 ± 49.2 µmol/L, p: .100), total thiol (379.2 ± 38.8 µmol/L versus 363.6 ± 56.4 µmol/L, p: .142) and disulfide (29.7 ± 11.7 µmol/L versus 29.3 ± 10.1 µmol/L, p: .864) levels were similar between the groups. Maternal disulfide/native thiol, disulfide/total thiol and native thiol/total thiol ratios were similar between the groups (p: .610, p: .565 and .562, respectively). The maternal serum thiol/disulfide profiles were not significantly correlated with maternal serum C-reactive protein, white blood cell count values and ongoing pregnancy outcomes (p > .05). CONCLUSIONS: The current study demonstrated that there was not any disturbance in maternal thiol/disulfide homeostasis in pregnancies complicated by PPROM at the time of initial diagnosis. Follow-up studies with larger sample size are needed to confirm our results.

The maternal serum thiol/disulfide homeostasis is impaired in pregnancies complicated by idiopathic intrauterine growth restriction.

PURPOSE: To investigate the maternal serum thiol/disulfide homeostasis in pregnancies complicated by idiopathic intrauterine growth restriction (IUGR) and to compare the results with healthy pregnancies. MATERIALS AND METHODS: This descriptive cohort study included 55 pregnant women complicated by idiopathic IUGR and 57 similar gestational aged healthy pregnant women in the third trimester of gestation. Maternal serum samples were collected at the day of diagnosis and the thiol/disulfide homeostasis was measured by using an automated assay method. The patients were followed up until delivery and perinatal outcomes were recorded. RESULTS: Maternal serum native thiol (308.1 ± 40.7 µmol/L vs. 282.4 ± 60.6 µmol/L) and total thiol (346.8 ± 48.1 µmol/L vs. 324.0 ± 62.2 µmol/L) concentrations were significantly lower in IUGR group compared with healthy controls (p: .010 and p: .032, respectively), whereas disulfide (19.3 ± 8.7 µmol/L vs. 20.8 ± 7.8 µmol/L) concentrations were similar between the groups (p: .350). Maternal serum disulfide/native thiol and disulfide/total thiol ratios were higher in IUGR group compared with healthy controls (p: .014 and p: .017, respectively), whereas native thiol/total thiol ratio was significantly lower in IUGR group compared with healthy controls (p: .016). CONCLUSIONS: This study suggests that there is an impaired maternal thiol/disulfide homeostasis in pregnancies complicated by idiopathic IUGR during the third trimester of gestation.

Amniotic fluid oxidant-antioxidant status in foetal congenital nervous system anomalies.

Objective This study aimed to evaluate the oxidant-antioxidant status of amniotic fluid in pregnant women with foetal congenital malformations of the central nervous system. Methods We studied pregnant women with foetal congenital nervous system anomalies at 16-22 weeks' gestation (n = 36). The control group (n = 30) consisted of pregnant women at the same gestational age who underwent amniocentesis, resulting in a normal karyotype. We analysed glutathione, catalase, and malondialdehyde levels in amniotic fluid. Enzyme activation was measured by spectrophotometry. Results The demographic features of the groups were similar in terms of age, parity, body mass index, and gestational weeks. We detected lower glutathione and catalase levels in the foetal congenital anomaly group than in the control group. We detected higher malondialdehyde levels in the foetal congenital anomaly group than in the control group. Conclusion In the organism, the rate of formation of free radicals and their rate of removal are balanced, and this is called oxidative balance. As long as oxidative stability is achieved, the organism is not affected by free radicals. This fact should be kept in mind to avoid any type of teratogenic agent that could lead to congenital disorders.

Laparoscopic repair of ureter damaged during laparoscopic hysterectomy: Presentation of two cases.

Ureter injuries are uncommon but dreaded complications in gynecologic surgery and a frequent cause of conversion to laparotomy. Recently, a few papers reported the repair of gynecologic ureteral injuries using laparoscopy with encouraging results. In these case reports, we aimed to present two laparoscopically repaired ureter injuries during total laparoscopic hysterectomies (TLH). In the first case, the ureter was transected during the dissection of the cardinal ligament, approximately 7 to 8 cm distal to the ureterovesical junction (UVJ), and in the second case, it was damaged approximately 10 cm distal to the UVJ. Both transections were identified during surgery. The injured ureter was repaired without converting to laparotomy or additional trocar insertion. Ureteroureterostomy was performed in both cases uneventfully. Although ureteric injury is a rare complication during TLH, it can be managed by the same surgeon laparoscopically during the same procedure.

Relationship between maternal blood ceruloplasmin level, catalase and myeloperoxidase activity and neural tube defects.

OBJECTIVES: The exact pathogenesis of neural tube defects (NTDs) is poorly understood. We aimed at evaluating maternal anti-oxidant capacity (ceruloplasmin level, myeloperoxidase and catalase activity) in pregnancies complicated by NTDs. MATERIAL AND METHODS: Fifty-four mothers with NTD-affected pregnancies and 61 healthy mothers, matched for gestational age, were recruited. Maternal venous blood samples were obtained after detailed fetal ultrasound examination to measure myeloperoxidase, catalase activity and ceruloplasmin levels. The clinical characteristics of all participants were collected. RESULTS: Maternal blood catalase activity was significantly lower in the study group (117.1 ± 64.8 kU/L) as compared to controls (152.2 ± 110.6 kU/L) (p = 0.044). Maternal blood ceruloplasmin levels were also significantly lower in the study group (180.5 ± 37.7 U/L) as compared to controls (197.9 ± 35.9 U/L) (p = 0.012). Myeloperoxidase activity was similar in both groups (112.6 ± 22.2 U/L vs. 113.6 ± 38.1 U/L) (p = 0.869). CONCLUSIONS: In the present study, maternal blood ceruloplasmin level and catalase activity were found to be lower in NTD-affected pregnancies as compared to healthy controls. Thus, it seems safe to conclude that impaired antioxidant capacity may play a role in the development of NTDs during pregnancy, in addition to the genetic, environmental and metabolic factors.

Maternal serum thiol/disulfide homeostasis in pregnancies complicated by neural tube defects: report of a preliminary study.

OBJECTIVE: To determine and evaluate the maternal serum thiol/disulfide homeostasis in pregnancies complicated by neural tube defects (NTD) via a novel method. METHODS: Seventy-three pregnant women with NTD (study group) and seventy-one healthy control pregnant women (control group) were included in the study. A new and fully automated method was used to measure plasma native thiol, total thiol and disulfide levels, based on the reduction of dynamic disulfide bonds to functional thiol groups by sodium borohydrate. RESULTS: The study and control groups were gestational age-matched. There were no statistical differences in demographic variables regarding age, gravidity, parity and body mass index. The serum native thiol levels (-SH) were 360.5 ± 50.3 and 353.3 ± 31.0 µmol/l in study and control groups, respectively, which was not statistically different (p = 0.308). The native thiol/total thiol, disulfide/native thiol and disulfide/total thiol ratios were not statistically significantly different (p > 0.05). CONCLUSION: Our preliminary results show that maternal serum thiol/disulfide homeostatis does not change in pregnancies complicated by NTD. Larger further studies are required to evaluate the relation of oxidative stress and development of NTD.

Is progestogen supplementation necessary to prevent abortion?

A prospective study was conducted to evaluate the effect of progestogens on the pregnancy outcome of threatened abortion (TA). A total of 251 pregnant women less than 20 weeks of gestational age (GA) were included. Group 1 consisted of women with vaginal bleeding who had already been under treatment with progestogens and Group 2 was composed of women with vaginal bleeding who were only followed without progestogen therapy, whereas Group 3 was the control group without any vaginal bleeding or progestogen therapy. The pregnancy outcomes and serum progesterone levels were compared among the groups. The mean serum progesterone concentrations were statistically significantly higher in Group 1 in comparison to Group 2 and 3 (p < 0.001). Abortion rates were similar among the study groups. Although progestogen supplementation leads to increased level of serum progesterone, this finding does not translate to its beneficial effect on the pregnancy outcomes in cases of TAs.

Cesarean Scar Pregnancy Managed with Conservative Treatment.

Cesarean scar pregnancy (CSP) is a rare, but life-threatening type of ectopic pregnancy. An exact and early diagnosis of CSP is very important for prognosis. The aim of the present study was to describe 4 women with CSP and discuss their clinical presentations, diagnoses, and various management options along with the published literature. Four women with a suspicion of CSP or cervical pregnancy were referred to our hospital between August 2013 and January 2014. All the patients were counseled about medical management options. After the treatment, serum beta human chorionic gonadotropin (ß-hCG) levels were followed weekly until they reached <5 mIU/mL. All the patients were diagnosed at the first trimester, with the average gestational age of 6.4±0.9 weeks. Treatment was systemic methotrexate (MTX) treatment in 3 of the 4 women, requiring no further intervention. The remaining 1 woman was treated with an intragestational administration of MTX. The mean time passed until ß-hCG reached <5 mIU/mL was 10.2±2.9 (range, 8-14) weeks, and the mean time passed until the gestational sac resolved was 21.5±3.5 (range, 18-25) weeks. Based on this limited number of case-series experience, it seems that CSP should be treated conservatively even if there are visible fetal cardiac activity, fetal poles, large gestational sacs, and high initial ß-hCG levels. Although the complete remission of the lesion takes a relatively long time, medical management via a noninvasive approach and follow-up should be tried as the first choice of therapy.

Microdose Flare-up Gonadotropin-releasing Hormone (GnRH) Agonist Versus GnRH Antagonist Protocols in Poor Ovarian Responders Undergoing Intracytoplasmic Sperm Injection.

BACKGROUND: Microdose flare-up GnRH agonist and GnRH antagonist have become more popular in the management of poor ovarian responders (POR) in recent years; however, the optimal protocol for POR patients undergoing in vitro fertilization has still been a challenge. METHODS: In this observational study design, two hundred forty four poor ovarian responders were retrospectively evaluated for their response to GnRH agonist protocol (group-1, n=135) or GnRH antagonist protocol (group-2, n=109). Clinical pregnancy rate was the primary end point and was compared between the groups. Student t-test, Mann Whitney U test and χ (2)-test were used to compare the groups. The p<0.05 was considered to show a statistically significant result. RESULTS: The mean total gonadotropin doses were 3814±891 IU in group 1 and 3539±877 IU in group 2 (p=0.02). The number of metaphase-II oocytes (3.6±2.4 vs. 2.8±1.9, p=0.005) and implantation rates (27.8% vs. 18.8%, p=0.04) in group 1 and group 2, respectively were significantly different. The fertilization rate in group 1 and group 2 was 73% vs. 68%, respectively (p=0.5) and clinical pregnancy rate was 19.8% vs. 14.4%, respectively (p=0.13). CONCLUSION: The GnRH agonist microdose flare-up protocol has favorable outcomes with respect to the number of oocytes retrieved and implantation rate; nevertheless, the clinical pregnancy rate was found to be similar in comparison to GnRH antagonist protocol in poor ovarian responders. GnRH antagonist protocol appears to be promising with significantly lower gonadotropin requirement and lower treatment cost in poor ovarian responders.

Maternal and fetal risk factors affecting perinatal mortality in early and late fetal growth restriction.

OBJECTIVE: To determine the factors which affect the perinatal deaths in early and late fetal growth restriction (FGR) fetuses using threshold of estimated fetal weight (EFW) < 5(th) percentile. MATERIALS AND METHODS: This retrospective study included singleton 271 FGR fetuses, defined as an EFW < 5(th) percentile. All fetuses considered as growth restrictions were confirmed by birth weight. Fetuses with multiple pregnancy, congenital malformation, chromosomal abnormality, and premature rupture of membrane were excluded. Samples were grouped in early and late FGR. Early FGR fetuses was classified as gestational age at birth ≤ 34 weeks and late FGR was classified as gestational age at birth > 34 weeks. Factors which affect the perinatal deaths were analyzed descriptively in early and late FGR. The perinatal mortality was calculated by adding the number of stillbirths and neonatal deaths. RESULTS: The study included 86 early and 185 late FGR fetuses, 31 resulted in perinatal deaths, 28 perinatal deaths were in early FGR, and three perinatal deaths were in late FGR. Perinatal deaths occurred more commonly in early FGR fetuses with an EFW < 3(rd) percentile. Prior stillbirth, preeclampsia, the degree of increasing vascular impedance of umbilical artery(UA) and uterine artery (UtA) showed significant correlation with perinatal death in early FGR. All three perinatal deaths in late FGR occurred in fetuses with EFW < 3(rd) percentile and severe oligohydramnios. Also, placental abruption and perinatal death was found significantly higher in increased vascular impedance of UtAs whatever the umbilical artery Doppler. CONCLUSION: Only EFW < 3(rd) percentile and severe olgohydramnios seem to be contributing factors affecting perinatal death in late FGR in comparison with early FGR.