A late-onset hematoma developed after sexual intercourse following sacrospinous hysteropexy and mid-urethral sling surgery: case report

Introduction: Sacrospinous hysteropexy is a minimally invasive surgical procedure option for apical prolapse repair. Despite a significant number of postoperative hemorrhage and hematoma cases reported in the literature, life-threatening hemorrhage as a complication after sacrospinous hysteropexy is rare. In this case, in addition to sacrospinous hysteropexy, midurethral sling surgery was performed via the needleless technique for stress urinary incontinence. The case presented here is of a hematoma that developed following sexual intercourse on the 10th postoperative day after sacrospinous hysteropexy and its successful management and treatment without re-operation. A review of the literature did not reveal any cases similar to the present one. Method: Both sacrospinous hysteropexy using the Surelift® Contasure Prolapse System and midurethral sling surgeries were performed without any intraoperative complications. Case: A 40-year-old, female patient who had undergone both sacrospinous hysteropexy and midurethral sling surgery presented with pain following sexual intercourse on the 10th postoperative day. A hematoma of 4 cm was palpated at vaginal examination on the right posterolateral site and confirmed with computed tomography (CT) and magnetic resonance imaging (MRI). A vaginal tamponade was put in place and removed after 2 days follow-up in the hospital. After two weeks, contrast MRI revealed a hematoma smaller in size and after one month the hematoma was not observed. Discussion: Vascularity of the sacrospinous ligament (SSL) space includes an abundance of collateral blood vessels and significant anatomical variations can result from anastomosis. Finding and repairing injured vessels during SSL and pararectal area surgeries transvaginally or via laparotomy is difficult even for the experienced surgeon. Although sacrospinous hysteropexy is a minimally invasive transvaginal procedure, adverse effects may result due to the physical trauma of sexual intercourse so the patient should be warned to avoid sexual intercourse during the postoperative recovery period. If concurrent procedures have been performed along with sacrospinous hysteropexy, finding the source of the complication is essential for management and treatment. Conclusion: Knowledge of treatment options and pelvic vascular anatomy is fundamental for the diagnosis and management of complications. Although the literature is lacking in relevant data and case studies, the example of this case indicates that having sexual intercourse can result in postoperative development of hematoma in the SSL area, and that the patient should be warned to avoid sexual intercourse during the 6-week postoperative period. Vaginal packing should be the first treatment approach for management of intraoperative and postoperative hematoma and hemorrhage

A case report of twin reversed arterial perfusion sequence with expectant management

Acardiac twin or TRAP (twin reversed arterial perfusion) sequence is a rare complication of monochorionic pregnancies. In these cases, the heart is either absent or non-functional. It’s controversial whether conservative management or therapeutic treatment is better in TRAP-sequence. In this case, we present a 19-years old, primigravida diagnosed with spontaneous monochorionic monoamniotic twin pregnancy at 7th week of gestation. One of the fetuses had a crown-rump length of 8 mm and fetal heart rate 122/minute while the other one had a crown-rump of 7 mm with no detected fetal heartbeat. At the 11th week of gestation, the acardiac twin continued growing despite the absence of the fetal heart beat and fetal extremities. The cranium could not be evaluated clearly. The diagnosis of TRAP sequence was confirmed by the reversed direction of flow observed in the umbilical artery. Since the patient and her husband did not want any intervention, no interventional diagnostic and treatment modalities were applied. Preterm labor started at the 32th week. Because the presentations were transverse and breech, pump and acardiac fetus, respectively, a cesarean delivery was performed. A healthy female baby, weighing 1650 gr with APGAR scores of 9-10, first and fifth minutes, respectively, was delivered along with the acardiac fetus which was 1550 gram in weight, fetal heart beat negative, with upper and lower extremity deformities. The uniqueness of the present case is that there was no significant difference in the weight of both twins. The acardiac twin was as large as the pump twin. Except for twenty days hospitalization because of neonatal respiratory distress syndrome, which was a consequence of preterm labor, there were no problems with the pump twin even though managed conservatively. In monochorionic twin pregnancies, when one of the twins is found to be fetal heartbeat negative and it continues to grow with concomitant structural abnormalities, the TRAP sequence should come to mind. If the acardiac fetus is small and the pump fetus has no complications, the conservative approach can be considered. Our goal should be to deliver the pump twin with minimal complications. To achieve this, follow-ups and treatment should be individualized for each patient, the pump fetus should be monitored closely

Maternal and Neonatal Outcomes Related to Iron Deficiency Anemia and Serum Ferritin Status: A Multicenter Prospective Study From Eastern Marmara, Turkey

Aim:The aim was to evaluate the incidence of iron deficiency anemia in pregnancy in the East Marmara region of Turkey in order to determine its prevalence along with the effects and associations of iron supplementation on maternal and neonatal outcomes.Materials and Methods:This study was conducted in six centers and included a total of 1102 pregnant women. Blood samples were collected for hematological status and serum ferritin levels during pregnancy, and the adverse maternal and perinatal outcomes were determined. Iron deficiency anemia was diagnosed according to the World Health Organization criteria as hemoglobin level of < 11 g/dl and ferritin level of <15 μg/dL.Results:The rate of anemia was 19.8%, with 44% of them receiving iron supplementation. The maternal age was lower in the anemic group (26.5 vs. 27.7, p = 0.01). Selective iron use was more frequent in the anemic group, while routine iron use was more frequent in the non-anemic group (47.1% vs. 29.3%; p = 0.01).Conclusion:Iron deficiency anemia is a frequent problem in pregnancy. However, many anemic pregnant women do not receive iron therapy. Iron supplementation may have positive effects on maternal and perinatal outcomes. In order to combat iron deficiency anemia in pregnancy, wide spread use of iron supplements should be established

Management of abnormal cytology results and correlation of cytopathologic results accompanied by colposcopy in our clinic.

Aim: Pap smear test is a major screening test for early diagnosis and treatment of cervix cancer. The aim of our study was to assess the value of colposcopy and histopathologic examination in the management of patients with abnormal cervical cytology by Bethesda Classification.Methods: In this study, we aimed to compare and evaluate the diagnosis of 12,381 cytology material examined in our gynecology clinic during the years between 2014 and 2016 with their cytopathology results.Results: 498 of 12,381 patients had abnormal cytological findings (4.02%). The rates of Atypical Squamous Cells of Undetermined Significance (ASC-US), Atypical Glandular Cells of Undetermined Significance (AG-US), Low Grade Squamous Intraepithelial Lesions (LG-SIL) and High Grade Squamous Intraepithelial Lesions (HG-SIL) were found to be 1.9%, 0.4%, 1% and % 0.1, respectively. Atypical squamous cell cannot exclude HSIL (ASC-H) rate were found as % 0.4. The rate of abnormal cytology in cervical intraepithelial lesions was 2.1. Positive predictive values of abnormal smear results were 21.7% for ASC-US, 41.9% for LGSIL, 100% for HGSIL, 12.5% for AGUS and 50% for ASC-H. Conclusion: The Pap smear test is a cheap and easily applied screening test. Early diagnosis of cervix cancer can be made by routine Pap smear testing. The efficiency in clinical use of the cervical cytology screening test is determined by biopsy verification. As the ratio of epithelial cell abnormality is variable in different populations, the ASC (Atypical Squamous Cell) / SIL (Squamous Intraepithelial Lesion) is a more definite variable to be used for quality assurance

A randomized comparison of a single-incision needleless (Contasure-needlelessA (R)) mini-sling versus an inside-out transobturator (Contasure-KIMA (R)) mid-urethral sling in women with stress urinary incontinence: 24-month follow-up results

yassa, murat/0000-0001-8661-1192; dogan, ozan/0000-0002-0016-8749WOS: 000443429400022PubMed: 29549394There is a shortage of reliable data on the efficiency of the under-investigated mini-slings to treat stress urinary incontinence (SUI). We aimed to compare the effectiveness of the single-incision needleless mini-sling (SIMS) with the transobturator inside-out mid-urethral sling (TOT). Two hundred one women with clinically proven SUI were included in this single-center prospective randomized trial. The patients were randomly allocated to the groups. All surgeries were done by the same single surgeon. Examinations were done by one other blinded surgeon. The patients were followed up for 24 months. Objective cure was defined as the absence of SUI and negative cough-stress test. Subjective cure was defined as no stress leakage of urine after surgery in a validated questionnaire. Failure of the surgery was defined as the need for reoperation. Every complaint was categorized by the IUGA/ICS Classification of Prosthesis-related Complications. The objective (85.4% versus 89.9%, p = 0.362) and subjective (87.6% versus 89.9%, p = 0.636) cure rates were similar with the TOT and SIMS at the postoperative month 24, respectively. The mesh exposure 1 cm rate was 3.4% for both groups, and the mesh exposure > 1 cm rate was 2.2% for both groups. Overall failure rates were 3.4% and 2.2% for the TOT and SIMS group, respectively. No viscus organ perforation was noted. Complications with the SIMS procedure were less painful compared with TOT (p = 0.024). Single-incision needleless mini-slings exhibited similar cure rates as the trans-obturator mid-urethral slings from both the patient and clinician points of view in 24 months of follow-up. Mini-slings resulted in significantly less postoperative pain than trans-obturator mid-urethral slings

A randomized prospective comparison of the needleless mini-sling "hammock" and "U-shape" configurations for management of stress urinary incontinence: 18 month follow-up results

yassa, murat/0000-0001-8661-1192; dogan, ozan/0000-0002-0016-8749WOS: 000431871800015PubMed: 29556707Objective To compare the efficacy of needleless mini-sling placed either retropubic (U-shape) or trans-obturator (hammock-shape) to treat stress urinary incontinence. Setting One hundred and twenty six women were randomized in a 2:1 ratio to receive hammock-shaped or U-shaped of Contasure-NDL. Methods All surgical procedures were performed by one senior surgeon experienced in anti-incontinence surgery with mesh. Cough-stress test was considered for objective outcome. Subjective outcomes consisted of International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), Patient Global Impression of Improvement (PGI-I) and three-item Likert scale to measure satisfaction. Assessments were performed preoperatively and at postoperative 6th, 12th and 18th month. Results The objective cure rates at postoperative 6th and 12th month were significantly lower in U-shape group compared to hammock-shape group (85.4 vs. 96.4%; p = 0.034) and was comparable with hammock-shape group at 18 th month postoperative (90.2 vs. 96.4%, respectively; p = 0.216). The subjective cure rates at postoperative 6th, 12th and 18th month were similar between groups (90.2/90.2/100% vs. 96.4/96.4/96.4%, respectively; p > 0.05). Median of total ICIQ-SF scores was significantly lower in hammock-shaped group (1.62 +/- 2.92) compared to U-shape (3.80 +/- 2.64) at 18th month (p < 0.001). The rate of patients reported as very satisfied or satisfied to the Likert scale was 90.2% in U-shape group and 96.4% in hammock group. Patients' responses to PGI-I were majorly distributed to "much better" and "very much better" with a mean score of 1.93 +/- 2 in U-shape and 1.33 +/- 1 in hammock group at 18th month of follow-up (p < 0.001). Conclusion U-shape placement of needleless single-incision mini-sling mimicking the retropubic route did not satisfy in achieving the patient's goal when compared to hammock-shape placement

Discriminating Performance of Early Uterine and Cervical Artery Pulsatility and Resistivity In Pre-Invasive Cervical Lesions

yassa, murat/0000-0001-8661-1192; dogan, ozan/0000-0002-0016-8749WOS: 000454997800010Objectives: The aim of the present study was to investigate the diagnostic effectiveness of uterine and cervical vascularity alone or in combination with human papillomavirus (HPV) DNA testing and with cytology. Methods: Data were prospectively collected from 129 patients in an outpatient clinic of a secondary setting. Routine liquid-based cervical cytology and HPV-DNA testing were obtained. An abnormal result of any of these high-risk types was viewed as positive. Pulsatility (PI) and resistance (RI) indices of uterine (UA) and cervical (CA) arteries were assessed by Doppler sonography. Pathological diagnosis was considered as the gold standard for assessment. Diagnostic efficiency of alone and joint screening of the three indices for discriminating cervical intraepithelial neoplasia (CIN-I) or above from below was assessed. Results: UA-RI and CA-RI were significantly lower in the HPV (+) group than in the controls (p=0.02 and p=0.03, respectively). In subsequent sub-analysis among patients with positive HPV-DNA, UA-PI was significantly higher in the HPV-16 (+) group than in the HPV-18 (+) group (p=0.04). High-risk HPV (Hr-HPV) testing had the highest sensitivity compared with Doppler and cytology (76.5%, 64.7%, and 58.5%, respectively). Combining CA-RI with cytology or Hr-HPV significantly reduced the sensitivity (23.5% and 29.4, respectively) but improved the specificity from 54.4% to 69.8% and 40.9% to 70.7%, respectively. Combining UA-PI with Hr-HPV slightly increased the positive predictivity when compared with testing Hr-HPV alone (36.1% vs. 33.3%). Conclusion: The potential of the Doppler indices of UA and CA was doubtful in discriminating CIN-I or above lesions in the early period. In addition, RI of UA and CA differed with regard to the presence of HPV infection, whereas CA-RI differed in high-risk HPV cases

A case report of twin reversed arterial perfusion sequence with expectant management

Acardiac twin or TRAP (twin reversed arterial perfusion) sequence is a rare complication of monochorionic pregnancies. In these cases, the heart is either absent or non-functional. It’s controversial whether conservative management or therapeutic treatment is better in TRAP-sequence.In this case, we present a 19-years old, primigravida diagnosed with spontaneous monochorionic monoamniotic twin pregnancy at 7th week of gestation. One of the fetuses had a crown-rump length of 8 mm and fetal heart rate 122/minute while the other one had a crown-rump of 7 mm with no detected fetal heartbeat. At the 11th week of gestation, the acardiac twin continued growing despite the absence of the fetal heart beat and fetal extremities. The cranium could not be evaluated clearly. The diagnosis of TRAP sequence was confirmed by the reversed direction of flow observed in the umbilical artery. Since the patient and her husband did not want any intervention, no interventional diagnostic and treatment modalities were applied. Preterm labor started at the 32th week. Because the presentations were transverse and breech, pump and acardiac fetus, respectively, a cesarean delivery was performed. A healthy female baby, weighing 1650 gr with APGAR scores of 9-10, first and fifth minutes, respectively, was delivered along with the acardiac fetus which was 1550 gram in weight, fetal heart beat negative, with upper and lower extremity deformities. The uniqueness of the present case is that there was no significant difference in the weight of both twins. The acardiac twin was as large as the pump twin. Except for twenty days hospitalization because of neonatal respiratory distress syndrome, which was a consequence of preterm labor, there were no problems with the pump twin even though managed conservatively.In monochorionic twin pregnancies, when one of the twins is found to be fetal heartbeat negative and it continues to grow with concomitant structural abnormalities, the TRAP sequence should come to mind. If the acardiac fetus is small and the pump fetus has no complications, the conservative approach can be considered. Our goal should be to deliver the pump twin with minimal complications. To achieve this, follow-ups and treatment should be individualized for each patient, the pump fetus should be monitored closely

Does Suture Material Affect Uterine Scar Healing After Cesarean Section? Results from a Randomized Controlled Trial

dogan, ozan/0000-0002-0016-8749; ELLIBES KAYA, ASKI/0000-0002-1323-7416WOS: 000498685000012PubMed: 29667541Background: Impaired healing of the uterine scar after cesarean has been associated with adverse gynecological and obstetric outcomes. Although a large number of studies have been conducted on the events leading to this, information obtained from prospective randomized studies examining the role of suture material in the formation of cesarean scar defect (CSD) is lacking. Objective: To evaluate the effects of synthetic suture materials on CSD formation. Study design: We performed a two-arm 1:1 randomized study in women with singleton pregnancies undergoing elective primary cesarean delivery after the 38th week of gestation. Uterine scar closure was performed using synthetic absorbable monofilament and multifilament sutures. The primary outcome was residual myometrial thickness (RMT) in the area of the scar, measured by transvaginal ultrasound 6-9 months after birth. Secondary outcomes included differences in mean operative time, mean estimated blood loss at the time of surgery, and the rates of postoperative gynecological sequelae. Results: Complete follow-up was obtained from 94 (88%) of 107 participants. RMT was thicker in the monofilament compared to the multifilament suture group (5.5 +/- 2.24 vs. 4.18 +/- 1.76, p = 0.01). Hemoglobin delta was higher in the monofilament suture group (1.59 +/- 0.96 vs. 1.25 +/- 0.60, p = 0.04). There was no statistically significant difference between the monofilament suture and multifilament suture groups in terms of gynecological sequelae. Conclusion: Closure of the uterine scar with monofilament suture has a positive effect on scar healing and increases RMT thickness

Predictive factors of methotrexate treatment success in ectopic pregnancy: A single-center tertiary study

dogan, ozan/0000-0002-0016-8749WOS: 000445820800010PubMed: 30688925OBJECTIVE: It is controversial whether medical or surgical treatment options have more successful results in ectopic pregnancy treatment. Although high pretreatment serum hCG levels have been known to be the most important predictor, the appropriate treatment modality for a specific range of hCG level remains unclear. Furthermore, the variables that make a patient a bad candidate for single-dose methotrexate treatment is unclear. The aim of this study was to identify predictive factors associated with the success of single-dose methotrexate treatment in women with ectopic pregnancy. METHODS: In this retrospective study, 101 women with tubal ectopic pregnancies who had been treated with single-dose methotrexate were selected. The gestational ages, pretreatment hCG values, ectopic mass size, and fluid presence in the abdomen were compared between the groups. RESULTS: The mean age of the patients was 30.6 +/- 5.8 (range, 19-42) years, and the gestational age at first injection was 7.0 +/- 2.13 (range, 2.3-13.6) weeks. The overall treatment success rate was 77.2% (n=79). The mean duration of hospital stay was 4.21 +/- 1.89 days in the successfully treated group and 6.92 +/- 2.13 days in the failure group (p<0.05). The rate of treatment failure in patients with abdominal fluid was 37.8%, and it was 12.7% in the non-fluid group (p=0.03). hCG values on days 1, 4, and 7 were significantly higher in the unsuccessful group (3887-2589 mIU/mL, 2814-1287 mIU/mL, and 1119-285 mIU/mL, respectively; p<0.05). The cutoff hCG value, which determined the failure of methotrexate treatment, was found to be 1362 mIU/mL. CONCLUSION: In present study, patients with hCG value <1362 mIU/mL were found to be good candidates for methotrexate treatment. Although not strictly decisional, this hCG threshold level can be used to decide on the likelihood of methotrexate success or failure. Detection of abdominal fluid on ultrasonography also can be assessed as a bad prognostic factor, but size of ectopic mass does not correlate with methotrexate treatment success