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.