Thai Interest Group for Endometriosis (TIGE) consensus statement on endometriosis-associated pain.

This consensus statement has been developed by the Thai Interest Group for Endometriosis (TIGE) for use by Thai clinicians in the diagnosis and management of endometriosis. TIGE is a group of clinical and academic gynaecologists with a particular interest in endometriosis. Endometriosis is an oestrogen-dependent inflammatory disease which causes chronic symptoms such as dysmenorrhoea, chronic pelvic pain, dyspareunia and subfertility, and it is common in reproductive-age women. There is limited overall data on its prevalence in different clinical settings in Thailand, but it is clear that the disease causes significant problems for patients in terms of their working lives, fertility, and quality of life, as well as placing a great burden on national healthcare resources. Decisions about selecting the appropriate treatment for women with endometriosis depend on many factors including the age of the patient, the extent and severity of disease, concomitant conditions, economic status, patient preference, access to medication, and fertility need. Several hormonal treatments are available but no consensus has been reached about the best option for long-term prevention of recurrence. Bearing in mind differences in environment, genetics, and access to the healthcare system, this treatment guideline has been tailored to the particular circumstances of Thai women.

Diagnostic accuracy of 3D-transvaginal ultrasound in detecting uterine cavity abnormalities in infertile patients as compared with hysteroscopy.

OBJECTIVE: To assess diagnostic accuracy of 3D transvaginal ultrasound (3D-TVS) compared with hysteroscopy in detecting uterine cavity abnormalities in infertile women. STUDY DESIGN: This prospective observational cross-sectional study was conducted during the July 2013 to December 2013 study period. Sixty-nine women with infertility were enrolled. In the mid to late follicular phase of each subject's menstrual cycle, 3D transvaginal ultrasound and hysteroscopy were performed on the same day in each patient. Hysteroscopy is widely considered to be the gold standard method for investigation of the uterine cavity. Uterine cavity characteristics and abnormalities were recorded. Diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were evaluated. RESULTS: Hysteroscopy was successfully performed in all subjects. Hysteroscopy diagnosed pathological findings in 22 of 69 cases (31.8%). There were 18 endometrial polyps, 3 submucous myomas, and 1 septate uterus. Three-dimensional transvaginal ultrasound in comparison with hysteroscopy had 84.1% diagnostic accuracy, 68.2% sensitivity, 91.5% specificity, 79% positive predictive value, and 86% negative predictive value. The positive and negative likelihood ratios were 8.01 and 0.3, respectively. 3D-TVS successfully detected every case of submucous myoma and uterine anomaly. For detection of endometrial polyps, 3D-TVS had 61.1% sensitivity, 91.5% specificity, and 83.1% diagnostic accuracy. CONCLUSION: 3D-TVS demonstrated 84.1% diagnostic accuracy for detecting uterine cavity abnormalities in infertile women. A significant percentage of infertile patients had evidence of uterine cavity pathology. Hysteroscopy is, therefore, recommended for accurate detection and diagnosis of uterine cavity lesion.

Associated factors of prenatal depression among teenage pregnant women at King Chulalongkorn Memorial Hospital.

OBJECTIVE: Depression during pregnancy is associated with deteriorating maternal health and increasing risk of preterm birth, fetal growth restriction, and suicidal attempt. The problems may be worse in adolescents who are more vulnerable. This study was conducted to determine the percentage of depression among teenage mothers and its associated factors. MATERIAL AND METHOD: Two hundred teenage pregnant women aged between 13 and 19 years who visited King Chulalongkorn Memorial Hospital (KCMH) participated in the present study. They were asked to complete the validated Thai Edinburgh Postnatal Depression Scale (EPDS) questionnaire for depression screening. The cut-offscore of 11 was used for the diagnosis of prenatal depression. RESULTS: Ninety-two (46%) teenage pregnant women were found to have prenatal depression using the EPDS cut-off score of 11. The mean age of participants was 17.5 years with the mean gestational ages of 23 weeks. Most of the participants (67%) resignedfrom school and 16% had history of attempted abortion during current pregnancy. There was no significant association between prenatal depression and unplanned pregnancy, unemployment, leaving school, or trimester at screening. Logistic regression analyses showed that history of attempted abortion and inadequate income were significantly associated with prenatal depression (odd ratio = 8.03, 95% CI 1.59 to 40.37 and 4.16, 95% CI 1.35 to 12.83, respectively). CONCLUSION: Prenatal depression was common among teenage pregnant women who visited KCMH. Attempted abortion and inadequate income were found to be significantly associated with prenatal depression.

Randomized comparison of lower and standard dosages of transdermal estradiol on serum estradiol levels and vaginal maturation index.

OBJECTIVE: To evaluate serum estradiol (E2) in postmenopausal women who received 0.025 mg/d or 0.05 mg/d transdermal estradiol, in an equivalent trial. MATERIAL AND METHOD: One hundred and eight postmenopausal women were randomized into 0.025 mg/d and 0.05 mg/d of transdermal E2 matrix patch. After 12 weeks, serum E2 and vaginal maturation index (VMI) were checked in both groups. Adverse effects, such as breast tenderness, application site reaction, weight gain, and headache, were also assessed. RESULTS: Serum E2 in 0.025 mg/d and 0.05 mg/d groups were 42.43 +/- 35.11 and 48.41 +/- 22.36 pg/mL, respectively. There was no statistically significant difference between the groups. Equivalence was found under CI of +/- 14 pg/mL. Mean value of superficial cells and vaginal maturation index (VMI) were comparable between both groups. Adverse effects seem to be less in the lower dosage group compared to the standard dosage group. CONCLUSION: The lower dosage (0.025 mg/d) of the transdermal E2 matrix system is probably an appropriate treatment option for postmenopausal women who need minimal effective and minimal adverse effects.

Risk factors for cesarean hysterectomy in cesarean delivery.

OBJECTIVE: To identify the risk factors for cesarean hysterectomy. MATERIAL AND METHOD: A case-control study was conducted by reviewing the medical records of pregnant women delivered in King Chulalongkorn Memorial Hospital between January 1994 and December 2004. Cases included pregnant women who underwent hysterectomy immediately or within 24 hours after cesarean delivery, whereas control referred to pregnant women who underwent cesarean section at the same period. RESULTS: Of the 109,005 deliveries, twenty-seven women (0.25/1000-delivery) underwent cesarean hysterectomy. With multivariate analysis, the risk factors significantly associated with peripartum hysterectomy were placenta previa (adjusted OR = 67.96, 95% CI = 15.32, 301.46) and multiparity (adjusted OR = 7.30, 95% CI = 1.24, 43.19). When compared to controls, cases with cesarean hysterectomy had higher incidence of maternal and neonatal morbidities, needed more blood transfusion and required longer hospital stays. Operation performed in daytime found to have less mean blood loss (1,766 ml) compared to operation at nighttime (5,730 ml). CONCLUSIONS: Placenta previa and multiparity were significant risk factors of cesarean hysterectomy. Cesarean section in these cases should be done by experienced obstetricians with good preoperative care and if possible, during the daytime. Before an operation, each patient and her family should be counseled and informed regarding the risk for complications included hysterectomy.

Infected endometrioma in pregnancy masquerading as acute appendicitis.

BACKGROUND: A pregnancy complicated by ovarian endometrioma is rare. Other complications of ovarian endometrioma in pregnancy, i.e., rupture and infection are also rare. CASE: A 35-year-old woman, gravida 2, para 0-0-1-0, at 35 weeks' pregnancy, came to the hospital with a right abdominal pain. She also had a history of diarrhea. She had history of infertility and preexisting right endometrioma. The investigations revealed leukocytosis with neutrophils predominant. The preoperative diagnosis was acute appendicitis. Infected right ovarian endometrioma was demonstrated during exploratory laparotomy, opened and drainage of the right endometrioma and appendectomy were performed. The final diagnosis was infected ovarian endometrioma in pregnancy, later confirmed by a pathological report. CONCLUSION: Although complication of ovarian endometrioma such as infected endometrioma during pregnancy is rare, it should be included in the differential diagnosis of pelvic pain during pregnancy, especially in the patient who has history of ovarian endometrioma.

Laparoscopic finding in Thai women with chronic pelvic pain.

OBJECTIVE: To study the laparoscopic findings in Thai women with chronic pelvic pain. SETTING: The Gynecology Endoscopy unit, Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial hospital. DESIGN: Descriptive study. MATERIAL AND METHOD: The medical records of Thai women with chronic pelvic pain undergoing laparoscopic diagnosis from January 1996 to December 2001 at King Chulalongkorn Hospital were reviewed. Patients' characteristics and laparoscopic findings were reviewed and analyzed. RESULTS: One hundred and ten eligible women were enrolled in this study. The mean age was 33.9 +/- 7.2 years old (16-54 years old). Sixty-seven (60.90%) women had endometriosis, 14 (12.73%) women had pelvic adhesion, 4 (3.64%) women had myoma uteri, 4 (3.64%) women had tubal occlusion and 13 (11.81%) women had normal findings. The majority (38.15%) of endometriosis findings were in minimal stage of American Fertility Society (AFS) scores. CONCLUSIONS: The vast majority of causes of chronic pelvic pain in women in this study was pelvic endometriosis. Laparoscopic diagnosis was an important tool for identifying the causes in Thai patients.

Bilateral tubal pregnancies after tubal sterilization in a human immunodeficiency virus seropositive woman.

Bilateral tubal ectopic pregnancies are rare occurrences. Bilateral tubal ectopic pregnancy in a patient who had undergone tubal sterilization is also very rare. The authors report a case of a 32-year-old, gravida 2, parity 1, human immunodeficiency virus seropositive who had previously undergone tubal sterilization. She presented with abdominal distention and vaginal bleeding after 12 weeks of amenorrhea. Pre-operative diagnosis was ruptured ectopic pregnancy. Emergency exploratory laparotomy and bilateral salpingectomy were performed. The pathology report confirmed bilateral tubal pregnancies. She was well at the fifth day of discharge and four-week follow-up. Ectopic pregnancy should always be suspected in reproductive-age patients presenting with amenorrhea even if they have undergone tubal sterilization. To the authors' knowledge, there has been no report of bilateral tubal pregnancy in a patient with human immunodeficiency virus seropositive after tubal sterilization.