Subcutaneous vs intravenous fentanyl for labor pain management: a multicenter randomized controlled trial.

BACKGROUND: Labor pain is the most intense pain a woman will experience during her lifetime. Epidural anesthesia is recommended as the most effective method for pain relief, but it has several limitations. Fentanyl has high analgesic potency with short-acting duration, but the large-scale trials that assessed the effectiveness and safety of it for labor pain management are still limited. OBJECTIVE: This study aimed to compare the effectiveness and harm and maternal satisfaction of subcutaneous vs intravenous fentanyl for labor pain management. STUDY DESIGN: We conducted a multicenter, open-label randomized controlled trial. A total of 226 women were randomized to receive intravenous or subcutaneous fentanyl for labor pain management. Pain scores were evaluated before and after fentanyl administration at 5, 30, and 60 minutes and then every 60 minutes until delivery. The data were analyzed based on the intention-to-treat principle. RESULTS: Both intravenous and subcutaneous fentanyl significantly decreased labor pain from baseline to delivery (overall mean change, -1.39; 95% confidence interval, -1.62 to -1.17; and -0.89; 95% confidence interval, -1.24 to -0.05, respectively). The reduction in the pain score between the 2 groups was not different (overall mean difference, -0.35; 95% confidence interval, -0.76 to 0.05). Maternal satisfaction was high for both intravenous and subcutaneous fentanyl (89.4% and 93.8%, respectively). There was no difference in the maternal satisfaction rate between the 2 groups (relative risk, 0.95; 95% confidence interval, 0.88-1.03). No serious maternal and neonatal adverse effects were observed. CONCLUSION: Both intravenously and subcutaneously administered fentanyl were safe and significantly reduced pain from baseline to delivery among low-risk pregnancies. Maternal satisfaction with the childbirth experience was high regardless of the route of administration of fentanyl. No serious adverse effects of fentanyl were observed in either the mothers or the neonates.

Epidemiology and factors associated with preterm births in multiple pregnancy: a retrospective cohort study.

OBJECTIVE: Multiple pregnancies carry an increased risk of maternal and perinatal complications, notably prematurity. Few studies have evaluated the risk factors for preterm births in multiple pregnancies within the Thai population. This study aims to ascertain maternal and perinatal outcomes and identify factors linked to preterm births in multiple pregnancies. METHODS: This study was carried out at Khon Kaen University, Faculty of Medicine, Department of Obstetrics and Gynecology in Thailand. We reviewed the medical records of women with multiple pregnancies who delivered at a gestational age of more than 20 weeks between January 1, 2012 and December 31, 2021. We excluded patients with incomplete data or those for whom data were missing. RESULTS: Out of 21,400 pregnancies, 427 were multiple pregnancies, constituting approximately 1.99%. Over the ten-year period, 269 multiple pregnancies (65.1%) resulted in preterm births. Of these, 173 (64.3%) were monochorionic twins, and 96 (35.7%) were dichorionic twins. Monochorionic twins had a notably higher rate of preterm delivery (AOR, 2.06; 95%CI 1.29-3.30). Vaginal delivery was observed in 7.9% of the cases, while cesarean sections were performed for both twins in 91.5% of cases. In 0.5% of the cases, only the second twin was delivered by cesarean section. In terms of neonatal outcomes, 160 infants (19.4%) weighed less than 1,500 g at birth, and there were 78 perinatal deaths (9.4%). Birth asphyxia was noted in 97 cases (20.2%) among monochorionic twins and in 28 cases (8.1%) for dichorionic twins. CONCLUSION: The prevalence of multiple pregnancies was 1.99%, with 65.1% resulting in preterm births. Neonatal complications were notably more frequent in monochorionic twins. Monochorionic placenta and antepartum complications emerged as significant risk factors for preterm birth.

Epidemiology and prognostic factors for successful expectant management of early-onset severe features preeclampsia: A retrospective multicenter cohort study.

BACKGROUND: To determine the incidence of early-onset severe features preeclampsia among pregnant women and compare maternal complications and perinatal outcome characteristics of expectance and immediate delivery management with identified prognosis factors for successful expectant management. MATERIALS AND METHODS: A retrospective descriptive multicenter cohort study of pregnant women diagnosed with severe features preeclampsia before 34 weeks of gestation according to the American College of Obstetricians and Gynecologists guidelines was conducted at Khon Kaen University, Srinagarind Hospital and Khon Kaen Hospital between January 1, 2015 and December 31, 2019. Medical records were reviewed for incidence of early-onset severe features preeclampsia, with maternal complications and perinatal outcome characteristics compared for expectant and immediate delivery management. RESULTS: In total, 42,948 deliveries were recorded during the study period. Of these, 971 were diagnosed with severe features preeclampsia (22 per 1,000 deliveries). Two hundred and sixty-five women (6.3 per 1,000 deliveries) were diagnosed with early-onset severe features preeclampsia before 34 weeks of gestation. No differences were recorded in characteristics between the expectant and delivery management groups. Perinatal outcomes were significantly different between the expectant and delivery management groups; birth weight below 1,500 g (23.5 % versus 58.9 %, p < 0.001), neonatal intensive care unit (65.9 % versus 87.2 %, p < 0.001); neonatal resuscitation (22.3 % versus 57.1 %, p < 0.001). Birth asphyxia, stillbirth and intrapartum death only occurred in women with early-onset severe features preeclampsia in the delivery management group. CONCLUSIONS: Incidence of early-onset severe features preeclampsia was 6.3 per 1,000 deliveries. For women with complications such as early-onset severe features preeclampsia, expectant management significantly benefitted neonatal outcomes, with no differences in maternal outcomes compared to the immediate delivery management group. The gestational age at diagnosis of more than 30 weeks and uric acid level of less than 5.5 mg/dL (327.14 µmol/L) were significant factors for the successful expectant management.

Fetal and Neonatal Modified Myocardial Performance Indices in Preeclamptic versus Normotensive Pregnancies: A Prospective Cohort Study.

OBJECTIVE: To compare fetal and neonatal cardiac functions in terms of global, systolic, and diastolic function between the preeclampsia and normotensive blood pressure of pregnancies. METHODS: A prospective cohort study was conducted at a university hospital in Northeast Thailand. Twenty-nine pregnancies diagnosed as preeclampsia with or without severe features were compared with 29 normotensive pregnancies. Global cardiac, systolic, and diastolic function were assessed at prenatal and postnatal periods, by a professionally trained obstetrician and pediatric cardiologist, respectively. RESULTS: The fetal left modified myocardium performance index (Mod-MPI) in preeclampsia and normotensive blood pressure were 0.60±0.08 and 0.59±0.08 (p-value=0.341), respectively, while fetal right Mod-MPI were 0.57±0.16 and 0.54±0.21 (p-value=0.861), respectively. There were no statistically significant differences in terms of fetal isovolumic contraction time (ICT), isovolumic relaxation time (IRT), ejection time (ET), aortic peak systolic velocity (Ao PSV), pulmonary artery peak systolic velocity (PA PSV), mitral valve (MV) E:A ratio, or tricuspid valve (TV) E:A ratios between the two groups. Neonatal mitral valve E peak systolic velocity (MV-E PV) in preeclamptic and normotensive blood pressure groups were significantly different at 51.1±8.02 cm/s and 43.56±5.21cm/s (p-value=0.036), respectively, whereas neonatal left Mod-MPI, mitral valve A peak systolic velocity (MV-A PV), MV E:A ratio, and Ao PSV were not significantly different (p-value=0.436, 0.119, 0.379, and 0.709), respectively. CONCLUSION: Neonatal MV-E PV of the preeclampsia group was significantly higher than the normotensive blood pressure group, while there were no statistically significant differences in terms of global cardiac and diastolic functions during the fetal period between two groups.

Transperineal versus transvaginal sonographic measurements of cervical length in pregnant women between 16 and 24 weeks of gestation.

PURPOSE: To investigate the correlation between cervical length measurements using transvaginal and transperineal approaches at 16-24 weeks of gestation. METHODS: The prospective study recruited 110 singleton pregnant women. All the measurements were performed by one operator who was blinded to the results of both approaches. Cervical length was first measured by transvaginal sonography (TVUS) then transperineal sonography (TPUS). The transvaginal approach was used as the reference measurement. Patient preference regarding the sonographic approaches was evaluated using questionnaire. RESULTS: Cervical length was successfully measured by TVUS in all cases. TPUS was successful in 108/110 participants. There was high correlation between the results of TVUS and TPUS (Pearson's correlation coefficient was .94; 95% CI .9 to .95. Lin's concordance correlation coefficient was .94; 95% CI .92-.96). The estimated difference in cervical length measured using TVUS and TPUS was .2 mm. The 95% tolerance interval for paired observation was -1.8 to 2.3 mm. The interobserver coefficient of TPUS measurement was .98 (95% CI .92-.99). TPUS was rated as resulting in mild or no discomfort and was preferred by most women. CONCLUSION: TVUS and TPUS techniques showed high correlation in cervical length measurement with high interobserver reliability. More patients preferred TPUS. TPUS should be considered as an alternative method of cervical length measurement.

Incidence, characteristics, maternal complications, and perinatal outcomes associated with preeclampsia with severe features and HELLP syndrome.

OBJECTIVE: To determine the incidence of preeclampsia with severe features among pregnant women and evaluate the characteristics, maternal complications, and perinatal outcomes between nonsevere preeclampsia versus preeclampsia with severe features and hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome. MATERIALS AND METHODS: A retrospective descriptive study was conducted at Khon Kaen University's Srinagarind Hospital, a tertiary care facility in northeast Thailand. The pregnant women who had been diagnosed with preeclampsia according to American College of Obstetricians and Gynecologists guidelines from January 1, 2012 to December 31, 2016 were identified and their medical records were reviewed. Various characteristics were examined to compare maternal complications and perinatal outcomes. RESULTS: There was a total of 11,199 deliveries during the study period, out of which 213 preeclamptic women were identified. One hundred and seven women (9.6 per 1,000 deliveries) were diagnosed with nonsevere preeclampsia, 90 (8 per 1,000 deliveries) had preeclampsia with severe features, and 16 (1.4 per 1,000 deliveries) had HELLP syndrome. Twenty-one women (9.9%) experienced postpartum hemorrhage; 11 (10.3%) in the nonsevere features preeclampsia group and 10 (9.4%) in the preeclampsia with severe features and HELLP syndrome group. Placental abruption (3 women; 1.4%) and heart failure (1 women; 0.4%) only occurred among women in the preeclampsia with severe features group. Neonatal complications were significantly higher in the preeclampsia with severe features and HELLP syndrome group (low birth weight =35.1% versus 74.3%, p<0.001; birth asphyxia =4.4% versus 18.2%, p=0.001; neonatal intensive care unit admission =7.0% versus 30.9%, p<0.001; neonatal resuscitation =15.8% versus 42.7%, p<0.001). Stillbirths only occurred in cases of preeclampsia with severe features and HELLP syndrome (3 cases, 1.4%). Intrapartum death was higher in cases of preeclampsia with severe features and HELLP syndrome, but without statistical significance (2.6% versus 6.4%, p=0.190). CONCLUSION: The incidence of preeclampsia with severe features and HELLP syndrome was 9.5 per 1,000 deliveries. Severe maternal and perinatal outcomes were more commonly observed.

Short cervix detection in pregnant women by transabdominal sonography with post-void technique.

PURPOSE: This study aimed to evaluate the diagnostic properties of transabdominal sonography with the post-void technique for cervical length measurement. METHODS: This study was a prospective cohort study. The inclusion criteria were pregnant women aged 18-40 years with gestational age of 18-23 completed weeks. Transabdominal sonography with vertical bladder depth of less than 5 cm and transvaginal cervical length measurements were carried out by a single experienced sonographer. RESULTS: There were 307 eligible pregnant women. The mean age of all subjects was 29.0 years. The mean cervical length obtained through transabdominal and transvaginal measurement was 3.33 and 3.47 cm, respectively. Ten patients (3.3 %) were identified as having a short cervix using transvaginal sonography, and 12 patients (3.9 %) were identified using transabdominal sonography. CONCLUSION: Transabdominal sonography with vertical bladder depth of less than 5 cm performed better compared with transvaginal sonography. It may not be necessary to perform transvaginal sonography if transabdominal sonography reveals the cervical length to be more than 2.5 cm.

Second trimester genetic ultrasound for Down syndrome screening at Srinagarind Hospital.

OBJECTIVE: To assess the value of second trimester genetic ultrasound for screening of Down syndrome conducted at Srinagarind Hospital, Khon Kaen, Thailand. MATERIAL AND METHOD: The present study sample comprised of 4,033 pregnant women at high risk forfetal chromosomal abnormality, from 17th to 23th week, who had performed second trimester genetic ultrasound before genetic amniocentesis between September 1996 and December 2011. Archived medical records relating to results ofgenetic ultrasound and genetic amniocentesis were extracted and studied. MAIN OUTCOME MEASURE: Sensitivity ofgenetic ultrasound in the detection of fetal Down syndrome. Results: There were 3,966 chromosomally normal pregnancies (98.3%), 43 fetuses with Down syndrome (1.1%), and 24 fetuses with other chromosomal abnormality (0.6%). 30 of 43 (69.8%) fetuses with Down syndrome had abnormal genetic ultrasound. The overall sensitivity of second trimester genetic ultrasound for detecting Down syndrome was 69.8% with a false-positive rate of 50.4% and likelihood ratio of 1.38. Of all the sonographic markers, short femur, and short humerus indicated the highest sensitivity at 65.1% and 44.2%. According to likelihood ratio (LR+), chest abnormality, 2 vessel umbilical cord, andfacial abnormality including cleft lip and palate, have highest likelihood ratio (LR+) of 61.49, 46.12, and 46.10, and had sensitivity at 4.7%, 2.3%, and 2.3% respectively. CONCLUSION: The sensitivity of second trimester genetic ultrasound for detection offetal Down syndrome at Srinagarind Hospital was rather high, and probably is an alternative method ofprenatalprediction for high risk pregnant women who refused genetic amniocentesis.

Prenatal three dimensional ultrasonography and expectant management of placental chorioangioma: a case report.

A 24-year-old Thai woman presented with large for date. Two dimensional (2D) and Doppler ultrasonography revealed a large placental mass with prominent vasculature suggestive of chorioangioma with polyhydramnios. Three-dimensional (3D) ultrasonography was used to demonstrate the better images for parental counseling. Close observation with serial ultrasonography was chosen with spontaneous decreasing of amniotic fluid. On the follow up, six months after birth, the baby had hepatic hemangioma, which responded to corticosteroid and propanoral. Although, there are several invasive therapeutic treatments adopted in the management of chorioangioma. Such procedures can cause serious complications. Expectant management should be another option because large chorioangiomas may have spontaneous infarction that improve fetal hemodynamics and clinical outcomes.

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.

Normogram of fetal middle cerebral artery peak systolic velocity at 20-37 weeks of gestation at Srinagarind Hospital.

OBJECTIVE: To establish normal references of fetal middle cerebral artery peak systolic velocity (MCA PSV) at 20 to 37 weeks of gestation at Srinagarind Hospital. MATERIAL AND METHOD: A descriptive cross-sectional study was performed Normal fetuses at 20 to 37 weeks of gestation were studied by gray scale ultrasonography initially and then Doppler of MCA PSV. RESULTS: At least 18 pregnant women of each gestational age with an uncomplicated singleton were enrolled The MCA PSV was increased as gestational age advanced from 24.34 cm/sec (SD 3.91) at 20 weeks to 59.04 cm/sec (SD 10.80) at 37 weeks. CONCLUSION: A normogram of fetal MCA PSV at 20 to 37 weeks of gestation at Srinagarind hospital was generated.

Fetal pleural effusions with spontaneous resolution: a case report.

A 42-year-old pregnant woman was referred with massive fetal bilateral pleural effusions. Observation with serial ultrasound was made. The documented spontaneous resolution of fetal pleural effusion was recorded. Neonatal examination revealed a completely healthy infant with normal respiration. Fetal pleural effusion can cause fetal lung compression, abnormal neonatal respiration and finally, neonatal mortality. Regular ultrasounds are one of the supportive options due to spontaneous resolution that can occur in 9 to 22% of the cases.

Fetal biometry charts for normal pregnant women in northeastern Thailand.

OBJECTIVES: 1) To construct normal fetal biometry charts of fetal biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) from 14 to 41 weeks of gestation in northeastern Thailand. 2) To compare the results with other studies. STUDY DESIGN: A cross sectional descriptive study. SETTING: Division of Fetal Diagnosis and Therapy, Department of Obstetrics and Gynecology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University. MATERIAL AND METHOD: The fetuses of 635 pregnant women with an uncomplicated singleton pregnancy between 14 and 41 weeks of gestation in northeastern Thailand from 1 October 2005 to 31 December 2006. All recruited pregnant women enrolled had an abdominal ultrasonography for fetal biometry and the results were compared with other studies using student's T distribution. MAIN OUTCOME MEASURES: Fetal biometry charts for normal pregnant women between 14 and 41 weeks of gestation in northeastern Thailand. RESULTS: Six hundred and twenty eight normal fetuses from 635 pregnant women were measured for fetal biometry charts. The comparison of the presented charts with others was significantly larger than the North in all parameters (except AC), but was consistent to those from the South (only BPD and FL). However when the authors compared then with central Thailand and Western countries, there were only significant differences in some gestational ages. CONCLUSION: The authors established normal fetal biometry charts for northeastern Thai pregnant women that could be implemented in the population of this region.

Pulsatility index of the middle cerebral artery in normal fetuses.

OBJECTIVE: To establish the reference ranges of the middle cerebral artery pulsatility index (MCA PI) in normal fetuses between 20 and 37 weeks gestation. STUDY DESIGN: A descriptive study. SETTING: Antenatal Care Clinic, Outpatient department, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University. SUBJECTS: At least sixteen women of each gestational age with an uncomplicated singleton pregnancy between 20 and 37 weeks gestation. METHOD: All recruited pregnant women were enrolled for abdominal Doppler ultrasonography to determine fetal MCA PI for each week of gestational age. MAIN OUTCOME MEASURES: The MCA PI reference range for normal fetuses between 20 and 37 completed weeks of gestation. RESULTS: The MCA PI decreased as gestational age advanced from 1.97 (SD 0.48) at 20 weeks to 1.15 (SD 0.18) at 37 weeks. CONCLUSION: We established the reference ranges of the fetal MCA PI for reference use in our Antenatal Care Clinic.