Laparoscopic removal of heterotopic cesarean scar pregnancy.

OBJECTIVE: To present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options. DESIGN: Surgical video article. The Institutional Ethics Committee approved the video reproduction. SETTING: Tertiary referral to a university hospital PATIENT: A 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine (IU) location, and the other was in a previous cesarean section scar. INTERVENTIONS: Scar pregnancy was excised laparoscopically, preserving IU pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-Loc sutures. MAIN OUTCOME MEASURES: Ongoing IU pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery. RESULTS: The procedure was completed in 67 minutes. Total blood loss was <100 cc. The ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37th-38th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38th week and reported having pain for 2 days. During the cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male infant (weight, 3,210 g; Apgar score, 9/10) was delivered. CONCLUSIONS: The most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during a cesarean section in approximately half of cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving IU pregnancy.

Safety of Laparoscopic Entry Points in Patients With a History of Abdominal Surgery: A Research Article.

INTRODUCTION: This study aimed to assess the safety of laparoscopic entry sites in patients with previous abdominal surgery who subsequently required re-operation. MATERIAL AND METHODS: This is a prospective study wherein the data of 118 patients who had undergone previous abdominal surgery and were subsequently re-operated at our center (Bakirköy Doctor Sadi Konuk Research and Study Hospital) were collected from October 2015 to October 2016. Careful attention was paid to gathering information regarding patients' age, parity, body mass index (BMI), type of previous surgery, type of incision made during previous surgery, and medical history. For this study, the abdomen was topographically divided into nine parts. During the operation, all quadrants were examined and evaluated for adhesion and the content of adhesion. RESULTS: Adhesions were found in 44% (55 out of 118) of the patients, while 56% (66 patients) had no adhesions in the abdomen. The majority of cases (74%) had a history of cesarean section, and 87% had a Pfannenstiel incision. Adhesions were reported in 37.5% (33 out of 88) of the patients with a previous history of cesarean section. A significant proportion of subjects with adhesion (83%) had anterior abdominal wall adhesions, including only the omentum, whereas 11.5% (six subjects) had umbilical adhesions. Subjects with a history of umbilical hernia repair had more adhesions. DISCUSSION: The present study sought to assess the safety of laparoscopic entry points in individuals with prior abdominal surgery. The rise in laparoscopic surgeries, favored for reduced wound infections and quicker recovery times, brings forth concerns about potential complications in those with previous abdominal operations. Historically, postoperative adhesions have been observed in a significant number of patients after gynecological procedures. Our research, however, found a lower adhesion rate, which could be due to the smaller size of our sample and fewer gynecological cases. Existing adhesions can complicate subsequent surgeries, increasing operational times and posing injury risks. Adhesions also elevate healthcare costs and patient morbidity and mortality. Moreover, complications like Trocar-related injuries, including damage to major organs, are pivotal. While certain trocar insertion techniques may have fewer complications, our results align with previous findings suggesting higher adhesion rates after non-gynecological surgeries. Therefore, alternative entry points or methods, such as the palmer site or direct trocar entry, are recommended for those with an abdominal surgery history. Notably, our study's limited sample size may affect its generalizability, urging future studies for broader insights. Comprehensive pre-surgery assessments are crucial to anticipate complications. Our research supports that laparoscopic surgeries are safe for many with prior abdominal surgery, but for certain patients, non-umbilical entry sites are advised to further mitigate risks. CONCLUSION: The umbilicus is one of the safest entry sites for primary trocar insertion in patients with a history of Pfannenstiel incision. However, the probability of umbilical adhesions is high in patients who have undergone umbilical mesh repair, median incision, or major abdominal surgery. In these patients, surgeons should prefer other laparoscopic entry sites, especially Palmer's point, rather than the umbilicus.

Evaluation of new biomarkers in stage III and IV endometriosis.

OBJECTIVE: To investigate the efficacy of new endometriosis biomarkers in diagnosis and treatment. METHODS: Thirty women with Stage III-IV endometriosis who were given an indication for surgery and 49 control patients were compared. Preoperative and postoperative serum levels of Annexin A5 (ANXA5), soluble intercellular adhesion molecule-1 (sICAM-1), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), soluble vascular cell adhesion molecule-1 (sVCAM-1), vascular endothelial growth factors (VEGF) and Ca-125 measurements were compared. RESULTS: AUCs of ANXA5, sICAM-1, IL-6, TNF-α, VCAM-1, VEGF biomarkers were not found to be significant in diagnosing endometriosis when evaluated alone (p > 0.05). Only the AUC of the Ca-125 biomarker values were found to be significant with 73% sensitivity and 98% specificity (p < 0.001). However, when Ca-125 and ANXA5 were evaluated together, it was concluded that the diagnosis of endometriosis could be made with 73% sensitivity and 100% specificity. CONCLUSION: When Ca-125 and ANXA5 are evaluated together, it seems to be more valuable than Ca-125 alone in diagnosing endometriosis.

Ovarian Response can be Predicted in Women with PCOS who have Ovulation Induction with Letrozole.

OBJECTIVE: To compare the clinical, metabolic, and hormonal characteristics of patients with and without selected dominant follicles in infertile women with PCOS who used letrozole for ovulation induction. STUDY DESIGN: A descriptive cohort study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology of Bagcilar Research and Training Hospital, Istanbul, Turkey, from October 2019 to November 2021. METHODOLOGY: Eighty-eight female patients with PCOS, who underwent ovulation induction by giving 5 mg/day letrozole, were screened for demographic characteristics, laboratory values, and dominant follicle development. Those who were given letrozole as the first treatment agent, those who took clomiphene citrate (CC) and started letrozole the following month, and those who were treated with letrozole and given letrozole again were recorded separately. Seventy-five patients responded to letrozole and developed a dominant follicle; 13 patients did not develop a dominant follicle. Threshold values were determined for statistically significant parameters between patients with and without dominant follicles. RESULTS: Follicle development occurred in 85.2% of the women. A statistically significant variable in clinical and metabolic values, between ovulating and non-ovulating groups could not be found. There was a significant difference between the two groups for the serum AMH value, total testosterone value, and FSH level. The authors found that follicle response was higher in those with AMH values less than 11.89 ng/mL, FSH levels higher than 6.25 Iu/L, and total testosterone less than 0.96 ng/mL. In this study, the pregnancy rate was found to be lower than in the literature (11%). CONCLUSION: Among the women with PCOS who had ovulation induction with letrozole, follicle development was higher in women with lower FSH, androgen and AMH values. KEY WORDS: Letrozole, Aromatase inhibitor, Androgens, Ovulation induction, AMH.

Association of Endometrioma Size with Serum Anti-mullerian Hormone.

OBJECTIVE: To evaluate the relationship between the size of endometrioma and serum Anti-mullerian hormone (AMH). STUDY DESIGN: A Descriptive study. PLACE AND DURATION OF STUDY: This study was conducted at the Bagcilar Training and Research Hospital, Istanbul, Turkey, from January 2015 to January 2020. METHODOLOGY: Healthy women of reproductive age, who were found to have unilateral endometrioma in ultrasonography, were included in the study group. There were 82 female patients with unilateral endometrioma in the study group and 96 healthy female patients with male factor infertility in the control group. Women with autoimmune disease, a history of pelvic infection or surgery, polycystic ovary syndrome, pregnancy, those undergoing infertility treatment, family history of premature ovarian failure, and those with atypical or suspected endometrioma were excluded. Age, gravida, serum AMH value, and endometrioma size of the study and control groups were recorded. In addition, the endometrioma group was divided into 2 groups with a cut-off size of greater or less than 40 mm. AMH values ​​were evaluated in these two groups. RESULTS: AMH values ​​of women with endometrioma were significantly lower than the control group (2.03 ng/ml and 3.87 ng/ml, respectively, p<0.001). When the relationship between endometrioma size (greater than 40 mm and less than 40 mm) and AMH was examined, no statistically significant difference was found among serum AMH values (1.89 ng/ml and 2.07 ng/ml, respectively, p=0.65). CONCLUSION: The presence of endometrioma was associated with lower AMH suggesting lower ovarian reserve, but endometrioma size was not associated with significant difference in the AMH values. KEY WORDS: Endometrioma, AMH, Ovarian reserve, Endometrioma size.

Open abdomen technique used in complications of major gynecological oncology surgery.

OBJECTIVE: To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery. METHODS: We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques. RESULTS: Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively. CONCLUSION: Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.

Diagnostic office hysteroscopy; why is it still painful procedure despite the surgical experience and mini-hysteroscope?

AIM: To evaluate the effect of cervical canal features on pain during outpatient hysteroscopy performed by experienced surgeons using mini-hysteroscope. METHODS: A prospective observational study was conducted on 303 women undergoing diagnostic hysteroscopy without anesthesia. Pain intensity was evaluated using the visual analog scale (VAS) when the cervical canal was passed. The patients were divided into two groups according to the VAS score: painless or mild pain (VAS <4) and moderate or severe pain (VAS ≥ 4). The relationship between cervical canal characteristics (length, version, and flexion positions, history of cervical intervention, stenosis, synechiae), obstetric and gynecological history, preoperative anxiety level, procedure duration, and pain intensity was examined. RESULTS: Moderate pain (4 ≤ VAS < 7) was observed in 38% of patients (n = 117) and 14 patients (5%) experienced severe pain (VAS ≥ 7). In multivariate analysis, nulliparity (p = 0.01; OR, 4.6; 95% CI, 1.7-13.2), postmenopausal state (p = 0.02; OR, 2.2; 95% CI, 1.2-4.3), excessive flexion of the cervix and retroverted uterus (p <0.001; OR, 4.1; 95% CI, 2.0-8.5) were identified as risk factors for a painful procedure. Diagnostic hysteroscopy was successful in 98% of the patients. The pain was the primary cause of the failed hysteroscopy. CONCLUSION: In addition to nulliparity and postmenopausal status, unfavorable features of the cervical canal, such as the excessive flexion position of the cervix and uterine retroversion are significant causes of pain during outpatient hysteroscopy.

High visceral adiposity index is associated with female orgasmic disorder in premenopausal women: a cross-sectional study.

This study aimed to evaluate the association between the visceral adiposity index (VAI) and female sexual dysfunction (FSD). This cross-sectional study included 165 premenopausal, sexually active women admitted to the gynaecology outpatient clinic between January 2021 and April 2021. Female Sexual Function Index (FSFI) was used to assess the sexual function of the women. After measuring body mass index (BMI) and waist circumference (WC), biochemical serum analysis was performed. The VAI was calculated for all participants. The relationship between VAI and total FSFI and subdomain scores was investigated. Of the participants, FSD was detected in 65.5%. There was no relationship between the total FSFI scores and age, BMI, WC and VAI (p = .126, p = .675, p = .790, p = .220, respectively). Increased VAI levels were associated with dysfunction in orgasm (p = .008). Although VAI seems not to be directly related to FSD, it may predict the orgasmic disorder in women.Impact StatementWhat is already known on this subject? Obesity and female sexual dysfunction (FSD) are common health problems which adversely affect the biopsychosocial well-being. Although the relationship between FSD and obesity, body mass index (BMI) and waist circumference (WC) has been widely discussed in the literature to date, there is not enough evidence for the link between FSD and visceral adiposity index (VAI) which is a reliable indicator of visceral fat dysfunction.What do the results of this study add?The results of this study showed that none of the factors indicating obesity such as BMI, WC and VAI were correlated with the total FSFI scores. However, a significant positive correlation was found between the VAI and female orgasmic disorder (FOD).What are the implications of these findings for clinical practice and/or further research? The VAI may be a useful tool for detecting FOD patients. Diagnosis and treatment of orgasmic disorder would significantly improve the patient's quality of life and general well-being. Further large-scale and high-evidence studies are needed to clarify the impact of obesity on FSD and the relationship between VAI and FOD.

Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri.

AIM: This study aimed to compare the surgical outcomes of laparoscopic hysterectomy (LH) and vaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy procedures in women with undescended-enlarged uteri. MATERIALS AND METHODS: This cross-sectional study was conducted with 78 women who underwent LH (48 patients) or vNOTES hysterectomy (30 patients) for benign gynecological pathologies. The dimension of the uterus, operation time, intraoperative blood loss, the presence of peri-, postoperative complications, conversion to laparotomy, pre-, postoperative hemoglobin (Hb), and hematocrit (Hct) levels, postoperative hospital stay, total dose of postoperative analgesics, VAS scores at the postoperative 6th and 24th hours, and the final pathology reports were recorded. RESULTS: There was no significant difference between LH and vNOTES hysterectomy groups regarding age (47 vs. 47.5 years, p = 0.92), parity (2 vs. 2, p = 0.74), and BMI (30.8 vs. 28.2 kg/m2, p = 0.31). The patients in the vNOTES hysterectomy group had significantly shorter durations of surgery (45 vs. 160 min) and hospitalization (48 vs. 72 h) than the LH group (p < 0.001, p < 0.001, respectively). The 24th hour VAS score was lower (VAS score 2 vs. 3, p = 0.003) in favor of the vNOTES hysterectomy group. In matched group analysis, the 24th hour VAS score (2 vs. 3, p = 0.008), operation time (45 vs. 157, p < 0.001), and hospitalization (48 vs. 72, p < 0.001) were lower in the vNOTES hysterectomy group than the LH group. CONCLUSION: vNOTES hysterectomy provides favorable outcomes compared to conventional LH considering the shorter operation time, hospitalization, and lower 24th h VAS score.

Effect of metformin and detorsion treatment on serum anti-Müllerian hormonelevels and ovarian histopathology in a rat ovarian torsion model

Background/aim: Adnexal torsion is a common gynaecological emergency, and considered to be a problem mostly in reproductive-age women. To evaluatethe effect of metformin and detorsion treatment on reducing ovarian reserve in an ovarian torsion model. Materials and methods: Twenty-four nonpregnant, Wistar Hannover rats were included in the study. Animals were divided into 3 groups: the control group, the detorsion only group, and the metformin + detorsion group. The first group received only laparotomy. In the second group, ovaries were fixed to the abdominal wall after performing 360° ovarian torsion, followed by detorsion after a 3-h period of ischemia. The third group underwent the same torsion and detorsion procedures as the second group, and received 50 mg/kg metformin by gavage for 14 days. Ovarian damage scores, follicle counts, and AMH levels were evaluated. Results: The total damage score was significantly increased in the detorsion only group compared to the metformin+detorsion and control groups. Pre-operative/post-operative AMH decreases were statistically significant in negative direction in the detorsion only group when compared to the metformin+detorsion and control groups (P = 0.001). Conclusion: Metformin+detorsion treatment may be effective in protecting the ovarian reserve after ovarian torsion.

Laparoscopic Management of a Torsioned Round Ligament Fibroid.

Round ligament fibroids are rare tumors and can present as inguinal, adnexal, or vulvar masses. Preoperative diagnosis can be made by ultrasonography or magnetic resonance imaging (MRI). A 28-year-old virgin female presented with pelvic pain that persisted for a few days. Her sonographic evaluation detected a well-defined hyperechoic 45 × 40 mm right adnexal mass interfering endometrioma. A contrast-enhanced pelvic MRI showed a 43 × 39 × 32 mm solid mass located in the right adnexa. Laparoscopic exploration revealed a well-defined double torsion around the peduncle pinky solid mass arising from the right round ligament. The mass was resected with the final histopathological diagnosis being leiomyoma. The diagnosis of round ligament fibroids can be challenging, and laparoscopy is one of the first options where surgical facilities are available.

The Role of Serum Caspase 3 Levels in Prediction of Endometriosis Severity.

BACKGROUND/AIMS: To identify the role of serum caspase 3, Annexin A2 (ANXA2), and Soluble Fas Ligand (sFasL) levels in the prediction of endometriosis severity. METHODS: The study was performed on 90 women who were candidates for laparoscopic surgery due to endometrioma or any other benign ovarian cysts detected by ultrasound examination, pelvic pain, or infertility. The control group comprised 29  patients. The second group comprised 29 patients with stage I-II endometriosis and the third group comprised 30 patients with stage III-IV endometriosis. RESULTS: Significant differences were detected between the control and stage III-IV endometriosis groups and between stage I-II and stage III-IV endometriosis groups in terms of caspase-3 levels (both, p < 0.001), ANXA2 levels (p = 0.007 and p = 0.002), and sFasL levels (p = 0.022 and p = 0.044). After receiver operating characteristic analysis, the area under curve was 93% (95% CI 57-82) at 10.7 ng/mL cut-off level for caspase-3 with 90% sensitivity and 87% specificity. CONCLUSION: Serum caspase-3 level may be a reliable predictor of endometriosis severity.

Borderline ovarian tumors: clinical characteristics, management, and outcomes - a multicenter study.

BACKGROUND: The optimal surgical management and staging of borderline ovarian tumors (BOTs) are controversial. Institutions have different surgical approaches for the treatment of BOTs. Here, we performed a retrospective review of clinical characteristics, surgical management and surgical outcomes, and sought to identify variables affecting disease-free survival (DFS) and overall survival (OS) in patients with BOTs. METHODS: A retrospective review of ten gynecological oncology department databases in Turkey was conducted to identify patients diagnosed with BOTs. The effects of type of surgery, age, stage, surgical staging, complete versus incomplete staging, and adjuvant chemotherapy were examined on DFS and OS. RESULTS: In total, 733 patients with BOTs were included in the analysis. Most of the staged cases were in stage IA (70.4 %). In total, 345 patients underwent conservative surgeries. Recurrence rates were similar between the conservative and radical surgery groups (10.5 % vs. 8.7 %). Furthermore we did not find any difference between DFS (HR = 0.96; 95 % confidence interval, CI = 0.7-1.2; p = 0.576) or OS (HR = 0.9; 95 % CI = 0.8-1.1; p = 0.328) between patients who underwent conservative versus radical surgeries. There was also no difference in DFS (HR = 0.74; 95 % CI = 0.8-1.1; p = 0.080) or OS (HR = 0.8; 95 % CI = 0.7-1.0; p = 0.091) between complete, incomplete, and unstaged patients. Furthermore, receiving adjuvant chemotherapy (CT) for tumor stage ≥ IC was not an independent prognostic factor for DFS or OS. CONCLUSIONS: Patients undergoing conservative surgery did not show higher recurrence rates; furthermore, survival time was not shortened. Detailed surgical staging, including lymph node sampling or dissection, appendectomy, and hysterectomy, were not beneficial in the surgical management oF BOTs.

Management of unilocular or multilocular cysts more than 5 centimeters in postmenopausal women.

OBJECTIVE: To evaluate the malignancy potential of large unilocular and multilocular ovarian cysts in postmenopausal women and to discuss their appropriate management. STUDY DESIGN: This retrospective study included 204 postmenopausal patients who underwent surgery for simple adnexal cysts or cysts with isolated septal structures at the Gynecology and Obstetrics Clinic of Bakirkoy Dr Sadi Konuk Training and Research Hospital. Data obtained from patient and computer records included patient age, follow-up period, ultrasonography reports, surgery information, histopathological evaluation results, and cancer antigen-125 (CA-125) levels at diagnosis and during follow-up. The Kruskal-Wallis test was used to compare three or more groups. The Chi-square test or Fisher's exact test was used to compare qualitative parameters, while relationships between parameters were analyzed by using Spearman's correlation analysis. RESULTS: A total of 236 cysts were identified in 204 postmenopausal women who underwent surgery. The cysts were categorized as having unilocular cyst morphology or complex structures without morphological abnormalities other than septa in 182 (77.1%) and 54 cases (22.9%), respectively. The mean cyst diameter was 6.6±3.1cm (range, 2.7-30cm) with diameters ≥5cm in 176 cysts (75%). The median cyst volume was 88.5 cm(3) (range, 10-2636; interquartile range: 81) and the mean morphology index was 1.2 (range, 1-6), with 16 cysts (6.8%) ≥5. No malignancy or borderline histology was observed in any patient. CONCLUSIONS: Among postmenopausal women, cysts that are unilocular or contain isolated septa, have a low-risk of malignancy even when they are larger than 5cm. Rather than undergoing emergency surgery, these patients may be followed up conservatively with intermittent transvaginal ultrasonography.

Could body mass index be an indicator for endometrial biopsy in premenopausal women with heavy menstrual bleeding?

PURPOSE: To evaluate the role of body mass index (BMI) in women with premenopausal heavy menstrual bleeding (HMB) to identify patients who should undergo endometrial biopsy. METHODS: This prospective cohort study included 1120 premenopausal women who presented to the Gynecology Clinic, Bakirkoy Dr. Sadi Konuk Training and Research Hospital in Istanbul, Turkey, due to HMB and who underwent endometrial sampling. The abnormal endometrial histopathological results were analyzed by separating patients into groups of all abnormal findings (hyperplasia without atypia + hyperplasia with atypia + carcinoma) and hyperplasia with atypia + carcinoma. Sensitivity and specificity of the abnormal histopathological results were calculated in both groups using BMI cut-off values as 25, 30 and 35 and age cut-offs as 40 and 45 years. RESULTS: The rate of hyperplasia with atypia and carcinoma was sevenfold higher in women with a BMI ≥30 compared to those with a BMI ≤30 (95 % CI 2.4-17.9). In the analyses, BMI was a stronger risk factor in women younger than 45 years of age. The risk of endometrial carcinoma and atypical hyperplasia was twofold higher in patients older than 45 years when compared with patients younger than 45 years (95 % CI 1.1-5.1). CONCLUSIONS: All women with a BMI ≥30 and presenting premenopausal HMB should undergo endometrial biopsy regardless of age.

The Effect of Intrauterine Lidocaine and Rectal Indomethacin on Pain during Office Vaginoscopic Hysteroscopy: Randomized Double-Blind Controlled Study.

BACKGROUNDS/AIMS: The aim of this study was to investigate the effect of rectal and intrauterine anesthesia during vaginoscopic hysteroscopy. METHODS: This was a randomized, double-blind, placebo-controlled study. Patients were randomized to rectal indomethacin, intrauterine lidocaine and placebo groups. Patients with conditions that could cause or contribute to pelvic pain were excluded. Pain was evaluated with Visual Analog Scale, when the cervical canal was passed, while within the cavity and at 10 min after procedure. The Analog Pain Scale scores of the 3 groups were compared with the Kruskal-Wallis 1-way analysis of variance test. A value of p < 0.05 was accepted as statistically significant. RESULTS: The study included a total of 206 patients. No difference was seen between the groups in respect of indication, age, gravid and duration of procedure. While the anesthesia was determined as superior to the placebo in reducing pain at all 3 stages (p < 0.05), intrauterine lidocaine was determined to be more effective than rectal indomethacin in reducing pain within the cavity and 10 min after the procedure (p < 0.05). CONCLUSION: Rectal or intrauterine anesthesia applied with the vaginoscopic technique is useful in hysteroscopy. However, intrauterine anesthesia is more effective in reducing pain.

Ischemia-Modified Albumin (IMA): A Novel Marker for Preeclampsia Independent of Uterine Artery Notching Identified by Doppler Ultrasound.

OBJECTIVE: To determine the predictive value of second trimester serum ischemia-modified albumin (IMA) levels for preeclampsia (PE), small for gestational age (SGA) and gestational diabetes mellitus (GDM). METHODS: The study was conducted at a tertiary care hospital between May and August 2014. Healthy pregnant women (n = 88) who were screened for fetal anomalies with ultrasound at 20-24 weeks of gestation were included in the study. Doppler measurements of the bilateral uterine arteries were performed in all the patients. Serum samples were obtained for an IMA assay. The maternal serum IMA levels were compared in pregnant women who had normal and abnormal uterine artery Doppler findings, including notching, and also in pregnant women who subsequently developed PE, SGA, and GDM during the follow-up period. RESULTS: Uterine artery notching was not significantly predictive for PE, GDM or SGA (p > 0.05). There was no significant difference between notching of the uterine arteries and serum IMA levels (p > 0.05). Eight pregnant women (9.1%) subsequently developed PE. Serum IMA levels were significantly elevated in patients with PE compared with patients who did not subsequently develop PE (p = 0.002). However, serum IMA levels were not significantly different in patients who subsequently developed SGA and GDM compared with women who did not (p > 0.05). There was no correlation between serum IMA levels and maternal characteristics and laboratory findings. CONCLUSION: Maternal serum IMA levels at 20-24 weeks' gestation might be a predictive biomarker for PE, independent of notching of the uterine arteries, maternal characteristics and laboratory findings.

Can Platelet Count and Platelet Indices Predict the Risk and the Prognosis of Preeclampsia?

OBJECTIVE: To compare the hematocrit, platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW), PC to MPV ratio in the mild preeclamptic (mPE), severe preeclamptic (sPE) and healthy normotensive pregnant women to evaluate whether these parameters have a predictive and prognostic significance in determining the risk and the severity of preeclampsia (PE). METHODS: A retrospective case-control study was designed including the patient population (N = 284) composed of 49 mPE, 70 sPE, 165 healthy normotensive pregnant women for controls. Preceding medical histories of all the cases were insignificant. RESULTS: In comparison of the preeclamptic patients with controls; there was statistically significant difference in PC (p = 0.023; p < 0.05), MPV(p = 0.023; p < 0.05), PC/MPV ratio (p = 0.005; p < 0.01). But there was no difference between sPE and mPE. Cut-off value for MPV was calculated as 9 for the diagnosis of PE (p < 0.01), the odds ratio was 1.999. The cut off value for PC was 190, the odds ratio was 1.932. The cut off value was 19.9 for the PLT/MPV, the odds ratio was 2.42. CONCLUSION: We suggest that the increasing platelet turnover in PE causes a decrease in the PC, an increase of MPV value and especially a decrease in PC/MPV ratio pointing that these parameters may play an important role in predicting the risk of PE while they have no role on predicting the severity of PE. According to our findings we can suggest that the patients with these cut-off values of PC and platelet indices, should be carefully followed for the development of PE.

Bilateral sacrospinous fixation without hysterectomy: 18-month follow-up.

OBJECTIVE: The aim of this study was to evaluate the results of bilateral sacrospinous fixation (SSF), which was performed with surgical mesh interposition and bilateral vaginal repair. MATERIAL AND METHODS: Twenty-two patients underwent SSF between 2010 and 2012, and the results were evaluated retrospectively. The results at preoperative and postoperative 6(th), 12(th), and 18(th) months of the pelvic organ prolapse quantification system (POP-Q) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) were compared using Friedman and Wilcoxon Signed Ranks tests. Values of p<0.05 and <0.01 were considered statistically significant. RESULTS: According to the POP-Q, significant healing was observed on all vaginal vault points (p=0.001), and no prolapse was observed until the 18-month follow-up stage. There were also prominent patients who felt satisfactory with respect to their sexual life according to PISQ-12 (p=0.001). CONCLUSION: This technique appears to provide an adequate clinical resolution, and it may be the primary surgical option for women with pelvic organ prolapse.