Conservative treatment of vaginal vault granulation tissue following total abdominal hysterectomy.

OBJECTIVE: To study the incidence, symptoms and spontaneous regression rate of vault granulation tissue in relation to their sizes following total abdominal hysterectomy for benign conditions. METHODS: Prospective descriptive study; 352 patients who underwent total abdominal hysterectomy for benign conditions between September 1995 and April 1996 were included. All patients with vault granulation tissue were followed up until the 20th week after the operation. The main outcome measures were incidence of vault granulation tissue, symptoms, sizes of lesions, spontaneous regression rate and relationship between size and regression rate. RESULTS: The incidence of vault granulation tissue was 34%. Nearly 60% of the lesions were < or = 5 mm. Spontaneous regression occurred in 52% of the cases. If the lesion was < or = 5 mm the chance of it to completely disappear was 72% whereas the same would happen in only 33% if the lesion was > 5 mm (P < 0.01, significant). Although only 7% of the patients with lesions < or = 5 mm had symptoms as compared to 18% of those with lesions > 5 mm; the difference was not statistically significant. CONCLUSIONS: Vault granulation tissue is a common complication, occurring in approximately one-third of patients who had total abdominal hysterectomy. The results of our study suggests that if the lesions are small (< or = 5 mm) it would be reasonable to leave them alone as few give symptoms and most regressed spontaneously; saving the patients' time, inconvenience, expenses and discomfort.

Failed instrumental delivery: Ramathibodi Hospital, 1980-1988.

All cases (70) of failed instrumental deliveries which occurred between 1980 and 1988 at Ramathibodi Hospital, Bangkok, Thailand were critically reviewed. The incidence of failure was 0.5%, and failure occurred more often in primigravidae. Failure to appreciate the true level of the fetal head and too early intervention accounted for failure in 50% of the cases. Failed instrumental delivery can be minimized if the prerequisites for the procedure are strictly adhered to.

Outcome of premature rupture of membranes (PROM) at term: Ramathibodi Hospital, 1988.

Management of PROM at term is still controversial and varies between immediate induction and awaiting a certain length of time. In this retrospective study, mode of delivery of 202 patients who presented at term with premature rupture of membranes were reviewed. Of these, 77 went into spontaneous labour while awaiting induction. The caesarean section rate among such patients (16%) was significantly lower than that of the remaining 125 patients (46%) whose labour was induced. There was no neonatal infection in either group. Further prospective randomized study is needed to confirm this finding.

The relationship between head level on admission and mode of delivery in primigravidae.

Controversy still exists over the significance of the fetal head level in early labor, whether it bears any relationship with mode of delivery. In this prospective study, correlation was made between fetal head level on admission of 98 primigravidae and mode of delivery. Contrary to the findings of recent reports the result of this study seems to show a higher cesarean section rate among patients who presented with high head (> or = 4/5 in early labor).

Elective induction of labor: Ramathibodi Hospital (Jan-Jun, 1990).

To assess the outcome of elective induction of labor, 262 deliveries were studied retrospectively and compared with 249 controlled cases whose labor began spontaneously. Elective induction accounted for 61 per cent of all patients induced with the overall induction rate of 11 per cent. Sixty-two per cent of the private cases as opposed to 24 per cent of the nonprivate cases were induced before the expected date of confinement. Among private cases, the cesarean section rate was similar whether the patients were induced or admitted in spontaneous labor. However, when considering the nonprivate cases the cesarean section rate was twice as high if the patients were induced. Mean maternal height and fetal birth weight were similar in both the study and control groups but there were more cases of low birth weight infants in the study group. The fetal outcome as indicated by 5-minute Apgar score was not less than five in both groups.

Treatment of atonic postpartum hemorrhage with a prostaglandin E2 analogue.

Atonic postpartum hemorrhage constitutes a dramatic clinical situation, with acute danger to the life of the mother. The present report is a 3 yrs prospective study using a Prostaglandin E2 analogue (Sulprostone) in the management of 22 cases with severe postpartum hemorrhage due to uterine atony unresponsive to conventional therapy. Successful control of hemorrhage in cases of blood loss more than 1,500 ml occurred in 83 per cent. Precipitated labour was the most common predisposing factor encountered in this group of atonic postpartum hemorrhage. Side effects of the prostaglandin therapy was tolerable and self-limited. The use of intramuscular administered Sulprostone appears to be an adjunctive treatment in uncontrollable atonic postpartum hemorrhage.

Diabetic ketoacidosis in pregnancy.

Diabetic ketoacidosis, though uncommon, is a very serious complication in obstetrics. We reported 5 cases, which in retrospect could all have been prevented from occurring. Either a strong family of diabetes mellitus or presence of glycosuria were present in 4 cases. In 3 cases, the use of sympathomimetic and corticosteroid was the predisposing factor. Clinicians should have an index of suspicion in patients at risk and it might be prudent to screen for diabetes where the use of sympathomimetic and corticosteroid.

Uterine rupture and labor induction with prostaglandins.

Uterine rupture in patients with labor induction with prostaglandin E2 application though uncommon is a very serious complication and preventable in obstetrics. We reported three cases of spontaneous uterine rupture following induction of labor with intracervical PGE2 gel administration in a dosage of 3-6 mg and two in whom labor was augmented with oxytocin infusion. To avoid such a complication, intracervical PGE2 gel administration should be started with a smaller dose and should augmentation with oxytocin be required careful evaluation and monitoring by a specialist is desirable.

Graves' disease complicating pregnancy.

During the 12-yr period from 1981 to 1992, over 85,000 deliveries at Ramathibodi Hospital from 114 pregnancies (prevalence 0.1%) in 110 patients were complicated by Graves' disease. The diagnosis was made following conception in 52 per cent. Medical treatment with propylthiouracil was the main regimen. Maternal and perinatal outcome were related with thyroid status at delivery including thyrotoxic crisis, preeclampsia and preterm deliveries. There was no case of fetal goitre, hyperthyroidism, but fetal hypothyroidism occurred in 12.2 per cent which calls for close monitoring of antithyroid drug dosage and close neonatal-infant follow-up.

Topical application of honey in treatment of abdominal wound disruption.

The usefulness of honey application as an alternative method of managing abdominal wound disruption was assessed. Fifteen patients whose wound disrupted after Caesarean section were treated with honey application and wound approximation by micropore tape instead of the traditional method of wound dressing with subsequent resuturing. We achieved excellent results in all the cases with complete healing within 2 weeks. Honey application is inexpensive, effective and avoids the need to resuture which also requires general anaesthesia.

Serum level of magnesium attained in magnesium sulfate therapy for severe preeclampsia.

Serum magnesium levels were determined in severe preeclampsia patients who were treated with magnesium sulfate infusion. Forty-four patients with diagnosis of severe preeclampsia between 30-41 weeks gestation, given a conventional 5 g magnesium sulfate intravenous bolus infusion and 1 g/hr continuous infusion and continued 24 hours postpartum, were prospectively studied. The mean pre-treatment magnesium level was 2.3 +/- 0.3 mg/dl which was similar to those reports. The levels measured at 1/2, 1, 2, 4, 12 and 24 hours after initiation of magnesium infusion were 4.8 +/- 0.4, 4.7 +/- 0.4, 4.5 +/- 0.3, 4.7 +/- 0.3, 5.4 +/- 0.3 and 5.9 +/- 0.3 mg/dl respectively. After delivery the levels were measured immediately, 12, and 24 hours and found to be 4.7 +/- 0.4, 4.9 +/- 0.4, and 5.2 +/- 0.3 mg/dl respectively. The serum magnesium levels were also varied with maternal weight, the dose regimen used in our study is appropriate for Asian pregnant women whose body weight usually less than 70 kg.

Routine voluntary antenatal anti-HIV screening in Bangkok, Thailand.

The following recommendations are made as a result of this study. 1. Routine voluntary screening for HIV infection in all pregnant women is feasible and worthwhile. 2. Every seropositive result should be repeated for confirmation before coming to a definitive conclusion to avoid a misdiagnosis. 3. Routine screening of seronegative pregnant women should be repeated during the third trimester to detect seroconversion since this offers a chance for AZT administration to the seroconverted pregnant women for reduction of perinatal transmission. 4. There should be available the appropriate back up services for seropositive pregnant women such as: (i) C--Choice. Having been appropriately counselled the pregnant women should be able to terminate or continue with the pregnancy. (ii) H--High-risk pregnancy concept. The pregnant women should be treated as high-risk cases. Throughout their pregnancy and delivery only experienced personnel should manage them. (iii) I--Integrated services. From our experience it would be reasonable to integrate the care of seropositive pregnant women with any other high-risk cases. Special or anonymous clinics may create an atmosphere of uneasy feelings among the women who could be made to feel alienated and discriminated against. (iv) P--Provision of care. Comprehensive services must be available. These include an experienced counselling team, adequate laboratory services, services for safe first and second trimester therapeutic abortions, appropriate facility in the delivery suite (including Caesarean section) for infected cases, and dedicated paediatricians.

PIP: During January 1991-December 1993 at Ramathibodi Hospital in Bangkok, Thailand, 91 of 24,856 (0.36%) pregnant women screened at their first prenatal visit for HIV tested positive for HIV antibodies. All were asymptomatic. AZT (Azidothymidine) was not administered. 8% of the HIV-seropositive women later admitted that they already knew their HIV status before coming for prenatal care from blood tests at other institutions. Eight women who tested HIV seronegative at the first screening tested HIV seropositive during the second routine screening at 28-32 weeks gestation, for a seroconversion rate of 0.03/100 seronegative tests at first screening. Researchers compared the 91 pregnant women testing HIV seropositive at the first screening with 182 HIV-seronegative pregnant women. After pretest counseling (a video presentation and information on voluntary testing), 100% of all pregnant women agreed to undergo HIV testing. The HIV seroprevalence rate increased from 0.13% to 0.47% during the study period. The leading risk factor for HIV infection was multiple sex partners (26.4% vs. 8.8%; p 0.05). The partners of 12% of the HIV-seropositive pregnant women tested HIV seronegative, resulting in considerable anxiety and difficulty in counseling the couples. After post-test counseling, 85.7% of the original 91 women opted for induced abortion. 13 of the original women and all of the seroconverted cases continued the pregnancy. The pregnant women who seroconverted made up 38% of the deliveries. The perinatal transmission rate was 19%. Infants born to the 8 mothers who seroconverted were more likely to test HIV positive than those born to mothers who tested positive at the first screening (37.5% vs. 7.7%; p 0.05). AZT administration to these women would have likely reduced the perinatal transmission rate. An infection led to the death of 1 infant in the seroconverted group at 5 months. Pregnancy outcomes did not differ between the HIV-seropositive group and the HIV-seronegative group.