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We report a case of cervical ectopic pregnancy successfully treated with systemic methotrexate. Conservative management with single-dose methotrexate was undertaken, but owing to the failure of human chorionic gonadotropin (hCG) levels to fall by 15% by day 7 and the persistence of fetal cardiac activity, two further doses of methotrexate were required. The patient's hCG levels were monitored, and repeat transvaginal ultrasonography was performed until complete resolution of the pregnancy by spontaneous miscarriage. We describe the ultrasonographic findings, which showed that the sac size increased despite treatment. [ABSTRACT FROM AUTHOR]

Objective: To determine the perceived social stigma and familial attitides and perception of sexuality in infertile couples attending infertility clinics., Materials and Methods: Infertile couples attending infertility clinics between the years of 2014 and 2015 were requested to complete detailed evaluation forms including questions related to the social stigma on their infertility, their familial attitudes, and perception of sexuality. Any partner of the infertile couple accepting to enroll in the study was given the evaluation forms. Their scores related to answers and demographics, and parameters related to infertility were analyzed., Results: A total 598 partners of infertile couples enrolled in the study, 58% represented 177 couples. Their infertility was primary in 98.3% and the duration of marriage and infertility was 9.81±5.58 and 9.76±5.53 years, respectively. The perception of social exclusion was present in 38% (p<0.001) of infertile couple, which was more significantly pronounced in female partners (p=0.013). Fifteen percent of the infertile couples thought themselves as isolated in public and losing value in public (p<0.001). However, sixty percent of infertile couples thought that they would achieve a notable place in community after having a baby (p<0.001). Infertility was accepted as a reason of divorce in only 13% of infertile couples (p<0.001). The majority of perticipnats, irrespective of sex, rejected that infertile women or men lost sexual appeal (86%; p<0.001)., Conclusions: There is significant effect of infertility on familial attitudes and perception of sexuality of infertile couples. Unfortunately, there is significant negative social stigma on infertile couples., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Objective: To compare intracytoplasmic sperm injection (ICSI) outcomes of women with subclinical hypothyroidism with those of euthyroid women., Materials and Methods: A retrospective case-control study was conducted. Out of 2529 ICSI cycles evaluated, 41 women with hypothyroidism, 28 women with hyperthyroidism, and 128 women with subclinical hyperthyroidism were excluded, and 2336 cycles were analyzed. Women were identified as having subclinical hypothyroidism (case group, n=105) in the presence of a thyroid-stimulating hormone level >4.5 mU/L and normal free T4 and compared with euthyroid controls (n=2231)., Results: The mean age, body mass index, day 3 follicle-stimulating hormone level, and antral follicle count of the study patients were similar to the control group (p>0.5). The cycle cancellation rate of the study group was similar to the control group (13.3% vs. 7.6%, p=0.1). The clinical pregnancy rate was 21.2% in the study group, which was significantly lower than the 35.8% in the control group (p=0.04). The take-home baby rate was also significantly lower in the study group compared with the control groups (13.5% vs. 31.4% respectively, p=0.01)., Conclusion: Both the clinical pregnancy rate and the take-home baby rate is lower in women with subclinical hypothyroidism at the time of ICSI cycle., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Objective: Operations performed with local anesthesia can sometimes be extremely painful and uncomfortable for patients. Our aim was to investigate the optimal analgesic method in saline infusion sonograms., Materials and Methods: This study was performed in our Clinic of Obstetrics and Gynecology between March and August 2011. Ninety-six patients were included. Patients were randomly divided into groups that received saline (controls, group 1), paracervical block (group 2), or paracervical block + intrauterine lidocaine (group 3). In all groups, a visual analogue scale score was performed during the tenaculum placement, while saline was administered, and 30 minutes after the procedure., Results: When all the patients were evaluated, the difference in the visual analogue scale scores in premenopausal patients during tenaculum placement, during the saline infusion into the cavity, and 30 minutes following the saline infusion sonography were statistically different between the saline and paracervical block groups, and between the saline and paracervical block + intrauterine lidocaine group. However, there was no statistically significant difference between paracervical block and paracervical block + intrauterine lidocaine groups., Conclusion: As a result of our study, paracervical block is a safe method to use in premenopausal patients to prevent pain during saline infusion sonography. The addition of intrauterine lidocaine to the paracervical block does not increase the analgesic effect; moreover, it increases the cost and time that the patient stays in the dorsolithotomy position by 3 minutes., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Aim: To investigate the value of tetracycline sclerotherapy for management of recurrent or persisting non-neoplastic ovarian cysts in comparison to the aspiration without sclerotherapy., Material and Methods: Ninety-six patients with proven non-neoplastic ovarian cysts were randomized into two groups. Group 1 patients underwent cyst aspiration together with tetracycline sclerotherapy (n=48). Group 2 patients underwent only cyst aspiration without tetracycline sclerotherapy (n=48). Then, all patients were followed up monthly with ultrasonography for 12months. The procedure was considered to have failed if the recurring cyst, detected by ultrasound, was 4cm in size or greater., Results: There were no differences between the two groups regarding demographic data, initial cyst volume and tumor markers. Recurrence rates within 12months were 14.6% in group 1 and 50% in group 2 (P<0.001)., Conclusion: Based on the recurrence rates, we suggest transvaginal aspiration together with tetracycline sclerotherapy rather than only simple transvaginal aspiration in the management of non-neoplastic ovarian cysts., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

Aim: The aim of this study was to compare the effects of intrauterine-system-releasing 20 µg daily of levonorgestrel (LNG IUS) plus 1 mg 17 beta-estradiol daily, orally with combined oral pill containing 1 mg 17 beta-estradiol/2 mg drospirenone daily as hormone replacement therapy, on health-related quality of life (HRQoL) and climacteric symptoms in postmenopausal women., Materials and Methods: A 6-month prospective clinical trial was conducted at the Department of Obstetrics and Gynecology, Dr Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey. Ninety postmenopausal women were accepted to be part of the study. The Euro Quality of Life-5 Dimensions (EQ-5D) and Euro Quality of Life Visual Analogue Scale (EQ VAS) indexes for HRQoL and Kupperman indexes were compared between two groups of patients., Results: Kupperman indexes of both treatment groups decreased gradually over 6 months, but indexes decreased significantly more in the group with intrauterine-system-releasing 20 µg daily of levonorgestrel. Elevations were observed in EQ-5D indexes and VAS values of both groups. EQ VAS values significantly increased in the group on intrauterine progestogen system. Similar changes were observed in the EQ-5D indexes of both groups., Conclusion: A hormone replacement therapy regimen that includes an intrauterine progestin system decreased climacteric symptoms and increased HRQoL in postmenopausal women during a follow-up period of 6 months. The extent of the relief of symptoms was greater in this group than in women receiving oral combined hormone replacement therapy. It seems therefore that the intrauterine progestin system could represent a method of choice for endometrial suppression in women using estrogen replacement therapy with distinct advantages over systemically administered progestogens, which have been the subject of considerable debate as reported in the recent literature., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

Objective: To estimate prevalence of malignancy and dysplasia in cervical polyps and to judge whether cervical polyps need to be removed routinely. Also to investigate if a cervical polyp is an indicator of endometrial pathology and to assess the necessity of performing dilatation and curettage (D&C)., Materials and Methods: We retrospectively reviewed hospital records of 4,063 cervical polyp cases. Patients' age, menopausal status and pathological findings were recorded. Descriptive statistics, Pearson's χ(2), Fisher's exact test were used for statistical analysis. P value of ≤ 0.05 was accepted significant., Results: Among 4,063 cervical polyps, only 3 (0.1%) cases of malignancy were encountered which were metastasis from endometrium. There were also dysplastic (0.4%), metaplastic (2.1%), inflammatory (1%) changes. Accompanying endometrial pathologies were: endometrial cancer (0.3%), hyperplasia without atypia (1.3%), endometrial polyp (6.6%). There was statistically significant relation between menopausal status and malignancy of cervical polyps (P = 0.055) malignancy of endometrial cavity (P = 0.0001)., Conclusion: Routine removal of cervical polyps, although not mandatory, seems clinically prudent because pathological evaluation is needed to confirm the diagnosis and to rule out other possibilities. 10.9% of postmenopausal patients and 7.8% of premenopausal patients were diagnosed with any endometrial pathology accompanying cervical polyp. Therefore, cervical polyps can be a sign of endometrial disease, especially in postmenopausal women with cervical polyp endometrium should be evaluated more carefully.

Aim: To compare Pfannenstiel-Kerr (PKM) and Misgav-Ladach (MLM) methods in terms of operation-related features and neonatal outcome in primary cesarean deliveries., Methods: A total of 180 pregnant women randomized into PKM (n = 90) or MLM (n = 90) groups were included in this study. Primary outcome measures were total operative and extraction times, Apgar score, blood loss, wound complications, and the suture use. Secondary outcome measures were wound seroma and infection incidence, time of bowel restitution, and the perceived pain., Results: Total operation and extraction times were significantly shorter and less suture material was used in the MLM group than the PKM group (p < 0.001). Initially, higher scores obtained for 6 h-VAS in the MLM group (p < 0.05) were normalized after 24 h of the operation. PKM and MLM were similar in terms of preoperative and postoperative levels of hemoglobin and hematocrit, wound complication, bowel restitution, fever, seroma, infection, wound dehiscence and the need for transfusion, antibiotic, and analgesics., Conclusion: The operation-related morbidity of the MLM and PKM for primary C/S seem to be comparable; however, the MLM seems to be superior in terms of operation time and the amount of suture usage but inferior in pain scores in the early postoperative period.

Background/aims: To compare local anesthesia and forced coughing in terms of subjective pain perception during cervical punch biopsy., Methods: In this randomized controlled trial, 114 patients (mean age: 38.9 ± 9.0 years) scheduled for colposcopically directed cervical punch biopsy were randomly assigned to local anesthesia (n = 39), forced coughing (n = 39) and control (n = 36) groups. Pain perception was measured on a 10-cm visual analog scale (VAS) during the insertion of the speculum, injection of the local anesthetic to the cervix and the taking of the first cervical biopsy, as well as for the overall pain perceived during the entire procedure., Results: Experimental groups were similar in age, gravidity, parity and prior curettage. The pain score obtained during the first cervical biopsy was significantly lower if local anesthesia was applied (p = 0.016). Groups were similar in other pain subscores. The duration of the entire procedure was significantly longer (p < 0.001) in the local anesthesia group, while it was not significantly different in forced coughing patients compared to controls., Conclusion: Local anesthesia, but not forced coughing, provides significant pain relief during cervical biopsy. Based on similarity to control data in terms of pain relief and shortening of the operation, forced coughing per se seems related neither to pain relief nor a faster cervical biopsy., (Copyright © 2011 S. Karger AG, Basel.)

Objective: To investigate the effect of raloxifene therapy on menopausal symptoms, depression and anxiety scores using Kupperman's Scale, Hamilton Depression Rating Scale (HDRS) and Beck Anxiety Rating Scale (BARS) in osteopenic postmenopausal women., Methods: This was a prospective, randomised, parallel and open labeled clinical study. One-hundred thirty-two postmenopausal osteopenic women with natural menopause enrolled into the study. One-hundred twenty-four of them completed the study. Group I patients were treated with oral raloxifene (60 mg/day), Group II patients were treated with oral calcium supplementation (1000 mg/day) for 3 months. The patient's menopausal, depressive and anxiety symptoms were assessed by using Kupperman's Scale, HDRS and BARS, before and at the end of treatment. For statistical analysis unpaired t, ANOVA, RM-ANOVA, MANCOVA, Pearson correlation tests were used. Statistical significance level was established at p < 0.05., Results: Baseline Kupperman's Scale, HDRS and BARS scores were not different among two groups. At the end of 3 months of therapy, there was improvement in menopausal symptoms, depression and anxiety scores within both groups. When we compared change of scores before and after the treatment; group I scores were better than group II scores., Conclusion: Our results suggest that raloxifene may have a positive effect on mood in osteopenic postmenopausal women.

Objective: To compare a novel barbed suture, poliglecaprone-25 suture and stapler in Pfannenstiel incisions performed for benign gynecological procedures., Design: A randomized controlled non-inferiority trial with randomization in a 1:1:1 ratio., Setting: Istanbul Dr. Lutfi Kirdar Kartal Research and Training Hospital, Department of Obstetrics and Gynecology., Population: Patients between 18 and 45 years of age without prior lower abdominal incision and undergoing Pfannenstiel incisions for benign gynecological procedures., Methods: A total of 117 female patients randomized into barbed (n = 39), poliglecaprone-25 (n = 39) and stapler (n = 39) groups according to suture type. Skin closure techniques were compared in terms of length of incision (cm), adverse events (wound dehiscence, incisional infection, seroma and hematoma), subjective pain scores, patient satisfaction and postoperative scar cosmesis. MAIN OUTCOME MEASURES. The difference between three suture materials in terms of postoperative incision pain, patient satisfaction and scar cosmesis., Results: Skin closure techniques were similar in terms of length of incision (cm), adverse events and pain scores and Modified Hollander Cosmesis Score. Barbed (p < 0.001) and poliglecaprone-25 (p < 0.01) sutures were significantly better than staplers in terms of patient satisfaction., Conclusion: The three different methods of skin closure revealed comparable outcome except for a significant superiority of sutures to the stapler method in terms of patient satisfaction scores.

Objective: The purpose of the present study was to compare the current diagnostic clinical and laboratory approaches to women with vulvovaginal discharge complaint. The secondary outcomes were to determine the prevalence of infections in our setting and to look for the relation between vulvovaginal infections and predisposing factors if present., Method: Premenopausal women applying to our gynecology outpatient clinic with vaginal discharge complaint were enrolled prospectively into the study. Each patient evaluated clinically with direct observation of vaginal secretions, wet mount examination, whiff test, vaginal pH testing and chlamydia rapid antigen test. Each patient also evaluated microbiologically with vaginal discharge culture and gram staining. Clinical diagnosis was compared with the microbiological diagnosis (the gold standard). Diagnostic accuracy was measured with sensitivity, specificity, positive (ppv) and negative predictive values (npv)., Results: 460 patients were included in the study. 89.8% of patients received a clinical diagnosis whereas only 36% of them had microbiological diagnosis. The sensitivity, specificity, ppv, npv of clinical diagnosis over microbiological culture results were 95, 13, 38, 82%, respectively. The most commonly encountered microorganisms by culture were Candida species (17.4%) and Gardnerella vaginalis (10.2%). Clinically, the most commonly made diagnoses were mixed infection (34.1%), bacterial vaginosis (32.4%) and fungal infection (14.1%). Symptoms did not predict laboratory results. Predisposing factors (DM, vaginal douching practice, presence of IUD and usage of oral contraceptive pills) were not found to be statistically important influencing factors for vaginal infections., Conclusion: Clinical diagnosis based on combining symptoms with office-based testing improves diagnostic accuracy but is insufficient. The most effective approach also incorporates laboratory testing as an adjunct when a diagnosis is in question or treatment is failing.

Objective: This study aimed to determine the effectiveness of short-term maintenance treatment with cabergoline and to find out minimum effective dosage of cabergoline during maintenance treatment for patients with microadenoma-related and idiopathic hyperprolactinemia., Study Design: Cabergoline was administered orally at a dose of 0.5 mg twice per week to 164 de novo hyperprolactinemic patients until serum prolactin level normalized. After this initial treatment phase, patients started on maintenance phase for which they were previously randomized. No maintenance treatment (Group I, n = 36) or cabergoline 0.5 mg (Group II, n = 46), 0.25 mg (Group III, n = 39), 0.125 mg (Group IV, n = 43) was administered twice per week for 8 weeks as maintenance treatment. Then, maintenance phase was finalized and patients were followed up for 6 months. Mean serum prolactin levels through maintenance treatment phase and follow-up period were assessed between groups and within groups., Results: Except for group I, all the groups showed a similar pattern with fast decrease of serum prolactine level during maintenance phase and slower increase during the follow-up period. Notably, the average prolactin level was significantly lower at the last follow-up visit than at the diagnosis time in all of the groups. Stable normoprolactinemia of the groups at the end of follow-up period were 47.2, 37, 48.7, and 34.9%, respectively., Conclusions: The results indicate that short maintenance treatment in idiopathic and microadenoma-related hyperprolactinemia seems as effective as long maintenance treatment in the present study. But, further studies with larger study population and longer follow-up period are needed to make a decision about early treatment withdrawal. Also, during the maintenance treatment administration of medicine to patients should be tapered down to the lowest dose that will maintain prolactin levels normal.

Unlabelled: We present a case of uterine prolapse complicating a second trimester pregnancy which was managed successfully with a vaginal pessary., Case: A 19 year-old primigravid woman referred to the obstetric emergency unit at the 16th week of gestation complaining of uterine prolapse. A silicone ring-shaped middle-size vaginal pessary was placed into the vagina. On each control visit, when the vaginal pessary was removed, the uterine prolapse still persisted until birth. The patient gave birth at 38(th) week by spontaneous vaginal delivery to a healthy baby. After birth, with uterine contractions, uterine prolapse regressed progressively., Conclusion: The management and treatment of uterine prolapse in pregnancy should be individualized depending on the patient's preference. A vaginal pessary may be helpful to avoid complications of this condition and should be considered during patient counseling.

Purpose: To determine the diagnostic accuracy of different diagnostic methods (blind dilatation & curettage (D&C), transvaginal ultrasonography (TVS), sonohysterography (SH), and hysteroscopy) compared with gold standard (hysteroscopic biopsy's histopathologic result) in diagnosis of focal intrauterine lesions of recurrent postmenopausal bleeding., Methods: 36 postmenopausal women with recurrent vaginal bleeding after a normal D&C results were enrolled into the study. TVS, SH, hysteroscopy were performed on all patients. Outcomes of blind D&C, TVS, SH, and hysteroscopy were compared with results of gold standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LR) were calculated., Results: Blind D&C sensitivity, specificity, PPV, and NPV were 47, 68, 57, 59%, respectively in comparison with gold standard. Blind D&C fails to diagnose 70% of all focal intracavitary lesions. TVS sensitivity, specificity, PPV, NPV were 63, 78, 89, 41%, respectively. SH yielded better results; with 93% sensitivity, 56% specificity, 86% PPV, and 71% NPV. Hysteroscopy sensitivity, specificity, PPV, and NPV were 100, 44, 84, 100%, respectively., Conclusions: In experienced hands, SH can be an initial evaluation method of uterine cavity for detecting focal lesions in women with recurrent postmenopausal bleeding.

Objective: To investigate the relationship between adverse pregnancy outcomes and unexplained elevations of second trimester maternal serum human chorionic gonadotropin (hCG), alpha fetoprotein (AFP) levels and uterine artery Doppler measurements., Methods: A total of 144 women between 16-20 weeks of gestation that applied to our clinic for triple test were enrolled into the study. Study group consisted of 84 pregnant women with hCG and/or AFP levels > or =2 MoM. Control group comprised of 60 pregnant women with hCG and AFP levels <2 MoM. Study group was further subdivided into 3 subgroups: Subgroup I; only AFP> or =2 MoM (n=30), subgroup II; only hCG > or =2 MoM (n=64) and subgroup III; both AFP and hCG > or =2 MoM (n=10)., Result: Operative delivery rate (p = 0.0017), overall complication rate (p=0.0002), bilateral early diastolic notch presence rate (p = 0.015) were high and mean birth weight was low (p=0.045) in the study group. In subgroup I patients, low birth weight [LBW] (p = 0.0008), preterm delivery (p = 0.0001), preeclampsia (p = 0.003) and preterm premature rupture of membranes [PPROM] (p = 0.012) rates were high. In subgroup II patients, only small for gestational age baby [SGA] (p = 0.016) rate was high. In subgroup III patients LBW (p = 0.009), preterm delivery (p = 0.0001) and PPROM (p = 0.01) rates were high. According to Doppler velocimetry studies, bilateral early diastolic notch presence rate was high (p = 0.015) in the study group., Conclusion: Patients with high AFP levels and bilateral uterine artery diastolic notch presence, are candidates for pregnancy complications and these groups of patients should be followed up more intensively.

Essential thrombocythaemia (ET) is a disease characterized by an increased platelet count, megakaryocytic hyperplasia and a hemorrhagic or thrombotic tendency. Pregnancy in patients with ET can have a favorable outcome. However, ET has also been reported to complicate pregnancy by recurrent abortions, intrauterine death, and fetal growth retardation due to placental infarctions. ET has an unusual prevalence of intraabdominal (hepatic, portal and mesenteric) vein thrombosis, especially in young patients, which can lead to portal hypertension. There are ample cases in the literature of both essential thrombocytosis complicating pregnancy and portal hypertension complicating pregnancy, but the coincidence of both conditions appears to be unique. In this case report, we report a successful pregnancy in a patient with a prior diagnosis of essential thrombocytosis with remote secondary portal vein thrombosis and portal hypertension (PH).

Objective: To compare the efficacy of vaginal versus sublingual misoprostol for second-trimester pregnancy termination, and to evaluate the effect on the blood flow of the uterine and umbilical arteries., Methods: Forty-nine patients were randomized to receive either 200 microg of vaginal misoprostol every 6 hours or 200 microg of misoprostol sublingually every 6 hours. Doppler velocimetry studies were assessed immediately before and 60 minutes after the administration of the first dose. Standard descriptive calculations, Mann-Whitney U, Wilcoxon, and chi(2) tests were performed., Results: The mean interval between induction and onset of active labor, induction and delivery, and the duration of oxytocin administration were significantly shorter in the sublingual misoprostol group. Both routes of administration increased the Doppler indices for the uterine arteries; however, misoprostol via the sublingual route did not affect the umbilical arteries., Conclusion: Sublingual administration of misoprostol for second-trimester medical abortion results in a higher success rate and does not affect umbilical blood flow.

Pregnancy and cancer is a complex situation. The coincidence of chronic myelogeneous leukemia (CML) and pregnancy is an uncommon event, in part because CML occurs mostly in older age groups. The management of CML during pregnancy is a difficult problem because of the potential effects of the therapy on the mother and fetus. Imatinib is a relatively new drug in this era and it induces dramatic hematologic and cytogenetic responses in CML but it is not recommended for use during pregnancy or if the patient plans to conceive. In the literature there are very few reports of outcome of pregnancy conceived while on imatinib. In this report, we describe a successful pregnancy and labor under treatment of imatinib in a patient who was diagnosed with CML at the beginning of her pregnancy.

Single fetal death in a twin pregnancy in the late second or early third trimester is associated with significant morbidity and mortality rate in the surviving co-twin, especially in monochorionic twin pregnancies. The common causes are twin-to-twin transfusion syndrome, chromosomal abnormalities, and congenital anomalies of the fetus or anomalies of the umbilical cord-placenta. Here we report a case of monochorionic twin pregnancy in which one fetus had a single umbilical artery (SUA) while the co-twin had two umbilical arteries. The twin with SUA died in utero at the 30th week of gestation and the other fetus was delivered by cesarean section immediately due to fetal distress diagnosed by cardiotocography. Disseminated intravascular coagulation and multicystic encephalomalacia have been observed in the surviving neonate. This case and review of the literature suggest that neurologic complication rates are also increased in monochorionic twin pregnancies with single fetal demise despite the immediate delivery as in our case., (Copyright (c) 2005 S. Karger AG, Basel.)