Clinical analysis of emergency peripartum hysterectomies in a tertiary center.

OBJECTIVE: To investigate the incidence, indications, complications, and risk factors associated with increased mortality and morbidity of emergency peripartum hysterectomy (EPH). MATERIALS AND METHODS: The authors retrospectively analyzed 48 cases of EPH performed within six-year interval at Ondokuz Mayis University Hospital. EPH was defined as the operation performed for life-threatening hemorrhage which could not be controlled with conservative treatment modalities within 24 hours of a delivery. RESULTS: The incidence of EPH was 5.03 per 1,000 deliveries. The most common indication for EPH was abnormal placental adherence (n = 22, 45.8%), followed by uter- ine atony (n = 19, 39.6%). All the patients with placenta accreta had a history of repeat cesarian section (CS) and placenta previa.Total hysterectomy was performed in almost all of the patients (n = 47, 97.9%). All women required blood transfusions. Maternal morbidity was significant, with bladder injury (31.3%) and disseminated intravascular coagulation (18.7%) among the most common complications. There were one maternal (2.1%) and five neonatal deaths (10.4%). CONCLUSION: Since most of the EPH cases are associated with prior cesarean delivery, decision of the first CS should be made for true obstetrical indications.If conservative treatments fail to control massive obstetrical bleeding, blood products and an experienced obstetrician should be ready to perform EPH to decrease the maternal mor- bidity and mortality.

Clinical and molecular studies in two families with Fraser syndrome: a new FRAS1 gene mutation, prenatal ultrasound findings and implications for genetic counselling.

Fraser syndrome is a rare autosomal recessive genetic disorder characterized by cryptophthalmus, variable expression of cutaneous syndactyly of fingers and toes, genital ambiguity and renal agenesis/dysgenesis. We present here molecular and clinical findings of four fetuses with FS from two families. Molecular genetic studies in the two families revealed mutations in FRAS1 gene allowing better genetic counselling and subsequent prenatal diagnosis in one of the two families. In family one, a nonsense mutation (c.3730C>T, p.R1244X) previously described in a Polish patient was found. In family two a novel nonsense mutation previously not known was detected (c.370C>T, p.R124X). PGD is planned for family 1.

The comparison of effects of tibolone and conjugated estrogen-medroxyprogesterone acetate therapy on sexual performance in postmenopausal women.

OBJECTIVE: To compare the effects of two different postmenopausal regimens on sexual performance. METHODS: A single blind prospective clinical study was planned on fifty natural postmenopausal women with no absolute contraindication for hormone replacement therapy (HRT). A total of 25 women were randomized for tibolone therapy (group T) and the rest 25 for continuous conjugated estrogen (CE) 0. 625 mg plus medroxyprogesterone acetate (MPA) 2.5 mg (group E) for a year. Two women in group T and four women in group E were excluded from the study as they didn't attend the control visit. At baseline and after a year, sexual performance parameters (sexual desire, coital frequency, orgasm frequency, vaginal dryness/dyspareunia) and after therapy subjective well-being, vasomotor symptoms, and side effects were assessed by score method designed by us. RESULTS: Treatment with either preparation significantly improved subjective well-being, vasomotor symptoms and vaginal dryness. The rates of overall side effects between two groups were not found statistically different (P=0.84). Tibolone therapy increased sexual desire and coital frequency (P=0.001, P=0.014). CONCLUSIONS: Both tibolone and continuous combined CE/MPA effectively improve the findings of hypoestrogenism and subjective well being. Moreover, tibolone effectively increases sexual performance. It is seen that tibolone with acceptable androgenic side effects can be an appropriate selection for HRT in postmenopausal women with decreased sexual desire.

Analysis of the pregnancy-related deaths within the last two decades: a university hospital-based study from Turkey.

OBJECTIVE: To analyse the causes of pregnancy-related deaths at Ondokuz Mayis University Hospital. STUDY DESIGN: The death of a woman while pregnant or within 42 days of termination of pregnancy regardless of the cause of death, including accidental or incidental causes, was accepted as a 'pregnancy-related death'. Such deaths were evaluated in Ondokuz Mayls University Hospital in the years 1978-1997 inclusive. They were classified as direct obstetric, indirect obstetric, and accidental or incidental deaths. RESULTS: Eighty-seven pregnancy-related deaths were identified via hospital death records. Maternal mortality ratio was calculated to be 822.2 per 100,000 live births. Seventy seven percent of the deaths were due to direct obstetric causes; most commonly due to toxemia, infection and hemorrhage. CONCLUSION: Direct obstetric deaths, which are largely preventable with proper antenatal care and health services, are still problems in our country.

Estimation of the amniotic fluid volume using the Cavalieri method on ultrasound images.

OBJECTIVES: Presently, a design-based and practical method for measuring amniotic fluid volume (AFV) for routine clinical examinations has not been proposed. In this study we describe a new method, which combines the Cavalieri method with ultrasound imaging to estimate AFV. METHODS: We measured the AFVs of 14 women in the third trimester of pregnancy, and repeated our measurements three times for each woman. Parallel planimetric ultrasonographic images were obtained at every 2 cm along the longitudinal uterine axis. AFVs were calculated as the total of the multiples of the estimated cut surface areas by the section thickness. RESULTS: The mean estimated AFV was 380.5 cm3. The coefficient of error of each measurement was calculated and the mean was 0.108. The coefficient of correlation between the amniotic fluid index and our AFV estimations was 0.87. CONCLUSIONS: Design-based and efficient estimation of AFV is possible with the combination of consecutive ultrasound images and the Cavalieri method.

Tibolone versus four estrogen replacement therapy protocols and plasma lipid levels in postmenopausal women.

OBJECTIVES: To compare tibolone therapy with four different estrogen replacement therapy protocols, with regard to the effects on plasma lipid profiles. METHODS: The plasma lipid levels of 178 postmenopausal women in five different therapy groups were compared with each other as well as their baseline levels with 6-month intervals during 2-year follow-up. Student's t-test, paired t-test and Pearson correlation analysis were utilized for statistical analysis. RESULTS: HDL cholesterol levels increased significantly from baseline in groups using oral estrogen (P<0.05) but a slight non-significant decrease was seen in tibolone therapy (P>0.05). LDL cholesterol levels significantly decreased at the end of the second year in oral estrogen and tibolone users (P<0.05). Triglyceride levels increased non-significantly with estrogen therapy (P>0.05), whilst decreased significantly in the tibolone group (P<0.05). CONCLUSION: Tibolone may be a good alternative to estrogen replacement therapy in postmenopausal women, as it has beneficial effects on LDL cholesterol and triglyceride levels, which play important role in atherosclerosis.

Cigarette smoking and lipids and lipoproteins in cord plasma.

The effects of smoking on maternal and cord plasma lipid and lipoprotein levels were measured in 40 smoker mothers and their newborns and compared to nonsmokers. Significantly higher levels of total cholesterol, low density lipoprotein cholesterol and very low density lipoprotein cholesterol and lower levels of high density lipoprotein cholesterol were found in smoker mothers and their newborns in comparison to nonsmokers. These results suggest that smoking does not affect only the lipids and lipoproteins of pregnant women but also those of their fetuses.

Magnesium, zinc and iron levels in pre-eclampsia.

OBJECTIVE: To determine the change in erythrocyte and plasma magnesium, plasma zinc and serum iron concentrations in pre-eclampsia. METHODS: Twenty women with pre-eclampsia and 20 control subjects matched for gestational age were examined. The levels of magnesium, zinc and iron in all subjects were measured by flame atomic absorption spectrometry. In the pre-eclamptic women, who were supplemented with magnesium salts, these measurements were repeated after delivery. RESULTS: The intraerythrocytic magnesium levels before supplementation were significantly lower in the pre-eclamptic patients than in the healthy pregnant women (0.98 +/- 0.15 vs. 1.35 +/- 0.30 mmol/l; p < 0.001) and increased (to 1.25 +/- 0.25 mmol/l) after treatment with magnesium. The plasma magnesium and zinc, and the serum iron concentrations were not significantly different between the pre-eclamptic and the healthy pregnant women. CONCLUSIONS: Our results suggest that low cellular magnesium levels in women with pre-eclampsia may contribute to the development of hypertension in these patients, and that the measurements of plasma zinc and serum iron concentrations are of doubtful clinical value in the management of pre-eclampsia.

Do lipid profiles of postmenopausal women under oral hormone replacement therapy remain stable or reveal a multiphasic course in time?

The object of this study was to compare the effects of oral conjugated estrogen (CEE) alone, CEE plus medroxyprogesterone acetate (MPA) and tibolone on lipid profiles, and investigate whether these effects change in time. Plasma lipid levels were studied for CEE (n = 49), CEE + MPA (n = 50) and tibolone (n = 51). Mean per cent changes at certain intervals were compared with their previous intervals for each therapy. Paired t-test was used for statistical analysis. CEE alone had raised high-density lipoprotein (HDL) and triglyceride levels and lowered total cholesterol and low-density lipoprotein (LDL) levels at the end of the 2-year study period. Addition of MPA to the CEE regimen weakened the effect on HDL and triglyceride, augmented the decrease in total cholesterol and did not affect LDL. The tibolone group revealed similar but more prominent effects in total cholesterol and LDL levels. HDL and triglyceride levels were significantly below baseline in the first 6 months, but HDL changes vanished and triglyceride levels remained decreased at the end of 2 years. These data did not support a correlation between lipid levels and the biphasic incidence of cardiac events that were observed in the Heart and Estrogen/progestin Replacement Study (HERS), but revealed period-dependent changes in the tibolone group.

Histopathological evaluation of the connective tissue of the vaginal fascia and the uterine ligaments in women with and without pelvic relaxation.

This study aimed to compare connective tissue components within the uterine ligaments histopathologically in women with and without pelvic relaxation. The tissue samples obtained from the histopathologic specimens of 24 patients with uterine descensus who underwent vaginal hysterectomy and from twenty-one patients with no pelvic relaxation, in whom total abdominal hysterectomies were performed for benign reasons, were used as the study and control groups, respectively. From each hysterectomy material, samples for histological examination were taken from the vaginal fascia and from the cardinal, the uterosacral and the round ligaments (4 samples for each patient). The amount of collagen, cellularity and elastic fibers within the connective tissue were evaluated and scored by the co-author pathologist. Mann-Whitney U and Student t tests were used for the statistical analysis. The patients with pelvic relaxation had significantly higher scores of collagen and fewer scores of cellularity within the connective tissue samples, compared with the ones without relaxation (p < 0.01, p < 0.01). It was concluded that decreased fibroblasts and increased collagen content might be the key factors associated with pelvic support disorders.

Levels of stable metabolites of prostacyclin and thromboxane A2 and their ratio in normotensive and preeclamptic pregnant women during the antepartum and postpartum periods.

OBJECTIVE: To measure the levels of the circulating metabolites of prostacyclin and thromboxane A2 during the antepartum and postpartum periods in severe preeclamptic and eclamptic patients as well as in normotensive pregnant women. METHODS: 6-Keto-prostaglandin F1alpha (6-keto-PGF1alpha) and thromboxane B2 (TxB2) were measured in the plasma of 15 severe preeclamptic, 15 eclamptic, and 15 normotensive pregnant women during the antepartum and postpartum (5th day) periods. At the same time blood pressure measurements were obtained. Kruskal-Wallis, Wilcoxon rank-sum, and Wilcoxon's signed-rank tests were used for statistical analysis. RESULTS: 1) There was no significant difference in the levels of 6-keto-PGF1alpha and TxB2 of the normotensive pregnant women between the antepartum and the postpartum (5th day) periods. 2) In the severe preeclamptic and eclamptic groups, 6-keto-PGF1alpha levels showed significant increase after the delivery (P < 0.01, and P < 0.001, respectively). 3) In the severe preeclamptic and eclamptic groups TxB2 levels showed significant decrease after delivery (P < 0.01, and P < 0.001, respectively). 4) The 6-keto-PGF1alpha/TxB2 ratio both during the antepartum and the postpartum (5th day) periods showed significant differences between the severe preeclamptic and normotensive, and between the eclamptic and normotensive groups (P < 0.001, and P < 0.001 respectively). 5) No correlation was observed between the mean arterial pressure and the antepartum levels of 6-keto-PGF1alpha TxB2 or their ratios. CONCLUSIONS: Our study was able to demonstrate a significant difference in circulating metabolites of prostacyclin and TxA2 between normotensive pregnant women and those with severe preeclampsia and eclampsia. But no correlation was observed between the blood pressure and the antepartum 6-keto-PGF1alpha, TxB2 levels or their ratios. 6-keto-PGF1alpha levels increased and TxB2 levels decreased in the postpartum period (5th day). However, the 6-keto-PGF1alpha/TxB2 ratio was still low in the severe preeclamptic and eclamptic patients when compared with the control group. This situation shows that the pathophysiologic mechanism does not improve completely within a few days after delivery.

Basal and day 12 inhibin concentrations in the prediction of ovarian response to gonadotrophins in women with PCOS.

BACKGROUND: In this study, we aimed to investigate whether basal and day 12 serum total inhibin concentrations in women with polycystic ovarian syndrome (PCOS) were of predictive value for the estimation of the ovarian response to gonadotrophins. METHODS: Ovulation induction with a very low dose gonadotrophin protocol, starting with 37.5 IU/day, was performed for 40 cycles on 35 patients with PCOS. Day 3 (basal) serum total inhibin, FSH and oestradiol concentrations; day 12 dominant follicle diameter, inhibin and oestradiol concentrations and midluteal serum progesterone concentrations were measured during the 40 cycles. The correlations between basal and day 12 inhibin concentrations and some critical ovulation monitoring parameters were investigated. RESULTS: Ovulation was obtained in 14 out of 40 cycles: 21% of cycles with basal inhibin <1.0 IU/ml; 33.3% of cycles with basal inhibin between 1.0-1.9 IU/ml; and 83.3% of those with inhibin concentrations > or =2 IU/ml were ovulatory (P < 0.05). Ovulation was achieved in 91.6% of the cycles with a day 12 inhibin concentration > or =4 IU/ml. CONCLUSIONS: Basal inhibin concentrations may determine poor and good responders to ovulation induction with very low dose gonadotrophin protocol in patients with PCOS. The day 12 inhibin concentration was found to be a more sensitive parameter than the oestradiol concentration in the prediction of follicular maturation.

Evaluation of urethrovesical angle by ultrasound in women with and without urinary stress incontinence.

Our aim was to investigate the role of ultrasonographic imaging in the evaluation of genuine stress incontinence (GSI). The posterior urethrovesical angles (PUVA) of each of 50 incontinent (group I) and 50 control cases (group C) were measured by both transperineal and transvaginal ultrasonography (TP-USG, TV-USG). In group I the angles were 94.9 +/- 10.9 at rest and 102.7 +/- 16.1 by TP-USG (P<0.001), and 100.6 +/- 11.1 at rest and 103.3 +/- 9.6 during Valsalva by TV-USG (not significant). In the control group these measurements were 93 +/- 5.3, 96.2 +/- 7.9 (P<0.001) and 98 + 8.8, 101.1 +/- 10.3 (P=0.001) by TV-USG, respectively. The degree of alteration of the angle, originating with Valsalva maneuver (delta-PUVA) was 7.7 +/- 11.8 in group I and 3.2 +/- 4.95 in group C (P=0.014) by TP-USG, and 2.7 +/- 11.8 and 3.2 +/- 6.16 by TV-USG (NS). Our data reveal that PUVA and delta-PUVA have important roles in GSI pathophysiology; however, ultrasonography, especially by the transvaginal route, cannot be a reliable useful method as a diagnostic tool in the evaluation of GSI.