Turkiye Klinikleri Journal of Health Sciences

.: ORIGINAL RESEARCH
Shoulder-type Pain Formation After Spinal Anesthesia and the Effect of Non-invasive Method on Pain Reduction
Spinal Anestezi Sonrası Gelişen Omuz Tipi Ağrı Oluşumu ve Non-invaziv Yöntemin Ağrının Azaltılmasına Olan Etkisi
Derya KANZA GÜLa, Ayça SOLT KIRCAb
aDepartment of Gynecology and Obstetrics, İstanbul Medipol University Faculty of Medicine, İstanbul, TURKEY
bDepertment of Midwifery, Kırklareli University School of Health, Kırklareli, TURKEY
Turkiye Klinikleri J Health Sci. 2021;6(2):249-56
doi: 10.5336/healthsci.2020-75830
Article Language: EN
Full Text
ABSTRACT
 Objective: The effect of maternal up-head position on post-operative shoulder type pain (STP) during cesarean performed with spinal anesthesia and we planned it as a randomized controlled experimental study to evaluate the effectiveness of non-pharmacological methods in treatment. Material and Methods: Four hundred primiparous pregnant women who would undergo cesarean surgery with spinal anesthesia in the obstetrics service of a Private Nisa Hospital in İstanbul between February and August 2019 were included in the study. The participants were divided into two groups as head up position (n=200) and horizontal position (n=200) by simple random method. Dry hot application (n1=50 experimental group) and non-steroidal antiinflammatory drug (NSAID) gel application (n2=50 control group) were performed to 100 patients who developed STP in the post-operative period. Pain assessment before and after the procedure was performed with Visual Analog Scale (VAS). Results: When the groups are examined according to the maternal position, it was found that the incidence of STP in the horizontal position (31.5%) was higher than the head up 400 position (18.5%) (p<0.03). STP was 76% in the right arm, 6% in the left arm, and 18% in both arms (p<0.001). It was found that women with local dry hot application to shoulder pain had lower VAS 2 pain scores (1.62±1.44) than the group with NSAI gel application (2.32±1.64) (p<0.05). Conclusion: When STP developed after cesarean section was examined according to the maternal position during surgery; the pain was found to be less in the head up 400 position than in the horizontal position. Local dry hot application was found to be more effective in reducing pain in the acute period compared to NSAID gel application in patients with STP after surgery.

Keywords: Shoulder type pain; cesarean section; anesthesia spinal
ÖZET
 Amaç: Spinal anestezi ile gerçekleştirilen sezaryen sırasındaki maternal baş yukarı pozisyonun post-operatif omuz tipi ağrı (OTA)ya etkisi ve tedavide farmakolojik olmayan yöntemlerin etkinliğini değerlendirmek amacıyla randomize kontrollü deneysel bir çalışma olarak planladık. Gereç ve Yöntemler: İstanbul'da Özel Nisa Hastanesi kadın doğum servisinde Şubat-Ağustos 2019 tarihleri arasında spinal anestezi ile sezaryen ameliyatı olacak 400 primipar gebe çalışmaya alındı. Katılımcılar basit rastgele yöntemle baş yukarı (n=200) ve yatay pozisyon (n=200) olmak üzere 2 gruba ayrıldı. Ameliyat sonrası dönemde OTA gelişen toplam 100 hastaya kuru sıcak uygulama (n1=50 deney grubu) ve non-steroidal anti-inflamatuar ilaç (NSAİİ) uygulama (n2=50 kontrol grubu) yapıldı. İşlem öncesi ve sonrası ağrı değerlendirme Görsel Kıyaslama Ölçeği (GKÖ) ile gerçekleştirildi. Bulgular: Gruplar maternal pozisyon şekline göre incelendiğinde; yatay pozisyonda OTA'nın görülme sıklığının (%31,5), baş 400 yukardaki pozisyona (%18,5) göre daha fazla olduğu saptanmıştır (p<0,03). OTA sağ kolda %76, sol kolda %6, her 2 kolda %18 oranında görülmektedir (p<0,001). Omuz ağrısına lokal kuru sıcak uygulama yapılan kadınların GKÖ 2 ağrı puan ortalamalarının (1,62±1,44), NSAİİ jel uygulaması yapılan gruba göre (2,32±1,64) daha düşük olduğu tespit edilmiştir (p<0,05). Sonuç: Sezaryen sonrası gelişen OTA ameliyat sırasındaki maternal pozisyon şekline göre incelendiğinde; ağrının baş 400 yukardaki pozisyonda yatay pozisyona göre daha az olduğu saptanmıştır. Ameliyat sonrası OTA gelişen hastalarda lokal kuru sıcak uygulamanın NSAİİ jel uygulamaya göre akut dönem ağrıyı azaltmada daha etkin olduğu tespit edilmiştir.

Anahtar Kelimeler: Omuz tipi ağrı; sezaryen; spinal anestezi
REFERENCES:
  1. O'Boyle AL, Mulla BM, Lamb SV, Greer JA, Shippey SH, Rollene NL, et al. Urinary symptoms after bladder flap at the time of primary cesarean delivery: a randomized controlled trial (RTC). Int Urogynecol J. 2018;29(2):223-8. [Crossref]  [PubMed] 
  2. Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F, et al. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a Barrier to Universal Coverage World Health Report background paper, 30. World Health Organization; 2010. [Link] 
  3. Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR, et al. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One. 2016;5;11(2):e0148343. [Crossref]  [PubMed]  [PMC] 
  4. Zirak N, Soltani G, Hafizi L, Mashayekhi Z, Kashani I. Shoulder pain after caesarean section: comparison between general and spinal anaesthesia. J Obstet Gynaecol. 2012;32(4):347-9. [Crossref]  [PubMed] 
  5. Quinlan JD, Murphy NJ. Cesarean delivery: counseling issues and complication management. Am Fam Physician. 2015;1;91(3):178-84. [PubMed] 
  6. Shibli KU, Russell IF. A survey of anaesthetic techniques used for caesarean section in the UK in 1997. Int J Obstet Anesth. 2000;9(3):160-7. [Crossref]  [PubMed] 
  7. Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Yong WL. Anesthesiology 1. Miller's Anesthesia, Volumes 1 and 2. 7th ed. Philadelphia: Churchill Livingstone; 2010;112(1):260-1. [Crossref] 
  8. Chang SH, Lee HW, Kim HK, Kim SH, Kim DK. An evaluation of perioperative pregabalin for prevention and attenuation of postoperative shoulder pain after laparoscopic cholecystectomy. Anesth Analg. 2009;109(4):1284-6. [Crossref]  [PubMed] 
  9. Kaloo P, Armstrong S, Kaloo C, Jordan V. Interventions to reduce shoulder pain following gynaecological laparoscopic procedures. Cochrane Database Syst Rev. 2019;30;1(1):CD011101. [Crossref]  [PubMed]  [PMC] 
  10. Cift T, Ustunyurt E, Yilmaz C, Olmez F, Basar B. Shoulder tip pain after cesarean section. J Clin Diagn Res. 2015;9(8):QC04-6. [PubMed]  [PMC] 
  11. Jackson SA, Laurence AS, Hill JC. Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia. 1996;51(5):485-7. [Crossref]  [PubMed] 
  12. Berberoğlu M, Dilek ON, Ercan F, Kati I, Ozmen M. The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain. J Laparoendosc Adv Surg Tech A. 1998;8(5):273-7. [Crossref]  [PubMed] 
  13. Tharanon C, Khampitak K. The effect of peritoneal gas drain on postoperative pain in benign gynecologic laparoscopic surgery: a double-blinded randomized controlled trial. Int J Womens Health. 2016;10;8:373-9. [Crossref]  [PubMed]  [PMC] 
  14. Karlström A, Engström-Olofsson R, Norbergh KG, Sjöling M, Hildingsson I. Postoperative pain after cesarean birth affects breastfeeding and infant care. J Obstet Gynecol Neonatal Nurs. 2007;36(5):430-40. [Crossref]  [PubMed] 
  15. Sutton CD, Carvalho B. Optimal pain management after cesarean delivery. Anesthesiol Clin. 2017;35(1):107-24. [Crossref]  [PubMed] 
  16. Aydın A, Araz A, Asan A. [Visual analog scale and affect grid: an application to Turkish culture]. Türk Psikoloji Yazıları. 2011;14(27):1-13. [Link] 
  17. Aslan FE, Öntürk KZ. Ağrı ölçümü ve değerlendirilmesi. Aslan FE, editör. Ağrı Doğası ve Kontrolü. 1. baskı. Ankara: Akademisyen Tıp Kitapevleri; 2014. p.67-100.
  18. George D, Mallery M. SPSS for Windows Step by Step: A Simple Guide and Reference, 17.0 update. 10th ed. Boston: Pearson; 2010.
  19. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Kirmeyer S, Mathews TJ, et al. Births: final data for 2009. Natl Vital Stat Rep. 2011;3;60(1):1-70. [PubMed] 
  20. Phelps P, Cakmakkaya OS, Apfel CC, Radke OC. A simple clinical maneuver to reduce laparoscopy-induced shoulder pain: a randomized controlled trial. Obstet Gynecol. 2008;111(5):1155-60. [Crossref]  [PubMed] 
  21. Shin HY, Kim SH, Lee YJ, Kim DK. The effect of mechanical ventilation tidal volume during pneumoperitoneum on shoulder pain after a laparoscopic appendectomy. Surg Endosc. 2010;24(8):2002-7. [Crossref]  [PubMed] 
  22. Dixon JB, Reuben Y, Halket C, O'Brien PE. Shoulder pain is a common problem following laparoscopic adjustable gastric band surgery. Obes Surg. 2005;15(8):1111-7. [Crossref]  [PubMed] 
  23. Sarli L, Costi R, Sansebastiano G, Trivelli M, Roncoroni L. Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy. Br J Surg. 2000;87(9):1161-5. [Crossref]  [PubMed] 
  24. Jorgensen JO, Gillies RB, Hunt DR, Caplehorn JR, Lumley T. A simple and effective way to reduce postoperative pain after laparoscopic cholecystectomy. Aust N Z J Surg. 1995;65(7):466-9. [Crossref]  [PubMed] 
  25. Barczyński M, Herman RM. Low-pressure pneumoperitoneum combined with intraperitoneal saline washout for reduction of pain after laparoscopic cholecystectomy: a prospective randomized study. Surg Endosc. 2004;18(9):1368-73. [Crossref]  [PubMed] 
  26. Esmat ME, Elsebae MM, Nasr MM, Elsebaie SB. Combined low pressure pneumoperitoneum and intraperitoneal infusion of normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy. World J Surg. 2006;30(11):1969-73. [Crossref]  [PubMed] 
  27. Akhavan A, Gainsburg DM, Stock JA. Complications associated with patient positioning in urologic surgery. Urology. 2010;76(6):1309-16. [Crossref]  [PubMed] 
  28. Kikuchi C, Tonozaki S, Gi E, Watanabe M, Shimizu H. [Shoulder-tip pain during cesarean section under combined spinal-epidural anesthesia]. 2014;63(2):149-52. [PubMed] 
  29. Kandil TS, El Hefnawy E. Shoulder pain following laparoscopic cholecystectomy: factors affecting the incidence and severity. J Laparoendosc Adv Surg Tech A. 2010;20(8):677-82. [Crossref]  [PubMed] 
  30. Arias-Buría JL, Valero-Alcaide R, Cleland JA, Salom-Moreno J, Ortega-Santiago R, Atín-Arratibel MA, et al. Inclusion of trigger point dry needling in a multimodal physical therapy program for postoperative shoulder pain: a randomized clinical trial. J Manipulative Physiol Ther. 2015;38(3):179-87. [Crossref]  [PubMed] 
  31. Lin YH. Effects of thermal therapy in improving the passive range of knee motion: comparison of cold and superficial heat applications. Clin Rehabil. 2003;17(6):618-23. [Crossref]  [PubMed] 
  32. Matsumoto S, Shimodozono M, Etoh S, Miyata R, Kawahira K. Effects of thermal therapy combining sauna therapy and underwater exercise in patients with fibromyalgia. Complement Ther Clin Pract. 2011;17(3):162-6. [Crossref]  [PubMed] 
  33. González-Iglesias J, Fernández-de-las-Pe-as C, Cleland JA, Gutiérrez-Vega Mdel R. Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2009;39(1):20-7. [Crossref]  [PubMed] 

.: Up To Date

Login

 Forgot your password?

 New Registration  

Contact

Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com