Nomogram of fetal right portal vein diameter at gestational age 30 to 35 weeks and prediction of small for gestational age at birth.

AIM: To construct the nomogram of fetal right portal vein (RPV) diameter at 30 to 35 weeks' gestation in Thai pregnant population and the use of RPV measurement to predicting small for gestational age (SGA) fetus. METHODS: A prospective, cross-sectional study of singleton pregnancies at antenatal visit between 30 and 35+6 weeks of gestation in single center, Bhumibol Adulyadej Hospital (BAH) was conducted from January to August 2020. Ultrasonography of fetal biometry and RPV diameter measurement were performed as well as immediate newborn birth weight measurement. The nomogram of fetal RPV was developed for standardization for Thai people. RESULTS: A total of 219 singleton pregnant women were enrolled and ultrasonographic measurement of RPV and fetal biometry was obtained. Mean maternal age and gestational period were 29.4 years and 33.0 weeks, respectively. One third of participants were classified as obese. RPV diameter ranged from 1.85 to 6.07 mm and increased linearly with gestational age. The optimal threshold of RPV diameter for diagnosis SGA was less than 3.06 mm with area under ROC curve at a level of 0.613 (95%CI 0.496 to 0.731). Sensitivity and specificity were 38.46% and 83.94%, respectively. There was no fetal death or neonatal morbidity in the present study. CONCLUSION: RPV diameter increases in size depending on gestational age. RPV diameter at 30 to 35+6 weeks gestation was a useful measurement for SGA prediction. RPV measurements greater than 3.06 mm strongly indicated normal fetal growth.

A Comparative Study of the Spontaneous Labor Rate in Scheduled Elective Cesarean Section at 38 Weeks versus 39 Weeks of Gestation in Parturient with Previous Cesarean Section.

Objective: To assess the effect of the different scheduled gestational age for a repeat elective cesarean section (CS) on emergency cesarean section rate and adverse pregnancy outcomes in pregnant women with history of previous CS. Material and Method: A prospective cohort study of singleton pregnant women who had a history of CS and were scheduled for a repeat elective CS to be performed. The cases were divided into two groups of which the elective CS was appointed at 38 or 39 weeks of gestation as study and control groups, respectively. Emergency cesarean section rate, maternal and neonatal complications were defined as main outcomes. Results: Of 415 scheduled elective repeat cesarean deliveries performed at 38 weeks of gestation or later, 209 were scheduled between 38 0/7 and 38 6/7 weeks (study group), and 206 were scheduled between 39 0/7 and 39 6/7 weeks (control group). Most of the cases had one previous cesarean delivery. The emergency CS rate before schedule in the study group was significantly less than in the control group (15.3% vs. 51%, p<0.001). Spontaneous labor pain was a major factor to have unplanned delivery. The maternal intra-operative complications were significantly increased in women who had emergency cesarean before schedule compared to elective CS on scheduled in 38 weeks group (25% vs. 12.9%, p<0.001) and 39 weeks group (31.4% vs. 14%, p<0.001). The major intra-operative complication was uterine atony. There were no statistically significant differences in maternal post-operative and neonatal complications in scheduled elective CS in 38 and 39-week group. Transient tachypnea of the newborn (TTNB) was higher in elective CS at 38 week compared to emergency CS. Conclusion: The emergency CS rate in 39 weeks gestation group was significantly higher than 38 weeks group. The incidence of adverse maternal intra-operative complications was statistically difference with emergency CS when compared to elective CS in case and control groups. Recommendation of elective repeated CS at GA39 weeks may be suitable only under some circumstances. The number of prior CS is one of factors that should be considered.

Efficacy of Delayed versus Immediate Cord Clamping in Late Preterm Newborns following Normal Labor: A Randomized Control Trial.

Background: Premature neonates are susceptible to anemic problems with low iron storage. Delayed cord clamping (DCC) has been studied and its beneficial value has been supported by existing research in newborns with very low birth weights. But there were only few data pertinent to late preterm infants. Objective: To investigate the effect of delayed cord clamping (DCC) as compared with immediate cord clamping (ICC) on the hematocrit level at 48 hours in late preterm neonates after vaginal delivery. Material and Method: The design consisted of a randomized controlled trial. One hundred pregnant women who were admitted because of preterm labor (GA 34-36(+6) week) in active phase were recruited and allocated into two groups, designated as the ICC and DCC groups. The DCC were defined as the case in which patients underwent the umbilical cord clamping at 120 seconds after birth. At 48 hours after delivery, both the hematocrit (Hct) and microbilirubin (MB) levels of newborns were determined. Also, neonatal and maternal complications were recorded. Result: Eighty-six neonates were analyzed. There were no statistical differences in the baseline data of maternal symptoms and newborns between the two groups. Neonates in the DCC group had a significantly higher hematocrit level than the ICC group (55.4% and 47.6%, respectively: p = 0.02). The MB level in the DCC group was also significantly higher than in the ICC group (9.4% and 8.6 mg %, respectively: p = 0.04). However, phototherapy and length of hospitalization in both groups were not different. There were no serious maternal and fetal complications in either group. Conclusion: The DCC procedure could raise the Hct level in the late preterm newborns without serious adverse effects. But more evidence is needed to explore the possible benefit of this procedure.

Comparative Study of Postoperative Pain between Maylard Incision and Pfannenstiel Incision in Gynecologic Surgery: A Randomized Controlled Trial.

Background: Postoperative pain has many adverse effects for the patients with laparotomy operation. There are few studies that compare between Maylard and Pfannenstiel incision in term of pain and wound complication after operation. Objective: To compare the postoperative pain and wound complications between the muscle-cutting Maylard incision and the Pfannenstiel incision in women who needed benign gynecologic surgery. Material and Method: This randomized controlled trial study compared two laparotomy techniques, Maylard and Pfannenstiel method. Ninety cases of benign gynecologic conditions were recruited and randomly assigned to receive either Maylard or Pfannenstiel incision from August 2014 to October2015 at Thammasat University Hospital, Thailand. Visual analogue scale (VAS) was applied to measure postoperative pain. Baseline characteristics of the study groups and postoperative outcomes were analyzed. Results: From the planned 90 recruited cases, there were 81 cases for complete analysis, 41 in Maylard and 40 in Pfannenstiel group. There were no difference in age, body mass index, education level, previous abdominal surgery and type of operation between Maylard and Pfannenstiel group. Duration of operation, type of anesthesia and dosage of analgesic drug were not statistically significant between both groups. Length of surgical wound was longer in Maylard than in Pfannenstiel group (17.27±0.6 vs. 14.13±0.8 cm, p = 0.04). Postoperative pain score (VAS) at 3, 6, 12, 24 and 48 hours were not statistically different between two groups. Pain score at 72 hours and 7th day in Maylard group showed significantly less than in Pfannenstiel group (0.51±0.5 vs. 1.10±1.0 p = 0.04, 0.12±0.3 vs. 0.23±0.4, p = 0.01, respectively). The numbers of participants with moderate to severe pain (VAS >4) in Maylard group were less than in Pfannenstiel group at 3, 6, 12 and 24 hours but after that there was no statistically difference. There were no postoperative wound complications such as disruption, infection or hematoma in all participants in this study. Conclusion: Postoperative pain up to 48 hours in both Maylard and Pfannenstiel group showed similar VAS but after 48 hours; the Maylard group showed less pain. Even though the surgical wound length in Maylard group was longer than Pfannenstiel group, numbers of cases with VAS >4 within 24 hours in Maylard were less than in Pfannenstiel group. Postoperative pain up to 48 hours in both Maylard and Pfannenstiel group showed similar VAS but after 48 hours; the Maylard group showed less pain. Even though the surgical wound length in Maylard group was longer than Pfannenstiel group, numbers of cases with VAS >4 within 24 hours in Maylard were less than in Pfannenstiel group.

Nomogram of Intracranial Translucency in the First Trimester Ultrasound of Pregnant Women at Thammasat University Hospital.

Objective: The aim of the study was to determine normative values of intracranial translucency (IT) by ultrasonography in singleton pregnant women patient at Thammasat University Hospital during the first trimester. Material and Method: The first trimester singleton pregnant women (11-13 weeks) underwent routine ultrasonography screening. The gestational age was calculated by measuring the length of the embryo or fetus from the top of its head to bottom of the buttocks (crown-rump length; CRL) and IT of the brain region in the mid-sagittal planefetal face position. Repeated ultrasonography was performed in the second trimester period as well as after birth infant check-up for disability. Results: One hundred and ninety one singleton pregnant women were examined by an ultrasonography to measure CRL, GA and IT. The average age was 29.71±5.09 years (16-39 years). All participants were healthy without a history of anomaly in previous pregnancies. Half of cases were nulliparity. Participants were followed until birth. There was no open neural tube defect baby in this study. Median GA, CRL and IT in this study were 12.6+0.7 weeks, 64.0±10.2 (40.0-80.9) and 1.3±0.3 (0.5-2.5) mm, respectively. IT measurement value increased in correlation with increasing CRL and advancing GA (p<0.05). Conclusion: IT values increased significantly with CRL and GA increasing.

Co-Existing Ovarian Mucinous Cystadenocarcinoma with Mature Cystic Teratoma: A Rare Case Report.

Background: Mature cystic teratoma is the most common benign germ cell ovarian tumor. Malignant transformation is uncommon. The pathology is mostly composed of squamous cell carcinoma. Mucinous cystadenocarcinoma should be differentiated between malignant transformation and the coincidental occurrence. Case Report: A case of an early stage mucinous ovarian cancer co-existing with mature cystic teratoma at the same ovarian side was reported. A 57-year-old woman presented with incidental palpable pelvic mass for two weeks. Right ovary consisted of multiloculated cyst and mature cystic teratoma. The patient underwent an exploratory laparotomy for a large ovarian cyst evaluation. Mucinous ovarian cancer was diagnosed as FIGO stage IC3 after operation. Histopathology report showed mucinous cystadenocarcinoma and mature cystic teratoma of the right ovary. There was no additional abdominal abnormality. Immunohistochemistry staining supported the diagnosis of metastatic adenocarcinoma of colon or intestinal type of mucinous ovarian cancer. Further investigation for locating other primary cancer site was then performed. The result was negative. The intestinal-type mucinous ovarian cancer co-existing with mature cystic teratoma of the right ovary was the final histopathological reading. The patient was then started on carboplatin/paclitaxel combination chemotherapy for 6 cycles after surgery. The patient showed complete remission at the end of the chemotherapy treatment. Conclusion: This was a rare case of mucinous ovarian cancer co-existing with mature cystic teratoma. Clinical acumen, immunochemistry staining and metastatic survey investigation played important roles for the final diagnosis.

The effects of promoting self-efficacy program on the oral contraceptive used behavior among adolescent mothers.

OBJECTIVE: To study the effects of a promoting self-efficacy program on the oral contraceptive used behavior among adolescent mothers. MATERIAL AND METHOD: This is a quasi-experimental study which based on a pretest-posttest design with group comparison. The participants were primiparous adolescent mothers aged 15-19 years who attended at antenatal care clinic, delivered and came for postpartum check-up at 6 weeks after delivery at Thammasat University Hospital from December 2013 to March 2014. RESULTS: Sixty adolescent mothers were selected through inclusion criteria and divided equally to study and control group. Study group participated in the effects of the promoting self-efficacy program combined with standard nursing care. Control group received only standard nursing care from the same nursing staff Demographic data of both groups had no statistical difference. Mean scores on oral contraceptive self-efficacy (OCSE) and oral contraceptive used behavior (OCUB) ofstudy group were higher than control group with a statistical significance (p < 0.001) at 12 weeks postpartum. CONCLUSION: Adolescent mothers had a high risk of unintended pregnancy due to inconsistent oral contraceptive usage. Promoting self-efficacy program regarding oral contraceptive behavior should be integrated to standard nursing care practice. This program could encourage adolescent mothers to engage correct and continuous oral contraceptive usage.

Postoperative Pain Relief in Major Gynaecological Surgery by Perioperative Parecoxib Administration: Thammasat University Hospital Study.

OBJECTIVE: To study postoperative pain relief in major gynaecological surgery by perioperative parecoxib administration in Thammasat University Hospital. MATERIAL AND METHOD: This double-blind randomized controlled clinical trial was conducted in Thammasat University Hospital, Pathumthani, Thailand from October 2013 to May 2014. One hundred and twenty patients who underwent elective gynaecological surgery were randomized assigned to study and control groups. Study group (n = 60) received 40 mg parecoxib and control group (n = 60) received placebo at 1 hour before surgery. The postoperative visual analog scale (VAS) at 3, 6, 12 and 24 hours, frequency of meperidine consumption in 24 hours and side effects of parecoxib were recorded. RESULTS: VAS of study group after operation at 3, 6, 12 and 24 hours was significantly lower than control group. Meperidine consumption in placebo group was significantly higher than study group (27.50 ± 19.36 and 48.75 ± 28.15 mg, respectively; p < 0.001). There was no side effect from parecoxib in this study. CONCLUSION: Intravenous postoperativeparecoxib injection could relief pain and reduced meperidine consumption. Parecoxib could be safely used in gynaecological surgery for postoperative pain relief

The effects of systematic management on maternal and neonatal complications in gestational diabetes subjects.

OBJECTIVE: To compare maternal and neonatal complications ofgestational diabetes mellitus (GDM) between conservative and systematic management. MATERIAL AND METHOD: This retrospective cohort study was conducted at Thammasat University Hospital, Thailand. GDM subjects who were diagnosed and treated from October 2004 to March 2007 were classified as the conservative management group (CMG). The participants who were diagnosed and treated from April 2007 to September 2009 were classified as the systematic management group (SMG). SMG was ambulatory-managed per standard protocol by a multidisciplinary team (physician, diabetes nurse case manager nutritionist and pharmacologist). RESULTS: There were 87 and 118 subjects in CMG and SMG, respectively. Mean age and body mass index before pregnancy in CMG and SMG were not statistical different. Oral glucose tolerance tests (50 and 100 gram) were similar in both groups. The prevalence of GDM A2 was 57.5 and 55.1% in CMG and SMG, respectively. Mean gestational age at DM clinic consultation and number of hospital admission of SMG was less than CMG (p < 0.001). Neonatal hypoglycemic episode in SMG was less than CMG (1.7 vs. 10.3; p = 0.007). Postpartum 75-gram glucose tolerance test appointments and percentages of underwent in SMG were more than CMG (p < 0.001). Other composite maternal and neonatal outcomes were not different in either group. CONCLUSION: Systematic management by a multidisciplinary team conducted according to a practical guideline has the benefit of neonatal hypoglycemia reduction and hospital admission included postpartum DM surveillance increments.

Incidental Finding of Metastatic Cutaneous Malignant Melanoma at Uterine Leiomyoma, A Thai University Hospital Experience: A Case Report.

BACKGROUND: Metastatic malignant melanomas to the uterus are extremely rare; to our knowledge, no more than 13 cases have been reported to date. CASE REPORT: A 44-years-old multigravida woman presented with a black and irregular surface mass at medial aspect of left thigh. There was also an enlarged left groin node. Wide excision with lymph node dissection revealed malignant melanoma. Further examination found a huge pelvic mass with left deep vein thrombosis consequent by pressure effect. Chest and complete abdominal computed tomography revealed an enlarged, fibroid uterus with pressure effect at left common iliac vein. A total abdominal hysterectomy and bilateral adnexectomy were performed. Intra-operative finding was scattered hyperpigment spots at surface of the uterus and its tumor Histopathological report showed metastatic malignant melanoma involving myometrium and uterine serosa. Diagnosis of stage IV malignant melanoma (uterine metastasis) was achieved. The patient was counseled about her diagnosis, stage, prognosis and further treatment. CONCLUSION: Uterine metastatic malignant melanoma was a rare condition. This report represents the first case of a cutaneous malignant melanoma involving a uterine leiomyoma in Thailand.

Twin Reversed Arterial Perfusion (TRAP) Sequence: A Case Report and Review of Treatment.

A cardiac twin or twin reversed arterial perfusion (TRAP) sequence is a rare unique complication of monozygotic multiple pregnancy. In this disorder, there is a normally formed donor (the pump twin) who has features of congestive heart failure (CHF) as well as a recipient (the acardiac twin) who lacks a well-defined a heart structure. Also evident are other structures, namely the TRAP sequencefrom pump to acardiacfetus via single artery-to-artery and vein-to-vein anastomoses directly between the two cords or indirectly on the chorionic plate. Overall, the perinatal mortality rate for the pump twin is 35-55%. Prenatal diagnosis and prognosis factors can be examined through ultrasound. The optimal management of a cardiac twin pregnancies is controversial. The expected treatment of acardiac anomaly presently relies on maximizing the chance ofterm delivery and preventing CHF in the healthy pump twin or interrupting vascularization between the two twins. This article reported the experience of acardiac twin management in Thammasat University Hospital and reviewed the current knowledge ofthe condition, prenatal diagnosis, prognosis factor and management options focusing on conservative management compared to invasive treatment.

Recurrence of Endometrioma Following Conservative Ovarian Endometrioma Cystectomy: Laparoscopy versus Laparotomy.

OBJECTIVE: To investigate the recurrence rate and disease-free interval between laparoscopy versus laparotomy for the conservative surgery of endometrioma. MATERIAL AND METHOD: A retrospective cohort study was conducted. The medical records of reproductive women who underwent conservative ovarian cystectomy surgery (laparoscopy or laparotomy) for endometrioma at Thammasat University Hospital were retrieved. The patients were followed through 24 months to evaluate the recurrence of endometrioma. Propensity scoring was used to adjust for confounding by indication and confounding by contraindication. Model for competing time to event was used in analysis. RESULTS: One hundred and twenty-eight and 114 patients were enrolled in laparoscopy and laparotomy groups, respectively. Mean age and body weight in laparotomy group were statistically higher than those in the other group were. Mean height and body mass index were, however not statistically different in either groups. In addition, the stage of disease and bilaterality in both groups were comparable. Diameter ofendometrioma in laparotomy group was significantly larger than that in laparoscopy group (7.0 ± 2.5 vs. 6.2 ± 1.8 cm, respectively; p = 0.004). After adjusting for propensity scoring, the endometrioma recurrence rate was significantly higher in laparoscopy group as compared to laparotomy group (27.3% vs. 14.9%, respectively; p = 0.02). However, the cumulative rate of pregnancy after surgery was not statistically different (4.7% vs. 4.4%, respectively; p = 1.0). CONCLUSION: The present study has demonstrated that the surgical technique has a strong impact on the recurrence or disease-free interval. Laparoscopy might not eradicate the disease pathology as effectively as open laparotomy in some situations, such as in cases with complexity of disease.

Bevacizumab, Carboplatin and Paclitaxel Combination Treatment in Advanced Stage Ovarian Cancer: The First Experience in Thammasat University Hospital, Thailand: A Case Report.

BACKGROUND: Bevacizumab, a humanized monoclonal antibody targeting vascular endothelial growthfactor (VEGF), has been approvedfor concurrent treatment with first line chemotherapy in advanced epithelial ovarian cancer. CASE REPORT: A case of an advanced stage epithelial ovarian cancer (EOC) receiving a combination of bevacizumab, carboplatin andpaclitaxel chemotherapy was reported. A 44-year-old woman was presented with abdominal discomfort and distention for 4 months. Bilateral 12 cm diameter ovarian tumors were diagnosed as FIGO stage IIIc after surgical staging operation. Histopathology report showed the mixed type of serous and endometriod adenocarcinoma. The patient was then started on carboplatin/paclitaxel combination chemotherapy for 6 cycles after surgery every 3 weeks. Bevacizumab (7.5 mg/ m2) was concurrently administered with chemotherapy every 3 weeks startingfrom the 2nd cycle. A complete remission was achieved after the end of the chemotherapy treatment. Bevacizumab was continued for one year after the completion of the standard chemotherapy. Bone marrow suppression, hypertension and proteinuria were not found during Bevacizumab treatment. At bevacizumab treatment completion, a platinum-sensitive recurrent ovarian cancer was diagnosed at the two weeks postprogram routine check-up. The patient was counseled to start second line chemotherapy treatment and has yet to come back with her decision. CONCLUSION: Combination of bevacizumab, carboplatin and paclitaxelfor first line chemotherapy in advanced EOC in this case had no serious side effects and need further study.

The effectiveness of sublingual or oral administration of misoprostol for cervical ripening before manual vacuum aspiration in first trimester termination of pregnancy: randomized controlled trial.

OBJECTIVE: To compare the effectiveness of misoprostol sublingual and oral routes before manual vacuum aspiration (MVA) in first trimester termination of pregnancy. MATERIAL AND METHOD: A double-blinded randomized controlled trial was conducted infirst trimester termination ofpregnancy cases. Eighty cases were recruited and divided into sublingual and oral groups. Both groups were randomized to receive 400 microg misoprostol two hours prior to MVA. Main outcomes were cervical dilatation, operative time, complications, side effects, pain scores, and patient satisfactions. RESULTS: Sublingual group had significantly more cervical dilatation and shorter operative time than oral group (7.3 +/- 1.5 vs. 5.9 +/- 1.4 mm, p<0.001 and 5.2 +/- 3.3 vs. 7.3 +/- 4.6 min, p = 0.02, respectively). However there were similar side effects, pain scores, and patient satisfactions in two groups. The present study had no uterine perforation, cervical tear hemorrhage, or re-evacuation. CONCLUSION: Sublingual misoprostol route was more effective for cervical priming prior to MVA in first trimester therapeutic abortion than oral route.

Maylard incision in gynecologic surgery: 4-year experience in Thammasat University Hospital.

OBJECTIVE: To present the results of Maylard incisionfor gynecologic surgery in Thammasat University Hospital during the past four years. MATERIAL AND METHOD: A retrospective study of gynecologic surgery performed via the Maylard muscle cutting incision compare to Pfannenstiel muscle splitting and midline incision. Data came from subjects who underwent gynecologic surgey at Thammasat University Hospital, Pathumthani, Thailand friom January 2010 to December 2013. RESULTS: In the period of 4 years, there were 283 cases of elective surgery that performed via Maylard, Pfannenstiel and midline incision by the single experience gynecologic surgeon team. One hundred and six cases were performed via Maylard incision technique. The remaining 59 and 118 cases were performed via Pfannenstiel and midline incision technique, respectively. Two-thirds and one-thirds of cases underwent hysterectomy and conservative surgery, respectively. Benign conditions were the major indicationfor surgery at the percentage of 83.4. Operative results were not significantly different from well-known midline and Pfannenstiel incision in terms of blood loss, time to first meal and postoperative pain. Operative time in Maylard incision was longer than in Pfannenstiel incision. Length of stay in Maylard incision was longer than Pfannenstiel but shorter than midline incision. Overall complications (eoperation, bowel injuries, urinary bladder injuries and blood transfusion rate) were not significantly different. CONCLUSION: Maylard incision provides similar operative results with midline and Pfannenstiel technique. Even though it takes more time for abdominal entry but it gives more operative exposure than Pfannenstiel incision. In the woman with previous low transverse scar and gynaecologic surgery is needed, Maylard incision could be an optional technique that provides cosmetic and successfud results. Hand on training for Maylard incision from their mentors should be encouraged to more practice.

Prenatal diagnosis of placenta accreta by colour Doppler ultrasonography: 5-year review.

OBJECTIVE: To determine the accuracy of colour Doppler ultrasonography to diagnose placenta accreta. MATERIAL AND METHOD: The authors reviewed cases of placenta accreta between January, 2008 and December, 2012. Ultrasonographic images consistent with signs ofplacenta accreta (numerous vascular lacunae, loss ofsubplacentalsonolucent space, absent lower uterine segment between bladder-placenta, turbulent or complicated blood flow at the uteroplacental interface) were correlated with findings at the time of surgery and pathologic examination. RESULTS: Over 60 months, 12 cases (0.48/1,000 deliveries) with suspected placenta accreta by ultrasonography were studied. The median gestational age atfirst diagnosis was 24 weeks. All cases had at least one previous cesarean delivery. At surgery, all cases had an adherent placenta requiring hysterectomy (five accreta, three increta, andfourpercreta). Four cases (33%) had accidental tear of urinary bladder Nine cases (75%) required blood transfusions. CONCLUSION: Colour Doppler ultrasonography appears useful in antenatal diagnosis ofplacenta accreta.

Physical health consequences of child sexual assault in Police General Hospital.

OBJECTIVE: To determine demographic data and physical health consequences of Child Sexual Assault (CSA) victims at the Police General Hospital (PGH). MATERIAL AND METHOD: The medical records of CSA age one to 12 years at PGH between January 1, 2012 and December 31, 2012 were retrospectively reviewed. RESULTS: Of 124 child victims, 120 (96.8%) were female andfour (3.2%) were male, aged between one and 12 years (mean, 8.12 ± 3.54 years). Most of assailants were acquaintance or boyfriend The majority of victims had no body injury, 114 (91.9%). Genital injuries offemale victims were found in 40.8% of the cases and commonly seen at hymen. Anal injury was found in one case. Sexual transmitted infections included gonococcal 12.9%, chlamydial 4.0%, and trichomanas 1.7% were found. Two pregnancy cases were found. CONCLUSION: Most of CSA had no physical injury. None of the injury cases required any suture or hospital admission. Majority of sexual injury was new hymenal tear.

Spontaneous uterine rupture at non-cesarean section scar site with placenta percreta in the second trimester: a case report.

BACKGROUND: Uterine rupture was a common occurrence at previously cesarean-sectioned scar Early sign ofuterine rupture was a severe fetal bradycardia. CASE REPORT: A 30-year-old, 3 gravida, 1 para woman was presented with an acute abdominal pain and hypovolemic shock. Her gestational age was estimated at 18 weeks by emergency pelvic ultrasound. She had a lower segment scar from a previous caesarean section. Initially, alive intrauterinepregnancy with massive hemoperitoneum was a provisional diagnosis. During exploratory laparotomy, a ruptured of the right uterine fundus was found with placenta percreta. Hysterectomy was performed. Fetal weight was 450 grams, APGAR score 0, 0 and the fetus could not survive. The patient was discharged on the 4th day after surgery in healthy condition. CONCLUSION: Uterine rupture is a catastrophic kituation. Severefetal bradycardia might be an early sign. This case demonstrates the importance ofclinical judgment based on clinical acumen.

Silent abnormal placentation linkage to peripartum hysterectomy: Thammasat University Hospital 6-year study.

OBJECTIVE: To determine the prevalence, indications, types and complications of peripartum hysterectomy at Thammasat University Hospital, Thailand. MATERIAL AND METHOD: A retrospective peripartum hysterectomy (PH) study. Data came from parturient who delivered at Thammasat University Hospital, Pathumthani, Thailand between January 2007 and December 2012. RESULTS: In the period of 6 years, there were 37 cases of PH among 28,023 parturient. The overall prevalence of PH was 1.32 per 1,000 deliveries with average parturientage of 30. Nineteen hysterectomies were performed after vaginal delivery (1.1/1,000) and the remaining 18 hysterectomies were performed after cesarean section (1.67/1,000). Seven cases (18.9%) were performed as subtotal and the remaining 30 cases (81.1%) as total hysterectomy Major indication of PH was uterine atony (75.7%, 28/37) followed by abnormal placentation (10.8%, 4/37) and uterine rupture (5.4%, 2/37). From hysterectomy specimens, placenta accreta, placenta increta and placenta percreta were found in 5, 3, and 3 cases, respectively. Two cases of cervical intraepithelial neoplasia were later discovered from hysterectomy specimens. Three cases of placentapercreta were associated with pre-operative diagnosis of placenta adherent, uterine rupture and placenta previa. The average estimated blood loss was 2,416 ml. The overall surgical complication rate was 35.1% (13/37). The rate of reoperation, maternal death, wound infection, gut obstruction and lung complications were 16.2, 8.1, 2.7, 2.7 and 2.7 percent, respectively. CONCLUSION: Peripartum hysterectomy is a major hazardous procedure carrying a high mortality and morbidity rate. In this study, maternal mortality was 8.1%. Silent abnormal placentation was found in 21.2 percent (7/33) of hysterectomy specimen.

Fifteen-Centimeter Giant Tamoxifen-Associated Endometrial Polyp Presenting With Constipation: A Case Report and Review of the Literature.

Endometrial polyps are benign disorganized growth of endometrial glands and stroma in the uterine cavity. They are associated with subfertility, abnormal uterine bleeding, and tamoxifen use. While most polyps are smaller than 2 cm in size, rare giant polyps can cause concerns over malignancy. We report a case of a 15 cm giant endometrial polyp in a 58-year-old woman with a history of tamoxifen use who presented with an uncommon complaint of constipation. Additionally, a literature review of giant endometrial polyp cases is presented. This case represents the largest reported endometrial polyp to date.