Expectant management of triplets or multifetal reduction to twins; comparison of preterm delivery and live birth rates.

OBJECTIVE: The management of multiple pregnancies is still a challenge. The aim of this study was to compare the outcome of triplet pregnancies managed expectantly or by multifetal pregnancy reduction to twins. STUDY DESIGN: For this retrospective, comparative and monocentric study, the medical files of all women with triplets who admitted to our institution over a 13-year period were examined. Women requesting multifetal pregnancy reduction to have twins formed the study group, and women with triplets who wished to continue their pregnancies formed the control group. Main outcome measures were durations of pregnancies presented as number of weeks gestation, abortion rates, term and preterm birth rates, fetal loss and live birth rates. RESULTS: During the study period, 171 women with triplets admitted to our institution. One hundred fifty one patients are included in this study. Forty-five women carrying triplets wished to continue their pregnancies and 106 women requested multifetal pregnancy reduction to have twins. Fetal reduction of triplets to twins was associated with a significantly lower incidence of birth before 34th gestational week and higher incidence of late preterm and term birth rates without changing live birth rates. CONCLUSION: Multifetal pregnancy reduction of triplet pregnancies to twins resulted in a later gestational age at birth compared with the triplet gestations managed expectantly.

McDonald versus modified Shirodkar rescue cerclage in women with prolapsed fetal membranes.

Purpose: We compared the efficacy of modified Shirodkar and McDonald rescue cerclage techniques in women with singleton pregnancies.Methods: The study sample included 47 women who presented at two tertiary hospitals in Turkey from 2008 to 2017 and underwent rescue cerclage due to cervical incompetence and cervical dilatation with fetal membranes prolapsed into the vagina. The outcomes were compared by cerclage technique used, Shirodkar or McDonald.Results: The McDonald cerclage was applied in 27 cases, and modified Shirodkar cerclage in 20 cases. A longer cerclage-to-birth interval (83.8 ± 37.6 vs. 63.7 ± 38.9 days) and later gestational age at delivery (33 vs. 31 weeks) were observed with the Shirodkar cerclage, although these differences were not statistically significant (p = .08 and .63, respectively). Both groups had similar delivery rates after 28, 32, and 37 weeks (p = .20, .15, and .25, respectively), whereas the modified Shirodkar technique resulted in a higher rate of live births although these differences were not statistically significant (85% vs. 63%, p = .09).Conclusion: The effects of the McDonald and modified Shirodkar cerclage procedures on prolonging pregnancy and improving the live birth rate were similar. Therefore, either technique can be applied to prevent neonatal loss due to advanced prematurity.

Does pregnancy interval after laparoscopic sleeve gastrectomy affect maternal and perinatal outcomes?

Background: Obesity is a global health epidemic and is associated with many maternal and neonatal complications. Laparoscopic sleeve gastrectomy (LSG) is among the surgical treatments for obesity. The appropriate timing of pregnancy following LSG remains controversial and few studies have evaluated this public health issue. Objective: To evaluate the effect of pregnancy timing after LSG on maternal and perinatal outcomes. Study design: We performed a retrospective observational study of 23 pregnant women who underwent LSG at a tertiary hospital in Turkey. Women who became pregnant within 18 months of undergoing LSG were included in the early pregnancy after LSG group, and those who became pregnant after 18 months were included the late pregnancy after LSG group. Maternal and perinatal outcomes were evaluated, including gestational diabetes mellitus (GDM), pregnancy-associated hypertensive disorders, preterm birth, mode of delivery, small and large for gestational age births (small for gestational age (SGA), large for gestational age (LGA)), birth injury, and congenital malformations. Results: Body mass index (BMI) at conception was higher in the early pregnancy after LSG group than in the late pregnancy after LSG group (30.48 versus 27.25, respectively; p = .03). Pregnancy interval after LSG did not impact maternal-fetal complications or mode of delivery. After a 75 g oral glucose tolerance test (OGTT) for GDM, 75% (n = 6) of the early pregnancy group presented with early dumping syndrome, compared to only 13.3% (n = 2) of the late pregnancy after LSG group (p = .009). Conclusions: LSG may reduce obesity-related gestational complications, such as GDM and LGA. The interval between LSG and conception did not impact maternal or neonatal outcomes. Screening for GDM can result in dumping syndrome in pregnancies after LSG.

The levonorgestrel-releasing intrauterine system is associated with a reduction in dysmenorrhoea and dyspareunia, a decrease in CA 125 levels, and an increase in quality of life in women with suspected endometriosis.

BACKGROUND AND AIMS: The aim of this study was to investigate the effectiveness of a levonorgestrel-releasing intrauterine device (LNG-IUS) in the symptomatic relief of pain in women with endometriosis and additionally, to assess the changes in women's life quality and serum cancer antigen (CA) 125 levels. MATERIALS AND METHODS: All women who had an LNG-IUS inserted for the treatment of dysmenorrhea, chronic pelvic pain or both for more than six months over a two-year period were included in the study. Each woman was asked to complete questionnaires of the Short Form-36 and visual analogue scales (VAS) in the first visit and the third, sixth, ninth and twelfth months after the LNG-IUS insertion. CA 125 levels were measured at each visit. RESULTS: Forty-five women were included in the study. At the end of 12 months, mean dysmenorrhoea VAS score decreased from 6.13 to 2.88, mean dsyspareunia VAS score from 6.04 to 2.61 and CA 125 level from 50.67 to 22.45. Endometriomas reduced in size in six women (mean size decreased from 31 to 20 mm) and disappeared in three. CONCLUSIONS: Several favourable outcomes were found following LNG-IUS insertion: (i) dyspareunia and dysmenorrhoea were clearly reduced; (ii) the size of endometriomas were decreased; (iii) CA 125 levels significantly decreased; (iv) a few women experienced the typical systemic adverse effects of progestogens; however, LNG-IUS-related adverse events were generally tolerable and the discontinuation rate was as low as 6.66% (3/45).

Incidence of echogenic amniotic fluid at term pregnancy and its association with meconium.

PURPOSE: The presence of echogenic amniotic fluid at term gestation on sonography is uncommon. The aim of our study was to investigate the incidence of echogenic amniotic fluid at term pregnancy, and to determine how often echogenic amniotic fluid was associated with meconium. METHODS: All singleton pregnant women at term who were admitted to our labor unit and who delivered within 24 h of the ultrasound scan were included in the study. For each woman, gestational age, maternal age, gravidity, parity, the character of the amniotic fluid on ultrasound at admission (clear or echogenic), birth weight, and the character of the amniotic fluid on artificial or spontaneous rupture of membranes or on cesarean section (clear/with vernix/meconium-stained) were recorded. RESULTS: When amniotic fluid was assessed on ultrasound, among 278 patients, 9 (3.2%) patients' amniotic fluid was echogenic. When the amniotic fluid was assessed at delivery, the rates of meconium-stained amniotic fluid in women with and without echogenic amniotic fluid were 44.44% (4/9) and 9.3% (25/269), respectively; the difference was statistically significant (p = 0.035). We found a sensitivity and specificity of 13.79 and 97.99%, and a positive and negative predictive value of 44.44 and 90.7%, respectively, for echogenic amniotic fluid seen on ultrasound in identifying meconium-stained amniotic fluid. CONCLUSIONS: The incidence of echogenic amniotic fluid at term gestation was found as 3.2 and 44.4% of cases of echogenic amniotic fluid was associated with meconium.

Rescue cerclage when foetal membranes prolapse into the vagina.

A cross-sectional study was conducted to evaluate the efficacy of rescue cerclage in patients with a dilated cervix and prolapsed foetal membranes. Thirty-five patients presenting with cervical dilatation and prolapsed foetal membranes were included in the study. A McDonald cerclage was placed in 27 patients. The duration of pregnancy prolongation and the number of deliveries after 28 weeks were evaluated. The median prolongation of pregnancy after cerclage placement differed significantly between the cerclage and bed-rest groups (64 days versus 13.5 days). Of the 27 patients who had cerclage, 17 (63%) delivered after 28 weeks of gestation, whereas all patients in the bed-rest group delivered before 28 weeks of gestation. The take-home baby rate was 63% in the cerclage group. When pregnancies were complicated by cervical dilatation with membrane prolapse into the vagina, placement of a McDonald cerclage in appropriately selected patients can be a beneficial therapeutic option. Impact statement Although the effectiveness and safety of rescue cerclage is controversial, our study provides strong support for the notion that cervical cerclage accompanied by long-term broad-spectrum antibiotics improves the perinatal outcomes in singleton gestations with membrane prolapsed into the vagina. Further prospective randomised trial is required to prove these findings.

Comparison of adverse perinatal outcomes after single-needle and double-needle CVS techniques.

OBJECTIVE: To determine the impact of the chorion villus sampling (CVS) technique on adverse perinatal outcomes. METHODS: In this case-control study, 412 women who underwent CVS at 11-14 weeks of gestation and 231 women who did not undergo any invasive procedure were retrospectively evaluated. The women in the CVS group were further divided into two groups according to the use of single-needle technique (n=148) vs. double-needle technique (n=264). The adverse outcomes were compared between controls and the two CVS groups, and regression analysis was used to determine the significance of independent contribution. RESULTS: The rate of preeclampsia for the control group was 2.2%, for the double-needle group was 3% and for the single-needle group was 8.1%. CVS with single-needle technique was found to be an independent and statistically significant risk factor for preeclampsia [odds ratio (OR)=2.1, 95% confidence interval (CI); 1.4-2.7, P=0.008]. CONCLUSION: The risk of preeclampsia after CVS appears to be increased with single-needle technique compared with double-needle technique.

Double notches: association of uterine artery notch forms with pregnancy outcome and severity of preeclampsia.

OBJECTIVE: To assess uterine artery Doppler waveforms and notches performed in the third trimester as a predictor of adverse outcomes. METHODS: Of 490 preeclampsia (PE) patients between 24 and 34 weeks gestation, 166 were diagnosed with mild PE and 324 were diagnosed with severe PE. Patients were divided into four groups (no notch, a unilateral notch, bilateral notches and double notches). RESULTS: Bilateral and double notches were predictive of shorter follow-up times, adverse laboratory outcomes, HELLP syndrome, prematurity, neonatal intensive care unit admission and perinatal mortality. CONCLUSION: Double notches represent progressive deterioration in the uterine artery and are predictive of adverse maternal outcomes.

A rare coexistence of villoglandular papillary adenocarcinoma of the uterine cervix and brenner tumor of the ovary.

Synchronous primary gynecological cancers have been reported to be seen rarely in the literature. In this report, we aimed to describe a 51-year-old patient with the coexistence of villoglandular papillary adenocarcinoma of the cervix uteri and Brenner tumor in the right ovary. She successfully underwent radical hysterectomy, bilateral salphing-oopherectomy and pelvic and para-aortic lymphadenectomy.

Vascular risk in women with a history of severe preeclampsia.

UNLABELLED: BACKGROUND. To assess markers of vascular dysfunction and risk in postpartum women with a history of severe preeclampsia. METHODS: Carotid intima-media thickness (CIMT) and brachial artery flow-mediated dilatation (FMD) measured by ultrasonography, and lipid profile and insulin resistance evaluated by biochemical assays were compared between 34 women with a history of severe preeclampsia and 42 women with a prior normal pregnancy at least 12-24 months postpartum. RESULTS: CIMT was higher and FMD lower in the preeclamptic than in the control group. We found a significant inverse correlation between CIMT and FMD in the preeclamptic group, but no difference in lipid profiles and insulin resistance between the groups. CONCLUSIONS: Women with a history of severe preeclampsia exhibit early structural and functional preatherosclerotic vascular impairment, which might explain their higher risk of future cardiovascular disease.

Normative values of fetal nasal bone lengths of Turkish singleton pregnancies in the first trimester.

OBJECTIVE: Evaluation of nasal bone improves the performance of first-trimester screening for trisomy 21. In this retrospective study we aimed to determine normative values related to the measurement of nasal bone length of the Turkish population during the first trimester ultrasonographic fetal screening. MATERIAL AND METHODS: Medical records of singleton pregnancies, whose first trimester fetal screening was performed between 2004 and 2010, were evaluated retrospectively. Pregnancies with any detected/suspicious anatomical or genetic fetal anomalies, biochemical abnormalities, increased nuchal translucency measurements, and pregnancies of artificial reproduction techniques were excluded from data analyses. Mean±standard deviation, median and percentile values of the length of nasal bone were calculated separately for 11(0-6), 12(0-6) and 13(0-6) gestational weeks. RESULTS: Nasal bone could be visualized in 99.6% of the included 1762 singleton pregnancies. In 16.5% of the cases nasal bones were only noted as present or absent. Mean maternal age was 29.67±4.50 years and mean gestational age was 12.54±0.61 weeks. Median values of nasal bone lengths were 1.7, 1.9, and 2.2 mm for 11(0-6), 12(0-6) and 13(0-6) gestational weeks respectively. Nasal bone length (NBL) increased linearly with advancing gestational age and CRL. NBL (mm)=[0.298xGestational Age (week)]-1.779, R(2)=0.318; p<0.001; NBL (mm)= [0.023 × CRL (mm)] + 0.520, R(2)=0.331; p<0.001. CONCLUSION: The present study presents normative values of nasal bone in the first trimester screening of normal singleton pregnancies of Turkish population. Nasal bone length increases with advancing gestational age and CRL.

Acute abdomen due to rupture of Sertoli cell tumor.

PURPOSE: To present a rare case of Sertoli cell tumor that presents with acute abdomen. CASE: A 28-year-old patient with symptoms of acute abdomen has presented to our emergency department. Her examinations revealed a 12 x 10 cm heterogeneous mass in the right ovarian fossa. Laparotomy was carried out immediately. Frozen pathological study revealed a low-grade sex-cord stromal cell tumor. Right salpingo-oopherectomy was performed. During 2 years of follow-up, there was no evidence of disease. CONCLUSION: Although rupture of a malignant ovarian tumor is an infrequent cause of acute abdomen, it should be considered in the differential diagnosis of acute abdomen.

The effect of magnesium sulfate treatment on blood biochemistry and bleeding time in patients with severe preeclampsia.

OBJECTIVE: The objective of this study was to observe the effects of magnesium sulfate on various blood biochemical parameters and coagulation status of patients with preeclampsia. METHODS: During a period of 4 years, 50 patients with severe or mild preeclampsia progressing to severe preeclampsia were included in the cross-sectional study. Prothrombine (PT), activated limited thromboplastin time (aPTT), magnesium level, biochemistry parameters, systolic, and diastolic blood pressure (BP) were measured. These parameters were remeasured in the second hour of magnesium sulfate treatment. RESULTS: After magnesium sulfate therapy; creatinine levels are decreased (p < 0.05), bleeding time is increased and serum magnesium levels are increased (p < 0.01), systolic and diastolic BP values decreased significantly (p < 0.01). PT, aPTT, platelet levels, and coagulation time did not change after treatment. CONCLUSION: Magnesium sulfate infusion prolonged bleeding time in patients with severe preeclampsia. This is clinically important because it worsens the present condition and causes possible complications.

The effect of tubal sterilization through electrocoagulation on the ovarian reserve.

BACKGROUND: The study was conducted to compare the effects of tubal sterilization through electrocoagulation and the application of mechanical clips on the ovarian reserve. STUDY DESIGN: Eighty-eight patients in the reproductive period with the desire of tubal sterilization were included in the prospective, randomized study. The patients were divided into two groups by simple randomization as tubal sterilization through electrocoagulation group and the application of mechanical clips group. Day-3 serum follicle stimulating hormone, luteinizing hormone, estradiol, inhibin-B and antimüllerian hormone and Day-3 total ovarian volume measurements and anthral follicle counts of all patients in the preoperative and 10th postoperative months were compared both within and between the two groups. RESULTS: A significant difference between the postoperative 10th-month Day-3 total ovarian volumes and anthral follicle counts was detected between the electrocoagulation and mechanical clips application groups. CONCLUSION: Tubal sterilization by electrocoagulation is very likely to have an adverse effect on the ovarian reserve in the postoperative period.

Treatment of a viable caesarean scar pregnancy with transvaginal methotrexate and potassium chloride injection.

PURPOSE: To present a case of an ectopic pregnancy in a previous caesarean scar in a woman who wishes to preserve her fertility, and its treatment with the local administration of potassium chloride (KCl) and methotrexate (MTX) via a transvaginal needle. CASE: A 35-year-old woman with a viable caesarean scar pregnancy was referred to our hospital. After an unsuccessful treatment attempt by administering 60 mg systemic methotrexate, the patient was treated with local administration of KCl and MTX using a transvaginal needle. The persistent ectopic mass was removed with dilatation and curettage (D&C) 1 week later. The patient had no complications and the treatment was successful in the follow-up examinations. CONCLUSION: Local MTX and KCl treatment using a transvaginal needle together with D&C can avoid unnecessary laparotomy, and helps to preserve the fertility of most women with a caesarean scar pregnancy.

Spontaneous uterine rupture during a second trimester pregnancy with a history of laparoscopic myomectomy.

Uterine rupture is one of the most feared obstetric complications, carrying an increased risk of maternal and perinatal morbidity and mortality. Here, we present a case of spontaneous uterine rupture during the first half of pregnancy. The patient did not report any recent trauma, however she had a history of laparoscopic myomectomy conducted three years earlier. The uterine rupture was 6-7 cm in length, located at the fundal level and was thought to originate from the previous myomectomy scar. In this report, we discuss the importance of choosing the right surgical technique and suturing method in patients undergoing myomectomy who desire to conceive in the future, and how obscure the findings of uterine rupture during pregnancy can be.

The shrinking of an anterior sacral meningocele in time following transdural ligation of its neck in a case of the Currarino triad.

In this paper we present an adult patient with the Currarino triad, associated with six habitual abortuses and chronic constipation. Our aim is to report the effectiveness of a simple surgical technique in the treatment of anterior sacral meningocele in the Currarino Syndrome. The presentation of the Currarino Syndrome in adulthood is extremely uncommon. We performed a posterior procedure via lumbar and sacral partial laminectomy and transdural ligation of the neck of the meningocele mass. There were no additional neurological deficits and no recurrence of the presacral mass over the 2-year follow up period. When an adult female with habitual abortus and chronic constipation is seen, the possible presence of the Currarino Triad should be investigated and treated. The anterior sacral meningocele in a case of the Currarino Triad regresses over time following transdural ligation of its neck.

Umbilical cord thickness in the first and early second trimesters and perinatal outcome.

OBJECTIVES: To study the association between thickness of the umbilical cord at 11+0 to 14+6 gestational weeks and perinatal outcome. METHODS: We studied 216 pregnant women between 11+0 and 14+6 weeks' gestation with singletons, intact membranes, normal volumes of amniotic fluid and a regular menstrual period. Patients with umbilical cord measurements below the 5(th) centile were defined as thin umbilical cord group and those between the 5(th) and 95(th) or above 95(th) centile were defined as non-lean umbilical cord group. Abortion or fetal demise, preeclampsia, mode of delivery, gestational age at delivery, birth weight, and 5-min Apgar scores were noted. RESULTS: A statistically significant difference existed between the mean gestational age, mode of delivery, birth weight and adverse perinatal outcome of the two groups. The relative risk of the adverse perinatal outcome in lean umbilical cords was 6.92 (2.71-17.67; 95% CI). The umbilical cord thickness correlated with birth weight (P<0.05). CONCLUSIONS: Sonographic finding of a lean umbilical cord at 11+0 to 14+6 weeks' gestation should prompt the physician to strict monitoring of pregnancy.

Nomogram of the fetal gastric size development in normal pregnancy.

OBJECTIVE: To construct an ultrasonographic nomogram of the fetal gastric size with gestational age in normal singleton pregnancy. PATIENTS AND METHODS: Out of 17 000 outpatient pregnant women who were admitted to our hospital, a total of 250 fetal measurements were randomly collected from routine ultrasonographic examinations performed in women with normal singleton pregnancies between 13 and 39 weeks of gestation without medical or obstetric complications. None of the fetuses had detectable fetal malformations. The ultrasound plane which provided the largest stomach area including the pylorus on a transverse and oblique section was used for definition and measurement of gastric longitudinal dimensions. The transverse section at the center of the gastric corpus was used for transverse and anteroposterior dimensions. Biparietal diameter, abdominal circumference were also measured. RESULTS: The fetal gastric longitudinal, anteroposterior and transverse dimensions were significantly correlated with gestational age (r values 0.74, 0.71, and 0.49, respectively). There was a significant correlation measurements between gastric size and AC. The correlation coefficents for gastric dimensions with gestational age was larger than those with AC (r=0.732, 0.702 and 0.489, respectively). The ratio of fetal gastric anteroposterior dimension to fetal AC was a constant parameter calculated as 1/3. CONCLUSION: Fetal stomach dimensions in normal pregnancy correlate with gestational age and nomogram of fetal gastric development appears to be useful in assessment of normal fetal growth.

Brain damage to the survivor within 30 min of co-twin demise in monochorionic twins.

Single fetal death in a twin pregnancy in the late second or early third trimester is associated with significant morbidity and mortality rate in the surviving co-twin, especially in monochorionic twin pregnancies. The common causes are twin-to-twin transfusion syndrome, chromosomal abnormalities, and congenital anomalies of the fetus or anomalies of the umbilical cord-placenta. Here we report a case of monochorionic twin pregnancy in which one fetus had a single umbilical artery (SUA) while the co-twin had two umbilical arteries. The twin with SUA died in utero at the 30th week of gestation and the other fetus was delivered by cesarean section immediately due to fetal distress diagnosed by cardiotocography. Disseminated intravascular coagulation and multicystic encephalomalacia have been observed in the surviving neonate. This case and review of the literature suggest that neurologic complication rates are also increased in monochorionic twin pregnancies with single fetal demise despite the immediate delivery as in our case.