Transvaginal sonographic assessment of endometrial status in pre- and postmenopausal women before hormone replacement therapy (HRT)

Estrogen plays an important role in the genesis and growth of gynecological tumor. Transvaginal sonography assessment of endometrial status is most commonly used in menopausal women to investigate significant findings before hormone replacement therapy (HRT) in pre- and postmenopausal women. One hundred and eighty-six pre- and postmenopausal women with no known history of HRT were transvaginally measured for endometrial thickness of the uterus and pelvic organs. Their age (mean ± standard deviation) was 51.4 ± 5.8 years (range 38 – 75 years); 48.4% were in pre-menopause group, the rest were in post-menopause group. In the latter group, most of them (64%) had had amenorrhoea for 1-5 years. The endometrial thickness in post-menopause group was 4.7 ± 3.4 mm (0 – 22 mm). Myoma was found in 10 cases (5.4%) and ovarian cyst in 6 (3.2%). There were six cases (3.2%) of endometrial hyperplasia. Transvaginal sonography would be useful in the evaluation of endometrium and pelvic organs before HRT

Fetal structural anomaly screening at 11-14 weeks of gestation at Maharaj Nakorn Chiang Mai Hospital.

OBJECTIVE: To determine the detection rate by ultrasound scanning of fetal anomaly by first trimester (11-14 weeks of gestation). MATERIAL AND METHOD: A prospective descriptive study of 597 pregnant women undergoing Nuchal Translucency (NT) measurement at 11-14 weeks of gestation at Maharaj Nakorn Chiang Mai Hospital. The sonographic examinations focused on NT thickness and fetal structural survey. The final diagnoses were based on neonatal outcomes assessed by the pediatricians and abortuses evaluated by the pathologists. The main outcome measure was the detection rate of fetal anomaly using ultrasonographic examination. RESULTS: Of 597 pregnant women recruited into the present study, the mean age was 29.41 +/- 5.8 years, the incidence of fetal anomaly was about 4% (24 from 597 cases). The detection rate by first ultrasound scans was 58% (14 from 24 cases) and the most common detected structural anomaly was cystic hygroma and exencephaly. The rate of undetected fetal anomalies was 42% (10 from 24 cases). Abnormal NT was found in 16 from a total of 597 cases (2.7%), most of them, however, had normal karyotype and no gross anomaly at birth. CONCLUSION: First trimester (11-14 weeks) ultrasound scan is probably a useful method for detection of fetal structural anomalies with a relatively high detection rate, and may be a good adjunct to the conventional examination.

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.

Neural tube defects: a different pattern in northern Thai population.

The objective of this descriptive study was to describe the demographic and sonographic patterns of fetal neural tube defects (NTDs) in Thai pregnant women. The study was conducted at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. The subjects included all pregnancies with diagnosis of fetal neural tube defects. Basic clinical data of the subjects was prospectively collected at the time of diagnosis for NTDs and followed-up until delivery. Antenatal diagnosis was based on sonographic criteria. The results showed that the incidence of NTDs was 0.66/1,000 births, however, spina bifida was very rare, found in only 0.06/1,000 births, similar to encephalocele. All anencephalic fetuses had no concurrent spina bifida, and only a few cases had other associated anomalies. Ultrasound was able to diagnose NTDs with very high accuracy. All cases of antenatal diagnosis were electively terminated. In conclusion, NTDs in the Thai population were rather rare when compared to that of the Europeans and spina bifida was extremely rare. The accuracy of antenatal diagnosis of NTDs with ultrasound was highly reliable.

Prenatal diagnosis of hemoglobin Bart's hydrops fetalis by HPLC analysis of hemoglobin in fetal blood samples.

Since HbF and HbA are not found in fetuses with Hb Bart's hydrops fetalis the feasibility of prenatal diagnosis of homozygous alpha-thalassemia 1 by fetal hemoglobin typing was examined. Blood samples were obtained from fetuses at 18 to 22 weeks of gestation by cordocentesis in 32 pregnant women at risk of having a child with homozygous alpha-thalassemia 1 (alpha-thal-1). The samples were analyzed by a PCR-based method for the diagnosis of alpha-thal-1 (SEA type) and the proportion of hemoglobin fractions were determined by automated HPLC. DNA analysis showed that 8 of the 32 fetuses were homozygotes for alpha-thal-1, 17 were heterozygous for alpha-thal-1 (alpha-thal-1 trait), and a normal complement of four a-globin genes was found in 7 cases. The Hb typing in fetuses with homozygous alpha-thal-1 showed a peak of unbound Hb (Hb Bart's and Hb Portland) and no HbF, HbA and HbA The alpha-thal-1 trait chromatograms showed unbound Hb, pre HbF, HbF and HbA peaks. The chromatogram of normal fetuses showed HbF and HbA peaks without HbA2. In these cases the HbA proportion is between 3% and 10% with no apparent differences between the 18h and 22nd week of gestation. As the analysis of fetal Hb types by HPLC is facile and speedy and the results correspond with those obtained by DNA analysis, fetal Hb typing by automated HPLC is a convenient prenatal diagnostic method for homozygous alpha-thal-1. The method is recommended for prenatal diagnosis in populations with a high frequency of alpha-thal-1.

Prenatal sonographic markers of trisomy 21.

OBJECTIVE: To describe the sonographic characteristics of fetuses with trisomy 21. DESIGN: A prospective descriptive analysis. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. SUBJECTS: Pregnancies at risk of trisomy 21 between 14-27 weeks' gestation. RESULTS: Thirty-six fetuses with subsequently proven trisomy 21 were prenatally evaluated by ultrasound in the second trimester. The main indications for detailed ultrasound examinations were advanced maternal age and abnormal findings on routine ultrasound. All of them had chromosome analysis by amniocentesis or cordocentesis. Nineteen (52.78%) had one or more abnormal findings. The common sonographic findings included thickened nuchal fold (33.33%), short femur (19.44%), and mild pyelectasis (22.22%). The other uncommon abnormalities included major anomalies (cardiac malformations, ventriculomegaly, duodenal atresia, esophageal atresia), hyperechoic bowel, echogenic intracardiac foci, abnormalities of extremities. In this study, rare minor markers but more specific markers including sandal gap, clinodactyly and mid-phalanx hypoplasia of the fifth finger were demonstrated. CONCLUSION: About half of the fetuses with trisomy 21 had abnormal sonographic findings in the second trimester. The most common marker was thickened nuchal fold. Although prenatal ultrasound can not permit a definite diagnosis of trisomy 21, about half of them have sonographic markers, warranting cytogenetic testing.

Sonographic morphology scores (SMS) for differentiation between benign and malignant ovarian tumor.

The objectives of this cross-sectional descriptive analysis are to determine the sensitivity and specificity of sonographic morphology scores (SMS) in distinguishing between benign and malignant ovarian tumors and to determine the best cut-off score. The study was conducted at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. Two hundred and forty eight nonpregnant patients scheduled for elective surgery for ovarian tumors between July, 1996 and March, 1998 were recruited into the study and were sonographically examined in 24 hours of surgery by the same sonographer to evaluate inner wall structure, wall thickness, septum, echogenicity and score of the tumors. The final diagnosis was pathologically confirmed as the gold standard. It was found that the score of 9 from reciever operating characteristic curve was the best cut-off score, giving the sensitivity of 93.1 per cent and specificity of 75.6 per cent. In conclusion, the SMS system is probably useful in distinguishing ovarian malignancy from benign ovarian tumor.

Prenatal diagnosis of VACTERL association: a case report.

A prenatal diagnosis of VACTERL association, a combination of vertebral (V), anal (A), cardiac (C), tracheoesophageal (TE), renal (R) and limb (L) anomalies was made at 30 weeks of gestation, based on the sonographic demonstration of vertebral defects, bilateral renal agenesis, and left lower limb defects. Additionally, severe oligohydramnios and fetal growth restriction were also documented. After proper counseling, elective termination of pregnancy was done, resulting in a stillborn infant with multiple malformations compatible with the VACTERL association. The postnatal X-ray and autopsy revealed verterbral defects, anorectal atresia with undetermined sex, cardiac defect of ventricular septal defect, tracheal agenesis with distal atresia of esophagus, bilateral renal agenesis, and limbs defects. The chromosomal study revealed normal, 46,XY. This report emphasizes the important role of prenatal ultrasound in the diagnosis and management of this disorder.

Prenatal diagnosis: 10-year experience.

To evaluate the indications and results of prenatal diagnosis of the high risk pregnant women attending the antenatal care clinic at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University during 1988-1998, we analysed 2,315 amniocenteses, 1,000 cordocenteses, and 11,895 obstetric ultrasound examinations. Among the amniocentesis group, 2,017 cases (87%) were done with the indication of advanced maternal age. The prevalence of major abnormal fetal chromosomes among high risk pregnancies was 1:58. Of 1,000 cases with cordocentesis, the most common indication was fetal risk of severe thalassemia (658 cases; 65.8%) and followed by fetal risk of chromosome abnormalities (272 cases; 27.2%). In the group of cordocentesis for diagnosis of thalassemia, 99 and 49 pregnancies were affected with Hb Bart's disease and homozygous beta-thalassemia, respectively. Thirty three cases with indication of chromosome analysis had fetuses with abnormal chromosomes. The major indications of ultrasonography included suspicion of intrauterine growth restriction (IUGR), determination of gestational age and screening anomalies, respectively. In conclusion, our extensive experience has enabled us to prenatally detect most fetuses with severe thalassemia, and fetuses with abnormal chromosomes as well as anomalies in a significant number, contributing a great deal to our population. Therefore, we recommend that systematic prenatal diagnosis, either amniocentesis, cordocentesis or ultrasound should be provided to every high risk pregnant woman for a healthy newborn.

Prenatal sonographic diagnosis of holoprosencephaly.

The purpose of this series was to describe the sonographic features of fetal holoprosencephaly prenatally. The study was undertaken at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. A total of 12 fetuses with prenatal diagnosis of holoprosencephaly were sonographically evaluated and followed-up. The study revealed that all showed monoventricular cavity, fused thalami, no falx and cavum septum pellucidum. Eight of them were correctly diagnosed sonographically in the first two trimesters. Extrafacial anomalies were also identified in half of the fetuses and all of them had facial abnormalities. Twenty-five per cent (3 cases) had polyhydramnios and only one case had oligohydramnios. Chromosome study revealed that 70 per cent had normal chromosomes, 30 per cent were aneuploidy, trisomy 13; 2 cases and trisomy 18; 1 case. In conclusion, this series indicates that ultrasound has a high predictive value in the diagnosis of holoprosencephaly. The most valuable clue to the diagnosis is the demonstration of the single ventricle. Additionally, demonstration of facial abnormalities may add confidence to the diagnosis. Conversely, should any of these facial features be serendipitously encountered, a careful examination of the intracranial contents is recommended.

Termination of second-trimester pregnancy with intracervicovaginal misoprostol.

To evaluate the efficacy and side effects of intracervicovaginal misoprostol in termination of second-trimester pregnancy in women with live fetuses. A total of 50 pregnant women between 14 and 27 week's gestation undergoing termination of pregnancy for medical, obstetrical and genetic reasons were recruited to receive 200 ug misoprostol gel administered intracervicovaginally every 12 hours. The rates of successful abortions within 24 hours and 48 hours were 54 per cent and 92 per cent respectively. The mean time from induction to abortion was 27.5 hours. The rate of complete abortion, defined as the passage of the fetus and placenta without operative assistance was 80 per cent. Side effects were fever (8%), nausea and vomiting (6%) and diarrhea (2%). Thirty one patients (62%) required meperidine as analgesia. Two patients (4%) had postpartum hemorrhage. Intracervicovaginal misoprostol is an effective, cheap, safe and relatively convenient method for termination of second-trimester pregnancy with a live fetus.

A comparison of serum magnesium sulfate levels in pregnant women with severe preeclampsia between intravenous and intramuscular magnesium sulfate regimens: a randomized controlled trial.

The frequency of blood samples that achieved therapeutic level was lower in the group of maintenance with intravenous regimen than the intramuscular regimen significantly at 15, 30, 60, 120 and 240 minutes after loading dose. The mean level of serum magnesium sulfate in the intravenous group was significantly lower than intramuscular group. This study supported to choose the maintenance by intramuscular regimen. However, further study is required to analyse the effect of higher level of magnesium sulfate in Thai patients.

Accuracy of ultrasonic fetal weight estimation: a comparison of three equations employed for estimating fetal weight.

This study was conducted to compare the accuracy in estimating the fetal weight of three equations with ultrasound in 104 pregnant women. Equation I log 10 (EFW) = 1.85479 + 0.09008 (BPD) + 0.02466 (AC) Equation II log 10 (EFW) = 2.24784 + 0.09122 (FL) + 0.002798 (BPD x AC) -0.0010112 (AC x FL) Equation III log 10 (EFW) = -1.7492 + 0.166 (BPD) + 0.046 (AC) - 2.646 (AC x BPD)/1000 There was no difference in either the overall mean errors of 95 per cent CI among the three equations, except in the least error for equation II in these with birthweight of less than 2,000 grams and for equation III in these with birthweight of more than 3,000 grams. It was concluded, therefore, that predictions based on either equation I or II developed from local Thai population, which have an almost identical overall mean error when compared with one another or with Shepard's (i.e. equation III), can be used in our clinical.

Study of intrauterine growth from birthweight at Maharaj Nakhon Chiang Mai Hospital.

Intrauterine growth curve and normogram for newborns at Maharaj Nakhon Chiang Mai Hospital are constructed. Birthweight at various gestational weeks of deliveries were determined within 24 hrs after birth. All 1,311 Thai pregnant women selected, fitted the criteria of inclusion deliveries at Maharaj Nakhon Chiang Mai Hospital from May 1983 to April 1991 (8 yrs). Their gestational age distribution was between 28 wks to 42 wks. Clinical status at birth was satisfactory. There were no obstetric or medical complications during pregnancy. Mean birthweight and standard deviation of newborns for each gestational age at delivery were calculated and presented in tabular and graphic form. Mean birthweight for 40 wks of gestation was 3.144 +/- 382 g. In addition, normogram of 10th, 50th, 90th percentile ranks of birthweight for each gestational age was constructed. These values may be useful as baseline data of intrauterine growth curve to evaluate fetal growth in our population.

Ultrasonic measurement of the fetal head to abdominal circumference ratio in normal pregnancy.

The relation between fetal HC/AC ratio and menstrual age was determined from 14th-40th weeks gestations by analysis of 1,211 measurements examined with real-time ultrasound scanner Aloka 630, 650. The mean HC/AC ratio with +/- 2SD and percentile ranks were determined and presented in both graphic and tabular forms. The mean ratio was 1.207 at 14 week's but decreased slowly until 30 week's when the ratio was 1.110 thereafter there was a rather sharp fall in the mean ratio 1.010 at 36 weeks and 0.967 at 40 weeks and then the variability decreases. Interestingly, HC/AC ratio value for each gestational week in this study was not so different from those of western studies. We hope that the value from this large series is important baseline data for evaluation of fetal growth in our population and is more appropriate for application with Thai women than caucasian data.

Ultrasonic fetal transverse trunk diameter in normal northern Thai women.

Fetal transverse trunk diameter (TTD) were measured by two obstetric sonographers, using Aloka model SSD 630 and 650. The measurements were performed on 1,009 occasions in 235 women during normal pregnancies between the 14th and 40th weeks (age range 17-37 years) (4.5 measurements per pregnancy, on average). The relation between TTD and menstrual age was determined and mathematical modeling of the data demonstrated that the linear quadratic function was optimal (r2 = 0.973). The most fitted regression equation was obtained by regression analysis. 1.) TTD = -2.69055 + 0.38326 G.A - 0.00140137 GA2 2.) GA = 7.222585 + 2.82632 TTD + 0.02605 TTD2. Interestingly, TTD value for each gestational week in this study is not so different from that of the European data. Predicted TTD values for a given gestational week were determined and presented in tabular form. The values from this study may be important baseline data for evaluation of fetal growth in our population.

A comparison of intravenous magnesium sulfate regimens in preeclampsia-eclampsia between rate 1 gram and 2 grams per hour.

A randomized clinical trial was conducted to compare the ratio of serum magnesium that achieved therapeutic levels and mean serum magnesium levels among patients diagnosed as cases of severe pre-eclampsia or eclampsia. Forty-nine patients met the inclusion criteria, i.e. single pregnancy, and no significant medical or surgical complications. The patients were assigned, by simple randomization, to either a 1 g (the first group, n=24) or 2 g/h (the second groups, n=25) maintenance dose of magnesium sulfate. Blood samples were obtained thrice, i.e. two and four hours after the loading dose and at two hours after delivery. Both groups were comparable according to age, gestational age, body weight, blood pressure, gravidity, parity, urine output per hour, serum BUN and creatinine, apgar score as well as patellar reflex. It was found that the first group had mean serum magnesium levels (+S.D.) at two and four hours after the loading dose and 2 hours after delivery of 3.50+0.32 mEq/L, 3.51+0.28 mEq/L, respectively. The second group had mean serum magnesium levels (+S.D.) at two and four hours after the loading dose and two hours after delivery of 4.53+0.37 mEq/L, 4.66+0.49 mEq/L and 4.79+0.45 mEq/L, respectively. The difference between mean serum magnesium levels of both groups at each interval, was statitistically significant (p=0.000). The rate of serum magnesium that achieved therapeutic levels at two and four hours after the loading dose and 2 hours after delivery were 8.7, 10 and 8.3 percent of blood samples from the first group and 100 percent of all blood samples from the second group. The difference between the rate of serum magnesium that achieved therapeutic levels in both groups at each interval that was obtained was statistically significant (p=0.000).

Sonographic femur length/abdominal circumference ratio in normal pregnancies among Thais.

The relationship between sonographically measured foetal length (FL) and abdominal circumference (AC) (expressed as FL/AC ratio * 100) was studied in 455 normal pregnancies between the 14th and 40th gestational weeks. By analysis of 1,197 measurements for each parameter, this ratio was found to be independent of menstrual age, with a normal range after 21 weeks (mean + 2 S.D.) of 2038 + 2.6. This mean ratio is different from the values of a previous western study (22+2). The ratio obtained from the Thai study hopefully will be the baseline for the Thai population and may be used for further study about intrauterine growth retardation.