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AIM: To compare the outcome of intracytoplasmic sperm injection (ICSI) pregnancies complicated by spontaneous loss of a dichorionic co-twin with that of singleton ICSI pregnancies. METHODS: The study group included dichorionic ICSI pregnancies with co-twin loss (n = 33) and the control group included ICSI pregnancies with a singleton from the beginning (n = 327). Primary outcome measures were obstetric complications, including preterm delivery, newborn small for gestational age, gestational diabetes, gestational hypertensive disorders and abruptio placenta; admission to neonatal intensive care unit (NICU) and perinatal mortality observed in the study and control groups. Statistical analysis was performed using spss for Windows, version 22.0. RESULTS: In the study group, there were 26 cases of first trimester (early) and 7 cases of second or third trimester (late) co-twin losses. Mean gestational age at delivery and mean birth weight were significantly lower in the whole study group compared to control (P < 0.05). Preterm delivery and NICU admission rates were significantly higher in the whole study group, compared to control (39.3% vs 14.6% and 36.36% vs 11.69% respectively, P < 0.05), but did not show significant difference between early loss subgroup and control (P > 0.05). Preterm delivery rate was significantly higher in the late loss subgroup compared to the early loss subgroup (85.71% vs 26.92% P < 0.05). CONCLUSION: Loss of a co-twin in dichorionic ICSI pregnancies is associated with increased risk of preterm birth. This risk is significantly higher in cases with late loss compared to the early loss cases.

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Objective: To investigate the effectiveness of the metabolic markers homocysteine, vitamin B12, folate, and B-type natriuretic peptide in maternal and cord blood for detecting congenital heart disease.Methods: Homocysteine, vitamin B12, folate, and B-type natriuretic peptide concentrations in maternal and cord blood samples at term were measured in the case (n = 42) and control (n = 43) groups with and without fetal congenital heart disease, respectively. Additionally, newborns with congenital heart disease were divided into two subgroups: those with (n = 30) and without (n = 8) 6-month infant survival. The case and control groups and case subgroups were compared with each other with respect to maternal age, gravidity, parity, gestational age at delivery, birth weight, maternal and cord blood levels of homocysteine, vitamin B12, folate, and B-type natriuretic peptide, and arterial cord blood pH and base excess values. Statistical analyses were performed using SPSS for Windows, version 22.0. The Student's t-test, the Mann-Whitney U test, and the χ2 test were used where appropriate. A p value of < .05 was considered statistically significant.Results: Mean maternal age, birth weight and median gravidity, parity and gestational age at delivery were not significantly different between the case and control groups, as well as between the case subgroups (all p > .05). Concentrations of metabolic markers in maternal blood were not significantly different between the two groups (p > .05). Homocysteine and B-type natriuretic peptide levels in cord blood samples were significantly higher, whereas folate levels were significantly lower in the case group compared with the control group (all p < .05). Cord blood B-type natriuretic peptide levels were significantly higher (p < .05) and arterial cord blood pH values were significantly lower (p < .05) in the case subgroup without 6-month infant survival compared with the case subgroup with 6-month infant survival.Conclusion: High cord blood B-type natriuretic peptide and homocysteine levels and low cord blood folate levels at term may be useful for predicting congenital heart disease in the neonate. Neonates with congenital heart disease who have high cord blood B-type natriuretic peptide and low pH values may have adverse outcomes.

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Objective: To investigate pregnancy outcomes and to define preventative measures against to risk factors and complications in pregnancy after liver transplantation. Secondary aim is to report postpartum allograft functions in these patients.Method: This is a case series study. All pregnant women with liver transplantations performed in our hospital were enrolled. Patients' hospital medical records, electronic records Neonatal Intensive Care Unit (NICU) records were used to collect data. Obstetric characteristics and antenatal complications, risk factors, pregnancy and neonatal outcomes, all aspects of liver transplant variables and allograft functions after pregnancy were studied.Results: A total of 11 patients were included in the study. All of them were singleton. Mean maternal age was 29.3 ± 3.9 years. And mean gestational week of delivery was 37.2 ± 2.2. 78% of the women were delivered at term (>37 weeks) only two babies were preterm and discharged from NICU without any complications. Birth weight (gr median ± SD) was 2575 ± 345. Five (45%) patients were nulliparous, majority of the cases (8/11, 72%) were conceived of pregnant with natural way. Live birth rate was 81% (9/11). Only one patient for each has suffered from fetal growth restriction, maternal anemia, maternal hyperthyroidism, and ulcerative colitis. Vaginal bleeding was seen in five women during the pregnancy. There was no maternal death, stillbirth or neonatal death. The mode of delivery for all live birth pregnancies was C-section. And none of them was emergency C-section. No complication of allograft function was seen after pregnancy.Conclusion: Pregnancy in women with liver transplantation is not associated with poor pregnancy outcomes and complications for both the mother and the neonates when these patients followed up at tertiary referral center with multidisciplinary approaches.

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OBJECTIVE: First trimester nuchal translucency (NT) measurement is considered to be an important tool in antenatal follow-up. This study aimed to evaluate the outcomes of pregnancies with increased NT at Baskent University Ankara Hospital between 2004 and 2016. MATERIALS AND METHODS: Patients with NT measurements ≥1.5 multiples of median (MoM) were divided into two groups; group I included increased NT cases without fetal anomalies (either abnormal fetal karyotype or congenital structural anomalies) or loss (intrauterine fetal death), and group II included increased NT cases with fetal anomalies or loss. The groups were compared with each other with respect to maternal demographic features and NT measurements. RESULTS: Karyotype analyses were normal in 73.1% of cases with increased NT (57/78). Among those, 21.1% (12/57) had structural anomalies, and to specify, 9.6% (5/52 over 18 weeks) had cardiac anomalies. Although maternal demographic features did not differ significantly, NT measurements, both as millimeters and MoM, were significantly higher in group II (p<0.05). According to the receiver operating characteristic (ROC) curves, the optimal cut-off values for NT measurements for predicting fetal anomalies or loss were 3.05 mm and 2.02 MoM. NT measurement >7 millimeters or NT MoM >4.27 resulted in poor fetal outcomes without exception. CONCLUSION: Higher NT measurements indicate poorer pregnancy outcomes. Our study indicates that fetal echocardiography must be considered for all cases with increased NT.

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A 39-year-old woman who became pregnant with twins after an intracytoplasmic sperm injection was referred at the ninth gestational week to determine chorionicity. Ultrasonographic examination showed a monochorionic diamniotic twin pregnancy. First trimester nuchal translucency measurements of the fetuses were 1.6 and 2.7 mm. A non-invasive prenatal test was performed and revealed low risk. One fetus appeared to be female and the other male at the 14th gestational week. Second trimester anatomic scanning results were otherwise normal for both fetuses. The newborns delivered at term appeared to be normal female and male babies phenotypically. At the fourth month, buccal cell analysis showed chimeric karyotypes, 46,XX[98]/46,XY[2] and 46,XY[98]/46,XX[2] in the female and male infant, respectively. The recognition of sex discordance despite monochorionicity may be a clue for the diagnosis of such rare cases of chimerism in dizygotic twins, most of which occur in pregnancies obtained by assisted reproductive technology.

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OBJECTIVE: To analyze the maternal and perinatal characteristics of small-for-gestational-age (SGA) newborns compared with appropriate-for-gestational-age (AGA) newborns in singleton pregnancies managed at our hospital between January 2006 and December 2015. MATERIAL AND METHODS: The study (n=456) and control (n=4925) groups included pregnancies resulting in SGA and AGA newborns, respectively. Additionally, two SGA subgroups were defined according to abnormal (n=34) and normal (n=57) Doppler findings. Maternal demographic features; intracytoplasmic sperm injection (ICSI) pregnancies; gestational age at delivery; birth weight; major congenital anomalies, karyotype abnormalities, and genetic syndromes; maternal and obstetric problems such as hypertensive disorders, diabetes, oligohydramnios, preterm birth; admission to the neonatal intensive care unit (NICU), and perinatal mortality were recorded, and the two groups were compared with respect to these parameters. RESULTS: Mean maternal age, parity, gestational age at delivery, and birthweight were significantly lower; the frequencies of ICSI pregnancies, hypertensive disorders, oligohydramnios, preterm delivery, major congenital anomalies, karyotype abnormalities and genetic syndromes, admission to the NICU and perinatal mortality were significantly higher in the study group (p<0.05). None of the study parameters were significantly different between the two SGA subgroups (p>0.05). CONCLUSION: The association of SGA with ICSI pregnancies, hypertensive disorders, oligohydramnios, preterm delivery, congenital/chromosomal anomalies, NICU admission and perinatal mortality may be important in perinatal care. Clinical suspicion of SGA necessitates appropriate monitorization and management. Although obstetric outcomes were not significantly different between the two SGA subgroups with abnormal and normal Doppler findings in this study, this finding must be evaluated with caution due to the small sizes.

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There is an association between preeclampsia (PE) and excessive morbidity and mortality. Some recent studies have revealed the presence of endothelial dysfunction in PE patients with inflammatory activity. Moreover, it has been argued that the chronic inflammatory state involved in PE leads to an acceleration in atherosclerosis. Accordingly, our goal in this study is to determine whether there is any coronary microvascular dysfunction and increase in the intima-media thickness in patients who had mild PE 5 years before, without the presence of any traditional cardiovascular risk factors. The study included 33 mild PE patients (mild preeclampsia is classified as a blood pressure (BP) of 140/90 mm Hg or higher with proteinuria of 0.3 to 3 g/d) whose mean age was 33.7 years old, and 29 healthy women volunteers whose mean age was 36.1 years old. Each subject was examined using transthoracic echocardiography 5 years after their deliveries. During the echocardiographic examination, coronary flow reserve (CFR) and carotid intima-media thickness (IMT) were measured. There was a statistically lower CFR value in PE patients as compared with controls (2.39 ± 0.48 vs. 2.90 ± 0.49; P < .001). On the other hand, there was a significant increase in their IMT and high-sensitivity C-reactive protein (hs-CRP) values (respectively, 0.59 ± 0.15 vs. 0.46 ± 0.10; P < .001 and 3.80 ± 2.10 vs. 2.33 ± 1.79; P = .004). There was a negative correlation between the CFR values of the PE patients and hs-CRP (r = -0.568; P = .001) and IMT (r = -0.683, P < .001) results.We determined in the study that there was impaired CFR and increased carotid IMT in patients with PE, and, moreover, that these adverse effects were significantly correlated with hs-CRP.

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The aim of this study was to evaluate the relationship between neonatal mortality-morbidity and pregnancies with preterm premature rupture of membranes (PPROM), particularly those complicated by histologic chorioamnionitis (HCA), in preterm infants. A retrospective study was conducted on 58 preterm neonates born to 46 pregnant women with PPROM. Maternal characteristics, placental examination, and neonatal morbidity and mortality were analyzed. Of 1,392 deliveries, 46 (3.3%) pregnancies and 58 newborn infants were complicated with PPROM. HCA was present in 21 (1.5%) cases, and 15 of them were <28 weeks of gestational age. In the HCA (+) group, 8/21(38%) neonates had 5-minute Apgar scores of <5, 12/21 (57.1%) infants had patent ductus arteriosus (PDA), and 16/21 (76.1%) infants had respiratory distress syndrome (RDS). The latency period was significantly longer and the rate of chorioamnionitis and percentage of major neonatal morbidity and mortality were significantly higher in preterm infants with gestational age <28 weeks. Respiratory distress syndrome, perinatal hypoxia and PDA were significantly associated with HCA in preterm infants.

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OBJECTIVE: The purpose of this study was to evaluate the effects of Silymarin on vascular endothelial growth factor (VEGF), soluble VEGF Receptor-1 (sVEGFR-1) and Interleukin-1 alpha (IL-1α) levels in placental tissue samples of severely preeclamptic women. MATERIAL AND METHODS: We conducted an in vitro study in Baskent University Faculty of Medicine, Ankara, Turkey between September 2008 and May 2009. A total of 16 placental tissue samples (8 from severe preeclamptic, and 8 from controls) were analysed. Placental samples were incubated, and VEGF, sVEGFR-1, and IL1-α were measured in culture media using an ELISA kit. The effect of Silymarin on these levels was investigated. Descriptive statistics were initially performed, followed by Mann Whitney U-test and Kruskal-Wallis test to compare means between groups. P values less than 0.05 were considered statistically significant. RESULTS: Eight patients were included in the severe preeclampsia (SP) group, whereas the remaining 8 patients were included in the control group. There were no significant correlations between gestational age and placental VEGF, sVEGFR-1 and IL-1α after 48 or 72 hours of incubation. Basal VEGF levels were lower in the SP group; however, it did not reach statistical significance. sVEGFR-1 and IL-1α levels were also similar between the SP and control groups (p>0.05). After 48 and 72 hours of incubation, sVEGFR-1 levels in Silymarin-added SP and control placental cultures were lower than in the samples without Silymarin addition; however, this difference also did not reach significance. CONCLUSION: Although we could not demonstrate a significant effect on placental cytokines, considering the role of vasospasm, inflammation, angiogenesis, endothelial cell activation, and oxidative stress in preeclampsia, the potential benefits of Silymarin should be evaluated in future trials with a larger sample size.

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AIM: The aim of this retrospective study was to investigate the relation between perinatal complications in twin pregnancies and the combination of first-trimester maternal serum pregnancy-associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotrophin (ß-hCG) levels. MATERIAL AND METHODS: The study was conducted at the Perinatology Department of Baskent University between January 2005 and December 2011. In total, 104 patients with twin pregnancies were recruited. The association of first-trimester maternal serum-screening markers with perinatal complications was investigated for small-for-gestational-age (SGA) fetuses or intrauterine growth restriction (IUGR), preterm delivery (before 34 weeks of gestation), pregnancy-induced hypertension (PIH), and growth discordance between fetuses. RESULTS: Low serum PAPP-A (below 10th percentile) levels were not correlated with preterm labor, PIH, or IUGR in twin gestations. Elevated free ß-hCG levels (>90th percentile) were linked to increased rates of PIH and small-for-gestational-age fetuses or IUGR. CONCLUSION: Elevated first-trimester free ß-hCG was related to adverse pregnancy outcomes in twin pregnancies, whereas low PAPP-A levels were not linked to adverse pregnancy outcomes.

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OBJECTIVE: To evaluate first and second-trimester maternal serum markers in pregnancies complicated with inherited thrombophilias. METHODS: A case-control study was conducted in 50 pregnancies complicated with hereditary thrombophilia and 100 control pregnancies. RESULTS: Each woman with inherited thrombophilia received low molecular weight heparin (LMWH) throughout her pregnancy. Gravidity, parity, number of first-trimester and second-trimester abortions, and rate of adverse pregnancy outcomes (APO) were significantly higher in the thrombophilia group compared to the control group (P < 0.001 for all). Among the thrombophilia group median values of pregnancy associated placental protein-A (PAPP-A) (0.6 vs. 0.9; P < 0.001) and free ß-human chorionic gonadotropin (ß-hCG) (0.9 vs. 1.1; P = 0.001) in the first trimester; median values of α-fetoprotein (AFP) (0.7 vs. 1.1; P = 0.027), unconjugated estriol 3 (uE3) (0.9 vs. 1.1; P < 0.001), and hCG (0.7 vs. 1.2; P < 0.001) in the second trimester were significantly lower with respect to control pregnancies. Multivariate analysis revealed that low uE3 and hCG levels were independently associated with APO. CONCLUSION: Pregnant women with hereditary thrombophilias, all of whom were treated with LMWH, had decreased levels of all first and second trimester serum markers. In addition, levels of hCG and uE3 in the second trimester could independently predict placenta-related disorders and adverse outcomes in these patients.

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OBJECTIVE: To define normal values of second trimester fetal nasal bone length (NBL) in a low-risk Turkish population. METHOD: Prenatal records of singleton fetuses who underwent second trimester ultrasonographic examination in the 16 to 23 weeks of pregnancy were retrospectively analyzed for NBL and biometric measurements (BPD, FL and HL). The relationship among NBL and gestational age (GA), biparietal diameter (BPD), femur length (FL) and humerus length (HL) was determined. Additionally, percentile values of NBL for each gestational week were provided. RESULTS: A total of 1467 fetuses were included in this study. There was a significant linear association among NBL and GA (R(2) = 0.709), BPD (R(2) = 0.752), FL (R(2) = 0.742) and HL (R(2) = 0.747). Fifth percentile values of fetal NBL were 3.11 mm for 16th, 3.50 mm for 17th, 3.70 mm for 18th, 4.10 mm for 19th, 4.50 mm for 20th, 4.62 mm for 21st, 5.24 mm for 22nd and 5.37 mm for 23rd gestational weeks. CONCLUSION: The study provides normal ranges of NBL between 16 and 23 weeks of pregnancy in a low-risk Turkish population. Future studies with larger sample sizes including pregnancies carrying high risk for aneuploidy are needed to define cut-off values for NBL.

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OBJECTIVE: To understand the reasons of the cesarean delivery on maternal request (CDMR) without medical indication would help to reduce the rates of unnecessary cesarean-delivery (CD). The objective of this study is to determine the basal knowledge of women regarding normal delivery (ND) and CD and also to assess their attitudes about CDMR, and to find out the reasons influencing those attitudes. METHODS: The study included 400 women who completed a 45-item questionnaire that assessed their basal knowledge of ND, CD, and their attitudes and beliefs about the mode of delivery and CDMR. RESULTS: Mean age of the study population was 32 ± 10.2 years (range 18-66). Majority of the women would choose the ND because of its 'being completely natural' (89%) and no anesthesia and operative risk related with ND (76%). Only 33% of the women indicated that ND might cause genital organ prolapse and/or stress urinary incontinence and just 26% and 24% of the women would choose CD to prevent pelvic organ prolapse and stress urinary incontinence, respectively. On the other hand, 50% and 54% of the women would indicate that they could choose CD in order to prevent labor pain and to minimize the risk of fetal distress during the labor. Furthermore, 47% of the women had an opinion that that CD could be performed by maternal request without medical indication. Educational level had no effect of CDMR although more educated women had more accurate knowledge about the some risk and benefits of ND and CD. Binary logistic regression analysis revealed that fear of labor pain (p = 0.02, OR: 15.0, CI: 0.494-0.966), maternal age (p = 0.01, OR: 6.3,CI: 1.00-1.05), and knowledge about the relation between the ND and pelvic organ prolapse/urinary incontinence (p < 0.001, OR: 4.8, CI: 0.549-0.966) were the independent prognostic variables for the CDMR. CONCLUSION: Although majority of the women had wrong idea or no idea about the risks and benefits of CD, nearly half of them indicated that women can always demand CDMR. This study shows that basal knowledge of the women should be improved by education.

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OBJECTIVE: To evaluate whether hyperemesis gravidarum (HG) affects first-trimester maternal serum PAPP-A and free ß-hCG levels. METHOD: An observational study was conducted in 115 cases of HG and 110 control pregnancies who attended the first-trimester prenatal screening program between January 2006 and July 2010. RESULTS: Maternal serum TSH levels were lower and free T4, and transaminases (ALT, AST) levels were higher in pregnancies complicated with HG compared with controls (p < 0.05 for all). In HG cases, median values of maternal serum PAPP-A were significantly higher with respect to normal pregnancies (1.2 vs 1.0 MoM; p = 0.009). Similarly, median values of free ß-hCG were 1.3 MoM in HG pregnancies and 1.0 MoM in controls (p = 0.006). Multivariate analysis revealed that PAPP-A and hCG were independently associated with HG after controlling for TSH, free T4, AST, and ALT. CONCLUSION: HG is associated with elevated levels of PAPP-A and free ß-hCG, and such changes are independent of serum indicators of thyroid and liver function.

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OBJECTIVE: The aim of this study was to compare the CD57+ Natural Killer (NK) cell counts in normal pregnancies and in cases grouped according to different types of early pregnancy failure. MATERIALS AND METHODS: A prospective case control study which was set in Baskent University Faculty of Medicine, Obstetrics and Gynecology Department. A total of 119 women whose pregnancies ended in the first trimester were divided into elective pregnancy termination, incomplete miscarriage, intrauterine demise, ectopic pregnancy and recurrent pregnancy loss groups. CD57+ NK cells were stained and counted in the histologic preparations of the decidua in all of these groups. RESULTS: CD57+ NK cell counts were 2.14+/-1.42 in control, 2.24+/-1.92 in incomplete miscarriage, 1.82+/-1.34 in intrauterine demise, 2.54+/-1.80 in ectopic pregnancy and 3.42+/-2.15 in recurrent pregnancy failure group. There were no statistically significant differences between the control group and the other four groups with respect to the CD57+ NK cell counts. CONCLUSION: This study suggests that CD57+ NK cell count is not associated with early pregnancy failure.

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AIMS: To determine whether there is a relationship between Helicobacter pylori (H. pylori) infection, iron deficiency anemia and thrombocytopenia in pregnant women. METHODS: Hemoglobin and ferritin levels and platelet counts of pregnant women were measured during the third trimester. H. pylori infection was determined using a 14C-urea breath test (14C-UBT) after delivery. Statistical analyses were determined with a Mann-Whitney U-test and the chi(2) test. Statistical significance was determined with a P-value less than .05. RESULTS: Seventy-two of 117 women had positive results on the 14C-UBT. Overall, 27 of 117 pregnant women had anemia (23.1%), and all them were in the H. pylori-positive group; 18 of 27 (66.7%) had iron deficiency anemia. Median hemoglobin levels and neonatal body weights were 12.0 g/dL vs 12.0 g/dL and 3320.0 grams vs 3520.0 grams in the H. pylori-positive and negative groups, respectively. Serum hemoglobin and ferritin levels and neonatal body weight were found to be lower in the anemic group compared with the non-anemic group among H. pylori-infected women (P = 0.0001, P = 0.02, P = 0.008, respectively). There were no statistically significant differences with regard to gestational thrombocytopenia between the H. pylori-positive and H. pylori-negative groups (P = 0.532). CONCLUSIONS: Our study indicates that there is a strong relationship between H. pylori infection and iron deficiency anemia in women with uncomplicated pregnancy. However, an association between H. pylori infection and thrombocytopenia was not found.

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OBJECTIVE: Gestational diabetes mellitus (GDM) affects 2-10% of all pregnant women, causing increased morbidity and mortality, and is tested for in the second trimester of pregnancy. The purpose of the present study was to predict GDM in the first trimester. DESIGN AND METHODS: The study included 271 patients who were between the 10th and 14th week of gestation. Fasting glucose and insulin were measured in the first trimester and the homeostasis model assessment-insulin resistance index (HOMA-IR) was calculated for each patient. These values were compared with the results of the second-trimester glucose tolerance test. RESULTS: HOMA-IR values were higher in women with GDM. A cut-off value of 2.60 for HOMA-IR was calculated at the end of the study. CONCLUSION: Accepting patients whose HOMA-IR value is higher than 2.60 in the first trimester seems to be a good method to predict GDM.

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OBJECTIVE: To establish an early, safe, and well-tolerated time to start oral hydration after cesarean delivery. METHODS: A prospective randomized trial of women delivered by cesarean under regional anesthesia at Alanya Research and Medical Center, Turkey, between 2005 and 2006. A clear liquid drink was given to 100 women in the early oral intake (EOI) group 2 hours after surgery, and to 100 women in the delayed oral intake (DOI) group 8 hours after surgery. If the drink was tolerated, solid foods were then given gradually. RESULT: In the EOI and DOI groups, respectively, the mean time for the return of bowel movements was 4.4+/-1.9 h vs 6.3+/-2.4 h; mean time elapsed until initial passage of flatus was 12.1+/-5.5 h vs 24.1+/-6.0 h; and mean duration of hospitalization was 29.6+/-5.5 h vs 44.6+/-6.8 h (P<0.05). CONCLUSION: Following cesarean delivery under regional anesthesia, oral hydration given as early as 2 hours after the operation is safe and well tolerated.

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OBJECTIVE: To determine menopause-related symptoms and quality of life in women aged 40-80 years living in a rural area of Turkey. METHODS: A total of 338 women were evaluated in this cross-sectional study. As data sources we used a questionnaire that elicited information on the descriptive, fertility and menopausal characteristics of the women, the Menopause Rating Scale (MRS) and the Short Form-36 (SF-36). RESULTS: The mean age at menopause was 46.5 +/- 0.4 years. The complaint stated most often as 'severe or very severe' was 'hot flushes and sweating' (50.7%). The physical functioning, physical role, bodily pain, general health, social functioning, emotional role and mental health scores of postmenopausal women were statistically higher (p < 0.05) than those of premenopausal women. Scores on physical function, physical role, general health and social function decreased significantly with age in postmenopausal women (p < 0.05), while none of the quality-of-life domain scores differed significantly with age in premenopausal women. CONCLUSIONS: Quality of life is worse in postmenopausal women than premenopausal women, and in older than younger women in the postmenopausal period. Thus rural populations are primarily in need of public health care in the postmenopausal period.

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