A comparison of 2 cesarean section methods, modified Misgav-Ladach and Pfannenstiel-Kerr: A randomized controlled study.

BACKGROUND: The modified Misgav-Ladach method (MML) is a minimally invasive cesarean section procedure compared with the classic Pfannenstiel-Kerr (PK) method. OBJECTIVES: The aim of the study was to compare the MML method and the PK method in terms of intraoperative and short-term postoperative outcomes. MATERIAL AND METHODS: This prospective, randomized controlled trial involved 252 pregnant women scheduled for primary emergency or elective cesarean section between October, 2014 and July, 2015. The primary outcome measures were the duration of surgery, extraction time, Apgar score, blood loss, wound complications, and number of sutures used. Secondary outcome measures were the wound infection, time of bowel restitution, visual analogue scale (VAS) scores at 6 h and 24 h after the operation, limitations in movement, and analgesic requirements. At 6 weeks after surgery, the patients were evaluated regarding late complications. RESULTS: There was a significant reduction in total operating and extraction time in the MML group (p < 0.001). Limitations in movement were lower at 24 h after the MML operation, and less analgesic was required in the MML group. There was no difference between the 2 groups in terms of febrile morbidity or the duration of hospitalization. At 6 weeks after the operation, no complaints and no additional complications from the surgery were noted. CONCLUSIONS: The MML method is a minimally invasive cesarean section. In the future, as surgeons' experience increases, MML will likely be chosen more often than the classic PK method.

Vitamin D deficiency in pregnancy may affect fetal thymus development.

OBJECTIVES: The aim of our study was to evaluate the association of vitamin D deficiency (VDD) during pregnancy with thymus size in full-term fetuses. MATERIAL AND METHODS: In this prospective study, we evaluated mid-pregnancy serum 25-hydroxyvitamin D3 (25(OH)D3) concentrations. The fetal thymus size was measured by ultrasound in the third trimester. Neonatal 25(OH)D3 levels were evaluated by umbilical cord blood sampling. Correlation of maternal and neonatal vitamin D levels and association between thymus size and both, maternal and neonatal vitamin D concentrations were investigated. RESULTS: Serum 25(OH) D3 concentrations were within the normal range in 48 (29.8%) mothers and 10 (13.1%) new-borns. A strong correlation between mid-pregnancy maternal and neonatal 25(OH)D3 concentration (r = 0.8, p < 0.001) was found. A significant linear correlation was observed between both, maternal and neonatal 25(OH)D3 concentrations and thymus perimeter length (r = 0.45, p = 0.04 and r = 0.43, p < 0.01, respectively). Both, maternal and fetal VDDs were associated with decreased thymus perimeter (p = 0.04, p = 0.03). CONCLUSIONS: Vitamin D deficiency during pregnancy may be associated with smaller fetal thymus. Our data suggest that VDD in pregnancy may lead to systemic inflammatory response in the fetus.

The association of HLA-G and immune markers in recurrent miscarriages.

OBJECTIVE: To determine role of human leukocyte antigen (HLA)-G, CD8, CD16, CD56, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α for recurrent miscarriages in feto-maternal interface. METHOD: Chorion and decidua samples were obtained from 11 women with unwanted pregnancies (healthy pregnancy, HP) and 10 women with missed abortion diagnosis after at least two pregnancy losses (recurrent miscarriage, RM). In addition, endometrial tissues were obtained from 10 non-pregnant women (NonP). The expressions of markers were evaluated using the Western blot analysis. The values obtained between different groups were compared. RESULTS: The highest protein expression of CD56 was found in the HP compared to NonP and RM. Meanwhile, the lowest protein expression of CD16 was observed in the NonP compared to HP and RM. The HLA-G expression exhibited the highest level in HP; however, there was no statistically significant difference between groups. CD8 and IFNγ expressions were lowest in the NonP group; however, TNF-α was highest in the RM group. CONCLUSIONS: The CD56 expression of uterine NK cells may be an indicator of a HP. However, not statistically significant, the increased expression of CD16, CD8, and also significantly increased expression of TNF may be associated with the predominant cytotoxic activity in the maternal immune system in patients with RM. Although there was no change in the expression of HLA-G, this finding may mean that the maternal immune system is unresponsive to HLA-G-mediated immunosuppressive signals originating from the fetus in these cases.

Comparison of the effects of letrozole and cabergoline on vascular permeability, ovarian diameter, ovarian tissue VEGF levels, and blood PEDF levels, in a rat model of ovarian hyperstimulation syndrome.

OBJECTIVE: To evaluate the effects of letrozole and cabergoline in a rat model of ovarian hyperstimulation syndrome (OHSS). STUDY DESIGN: In this prospective, controlled experimental study, the 28 female Wistar rats were divided into four subgroups (one non-stimulated control and three OHSS-positive groups: placebo, letrozole, and cabergoline). To induce OHSS, rats were injected with 10 IU of pregnant mare serum gonadotropin from day 29 to day 32 of life, followed by subcutaneous injection of 30 IU hCG on day 33. Letrozole rats received with a single dose of 0.1 mg/kg letrozole via oral gavage, on the hCG day. Cabergoline rats received with a single dose of 100 µg/kg cabergoline via oral gavage, on the hCG day. All animals were compared in terms of body weight, vascular permeability (VP), ovarian diameter, ovarian tissue VEGF expression (assessed via immunohistochemical staining), and blood pigment epithelium-derived growth factor (PEDF) levels. RESULTS: The OHSS-positive placebo group (group 2) exhibited the highest VP, ovarian diameter, extent of VEGF staining, and lowest PEDF level, as expected. No significant difference was evident between the letrozole and cabergoline groups in terms of any of body weight; VP; PEDF level; ovarian diameter; or the staining intensity of, or percentage staining for, VEGF in ovarian tissues. CONCLUSIONS: Letrozole and cabergoline were equally effective to prevent OHSS, reducing the ovarian diameter, VP, and PEDF and VEGF levels to similar extents.

Thyroid antibodies in euthyroid and subclinical hypothyroidic pregnant women with autoimmune hypothyroidism: effects on hematological parameters and postpartum hemorrhage.

OBJECTIVES: The aim of the study was to investigate the relationship between thyroid antibodies and hematological parameters in euthyroid or subclinical hypothyroidic (S H) pregnant women with autoimmune hypothyroidism and to verity whether these pregnant women are affected by a higher rate of postpartum hemorrhage. MATERIAL AND METHODS: Thirty-six out hyroid and 21 S H pregnant women with autoimmune thyroid disease and 52 healthy pregnant women were evaluated. The relationship between thyroid hormones, thyroid antibodies level, the dosage of Levotroxin (LT4) and hematological parameters and the amount of postpartum bleeding was investigated. RESULTS: The mean platelet volume (MPV), was significantly higher in the SH group than in the euthyroid group and in the euthyroid group than healthy group (p<0.001). Hemoglobin (Hb) was significantly lower in both the SH group and the euthyroid group than control group (p<0.001). Other hematological parameters and the amount of postpartum bleeding did not differ between the groups. The correlation between Hb and fT3, FT4 was significant and positive, whereas between Hb and T SH was significant and negative (r=0.3 p<0.01, r=0.2 p=0.01, and r = -0.18 p=0.04, respectively). There was a significant and negative correlation between the PLT count and FT4, PT and FT3 (r = -0.2 p=0.01, r = -0.3 p<0.01, and r = -0.3 p<0.01, respectively). CONCLUSION: It has been described that being thyroid antibody-positive (TAb+) may be a risk factor for anemia and high MPV. However euthyroid and SH pregnant women with thyroid antibodies do not differ in terms of other coagulation parameters and postpartum hemorrhage from healthy controls.

Fetal programming of polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects up to 6.8% of reproductive age women. Experimental research and clinical observations suggest that PCOS may originate in the very early stages of development, possibly even during intrauterine life. This suggests that PCOS is either genetically-transmitted or is due to epigenetic alterations that develop in the intrauterine microenvironment. Although familial cases support the role of genetic factors, no specific genetic pattern has been defined in PCOS. Several candidate genes have been implicated in its pathogenesis, but none can specifically be implicated in PCOS development. Hypotheses based on the impact of the intrauterine environment on PCOS development can be grouped into two categories. The first is the "thrifty" phenotype hypothesis, which states that intrauterine nutritional restriction in fetuses causes decreased insulin secretion and, as a compensatory mechanism, insulin resistance. Additionally, an impaired nutritional environment can affect the methylation of some specific genes, which can also trigger PCOS. The second hypothesis postulates that fetal exposure to excess androgen can induce changes in differentiating tissues, causing the PCOS phenotype to develop in adult life. This review aimed to examine the role of fetal programming in development of PCOS.

Myo-inositol is a promising treatment for the prevention of ovarian hyperstimulation syndrome (OHSS): an animal study.

PURPOSE: To evaluate the efficacy of myo-inositol (MI) pretreatment in OHSS. METHODS: In this experimental OHSS rat model, 42 immature Wistar albino female rats were divided into 6 groups: (1) the control group, (2) the ovarian stimulation group, (3) the OHSS group, (4) the OHSS + Metformin group, (5) OHSS + MI group, (6) OHSS + Metformin + MI group. OHSS was established after treatment with metformin and myo-inositol for 14 days, in the meanwhile the treatment of metformin and myo-inositol was also continued. All animals were killed 48 h after hCG administration and were compared in terms of vascular permeability, ovarian weight and diameter, ovarian VEGF, COX-2 and PEDF expression (immunohistochemistry), serum PEDF and estradiol (E2) levels. RESULTS: Vascular permeability, VEGF and COX-2 expressions were reduced in animals treated with MI and/or metformin. While PEDF expression was increased in the groups taking metformin, there was no difference in PEDF expression in the group taking MI and OHSS group. There was no significant difference in serum PEDF levels between groups. Blood E2 levels were decreased in groups treated with MI or metformin compared to the OHSS group. CONCLUSIONS: Our data demonstrate that myo-inositol is effective in preventing OHSS, similar to metformin. Although the two drugs are thought to act through distinct mechanisms, there is no apparent benefit to co-treatment with both drugs in an animal model of OHSS. Administration of myo-inositol prior to IVF treatment may favor the control of ovulation induction. Further studies are necessary to elucidate the mechanism of action and further support our findings.

Does uterine prolapse alter endometrial cyclooxygenase 2 expression and promote the development of premalignant lesions?

OBJECTIVE: The aim of this study was to evaluate the expression of cyclooxygenase 2 (COX-2) and its association with the development of premalignant lesions in gland structures of the endometrium in patients with uterine prolapse, a condition which exposes the uterus to mechanical and infectious stress. METHODS: The study included 102 patients who underwent hysterectomy to correct grade 3-4 uterine prolapse and 105 patients who underwent hysterectomy for other causes. Endometrial gland structures underwent immunohistochemical staining and COX-2 expression was graded. Grades 0 and 1 represent low expression; grades 2 and 3 correspond to high levels of COX-2 expression. RESULTS: The prevalence of grade 2-3 COX-2 expression was significantly higher in the endometrial gland structures of patients with prolapse and hyperplasia compared to the remaining patients (p = 0.014). Grade 0-1 COX-2 expression was significantly more common in the endometrial gland structures of patients without uterine prolapse or hyperplasia (p = 0.004). Among the patients without endometrial hyperplasia, COX-2 expression was elevated in the endometrial gland structures of those with uterine prolapse compared to those without prolapse. CONCLUSION: Elevated COX-2 expression may explain the presence of unexpected premalignant lesions of the endometrium in patients with uterine prolapse.

Prophylactic vitamin D supplementation in ovarian hyperstimulation syndrome: an animal study.

PURPOSE: To investigate the effect of vitamin D in ovarian hyperstimulation syndrome (OHSS). METHODS: In this animal study, 28 immature female Wistar rats were divided into four groups: group 1 (control); group 2 (ovarian stimulation); group 3 (OHSS group); group 4 (OHSS + vitamin D group). All groups were killed 48 h after hCG administration and were compared in terms of vascular permeability, ovarian weight, ovarian diameter, vascular endothelial growth factor (VEGF) expression (immunohistochemistry) in ovarian tissue and pigment epithelium-derived factor (PEDF) level in the serum (ELISA test) with the Kruskal-Wallis and Mann-Whitney U tests. RESULTS: VEGF expression in the vitamin D group was similar to that in the OHSS group. However, the PEDF level was significantly higher in the vitamin D group (p = 0.013). CONCLUSIONS: Prophylactic vitamin D supplementation is not sufficiently effective in preventing OHSS. Vitamin D effectively increases PEDF, which has an opposing effect on VEGF, which plays a key role in OHSS. Thus, the protective effect of Vitamin D on OHSS should be investigated with a vitamin D deficient model in the study group.

The effect of place of residence and lifestyle on vitamin D deficiency in pregnancy: Comparison of eastern and western parts of Turkey.

OBJECTIVE: The aim of this study was to determine the prevalence and the predictive factors of vitamin D deficiency in pregnancy and the compliance with "The National Vitamin D Support Program" at Turkey's easternmost and westernmost provinces. MATERIAL AND METHODS: Lifestyles of women at 24-28 weeks of pregnancy were assessed using a questionnaire form, and serum 25-hydroxyvitamin D3 (25(OH)D3) levels were measured. RESULTS: Vitamin D deficiency (≤20 ng/mL) in pregnant women had a prevalence of 27.8% in Izmir and 76.3% in Erzurum. The compliance of "The National Vitamin D Support Program" was 8% in Izmir and 32.6% in Erzurum. Clothing style, fish consumption, seaside holiday duration, and 1200 IU/day vitamin D replacement had an effect on 25(OH)D3 levels in pregnant subjects in Izmir, whereas only holiday duration and 1200 IU/day vitamin D replacement affected 25(OH)D3 levels in Erzurum. However, when a threshold for 25(OH)D3 level was considered ≥32 ng/mL, lifestyles did not affect 25(OH)D3 level. CONCLUSION: The effect of lifestyle on 25(OH)D3 level in pregnancy is limited, especially in cold regions. We recommended increasing the compliance with "The National Vitamin D Support Program" at the follow-up of all pregnant women, irrespective of region and season.

Uterine closure with unlocked suture in cesarean section: Safety and Quality.

OBJECTIVE: Comparing locked and unlocked uterine closure techniques in terms of bleeding control and uterine incision healing. METHODS: The patients undergoing cesarean section in Sifa University Hospital between May - October 2012 were accepted to this prospective controlled study. Primarily, safety was evaluated. The hemoglobin count (HC) and serum creatine kinase (CK) levels of the patients in the locked (n = 47) and unlocked (n = 35) groups were measured just before and 24 hours after operation. Hemoglobin deficit, increase in CK and the additional hemostatic sutures were compared. Secondly, uterine scar healing was evaluated three months later. Scar thickness, niche and percentage of thinning of the scar region of the locked (n = 27) and unlocked (n = 32) groups were calculated and compared. RESULTS: The hemoglobin deficit was similar in two groups. CK rise was less in the unlocked group but it was not significant (P = 0.082). Unlocked group needed more additional sutures (P = 0.016). The thickness of the niche and the percentage of thinning of the scar region were significantly less in the unlocked group (P= 0.002, P=0.000). CONCLUSIONS: Unlocked uterine closure technique is safe and has less damage to the myometrium.

Mid-pregnancy vitamin D levels and postpartum depression.

OBJECTIVES: Postpartum depression (PPD) is a common disorder that affects 10-15% of postpartum women, and it can have negative effects on both the mother and newborn. Recent studies have suggested that low levels of vitamin D are associated with poor mood and depression. The aim of this prospective study was to evaluate a possible association between PPD and serum levels of 25-hydroxy vitamin D3 (25(OH)D3), a reliable measurement of vitamin D, during mid-pregnancy. STUDY DESIGN: The source population consisted of all pregnant women between 24 and 28 gestational weeks from June 2012 to October 2012 at Bornova Health Research and Application Hospital, Sifa University. In order to better evaluate a possible effect between vitamin D levels and PPD, individuals with characteristics that put them at risk for developing PPD were excluded from the study. Serum 25(OH)D3 levels were evaluated mid-pregnancy in the study group. Serum 25(OH)D3 concentrations ≤20ng/mL (50nmol/L) were classified as a mild deficiency and those ≤10ng/mL (25nmol/L) were classified as a severe deficiency. Pregnant subjects having complications during birth or with the newborn after delivery were excluded from the study. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess maternal PPD 1 week, 6 weeks, and 6 months after delivery. A Pearson correlation was used to measure the strength of the associations between the EPDS scores and vitamin D levels analyzed during the three time periods. A logistic regression analysis was used to determine the independent effects of vitamin D on PPD. RESULTS: Six hundred and eighty-seven pregnant women were included in this study. After excluding women due to PPD risk factors (in two stages), 179 pregnant women were screened for vitamin D levels during mid-pregnancy and in the 6th month postpartum. Eleven percent of our study group had severe vitamin D deficiency and 40.3% had mild vitamin D deficiency. The frequency of PPD was 21.6% at the 1st week, 23.2% at 6th week, and 23.7% at the 6th month. There was a significant relationship between low 25(OH)D3 levels in mid-pregnancy and high EPDS scores, which is indicative of PPD for all three follow-up periods (p=0.003, p=0.004 and p<0.001, respectively). In addition, there was a significant negative correlation between vitamin D levels and EDPS at all three time points (r=-0.2, -0.2, -0.3, respectively). CONCLUSIONS: Vitamin D deficiency in mid-pregnancy may be a factor affecting the development of PPD. More extensive studies are required to be carried out on this subject.

Ultrasonographic visceral fat thickness in the first trimester can predict metabolic syndrome and gestational diabetes mellitus.

The aim of this study is to evaluate whether ultrasonographic visceral fat thickness measurement in the early gestational period is useful for predicting the development of gestational diabetes mellitus (GDM) and metabolic syndrome (MS). The visceral fat thickness and subcutaneous fat thickness were measured via ultrasound at the first prenatal visit. The correlation between visceral and subcutaneous fat thickness and MS parameters, such as dyslipidemia, hypertension, and insulin resistance, was assessed. We also compared the use of visceral fat thickness measurement with body mass index (BMI) and waist circumference (WC) measurements for predicting the development of GDM. The subcutaneous fat thickness was found to be similar in the normal glucose metabolism and GDM groups at the first visit, whereas the visceral fat thickness was found to be considerably higher in the GDM groups (p = 0.04). The visceral fat thickness in the early stage of the gestation was correlated with hyperglycemia, dyslipidemia, high diastolic blood pressure, and insulin resistance. In contrast to subcutaneous fat thickness, BMI, and WC, only the visceral fat thickness was correlated with insulin resistance. The subcutaneous and visceral fat thicknesses at the first visit were significantly higher in the MS group (p = 0.02). There was a good correlation between visceral and subcutaneous fat thicknesses (r = 0.492, p < 0.001); however, there were poor correlations between visceral fat thickness and BMI and WC (r = 0.338, p = 0.01; r = 0.312, p = 0.02). The visceral fat thickness seemed to be a more sensitive predictor of GDM than WC and BMI. The optimal cutoff points for predicting GDM were visceral fat thickness 19.5 mm [area under curve (AUC) = 0.66, p = 0.043], WC 103.5 cm (AUC = 0.64, p = 0.079), and BMI 34.5 (AUC = 0.64, p = 0.069). Ultrasonographic visceral fat thickness measurement in the early period of gestation may be an easy, safe, and cost-effective scan test for predicting the development of metabolic diseases and GDM.

The efficacy of complete blood count parameters in the diagnosis of tubal ectopic pregnancy.

OBJECTIVE: Ectopic pregnancy (EP) is the major cause of maternal morbidity and is responsible for maternal mortality in the first trimester. In order to reduce undesirable results, it is necessary to find rapid and accurate, non-surgical diagnostic tests for ER The goal of the study was to investigate the differences in complete blood count parameters between tubal EPs and healthy pregnancies in be used in the diagnosis of ectopic pregnancy. STUDY DESIGN: White blood cell (WBC), neutrophil, monocyte, lymphocyte, platelet (PLT) counts, mean PLT volume (MPV) and PLT distribution width (PDW) levels in the complete blood count samples have been obtained from subjects with diagnosed tubal EP (n=78; study group) and women with healthy intrauterine gestations (n=79; control group). Statistical comparisons between groups were performed using the t test. RESULTS: PDW levels were found to be significantly higher in the control group than EP (p<0.001). However no differences between the study and control groups with regard to PLT and MPV levels were observed. WBC levels were found to be significantly higher in the EP group as compared to controls (p<0.001). When leukocyte differentials were compared, monocyte counts in the EP group were significantly higher than in controls (p=0.005). No statistically significant differences in neutrophil and lymphocyte values were observed in either group. CONCLUSION: PDW as an indicator of PLT activation is lower in tubal EP than intrauterine pregnancy so, possibly endometrial invasion in the intrauterine pregnancy needs more PLT activation. Monocyte counts are higher in tubal EP, indicating that monocyte activation in the pathophysiology of EP could be effective in the formation of tubal motility and microenvironment regulation.