Recommendations on routine mid-trimester anomaly scan.

The purpose of this paper is to discuss the minimal requirements of the routine mid-trimester anomaly scan in Asian countries after taking into account various factors, including local circumstances, medical practice, guidelines, and availability of experienced sonographers and high-resolution ultrasound machines, which affect the prenatal detection rate of fetal anomalies. In general, a routine mid-trimester anomaly scan includes the assessment of the number of fetuses, fetal cardiac activity, size, anatomy, liquor and placental location. The most controversial issue is which fetal structures should at least be examined. We discussed the requirements of a basic routine scan, as well as the optional views, which can be obtained if feasible to improve the detection of fetal, placental or maternal abnormalities. Routine anomaly scan remains a clinical challenge.

The influence of MR imaging on changes in patient counseling in obstetric patients with suspected fetal anomalies by ultrasound.

OBJECTIVE: To determine the frequency of additional information provided by magnetic resonance (MR) imaging in supplement to ultrasound (US) in patients with fetal anomaly and to determine the influence of MR imaging findings on patient counseling. MATERIAL AND METHOD: MR imaging offetus was performed in 26 patients who have abnormal ultrasound results. Referring obstetricians were asked about how the additional information provided by MR imaging have effect on their decision marking, patient counseling, and case management. RESULTS: MR imaging in 23 of 26 fetuses was technically successful. MR imaging provided additional information in 14/23 (60.9%) cases. In the other nine (39.1%) cases, MR imaging confirmed US diagnosis but did not give supplementary information. Additional information from MR imaging affected patient counseling in five (21.7%) cases and did not affect patient counseling in the other nine (39.1%) cases. In 14 cases with additional information from MR imaging, there were isolated CNS involvement in five (35.7%) cases, isolated extra-CNS involvement in two (14.3%) cases, multisystem involvement in five (35.7%) cases, and other-category in two (14.3%) case. CONCLUSION: MR imaging can provide additional information that have influence on patient counseling and patient care, particularly in cases with CNS and multisystem anomaly.

Effect of Colpexin Sphere on pelvic floor muscle strength and quality of life in women with pelvic organ prolapse stage I/II: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Colpexin Sphere was effective for advanced pelvic organ prolapse. The aim of this study was to assess the effect of Colpexin Sphere in women with pelvic organ prolapse (POP) stage I or II on pelvic floor muscle strength, quality of life, and POP stage. METHODS: Women were randomly divided into Colpexin Sphere with pelvic floor muscle exercise group and exercise only group for a 16-week period. They had Colpexin pull test and digital test every 4 weeks. Quality of life and POP stage were re-evaluated at the end of treatment. RESULTS: Ninety-one women were recruited and 85 completed. Colpexin Sphere plus pelvic floor exercise improved pelvic floor muscle strength. There was no significant difference between both groups. Vaginal symptom score decreased in both groups while the stages of prolapse did not change. CONCLUSIONS: Colpexin Sphere plus pelvic floor exercise and exercise alone improved pelvic floor muscle strength.

Fetal loss associated with second trimester amniocentesis.

OBJECTIVE: To evaluate the fetal loss rate associated with second trimester amniocentesis. METHODS: All cases of pregnant women ≥35 years old with gestational age beyond 16 weeks between 1997 and 2006 were included in this study. The study group consisted of all cases that the patients decided to have second trimester genetic amniocentesis. The control group was a randomized selection of pregnant women who refused any procedures. The ratio of the study case to the control case was 2:1. The fetal loss rates after amniocentesis before 24, and 28 complete weeks and the pregnancy outcome were analyzed. RESULTS: 2,990 cases in the study group and 1,495 cases in the control group were used for this analysis. The mean maternal age in the study group and control group were 36.89 ± 1.63 and 36.78 ± 1.59 years old, respectively (P = 0.239). The procedure-related fetal loss before 24 and 28 complete weeks were 0.17 and 0.50%, respectively. The most common presenting symptom before fetal loss in the study cases was abdominal pain. Almost all of the cases leading to abortion had symptoms initiated after 48 h post procedure. Significantly higher chances of abortion occurred in pregnant women ≥41 years old (P = 0.008). CONCLUSION: The procedure-related fetal loss rates in pregnant women ≥35 years old after amniocentesis before 24 and 28 complete weeks were 0.17 and 0.50%, respectively. The certain factors influencing the risk of fetal loss might be independent of the amniocentesis procedure.

Effect of colpexin sphere on pelvic floor muscle strength in women with pelvic organ prolapse: a randomized controlled trial (a preliminary report).

OBJECTIVE: The aim of this study was to assess the effect of Colpexin Sphere with pelvic floor exercise in women with stage I and II pelvic organ prolapse on improving pelvic floor muscle strength compared with the pelvic floor exercise only. METHODS: The women were divided into two groups: one group used Colpexin Sphere with pelvic floor muscle exercise, and the other group did pelvic floor exercise only for a 16-week period. The efficacy was evaluated at baseline and 16-week for comparison of pelvic floor muscle strength. RESULTS: A total of 50 women were enrolled and 48 women completed the full 16-week assessment. A statistically significant improvement in pelvic floor muscle strength as compared with baseline values and at 16 weeks was shown in both groups, with mean difference pull test contraction values of 2.25 + 3.28 N (P < 0.05) in the study group and 1.38 + 2.17 N (P < 0.05) in the control group. There was no statistically significant difference in improving pelvic floor muscle strength between the study and the control groups. CONCLUSION: Even though Colpexin Sphere plus pelvic floor exercise improved pelvic floor muscle strength, the improvement was not statistically different from exercise alone.

Prevalence and risk factors of anorectal dysfunction in women with urinary incontinence.

PURPOSE: To evaluate the prevalence and risk factors of anorectal dysfunction among women with urinary incontinence. METHOD: This cross-sectional study was conducted among women attending the urogynecology clinic. Women with symptoms of urinary incontinence were requested to complete a structured questionnaire. RESULTS: Four hundred and thirteen women participated in the study and 43.8% had at least one anorectal symptom. The prevalence rates of anal incontinence, constipation, and difficult defecation were 8.0, 38.0, and 25.7%, respectively. The risk factors associated with anorectal dysfunction were age and number of parity. CONCLUSION: Anorectal dysfunction was prevalent among women with urinary incontinence; age and number of parity were the risk factors. All women with symptoms of urinary incontinence should be evaluated about anorectal symptoms.

The characteristics and satisfaction of the patients using vaginal pessaries.

OBJECTIVE: To study the characteristics of pelvic organ prolapse (POP) patients that used a pessary. DESIGN: Prospective, descriptive study. SETTING: Urogynecology Clinic, Ramathibodi Hospital, Faculty of Medicine, Mahidol University. MATERIAL AND METHOD: The authors conducted a prospective, observational study. The average age, parity, average body mass index, menopausal age, pessary type, and reasons for pessary use were collected in the present study. The symptoms, satisfaction, complication, and continuation rates after use were recorded. RESULTS: For the 40 subjects, the average age was 70.4 years, the average of parity, body mass index, and menopausal age were 4, 24.5 kg/m2, and 22 years, respectively. The reasons for choosing a pessary included mostly risks and reluctance to undergo surgery. The complications from using a pessary were vaginal erosion, which was found in one case. Thirty-seven patients (92.5%) were satisfied and continued to use pessaries. CONCLUSION: Most POP patients had a favorable outcome in terms of satisfaction with the pessary use and continued to use pessaries.

The value of mid-trimester routine ultrasonographic screening in antenatal detection of congenital malformations.

OBJECTIVE: To evaluate the detection rate of major fetal anomalies by mid-trimester routine ultrasound screening in a single center with low-risk population. MATERIAL AND METHOD: The present study was a cross sectional study. All pregnant women attending the antenatal clinic between January 1996 and December 2002 had routine ultrasound screening between 18-22 weeks'gestation. The ultrasonographic results were compared with the pregnancy outcome in aspects of prediction of major fetal anomalies. RESULTS: Three hundred and sixteen fetuses out of 29,839 (1.06%) had major anomaly. One hundred and forty four fetuses (45.57%) were diagnosed as having major anomaly by routine ultrasound screening. One hundred and seventy two fetuses (54.43%) were undiagnosed. The sensitivity, specificity, positive predictive value, and negative predictive value were 45.57%, 99.97%, 94.74% and 99.42% respectively. CONCLUSION: Although the rate of the detection of major congenital fetal anomaly was low, almost all lethal and life threatening anomalies could be diagnosed antenatally thus allowing the option of counseling, pregnancy termination, or selective referral.

Effects and safety of Pueraria mirifica on lipid profiles and biochemical markers of bone turnover rates in healthy postmenopausal women.

OBJECTIVE: To evaluate the effect of Pueraria mirifica on lipid profiles and biochemical markers of bone turnover rates in healthy postmenopausal women and to evaluate the safety of Pueraria mirifica on endometrium; breast tissue; and hematologic, hepatic, and renal systems. DESIGN: This was a randomized, double-blind, placebo-controlled study in a university hospital of healthy postmenopausal women aged 45 to 60 years old. Women were enrolled voluntarily and randomly received 20, 30, or 50 mg Pueraria mirifica in capsules or identical placebo once daily for 24 weeks. Outcome measures were lipid profiles, bone-specific alkaline phosphatase level, endometrial thickness, endometrial histology, breast ultrasonography, complete blood count, liver function test, and renal function test. RESULTS: After 24 weeks of treatment, 71 women were evaluated. Of the 71 women, 51 randomly received varying doses of Pueraria mirifica and 20 received placebo. Pueraria mirifica and placebo significantly increased triglyceride levels by 15% from baseline levels (P<0.05). The Pueraria mirifica group showed a significant decrease in bone-specific alkaline phosphatase levels after 24 weeks of treatment compared with the placebo group; from 0.22+/-0.18 U/L to 0.13+/-0.01 U/L in the Pueraria mirifica group and from 0.20+/-0.10 U/L to 0.20+/-0.14 U/L in the placebo group. Endometrial thickness did not change after treatment in both groups (P>0.05). No endometrial proliferation or hyperplasia was reported after 24 weeks of treatment in both groups. There were no significant differences in adverse effects on breast tissue, complete blood count, and liver and renal function tests between the Pueraria mirifica and placebo groups in this study. CONCLUSION: Pueraria mirifica at a dose of 20, 30, and 50 mg/d for a 24-week period demonstrated an estrogen-like effect on bone turnover rate. Pueraria mirifica did not demonstrate an estrogen-like effect on endometrial thickness and endometrial histology. Mild adverse effects occurred after Pueraria mirifica and placebo treatment.

Prenatal ultrasonographic findings in "trisomy 13".

OBJECTIVE: To evaluate the accuracy of prenatal ultrasonographic diagnosis in fetuses with trisomy 13. MATERIAL METHOD: The present study consisted of all fetuses diagnosed of trisomy 13 and delivered at Ramathibodi Hospital between 1997 and 2006. RESULTS: There were 15 cases of trisomy 13. Twelve cases (80.0%) were detected by prenatal ultrasonographic examination, and 3 cases (20.0%) were missed. Mean maternal age was 31.4 years old. Sixty-six percent were diagnosed in 2" trimester (mean 19.4 weeks). The earliest gestational age for detection was 12 weeks 6 days. The most common abnormal ultrasonographic findings were holoprosencephaly (46.7%), and facial defects (40.0%). CONCLUSION: The accuracy of prenatal sonographic diagnosis in trisomy 13 fetuses was 80%. The most sensitive prenatal ultrasonographic findings in trisomy 13 were holoprosencephaly and facial defects.

Effect of Pueraria mirifica on vaginal health.

OBJECTIVE: To evaluate the effect of Pueraria mirifica on vaginal symptoms, vaginal health index, vaginal pH, and vaginal cytology in healthy postmenopausal women. DESIGN: A randomized, double-blind, placebo-controlled study. Healthy postmenopausal women, age 45 to 60 years old, were enrolled voluntarily and randomly received 20, 30, or 50 mg of Pueraria mirifica in capsules or placebo in identical capsules once daily for 24 weeks. RESULTS: After 24 weeks of treatment, 71 women were evaluated. Fifty-one of 71 randomly received one of the three doses of Pueraria mirifica, and the remaining 20 received placebo. The mean vaginal dryness symptom in the Pueraria mirifica group decreased after 12 weeks of treatment. Pueraria mirifica increased vaginal maturation index (parabasal:intermediate:superficial cells) from 46:43:11 to 11:65:24 after 24 weeks of treatment. There was no significant difference of adverse effects between the Pueraria mirifica and placebo groups in this study. CONCLUSIONS: Pueraria mirifica was proven to exhibit estrogenicity on vaginal tissue, to alleviate vaginal dryness symptoms and dyspareunia, to improve signs of vaginal atrophy, and to restore the atrophic vaginal epithelium in healthy postmenopausal women.

Impact of stress urinary incontinence and overactive bladder on quality of life in Thai women attending the urogynecology clinic.

OBJECTIVE: To investigate the impact of stress urinary incontinence (SUI) and overactive bladder (OAB) on the quality of life (QOL) using disease specific health-related QOL questionnaire. MATERIAL AND METHOD: Three hundred and nineteen women with SUI and/or OAB, attending the urogynecolgy clinic, Ramathibodi Hospital were recruited in the present study. Information on QOL was collected, using the Thai version of modified incontinence-specific quality of life questionnaire (I-QOL) and short form incontinence impact questionnaire (IIQ-7). RESULTS: In 319 cases, the diagnosis of SUI, OAB, and both were 55 cases, 78 cases, and 186 cases, respectively. There was no statistically significant difference in patients' characteristics in three groups. The patients with both SUI and OAB showed significantly lower scores in all domains of I-QOL than the SUI and OAB groups, whereas QOL, assessed by IIQ-7, showed significant impairment in the combined SUI and OAB group, only in the emotional health domain. CONCLUSION: Stress urinary incontinence and overactive bladder have a detrimental impact on patient health-related QOL. Women with a combination of SUI and OAB have the greatest impairment in QOL.

Transvaginal color Doppler sonographic assessment of uterus and ovaries in postmenopausal women: the effect of local estrogen treatment.

OBJECTIVE: The objective was to evaluate the effect of local estrogen treatment on the uterus and ovaries using transvaginal color Doppler sonography. MATERIALS AND METHODS: A 12-week randomized open-label study of postmenopausal women taking local estrogen treatment and controls was conducted. The study group was treated with either a 25-mum estradiol vaginal tablet or 1g of conjugated estrogen cream intravaginally each day for 2 weeks followed by twice a week for 10 weeks. The control group did not receive any type of hormone replacement therapy. All women underwent transvaginal ultrasonography and color Doppler imaging of the uterine arteries both before starting local estrogen treatment and after treatment. The uterine volume, ovarian volume, endometrial thickness, and uterine arterial blood flow of the two groups were evaluated. Statistical analysis was performed using paired and unpaired Student's t-test. A p value of <0.05 was considered statistically significant. RESULTS: Of the 53 postmenopausal women recruited to this study, 26 women received local estrogen treatment for treatment of urogenital symptoms and 27 untreated women constituted the control group. The mean age was 54.85+/-5.51 years. The uterine and ovarian volumes were not significantly different before and after treatment in either of the groups. The endometrial thickness did not change in the local estrogen treatment group (4.00+/-1.60 and 4.30+/-1.20mm) or in the control group (3.90+/-1.40 and 3.70+/-1.50mm). The mean resistance indices in the local estrogen treatment group before and after treatment (1.01+/-0.10 and 0.96+/-0.10) were not significantly different from those of the control group (0.96+/-0.15 and 0.97+/-0.10). The mean pulsatility index after 12 weeks of treatment was lower than before treatment, although not statistically significantly (3.69+/-1.32 and 4.27+/-1.49; p>0.05), and the mean pulsatility indices did not differ between the study and the control groups. CONCLUSION: The volumes of the uterus and the ovaries, including endometrial thickness, were not affected and did not show any significant influence of the 12-week local estrogen treatment. The uterine arterial blood flow did not significantly change after treatment.

Intrapartum fetal abdominal circumference by ultrasonography for predicting fetal macrosomia.

OBJECTIVE: To evaluate the diagnostic value of sonographic measurement of fetal abdominal circumference (AC) for the prediction of fetal macrosomia. MATERIAL AND METHOD: A prospective clinical trial was conducted at Department of Obstetrics and Gynecology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. The study consisted of 361 singleton pregnant women who were admitted for delivery at labor room. All women underwent sonographic measurements of the fetal abdominal circumference (AC) during the early intrapartum period. The AC values were correlated to actual fetal birth weight. The cut-off value of AC for predicting of fetal macrosomia was analyzed. RESULTS: Among 361 cases, the mean maternal age was 29.0 +/- 5.5 years (range, 15-46). The median gestational age was 39 weeks (range, 31-42). The mean fetal birth weight was 3,179.83 +/- 450.91 gm (range, 1,180-4,560). The prevalence of macrosomia was 11.08% (40/361). A cut-off value of abdominal circumference > or = 35 cm was the best predicting of fetal macrosomia. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 87.50%, 84.74%, 85.04%, 41.67%, and 98.19%, respectively. CONCLUSION: The intrapartum fetal AC measurement was useful in predicting of fetal macrosomia. An AC measurement of > or = 35 cm was the best value of fetal macrosomia prediction.

Pregnancy outcome of twin pregnancy in Ramathibodi Hospital.

OBJECTIVES: To evaluate maternal and neonatal complications and pregnancy outcomes of twin pregnancies. MATERIAL AND METHOD: The retrospective analysis included data on the twin pregnancies delivered at Ramathibodi Hospital between January 1995 and December 2000. The data retrieved from the medical records included demographic data, complications of pregnancy, and maternal and neonatal outcomes. Statistical analysis was performed. RESULTS: Of 374 twin pregnancies, 321 cases had completed medical records. Incidence of twin pregnancies was 8.6 per 1,000 births. Most common maternal complication was preterm delivery (49.2%). Other maternal complications were anemia (21.5%), pregnancy induced hypertension (13.4%), premature rupture of membranes (10%), postpartum hemorrhage (5.6%) and antepartum haemorrhage (1.9%), respectively. Median gestational age at delivery was 37 weeks. Most common route of delivery was caesarean section (58.3%). Most common neonatal complication was low birth weight (62.3%). Perinatal mortality rate was 45 per 1,000 births. Prematurity was the most common cause of neonatal death. No neonatal death was found after 34 weeks of gestation. CONCLUSION: Twin pregnancy has high maternal and neonatal complications, especially preterm delivery that increases risk of significant neonatal morbidity and mortality.

How to approach common urogynaecological problems?

Urogynaecology is dedicated to the treatment of women with pelvic floor dysfunction such as urinary orfecal incontinence and prolapse (bulging or falling) of the vagina, bladder and/or the uterus. Pelvic organ prolapse simply means displacement from the normal position. On average, 11% of women will undergo surgery for this condition. Pelvic organ prolapse quantification system (POP-Q) is an objective, site-specific system for describing the anatomic position that can be used to determine the stage of the prolapse. Urinary incontinence (leakage of urine) is a very common condition affecting at least 10-20% of women under age 65 and up to 56% of women over the age of 65. The most common subtypes of urinary incontinence are (1) stress urinary incontinence (SUI) ; (2) urge urinary incontinence (UUI) ; and (3) mixed urinary incontinence (MUI). Patients presenting with symptoms of pelvic organ prolapse or incontinence should undergo a thorough medical evaluation consisting of a targeted history (include bladder diary or voiding diary), physical examination, urinalysis and urine culture, and postvoid residual volume (PVRV) by pelvic ultrasound. Treatment options for patients with pelvic organ prolapse and urinary incontinence are nonsurgical (lifestyle interventions, pelvic floor muscle rehabilitation, and pessary placement) and surgical management.

Labial leiomyoma: a case report.

Leiomyoma is common in the myometrial layer of the uterus, and rarely found in other genital organs. Previous reports show multiple sites of leiomyoma outside the uterus eg. vagina, oral mucosa or mandible vascular leiomyoma. Leiomyoma is normally a benign smooth muscle tumor and behaves as a hormone sensitive tumor Leiomyomas develop during the reproductive age and regress after menopause. The case of a 25 year old female with a large left labial leiomyoma presented as Bartholin's cyst. Illustrates the diagnostic difficulties in such cases. The management in this case was surgical excision. The definite diagnosis was confirmed by histologic examination as a labial leiomyoma.

Pregnancy induced hypertension in twin pregnancy.

OBJECTIVE: To compare the incidence, severity and pregnancy outcomes of pregnancy induced hypertension in twins and singleton gestations. MATERIAL AND METHOD: The cohort study enrolled 305 twins and 298 singleton gestations at Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand between January 1996 and December 2001. The rates of pregnancy induced hypertension and pregnancy outcomes were statistically analysed in both groups. P-value of< 0.05 was considered statistically significant. RESULTS: Pregnancy induced hypertension was found to at develop 18.36% in the twin gestations, compared with 5.03% in the singleton gestations (P < 0.05). Women with twin gestations had higher rates of pregnancy induced hypertension (RR 3.65, 95% CI 2.11-6.30, P<0.05) and occurred earlier than singleton gestations (35.86+/-2.50 VS 37.40+/-1.18 weeks, P<0.05). Twin gestations with pregnancy induced hypertension had significantly higher rate of cesarean delivery, low birthweight, NICU admission and perinatal death than singleton gestations with pregnancy induced hypertension (P< 0.05). Moreover the abruptio placenta, postpartum hemorrhage and perinatal mortality in twin gestations with pregnancy induced hypertension group were significantly higher than in normotensive group (P< 0.05). CONCLUSION: The incidence of pregnancy induced hypertension was significant higher and occurred earlier with greater adverse pregnancy outcomes among twin gestations than singleton gestations. Moreover, the rate of adverse maternal and perinatal outcomes in twin gestations with pregnancy induced hypertensive group was higher than in normotensive group.

Adnexal masses in pregnancy.

OBJECTIVE: To determine incidence and maternal and fetal outcomes of pregnant women undergoing surgical management for adnexal mass. MATERIAL AND METHOD: A cohort study was performed in patients who presented with adnexal masses in pregnancy that required surgical management during April, 1986 to March, 2001. The maternal and fetal outcomes were analyzed. RESULTS: One hundred eighteen patients of 116,323 deliveries were identified with adnexal masses that required surgical management. The incidence was 1 in 986 deliveries. One hundred and three cases had complete data for analysis. A malignant tumor or a tumor of low malignant potential was found in 3 cases (2.9%). In 4 patients, the only finding at the time of operation were leiomyomas. Eighty-four of 103 cases (81.6%) had an elective operation and 19 cases (18.4%) had an emergency operation. There were 3 spontaneous abortions, 3 preterm deliveries, and 1 intrauterine growth restriction in all patients. Patients who underwent elective and emergency operation had the same adverse pregnancy outcome. CONCLUSION: The incidence of an adnexal mass during pregnancy in our population was consistent with what has been reported in the literature. The percentage of malignant tumors or tumors of low malignant potential was 2.9%. Patients who underwent elective operation had the same adverse pregnancy outcome compared with those who underwent emergency operation.

A randomized trial of oral and vaginal misoprostol to manage delivery in cases of fetal death.

OBJECTIVE: To compare the effectiveness and side effects of oral and vaginal misoprostol for the termination of second and third trimester pregnancy with intrauterine fetal death. METHODS: Eighty pregnant women at 16-41 weeks' gestation with intrauterine fetal death were randomized in two groups to receive either 400 micro g of misoprostol orally every 4 hours (n = 40) or 200 micro g of misoprostol vaginally every 12 hours (n = 40) until the termination of pregnancy was completed. The adverse effects, progress, and outcomes of delivery were assessed. RESULTS: The groups were similar in age, weight, height, gestational age, parity, and modified Bishop scores before intervention. The mean induction-to-delivery time in the oral group (13.95 [standard deviation (SD) = 5.63] hours) was significantly shorter than the time in the vaginal group (18.87 [SD = 10.38] hours, P =.001). The number of deliveries within 24 hours after the initial drug administration in the oral group (92.5%) was significantly higher than the number in the vaginal group (67.5%, P <.001), and all delivered within 48 hours after the initial drug administration. However, the gastrointestinal side effects in the oral group was significantly higher than in the vaginal group (P =.005). CONCLUSION: Misoprostol (400 micro g given orally every 4 hours) was more effective than misoprostol (200 micro g given vaginally every 12 hours) for the termination of second and third trimester pregnancy with intrauterine fetal death, but with more gastrointestinal side effects.