Evaluation of second-trimester maternal serum betatrophin levels and lipid and carbohydrate metabolism parameters in patients with gestational diabetes mellitus.

OBJECTIVE: We investigated the role of betatrophin in the etiopathogenesis of gestational diabetes mellitus (GDM) and its association with lipid and carbohydrate metabolism in patients with GDM and normoglycemic pregnant women. MATERIALS AND METHODS: A total of 60 patients [30 pregnant women with GDM (study group) and 30 healthy age-, body mass index-, and gestational agematched pregnant women (control group)] were included in this study. Serum betatrophin, fasting glucose, insulin, glycated hemoglobin A1c (HbA1c), and C-peptide levels, as well as lipid parameters, were measured. RESULTS: Serum betatrophin, fasting glucose, HbA1c, insulin, and C-peptide levels were significantly higher in the GDM group than in the control group (p<0.001, p=0.009, p=0.013, p<0.001, and p<0.001, respectively). Levels of triglycerides and very-low-density lipoprotein cholesterol were significantly higher in the GDM group (p=0.020 and p=0.020, respectively), but total cholesterol and LDL cholesterol levels were similar in the two groups (p=0.810 and p=0.273, respectively). Betatrophin levels in the GDM group were correlated positively with insulin levels (r=0.336, p=0.009) and the homeostatic model assessment of insulin resistance (HOMA-IR) score (r=0.269, p=0.038), and negatively with the C-peptide levels (r=-0.399, p=0.002); they were not correlated with any other glucose or lipid parameters. Multivariate stepwise linear regression analysis demonstrated that insulin levels (ß=0.134, p=0.013) and the HOMA-IR score (ß=0.112, p=0.017) were associated independently with serum betatrophin levels. CONCLUSION: These results demonstrate that serum betatrophin levels were significantly higher in pregnant women with GDM than in normoglycemic pregnant women. The levels of betatrophin were correlated significantly with insulin resistance parameters, which is a key feature of GDM pathophysiology.

The Non-Ergot Derived Dopamine Agonist Quinagolide as an Anti-Endometriotic Agent.

AIM: The study aimed to investigate the efficacy of a dopamine agonist, quinagolide, on experimentally induced endometriosis in a rat model. METHODS: Twenty female Wistar rats were used in this experiment. Endometriosis was surgically induced by transplantation of autologous endometrial tissue. A second laparotomy was performed 4 weeks after the first one to assess the pre-treatment implant volumes, and peritoneal lavage with saline solution was performed to assess the peritoneal cytokine levels. Rats were randomized to treatment with quinagolide or saline. At the end of the treatment period, a third laparotomy was performed to compare pre- and post-treatment implant volumes and cytokine levels within the groups. Implants were excised to compare glandular tissue (GT) and stromal tissue (ST) scores between the groups. RESULTS: In the quinagolide group, post-treatment volume was statistically significantly reduced compared with pre-treatment volume (p = 0.01). There were significant decreases in interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) levels in peritoneal fluid samples in quinagolide-treated rats when compared to pre-treatment levels (p = 0.03 and p < 0.01). Histopathologically, both GT and ST scores were significantly lower in the quinagolide group compared to the control group (p = 0.01 and p = 0.02). CONCLUSIONS: Quinagolide caused a significant regression in endometriotic implants and it also significantly reduced the levels of IL-6 and VEGF in peritoneal fluid.

Giant invasive mole presenting as a cause of abdominopelvic mass in a perimenopausal woman: An unusual presentation of a rare pathology.

Invasive mole is a benign gestational trophoblastic disease that arises from the myometrial invasion of any gestational event via direct extension through tissue or vascular structures. Invasive mole (and other gestational trophoblastic diseases) may present with life-threatening complications including uterine perforation, excessive bleeding, acute hemoperitoneum, and abdominal pain. We report a case of invasive mole presenting as abdominal distention in a 51-year-old perimenopausal woman (gravida 12, para 12, abortion 0). The patient was admitted to the gynecology clinic with a giant uterine mass filling the pelvic and abdominal cavity. To our knowledge, this is the first case in the literature of a gestational trophoblastic neoplasia presenting with uterine mass of 28 weeks' gestational size in this age group. Interestingly, complications such as uterine rupture or invasion of the adjacent structures (such as parametrial tissues or blood vessels) had not developed in our patient despite the considerable enlargement of the uterus.

Efficacies of vitamin D and omega-3 polyunsaturated fatty acids on experimental endometriosis.

OBJECTIVE: The aim of this study was to investigate the effects of 1,25-dihydroxyvitamin-D3 (vitamin D) and omega-3 polyunsaturated fatty acids (omega-3 PUFA) on experimentally induced endometriosis in a rat model. MATERIALS AND METHODS: A prospective, single-blind, randomized, controlled experimental study was performed on 30 Wistar female rats. Endometriosis was surgically induced by implanting endometrial tissue on the abdominal peritoneum. Four weeks later, a second laparotomy was performed to assess pre-treatment implant volumes and cytokine levels. The rats were randomized into three groups: vitamin D group (42 µg/kg/day), omega-3 PUFA group (450 mg/kg/day), and control group (saline 0.1 mL/rat/day). These treatments were administered for 4 weeks. At the end of treatment, a third laparotomy was performed for the assessment of cytokine levels, implant volumes (post-treatment) and implants were totally excised for histopathologic examination. Pre- and post-treatment volumes, cytokine levels within the groups, as well as stromal and glandular tissues between the groups were compared. RESULTS: The mean post-treatment volume was statistically significantly reduced in the omega-3 PUFA group (p=0.02) and the level of the interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), vascular endothelial growth factor (VEGF) in the peritoneal fluid were significantly decreased at the end of treatment in the omega-3 PUFA group (p=0.02, p=0.03, and p=0.03, respectively). In the vitamin D group, only IL-6 levels were significantly decreased. In the histopathologic examination, the glandular tissue and stromal tissue scores of the implants were significant lower in the omega-3 PUFA group (p=0.03 and p=0.02). CONCLUSION: Omega-3 PUFA caused significant regression of endometriotic implants. Vitamin D has not been as effective as omega-3 PUFA on endometriosis.

Additional surgical risk factors and patient characteristics for mesh erosion after abdominal sacrocolpopexy.

AIM: The aim of this study is to determine the risk factors of mesh exposures following abdominal sacral colpopexy (ASC) in which polypropylene mesh is used. METHODS: This is a retrospective cohort study of patients who underwent ASC and were subsequently followed for development of mesh exposure for vaginal/vault prolapse between 2002 and 2012. Demographics and risk factors of the patients who did develop mesh exposure after ASC and the ones who did not were compared. RESULTS: In 42 months of survey, 19 of the 292 patients who underwent ASC developed mesh exposure. It was found that rates of patients with stage 3-4 prolapse were significantly greater in the mesh exposure group than in the control group (P = 0.04). Rates of mesh exposure were lower in patients with previous hysterectomy (P = 0.03). Also, it was found that concomitant hysterectomy or three or more additional procedures increased the risk of mesh exposure (P = 0.03 and P = 0.02). CONCLUSION: In abdominal sacrocolpopexy operations in which polypropylene meshes are used, stage 3 or 4 prolapse, concomitant hysterectomy and three or more additional procedures increase the risk of mesh exposure development.

Should omentectomy be a part of surgical staging in patients with endometrioid adenocarcinoma of the uterine corpus?

BACKGROUND: The purpose of the study was to determine the prevalence of omental metastasis in endometrioid adenocarcinoma and to correlate risk variables with this spread. METHODS: A retrospective analysis of patients with endometrioid adenocarcinoma who underwent omentectomy in addition to staging laparotomy was performed. RESULTS: Omental metastases were noted in 11 of the 322 patients with endometrioid adenocarcinoma (3.4%). Multivariate analyses showed that there was a significant correlation between omental metastasis and positive peritoneal cytology, adnexal involvement, and grade 3 tumor (p = 0.028, p = 0.001, and p = 0.01, respectively). There was no statistical relationship between omental metastasis and lymphovascular space involvement, deep myometrial invasion, and lymph node metastasis (p = 0.087, p = 0.97, and p = 0.92, respectively). CONCLUSION: Grade 3 endometrioid adenocarcinomas, especially those that are complicated by deep myometrial invasion, have a pattern of intra-abdominal spread similar to more aggressive endometrial cancers, with frequent involvement of the omentum. Overall, we conclude that 37.5% (3/8) of patients who had a grade 3 tumor and omental metastasis stage IV disease would have been missed if a staging operation similar to that employed for ovarian cancer had not been performed.

Prolene mesh migration into the rectum after sacral colpopexy presented with frozen pelvis.

INTRODUCTION: Pelvic organ prolapse (POP) is a common gynecological problem. Repair with synthetic materials such as prolene mesh has become a popular approach in prolapsus surgery. Migration of synthetic materials can cause serious complications. PRESENTATION OF CASE: A 69-year-old woman was admitted to the hospital with a complaint of sensation of fullness and a feeling of a foreign material protruding during defecation. The patient underwent exploratory laparotomy. Prolene mesh was detected in sacral region but resection of the mesh could not be conducted because of dense adhesions causing frozen pelvis. The migrated prolene mesh was resected transanally. DISCUSSION: Genital prolapse or genital hernia is described as the protrusion of pelvic organs along the vagina. It is one of the common gynecological conditions that affect the quality of life in women. Mesh migration is a well-known clinical pathology. CONCLUSION: Mesh migration is a serious complication after sacral colpopexy. Surgical resection of migrated mesh can be difficult due to dense adhesions.

Immediate colposcopic evaluation in postmenopausal women with low-grade squamous intraepithelial lesion cytology.

OBJECTIVE: To compare the final diagnosis among pre- and postmenopausal women with low-grade squamous intraepithelial lesion (LGSIL) cervical smear results. DESIGN: Retrospective, comparative study. SETTING: Departments of obstetrics and gynecology in two teaching and research hospitals. POPULATION: Data were evaluated on 712 women with LGSIL between April 2005 and April 2011. METHODS: Results from 129 postmenopausal women with LGSIL were compared with 583 premenopausal women with a similar LGSIL result with respect to sociodemographic data and histopathology. MAIN OUTCOME MEASURES: Final clinicopathological diagnosis. RESULTS: The mean age of the pre- and postmenopausal women was 37.2 and 52.5 years, respectively, and lesions of cervical intraepithelial neoplasia grade 2 or worse were detected by biopsy and/or endocervical curettage in 13.6 and 9.3%, respectively. There was no significant difference between the final diagnosis among pre- and postmenopausal women with LGSIL cytology (relative risk 1.43; 95% confidence interval 0.82-2.48; p= 0.19). Invasive cervical cancer was detected in three premenopausal (0.5%) and two postmenopausal women (1.6%). CONCLUSIONS: Cervical pre-invasive and invasive disease rates were similar in pre- and postmenopausal women with LGSIL cytology. For this reason, LGSIL in postmenopausal women should be considered more seriously, and colposcopic evaluation may be as acceptable an option in the management of LGSIL in this group of patients as it is with premenopausal women.

Malignant transformation arising from mature cystic teratoma of the ovary: a report of six cases.

AIM: Malignant transformation of mature cystic teratoma (MCT) is an uncommon complication. Preoperative diagnosis is difficult because of the lack of specific symptoms and signs indicating malignancy. Thus, we retrospectively analyzed the clinical characteristics of patients and the role of surgery in their management. MATERIAL AND METHODS: During a 9-year period (2002-2010), six patients with malignant transformation arising from ovarian MCT were treated at the Gynecologic Oncology Unit of Bakirkoy Woman and Children's Training and Research Hospital. A retrospective chart review and analysis of the patients' data were conducted. RESULTS: Malignant transformation arising from ovarian MCT accounted for 1.9% of all ovarian MCT (6/321). Three cases were stage IA and the other three were stage IC. Histologically, three of six cases had squamous cell carcinoma (50%), two had a carcinoid tumor (33%), and one had mucinous adenocarcinoma (17%). All patients underwent comprehensive surgical staging. Two patients received adjuvant chemotherapy and one received adjuvant chemoradiation. Five of six patients were observed for 16-104 months and no recurrence was detected. One patient with a carcinoid tumor in stage IC died of disease within 34 months following the surgery. CONCLUSION: Early detection of malignant transformation arising from MCT is mandatory for treating patients, but in most patients malignancy was detected intraoperatively. Surgical cytoreduction with a complete staging procedure and adjuvant treatment may be reasonable for stage IC. Additionally, prognosis is better when the tumor is completely excised and does not extend beyond the capsule.

Cesarean scar pregnancy: a rare cause of uterine arteriovenous malformation.

A 38-year-old gravida 4, para 2 woman with a history of two Cesarean sections and one curettage was referred to our hospital, because of painless vaginal bleeding and 6 weeks + 2 days of amenorrhea. The first diagnosis was Cesarean scar pregnancy, managed with methotrexate. Subsequently, an arteriovenous malformation developed, which was diagnosed with color Doppler imaging. The diagnosis was confirmed with angiography. Successful bilateral uterine artery embolization was performed with ethylene vinyl alcohol copolymer (Onyx), n-butyl-2-cyanoacrylate (Histoacryl), and gelfoam.

Benign cystic mesothelioma: a case series with one case complicated by pregnancy.

Benign cystic mesothelioma (BCM) is a rare tumor of unknown origin, most frequently encountered in women of reproductive age and with unknown etiology. Most patients have a history of previous pelvic operation, endometriosis, or pelvic inflammatory disease. Preoperative diagnosis is difficult. We report the cases of three patients, with one case complicated by pregnancy, and discuss the diagnostic evaluation and treatment of this rare disease. Complete surgical resection is recommended if feasible. However, recurrent disease is not uncommon. Clinical positive effects of different adjuvant medical treatments are also discussed.

Cesarean techniques in cases with one previous cesarean delivery: comparison of modified Misgav-Ladach and Pfannenstiel-Kerr.

AIM: To compare the effectiveness of the Pfannenstiel-Kerr method (PKM) or modified Misgav-Ladach method (MMLM) in previous cesarean sections (C/Ss). METHODS: Hundred and fifteen gravidas were included with previous one C/S, using either a PKM or MMLM. Demographic characteristics, operative outcomes, surgical complications, and neonatal outcomes were compared in two groups. RESULTS: The mean operative time (18.0 ± 3.5 vs. 23.5 ± 5.7 min; p < 0.0001) and mean extraction time (90.1 ± 41.2 vs. 208.1 ± 79.1 s; p < 0.0001) were significantly shorter in the MMLM group than the PKM group. Postoperative recovery (mobilization, normalization of bowel function, need for analgesics, time to oral feeding, and intra-operative blood loss) was similar between the MMLM and PKM groups. CONCLUSION: The MMLM appears to be a faster alternative to PKM for previous C/Ss, with similar results as in previous studies with primary CSs.

Angiokeratoma of the clitoris with evident vulvar varicosity.

Angiokeratomas of the vulva are uncommon, benign vascular lesions that are generally located on the labia. However, the clitoris is an extremely rare location, with only three published cases. We report a case of clitoral angiokeratoma in a 22-year-old nulligravida with a history of surgery to remove a clitoral mass at 6 years of age. The case described herein is distinguished from the other case reports by an accompanying varicose structure involving the vulva.

Twin pregnancies complicated by a single malformed fetus: chorionicity, outcome and management.

The objective of this study was to evaluate the impact of one abnormal fetus in a twin pregnancy, to compare impact of chorionicity and clinical outcome of intervention and expectant management. Thirty-seven dichorionic (DC) twins and 18 monochorionic (MC) twins complicated with one malformed fetus were evaluated for gestational age, birthweight and perinatal outcome. Six hundred and forty-two twin pregnancies were evaluated in the database. The control groups consisted of 429 DC and 86 MC twins without anomalous fetus. Mean birthweight and gestational age at birth for DC control group were (n = 429; 2137g and 34.71 weeks), DC study group, n = 37; 2117g (p = .338) and 33.97 weeks (p = .311), and DC study group with major malformations, n = 30; 2019g (p = .289) and 33.3 weeks (p = .01), and showed only significance for gestational age. There was no statistical significance between MC control group, n = 86; 2097g and 34.93 weeks, and MC study group, n = 18; 2237g (p = .338), and 34.42 weeks (p = .502). Because of limited data, the preliminary evaluation for expectant management and intervention, and survival of at least one normal fetus showed no impact. We conclude that, although, all DC twin pregnancies have a risk for preterm delivery, DC twins complicated with major malformation of one twin, have a lower mean gestational age at birth. Preliminary results for intervention does not improve fetal outcome for DC and MC twins and needs further evaluation with greater studies of impact or review.

Multiple repeated cesarean deliveries: operative complications in the fourth and fifth surgeries in urgent and elective cases.

OBJECTIVE: To evaluate the maternal and neonatal risk related with multiple repeated cesarean sections. MATERIALS AND METHODS: A case control study was conducted in a single tertiary maternity and children's center. The outcome of a study group including 122 pregnant women undergoing cesarean section for the fourth or fifth time was compared with a control group comprising 146 women sectioned for the second and third time. All multiple repeated cesarean sections were divided into urgent and elective groups to compare the outcome measures of demographic, neonatal, intra- and post-operative data. RESULTS: Compared with the control group, the study group had significantly lower birth weights (p=0.026), lower Apgar scores at 1 minute (p=0.0001) and 5 minutes (p=0.042), higher numbers of fetal death (p=0.03), higher rate of omentum adhesions (p =0.0001) and peritoneal adhesions (p=0.008), increased risk of cesarean hysterectomy (p = 0.014), increased need for transfusion (p = 0.018), and an increase in hospitalization days (p=0.005). Compared with the elective group, preterm birth incidence was higher (p = 0.01) and birth weight was lower (p=0.004) in the urgent group. The risk for myometrium herniation (p=0.018), need for drainage during operation (p=0.018), and post-operative fever (p =0.001) was also more common in the urgent group. CONCLUSION: Multiple repeated cesarean sections increase the risks for operative complications and poor perinatal outcomes. Patients must be informed about the related risks of multiple repeated cesarean sections and tubal ligation needs to be encouraged.

Brenner tumor in pregnancy: clinical approach and pathological findings.

The Brenner tumor is an uncommon ovarian tumor in pregnancy with only three previous cases in the English published reports. A 35-year-old woman delivered abdominally because of distress symptoms and a Brenner tumor was resected incidentally. Histological examination revealed a tumor composed of epithelial nests and areas of stromal luteinization. The patient was treated conservatively. Brenner tumor should be considered in the differential diagnosis of adnexal masses during pregnancy. These tumors are mainly benign and show typical luteinization associated with the hormonal milieu in pregnancy.

Multidisciplinary approach in cystic hygroma: prenatal diagnosis, outcome, and postnatal follow up.

BACKGROUND: The aim of the present study was to determine prenatal follow up and clinical outcome in fetuses born with cystic hygroma. METHODS: A series of 64 cystic hygroma patients, who were diagnosed in the first and the second trimester of pregnancy, was enrolled. Associated structural abnormalities, karyotype analysis and pregnancy outcome were studied. Survivors were followed for their fetal outcome and prognosis. RESULTS: There were 64 new cases of cystic hygroma in 8524 subjects screened (0.75%). Thirty-nine (60.9%) were of non-septated and 25 (39.1%) were of septated cystic hygroma. Chromosomal abnormalities were present in 25 (39.1%). The most common abnormality in non-septated cystic hygroma was trisomy 21 (10, 27.8%), and that in septated cystic hygroma was Turner syndrome (5, 23.8%). Associated structural malformations are common in cystic hygroma and overall survival was poor. Nine of the present infants were live-born and were subsequently followed up. Two had cardiac pathology and died after cardiac operation, two others were diagnosed with axillary cystic hygroma, had an excellent prognosis and responded well to treatment, and another two had cranial findings with mild neurological sequel. Only three cases had, at birth and in the follow-up period, no complications. CONCLUSION: Cystic hygroma is highly correlated with adverse perinatal outcome. Prenatal diagnosis and invasive procedures are vital for counselling with close follow-up after delivery for appropriate medical support. A multidisciplinary approach is strictly recommended in live-born children.

Results of the tension-free vaginal tape procedure for treatment of female stress urinary incontinence: a 5-year follow-up study.

OBJECTIVE: We evaluated the long-term cure rates, surgical complications rates after treatment of urodynamically confirmed primary genuine stress incontinence with tension-free vaginal tape (TVT). METHODS: We performed a retrospective review of all patients undergoing the TVT procedure over a 5-year period to report intraoperative complication, postoperative complications and subjective cure rates. RESULTS: TVT was performed on 600 patients under general anesthesia. Among these patients, 563 were followed up for least 5 years; the remaining 47 patients could not be followed up. The mean follow-up interval was 63.1+/-3.1 (range 60-70) months. The mean age of the women was 51.7+/-11.6 years and mean body mass index 31.7+/-3.0 kg/m(2). Sixty-two percent (347) of women underwent the TVT procedure in conjunction with other vaginal surgery, and 38% (216) underwent TVT alone. The subjective analysis of the effect of surgery on the symptom of GSI was that, overall, 86.7% were completely cured, 6.0% were significantly improved and 7.3% found no change in the severity of her incontinence. No major nerve or vessel injury occurred, but 17 patients (3.0%) incurred bladder injury during the surgery. De novo voiding urgency occurred in 36 patients (6.4%). Thirty patients (5.3%) developed voiding problem, of which 19 patients had short-term voiding problem. CONCLUSION: The TVT procedure is a relatively safe and effective, minimally invasive surgical technique for the treatment of female urinary stress incontinence.

Re-laparotomy after cesarean section: operative complications in surgical delivery.

OBJECTIVE: To determine the risk factors causing re-laparotomy and the indications, management and outcomes of re-laparotomy after a cesarean section. METHODS: We had, during the study period of January 2002 to January 2007, 28,799 cesarean sections and 35 cases with re-laparotomy. We studied the patients' age, parity, indications for cesarean section and indications for re-laparotomy, time interval after cesarean section to reopening of the abdomen, type of surgery, need for blood transfusion and span of hospital stay. RESULTS: The incidence of re-laparotomy was 0.12%. Cases with placental abruption and previous cesarean > or =3 had a higher risk for re-laparotomy. Procedures that were performed at re-laparotomy were drainage and resuturing of hematomas (n = 8), resuturing of uterus and securing hemostasis with stitches (n = 10), bladder repair (n = 1), herniation repair (n = 1), total abdominal hysterectomy (n = 2), subtotal abdominal hysterectomy (n = 5), and draining and resuturing of broad ligament, parametrium, abdominal wound, and cutaneous and subcutaneous tissue due to infection and abscess formation (n = 8). Two cases required admission into the intensive care unit. We had one case with maternal mortality. Majority of the complications were revealed at an early period and these were hemorrhagic cases mostly. CONCLUSION: Although the rate of re-laparotomy after cesarean section is low, several actions must be undertaken to decrease the need for re-laparotomy. In particular, cases with placental abruption and previous cesarean > or =3 are with higher risk for re-laparotomy and have a 15-fold risk for re-laparotomy after cesarean section.