Comparing the outcomes of termination of second trimester pregnancy with a live fetus using intravaginal misoprostol between women with and without previous cesarean section

OBJECTIVE

To compare the outcomes of termination of pregnancy with live fetuses in the second trimester (14-28 weeks), using misoprostol 400 mcg intravaginal every 6 h, between women with previous cesarean section (PCS) and no previous cesarean section (no PCS).

METHODS

A comparative study was conducted on a prospective database of pregnancy termination in the second trimester, Chiang Mai university hospital. Inclusion criteria included: (1) singleton pregnancy; (2) gestational age between 14 and 28 weeks; and (3) pregnancy with a live fetus and medically indicated for termination. The participants were categorized into two groups; PCS and no PCS group. All were terminated using misoprostol 400 mcg intravaginal every 6 h. The main outcomes were induction to fetal delivery interval and success rate, defined as fetal delivery within 48 h.

RESULTS

A total of 238 women, including 80 PCS and 158 no PCS, were recruited. The success rate of fetal delivery within 48 h between both groups was not significantly different (91.3% vs. 93.0%; p-value 0.622). The induction to fetal delivery interval were not significantly different (1531 vs. 1279 min; p-value > 0.05). Gestational age was an independent factor for the success rate and required dosage of misoprostol. The rates of most adverse effects of misoprostol were similar. One case (1.3%) in the PCS group developed uterine rupture during termination, ending up with safe and successful surgical removal and uterine repair.

CONCLUSION

Intravaginal misoprostol is highly effective for second trimester termination of pregnancy with PCS and those with no PCS, with similar success rate and induction to fetal delivery interval. Gestational age was an independent factor for the success rate and required dosage of misoprostol. Uterine rupture could occur in 1.3% of PCS, implying that high precaution must be taken for early detection and proper management.

SYNOPSIS

Intravaginal misoprostol is highly effective for termination of second trimester pregnancy with a live fetus, with a comparable success rate between women with and without previous cesarean section, with a 1.3% risk of uterine rupture among women with previous cesarean section.

Effectiveness and adverse effects of vaginal misoprostol as a single agent for second trimester pregnancy termination: the impact of fetal viability

PURPOSE

To compare the effectiveness of vaginal misoprostol for second-trimester termination between pregnancies with a dead fetus in utero and those with a live fetus and to identify factors associated with the success rate.

METHODS

Singleton pregnancies with live fetuses and dead fetuses, between 14 and 28 weeks of gestation, with an unfavorable cervix, were recruited to have pregnancy termination with intravaginal misoprostol 400 mcg every 6 h.

RESULTS

Misoprostol was highly effective for termination, with a low failure rate of 6.3%. The effectiveness was significantly higher in pregnancies with a dead fetus (log-rank test; p: 0.008), with a median delivery time of 11.2 vs. 16.7 h. Fetal viability, fetal weight or gestational age, and an initial Bishop score were significantly associated with the total amount of misoprostol dosage used for induction. Fetal viability and gestational age/fetal weight were still independent factors after adjustment for other co-factors on multivariate analysis.

CONCLUSION

Vaginal misoprostol is highly effective for second-trimester termination, with significantly higher effectiveness in pregnancies with a dead fetus. Also, the effectiveness is significantly associated with birth weight/gestational age, and initial Bishop score.

Prenatal Detection of Rapid Progressive Changes in Massive Lymphangioma from Flank to the Lower Extremity

Lymphangioma is a congenital anomaly in which abnormal lymphatic drainages localize to form a benign mass, but it has the tendency to grow in size and the potential to infiltrate surrounding structures, causing devastating effects and leading to severe morbidity. The most common site of lymphangioma is the neck region (cystic hygroma colli), whereas lymphangioma in the lower limbs is very rare, accounting for only 2% of cases. Accordingly, the prenatal diagnosis of lymphangioma of the lower limbs has been scarcely reported. This study describes two cases of lymphangioma of the lower limbs, focusing on unique sonographic features and the natural course of rapidly progressive changes, which is different from nuchal lymphangioma. Based on previous isolated case reports together with our two cases, lymphangioma of the lower limbs usually develops in the second trimester, tends to have rapidly progressive changes, and is unlikely to be associated with aneuploidy and structural anomalies. Diagnoses can be made by using sonographic findings pertaining to the subcutaneous complex and multi-septate anechoic cystic lesions in the lower limbs, the latter of which can infiltrate visceral structures. Prenatal detection can be helpful in laying the groundwork for providing counseling to the parents and the planning of management strategies, i.e., opting to terminate the pregnancy, revising delivery plans, and looking towards the postnatal management of the infant.

A preliminary study on the effectiveness of maternal to neonatal transfer of antibodies against SARS-CoV-2 in the women vaccinated with heterologous CoronaVac-ChAdOx1

The objective is to evaluate the effectiveness of placental transfer of maternally derived SARS-CoV-2 IgG antibodies after the vaccination of pregnant women with heterologous CoronaVac-ChAdOx1. Thirty pregnant women were vaccinated with CoronaVac as the first dose, followed by ChAdOx1 3 weeks later. The antibody levels in the maternal blood and in the umbilical cord blood at the time of delivery were determined. The results showed that the vaccination effectively increased antibody levels in both mothers and newborns. The antibody levels in the mothers were strongly correlated with those in the newborns (P < .001). The high levels of passive immunity in the newborns were achieved when the first and second doses of vaccination were given more than 40 and 20 d before delivery, respectively. After 1 month of the second dose, the immune levels seemed to decline in the mothers but increase in the newborns. The antibody levels in the newborns appear to be higher than those in the mothers in cases of delivery after 20 d of the second dose (1419 ± 699 vs 1222 ± 593 BAU/L; p < .05). In conclusion, heterologous CoronaVac-ChAdOx1-S schedule can increase antibody levels in a short time during pregnancy. Also, the regimen effectively increases immunity in the newborns. The antibody levels in the newborns appear to be higher than that in the mothers in most cases, if receiving the second dose more than 3 weeks before delivery. Therefore, the regimen should be considered as an effective regimen for pregnant women, especially in settings where mRNA vaccine is not available.

Placental Transfer Immunity to the Newborns in a Twin Pregnant Women Vaccinated with Heterologous CoronaVac-ChAdOx1

Pregnant women who receive the COVID-19 vaccine develop anti-SARS-CoV-2 antibodies, which can be transferred to the fetus. However, the effectiveness of placental transfer has not been evaluated in twin pregnancy, especially in cases vaccinated with heterologous CoronaVac (Sinovac)-ChAdOx1 (Oxford-AstraZeneca) regimen, which was commonly used in many countries. Case: A 34-year-old Thai woman with a twin pregnancy attended our antenatal care clinic at 21 + 2 weeks of gestation and requested COVID-19 vaccination. Her medical history and physical examination were unremarkable. She had not received COVID-19 vaccination before. Ultrasound screening for fetal anomaly revealed a dichorion diamnion twin pregnancy. Both twins showed no structural anomaly. She received the CoronaVac vaccine at 21 + 2 weeks of gestation without serious side effects and the ChAdOx1 vaccine at 24 + 2 weeks of gestation. Cesarean delivery was performed at 36 + 5 weeks of gestation, giving birth to the two healthy babies. The levels of anti-spike protein IgG levels (BAU/mL) in maternal blood just before delivery and umbilical cord blood of the two newborns were 313.349, 678.219, and 874.853, respectively. The levels of % inhibition (wild-type and delta) in the two newborns were also higher than those in the mother. In conclusion, heterologous CoronaVac-ChAdOx1-S vaccination in a twin pregnancy could effectively provide protective immunity to both twin newborns. The antibody levels in both were approximately two times higher than those in the mothers. This case report may serve as a reference in counseling couples with a twin pregnancy, while the studies on placental transfer of vaccine-derived antibodies in twin pregnancy are currently not available, especially in countries experiencing a vaccine shortage or unavailability of mRNA vaccines.

Outcomes of Pregnancy Termination of Dead Fetus in Utero in Second Trimester by Misoprostol with Various Regimens

Objective: To determine the efficacy and adverse outcomes of misoprostol with various regimens for the second-trimester-pregnancy termination of a dead fetus in utero (DFIU). Patients and Methods: A retrospective descriptive study, based on the prospective database, was conducted on pregnancies with dead fetuses in utero in the second trimester. All patients underwent pregnancy termination with various regimens of misoprostol. Results: A total of 199 pregnancies meeting the inclusion criteria were included. The mean age of the participants and the mean gestational age were 30.2 years and 21.1 weeks, respectively. The two most common regimens were 400 mcg injected intravaginally every six hours and 400 mcg taken orally every four hours. In the analysis of the overall efficacy, including all regimens, the mean fetal delivery time was 18.9 h. When considering only the cases involving a delivery within 48 h (success cases), the mean fetal delivery time was 13.6 h. The rates of fetal delivery for all cases at 12, 24, 36, and 48 h were 50.3%, 83.8%, 89.3%, and 93.9%. In the comparison between the various regimens, there were no significant differences in the rate of fetal delivery at 12, 24, 36, and 48 h and adverse effects such as chill, diarrhea, nausea, vomiting, and other parameters such as the requirement for intravenous analgesia, the requirement for curettage for incomplete abortions, the mean total dose of misoprostol, and the rate of postpartum hemorrhage (PPH). Nevertheless, the rate of fever was significantly higher in the regimen of intravaginal insertion of 400 mcg every six hours and that of the requirement for oxytocin was significantly higher in the regimen of oral supplementation of 400 mcg every four hours. Conclusions: The overall success rate within 48 h was 93.6%, which was not different among the various misoprostol regimens. In addition, there were no significant differences in the mean fetal delivery times and the rates of fetal delivery at 12, 24, 36, and 48 h. However, some parameters such as fever, oxytocin requirement, and mean total dose of misoprostol were statistically significant between regimens. In the aspect of global health, misoprostol can be a good option in clinical practice, especially in geographical areas with low-resource levels.

Change of contraceptive preference after the free-LARC program for Thai teenagers

Background

In 2014, the Thai government launched a free-of-charge long-acting reversible contraception (LARC) program for Thai female adolescents. However, its acceptance had not been reported. Therefore, this study aimed to describe contraceptive use among women of reproductive age before and after the program was implemented.

Methods

This retrospective cross-sectional study was carried out from the medical records of 9000 women of reproductive age, who attended the Family Planning Clinic at Maharaj Nakorn Chiang Mai Hospital between 2009 and 2018. The Chi-square test was used to compare the contraceptive methods administered before and after the program was implemented, and binary logistic regression was used to find the factors associated with implant use after completion of the program.

Results

Depot medroxy progesterone acetate (DMPA) injection was the most popular contraceptive method used among 40.9% of the women. The rates of subdermal implant use were increased significantly after the program was implemented (2.3–9.3%, p < 0.001). Implant use for adolescents aged less than 20 years increased from 2.6% to 56.4%, while DMPA was the most popular method used among adult women at 36.4%. Factors associated significantly with implant use after implement of the program included age of less than 20 years (aOR = 4.17 (CI: 1.84–9.44); p = 0.001) and nulliparity (aOR = 8.55 (CI: 3.77–19.39); p < 0.001).

Conclusion

This study showed a significant increase in contraceptive implant use after the free-LARC program for adolescents had been applied.

Statement of implications

Contraceptive implant is the most effective hormonal reversible contraception. Its use rate is low among all age groups, but increased clearly after the free-of-charge program was applied for adolescents.

Strong Positive Dichlorophenolindophenol Precipitation Suggests Hb Dhonburi (or Hb Neapolis) (HBB: c.380T>G) Inheritance in a Couple at Risk for Severe β-Thalassemia

Hb Dhonburi (also known as Hb Neapolis) (HBB: c.380T>G) is an unstable hemoglobin (Hb) variant that cannot be detected by high performance liquid chromatography (HPLC) or capillary electrophoresis (CE) in routine laboratory diagnosis. This could lead to prenatal misdiagnosis unless a molecular analysis is applied. Here, we report a Thai couple with a positive result for the dichlorophenolindophenol precipitation (DCIP) screening test. After routine laboratory investigation, the female was diagnosed with heterozygous Hb E (HBB: c.79G>A) during pregnancy; however, the male, whose case we present herein, was suspected to carry a rare heterozygous β-thalassemia (β-thal). Therefore, they were designated as a couple at-risk for having a fetus with a serious thalassemia genotype: compound heterozygosity for Hb E with β-thal (Hb E/β-thal). Based on the result of the DCIP test, his DNA was sequenced for a causative mutation and revealed heterozygosity for a rare Hb variant, Hb Dhonburi. Theoretically, this couple was not at risk for Hb E/β-thal. Furthermore, this case demonstrates for the first time that in addition to a common Hb variant, i.e. Hb E, Hb Dhonburi (Hb Neapolis) also gives positive DCIP results, even in the heterozygous state.

Randomized controlled trial comparing efficacy between a vaginal misoprostol loading and non-loading dose regimen for second-trimester pregnancy termination

AIM

The aim of this study was to compare the efficacy of vaginal misoprostol loading dose regimen with non-loading dose regimen for termination of second-trimester pregnancy with live fetuses.

MATERIAL AND METHODS

A randomized controlled trial was conducted on pregnant women with a live fetus at 14-28 weeks. The patients were randomly allocated to receive either the vaginal misoprostol loading dose regimen (600 mcg, then 400 mcg every 6 h) or the non-loading dose regimen (400 mcg every 6 h). Failure to abort within 48 h was considered to be a failure.

RESULTS

Of 157 recruited women, 77 were assigned to be in group 1 (loading group) and 80 were in group 2 (non-loading group). The median abortion time was not statistically different between the groups (14.08; 95% confidence interval: 12.45-17.77 h and 14.58; 95% confidence interval: 12.8-17.27 h, P > 0.05). The rates of abortion within 24 h and 48 h were also comparable between the groups. Fever and chills were more common in the loading group. No other serious complications, such as postpartum hemorrhage and uterine rupture, were found.

CONCLUSION

Vaginal misoprostol in the loading dose regimen had a similar efficacy to the non-loading dose regimen but was associated with more adverse maternal effects.

Sexual in menopausal women comparing perimenopausal and postmenopausal women

OBJECTIVE

To compare aspects of sexual function between perimenopausal and postmenopausal women.

MATERIAL AND METHOD

One hundred forty women, 70 perimenopausal women and 70 postmenopausal patients in the menopause clinic were interviewed at a first visit regarding aspects of sexual function compared between now and during the previous one-year period. All data were compared between perimenopausal and postmenopausal women.

MAIN OUTCOME MEASURE

The following sexual function including sexual thoughts/fantasies, sexual desire, frequency of sexual intercourse, sexual excitement during sex, moisture in vagina during sex, amount of vaginal lubrication during sex, pain or discomfort during sex, vaginal stretching/flexibility during sex, intensity of orgasm during sex, sexual appeal in client's opinion, overall sexual satisfaction and sexually related anxiety were compared between groups.

RESULTS

The mean age (+/- SD) of perimenopausal and postmenopausal women were 49.4 (+/- 3.0) years and 52.2 (+/- 2.8) years respectively in which there was no significant difference. Most women in both groups had sexual intercourse one to four times per month. There was statistically significant difference between groups in the following aspects, sexual thoughts/fantasies, sexual desire, frequency of sexual intercourse, sexual excitement during sex, moisture in vagina during sex, amount of vaginal lubrication during sex. All items had a negative impact on sexual function but a higher impact was found in postmenopausal women. However sexually related anxiety was unchanged in both and no significant difference was detected.

CONCLUSION

Some sexual functions were significantly impaired in postmenopausal compared to perimenopausal women. However, the overall sexual satisfaction and sexually related anxiety were unchanged in postmenopausal women. So sexual problems are present but are not considered the most important problem among Thai women.

How to manage unresponsiveness to misoprostol in failed second trimester pregnancy termination

AIM

To present the experience of management of second trimester pregnancy termination by misoprostol after failure to abort within 48 h of its use.

MATERIAL AND METHODS

A retrospective, cohort descriptive study was carried out in the Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University Thailand between 1998 and 2010. All women at 14-28 weeks of gestation who failed to abort using misoprostol within 48 h were included. Management of failed pregnancy termination among these women is described here.

RESULTS

Of a total of 680 women undergoing termination of pregnancy, 68 (10%) failed to abort. Mean maternal age was 28.71 years and mean gestational age was 19.91 weeks. Further management after failure included additional administration of misoprostol only (19.1%), modified condom balloon technique only (17.7%), modified condom balloon technique plus other methods (16.1%), while 47.1% needed only oxytocin as necessary. The mean interval between initiation of termination and delivery was 96.97 h.

CONCLUSION

  Failure of pregnancy termination using misoprostol can be successfully managed by introducing additional misoprostol, modified condom balloon technique and oxytocin infusion. These methods should be considered before proceeding to hysterotomy.

Outcomes of pregnancy termination by misoprostol at 14-32 weeks of gestation: a 10-year-experience

OBJECTIVE

To review outcomes of pregnancy termination between 14-32 weeks of gestation based on a 10-year-experience of misoprostol use at Maharaj Nakorn Chiang Mai Hospital.

STUDY DESIGN

A retrospective, descriptive study

MATERIAL AND METHOD

Based on the authors' prospective database, all pregnancy terminations by misoprostol between 14-32 weeks of gestation between 1998 and 2008 were reviewed. The main outcomes included success rate of termination, mean induction-to-abortion time, and complication rate. In addition, regimens and routes of drug administration as well as indications for termination of pregnancy were also analyzed.

RESULTS

Seven hundred forty one pregnancy terminations were performed using misoprostol with dosage varied from 50 mcg to 800 mcg, mostly 400 mcg intravagina every three hours. The most common indication for pregnancy termination was severe fetal thalassemia (35.8%). The majority of cases were pregnancies with live fetuses and only 18.2% were associated with a dead fetus in utero. Success rate of termination within 48 hours was 85.9%. Pregnancies with previous cesarean section accounted for 8.6% of cases. The mean gestational age was 20.94 weeks. The mean abortion time was 25.35 hours, ranging from 1.25 to 247.88 hours. The two most common adverse effects were chill and fever (43.7% and 34.3%). The rate of analgesia needed was 39.3%. No serious adverse complications such as uterine rupture were found

CONCLUSION

This experience suggests that misoprostol has a high efficacy for pregnancy termination with acceptable minor side effects and it is relatively safe when used with precaution.

Rectal misoprostol in management of retained placenta: a contradictory result

BACKGROUND

Retained placenta is one of the common problems in obstetric practice. The most common procedure to manage cases with retained placenta is manual removal of placenta (MROP) under general anesthesia. Recent data indicates that misoprostol may be helpful in decreasing the rate of MROP.

OBJECTIVE

To assess the efficacy of rectal misoprostol in women with delayed placental separation.

MATERIAL AND METHOD

A descriptive, retrospective cohort was conducted. All pregnant women with retained placenta longer than 30 minutes after fetal delivery, either in second or third trimester that received 800 mcg rectal misoprostol were included in the present study. Successful treatment was defined as spontaneous placental expulsion within 30 minutes after rectal misoprostol administration.

RESULTS

The rate of spontaneous placental expulsion within 30 minutes after misoprostol administration was very low, only three out of 20 cases (15%).

CONCLUSION

High dose rectal misoprostol does not give a promising result in cases of retained placenta. It is ineffective to facilitate placental separation in cases of retained placenta and does not seem to decrease the rate of MROP.

Randomized controlled study comparing misoprostol moistened with normal saline and with acetic acid for second-trimester pregnancy termination. Is it different?

OBJECTIVE

To compare the efficacy and adverse effects of 400 µg intravaginal misoprostol for second-trimester pregnancy termination in live fetuses between two groups: one in which misoprostol was moistened with normal saline solution (NSS) and the other in which misoprostol was moistened with acetic acid.

MATERIALS AND METHODS

A total of 179 pregnant women between 14 and 28 weeks of gestation with live fetuses indicated for pregnancy termination were recruited. They were randomly allocated to receive 400 µg intravaginal misoprostol either moistened with NSS (n = 96) or moistened with acetic acid (n = 83). The same dosage was then repeated every 3 h if adequate uterine contractions were not achieved until 48 h after the initiation of misoprostol. The main outcomes were mean abortion time, success rate, and adverse effects.

RESULTS

The mean abortion time was not significantly different between the groups (24.98 ± 16.42 h vs 25.89 ± 10.34 h, P > 0.05). The rates of abortion within 24 h and 48 h and the adverse effects were also comparable between the groups. Chills and fever were the most common adverse effects in this study.

CONCLUSION

Intravaginal misoprostol either moistened with NSS or acetic acid was comparable in terms of efficacy and adverse effects.

Bone mineral density in women using depot medroxyprogesterone acetate (DMPA) for at least 2 years compared to a control group: a cross sectional study

OBJECTIVE

To compare the effect of long-term use of depot medroxyprogesterone acetate (DMPA) on bone mineral density (BMD) in Thai women compared to the control.

MATERIAL AND METHOD

A cross sectional study was conducted on Thai women of reproductive age who used DMPA (50 subjects) for contraception for at least 2 years and non-hormonal users (50 subjects). BMD was measured at the lumbar spine, femur and distal radius, and ulna.

RESULTS

There was significantly lower BMD at the lumbar spines in the DMPA group but there was no significant difference in BMD between groups at the femur distal radius, and ulna.

CONCLUSION

Long-term use of DMPA has a negative impact on lumbar spine BMD.

Second-trimester pregnancy interruption with vaginal misoprostol in women with previous cesarean section

OBJECTIVE

To describe the experience of misoprostol use for pregnancy interruption in the second trimester of women with previous cesarean section.

MATERIAL AND METHOD

Seventeen pregnant women with viable fetuses and with previous cesarean section indicated for second trimester pregnancy interruption attending Maharaj Nakorn Chiang Mai Hospital were recruited. All received the same regimen of 400 mcg intravaginal misoprostol every 6 hours. The data was analyzed for demographic characteristics, the adverse outcomes, success rate, and time interval to fetal expulsion.

RESULTS

The incidences of adverse outcomes were as follows, fever (47.1%), chill (23.5%), and nausea (17.6%). No uterine rupture occurred in this series at all. The rate of oxytocin use and analgesia requirement was 29.4%. Success rate of pregnancy interruption was 100%, though two of them had an abortion time of more than 48 hours. Time interval from misoprostol administration to fetal expulsion was 25.9 +/- 34. 1 hours (range 4.0-142.7 hours).

CONCLUSION

This case series reaffirms the efficacy of misoprostol and suggests that misoprostol may relatively be safe even in cases with previous cesarean section. Therefore, misoprostol may be an option of pregnancy interruption in the second trimester to avoid unnecessary surgical procedure including hysterotomy. However, the safety should be tested by further studies with a larger sample size.

Mammographic changes related to different types of hormonal therapies

OBJECTIVES

To determine the effects of different types of hormone therapies (HT) on mammographic breast density changes.

MATERIAL AND METHOD

Between 1999 and 2002, mammograms obtained before and 12-18 months after different types of HT in 170 women were evaluated Estrogen alone (n = 66), or estrogen in cyclic (n = 59) or continuous (n = 45) combination with progesterone were used. The baseline mammographic density was classified according to the Breast Imaging Reporting and Data Systems (BI-RADS). The serial changes observed mammographically were categorized as follows; no change, minimal change (10-25% increased density), moderate change (26-50% increased density), and marked change (> 50% increased density).

RESULTS

Twelve (7%) of the women developed an increase in parenchymal density after HT: Mammographic changes were minimal change in five (2.9%) of the women, moderate change in four (2.3%), and marked change in three (1.8%). No mammographic change was observed in women receiving cyclic estrogen-progesterone. A greater percentage of women who had undergone continuous estrogen-progesterone therapy (22.2%, 10 of 45) demonstrated more change than those who had estrogen alone (3%, 2 of 66). The difference was statistically significant (p < 0.01).

CONCLUSION

Changes of increased density after HT was seen in only 7% of mammograms and depended on the selected hormone regimen.

One year study of Implanon on the adverse events and discontinuation

OBJECTIVE

To determine adverse events and discontinuation of Implanon in healthy Thai women between 16 and 45 years of age.

DESIGN

Prospective descriptive study.

SETTING

Family Planning Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University.

SUBJECTS

Ninety-two female volunteers with eligible criteria, no contraindication for hormonal contraceptive and wished to have long-term contraception were recruited.

MAIN OUTCOME MEASURES

Determination of adverse events was done three months after Implanon insertion. Discontinuation of Implanon use was reviewed during the study period of one year

RESULTS

Amenorrhea (40.2%) and infrequent bleeding (39.1%) were the most menstrual adverse events. While most non-menstrual adverse events were headache/dizziness (27.2%) and lower abdominal pain (23.9%). Severe non-menstrual side effect was rare (1-2%). Seven subjects (7.6%) discontinued using Implanon during the one year period of study.

CONCLUSION

Implanon demonstrated a high continue rate at the first year of insertion. It produced similar adverse events like other progestin-only contraceptives. Counseling before insertion is important for increased client satisfaction and a higher continuation rate.

Immediate complications of laparoscopic tubal sterilization: 11 years of experience

OBJECTIVE

To evaluate the complications of laparoscopic tubal sterilization.

METHOD

A retrospective study of laparoscopic tubal sterilization performed at Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai, Thailand was conducted. The details of the operation, including complications and operation time were collected from the operative and family planning registry.

RESULTS

Between January 1987 and December 1997, 948 cases of laparoscopic tubal sterilization were performed as an outpatient setting. The combination of intravenous sedation and local anesthesia was employed in all cases. Minor intra-operative complications were found in 4.6% of cases. The most frequent complications were meso-salphingeal and meso-ovarian bleeding. No serious complication was found in this study. The mean operation time was 19.3 minutes (range 5-75 minutes).

CONCLUSION

The present study suggested that out-patient laparoscopic tubal sterilization under the combination of intravenous sedation and local anesthesia is a convenient and relatively safe procedure.

Therapeutic termination of second trimester pregnancies with intrauterine fetal death with 400 micrograms of oral misoprostol

OBJECTIVE

To assess the efficacy and maternal side-effects of oral misoprostol for second trimester termination of pregnancies with intrauterine fetal death.

METHODS

A prospective descriptive study was conducted on 63 pregnant women who had intrauterine fetal death with unfavorable cervix (Bishop scores </=4). All received 400 micro g of misoprostol orally every 4 h until favorable cervix was achieved. Main outcome measures included success rate of termination within 12, 24, 36 and 48 h, mean induction to delivery time and maternal side-effects.

RESULTS

The success rates of termination within 12, 24, 36, 48 h were 50.8%, 84.1%, 88.9% and 92.1%, respectively. Mean induction to delivery time in cases of delivery within 48 h was 13.2 +/- 8.4 h, range 2.25-22.9 h. The most common maternal side-effect was chill (33.3%). No serious maternal complication was detected.

CONCLUSION

400 micro g oral misoprostol every 4 h is effective for pregnancy termination in cases of intrauterine fetal death and may be an alternative regimen because of its ease and convenience.

Symptoms of estrogen deficiency in nursing personnel in Maharaj Nakorn Chiang Mai Hospital

OBJECTIVE

To determine the self-reported prevalence and severity of climacteric symptoms of estrogen deficiency in nursing personnel working in Maharaj Nakorn Chiang Mai Hospital during the year 2002.

DESIGN

Cross-sectional descriptive study.

SETTING

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University.

SUBJECT

Six-hundred and eight nursing personnel, including professional nurses and practical nurses, aged 40-60 years, working in Maharaj Nakorn Chiang Mai Hospital.

MATERIAL AND METHOD

The same sets of questionnaires were provided and distributed to each subject. Subjects had self assessment under individual decision with written consent and data was prospectively collected. The data were analyzed using software SPSS version 10 and presented in frequencies and percentage.

MAIN OUTCOME MEASURE

The prevalence and severity of each climacteric symptoms.

RESULTS

Five-hundred and seventy five of 608 subjects (94.6%) responded to the questionnaires, 62.6% of them were in normal reproductive period, while the remainder (37.4%) were in the menopausal period. The latter group was divided into 4 subgroups of pre/peri-menopause, post menopause, surgical menopause and premature ovarian failure. The prevalence of climacteric symptoms was systematically classified as follows, vasomotor instability 40.7% (severe cases, 5.4%), psychosomatic symptoms 50.9% (severe cases, 3.9%), lower urinary tract symptoms 29.1% (severe cases, 2.4%), lower genital tract symptoms 34.0% (severe cases, 2.7%), and other symptoms 50.7% (severe cases, 4.3%). The first five most common symptoms were as follows, forgetful 84.1% (severe cases, 7.9%), myalgia 74.3% (severe cases, 10.6%), anxious 71.0% (severe cases, 5.3%), tired 70.0% (severe cases, 4.1%), headache 68.3% (severe cases, 8.3%). The least common symptom was needle pain, the prevalence was 19.7% (severe cases, 1.3%). The overall prevalence of women using hormone replacement therapy was 13.1%, only 8.9% were current users.

CONCLUSION

Focusing on each symptom of climacteric symptoms, the authors found high prevalence in psychosomatic symptoms and other symptoms such as forgetful, myalgia, anxious, tired and headache. While the classic symptom (vasomotor instability) was found to be low in the present study which was different from the previous reports. This may be due to the racial or cultural and educational factors among different populations.

Mammographic change in hysterectomized women on 0.625 mg/day of conjugated equine estrogen

OBJECTIVE

To compare the mammographic change before and after conjugated equine estrogen (CEE) 0.625 mg/day in hysterectomized women.

DESIGN

A retrospective descriptive study.

SETTING

Menopause clinic, Maharaj Nakorn Chiang Mai Hospital.

MATERIAL AND METHOD

Dedicated mammograms and demographic data of 66 women who had been hysterectomized were reviewed. Post surgical menopausal women were recruited for the study. CEE 0.625 mg/day was given just after the operation. The baseline mammography was done before the initiation of HRT and they were compared with the follow-up mammography performed 12-18 months after therapy. The degree of increase in mammographic density was classified as follows: minimal changes (10-25% increased density), moderated change (26-50% increased density), and marked change (> 50% increased density).

RESULTS

The mean age +/- SD was 47 +/- 4.3 years old. The mean duration +/- SD of hormone used was 13.5 +/- 2.4 months. The most common indication for operation was myoma uteri (43.9%). On the baseline mammogram, 5 cases had cystic change and one case had a small circumscribed solid mass suspected to be fibroadenoma. On the follow-up mammograms, there were 2 cases (3.0%) detected to have significantly increased breast density. One was moderately increased and the other was markedly increased, but cystic changes and one fibroadenoma were not changed.

CONCLUSION

CEE has little effect on increased mammographic density.

A comparison of 100 microg oral misoprostol every 3 hours and 6 hours for labor induction: a randomized controlled trial

OBJECTIVE

To compare the efficacy and safety of 100 microg oral misoprostol for induction of labor between the regimen of 3 hour and 6 hour interval administration.

METHODS

Singleton pregnancies indicated for induction of labor between 34 and 42 weeks of gestation in the condition of unfavorable cervix (Bishop score < or = 4) and no contraindication for prostaglandins therapy were recruited into the study. All pregnant women were randomly assigned to receive 100 microg oral misoprostol every 3 hours or 6 hours until the cervix was favorable for amniotomy, spontaneous rupture of membranes or active labor occurred.

RESULTS

The mean time interval from induction to vaginal delivery was significantly shorter in the 3 hour interval group, compared with the 6 hour interval group (13.82 +/- 6.98h and 17.66 +/- 7.48h, P = 0.0019). There was no significant difference between the groups with regard to mode of delivery, analgesic requirement, maternal complication and neonatal outcome.

CONCLUSIONS

100 microg oral misoprostol every 3 hours is more effective for labor induction than every 6 hours but there was no difference in mode of delivery, analgesic requirement, maternal complications and neonatal outcome. A dose of 100 microg misoprostol orally every 3 hours seems to be the optimum regimen and the new option for labor induction. However, further study should be performed.

Demographic characteristics of women with self use of misoprostol for pregnancy interruption attending Maharaj Nakorn Chiang Mai Hospital

OBJECTIVE

To ascess the demographic characteristics of pregnant women and their partners including details of self use of misoprostol for pregnancy interruption.

STUDY DESIGN

Prospective descriptive study.

SETTING

Department of Obstetrics and Gynecology, Maharaj Nakorn Chiang Mai Hospital.

SUBJECTS

103 pregnant women with self use of misoprostol for pregnancy interruption from June 1999 to June 2001.

METHOD

All subjects were interviewed use the same set of questionnaires.

RESULTS

The mean age of the women and their partners were 20.81 +/- 4.10 and 22.46 +/- 5.05 years old respectively. The mean gestational age was 13.85 +/- 5.37 weeks. The most common reason for pregnancy interruption was that they wanted to continue studying. The number of misoprostol tablets used ranged from 1-11 and 87.4 per cent of the women applied this drug via the vaginal route. The main source of drug purchasing was from friends, while the mean total cost was 663.16 +/- 711.32 Baht. No major side effect was detected in the present study.

CONCLUSION

Misoprostol, the agent primarily used for gastric and duodenal ulcer prevention, is now used by pregnant women to interrupt their pregnancies. The present study is only the evidence reflecting the tip of the iceberg in this society, changing in sexual behavior, change in abortion techniques, and knowledge on contraception. Though major complications were not found in this study, misoprostol should not be considered safe, because several patients have encountered bleeding or incomplete abortion and required hospital stay.

A comparison between 50 mcg oral misoprostol every 4 hours and 6 hours for labor induction: a prospective randomized controlled trial

OBJECTIVE

To compare the effectiveness and safety between 50 mcg oral misoprostol every 4 hours and 6 hours for labor induction.

DESIGN

A prospective randomized controlled trial.

SETTING

Department of Obstetrics & Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

SUBJECTS

Eighty nine pregnant women of at least 34 weeks' gestation with indications for labor induction in the condition of unfavourable cervix (Bishop score < or = 4) and no contraindication to prostaglandin therapy.

INTERVENTIONS

All pregnant women were randomized to receive either 50 mcg misoprostol orally every 4 hours or 6 hours.

MAIN OUTCOME MEASURES

Treatment interval from induction to vaginal delivery, maternal and neonatal complication.

RESULTS

The mean treatment intervals from induction to vaginal delivery were 22.10 +/- 18.49 hours and 20.91 +/- 11.98 hours in the misoprostol group every 4 hours and 6 hours, respectively. The treatment intervals between the two groups were not statistically significant. There was also no significant difference between both groups with regard to maternal and neonatal complications.

CONCLUSION

The effectiveness in terms of treatment interval from induction to vaginal delivery were comparable between the two groups, but administration of misoprostol every 6 hours was found to have a slightly shorter interval, although it did not reach statistical significance. No serious maternal and neonatal complication was demonstrated in both groups. Either regimen in this study can be an alternative for labor induction.

Second trimester pregnancy termination with 800 mcg vaginal misoprostol

OBJECTIVE

To demonstrate the efficacy of 800 microgram vaginal misoprostol tablet for second trimester pregnancy termination.

DESIGN

Prospective descriptive study.

SETTING

Maharaj Nakorn Chiang Mai Hospital, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University.

SUBJECT

Pregnant women meeting the inclusion criteria including (1) singleton pregnancy with live fetus, (2) gestational age of 14-28 weeks, (3) indication for therapeutic termination, (4) closed and uneffaced cervix, (5) absence of uterine contraction and leakage of amniotic fluid, (6) no previous classical uterine scar, (7) no contraindication for misoprostol such as hypersensitivity.

INTERVENTION

800 microgram misoprostol tablet intravagina every 12 hours.

MAIN OUTCOME MEASURES

Mean induction delivery time, mean abortion time, maternal side effects.

RESULTS

The mean induction delivery time was 21.38 + 13.68 hours, mean abortion time was 21.56 +/- 13.68 hours. Diarrhea was the most common side effect occuring in 40 per cent of patients.

CONCLUSIONS

800 mcg vaginal misoprostol every 12 hours is effective but if we want high efficacy along with fewer side effects, lower dose and interval should be further studied.

Therapeutic termination of second trimester pregnancy with vaginal misoprostol

OBJECTIVE

To evaluate the efficacy of vaginal misoprostol in therapeutic termination of second trimester pregnancy with a live fetus.

DESIGN

Prospective descriptive study.

SETTING

Maharaj Nakorn Chiang Mai Hospital, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University.

SUBJECTS

Pregnant women meeting the inclusion criteria including 1) pregnancy with a live fetus, 2) gestational age of 14-28 weeks, 3) having an indication for therapeutic termination, 4) Bishop's score of < or = 4, 5) absence of uterine contraction and leakage of amniotic fluid, 6) no previous classical uterine scar and 7) no contraindication for misoprostol such as hypersensitivity.

INTERVENTION

400 microgram misoprostol gel intravagina every 12 hours.

MAIN OUTCOME MEASURES

Mean induction-delivery time, mean abortion time, maternal side effects.

RESULTS

Sixty eight pregnant women were recruited into the study. The mean induction-delivery time was 35.58 +/- 34.13 hours, mean abortion time was 35.80 +/- 34.13 minutes. Fever was the most common side effect occuring in about two-third of the patients, but no serious maternal complication was observed.

CONCLUSION

400 microgram vaginal misoprostol is effective for therapeutic termination of second trimester pregnancy with no serious side effects. However, the response to this treatment was markedly varied from patient to patient.

Prenatal diagnosis of campomelic dysplasia

A pregnant woman of 24 weeks' gestation underwent ultrasound examination for fetal anomaly screening. The ultrasound findings revealed a single fetus with biparietal diameter of 61 mm, which was consistent with menstrual dates. The thoracic cage was small compared to the abdomen with hypoplastic scapulae and normally ossified unfractured ribs. All bony structures demonstrated normal echogenicity. The upper long bones were normal length and shape. Both femurs and tibiae were obviously bowed anteriorly, and slightly shortened. Bilateral talipes equinovarus were clearly demonstrated. A prenatal diagnosis of campomelic dysplasia was made and was confirmed by postnatal radiography and autopsy. The sonographic diagnosis in this case was based on the findings of small thorax, hypoplastic scapulae and bowed tibiae and femurs.

Early prenatal sonographic diagnosis of congenital hypophosphatasia

A pregnant woman of 14 weeks' gestation was sonographically examined due to large-for-dates uterine size. The ultrasound examination showed poor ossification of all bony structures. All limbs were shortened with no evidence of fractures. The echodensity approximated that of the surrounding organs. No acoustic shadowing was observed. Based on these sonographic findings, skeletal dysplasia and short-limb dwarfism were diagnosed, the most likely condition being congenital hypophosphatasia. Early cordocentesis was successfully performed at 15 weeks' gestation to determine fetal alkaline phosphatase concentration. This was undetectable. The prenatal diagnosis of congenital hypophosphatasia was made. After counselling, the woman decided to opt for termination of pregnancy which was performed vaginally. Post-abortion findings confirmed the prenatal diagnosis. To our knowledge, this is the earliest sonographic diagnosis of this condition reported.

Prenatal diagnosis of Meckel syndrome: a case report

OBJECTIVE

To demonstrate the major sonographic findings associated with Meckel syndrome and to emphasize the importance of prenatal sonography in helping to establish the correct diagnosis.

SUBJECTS

Two fetuses with prenatal diagnosis of Meckel syndrome were sonographically evaluated.

RESULTS

Both fetuses were demonstrated to have evidence of renal cystic dysplasia, occipital cephalocele and postaxial polydactyly. One case was diagnosed at 16 weeks of gestation whereas the other was detected at 36 weeks. Of interest, the first case had only unilateral renal cystic dysplasia and contralateral renal agenesis and mild degree of oligohydramnios. The other related anomalies which were not detected prenatally included cerebellar hypoplasia in case 1 and micrognathia in case 2.

CONCLUSION

The main sonographic findings included renal cystic dysplasia, occipital cephalocele and postaxial polydactyly.

Pregnancy outcome of threatened abortion with demonstrable fetal cardiac activity: a cohort study

Pregnancy with visible fetal heart beat complicated by first trimester threatened abortion had significant increased risk of subsequent spontaneous abortion compared with normal pregnancy.

OBJECTIVE

To compare pregnancy outcomes in cases complicated by first trimester threatened abortion with those that were not.

METHODS

Prospective cohort study of 255 cases of first trimester threatened abortions but with visible heart beat and 265 other normal pregnancies.

RESULTS

Spontaneous abortion rates of 5.5% (with relative abortal risk of 2.91) was found for study group, compared to 1.88% for controls (p < 0.05). Preterm delivery was also higher, but was not statistically significant.

CONCLUSIONS

First trimester bleeding with visible fetal heart beat appears to associate significantly with higher subsequent spontaneous abortion rate than those without.

Transvaginal ultrasound in threatened abortions with empty gestational sacs

OBJECTIVE

To determine whether transvaginal ultrasound criteria alone can distinguish viable from non-viable gestational sacs at a single examination.

METHOD

A prospective descriptive study was undertaken and analysis performed on 211 pregnancies complicated by threatened abortion and empty gestation sacs diagnosed by transvaginal ultrasound. The main outcome measure was the final diagnosis of viable or non-viable gestation on subsequent transvaginal sonography.

RESULTS

The study shows that a single transvaginal ultrasound examination is useful in differentiating viable from non-viable gestation sacs. The mean sac diameter (MSD) was found to be the most useful criterion for determining non-viability. An MSD of > or = 17 mm that lacked an embryo and an MSD of > or = 13 mm without visible yolk sac were reliable predictors of non-viable gestation sacs at a single examination with 100% specificity and 100% positive predictive value. An MSD > or = 13 mm without visible yolk sac was the most sensitive criterion. Using MSD criteria, 73% of non-viable gestations could be reliably identified without any false-positive diagnoses. Deformed shape, low position and thin decidual reaction are strong indicators of non-viable gestations but are not 100% accurate. There is still a significant proportion of empty sacs, where no accurate distinction between viable and non-viable can be made according to one criterion at a single examination and in these cases serial examinations should be carried out before any active management is advocated.

CONCLUSION

In most cases, transvaginal sonographic criteria alone can distinguish viable from non-viable empty gestational sacs at a single examination.

Transvaginal sonographic features in diagnosis of ectopic pregnancy

OBJECTIVES

To evaluate the efficacy of pelvic transvaginal sonography (TVS) in patients with clinical presentation of extrauterine pregnancy (EUP) and positive beta-hCG.

METHODS

Three hundred and twenty-one patients with clinical suspicion of EUP were subjected to TVS at Maharaj Nakorn Chiang Mai Hospital. The criteria for entry to the study were (1) clinical suspicion of EUP, with stable hemodynamic condition, (2) correct final diagnosis must be known, (3) serum beta-hCG must be determined, by assay sensitivity of 10 mIU/ml (4) TVS was examined by the same sonographer. Frequencies of each TVS feature in EUP and IUP were determined. Among the patients with positive beta-hCG and empty uterus, the accuracy indices of various TVS features in predicting EUP were calculated.

RESULTS

Patients with measurable beta-hCG were divided into two main groups, namely those with demonstrable typical intrauterine gestational sac (52/201), and those without (149/201). None of the subjects in the first group had EUP. Among the latter group of patients, with empty uterus, TVS signs could be further divided into 3 subgroups: (1) Direct sign, clear evidence of extrauterine gestational sac. This group had positive predictive value 100%, but low sensitivity (26%). (2) Indirect signs of EUP, i.e. adnexal mass and pelvic fluid, especially echogenic fluid. Echogenic fluid, adnexal mass and their combination had positive predictive value for EUP 92.3%, 92.8% and 95.0%, respectively. Complex adnexal mass gave the highest sensitivity (85.7%). (3) No positive sign on TVS, which is very unlikely to be EUP, and was found in only 2.8% of EUP.

CONCLUSIONS

The results of this study indicate that TVS can help to facilitate the diagnosis of EUP in most cases. EUP can be confidently diagnosed by demonstration of adnexal ring, and excluded by visualization of intrauterine sac. Complex adnexal mass and echogenic fluid are extremely helpful in making the diagnosis.