Marmara Medical Journal Marmara Üniversitesi Tıp Fakültesi Dergisi

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2 Marmara Medical Journal Marmara Üniversitesi Tıp Fakültesi Dergisi Editör Prof. Dr. Mithat Erenus Koordinatörler Seza Arbay, MA Dr. Vera Bulgurlu Editörler Kurulu Prof. Dr. Mehmet Ağırbaşlı Prof. Dr. Serpil Bilsel Prof. Dr. Safiye Çavdar Prof. Dr. Tolga Dağlı Prof. Dr. Haner Direskeneli Prof. Dr. Kaya Emerk Prof. Dr. Mithat Erenus Prof. Dr. Zeynep Eti Prof. Dr. RainerVV. Guillery Prof. Dr. Oya Gürbüz Prof. Dr. Hande Harmancı Prof. Dr. Hızır Kurtel Prof. Dr. Ayşe Özer Prof. Dr. Tülin Tanrıdağ Prof. Dr. Tufan Tarcan Prof. Dr. Cihangir Tetik Prof. Dr. Ferruh Şimşek Prof. Dr. Dr. Ayşegül Yağcı Prof. Dr. Berrak Yeğen Doç. Dr. İpek Akman Doç. Dr. Gül Başaran Doç. Dr. Hasan Batırel Doç. Dr. Nural Bekiroğlu Doç. Dr. Şule Çetinel Doç. Dr. Mustafa Çetiner Doç. Dr. Arzu Denizbaşı Doç. Dr. Gazanfer Ekinci Doç. Dr. Dilek Gogas Doç. Dr. Sibel Kalaça Doç. Dr. Atila Karaalp Doç. Dr. Bülent Karadağ Doç. Dr. Handan Kaya Doç. Dr. Gürsu Kıyan Doç. Dr. Şule Yavuz Asist. Dr. Asım Cingi Asist. Dr. Arzu Uzuner

3 Marmara Medical Journal Marmara Üniversitesi T p Fakültesi Dergisi DERGİ HAKKINDA Marmara Medical Journal, Marmara Üniversitesi Tıp Fakültesi tarafından yayımlanan multidisipliner ulusal ve uluslararası tüm tıbbi kurum ve personele ulaşmayı hedefleyen bilimsel bir dergidir. Marmara Üniversitesi Tıp Fakültesi Dergisi, tıbbın her alanını içeren özgün klinik ve deneysel çalışmaları, ilginç olgu bildirimlerini, derlemeleri, davet edilmiş derlemeleri, Editöre mektupları, toplantı, haber ve duyuruları, klinik haberleri ve ilginç araştırmaların özetlerini, ayırıcı tanı, tanınız nedir başlıklı olgu sunumlarını,, ilginç, fotoğraflı soru-cevap yazıları (photo-quiz),toplantı, haber ve duyuruları, klinik haberleri ve tıp gündemini belirleyen güncel konuları yayınlar. Periyodu: Marmara Medical Journal -Marmara Üniversitesi Tıp Fakültesi Dergisi yılda 3 sayı olarak OCAK,MAYIS VE EKİM AYLARINDA yayınlanmaktadır. Yayına başlama tarihi: Yılından itibaren yanlızca elektronik olarak yayınlanmaktadır Yayın Dili: Türkçe, İngilizce eissn: Temel Hedef Kitlesi: Tıp alanında tüm branşlardaki hekimler, uzman ve öğretim üyeleri, tıp öğrencileri İndekslendiği dizinler: EMBASE - Excerpta Medica,TUBITAK - Türkiye Bilimsel ve Teknik Araştırma Kurumu, Türk Sağlık Bilimleri İndeksi, Turk Medline,Türkiye Makaleler Bibliyografyası,DOAJ (Directory of Open Access Journals) Makalelerin ortalama değerlendirme süresi: 8 haftadır Makale takibi -iletişim Seza Arbay Marmara Medical Journal (Marmara Üniversitesi Tıp Fakültesi Dergisi) Marmara Üniversitesi Tıp Fakültesi Dekanlığı, Tıbbiye cad No:.49 Haydarpaşa 34668, İSTANBUL Tel: Faks: +90 O e-posta: mmj@marmara.edu.tr Yayıncı Plexus BilişimTeknolojileri A.Ş. Tahran Caddesi. No:6/8, Kavaklıdere, Ankara Tel: Faks: Yayın Hakları: Marmara Medical Journal in basılı ve web ortamında yayınlanan yazı, resim, şekil, tablo ve uygulamalar yazılı izin alınmadan kısmen veya tamamen herhangi bir vasıtayla basılamaz. Bilimsel amaçlarla kaynak göstermek kaydıyla özetleme ve alıntı yapılabilir.

4 Marmara Medical Journal Marmara Üniversitesi Tıp Fakültesi Dergisi YAZARLARA BİLGİ Marmara Medical Journal Marmara Üniversitesi Tıp Fakültesi Dergisine ilginize teşekkür ederiz. Derginin elektronik ortamdaki yayınına erişim adresinden serbesttir. Marmara Medical Journal tıbbın klinik ve deneysel alanlarında özgün araştırmalar, olgu sunumları, derlemeler, davet edilmiş derlemeler, mektuplar, ilginç, fotoğraflı soru-cevap yazıları (photo-quiz), editöre mektup, toplantı, haber ve duyuruları, klinik haberleri ve ilginç araştırmaların özetlerini yayınlamaktadır. Yılda 3 sayı olarak Ocak, Mayıs ve Ekim aylarında yayınlanan Marmara Medical Journal hakemli ve multidisipliner bir dergidir.gönderilen yazılar Türkçe veya İngilizce olabilir. Değerlendirme süreci Dergiye gönderilen yazılar, ilk olarak dergi standartları açısından incelenir. Derginin istediği forma uymayan yazılar, daha ileri bir incelemeye gerek görülmeksizin yazarlarına iade edilir. Zaman ve emek kaybına yol açılmaması için, yazarlar dergi kurallarını dikkatli incelemeleri önerilir. Dergi kurallarına uygunluğuna karar verilen yazılar Editörler Kurulu tarafından incelenir ve en az biri başka kurumdan olmak üzere iki ya da daha fazla hakeme gönderilir. Editör, Kurulu yazıyı reddetme ya da yazara(lara) ek değişiklikler için gönderme veya yazarları bilgilendirerek kısaltma yapmak hakkına sahiptir. Yazarlardan istenen değişiklik ve düzeltmeler yapılana kadar, yazılar yayın programına alınmamaktadır. Marmara Medical Journal gönderilen yazıları sadece online olarak adresinden kabul etmektedir. Yazıların bilimsel sorumluluğu yazarlara aittir. Marmara Medical Journal yazıların bilimsel sorumluluğunu kabul etmez. Makale yayına kabul edildiği takdirde Yayın Hakkı Devir Formu imzalanıp dergiye iletilmelidir. Gönderilen yazıların dergide yayınlanabilmesi için daha önce başka bir bilimsel yayın organında yayınlanmamış olması gerekir. Daha önce sözlü ya da poster olarak sunulmuş çalışmalar, yazının başlık sayfasında tarihi ve yeri ile birlikte belirtilmelidir. Yayınlanması için başvuruda bulunulan makalelerin, adı geçen tüm yazarlar tarafından onaylanmış olması ve çalışmanın başka bir yerde yayınlanmamış olması ya da yayınlanmak üzere değerlendirmede olmaması gerekmektedir. Yazının son halinin bütün yazarlar tarafından onaylandığı ve çalışmanın yürtüldüğü kurum sorumluları tarafından onaylandığı belirtilmelidir.yazarlar tarafından imzalanarak onaylanan üst yazıda ayrıca tüm yazarların makale ile ilgili bilimsel katkı ve sorumlulukları yer almalı, çalışma ile ilgili herhangi bir mali ya da diğer çıkar çatışması var ise bildirilmelidir.( * ) ( * ) Orijinal araştırma makalesi veya vaka sunumu ile başvuran yazarlar için üst yazı örneği: "Marmara Medical Journal'de yayımlanmak üzere sunduğum (sunduğumuz) " -" başlıklı makale, çalışmanın yapıldığı laboratuvar/kurum yetkilileri tarafından onaylanmıştır. Bu çalışma daha önce başka bir dergide yayımlanmamıştır (400 sözcük ya da daha az özet şekli hariç) veya yayınlanmak üzere başka bir dergide değerlendirmede bulunmamaktadır. Yazıların hazırlanması Derginin yayın dili İngilizce veya Türkçe dir. Türkçe yazılarda Türk Dil Kurumu Türkçe Sözlüğü ( esas alınmalıdır. Anatomik terimlerin ve diğer tıp terimlerinin adları Latince olmalıdır. Gönderilen yazılar, yazım kuralları açısından Uluslararası Tıp Editörleri Komitesi tarafından hazırlanan Biomedikal Dergilere Gönderilen Makalelerde Bulunması Gereken Standartlar a ( Uniform Requirements For Manuscripts Submittted to Biomedical Journals ) uygun olarak hazırlanmalıdır. ( ulakbim.gov.tr /cabim/vt) Makale içinde kullanılan kısaltmalar Uluslararası kabul edilen şeklide olmalıdır (http..//

5 knasyaz/) kaynağına başvurulabilir. Birimler, Ağırlıklar ve Ölçüler 11. Genel Konferansı'nda kabul edildiği şekilde Uluslararası Sistem (SI) ile uyumlu olmalıdır. Makaleler Word, WordPerfect, EPS, LaTeX, text, Postscript veya RTF formatında hazırlanmalı, şekil ve fotoğraflar ayrı dosyalar halinde TIFF, GIF, JPG, BMP, Postscript, veya EPS formatında kabul edilmektedir. Yazı kategorileri Yazının gönderildiği metin dosyasının içinde sırasıyla, Türkçe başlık, özet, anahtar sözcükler, İngilizce başlık, özet, İngilizce anahtar sözcükler, makalenin metini, kaynaklar, her sayfaya bir tablo olmak üzere tablolar ve son sayfada şekillerin (varsa) alt yazıları şeklinde olmalıdır. Metin dosyanızın içinde, yazar isimleri ve kurumlara ait bilgi, makalede kullanılan şekil ve resimler olmamalıdır. Özgün Araştırma Makaleleri Türkçe ve İngilizce özetler yazı başlığı ile birlikte verilmelidir. (i)özetler: Amaç (Objectives), Gereç ve Yöntem (Materials and Methods) ya da Hastalar ve Yöntemler (Patients and Methods), Bulgular (Results) ve Sonuç (Conclusion) bölümlerine ayrılmalı ve 200 sözcüğü geçmemelidir. (ii) Anahtar Sözcükler Index Medicus Medical Subject Headings (MeSH) e uygun seçilmelidir. Yazının diğer bölümleri, (iii) Giriş, (iv) Gereç ve Yöntem / Hastalar ve Yöntemler, (v) Bulgular, (vi) Tartışma ve (vii) Kaynaklar'dır. Başlık sayfası dışında yazının hiçbir bölümünün ayrı sayfalarda başlatılması zorunluluğu yoktur. Maddi kaynak, çalışmayı destekleyen burslar, kuruluşlar, fonlar, metnin sonunda teşekkürler kısmında belirtilmelidir. Olgu sunumları İngilizce ve Türkçe özetleri kısa ve tek paragraflık olmalıdır. Olgu sunumu özetleri ağırlıklı olarak mutlaka olgu hakkında bilgileri içermektedir. Anahtar sözcüklerinden sonra giriş, olgu(lar) tartışma ve kaynaklar şeklinde düzenlenmelidir. Derleme yazıları İngilizce ve Türkçe başlık, İngilizce ve Türkçe özet ve İngilizce ve Türkçe anahtar kelimeler yer almalıdır. Kaynak sayısı 50 ile sınırlanması önerilmektedir. Kaynaklar Kaynaklar yazıda kullanılış sırasına göre numaralanmalıdır. Kaynaklarda verilen makale yazarlarının sayısı 6 dan fazla ise ilk 3 yazar belirtilmeli ve İngilizce kaynaklarda ilk 3 yazar isminden sonra et al., Türkçe kaynaklarda ise ilk 3 yazar isminden sonra ve ark. ibaresi kullanılmalıdır. Noktalamalara birden çok yazarlı bir çalışmayı tek yazar adıyla kısaltmamaya ve kaynak sayfalarının başlangıç ve bitimlerinin belirtilmesine dikkat edilmelidir. Kaynaklarda verilen dergi isimleri Index Medicus'a ( ery.fcgi?db=nlmcatalog) veya Ulakbim/Türk Tıp Dizini ne uygun olarak kısaltılmalıdır. Makale: Tuna H, Avcı Ş, Tükenmez Ö, Kokino S. İnmeli olguların sublukse omuzlarında kas-sinir elektrik uyarımının etkinliği. Trakya Univ Tıp Fak Derg 2005;22:70-5. Kitap: Norman IJ, Redfern SJ, (editors). Mental health care for elderly people. New York: Churchill Livingstone, Kitaptan Bölüm: Phillips SJ, Whisnant JP Hypertension and stroke. In: Laragh JH, Brenner BM, editors. Hypertension: Pathophysiology, Diagnosis, and Management. 2nd ed. New York: Raven Pres, 1995: Kaynak web sitesi ise: Kaynak makalerdeki gibi istenilen bilgiler verildikten sonra erişim olarak web sitesi adresi ve erişim tarihi bildirilmelidir. Kaynak internet ortamında basılan bir dergi ise: Kaynak makaledeki gibi istenilen bilgiler verildikten sonra erişim olarak URL adresi ve erişim tarihi verilmelidir. Kongre Bildirileri: Bengtsson S, Solheim BG. Enforcement of data protection, privacy and security in medical informatics. In: Lun KC, Degoulet P, Piemme TE, Rienhoff O, editors. MEDINFO 92. Proceedings of the 7th World Congress on Medical Informatics; 1992 Sep 6-10; Geneva, Switzerland. Amsterdam: North-Holland; 1992: Tablo, şekil, grafik ve fotoğraf Tablo, şekil grafik ve fotoğraflar yazının içine yerleştirilmiş halde gönderilmemeli. Tablolar, her sayfaya bir tablo olmak üzere yazının gönderildiği dosya içinde olmalı ancak yazıya ait şekil, grafik ve fotografların her biri ayrı bir imaj dosyası (jpeg yada gif) olarak gönderilmelidir.

6 Tablo başlıkları ve şekil altyazıları eksik bırakılmamalıdır. Şekillere ait açıklamalar yazının gönderildiği dosyanın en sonuna yazılmalıdır. Tablo, şekil ve grafiklerin numaralanarak yazı içinde yerleri belirtilmelidir. Tablolar yazı içindeki bilginin tekrarı olmamalıdır. Makale yazarlarının, makalede eğer daha önce yayınlanmış alıntı yazı, tablo, şekil, grafik, resim vb var ise yayın hakkı sahibi ve yazarlardan yazılı izin almaları ve makale üst yazısına ekleyerek dergiye ulaştırmaları gerekmektedir. Tablolar Metin içinde atıfta bulunulan sıraya göre romen rakkamı ile numaralanmalıdır. Her tablo ayrı bir sayfaya ve tablonun üst kısmına kısa ancak anlaşılır bir başlık verilerek hazırlanmalıdır. Başlık ve dipnot açıklayıcı olmalıdır. Sütun başlıkları kısa ve ölçüm değerleri parantez içinde verilmelidir. Bütün kısaltmalar ve semboller dipnotta açıklanmalıdır. Dipnotlarda şu semboller: ( ) ve P değerleri için ise *, **, *** kullanılmalıdır. SD veya SEM gibi istatistiksel değerler tablo veya şekildin altında not olarak belirtilmelidir. Grafik, fotoğraf ve çizimler ŞEKİL olarak adlandırılmalı, makalede geçtiği sıraya gore numaralanmalı ve açıklamaları şekil altına yazılmalıdır Şekil alt yazıları, ayrıca metinin son sayfasına da eklenmelidir. Büyütmeler, şekilde uzunluk birimi (bar çubuğu içinde) ile belirtilmelidir. Mikroskopik resimlerde büyütme oranı ve boyama tekniği açıklanmalıdır. Etik Marmara Medical Journal a yayınlanması amacı ile gönderilen yazılar Helsinki Bildirgesi, İyi Klinik Uygulamalar Kılavuzu,İyi Laboratuar Uygulamaları Kılavuzu esaslarına uymalıdır. Gerek insanlar gerekse hayvanlar açısından etik koşullara uygun olmayan yazılar yayınlanmak üzere kabul edilemez. Marmara Medical Journal, insanlar üzerinde yapılan araştırmaların önceden Araştırma Etik Kurulu tarafından onayının alınması şartını arar. Yazarlardan, yazının detaylarını ve tarihini bildirecek şekilde imzalı bir beyan ile başvurmaları istenir. Çalışmalar deney hayvanı kullanımını içeriyorsa, hayvan bakımı ve kullanımında yapılan işlemler yazı içinde kısaca tanımlanmalıdır. Deney hayvanlarında özel derişimlerde ilaç kullanıldıysa, yazar bu derişimin kullanılma mantığını belirtmelidir. İnsanlar üzerinde yapılan deneysel çalışmaların sonuçlarını bildiren yazılarda, Kurumsal Etik Kurul onayı alındığını ve bu çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedürlerin özelliği tümüyle kendilerine anlatıldıktan sonra, onaylarının alındığını gösterir cümleler yer almalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve TC. Sağlık Bakanlığı tarafından getirilen ve 28 Aralık 2008 tarih ve sayılı Resmi Gazete'de yayınlanan "Klinik araştırmaları Hakkında Yönetmelik" ve daha sonra yayınlanan 11 Mart 2010 tarihli resmi gazete ve sayılı Klinik Araştırmalar Hakkında Yönetmelikte Değişiklik Yapıldığına Dair Yönetmelik hükümlerine uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalar için de gereken izin alınmalı; yazıda deneklere ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir. Hasta kimliğini tanıtacak fotoğraf kullanıldığında, hastanın yazılı onayı gönderilmelidir. Yazı takip ve sorularınız için iletişim: Seza Arbay Marmara Universitesi Tıp Fakültesi Dekanlığı, Tıbbiye Caddesi, No: 49, Haydarpaşa 34668, İstanbul Tel: Faks: e-posta: mmj@marmara.edu.tr

7 İÇİNDEKİLER Orjinal Araştırma THE INCIDENCE OF LOW BIRTH WEIGHT IN 5000 LIVEBORN INFANTS AND THE ETIOLOGY OF FETAL RISK FACTORS Emel Altuncu, Sultan Kavuncuoğlu, Pınar Özdemir Gökmirza, Zeynel Albayrak, Ayfer Arduç. 46 THE ROLE OF VAGINAL MATURATION VALUE ASSESSMENT IN PREDICTION OF VAGINAL PH, SERUM FSH AND E 2 LEVELS Pınar Yörük, Meltem Uygur, Mithat Erenus, Funda Eren RELATIONSHIP BETWEEN ELEVATED SERUM CRP LEVEL AND DIABETES MELLITUS IN ACUTE MYOCARDIAL INFARCTION Kenan Topal, Sunay Sandıkçı, Hakan Demirhindi, Ersin Akpınar, Esra Saatçı...58 SOCIAL ISOLATION STRESS IN THE EARLY LIFE REDUCES THE SEVERITY OF COLONIC INFLAMMATION Sevgin Özlem İşeri, Fatma Tavsu, Beyhan Sağlam, Feriha Ercan, Nursal Gedik, Berrak C. Yeğen...65 Olgu Sunumu LAPAROSCOPIC APPROACH FOR EPIPHRENIC ESOPHAGEAL DIVERTICULA Osman Kurukahvecioğlu, Ekmel Tezel, Bahadır Ege, Hande Köksal, Emin Ersoy NEONATAL MIXED SEX-CORD STROMAL TUMOR OF THE TESTIS: A CASE REPORT Asıf Yıldırım, Erem Başok, Adnan Başaran, Ebru Zemheri, Reşit Tokuç SECONDARY MALIGNANCIES AFTER LYMPHOMA TREATED BY RADIOTHERAPY- CASE REPORT Alper Çelik, Suat Kutun, Turgay Fen, Gülay Bilir, Akın Önder, Abdullah Çetin TWO NEW KABUKI CASES OF KABUKI MAKE-UP SYNDROME Ahmet Sert, Mehmet Emre Atabek, Özgür Pirgon...86 Derleme IS THERE A HIDDEN HIV/AIDS EPIDEMIC IN TURKEY?: THE GAP BETWEEN THE NUMBERS AND THE FACTS Pınar Ay, Selma Karabey MAGNETIC RESONANCE IMAGING AND ANESTHESIA Berrin Işık. 98

8 ORIGINAL RESEARCH THE INCIDENCE OF LOW BIRTH WEIGHT IN 5000 LIVEBORN INFANTS AND THE ETIOLOGY OF FETAL RISK FACTORS Emel Altuncu, Sultan Kavuncuoğlu, Pınar Özdemir Gökmirza, Zeynel Albayrak, Ayfer Arduç Ministry of Health,Istanbul Bakırköy Maternity and Children Teaching Hospital, Department of Pediatrics, Istanbul, Türkiye. ABSTRACT Objective: To identify the low birth weight (LBW) incidence in 5000 live born babies in the Bakirkoy Maternity and Children Teaching Hospital. Material and Methods: LBW was defined as infant weight below 2500g and these infants constituted the study group. Babies with normal birth weight (NBW) chosen randomly in equal numbers from 5000 live born babies formed the control group. Presentation, route of delivery, congenital anomaly, multiple births and the sex of the infants were also recorded. Results: In the 5000 live born babies, incidence of LBW was 9.14%. The incidence of preterm and full term was 5.7% and 3.4%, respectively. Of the LBW infants, 62.8% were preterm, 37.2% were full term. The rate of multiple gestations was found to be 13.9% in LBW infants and 0.8% in NBW infants. Excluding multiple gestations, 46.4% of the babies in the LBW group were female, and 53.6% were male. In the NBW group, the rates were 46.3% and 53.7% respectively. Abdominal delivery was seen in 32.3% of the LBW infants and 21.6% in the NBW infants. The rate of breech presentation was higher in the LBW (5.1%) than in the NBW infants (1.3%). The incidence of congenital anomaly was 6.2% in the LBW group and 3.3% in the NBW group. Conclusion: The sex of the infant did not have any influence on the birth weight; however, multiple gestation and congenital anomaly were important factors. Additionally, abdominal delivery and non-vertex presentations were observed more frequently in the LBW infants. Keywords: Low birth weight, Incidence, Aetiology 5000 CANLI DOĞUMDA DÜŞÜK DOĞUM AĞIRLIKLI BEBEK ORANI VE ETYOLOJİDEKİ FETAL RİSK FAKTÖRLERİ ÖZET Amaç: Hastanemizde gerçekleşen 5000 canlı doğumdaki düşük doğum ağırlıklı (DDA) bebek oranını belirlemek amaçlandı. Gereç ve Yöntem: Doğum ağırlığı 2500g altında olan bebekler düşük doğum ağırlıklı olarak tanımlandı ve çalışma grubunu oluşturdu canlı doğum içinden basit rastgele yöntemle seçilen, DDA bebeklerle aynı sayıda normal doğum ağırlıklı (NDA) bebek alınarak kontrol grubu oluşturuldu. Tüm bebekler için cinsiyet, doğum şekli, çoğul gebelikler ve konjenital anomali varlığı öğrenildi. Bulgular: Beşbin canlı doğumda DDA sıklığı %9.14, term ve preterm DDA bebeklerin sıklığı ise sırasıyla %5.7 ve %3.4 idi. DDA bebeklerin %62.8'i preterm, %37.2'si term bulundu. Çoğul gebelik sıklığının DDA bebeklerde %13.9 ve NDA bebeklerde %0.8 olduğu görüldü. Çoğul gebelikler dışlandıktan sonra iki grup karşılaştırıldı. DDA bebeklerin %46.4'i kız, %53.6'si erkek, NDA bebeklerin %46.3'ü kız ve %53.7'sı erkekti. Sezeryanla doğum DDA bebeklerde (%32.3), NDA bebeklerden (%21.6) daha fazlaydı. Benzer şekilde, makat doğum DDA bebeklerde daha sık görüldü (sırasıyla %5.1 ve %1.3). Konjenital anomali sıklığı DDA bebeklerde %6.2 iken, bu oran NDA bebeklere %3.3 olarak bulundu. Sonuç: Bebeğin cinsiyetinin doğum ağırlığına etkisi görülmezken, çoğul gebelik ve konjenital anomali varlığı doğum ağırlığını etkilemekteydi. Ayrıca, DDA bebeklerde sezeryanla doğum ve baş geliş dışındaki prezentasyonlar daha sık görülmekteydi. Anahtar Kelimeler: Düşük doğum ağırlığı, Sıklık, Etyoloji İletişim Bilgileri: Emel Altuncu SB. Istanbul Bakırköy Maternity and Children Teaching Hospital,Department of Pediatrics, Istanbul, Turkey Marmara Medical Journal 2006;19(2);

9 Marmara Medical Journal 2006;19(2);46-51 Emel Altuncu, et al. The incidence of low birth weight in 5000 liveborn infants and the etiology of fetal risk factors INTRODUCTION Low birth weight (LBW) is responsible for 60% of the infant mortality in the first year of life and it carries a 40-fold increase in the risk of neonatal mortality during the first month 1-4. Since birth weight has a strong correlation with infant survival, attentions have been given to strategies that will reduce the proportion of infants with LBW. With recent advances in modern obstetric and neonatal care and technological development, high risk neonates have a greater chance of survival in the newly formed intensive care units. This also causes an increase in the rate of LBW infants, and subsequently an increased rate of long-term neurological sequelae. The World Health Organization has estimated that annually 24 million LBW infants are born in developing countries. As the prevalence of LBW infants is around 5% in many industrialized countries, it changes between 5-30% in underdeveloped or developing countries 3,5-12. If we take into account that, millions of LBW infants are born annually in the World, we need to begin researching the health of neonates starting with birth weight. In this prospective study, we aimed to identify the LBW incidence in 5000 live born babies in our hospital and the associated risk factors of LBW related to the infant. We also aimed to evaluate the rate of infants who were small for gestational age (SGA), rate of preterm delivery, their sex distribution, route of delivery, presentation, incidence of multiple gestations and congenital anomalies. METHODS In this prospective cross-sectional study, 5000 live born babies were evaluated randomly between October 2000-May 2001 in the Bakirköy Maternity and Children s Hospital in Istanbul. Aborted babies and stillbirths were excluded because of difficulties in accurately defining gestational age. The infants were weighed on an electronic metric scale in the delivery room immediately after birth. LBW was defined as infant weight below 2500g and these infants constituted the study group. Since the accurate date of the last menstrual period was not known in about one third of the mother and due to failing routines in the maternity ward, the gestational age was estimated by Ballard scoring performed in the first 24 hours after delivery. Babies born before 37 completed gestational weeks were defined as preterm. The neonates were examined and all anthropometric measurements were obtained at the same time. A baby was classified as SGA if the birth weight fell below the 10th percentile for gestational age, based on Lubchencho curves. The sex of the infants, presentation, route of delivery, congenital anomaly and multiple births were recorded on prepared forms. A history of congenital anomaly in the family was also obtained. Babies with normal birth weight (NBW) ( 2500g) chosen randomly in equal numbers from 5000 live born babies formed the control group and the same parameters were evaluated for this group. We used Chi Square and Mantel-Haenszel tests for statistical analysis. Statistical significance in this study was defined as p<0,05. RESULTS Of the 5000 live born babies, 457 were LBW infants. The overall incidence of the LBW was 9.14% and 62.8% of the LBW infants were preterm, 37.2% were full term. The incidence of preterm delivery and full term SGA was 5.7% and 3.4%, respectively. The preterm SGA incidence was 1.1%. NBW infants chosen randomly in equal numbers were 457 in number and incidence of preterm delivery was 2.4%. The mean gestational age and birth weight of the infants in two groups were shown in Table I. The birth weight of 3.3% of the LBW infants was less than 1000g, 10.7% weighed between g, 22.3% weighed between g and 63.7% were between g. There were 410 mothers in the LBW group and 456 mothers in the NBW group. The rate of multiple gestations was found to be 13.9% in the LBW infants and 0.8% in the NBW infants (Table I). There was a statistically significant difference between the two groups (x 2 =52.01, p=0.000). Multiple gestations were found to be an important risk factor in the aetiology of LBW. To evaluate the other risk factors related to the birthweight, we excluded the multiple gestations.excluding multiple gestations, there were 353 infants in the LBW group and 453 infants in the NBW group. In the LBW group, 46.4% were female, 53.6% were male and in the NBW group 46.3% were female, 53.7% were male (Table I). No 47

10 Marmara Medical Journal 2006;19(2);46-51 Emel Altuncu, et al. The incidence of low birth weight in 5000 liveborn infants and the etiology of fetal risk factors statistically significant difference was found when comparing the sex of the babies in the two groups (x 2 =0.01, p=0.97). Mode of delivery was compared between the two groups. Delivery by way of caesarean section was seen in 32.3% of the LBW group and this rate was 21.6% in the NBW group (Table I). The difference was statistically significant (x 2 =11.63, p=0.001). The indications for abdominal delivery are in Table II. Elective abdominal deliveries were more frequent in the NBW infants but the preference for caeserean section was based more commonly on perinatal problems among the LBW births. Table I: Characteristics of LBW and NBW infants LBW NBW The mean gestational age (w) 35.8 ± ± 0.6 The mean birth weight (g) ± ± Multiple gestation (%) Female (%) Male (%) Caesarean section (%) Non-vertex presentation (%) Congenital anomalies (%) Table II: The indications for abdominal delivery in LBW and NBW infants Indications LBW NBW n:353 % n:453 % Fetal distress Elective C/S IUGR/LGA Preeclampsia Abruptio placenta Oligohydroamniosis Non-vertex presentation Placenta previa Premature rupture of membranes Cord presentation Fetal anomaly Maternal hyperthyroidism

11 Marmara Medical Journal 2006;19(2);46-51 Emel Altuncu, et al. The incidence of low birth weight in 5000 liveborn infants and the etiology of fetal risk factors The rate of breech presentation was higher in the LBW (5.1%) than in the NBW infants (1.3%). 1.4% of the LBW infants were born by incomplete breech presentation, but there were no babies born by incomplete breech presentation among the NBW infants (Table I). LBW was associated with increased rate of non-vertex presentations (x 2 =16.46, p=0.000). In this study, congenital anomalies of the study and the control groups were evaluated (Table III). The incidence was 6.2% in the LBW group and 3.3% in the NBW group (Table I). The difference between the two groups was important (x 2 =3.86, p=0.04). Among the LBW newborns having isolated or multiple congenital malformations, 2.5% were SGA and 3.7% were premature. The incidence of congenital malformations in all SGA babies was 5.8%. In our preterm population, the malformation incidence was 6.5%, but 54% of the preterm infants with congenital anomalies were preterm SGA babies. 72% of the LBW infants with congenital anomalies were full term or preterm SGA. A family history of congenital anomalies was seen in 2.8% of the LBW infants and in 2.4% of the NBW babies. There was no important difference statistically (x 2 =0.12, p=0.72). Also, the effect of consanguinity between parents on birth weight was evaluated. 7.5% of the cases had first-degree consanguinity between the mother and father in the LBW group and this rate was 7.8% in the NBW group. Second or higher degrees of consanguinity rates were 7% and 5%, respectively in both groups. This result did not create a statistically significant importance (x 2 =0.05, p=0.81). and consanguinity between parents was not found to be a risk factor in the aetiology of LBW. Table III: Congenital anomalies of LBW and NBW infants LBW NBW Isolated defects Congenital hip dislocation 6 2 (+ Pes equinovarus) 3 - Sacral sinus 2 4 Myeloschisis 1 - Hypospadias 3 1 Cryptorchidism 1 1 Inguinal hernia - 1 Ambiguous genitale 2 - Anal atresia/small intestine stenosis 1 1 Cleft lip and palate 2 - Extremity anomalies 3 - Others (diastasis recti, hypotelorism, 1 4 cleft uvula, penile mass) Multiple anomalies Down s Syndrome - 1 Ambiguous genitalia, hydrocephaly, vaginal atresia, anal atresia 1 - Myelomeningocele, hydrocephaly, extremity anomaly 1 - Atypical face, cyanotic congenital heart disease, limb anomaly 1 - Cleft lip and palate, microcephaly, atypical face, syndactylism 1-49

12 Marmara Medical Journal 2006;19(2);46-51 Emel Altuncu, et al. The incidence of low birth weight in 5000 liveborn infants and the etiology of fetal risk factors DISCUSSION In this study, incidence of LBW infants was 9.14% and this was similar to the literature 13. Previous studies have reported similar results, for example, the LBW rates in two different studies in Turkey were 8.7% and 10%, respectively 14,15. In many developed countries, LBW rates are around 5% 12. The rate of LBW in our study was similar to rates reported in developed countries. The similarity to developed countries can be based upon the contribution of only live born neonates. The perinatal mortality (34.9 ) is very high in our country and a great number of LBW and very LBW infants are lost during parturition 4. So this leads to misinterpretation of the outcome. Although multiple gestations represented only 2.09% of the live births, they account for a disproportionately large share of adverse pregnancy outcomes. With the development of obstetrical approaches, the incidence of multiple gestations began to increase. The risk of giving birth to a LBW infant increased significantly in multiple gestations in our study and 80% of multiple gestations resulted in preterm birth. Studies dealing with the aetiology of LBW have shown us that, female sex is an important risk factor and this is attributed to the predisposition of the female sex to the other risk factors 6,16,17. In our study, the rate of male and female sex among LBW infants was similar and this led us to conclude that the sex of the infant did not affect the weight of the baby. Other important results were the significant differences in the method of delivery and the presentations of neonates between the LBW and NBW groups. The rate of caesarean section was much higher in the LBW births (32.3%) than in the NBW births (21.6%). Delivery by way of caesarean section was seen more frequently in LBW infants and this indicated once more that LBW infants were more prone to morbidity and mortality. The rate of cephalic presentation was 93.5% in the LBW group, but 98.7% in the NBW group. When compared with cephalic presentation, breech births were associated with an increased rate of LBW. Whereas, the overall incidence of breech presentation in deliveries is only 3% to 4%, for infants weighing less than 2500g at birth, the incidence may be 30% or greater. As compared with the NBW infants, birth trauma and umbilical cord prolapsus are seen more commonly in LBW and/or breech births. During labour, the umbilical cord passes the cervix before the head, so the umbilical cord is entrapped in between the cervix and head. After the beginning of compression, delay in labour increases hypoxia. With a LBW infant, the size of the head is even greater in relation to that of the buttocks and the chance of entrapment is markedly increased. This condition results in increased hypoxia and because it needs traction, it can cause trauma to the spinal cord and skeletal system. Goldenberg and Nelson found that, during labour, the premature fetus in breech presentation was 16 times more likely to die than the premature fetus in vertex presentation 18. For these reasons, in LBW neonatesthe most rational method of delivery is caesarean section 19. In view of this information it may be said that, identification of high-risk pregnancies and choice of appropriate method of delivery have been successfully achieved in our hospital parallel to the literature. Intrauterine growth retardation (IUGR) is a frequently reported outcome among infants with congenital malformations. The presence of IUGR may indicate an underlying structural abnormality or aetiologically it may predispose to defects rather than vice versa 20. The rate of congenital malformations was 6.2% in the LBW group, 3.3% in the NBW group indicating a strong association between LBW and malformations. Among the LBW neonates with isolated or multiple congenital malformations, 2.5% were SGA and 3.7% were premature. However, the incidence of congenital malformations in all SGA babies, was 5.8%. In our preterm population, malformation incidence was 6.5%, but 54% of the preterm infants with congenital anomalies were preterm SGA babies. If we take full term and preterm SGA infants into consideration together, 72% of LBW infants with congenital anomalies were SGA. In a study reported in our hospital in 1999, congenital malformations was the fourth leading cause of death (11.4%) in perinatal mortality cases 4. The significant role of congenital malformation in the aetiology of the LBW, especially for IUGR, causing an increase from 3.3% to 8% in the risk of LBW indicates a need to check for malformations by performing antenatal ultrasonography more strictly in IUGR fetuses.furthermore, it emphasızes the need for a higher number of more developed genetic laboratories. There was a limitation in this study. Because our study was performed in a maternity ward, if there were no symptoms or sings reflecting congenital infections, we did not check for congenital 50

13 Marmara Medical Journal 2006;19(2);46-51 Emel Altuncu, et al. The incidence of low birth weight in 5000 liveborn infants and the etiology of fetal risk factors infections because of high cost. So we did not include the incidence of congenital infections in the aetiology of LBW. In summary, improving the community health should start with improving baby health, and developing new strategies to decrease the incidence of LBW infants should be the one of our first goals. A history of a LBW infant should be an indication to seek recurrent cases of low birth weight and to ensure that close monitoring of fetal growth is implemented in subsequent pregnancies. REFERENCES 1. Papageorgion A, Bardin CL The extremely-lowbirth-weight infant. In:Avery GB,Fletcher MA, MacDonald MG, eds. Pathophysiology and Management of the Newborn. Philadelphia:Lippincott Williams&Wilkins, 1999: Klaus MH, Fanaroff AA. Care of the high risk infant. Philadelphia:WB Saunders Company, 1993: Wessel H, Cnattingius S, Bergstrom S, Dupret A, Reitmaier P. Maternal risk factors for preterm birth and low birth weight in Cape Verde. Acta Obstet Gynecol Scand 1996; 75: Hanedan S. SSK. Bakırköy Dogumevi, Kadın ve Çocuk Hastalıkları Egitim Hastanesi, Uzmanlık Tezi. Modifiye Wigglesworth sınıflaması ile perinatal mortalitenin dogumda degerlendirilmesi Geary M, Rafferty G, Murphy JF. Comparison of live born and stillborn low birth weight and analysis of aetiological factors. Ir Med J 1997; 90: Wu S, Goldenberg RL. Intrauterine growth retardation and preterm delivery: Prenatal risk factors in an indigent population. Am J Obstet Gynecol 1990;162: Basso O, Olsen J, Christensen K. Low birth weight and prematurity in relation to paternal factors: a study of recurrence. Int J Epidemiology. 1999;28: Raine T.The risk of repeating low birth weight and the role of prenatal care. Obstet and Gynecol 1994;8: Mc Cormick MC. The contribution of low birth weight to infant mortality and childhood morbidity. N Engl J Med 1985; 312: Leung TN, Roach VJ, Lau TK. Incidence of preterm delivery in Hong Kong Chinese. Aust N Z J Obstet Gynaecol 1998;38: Najmi RS. Distribution of birth weights of hospital born Pakistani infant. JPMA J Pak Med Assoc 2000;50: Low Birth weight. A tabulation of available information. Maternal Health and Safe Motherhood Programme. World Health Organization and UNICEF, Genova WTO/MCH/ Can G, Çoban A,Oneş U,Özmen M, İnce Z. Yenidoğan ve hastalıkları. In: Neyzi O, Ertuğrul T, eds. Pediatri, 2nd ed. İstanbul: Nobel Tıp Yayınevleri, 1993; Arısoy AE, Sarman G. Chest and mid-arm circumferences in the identification of low birth weight infants. J Trop Pediatr 1995 ; 41: Kayhan M, Argon S, Kırcalıoglu N. Anneye baglı düşük dogum agırlıgı nedenlerine ilişkin bir çalışma. Jinekoloji ve Obstetride Yeni Görüş ve Gelişmeler Dergisi 1991: 2: Herceg A, Simpson JM, Thompson JF. Risk factors and outcomes associated with low birth weight delivery in the Australian Capital Territory J Paediatr Child Health. 1994; 30: Steketee RW, Wirima JJ, Hightower AW, Slutsker L, Heymann DL, Breman JG. The effect of malaria and malaria prevention in pregnancy on offspring birth weight, prematurity and intrauterine growth retardation in rural Malawi. Am J Trop Med Hyg 1996;55(1 Suppl): Goldenberg R, Nelson K. The premature breech. Am J Obstet Gynecol 1997; Salmancı N. Düşük Doğum tartılı bebekler. In:Dağoğlu T, ed. Neonatoloji, 1st ed. Istanbul:Nobel Tıp Kitapevleri, 2000;22: Khoury MJ, Erickson JD, Cordero JF, Mc Carthy BJ. Congenital malformations and intrauterine growth retardation: a population study. J Pediatr 1988;82:

14 ORIGINAL RESEARCH THE ROLE OF VAGINAL MATURATION VALUE ASSESSMENT IN PREDICTION OF VAGINAL PH, SERUM FSH AND E 2 LEVELS Pınar Yörük 1, Meltem Uygur 1, Mithat Erenus 1, Funda Eren 2 1 Marmara University, Obstetrics and Gynecology, İstanbul, Türkiye 2 Marmara University, Pathology, İstanbul, Türkiye ABSTRACT Introduction: The objective of this study is to detect the correlation between vaginal maturation value (MV) and vaginal ph measurement, serum FSH and E 2 levels in women without vaginal infection. Materials And Methods: Fifty women with vasomotor symptoms were enrolled at the present study. All women underwent vaginal ph assessment, measurement of serum FSH and E 2 levels and vaginal MV measurement in addition to routine follow-up. For determination of vaginal MV, pap smear from lateral vaginal wall was obtained and evaluated. Results: In women with atrophic symptoms, the age and vaginal ph levels were significantly higher than women without these symptoms. Highly significant correlation between vaginal ph, vaginal MV and serum FSH was detected. Similarly highly significant inverse correlation was present between vaginal ph levels and vaginal MV. Discussion: In summary, this study confirms that vaginal ph and MV are similar to FSH in the identification of patients who have low estrogen levels or who are menopausal. Methods of deriving vaginal ph and MV are simple, practical, quick and economic. As a conclusion, the present study demonstrated that vaginal ph measurement and vaginal MV assessment is similar in diagnosis and monitoring of estrogen deficiency in women with urogenital atrophic symptoms. Keywords: vaginal maturation value, ph, menopause VAJİNAL PH, SERUM FSH VE E2 SEVİYELERİNİ ÖN GÖRMEDE VAJİNAL MATURASYON İNDEKSİNİN DEĞERİ ÖZET Giriş: Bu çalışmanın amacı vajinal enfeksiyonu olmayan kadınlarda vajinal maturasyon değeri (MV) ile vajinal ph, serum FSH ve E2 değerleri arasındaki korelasyonu saptamaktır. Materyal ve Metotlar: Vasomotor semptomları olan 50 kadın çalışmaya dahil edildi. Kadınlara rutin takibe ek olarak vajinal ph, vajinal MV, serum FSH ve E2 ölçümleri uygulandı. Sonuçlar: Atrofik semptomları olan kadınlarda yaş ve vajinal ph değerleri semptomu olmayan kadınlara oranla anlamlı olarak daha yüksek bulundu. Vajinal ph, vajinal MV ve serum FSH arasında kuvvetli bir korelasyon tespit edildi. Benzer şekilde, vajinal ph değerleriyle vajinal MV arasında da kuvvetli ters korelasyon gözlendi. Tartışma: Bu çalışmanın sonuçları menopozda olan veya düşük serum östrojeni olan kadınların ayırımında vajinal ph ve vajinal MV değerlerinin serum FSH ile benzer olduğunu doğrulamaktadır. Vajinal ph ve MV ölçümü basit, pratik,hızlı ve ekonomiktir. Vajinal ph ve vajinal MV ölçümünün ürogenital atrofik şikayetleri olan kadınlarda östrogen eksikliğinin tanısında ve takibinde benzer olduğu gösterilmiştir. Anahtar Kelimeler: vajinal maturasyon değeri, ph, menopoz İletişim Bilgileri: Pınar Yörük pinyoruk@yahoo.com Marmara University, Obstetrics and Gynecology, İstanbul, Türkiye Marmara Medical Journal 2006;19(2);

15 Marmara Medical Journal 2006;19(2);52-57 Pınar Yörük, et al. The role of vaginal maturatıon value assessment in prediction of vaginal ph, serum fsh and E2 levels INTRODUCTION Menopause has great impacts on life-quality of all women and is defined as cessation of menstrual bleeding for at least 12 months, serum FSH value 40 miu/ml, and serum E 2 level < 20 pg/ml. It has been known for decades that without vaginal infections, vaginal ph is 4.5 during the reproductive years and > 4.5 before menarche and after menopause 1. Only methods of deriving vaginal ph were not practical, and had low sensitivity and specificity due to contamination with cervical mucus, blood, or semen 2. Vaginal maturation value (MV) of Meisels 3 calculated from the ratios of superficial, intermediate and parabasal cells in vaginal smears has been used to detect vaginal atrophy and estrogen deficiency in postmenopausal symptomatic women. MV is a useful marker to examine vaginal maturation and reveal vaginal estrogen deficiency regardless of the presence of inflammation 4. After the introduction of vaginal ph device, it has been proposed that determination of vaginal ph in the absence of vaginitis in an outpatient setting might be a diagnostic feature of menopause. In this study we aimed to detect the correlation of vaginal MV with vaginal ph measurement, serum FSH and E 2 levels in women with climacteric symptoms. METHODS Study population: Fifty peri-postmenopausal otherwise healthy women attending to our menopause outpatient clinic with climacteric symptoms for the first time were enrolled at the present study. Demograpic characteristics including age, gravidy, parity and body mass index (BMI) and urogenital atrophic symptoms were questioned by the presence of vaginal dryness, dyspareunia, pruritus and dysuri. All women underwent vaginal ph assessment, measurement of serum FSH and E 2 levels and vaginal MV measurement in addition to routine follow-up. Amine test was carried out simultaneously with vaginal ph assessment in order to rule out vaginal infections and exclude false positive ph values. Women who have surgical menopause, systemic diseases, positive amine test, previous vaginal surgery involving more than 1/3 of the vagina, and women with history of current or past therapy of estrogenprogesteron replacement are excluded. Vaginal ph measurement: Vaginal ph levels are measured by Quickvue Advance ph and Amines Test, developed by Quidel Corporation (San Diego, USA). This device is composed of a foil wrapped test (contains nitrazine yellow for ph test and bromocresol green for amines test), and sterile amine controlled cotton swabs. Cotton swabs are applied to the lateral vaginal wall, then rubbed over the entire surface of the tests. Results are interpreted by formation of blue plus or minus sign on each test. Afterwards, nitrazine paper is contacted to the vagina for 5 seconds, and the color of the paper is compared with a colorimetric scale on an enclosed card, and the ph value is determined. Vaginal MV assessment: Cytological evaluation was performed by vaginal smears collected from the mid-third of the vaginal lateral wall and evaluated in our Pathology Department. In a total of 100 exfoliation cells, parabasal cells (P), intermediary cells (I), and superficial cells (S) were counted and results were expressed as the maturation value (MV) of Meisels 3. Superficial cells were assigned a point value of 1.0, intermediate cells were assigned a point value of 0.5, and parabasal cells were assigned a point value of 0. The number of cells in each category was multiplied by the point value, and the 3 results were added to arrive at a maturation value. A value of 0 to 49 indicated low estrogen effect, a value of 50 to 64 indicated moderate estrogen effect, and a value of 65 to 100 indicated high estrogen effect. All examinations were interpreted by the same cytopathologist without prior knowledge of the subjects data. Statistical analysis: In women with negative amine test, chi-square test, Pearson correlation test and logistic regression test were used where appropiate to assess vaginal ph levels and vaginal MV with menopausal status and urogenital atrophic symptoms. For statistical analysis SPSS 11.5 (SPSS, Inc, Chicago, IL, U.S.A.) was used. RESULTS Out of 50 women enrolled, 2 had positive amine test and remaining 48 women were included into the statistical analysis. The mean age was 54,7 years (range years), mean body mass index was 25,5. Of the 48 women 18 (37,5%) had serum FSH levels < 40mIU/ml. The mean FSH value, E 2 value, and MV were 53,3 miu/ml; 17,4 pg/ml and 49,1 respectively. The percentage of women with pruritus was 18,7% (n=9); dysuri was 27% (n=13), vaginal dryness was 64,6% (n=31) and dyspareunia was 70,8% (n=34). All of the women with urogenital atrophic symptoms had vaginal ph values >5.2 (mean value 6,5±0,48), MV< 65 (mean value 34,7±16,2), serum FSH levels > 40 miu/ml and E2 levels < 20 pg/ml. The 53

16 Marmara Medical Journal 2006;19(2);52-57 Pınar Yörük, et al. The role of vaginal maturatıon value assessment in prediction of vaginal ph, serum fsh and E2 levels demographic and hormonal characteristics of the women according to the presence of any of the questioned urogenital atrophic symptoms are listed in Table 1. In women with atrophic symptoms, the age and vaginal ph levels were significantly higher than women without these symptoms (p<0,003; p<0,001 respectively). In addition, women with atrophic symptoms had significantly lower serum E 2 levels, and vaginal MV (p<0,001; p<0,01 respectively) (Figure 1). However, serum FSH levels were statistically similar between groups probably due to high standart deviation values. There was no significant difference between groups according to gravidy, parity and body mass index. Table 1: The demographic and hormonal characteristics of the women according to the presence of vaginal atrophic symptoms (+) (-) n=34 (70,8%) n=14 (29,2%) n=48 (100%) General Features Mean ± SD Mean ± SD Mean ± SD Age (yrs) 56,4 ± 5,1 ¹ 50,1 ± 4,8¹ 54,7 ± 5,5 Gravidy 3,3 ± 2,5 4,1 ± 2,2 3,5 ± 2,4 Parity 1,8 ± 1,2 2,2 ± 0,8 1,1 ± 3,5 BMI 25,1 ± 3,4 26,4 ± 3,7 25,5 ± 3,5 Hormonal Features Mean ± SD Mean ± SD Mean ± SD Serum FSH (miu/ml) 70,1 ± 23,2 12,6 ± 3,7 53,3 ± 32,8 E2 (pg/ml) 11,2 ± 5,4 4 32,2 ± 15,5 4 17,4 ± 13,4 Vaginal Mean ± SD Mean ± SD Mean ± SD Maturation Value 34,7 ± 16,2 ³ 83,8 ± 9,4³ 49,1 ± 26,7 Parabasal 19,7 ± 27,7 4,6 ± 7,4 15,3 ± 24,5 Intermediate 75,6 ± 26,9 32,8 ± 35,3 63,1 ± 35,2 Superficial 4,7 ± 9,4 62,5 ± 34,1 21,5 ± 33 ph 6,5 ± 0,48 ² 4,6 ± 0,31² 5,9 ± 0,95 ¹ = p<0,003; ² = p<0,001; ³ = p<0,01; 4 = p<0,001 Figure 1: A-B) Different examples of atrophic vaginal smear (Pap stain x 100) 54

17 Marmara Medical Journal 2006;19(2);52-57 Pınar Yörük, et al. The role of vaginal maturatıon value assessment in prediction of vaginal ph, serum fsh and E2 levels Figure 2: The inverse correlation between serum FSH levels and vaginal MV. (r=-0,868; p<0,01) Figure 3: The inverse correlation between vaginal ph and vaginal MV (r=-0,903; p<0,01) Pearson correlation analysis showed highly significant inverse correlation between vaginal MV and serum FSH (r=-0,87; p<0.01) (Figure 2). Similarly highly significant inverse correlation was present between vaginal ph levels and vaginal MV (r=-0,9; p<0,01) (Figure 3). Calculated correlation was moderate between vaginal MV and serum E 2 levels (r=0,55; p<0,01). MV significantly decreased concomitant with increasing serum FSH levels and increasing vaginal ph values. On the other hand, the decrease in MV only moderately correlated with decreasing circulating E 2 values. Lineer regression analysis was performed and showed significant increase of vaginal ph and significant decrease of MV with rising serum FSH levels. In the present study the positive and negative predictive values for vaginal MV < 65 to predict serum FSH levels 40mIU/ml was calculated as 100% and 83% respectively. DISCUSSION In the present study vaginal MV assessment and vaginal ph measurement correlates with serum FSH and E 2 levels. Accordingly estrogen deficiency in women can be detected by simply determining MV in vaginal smear specimens as well as measuring vaginal ph performed during routine gynecologic follow-up. The menopausal transition period lead to the development of certain signs and symptoms adversely affecting the life-quality of most women due to systemic estrogen deficiency. Most prominent of these symptoms are vasomotor hot flushes, insomnia, urogenital atrophy and problems in sexual function 5. In spite of the fact that vaginal dryness due to atrophic vaginitis is known to be present in up to 40% of postmenopausal women 6, the real incidence might be even higher since women, especially in advanced ages, regard these symptoms as age specific. Capewell et al, proposed that some clinical characteristics can predict the atrophy degree 7. In their study of 120 postmenopausal women, they found a correlation, among the atrophy degree at the vaginal cytology and the vaginal dryness at physical examination, low parity and physical thinness 7. However, Davila et al demonstrated weak correlations between symptoms scores and objective measures of genital atrophy 8. They concluded that vaginal ph is the solid predictor of maturation value and may be the most reliable indicator of urogenital atrophy 8. In the present study, the strong inverse correlation between vaginal ph and MV confirms the previous findings. According to the results of the present study, MV measurement can aid the clinicians to predict serum FSH levels and vaginal ph values. MV assessment alone could be a guide for the diagnosis and management of a woman with urogenital atrophy regardless of the presence of atrophic symptoms. The positive correlation between vaginal ph and serum FSH has been demonstrated previously in the meta-analysis of 16 reports by Roy et al 9. In their study they confirmed that vaginal ph reflects circulating estradiol levels 9. Therefore, with the 55

18 Marmara Medical Journal 2006;19(2);52-57 Pınar Yörük, et al. The role of vaginal maturatıon value assessment in prediction of vaginal ph, serum fsh and E2 levels use of vaginal ph values, it is possible to monitor the introduction dose, change the continuation dose and route of therapy in women receiving estrogen replacement therapy (ET). In women with urogenital atrophic symptoms, who receive ERT, elevated vaginal ph decrease to lower levels resulting in partially or completely relief of the symptoms 9. In a postmenopausal woman who is on ET, vaginal ph value of > 4,5 indicates low circulating estradiol levels, which suggests the need for an adjustment of dose or route of hormone therapy 10. However in the present study decreasing serum E 2 levels were only moderately correlated with increasing vaginal ph values and decreasing MV. It has been demonstrated previously that in some women although serum E 2 levels are sufficient, vaginal atrophy may persist 11. For them, augmenting oral therapy with topical vaginal estrogen may be necessary 12. In the present study the demonstrated inverse correlation between vaginal ph and MV point out that MV < 65, similarly, suggests vaginal estrogen deficiency although sufficient circulating E 2 levels might be detected, and administration of ET or adjustments in dose or route of ET would be necessary. In women with vaginitis, vaginal ph measurement has increased false positive results due to overgrowth of facultatively and obligately anaerobic bacteria 13, and is useful only for monitoring antimicrobial therapy. Therefore, amine test is preferably performed simultaneously with the vaginal ph measurement to rule out vaginal inflammation even in asymptomatic women. Conversely, MV is not adversely affected and can be safely used to document estrogen deficiency in women with vaginal inflammation. From previous studies it is known that body mass index can influence serum E 2 values and consecutively vaginal ph 9. In the present study body mass index of women without vaginal atrophic symptoms was similar to women with vaginal atrophy. Therefore body mass index was not a confounding factor in the present study. The positive and negative predictive values should be calculated by epidemiologic population-based studies. The power of this study is not obviously enough to calculate a solid predictive value of vaginal ph or MV for menopausal status. On the other hand, percentages mentioned reflect the population referring to our clinic and might aid the clinicians in diagnosis and follow-up. It should also be noted that the population included into the present study was perimenopausal and early postmenopausal women; therefore results classified according to urogenital atrophic symptoms might not be generalized for older women who regard these symptoms as age specific. In the present study we concluded that vaginal MV is similar to vaginal ph in the identification of patients who have low estrogen levels or who are menopausal. In postmenopausal women receiving ET, vaginal MV calculation would aid the clinicians, in the same manner as vaginal ph, to monitor the therapy, change the dose or route of administration, or augment the therapy with a topical vaginal estrogen. Methods of deriving vaginal MV and ph are simple, practical, quick and economic. Moreover, MV can be obtained simultaneously with Pap smear test, which is a part of routine follow-up, does not require additional intervention, and easily interpreted at office setting. As a conclusion the present study demonstrated that vaginal maturation value assessment, unlike serum E 2 levels, is similar to vaginal ph values in diagnosis and management of estrogen deficiency in perimenopausal and early postmenopausal women with urogenital atrophic symptoms regardless of receiving past or current estrogen replacement therapy. REFERENCES 1. Cruickshank, R., Sharman A. The biology of the vagina in human subjects: I, glycogen in the vaginal epithelium and its relation to ovarian activity; II, the bacterial flora and secretion of the vagina at various age-periods and their relation to glycogen in the vaginal epithelium; III, vaginal discharge of non-infective origin. J Obstet Gynaecol Br Empire, 1934(41): , , Rein, M.F., Muller, M. Trichomonas vaginalis and trichomonias, in Sexually transmitted diseases, K.K. Holmes, et al., Editors. 1990, McGraw-Hill: New York Meisels, A. The maturation value. Acta Cytol, (4): Chiechi, L.M., Putignano, G., Guerra, V., Schiavelli, M.P., Cisternino, A.M., Carriero, C. The effect of a soy rich diet on the vaginal epithelium in postmenopause: a randomized double blind trial. Maturitas, (4): Zapantis, G., Santoro, N. The menopausal transition: characteristics and management. Best Pract Res Clin Endocrinol Metab, (1): Bachmann, G.A., Nevadunsky N.S. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician, (10): Capewell, A.E., McIntyre M.A, Elton R.A. Postmenopausal atrophy in elderly women: is a vaginal smear necessary for diagnosis? Age Ageing, (2): Davila, G.W., Singh, A., Karapanagiotou, I., Woodhouse, S., Huber, K., Zimberg, S., et al. Are 56

19 Marmara Medical Journal 2006;19(2);52-57 Pınar Yörük, et al. The role of vaginal maturatıon value assessment in prediction of vaginal ph, serum fsh and E2 levels women with urogenital atrophy symptomatic? Am J Obstet Gynecol, (2): Roy, S., Caillouette, J.C., Roy, T., Faden, J.S. Vaginal ph is similar to follicle-stimulating hormone for menopause diagnosis. Am J Obstet Gynecol, (5): Caillouette, J.C., Sharp, C.F. Jr., Zimmerman, G.J., Roy, S. Vaginal ph as a marker for bacterial pathogens and menopausal status. Am J Obstet Gynecol, (6): ; discussion Benjamin, F., Deutsch, S. Immunoreactive plasma estrogens and vaginal hormone cytology in postmenopausal women. Int J Gynaecol Obstet, (6): Notelovitz, M. Estrogen therapy in the management of problems associated with urogenital ageing: a simple diagnostic test and the effect of the route of hormone administration. Maturitas, Suppl: S Cauci, S., Driussi, S., De Santo, D., Penacchioni, P., Iannicelli, T., Lanzafarne, P. et al. Prevalence of bacterial vaginosis and vaginal flora changes in peri- and postmenopausal women. J Clin Microbiol, (6):

20 ORIGINAL RESEARCH AKUT MYOKARD ENFARKTÜSÜNDE YÜKSELMİŞ SERUM CRP DÜZEYİ VE DİABETES MELLİTUS İLE İLİŞKİSİ Kenan Topal 1, Sunay Sandıkçı 1, Hakan Demirhindi 2, Ersin Akpınar 3, Esra Saatçı 3 1 Adana Numune Eğitim ve Araştırma Hastanesi, Aile Hekimliği, Adana, Türkiye 2 Çukurova Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, Adana, Türkiye 3 Çukurova Üniversitesi Tıp Fakültesi, Aile Hekimliği Anabilim Dalı, Adana, Türkiye ÖZET Amaç: Günümüzde aterosklerozun enflamatuar bir hastalık olduğu ve serum CRP düzeyinin, aterosklerozun şiddeti ve genişliği ile korele şekilde yükseldiği kabul edilmektedir. Bu çalışmada, Ocak 2000 ile Temmuz 2000 tarihleri arasında, Adana Numune Eğitim ve Araştırma Hastanesi Koroner Yoğun Bakım Ünitesi ne (KYBÜ) AMİ tanısıyla yatırılıp trombolitik tedavi uygulanan 55 hastada infarkt tipi ve genişliği ile serum CRP düzeyleri arasındaki ilişki incelendi. Gereç ve Yöntem: Göğüs ağrısının başlangıcından itibaren 12. saatte serum CRP, kardiak troponin İ, CK- MB, LDH, AST, beyaz küre, sedimantasyon düzeyleri incelendi. Bulgular: Serum CRP düzeyi ortalama 24.5 mg/l, beyaz küre sayısı ortalama 14.2 X10 3 /ml olup belirgin olarak yüksekti. Serum CRP düzeyi ile infarkt tipi ve genişliği arasında ilişki yoktu. Ayrıca CRP yüksekliği ile diabetes mellitus varlığı arasında pozitif yönde bir ilişki olduğu görüldü (r: 0.479, p<0.01). Sonuç: AMİ nde serum CRP düzeyinin yükselmesi, akut koroner sendromlarda enflamasyonun rolünü göstermesi açısından önemlidir. Anahtar Kelimeler: Ateroskleroz, enflamasyon, CRP, akut myokard enfarktüsü RELATIONSHIP BETWEEN ELEVATED SERUM CRP LEVEL AND DIABETES MELLITUS IN ACUTE MYOCARDIAL INFARCTION ABSTRACT Aim: Today, atherosclerosis is accepted as an inflammatory disease and serum CRP levels increase in correlation with the severity and extensiveness of atherosclerosis. The aim of this study is to investigate the relationship between infarct type and extensiveness and serum CRP levels in 55 patients hospitalized in Intensive Care Unit of Adana Numune Hospital for acute myocardial infarction (AMI) between January-July Methods: Serum CRP, cardiac troponin I, CK-MB, LDH, AST, WBC, ESR levels were performed within 12 hours after the onset of chest pain. Results: Serum CRP and WBC were significantly high with 24.5 mg/l and 14.2 X10 3 /ml, respectively. There was no relationship between serum CRP level and infarct type and extensiveness. There was positive correlation between CRP and diabetes mellitus (r: 0.479, p<0.01). Conclusion: Elevated serum CRP levels in AMI shows the role of inflammation in acute coronary syndromes. Keywords: Atherosclerosis, inflammation, CRP, acute myocardial infarction İletişim Bilgileri: Esra Saatçı esaatci@cu.edu.tr Çukurova Üniversitesi Tıp Fakültesi, Aile Hekimliği Anabilim Dalı, Adana, Türkiye 58 Marmara Medical Journal 2006;19(2);58-64