Effect of lower uterine segment sweeping on progress of labor in nullipara.

Previous studies have shown that sweeping between the membranes and lower uterine segment was an effective procedure for reducing prolonged pregnancy. However, there has been no study to show the effect of lower uterine segment sweeping to the progress of the active phase of labor. This study was to determine the effect of lower uterine segment sweeping on the progress of the active phase of labor in nullipara. A total of four hundred nulliparous term pregnant women with spontaneous labor were randomized to one of two groups; the control group had routine vaginal examination while the study group had lower uterine segment sweeping at the time of each examination. Oxytocin infusion was given if there was dysfunctional labor. Progression of labor and the need for oxytocin augmentation were reviewed. Data were analyzed by chi square and Student t-test. Oxytocin was used in 67 per cent of the sweeping group and 62 per cent of the control group (p=0.3). The duration of the first stage (0.46), the second stage (0.38), and the third stage (0.28) of labor were not significantly different between the two groups. In conclusion, lower uterine segment sweeping did not reduce the need for oxytocin augmentation or lessen the duration of labor in nullipara.

Prevention and control of thalassemia in Ramathibodi Hospital, Thailand.

Eight thousand seven hundred and thirty-six pregnant women were screened for thalassemia and hemoglobinopathies by mean corpuscular volume less than 80 femtolitres (fl). Three thousand six hundred and seventy women (42%) were MCV less than 80 fl. In this group there were 2,390 women (70%) who had positive Hb typing by high performance liquid chromatography (HPLC) such as beta-thalassemia major, beta-thalassemia hemoglobin E disease, beta-thalassemia trait, heterozygous and homozygous hemoglobin E, alpha-thalassemia-1 trait and hemoglobin H disease and 77% of their partners came and had hemoglobin typing done. Seventy-five couples at risk for having severely affected thalassemia fetuses were detected from this screening program. Prenatal diagnosis was performed in 58 couples (77.3%). Eight affected fetuses were detected. All pregnancies with affected fetuses except one with beta-thalassemia/HbE were terminated. There were 3 fetal losses (6%) as the result of prenatal diagnosis procedure.

The epidemiology of cervical incompetence in Ramathibodi Hospital between 1982-1997.

Cervical incompetence is an important cause of midtrimester abortion. However, the etiology and diagnostic method have still not been established. This retrospective study was aimed to review epidemiology, management and outcome of cervical incompetence in Ramathibodi Hospital, Mahidol University, Thailand, from 1982 to 1997. Fifty seven patients were diagnosed as having cervical incompetence during this period. Fifty patients had elective cerclage. Seven patients had emergency cerclage. Success rate in this study was 94.6 per cent. Only 7 per cent of patients had complications such as chorioamnionitis and suture displacement. There was no other serious complication after treatment. Nowadays, there is still no established method to diagnose cervical incompetence in pregnancy. Treatment is usually based on past obstetric history. Cervical cerclage is an established treatment for this problem. Emergency cerclage is still controversial. The prevention is to avoid any procedure which can cause cervical trauma leading to cervical incompetence.

Maternal mortality in Ramathibodi Hospital: a 28-year comparative study.

A comparative review of maternal mortality rates at Ramathibodi Hospital from 1969 through 1996 including 176, 161 live births is presented. The data are divided into two time periods, both of 14 years, for comparison. A significant decrease in direct obstetric deaths secondary to infection and toxemia (P < 0.05). The rate of deaths due to indirect causes in unchanged. Deaths due to malignancies have increased. This study of maternal mortality demonstrates the need for increased contraceptive services, voluntary sterilization, patient education and preconceptional identification of high-risk patients for further reduction of the maternal mortality rate.

External cephalic version: first report from Thailand.

This prospective study was to preliminary report the safety and success rate of external cephalic version (ECV) in patients with breech presentation or transverse lie at 36 weeks of gestation or more. The aim of this procedure was to reduce the cesarean section rate from indication of breech presentation and transverse lie. This procedure was first started in the Obstetrics and Gynecology Department, Ramathibodi Hospital in June 1998. Thirty two patients were enrolled in this study. ECV was 65 per cent successful with the reversion rate of five per cent. There was no maternal or fetal complication related to this procedure. Factors associated with successful outcome in this study were the location of placenta, the position of fetal spine and the amount of amniotic fluid. A larger study is needed before the true success rate and the efficacy of this procedure can be apparent.

Plasma zinc level and intrauterine growth retardation: a study in pregnant women in Ramathibodi Hospital.

The study was designed to establish the relationship between plasma zinc level and intrauterine growth retardation in 405 normal pregnant women with an age range from 20 to 35 years, who attended and delivered at Ramathibodi Hospital The data were gathered from October 1994 to April 1995. The zinc levels were obtained from blood plasma collection and the assessment of fetal status was made after birth. Using criteria of babies with a birthweight of less than the 10th centile at delivery. Plasma zinc level in mother was collected during antenatal care and labour. Plasma zinc level was determined by Atomic Absorption Spectrophotometry. The plasma zinc levels in mothers during antenatal care, labour and infant birthweight were 66.73 micrograms/dl, 69.91 micrograms/dl and 3152.25 g respectively. Maternal plasma zinc levels during antenatal care, labour and infant birthweight in the intrauterine growth retardation infant group were significantly lower than that in normal growth infants (P < 0.05). In conclusion, our study shows that measurement of maternal plasma zinc concentration in the third trimester would highly suggest mothers at risk of delivering intrauterine growth retardation babies. Mothers selected in this way might benefit from dietary advice and zinc supplementation during the remaining pregnancy.

Vasa previa in Ramathibodi Hospital: a 10 years review.

Vasa previa is presented when fetal vessels cross the internal os as a velamentous insertion of the umbilical cord. This retrospective study is to review the diagnosis, the management, and the outcome of this condition over the 10 years period in Ramathibodi Hospital, Bangkok, Thailand. Five cases were diagnosed after the rupture of membranes with only one case diagnosed prior to the rupture of membranes. The fetal mortality was 50 per cent. Despite continued advances in diagnostic procedures, vasa previa still presents considerable risk to the fetus.

Emergency cervical cerclage: Ramathibodi Hospital experience.

This retrospective study is to evaluate the outcome of pregnancy after emergency cervical cerclage. Records of patients, who were treated with emergency cervical cerclage in Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, from 1982 to 1997, were reviewed. Maternal age, gravida, parity, past obstetric history, gestational age at cerclage, latency period, complication and outcome were noted. Only one of 7 patients who had this operation performed, aborted. The others continued pregnancy and all the babies were born alive. There was no serious maternal complication. This operation has a favorable outcome in selected cases.

Shoulder dystocia: fifteen years' experience in Ramathibodi Hospital.

Although shoulder dystocia does not occur frequently the adverse effect to the patient and especially to infants can be catastrophic. The purpose of this study was to evaluate the incidence, the factors which may be related to or predispose to this condition and the consequence to the patients and their infants. All cases of shoulder dystocia which occurred during the fifteen year period from January 1982 to December 1996 were scrutinized. There were 17 cases of shoulder dystocia from a total of 109,923 deliveries giving the incidence of 1.6 per 10,000 deliveries. Of these 17 patients, 11 (65%) were delivered by vacuum extraction. Two patients had postpartum hemorrhage requiring blood transfusion. Infants' birthweights ranged between 3350 to 5160 grams. Erb's palsy occurred in 6 infants and all made full recovery subsequently.

The use of low dose 1.5 mg prostaglandin E2 gel for cervical ripening and induction of labor at term with unfavorable cervix.

A prospective study was undertaken to evaluate the efficacy and safety of a 1.5 mg prostaglandin E2 gel applied intracervically for the initiation of cervical ripening before the induction of labor. All patients were required to have an initial Bishop score of four or less. There was a total of 220 pregnant women in this study and primipara accounted for 175 or 80 per cent of the pregnant women. The 1.5 mg PGE2 gel was found to be an effective means of cervical ripening in both primipara and multipara with a success rate of 77.7 and 93.3 per cent after the first application to 96 and 100 per cent in the second application, respectively. The mean induction to delivery time was 25.17 hours in primipara and 13.57 hours in multipara. The mean amniotomy to delivery time was 7.55 and 4.65 hours in primipara and multipara, respectively. The cesarean section rate was 48 per cent and 18 per cent in primipara and multipara, respectively. The side-effects were minimal. These results compare well with other reported studies using different dosages and routes.

Mid-trimester abortion using hypertonic saline or prostaglandin E2 gel: an analysis of efficacy and complications.

A total of 149 mid-trimester termination of pregnancies using hypertonic saline infusion (125) or prostaglandin E2 gel (24) have been analyzed for efficacy and complications. The mean induction to abortion time (I-A) was 31.7 +/- 9.2 hours in hypertonic saline (HSI) group and 28.4 +/- 27.7 hours in prostaglandin (PGE2) group. Retained placenta occurred in 76 (63.3%) in HSI group and 6 (25%) in PGE2 group. Four (3.3%) in HSI group had pyrexia over 38.5 degrees C and the only one case with proven sepsis developed disseminated intravascular coagulation defect (DIC) which accounted for one case (0.8%) of blood loss of more than 500 ml. There was also one case of mildly disturbed electrolytes in HSI group occurring during the instillation. Minor side-effects of nausea and vomiting occurred in 4 (16.7%) in the PGE2 group only.

Malignant Brenner tumor: a case of aggressive clinical course and cutaneous metastases.

Malignant Brenner tumor is a very rare ovarian tumor of which the definition of this entity and its biologic behavior remain controversial to this day. In this case report a 30-year-old patient with malignant Brenner tumor was presented with an aggressive clinical course and cutaneous metastases. The disease progressed from apparently unilateral ovarian involvement to intraabdominal, lung and cutaneous metastases. She expired within two months of diagnosis of disease. The histopathology of the ovarian tumor and the metastatic skin lesion are illustrated. In the authors' opinion this case should be categorized as a transitional cell carcinoma of the ovary.

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.

Amniotic fluid embolism: a case report.

A case of a 27-year-old, gravida 1, para 0 whose labor was induced with prostaglandin and followed by syntocinon was reported. During labor, she developed amniotic fluid embolism and died.

Control of uterine hyperactivity caused by prostaglandin with intravenous terbutaline: a case report.

Prostaglandin E2 is beginning to be used more widely for the induction of labor in this country. The main concern with vaginal administration is the difficulty in stopping uterine hyperactivity. This report is a case where intravenous terbutaline was given as soon as hyperactivity and fetal heart rate deceleration were detected. Using this treatment, hyperactivity was controlled and the fetal heart rate returned to normal. Unfortunately, cesarean section was necessary for fetal distress which developed two and a half hours later when syntocinon was started intravenously to augment the labor.

Ripening of the unfavorable cervix with prostaglandin E2: intracervical versus intravaginal route.

Forty-eight term primiparae women with unripe cervix (Bishop score of 4 or less) were randomly given either 1.5 mg of prostaglandin E2 in 3 ml of gel intracervically or 3 mg prostaglandin E2 tablet intravaginally to ripen the cervix. Intracervical administration caused favorable cervix in 36 per cent compared with 12 per cent in the intravaginal group, and induced spontaneous labor in 41 per cent compared with 69 per cent in the intravaginal group. Oxytocin augmentation was required in 88 per cent in the intracervical group compared to 62 per cent in the intravaginal group. The only significant difference statistically was the mean duration of the insertion of PGE2 to delivery being 16 hours and 23.5 hours in the intracervical and intravaginal routes respectively (P = 0.02). There was one case of hyperstimulation and one case of maternal death from amniotic fluid embolism in this study.

Induction of labor using intracervical prostaglandin E2 gel: the outcome.

A prospective study was undertaken to evaluate the safety and efficacy of a 3 mg prostaglandin E2 (PGE2) gel applied intracervically for the initiation of cervical ripening before the induction of labor. All patients were required to have an initial Bishop score of 4 or less. The 3 mg PGE2 gel was found to be an effective method of cervical ripening in primigravida and multigravida with a success rate of 76 and 86.8 per cent after the first application to 96.4 and 97.4 per cent after third application respectively. The mean induction to delivery time was 22 hours in primigravida and 13 hours in multigravida. The mean amniotomy to delivery time was 6 hours and 4 hours in primigravida and multigravida respectively. However, the incidence of cesarean section was not improved as expected and there was one instance of uterine hyperstimulation. The only serious complication was one uterine rupture that occurred in multigravida with the prolonged use of oxytocin.

Comparison of intravenous oxytocin with and without vaginal prostaglandin E2 gel in term pregnancy with premature rupture of membranes and unfavorable cervix.

Forty-seven nulliparous term pregnant women with PROM and unfavorable cervix, were randomly divided into 23 patients who were observed for four hours then followed by intravenous oxytocin, and 24 patients who were given 3 mg PGE2 gel intravaginally then followed by intravenous oxytocin four hours later. No statistically significant difference was observed between the two treatment groups with regard to Bishop score four hours after observation, intravenous oxytocin to delivery time, Apgar score at 1 and 5 minutes and maternal puerperal complications in both groups. It can be concluded that PGE2 did not significantly improve Bishop score or shorten the induction to delivery time in cases of PROM with unfavorable cervix. Intravenous oxytocin is still preferable both in terms of cost and effectiveness.

Advanced abdominal pregnancy: a case report.

A 37-year-old, gravida 5 with 41 weeks of gestation was admitted because of slight vaginal bleeding, abdominal pain, and absence of fetal movements for a few days. Previously she had been admitted to a provincial hospital with sudden severe abdominal pain and fainting at the second month of her pregnancy and ectopic pregnancy was suspected. She was discharged the following morning, after all signs and symptoms had completely disappeared without any special investigation. On her last admission all clinical examinations were normal but fetal heart sound was absent. The cervix was closed and uneffaced. Abdominal X-ray showed signs of fetal death. Sonography confirmed a dead fetus in utero but with placenta previa totalis. A laparotomy was performed. A macerated female fetus, weighting 3,800 g was found in the amniotic sac lying in the abdominal cavity. The placenta was attached to the dorsal surface of her abdomen close to the large intestine and the omentum; the entire placenta was untouched and left in the peritoneal cavity. There were no postoperative complications. She recovered well and was discharged after 7 days.

Fetal outcome in term frank breech primipara delivered vaginally and by elective cesarean section.

A retrospective study was carried out over a 3-year period comparing the fetal outcome of primiparous term frank breech delivered vaginally with those by elective cesarean section. There were 87 patients delivered by vaginal route and 176 by abdominal route. The staff delivered 13 per cent by vaginal route against 57 per cent by residents. There were no statistical differences in apgar score at 1 and 5 minutes with regard to the routes of delivery, different fetal birthweights and obstetrical experience of the accoucheur. There were no perinatal deaths. The concept of elective cesarean section in all primiparous term frank breech should be reconsidered.