Effectiveness of the model for prenatal control of severe thalassemia.

OBJECTIVE: The aim of the research was to determine effectiveness of the model for prenatal control in reducing new cases of severe thalassemia. METHODS: Pregnant women at six tertiary centers were recruited to follow the model, consisting of (1) carrier screening using mean corpuscular volume (for alpha-thal-1 and beta-thal) and CMU-E screen (for HbE trait), (2) carrier diagnosis, (3) the couples at risk were counseled and offered prenatal diagnosis, and (4) termination of affected pregnancy. All neonates were evaluated for thalassemia. RESULTS: Of the 12,874 recruited pregnancies, 7008 were valid for analysis. Of them, 281 couples were identified to be at risk, Of the 281, 58 affected fetuses were identified and 55 pregnancies were terminated, whereas three did not accept pregnancy termination. All 6727 neonates at no risk were proven to be unaffected. The model had sensitivity and positive predictive value of 100% and 20%, respectively. The model could detect all of affected fetuses. CONCLUSION: The model could prenatally identify affected fetuses with a detection rate and negative predictive value of 100%. The model was highly effective to prenatally detect affected fetuses with an acceptable false positive rate.

Is it time for routine ultrasound in late pregnancy at Bhumibol Adulyadej Hospital?

BACKGROUND: At term, about 3-5% of the presentations are breech. Vaginal breech deliveries are associated with increased maternal and fetal morbidity and mortality, but delivery by cesarean section in an emergency does not eliminate all maternal and perinatal morbidity. The use of external cephalic version can produce considerable cost savings in the management of the breech fetus at term. The accuracy in the assessment of fetal presentation and position is essential. OBJECTIVE: To study the accuracy of Leopold's maneuvers in the assessment of fetal presentation and position at Bhumibol Adulyadej Hospital. MATERIAL AND METHOD: Prospective cohort study of 1,528 singletons, pregnant women at gestational age between 34-40 weeks who attended antenatal care unit at Bhumibol Adulyadej Hospital between November 1, 2006 and March 30, 2009. All cases were examined by either residents or staff by using Leopold's maneuvers. The results of the examinations were recorded as cephalic or non-cephalic presentation. After that, the subjects were re-examined by the staff in the maternal and fetal medicine unit using ultrasound for gold standard. Maternal age, weight, height, gestational age, parity, estimated fetal weight, amniotic fluid index, placental site, and fetal presentation were recorded. The results of the two methods of examination were then analyzed for comparison and calculated in terms of means, standard deviation, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. RESULTS: The results of Leopold's maneuvers with 95% confidence interval revealed sensitivity 63.17 +/- 10.84%, specificity 93.35 +/- 1.25%, positive predictive value 34.04 +/- 7.82%, negative predictive value 97.98 + 0.74%, and accuracy 92.08 +/- 1.35%. CONCLUSION: Leopold's maneuvers are inexpensive, easy to perform, and noninvasive but the accuracy of such assessments vary depending on many factors especially experience of operators. The caregivers can reduce perinatal morbidity and mortality if they can diagnose all of non-vertex presentation in near term pregnancy. Routine use of ultrasound in near term pregnancy to diagnose non-vertex presentation has more benefit than cost.

Risk factors for primary postpartum hemorrhage in Bhumibol Adulyadej Hospital.

BACKGROUND: Postpartum hemorrhage remains one of the main causes of maternal morbidity and mortality in both developed and developing countries. Hemorrhages account for 28%of all direct maternal deaths and remain the most common cause of direct maternal deaths worldwide. OBJECTIVE: To study the incidence and risk factors for postpartum hemorrhage (PPH) in Bhunibol Adulyadej Hospital. MATERIAL AND METHOD: Retrospective cohort study of 19,429 patients who gave birth between P' January 2004 and 31st December 2007 at Bhumibol Adulyadej Hospital. One thousand five hundred and thirty women were enrolled in the present study, three hundred and eighty five women had postpartum hemorrhage and one thousand one hundred and forty-five had no postpartum hemorrhage. The present study analyzed one postpartum hemorrhage woman compared to three women who gave birth in nearly the same period and had no postpartum hemorrhage both vaginal deliveries and cesarean section. RESULTS: The PPH rate in Bhumibol Adulyadej Hospital was 1.98%. Maternal age, height and fetal birth weight were not different between the PPH group and no PPH group. The strongest risk factors for postpartum hemorrhage in the present study were prolonged 3rd stage of labor, retained placenta, lacerations of birth passage, and placenta previa. CONCLUSION: The strongest risk factors for postpartum hemorrhage in the present study were prolonged 3rd stage of labor, retained placenta, lacerations of birth passage, and placenta previa.

Chorionic villus sampling for early prenatal diagnosis at Bhumibol Adulyadej Hospital.

OBJECTIVE: To evaluate results of chorionic villus sampling for early prenatal diagnosis at Bhumibol Adulyadej Hospital. DESIGN: Retrospective descriptive study. SETTING: Perinatal unit, Department of Obstetrics and Gynaecology, Bhumibol Adulyadej Hospital. SUBJECTS: Three hundred and eighty three women were enrolled to chorionic villus sampling at the perinatal unit, Department of Obstetrics and Gynecology, Bhumibol Adulyadej Hospital, from November 10,1997 to October 17, 2006. RESULTS: During the present study periods three hundred and eighty three women were recruited, of these chorionic villus sampling for chromosome diagnosis were performed on 355 while 6 were for abnormal Thalassemia screening. Twenty two cases were excluded because ultrasound examination showed anembryonic pregnancy or fetal demise in utero in 13 cases, multiple fibroids in 4 cases, large area of placental hemorrhage in 3 cases, 1 case of multiple pregnancy and in 1 case the placenta was in an inappropriate position. The most common indication was elderly gravidarum (95.84%). Other indications were abnormal Thalassemia screening, abnormal ultrasound findings, family chromosome disorder previous Down syndrome, and severe oligohydramnios. The authors found eleven cases of chromosome abnormalities, four cases of maternal cell contamination and three cases of failed tissue culture (two cases from transcervical chorionic villus sampling and one case from transabdominal chorionic villus sampling) and two cases of mosaicism. There were two fetal losses in the present study and all the babies from the normal chromosome result looked normal. Second trimester amniocentesis following chorionic villus sampling was required due to maternal cell contamination, mosaicism and failed tissue culture. (2.77%) All cases had follow-up ultrasound scan during 18-20 weeks. CONCLUSION: The authors found that chorionic villus sampling is a possible alternative technique for prenatal diagnosis of cytogenetic abnormalities and abnormal Thalassemia screening in Thailand. It probably has a slightly higher rate of failed tissue culture and maternal cell contamination than amniocentesis, but it is generally done earlier in pregnancy than amniocentesis and is particularly advantageous for detecting certain genetic conditions.

Efficacy of external cephalic version with tocolysis in late pregnancy.

OBJECTIVE: To study the success rate and identify factors influencing the success rate of external cephalic. version (ECV) at Bhumibol Adulyadej Hospital. STUDY DESIGN: Prospective descriptive study. SETTING: Department of Obstetrics and Gynecology, Bhumibol Adulyadej Hospital. MATERIAL AND METHOD: All parturients attending the obstetrics unit at Bhumibol Adulyadej Hospital between October 1, 1997 and September 30, 2006, having completed 36 or more gestational weeks with singleton non-vertex fetus, who had no exclusion criteria for ECVwere given full information concerning a trial of ECV risk of cesarean section, and risk of emergency breech deliveries. Those who chose to undergo ECV after counseling were recruited and gave signed consent. One hundred and forty singleton, pregnant women with non-vertex presentation participated in this study. RESULTS: The success rate of ECV was 71.43%. Birth weight significantly affected the success rate of ECV Maternal weight, parity, gestational age, and placental site did not have any effect on the outcome. All fetuses in the present study were subsequently delivered without significant morbidity and no cases of perinatal mortality were recorded. CONCLUSION: ECV is a safe procedure with a high success rate in selective cases. ECV thus, is an effective alternative practice for non-vertex presentation, which can also reduce the rate of breech delivery and cesarean section. The major benefits of external cephalic version are reduced maternal morbidity and mortality from surgery.

50-grams glucose challenge test for screening of gestational diabetes mellitus in high risk pregnancy.

OBJECTIVE: To evaluate the cutoff value of the 1-hr, 50-gram glucose challenge test (GCT) for screening of gestational diabetes mellitus (GDM), in high-risk pregnancy, and to determine the prevalence of GDM in this group. STUDY DESIGN: Descriptive study (Diagnostic test). SUBJECTS: Eight hundred and thirty-eight pregnant women, 24-28 weeks, were identified and recruited based on risk indicators between January and October 2004. MATERIAL AND METHOD: A GCT was performed in this group. All women with plasma glucose value > or = 130 mg/ dl were given a 3-hr, 100-gram glucose tolerance test (OGTT) to diagnose gestational diabetes mellitus using Carpenter and Coustan diagnostic criteria. The receiver-operator characteristic (ROC) curve was used to identify the cut-off value of GCTfor detecting GDM. MAIN OUTCOME MEASURES: The cut-off value of GCTfor detecting GDM by using ROC curve with the sensitivity and specificity of various cut-off values. RESULTS: The ROC curve identified a GCT value of > or = 140 mg/dl as the cut-off value for detecting GDM, which showed the sensitivity and specificity of 95.3% and 48.6% respectively. The prevalence of GDM in high-risk pregnant women was 20.17% (169/838). CONCLUSIONS: Recommended threshold of 140 mg/dl used as the cut-off value of 50-gram, 1-hr GCTfor screening GDM in high-risk pregnancy.