Cirrhosis and pregnancy: a single centre experience.

PURPOSE: Cirrhosis is a diffuse pathology characterized by fibrosis of the liver and is the last stage of chronic liver diseases. It is a serious medical condition which seriously impacts reproduction and reproductive life span. The aim of this study is to evaluate the outcomes of pregnancies complicated with liver cirrhosis. METHODS: Retrospective chart review of the fetal and maternal results of 20 pregnant women with liver cirrhosis who had undergone antenatal follow-up and delivery at a tertiary center in a 12-year period was performed. RESULTS: Chronic hepatitis B was found to be the leading cause of liver cirrhosis in the study group, with a rate of 25% (n: 5/20). The average MELD score was calculated as 8.8 ± 3.5. Only three patients developed hepatic decompensation during pregnancy. Fetal demise was observed in 10% of the cases (n: 2/20, MELD scores 8 and 17). MELD score was significantly higher in the patients with adverse perinatal outcomes. CONCLUSION: Even though pregnancy is rarely observed in women with liver cirrhosis, many patients are able to achieve favorable maternal and fetal results without developing hepatic decompensation with appropriate management and close follow-up. The Model for End-Stage Liver Disease (MELD) score is a clinical tool utilized to estimate the severity and survival for chronic liver disease and was previously found to be associated with unfavorable outcomes in pregnant patients. Our study confirms this finding with the current experience from a tertiary care center.

The role of fetal fibronectin and plasminogen activator inhibitor 1 biomarkers in antenatal prediction of placenta accreta spectrum.

In this study, we aimed to assess the determining role of foetal fibronectin (FFN) and plasminogen activator inhibitor type (PAI-1) levels in the antenatal prediction of placenta accreta spectrum in cases with risk factors for placenta accreta spectrum. Singleton live pregnancies with placenta previa or low-lying placenta within 32-34 weeks of gestation were included in the study. The cases were divided into two groups after delivery as those with PAS and those with normal placentation. 54 cases diagnosed with placenta previa or low-lying placenta were included in the study. 17 of the cases underwent peripartum hysterectomy due to placenta accreta spectrum. 37 cases with normal placentation underwent caesarean delivery. Foetal fibronectin (p:.03) and PAI-1 (p:.02) levels were determined to be significantly different between cases with placenta accreta spectrum and cases with normal placentation. AUC for foetal FFN was calculated to be 0.69, while the AUC for, PAI-1was 0.66. Results for both FFN and PAI-1 were not found useful enough for the diagnosis of PAS. IMPACT STATEMENTWhat is already known on this subject? We lack biomarkers which can identify placenta accreta spectrum.What do the results of this study add? Maternal plasma levels of FFN and PAI-1 significantly altered in PASWhat are the implications of these findings for clinical practice and/or future research? If multiple of median values of FFN and PAI-1 levels in maternal blood are determined in future studies, it can be used in the antenatal diagnosis of PAS cases.

Evaluation of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in pregnant women with systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is associated with a higher risk of complications in pregnancy. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been evaluated in numerous inflammatory diseases. We evaluated the possible role of these markers in SLE pregnancies. Forty-six pregnant patients with an already established diagnosis of SLE were included in the study. Complete blood counts were obtained upon admission for delivery. Seven patients were diagnosed with a flare and managed with multiple medications, whereas rest of the patients were not on any treatment or managed with monotherapy. NLR and PLR values were also evaluated between two groups and no statistically significant difference was found (p=.44 and p=.80, respectively). This study is the first to evaluate the possible role of NLR and PLR in pregnant SLE patients in the literature. Further studies are warranted for an elaborate evaluation of NLR and PLR in lupus pregnancies.Impact StatementWhat is already known on this subject? Pregnancy in the setting of SLE is associated with a higher risk of complications. Active disease increases the risk of adverse outcomes further.What the results of this study add? This study is the first to evaluate NLR and PLR in pregnancies complicated by SLE. No significant association between the course of the disease in pregnancy and NLR/PLR was documented.What the implications are of these findings for clinical practice and/or further research? Further studies on the markers to predict prognosis of SLE in pregnancy are required to improve the maternal and neonatal outcomes in this exclusive group of high-risk patients.

Antenatal Findings of Keratitis-Ichthyosis-Deafness Syndrome.

BACKGROUND: Keratitis-ichthyosis-deafness (KID) syndrome is a congenital ectodermal disorder characterized by keratitis, ichthyosis, and deafness. This syndrome affects multiple systems and can be fatal. CASE: A 34-year-old G2, P1 woman was admitted to the Ege University School of Medicine in Izmir, Turkey because of a rapid increase in abdominal circumference at 32 weeks gestation. Fetal anatomic screening revealed complete chorioamniotic separation, hypoplasia of the cerebellar vermis, and dysmorphic facial findings such as frontal bulging. After the delivery, the baby's whole body had granular thickened skin. Bilateral dry eye, corneal edema, and bilateral retinopathy of prematurity were diagnosed. CONCLUSION: This case report highlights the importance of prenatal diagnosis through ultrasonography and magnetic resonance imaging. This is the first case report that has antenatal ultrasonographic features in the literature.

Comparison of indications and results of prenatal invasive diagnostic tests before and after the implementation of the use of cell-free fetal DNA: a tertiary referral center experience.

PURPOSE: In this study, we aimed to compare the changes in the number, yield, and the percentage of karyotyping indications of the invasive prenatal diagnostic tests between the periods before and after cell-free fetal DNA was introduced to clinical use. METHOD: The number of invasive prenatal diagnostic procedures such as amniocentesis and chorionic villus sampling, indication percentages and karyotype results in the periods before (January 1, 2009-December 31, 2010), (n = 1412) and after (January 1, 2016-December 31, 2017), and (n = 593) the introduction of cell-free fetal DNA was retrospectively evaluated. RESULTS: When compared with the period before cell-free fetal DNA came into clinical use, the number of invasive prenatal diagnostic tests decreased by 58% while their yield was found to have increased (4.4% vs. 10.3%) in the period after cell-free DNA began to be used (p < 0.001). While there was a decrease in the indications due to advanced maternal age, an increase was found in ultrasonography indications for structural anomaly and the risk of a single-gene disorder (p < 0.001). Amniocentesis rate was found to have decreased in invasive prenatal diagnostic procedure types, while an increase was reported in CVS rates (p < 0.001). CONCLUSIONS: Invasive prenatal diagnosis gradually decreases over the years, but the yield of invasive prenatal diagnostic tests increases. In parallel with the rapid development of modern molecular technologies and cheaper and easier access to the tests, we think that the number of invasive prenatal diagnostic tests will experience a more dramatic decrease in the following years.

Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr.

BACKGROUND: Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units. CASE: The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient's symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst. CONCLUSION: To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess.

Cervical cerclage in twin pregnancies: obstetric and neonatal outcomes.

BACKGROUND: Although there have been significant improvements in prenatal and neonatal care in recent years, twin pregnancies account for 17-20% of all preterm births and are associated with an increased risk of perinatal mortality and morbidity. AIMS: To evaluate the contribution of cerclage to the continuation of pregnancy in twin pregnancy cases required cervical cerclage. METHODS: Cases of twin pregnancies who performed cervical cerclage with follow-up and deliveries between January 2010 and January 2022 in the Department of Obstetrics and Gynecology, Ege University Faculty of Medicine Hospital, were retrospectively analyzed. Obstetric and neonatal outcomes were evaluated. RESULTS: A total of 23 women who performed cervical cerclage due to cervical insufficiency in twin pregnancies were evaluated retrospectively. The mean time between cerclage placement and delivery was 12.1 ± 7 weeks, maximum prolongation was in the obstetric history-indicated cerclage group. The gestational age at delivery was 20-38 (median 30) weeks. The rate of spontaneous preterm birth at < 34, < 32, < 28, and < 24 weeks was higher in the physical examination-indicated cerclage group. Overall neonatal survival was 82.5% (n = 33/40). CONCLUSION: The time between cerclage placement and birth were considered as an important gain for twin pregnancies at the limit of viability. Further studies are needed to better understand the role of cervical cerclage in preventing premature birth and to determine the indications for cerclage.

Perioperative Outcomes in Pregnant Women Who Underwent Surgery for Adnexal Torsion.

OBJECTIVE: To evaluate clinical characteristics, maternal and fetal outcomes in pregnant women who underwent surgery for adnexal torsion (AT). METHODS: All patients, who underwent surgical operation due to AT during pregnancy at the Department of Obstetrics and Gynecology, School of Medicine, Ege University between 2005 and 2020 were retrospectively investigated. Main clinical and perioperative outcomes were evaluated. RESULTS: A total of 21 patients who underwent surgery due to AT during pregnancy were included. Of all patients, 61.9% underwent laparoscopy and the remaining 38.1% underwent laparotomy. The most common surgical procedure was adnexal detorsion in both groups (48%). Mean gestational age at the time of diagnosis, duration of surgery and hospitalization were significantly lower in the laparoscopy group, when compared with the laparotomy group (p = 0.006, p = 0.001, and p = 0.001, respectively.) One of the patients had an infection during the postoperative period. Spontaneous abortion was only observed in one case. CONCLUSION: It can be concluded that the surgical intervention implemented for the exact diagnosis and treatment of AT (laparotomy or laparoscopy) did not have an unfavorable effect on pregnancy outcomes such as abortion, preterm delivery, and fetal anomaly. However, laparoscopy may be superior to laparotomy in terms of advantages.

OBJETIVO: Avaliar as características clínicas, e os desfechos maternos e fetais em gestantes submetidas à cirurgia de torção anexial. MéTODOS: Todas as pacientes operadas por torção anexial durante a gravidez no Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de Ege entre 2005 e 2020 foram investigadas retrospectivamente. Os principais resultados clínicos e perioperatórios foram avaliados. RESULTADOS: Foram inclusas 21 pacientes operadas por torção anexial durante a gravidez. De todos as pacientes, 61,9% foram submetidas à laparoscopia e as 38,1% restantes foram submetidas à laparotomia. O procedimento cirúrgico mais comum foi apenas a destorção anexial em ambos os grupos (48%). A idade gestacional média no momento do diagnóstico, a duração da operação e da hospitalização foram significativamente menores no grupo de laparoscopia em comparação com o grupo de laparotomia (p = 0,006, p = 0,001 e p = 0,001, respectivamente.) Uma das pacientes teve uma infecção no pós-operatório. Apenas em um caso observamos aborto espontâneo. CONCLUSãO: Pode-se concluir que a intervenção cirúrgica implementada para o diagnóstico exato e tratamento da torção anexial (laparotomia ou laparoscopia) não teve efeito desfavorável nos desfechos da gravidez, como aborto, parto prematuro e anomalia fetal. No entanto, a laparoscopia pode ser superior à laparotomia em termos de vantagens.

Pulmonary hypertension in pregnancy: experience from 45 cases at a tertiary care center.

OBJECTIVE: Pulmonary hypertension (PH) is a rare maternal cardiac disorder associated with high maternal and fetal mortality. The objective of our study was to evaluate the maternal and fetal outcomes in pregnant women with PH in a single health center. STUDY DESIGN: 45 pregnant patients with PH, who had undergone antenatal follow-up and delivery at the department of gynecology and obstetrics at a referral center were retrospectively investigated. Maternal and perinatal outcomes were evaluated and descriptive statistics were reported. RESULTS: According to the WHO classification; 35 patients (78%) were in Group 1; 9 patients (20%) in Group 2 and one patient (2%) were in Group 3. Thirty-three of the cases (73%) had mild, 8 (18%) moderate and 4 (9%) severe PH. The mean delivery week was 35.5. Twenty-four of the cases (56%) delivered before the 37th week and the remaining 19 cases (44%) in the 37th week or later. Rate of cesarean section delivery was 88%. Only one case of maternal death was reported, who was initially diagnosed with PAH during pregnancy. This patient had severe PH and was in Group 1 according to the WHO classification. CONCLUSION: While the mortality rates related to PH were reported to be between 30% and 56% several decades ago, recent studies have reported the mortality rates between 5% and 25%. It is believed that the decline in the maternal mortality depended on the developments in the treatment alternatives and multidisciplinary management. However, PH is still a serious condition which requires a multidisciplinary approach and a well-planned obstetric management.

Fetal arrhythmias: Ten years' experience and review of the literature.

Objective: Fetal arrhythmias complicate 1-2% of all pregnancies. Ultrasound evaluation and Doppler technology are indispensable in both diagnosis and management. Digoxin, sotalol, flecainide and amiodarone are widely accepted antiarrhythmic agents that are frequently. We reviewed the maternal and fetal outcomes in cases with fetal arrhythmia in a tertiary care center in the last decade. Materials and Methods: Fetal arrhythmias were classified under three main groups: Irregular rhythms, tachyarrhythmia and bradyarrhythmia. Detailed anatomical evaluation and fetal echocardiography were performed in all cases to determine whether a structural cardiac and extracardiac anomaly accompanied fetal arrhythmia and the type of fetal arrhythmia. Digoxin was started primarily as first-line therapy in patients with persistent fetal tachyarrhythmia. In cases, not responding to digoxin, other antiarrhythmic agents (sotalol, flecainide) were combined with treatment without discontinuing digoxin. Results: Fetal arrhythmia was detected in 36 cases during the study period. 50% (n=18/36) of the cases had supraventricular tachycardia, whereas 28% (n=10/36) of them were fetal bradyarrhythmia and 22% (n=8/36) of them were with various irregular rhythms. Transplacental therapy was initiated in 13 patients with persistent supraventricular tachycardia and atrial flutter regardless of the presence of hydrops. The success rate in transplacental therapy was 77% (n=10/13). Conclusion: Successful transplacental therapy was achieved in approximately 80% of cases and delivery could be postponed to advanced gestational weeks, confirming the crucial role of this treatment for the management of tachyarrhythmia.

Outcomes of antenatally diagnosed fetal cardiac tumors: a 10-year experience at a single tertiary referral center.

OBJECTIVE: The purpose of this study was to analyze the clinical and perinatal outcomes along with ultrasonographic characteristics of fetuses with a cardiac tumor. METHODS: The data were obtained retrospectively between January 2010 and December 2019 in a tertiary referral center. The Cardiovascular Profile Score (CVPS) was used for the diagnosis of heart failure. Clinical outcomes of the cases identified in the postnatal period were analyzed. RESULTS: Fourteen cases were evaluated with the fetal cardiac tumor. One case made the decision to terminate the pregnancy. Perinatal death was seen in 4 (30.7 %) cases out of 13 cases. In 3/14 (21.4%) cases, a solitary cardiac tumor was found while multiple cardiac tumors were found in 11/14 (78.6%) cases. All living cases 9/9 (100%) had the diagnosis of tuberous sclerosis complex (TSC). When the cases which survived were compared with the cases which died during the prenatal period, a significant difference in tumors' biggest diameters (16.44 ± 5.12 mm vs. 32.25 ± 9.28 mm; p: .011, respectively) was found. No statistically significant difference was found in the number of the tumor(s) and heart failure. CONCLUSION: Fetal cardiac tumors can have serious perinatal mortality. The cardiac tumor size was found to be associated with perinatal mortality. The survival is not different between the cases with solitary and multiple tumors and those with and without congestive heart failure.

Prenatal diagnosis of a case with tetrasomy 9p confirmed by cytogenetics, FISH, microarray analysis and review.

OBJECTIVE: Tetrasomy 9p is a rare fetal condition. Cases are usually mosaic. Here, we present a non-mosaic tetrasomy 9p case with cytogenetic analysis, fluorescence in situ hybridization, microarray data, ultrasound findings, and phenotypic presentation. CASE REPORT: A pregnancy was referred to cytogenetic analysis because of increased nuchal translucency in prenatal ultrasound at 13 weeks of gestation. Prenatal laboratory analysis revealed an extra marker chromosome with a non-mosaic pattern. Ultrasonographic findings were unilateral cleft lip and palate, micrognathia, and atrioventricular septal defect at the 17th week; additionally, ventriculomegaly, left axis deviation of the fetal heart, and a single umbilical artery were determined at the 23rd week. CONCLUSION: Phenotypic severity in non-mosaic tetrasomy 9p widely differs depending on the chromosomal content. We recommend performing appropriate genetic tests in those pregnancies with the suspicion of tetrasomy 9p, evaluating the mosaic state, and following those cases with detailed ultrasonographic examinations.

Effectiveness of segmental resection technique in the treatment of placenta accreta spectrum.

BACKGROUND: Placental accreta is a serious obstetrical entity and its management is challenging. The aim of this study was to evaluate and define our uterus sparing surgical technique in patients with placenta accreta spectrum. METHODS: The data of 21 patients who underwent uterine segmental resection during cesarean section with a preliminary diagnosis of placenta accreta spectrum at Ege University between January 2017 and December 2018 were evaluated retrospectively. RESULTS: Twenty-one patients were successfully treated with the segmental resection technique. In all cases, resected tissues were evaluated by histopathologically and the diagnosis of placenta accreta spectrum was confirmed. Hysterectomy was performed in two cases due to peri-partum hemorrhage that disrupted hemodynamics. None of the patients had complications such as visceral organ injury and wound infection. CONCLUSION: Our technique of uterine sparing surgery seems to be safe and effective in the management of placenta accreta spectrum without increasing complication rates.

Perioperative Outcomes in Pregnant Women Who Underwent Surgery for Adnexal Torsion / Resultados perioperatórios em mulheres grávidas submetidas a cirurgia para torção anexial

Abstract Objective To evaluate clinical characteristics, maternal and fetal outcomes in pregnant women who underwent surgery for adnexal torsion (AT). Methods All patients, who underwent surgical operation due to AT during pregnancy at the Department of Obstetrics and Gynecology, School of Medicine, Ege University between 2005 and 2020 were retrospectively investigated. Main clinical and perioperative outcomes were evaluated. Results A total of 21 patients who underwent surgery due to AT during pregnancy were included. Of all patients, 61.9% underwent laparoscopy and the remaining 38.1% underwent laparotomy. The most common surgical procedure was adnexal detorsion in both groups (48%). Mean gestational age at the time of diagnosis, duration of surgery and hospitalization were significantly lower in the laparoscopy group, when compared with the laparotomy group (p=0.006, p=0.001, and p=0.001, respectively.) One of the patients had an infection during the postoperative period. Spontaneous abortion was only observed in one case. Conclusion It can be concluded that the surgical intervention implemented for the exact diagnosis and treatment of AT (laparotomy or laparoscopy) did not have an unfavorable effect on pregnancy outcomes such as abortion, preterm delivery, and fetal anomaly. However, laparoscopy may be superior to laparotomy in terms of advantages.

Resumo Objetivo Avaliar as características clínicas, e os desfechos maternos e fetais em gestantes submetidas à cirurgia de torção anexial. Métodos Todas as pacientes operadas por torção anexial durante a gravidez no Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de Ege entre 2005 e 2020 foram investigadas retrospectivamente. Os principais resultados clínicos e perioperatórios foram avaliados. Resultados Foraminclusas 21 pacientes operadas por torção anexial durante a gravidez. De todos as pacientes, 61,9% foramsubmetidas à laparoscopia e as 38,1% restantes foram submetidas à laparotomia. O procedimento cirúrgico mais comum foi apenas a destorção anexialemambos os grupos (48%).Aidade gestacionalmédia nomomento do diagnóstico, a duração da operação e da hospitalização foram significativamentemenores no grupo de laparoscopia em comparação com o grupo de laparotomia (p=0,006, p=0,001 e p=0,001, respectivamente.) Uma das pacientes teve uma infecção no pós-operatório. Apenas em um caso observamos aborto espontâneo. Conclusão Pode-se concluir que a intervenção cirúrgica implementada para o diagnóstico exato e tratamento da torção anexial (laparotomia ou laparoscopia) não teve efeito desfavorável nos desfechos da gravidez, como aborto, parto prematuro e anomalia fetal. No entanto, a laparoscopia pode ser superior à laparotomia em termos de vantagens.

Do Leukocyte and Platelet Counts Have Benefit for \Preoperative Evaluation of Endometrial Cancer?

PURPOSE: The aim of this study was to investigate the association between preoperative leukocyte and platelet counts and the stage of the disease in patients with endometrial cancer. MATERIALS AND METHODS: Data for 100 patients undergoing total abdominal hysterectomy and bilateral salpingoophorectomy for benign uterine diseases and 177 patients surgically staged for endometrial cancer at Ondokuz Mayis University, Department of Gynecology and Obstetrics between 2005 and 2013, with preoperative complete blood count in the week prior to surgery including WBC, platelet count, pathologic evaluation for both benign and malign endometrium lesions, tumor stage and presence of lymphovascular space invasion (LVI), were retrospectively analyzed. RESULTS: The preoperative leukocyte count was significantly higher in patients with endometrial cancer when compared to the patients with benign diseases. However, there were no significant differences in platelet counts between the groups. Patients with advanced stage endometrial cancer had higher preoperative leukocyte counts when compared to the early stage disease whereas there was no difference in platelet count. Multivariate regression analysis identified preoperative leukocytosis as an independent prognostic factor for endometrial cancer. The optimal cut-off point for WBC was calculated as 10,500 to differentiate stage 1-2-3 and 4 with 88.9% sensitivity and 86.3% specificity (AUC: 0.901, 95% CI: 0.829-0.973, p<0.001, PPV: 25.8%, NPV: 99.3%). CONCLUSIONS: Preoperative leukocytosis is independently associated with advanced endometrial cancer.

Arthroscopic reconstruction of a ruptured patellar tendon: a technical note.

A traumatic patellar tendon rupture of a 35-year-old, otherwise healthy male was reconstructed with semi-tendinosus and gracillis tendons. Tendon grafts were harvested with an open-ended tendon stripper without dissecting them free from their tibial insertion. A transpatellar tunnel was drilled appropriate to the tendon size and a passing pin was used across the length of the patella. Graft bundles were passed in a standard fashion, traversing through the midst of the distal part of the patellar tendon via a beath pin with a loaded looped suture. The endo-button device was then flipped and fixed as an anchor. The patella was positioned at the original placement under arthroscopic visualization and the free ends of the hamstring tendons were attached to a post-fixation screw through the Krackow sutures. Tendon grafts were gathered on the tuberositas tibia and fixed with two additional staples. The patient could flex his knee up to 130 deg at the 3-month follow-up. It was demonstrated that arthroscopic reconstruction of a ruptured patellar tendon may be the optimal surgical choice to minimize trauma and begin early rehabilitation.