The effects of conservative and surgical approaches in tubal ectopic pregnancy on fertility.

BACKGROUND: Medical treatment, expectant approaches, and surgical treatment options are available in the treatment of ectopic pregnancy. Regardless of the treatment, in addition to its effectiveness, the main concern is to limit the risk of relapse and preserve fertility. OBJECTIVES: Determine the impact of medical or surgical treatment for ectopic pregnancy on future fertility. DESIGN: Retrospective. SETTING: Department of obstrtrics and gynecolgy at Ankara Etlik Zübeyde Hanim Women's Health Training and Research Hospital, Ankara, Turkey. PATIENTS AND METHODS: Patients who were treated for ectopic pregnancy between June 2016 and November 2019 were allocated into two groups. Expectant approach or medical treatment by methotrexate constituted the conservative treatment group while salpingectomy by laparoscopy indicated the surgical treatment group. MAIN OUTCOME MEASURES: Fertility rates within two years following treatment were evaluated according to treatment options. SAMPLE SIZE: 202 patients. RESULTS: Of the 202 patients, 128 had medical treatment and 74 patients had surgical treatment for ectopic pregnancy. Of 272 diagnosed with ectopic pregnancy, 70 were excluded for various reasons. Parity and unemployment rate was significantly higher in the surgical treatment (P=.006 and P=.12, respectively). Moreover, ectopic mass size and serum ß-hCG levels were significantly higher in the surgical treatment group (P<.001 and P<.001, respectively). There were no significant differences between the conservative and surgical treatment groups in time to pregnancy (17.0 months vs 19.0 months, P=.255). Similarly, there was no significant difference between the conservative and surgical treatment groups with respect to history of infertility (P=.12). There were no significant differences between the conservative and surgical treatment groups in terms of live birth (51.6% vs 44.6%) and ectopic pregnancy (2.3% vs 1.4%) (P=.72 for both). There was no significant difference between the conservative and surgical treatment groups with respect to infertility rate (35.9% vs 41.9%, P=.72) and admittance to the IVF program (3.9% vs 6.8%, P=.39) following ectopic pregnancy treatment. CONCLUSIONS: Reproductive outcomes did not differ significantly in women undergoing expectant management, medical treatment, and surgery for ectopic pregnancy. This finding suggests that clinicians should not hesitate to act in favor of surgical treatment for ectopic pregnancy even if there were concerns for future fertility. LIMITATIONS: Retrospective study.

Adnexal masses and pregnancy: a single-center experience of 9 years.

PURPOSE: This study aims to analyze the experience of a tertiary health center about the management of adnexal masses that have been diagnosed during pregnancy or detected accidentally during cesarean delivery. METHODS: This is a retrospective review of 160 women who underwent concurrent surgery for adnexal mass during cesarean section, 24 women who delivered vaginally and subsequently had surgery due to the prenatal diagnosis of adnexal mass and 10 women who underwent surgery for adnexal mass during pregnancy. Corresponding to the delivery and surgery times, 200 women who had no diagnosis of pregnancy-associated adnexal mass served as controls. RESULTS: The women in the control group and study groups had statistically similar gestational age at delivery, birth weight and preterm delivery (p > 0.05 for all). Miscarriage was significantly more frequent in women undergoing surgery for adnexal mass during pregnancy (p = 0.001). The women who had surgery for adnexal mass during pregnancy, at the time of cesarean section and following delivery were statistically similar with respect to surgery type and histopathological diagnosis (p > 0.05 for both). Malignancy was detected in none of the patients who underwent surgery for adnexal mass during pregnancy. Acute abdomen was the indication for the emergency surgery in six patients (3.5%) who had surgery for adnexal mass during pregnancy. Four patients (2.4%) had surgery for adnexal mass during pregnancy due to the high index of suspicion for malignancy. CONCLUSION: The risk of malignancy was relatively lower in this cohort of adnexal masses detected during pregnancy and cesarean delivery. Surgical management of adnexal masses should be postponed to postpartum period as such management leads to an increased risk of miscarriage. Unless there is a need for emergent surgery or cancer staging, vaginal delivery should be encouraged in women diagnosed with adnexal mass during pregnancy.

Vaginal Hysterectomy at the Time of Total Colpocleisis: A Single-Center Experience.

OBJECTIVE: This study aims to evaluate the five-year experience of a single center regarding the total colpocleisis procedure. METHODS: This is a retrospective review of 24 women who underwent total colpocleisis at the study center between January 2017 and January 2023. Every participant was informed about this study, and written consent was obtained from each participant who then took Pelvic Floor Distress Inventory-20 (PFDI-20), Body Appreciation Scale-2 (BAS-2) and Decision Regret Scale (DRS) questionnaires consecutively. RESULTS: Eight patients (33.3%) underwent total colpocleisis, whereas 16 patients (66.7%) had concomitant colpocleisis and vaginal hysterectomy. The number of total colpocleisis cases did not change significantly with respect to the past years (p=0.117). The patients who underwent total colpocleisis and the patients who had concurrent colpocleisis and hysterectomy were statistically similar with respect to age, gravidity, chronic disease, blood group, American Society of Anesthesiologists classification, anesthesia type, surgery timing and preoperative and postoperative hemoglobin values (p>0.05 for all). Operative time was significantly shorter in patients who had colpocleisis alone (p=0.001). Both patient groups were also statistically similar in aspects of blood loss, transfusion need, hospital stay, postoperative complications and follow-up time as well as PFDI-20, BAS-2 and DRS scores (p>0.05 for all). Endometrial atrophy (56.3%), endometrial hyperplasia (18.8%) and adenomyosis (12.5%) were the most common histopathological findings detected in vaginal hysterectomy specimens. CONCLUSION: The combination of vaginal hysterectomy and total colpocleisis appears as a safe and efficient approach which does not contribute to the surgery-related morbidity despite the significantly longer operative time.

Prognostic factors determining survival after extrapelvic recurrence in endometrioid type endometrial cancer.

OBJECTIVE: To define the factors that determine survival after extrapelvic recurrence in patients with endometrioid type endometrial cancer (EC).objective MATERIALS AND METHODS: Clinicopathological and survival data of surgically treated endometrioid type EC patients who recurred outside pelvis were reviewed. Patients who had non-endometrioid tumor, sarcomatous component in the final pathology and synchronous tumor were excluded. The period from surgery to recurrence was defined as time to recurrence (TTR) and the period from recurrence to death or last visit was defined as post-recurrence survival (PRS). RESULTS: Sixty-six patients with extrapelvic recurrence were included in the study. No residual disease was achieved in all patients at initial surgery. Median TTR was 18 months (range, 2-84). Recurrence developed within 1 year in 24 (36.4%) patients and between 13 and 24 months in 22 (33.3%) patients. Fifty-three of 66 patients (80.3%) had extraabdominal recurrence. The 2-year PRS of the all cohort with extrapelvic recurrence was 56%. In the univariate analysis, advanced FIGO stage, lymph node metastasis, adnexal metastasis and short TTR were associated with diminished PRS (p < 0.05). The salvage chemotherapy for recurrence had a tendency to be associated with improved PRS in the univariate analysis. Two-year survival was 81% and 37% in the patients who received chemotherapy and radiotherapy, respectively (p = 0.057). CONCLUSION: Almost half of the patients with extrapelvic recurrence died of disease within 2 years. Chemotherapy seemed to be more effective than radiotherapy as the salvage therapy of extrapelvic recurrences.

Neoadjuvant chemotherapy for locally advanced stage (IB2-IIA2-IIB) cervical carcinoma: Experience of a tertiary center and comprehensive review of the literature

Objective: This study aimed to evaluate neoadjuvant chemotherapy (NACT) for locally advanced stage cervical carcinoma. Materials and Methods: Data of 43 patients with locally advanced cervical carcinoma who had NACT were reviewed. NACT protocols implemented included cisplatin/5-fluorauracil, cisplatin/UFT, and carboplatin/paclitaxel. After NACT, the patients were re-examined, and patients who had a tumor size ≤40 mm underwent Piver-Rutledge type III radical hysterectomy, while other patients received radiotherapy. Following NACT, clinical responses were assessed according to the criteria of the World Health Organization. Results: The mean age of the patients was 49.4 years, and the median follow-up duration was 48 (range, 5-228) months. The median tumor sizes were 50 and 30 mm before and after NACT, respectively. Complete clinical response was observed in 4 (9.3%) patients, partial clinical response in 8 (18.6%), and pathologic complete response in 3 (6.9%). Stable disease was noted in 30 (69.9%) patients and progression in 1 (2.3%) patient. After NACT, 31 patients have undergone radical surgical procedures. The 5-year disease-free survival rate was 72%, and the 5-year disease-specific survival rate was 91%. Age, International Federation of Gynaecology and Obstetrics 2009 stage, histopathologic type, NACT protocol, rate of decrease in tumor size after NACT, clinical response, number of courses, tumor size before NACT, tumor size after NACT, and lymph node metastasis were not associated with disease-free survival. Conclusion: Following NACT, a significant reduction in tumor dimension was observed, and the probability of radical surgery is increased. However, clinical response was not predictive of survival.

The impact of vaginal cone therapy on stress urinary incontinence compared with transobturator tape.

OBJECTIVE: To emphasize the efficiency of vaginal cone (VC) therapy in stress urinary incontinence (SUI) through a comparison with transobturator tape (TOT). MATERIALS AND METHODS: A prospective randomized controlled study was conducted at the Etlik Zübeyde Hanim Maternity and Women Hospital during a one year study period. Forty women were allocated into two equal groups; those treated with VCs for a 3 month period, and women who underwent TOT procedures. These women were followed up at 6 weeks and 6 months after the treatments. Subjective cure was assessed using Wagner's Quality of Life Questionnaire. Objective cure was evaluated through a cough stress and pad test results. RESULTS: Maternal demographic features were comparable among groups. We observed improvement in pad weight test among groups when compared with the pretreatment state (p=0.015, p=0.005). Although the subjective cure rate was similar in both groups at the 6th week and 6th month follow up (65% vs. 75%; 75% vs. 80%) (p>0.05), the objective cure rate was significantly higher in the TOT group than in the VC group, as expected (10% vs. 80%; 30% vs. 75%) (p<0.05). CONCLUSION: The main treatment of SUI is surgery; however, VC could be offered as an alternative treatment for women who refuse surgery, those at high risk for surgery or it could be used temporarily before surgery.

The Effect of Preoperative Neutrophil-To-Lymphocyte Ratio and Platelet-To-Lymphocyte Ratio on Predicting Rupture Risk in Tubal Ectopic Pregnancies.

BACKGROUND: Consecutive measurements of ß-hCG levels and sonographic evaluation of adnexae are critical for choosing the optimal management in ampullar tubal ectopic pregnancies (EP). To select suitable patients for conservative approach, there is a need for an affordable and reliable marker for determining rupture risk. Evaluation of systemic inflammatory markers in combination with serum ß-hCG levels and ultrasound might help to decide the appropriate treatment option. OBJECTIVE: The purpose of the present study was to evaluate the diagnostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in determining the rupture risk in ampullar tubal EPs and to compare with intraoperative findings. METHODS: A total of 142 patients who underwent surgery for tubal EP were included. Seventy-two patients were in the intraoperatively diagnosed tubal rupture group and 70 patients without rupture findings were included in the control group. Both groups were compared for inflammation markers, ß-hCG levels, and sonographic findings. RESULTS: Both NLR and PLR levels were found to be significantly higher in the tubal rupture group (4.62 ± 3.13 vs. 2.67 ± 1.43, 162.94 ± 63.61 vs. 115.84 ± 41.15, p < 0.01, respectively). According to the receiver operating characteristic analysis performed for the diagnostic performance of tubal diameter measurement, ß-hCG, NLR, and PLR levels were significantly associated with histopathologically confirmed tubal rupture (p < 0.01). CONCLUSION: Systemic inflammatory markers are feasible and affordable tools for predicting tubal rupture risk in ampullar EPs and might be useful for determining surgery decision especially in low resource settings.

Bone recurrence after radical hysterectomy and lymphadenectomy in early-stage cervical cancer.

OBJECTIVE: To present the clinical, surgical, and pathologic features of bone recurrence in patients who underwent radical hysterectomy for early-stage uterine cervical cancer. MATERIALS AND METHODS: Data of 412 patients who underwent type III radical hysterectomy and pelvic ± paraaortic lymphadenectomy for stage 1B-2A epithelial cervical cancer were reviewed. Seven (1.7%) patients with bone recurrence in the first recurrence were included in the study. RESULTS: The median follow-up of the main cohort (n=412) was 46 (range=1-300) months. In this period, recurrence developed in 53 (12.9%) patients and recurrence was observed in bone in 13.2% (7 of 53) of these recurrences. Time to recurrence ranged from 9 to 45 months. Of the recurrences, five were in the axial skeleton and two were in the appendicular skeleton. Recurrence was observed in lumbar vertebrae in three patients, thoracic vertebrae in one patient, sacral vertebrae in one patient, lumbosacral vertebrae in one patient, and the left femur in two patients. Four patients had multiple recurrence in 3 patients despite isolated bone recurrence. Patients with multiple recurrences died within 6-25 months. All isolated bone recurrences were in the axial skeleton. Complete clinical response with salvage therapy was achieved in two patients with isolated bone recurrence. CONCLUSION: Complete clinical response and long postoperative survival can be achieved with salvage treatment when bone recurrence is solitary in cervical cancers.

The role of anti-Mullerian hormone in predicting the response to clomiphene citrate in unexplained infertility.

OBJECTIVE: To determine the role of anti-Mullerian hormone (AMH) levels in predicting the response to clomiphene citrate (CC) therapy for ovulation induction in women with unexplained infertility. MATERIALS AND METHODS: For this retrospective study, fifty consecutive patients who responded to CC were taken as Group 1, while fifty consecutive patients who failed to show adequate ovulatory response with CC were taken as Group 2. We compared the AMH levels of the two groups and receiver operating characteristic (ROC) curve was used to determine the threshold for AMH in predicting the ovulatory response to CC therapy. RESULTS: Mean age, body mass index, luteinizing hormone, prolactin, and thyroid-stimulating hormone values were similar in the two groups. AMH and antral follicle count (AFC) values were higher in Group 1 than in Group 2 (p = 0.001 and p = 0.001, respectively). There was a statistically significant negative correlation between FSH and AFC (r = -0.339, p = 0.001), while AFC and AMH displayed a statistically significant positive correlation (r = 0.713 and p = 0.001). AMH values and AFC were found to be predictors of the adequate ovulatory response to CC. The area under the ROC curve was 0.86 vs 0.80, respectively. At an AFC cutoff value of 14, the sensitivity and specificity for prediction of ovulation were 68% and 80%, respectively. CONCLUSION: The AMH and AFC cut-off values for the prediction of positive ovarian response to CC in patients with unexplained infertility were 2.78 ng/mL and 14, respectively. If further prospective and randomized studies confirm our results, these thresholds may be useful to predict successful ovulation induction and reduce the unresponsive cycles.

Low transcriptional activity of PON2 in recurrent abortion: A novel therapeutic agent?

OBJECTIVE: Oxidative stress has been reported to be associated with various pregnancy complications and to play key roles in many of them. An inadequate level of antioxidant defense may eventually lead to an early pregnancy loss. There is a lack of information about the roles of the PON2 and PON3 enzymes in the etiology of the cases of unexplained recurrent abortus. The aim of our study is to determine and present the data regarding the roles of these enzymes for the first time. MATERIALS AND METHODS: We measured the transcriptional levels of the PON2 and PON3 enzymes in the curettage materials obtained from the patients with unexplained recurrent abortus (n=25) and compared the results with those measured in the abortus materials from healthy pregnant women (n=50) who had undergone a voluntary abortion. The transcriptional activities of PON2 and PON3 enzymes were measured through quantification of their respective mRNAs by RT-qPCR assay. For each gene, 2-ΔCt replication values of the control and the patient groups were compared using the Student's t-test, and the p values were calculated thereafter. Fold-changes in the enzyme transcription levels were interpreted as up- or down-regulation. RESULTS: PON2 mRNA expressions were found to be highly decreased in the patient group (p=0.000002). PON3 transcription, when compared to the healthy pregnant women, was found to be down-regulated in the patient group; however, the difference was not statistically significant (p=0.69). CONCLUSIONS: In this study, we evaluated the expressional regulation of the PON2 and PON3 enzymes in unexplained recurrent abortus. Our results demonstrate for the first time that the expressions of PON2 and PON3 are down-regulated in the abortion specimens of the patients with recurrent miscarriage. Although both enzymes had low expression levels, the decrease in the transcriptional activity of PON2 revealed a high statistical significance. According to these results, it is rational to speculate that PON2 may be a novel therapeutic agent in the management of the cases with unexplained recurrent abortion.

Prediction of maternal near-miss in placenta previa: a retrospective analysis from a tertiary center in Ankara, Turkey.

AIM: To determine risk factors for severe complications during and after cesarean delivery (CD) in placenta previa (PP). METHODS: We reviewed retrospectively collected data from women with PP who underwent CD during a 6-year study period. We identified the complicated group based on the modified WHO near-miss criteria. Complicated and noncomplicated groups were compared considering clinical, laboratory, and sonographic features. RESULTS: Thirty-seven of 256 cases classified as near miss consisting of 14 peripartum hysterectomies, 12 uterine balloon placements, 10 great artery ligations, and four B-lynch suture placement procedures without maternal mortality. Perioperative complications included surgical wound infections (n = 5), bladder injury (n = 4), pelvic abscess (n = 1), and uterine rupture (n = 1). Logistic regression analyses demonstrated following features to be associated with maternal near miss in PP: (1) coexistent abruption (aOR 13.2, 95% CI 5.8-75.3), (2) morbidly adherent placenta (aOR 11.92, 95% CI 3.24-43.82), (3) number of hospitalizations for vaginal bleeding (≥3) (aOR 8.88, 95% CI 3.32-26.69), and (4) transvaginal cervical length (CL) measurement <10th percentile (aOR 5.5, 95% CI 2.1-15.4). CONCLUSION: Short cervical length, recurrent vaginal bleeding, morbidly adherent placenta, and concurrent placental abruption are independent predictors for subsequent severe maternal morbidity in PP cases. Early identification of these risk factors during PP follow-up may improve maternal outcome.

Isolated tubal torsion: Successful preoperative diagnosis of five cases using ultrasound and management with laparoscopy.

Our aim was to evaluate the presentation and diagnostic evaluation of patients with isolated tubal torsion and to evaluate the surgical approach to these patients. We also aimed to define the ultrasonographic diagnostic criteria. Five patients with isolated tubal torsion who were admitted to our gynecology department between January 2014 and January 2017 were evaluated and included in this study. All cases were diagnosed through ultrasonographic imaging alone. The preoperative findings of the patients were similar to those described in the literature. No further imaging modality was used for diagnosis and all patients were managed with laparoscopy. The clinical findings and ultrasonographic findings were consistent with literature. It may be difficult to preoperatively diagnose isolated tubal torsion, which is a rare clinical entity. Evaluation of these patients by an experienced sonographer and knowledge of the ultrasonographic findings of isolated tubal torsion may have vital preventive measures.

Molar pregnancy in cesarean section scar: A case report.

Cesarean scar ectopic pregnancies and molar pregnancies are two very rare obstetric pathologies. In both cases, serious morbidities are involved that require careful management. The coexistence of the two clinical conditions is far less common and there are a limited number of cases in the literature. In this case report, a 34-year-old patient with previous cesarean section was diagnosed as having a molar pregnancy in a cesarean scar through ultrasonography. The patient was asymptomatic at that time. Ultrasonography revealed a protruding mass at the cesarean section and her human chorionic gonadotropin level was measured as 59.705 mIU/mL. Due to the risk of severe bleeding, cesarean section scar excision and revision were performed via laparotomy after counselling the patient. Removal of all trophoblastic tissue was observed as a result of the frozen pathology and the operation was terminated. After the definite pathology result came as a complete molar pregnancy, the patient was followed up according to molar pregnancy follow-up protocols and cured completely. Despite the alternative treatment options (methotrexate application, curettage, uterine artery embolization) in such patients, the decision for surgery was made after counselling the patient. In this very rare clinical condition, patients should be closely monitored and the appropriate treatment option should be applied as soon as possible, taking into consideration the bleeding risks of both pathologies.

Surgical reconstruction in female genital mutilation.

Female genital mutilation (FGM) is an unusual condition for our country. However, an increase in FGM in future days can be predicted with the increasing numbers of exchange students coming from African countries, migration of refugees and socioeconomic relations with the African countries. We want to share our experience of two FGM victims admitted to our clinic with the request of reconstructive vulvar surgery before their marriage. Both women had WHO Type III FGM. Physical examination findings and surgical reconstruction techniques were presented.