Clinical and laboratory parameters associated with eclampsia in Thai pregnant women.

OBJECTIVE: Determine the risk factors and pregnancy outcomes of eclampsia in our institution. MATERIAL AND METHOD: The authors conducted a case-control study of 80 Thai pregnant women with eclampsia and 240 controls with mild preeclampsia who delivered at King Chulalongkorn Memorial Hospital, Bangkok, Thailand between 1995 and 2011. Information was abstracted on established and hypothesized risk factors for eclampsia documented in the medical records. RESULTS: The risk factors that were significantly associated with eclampsia compared to mild preeclampsia after using multivariate logistic regression analysis were maternal age < 20 years [adjusted odd ratio (aOR) 4.8, 95% confidence interval (CI) 1.7 to 14), antenatal care (ANC) < 4 visits (aOR 3.4, 95% CI 1.2 to 9.1), deep tendon reflex (DTR) > or = 3+ (aOR 15.1, 95% CI 15.3 to 42.7), serum uric acid > or = 6 mg/dL (aOR 8.3, 95% CI 13.5 to 19.8), serum creatinine > or = 0.9 mg/dL (aOR 18, 95% CI 4.8 to 67.5), and serum glutamate oxaloacetate transaminase (SGOT) > or = 44 IU/L (aOR 15.9, 95% CI 5.6 to 45.3). CONCLUSION: The risk factors of the development of eclampsia compared to mild preeclampsia are maternal age < 20 years, ANC < 4 visits, DTR > or = 3+, serum uric acid > or = 6 mg/dL, serum creatinine > or = 0.9 mg/dL, and serum SGOT > or = 44 IU/L. This information may be useful for obstetricians to predict which mild preeclamptic patients are at great risk for eclampsia and to consider administration of magnesium sulfate to prevent convulsion in these patients.

The occurrence of small for gestational age infants and perinatal and maternal outcomes in normal and poor maternal weight gain singleton pregnancies.

OBJECTIVE: To assess the occurrence of small for gestational age (SGA) infants and perinatal and maternal outcomes in singleton pregnancies with normal and poor maternal weight gain. MATERIAL AND METHOD: Pregnant women with normal pre-pregnancy body mass index (BMI) and attending the antenatal clinic at King Chulalongkorn Memorial Hospital (KCMH) between 2006 and 2010 were eligible for the present study. The Thai population guidelines recommend a total weight gain of 10 to 16 kg or > or = 0.27 kg/week during pregnancy. In contrast, in 2009 the Institute of Medicine (IOM) guidelines recommended a total weight gain of 11.5 to 16 kg or > or = 0.31 kg/week. Our patients were analyzed using both sets of guidelines based on a normal pre-pregnancy BMI (18.5-24.9 kg/m2). SGA infants, perinatal outcomes, and maternal outcomes were compared between women whose weight gain met or exceeded the recommendations (normal weight gain) and women who did not meet these recommendations (poor weight gain). RESULTS: A case-control of 1,152 singleton pregnancies was used for the analyses. Women with poor weight gain by the recommendation of the Thai population guidelines were significantly associated with SGA infants (1% in normal weight gain group and 2.6% in poor weight gain group adjusted odd ratio (aOR) 2.77, 95% confidence interval (CI) 1.06 to 7.28), preterm births (aOR 2.20, 95% CI 1.43 to 3.38), and low birth weight (LBW) infants (aOR 2.57, 95% CI 1.60 to 4.13). Women with poor weight gain by the recommendation in the 2009 IOM guidelines were significantly associated with preterm births (aOR 2.04, 95% CI 1.31 to 3.17), LBW infants (aOR 2.75, 95% CI 1.66 to 4.55), but not SGA infants (aOR 1.97, 95% CI 0.74 to 5.20). Maternal weight gain < 0.27 kg/week (Thai guidelines) was more likely to associate with SGA infants than maternal weight gain < 0.31 kg/week (2009 IOM guidelines). Women with normal weight gain by both recommendations were more likely to have pregnancy-induced hypertension and less likely to have gestational diabetes compared with women with poor weight gain. CONCLUSION: Poor maternal weight gain during pregnancy was associated with SGA infants, preterm births, and LBW infants. The Thai guidelines were a better predictor of SGA infants. The 2009 IOM guidelines should be used with caution in Thai patients.

Previous uterine operation and placenta previa.

OBJECTIVE: The primary objective was to examine the association between previous uterine operation and placenta previa. The secondary objectives were to study the association between cesarean hysterectomy and placenta previa and to evaluate the maternal and neonatal outcomes of placenta previa. MATERIAL AND METHOD: All medical records of placenta previa patients delivered at King Chulalongkorn Memorial Hospital between January 2006 and December 2008 were reviewed (215 records). Two hundred and six records were enrolled and nine records were excluded. Controls were selected by matching the first following patients delivered by cesarean section and none had a previa at delivery the same day as the index case. Student t-test, Mann-Whitney U-test and Chi-square test were used when appropriate. Odd ratio was calculated for evaluation of risk factors of placenta previa. RESULTS: Previous uterine operations were found in the placenta previa group more than the control group but with no statistically significant difference {previous c/s (18.9% vs. 16.5%, p = 0.6), previous myomectomy (1.5% vs. 0%, p = 0.1) and previous dilatation and curettage (17.5% vs. 11.2%, p = 0.1)}. Odd ratio of previous cesarean section and previous dilatation and curettage for placenta previa was 1.2 (95% CI 0.7 to 1.9) and 1.7 (95% CI 0.9 to 2.9), respectively. In the placenta previa group, there were more statistically significant differences and poorer maternal outcomes than in the control group, including blood loss (1,306.1 ml vs. 528.9 ml, p < 0.001), postpartum hemorrhage (9.2% vs. 0.5%, p < 0.001), cesarean hysterectomy (7.3% vs. 0%, p < 0.001), blood transfusion (27.7% vs. 1%, p < 0.001) and more poorer neonatal outcomes than in the control group, including preterm birth (30.5% vs. 3.9%, p < 0.001), lower birth weight (2,777.9 g vs. 3,186.3 g, p < 0.001), and lower APGAR score at first minute (8.24 vs. 8.66, p = 0.004) and at fifth minute (9.45 vs. 9.73, p = 0.035). CONCLUSION: In the present study, the majority of patients with placenta previa have no association with previous uterine operation. However it is potentially life-threatening to the mother and frequently results in high perinatal morbidity.

Assessment of medical ethics of fourth-year medical students.

From 2005 to 2008, the authors assessed the medical ethics of 779 medical students in the Department of Obstetrics and Gynecology at the Faculty of Medicine, Chulalongkorn University by using the Chula Method. This was conducted through a written examination asking the students to express their opinions about ethical issues. Their answers were rated as either Satisfactory (S) or Unsatisfactory (U). It was found that 750 students (96.3%) earned S while 29 students (3.7%) earned U. The results from this study can not be compared with the results from studies published in medical journals. Thus, knowledge about medical ethics is not complete even though it is intensively taught in medical schools and has been practiced for a long time. The authors would like to propose a new assessment of the medical ethics so that it can be systematically applied.

Intramuscular diclofenac for analgesia after cesarean delivery: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of intramuscular diclofenac in postoperative cesarean section pain control. STUDY DESIGN: A randomized controlled trial. SETTING: Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital. SUBJECTS: Eighty patients scheduled for elective cesarean section between October 2007 and April 2008. MATERIAL AND METHOD: All patients had cesarean section performed under spinal anesthesia with spinal morphine and randomized into two groups by a table of randomization. They were to receive diclofenac 75 mg intramuscular every 12 hours for 2 doses or standard rescue drugs (Tramadol). OUTCOME MEASUREMENTS: The number of patients who required rescue drugs, pain score (VAS), side effects of diclofenac, and satisfaction were evaluated for 48 hours postoperatively. RESULTS: In the diclofenac group, no patient required rescue drug compared to 20% of patients in the control group (p < 0.05). Median pain scores were less in the diclofenac group at 6 hours (1 (range 0-6) vs. 4 (range 0-6), p = 0.002), 12 hours (2 (range 0-5) vs. 3 (range 0-7), p = 0.031), and 24 hours (1.5 (range 0-4) vs. 3 (range 1-8), p < 0.0001), respectively. No side effects of diclofenac (e.g., gastrointestinal bleeding, bleeding tendency, uterine atony, or injection site irritation) were observed Satisfaction was comparable in both groups. CONCLUSION: Diclofenac can be used safely to reduce the requirement of rescue drugs for pain control in postoperative cesarean section.

Ibuprofen versus acetaminophen for the relief of perineal pain after childbirth: a randomized controlled trial.

OBJECTIVES: To evaluate efficacy of ibuprofen compared with acetaminophen for relief of perineal pain after childbirth, side effects of ibuprofen compared with acetaminophen and patient satisfaction in treatment between the 2 groups. MATERIAL AND METHOD: A total of 210 women who gave birth by spontaneous vaginal delivery with mediolateral episiotomy between June 2006 and November 2006 were randomly assigned to receive either ibuprofen (400 mg) (n = 106) or acetaminophen (1000 mg) (n = 104), both given orally when suturing was completed. Pain ratings were recorded before the treatment and at 1, 2, 3 and 4 hours after the treatment on a 10-cm visual analogue scale. Side effects and patient satisfaction were assessed at 24 hours. RESULTS: Pain in the ibuprofen group was considerably more reduced than the acetaminophen group at 1 hour of treatment (mean pain rating 2.18 vs. 2.88, respectively; p < 0.003). Even though, at 2, 3 and 4 hours of treatment ibuprofen seemed to give more reliefof pain than acetaminophen, they did not reach statistically significant differences (mean pain rating; at 2 hour: 1.59 vs. 1.97, p = 0.093; at 3 hour: 1.08 vs. 1.31, p = 0.183; and at 4 hour: 0.69 vs. 0.85, p = 0.169; respectively). There were no side effects and no significant differences in overall patient satisfaction between the two groups. CONCLUSION: Ibuprofen was consistently better than acetaminophen at 1 hour after treatment for relief of perineal pain after childbirth without any side effects. After 2 hours, ibuprofen and acetaminophen had similar analgesic properties.

Research publication by the Royal Thai College of Obstetricians and Gynecologists residency training program, 1994-2003.

OBJECTIVE: To evaluate the impact of the manuscript requirement policy on research publications from the Royal Thai College of Obstetricians and Gynecologists (RTCOG) residency training program. MATERIAL AND METHOD: Names and research titles of RTCOG residents from 1994 to 2003 were used to search for publications in the Medline system and Thai Index Medicus. RESULTS: There were 759 residents with 188 (24.8%) articles published. The publications per year varied from 4.8% to 17.0%. Residents were the first authors of 75 articles (39.9%). One hundred and thirteen articles (60.11%) were published in local medical journals. The majority of articles published in international journals (65.3%) were published in the Journal of the Medical Association of Thailand. After initiation of the publication promotion policy in 1999, the number of publications in which residents were not the first authors increased from 39.8% to 60.2%. CONCLUSION: The manuscript requirement policy can maintain the research publication rate.

Pyomyoma in a perimenopausal woman with intrauterine device.

Pyomyoma (suppurative leiomyoma) is a rare disease, which is considered to be a serious complication of uterine leiomyoma. Since 1945, only 18 patients have been reported and ours is the 19th. Although it is frequently reported in pregnant women or postmenopausal women who have vascular disease, our case is a 42-year-old woman in the perimenopausal period who presented with fever and a tender lower abdominal mass. She used the intrauterine device as a contraceptive method but leiomyoma had never been found before. Ultrasonographic findings suggested an ovarian tumor. She was diagnosed as having infected malignant ovarian cancer with an elevated CA 125 level that was initially treated with broad spectrum antibiotics; then she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathological findings showed acute and chronic inflammation of the endometrium with abscess formation in an intramural leiomyoma. The intrauterine device might be the origin of pyomyoma due to a direct spread of the infection from the uterine cavity. Pyomyoma may be difficult to diagnose especially in those with a nonspecific clinical presentation without any history of leiomyoma. Delayed diagnosis may result in serious complications, whereas adequate surgery and broad spectrum antibiotics may decrease serious morbidity and mortality.

Future cancer management with stem cell knowledge and technology.

Cancer has been proposed as a result of abnormal control of growth and development of stem cells for more than century. This is the "cancer stem cell hypothesis". Both cancer and stem cells share many common especial properties. They are immortal and have good differentiation potential. In addition, organogenesis and carcinogenesis are very similar processes. Recently, more evidence and convincing data from stem cell biology research are supporting this concept. Furthermore, the research provides new promising approaches for cancer diagnosis and treatment based on stem cell knowledge and technology. Upcoming data and evidence may revolutionize cancer management, making it more effective and safer.

Nasal bone hypoplasia in trisomy 21 at 15 to 24 weeks' gestation in A high risk Thai population.

OBJECTIVE: To assess the utility of nasal bone hypoplasia in the detection of fetuses with trisomy 21 in the second trimester in a high risk Thai population. MATERIAL AND METHOD: A prospective study involving pregnant women undergoing amniocentesis due to increased risk of aneuploidy from January 2005 to December 2005. Fetal biometry and nasal bone measurements were obtained at the time of amniocentesis. Linear regression model and diagnostic tests were analyzed using the SPSS computer program. RESULTS: A total of 407 fetuses were evaluated. In euploid fetuses, the Nasal Bone Length (NBL) increased linearly with advancing gestational age. Fetuses with Down syndrome had a significantly higher proportion of NBL below the 5th centile when compared with normal fetuses (p < 0.05). The optimal nasal bone threshold associated with trisomy 21 is a BiParietal Diameter/Nasal Bone Length (BPD/NBL) ratio of 10 or greater, yielded a sensitivity of 80%, specificity of 86% for detection of trisomy 21. CONCLUSION: Nasal bone hypoplasia is associated with an increased risk of Down syndrome in the presented population.

Embryonic stem cell bank.

Embryonic stem cell bank is a cornerstone for stem cell research. It is providing essential resources to support advances in research in this challenging field that promises broad-ranging cell and tissue therapy. It is important to make good quality and well characterized embryonic cell lines that will be available for both research and clinical purposes. This article provides a concise summary on embryonic stem cell banking processes from cell line characterization, storage, quality assurance, safety testing, distribution, and post-distribution monitoring. It also states the importance of an international network and collaboration for technology and knowledge transfer Moreover, the Bank should play a substantial role as a national reference and a training center for stem cell research.

Conventional and novel methods for embryonic stem cell line derivation.

Cell therapy is the promising therapeutic tool for the next decade. "Regenerative Medicine" based on cell and tissue replacement therapy is proposed as a revolutionary approach to various chronic and incurable conditions. The first key step for successful cell therapy is the establishment of clinical grade human Embryonic Stem Cell (hESC) lines. This article provides a concise summary on conventional and novel methods for hESC line derivation. There is also discussion on progression, future direction and problems in hESC line development. In Thailand, more advance knowledge, skill, and technology are required to develop the first human embryonic stem cell line and step forward to make cell therapy a reality.

Cell therapy: hype or hope.

Cell therapy is a promising therapeutic tool for the next decade. It has a potential to cure a number of chronic diseases and conditions related to aging processes or degenerative changes. In addition, it could be used to replace cells and tissues in injured organs. Furthermore, it may provide a novel approach to congenital anomalies and genetic disorders where current therapeutic options are limited However, many crucial questions need answers to ensure a safe, effective and successful solution in the field of cell therapy. In Thailand, innovative knowledge and expertise in stem cell biology and technology are required as the key elements to make cell therapy a "real" hope.

Introduction to stem cell medicine.

Embryonic stem cell is the promising novel therapeutic tool for various degenerative diseases and tissue injuries. With the concept of cell and tissue therapy, many chronic disorders will be curable. The present article provides basic knowledge of stem cell in areas of definition, classification and future clinical applications. In addition, stem cell application is not only focusing on regenerative purpose, but also concentrating on more understanding about the early human development and the pathophysiology of genetic diseases at the cellular level. However, there are some technical problems and ethical concern that should be resolved before applying stem cells into clinical practice.

International stem cell research; networking and collaboration.

Stem cell research has obtained more attention during the last decade because of its strong potential as a new tool to cure many chronic diseases. In addition, stem cell knowledge is an important basis for understanding pathophysiology at the cellular level and developing disease models for experimental research. There are different limitations on resources, budget, policy and regulation among countries. As a result, each country has particular advantages and disadvantages in stem cell research. This result in the establishment of international networks and collaborations to coordinate and promote stem cell research aimed at medical applications.