Result of ambulatory diet therapy in gestational diabetes mellitus.

OBJECTIVES: To evaluate the effectiveness of an ambulatory program for glycemic control of women with gestational diabetes mellitus (GDM). MATERIAL AND METHOD: A total of 33 women with GDM whose FBS from OGTT > or = 105 mg/dl were scheduled to attend weekly ambulatory care for dietary therapy with their family. FBS and 2-hour postprandial blood glucose were monitored every visit for a few weeks. At the end of this program, those with poor glycemic control were admitted for further tight dietary control by conventional 3-day course after which insulin was finally started for the women whose glycemic control remained poor. RESULTS: After the ambulatory program, 14 of 33 cases (42.4%) achieved good glycemic control without hospitalization. Another 6 cases (18.2%) did not need insulin therapy after admission for 3-day intensive dietary therapy. Altogether, 20 out of 33 cases (60.6%) of GDM whose FBS from OGTT > or = 105 mg/dl could avoid insulin therapy after attending the ambulatory program alone or with additional 3-day intensive dietary therapy course. Similar effectiveness was observed from the authors' previous study on 3-day intensive dietary therapy alone. CONCLUSION: The authors' current ambulatory dietary therapy program has shown to be effective in achieving good glycemic control and avoiding unnecessary insulin therapy and admission in most cases of women with GDM. In the future, an even more effective ambulatory diet control may ascertain that once a woman is hospitalized, insulin should be started right away.

Efficacy of fetal echocardiography and an evaluation of indications.

Fetal echocardiography has been accepted as a prenatal noninvasive diagnostic tool of cardiovascular diseases in fetuses for more than three decades. There are limited data in Thailand. A retrospective study of prenatal, natal and postnatal data of pregnant women who had fetal echocardiography at Siriraj Hospital, Bangkok, Thailand, from January 1999 to July 2005 was conducted. In total, there were 117 pregnant women who had fetal echocardiography under standard indications. Median age of pregnant women was 30.2 (17.3-44.2) years old. Median gestational age at the first fetal echocardiography was 29 (17-40) weeks. Median number of time the women had fetal echocardiography was 1 (1-10). Indications for fetal echocardiography were; obstetricians suspected of fetal cardiovascular diseases, multiple anomalies, family history of congenital heart diseases, chromosome anomalies, hydrops fetalis, and other indications (53.8%, 12%, 11.1%, 8.5%, 8.5% and 6.0% respectively). There were 49 (41.8%) cases who had abnormal cardiovascular problems, i.e., structural heart diseases 26 cases, rhythm disturbance 15 cases, and cardiac masses 8 cases. Upon comparison with postnatal echocardiography and/or autopsy findings, fetal echocardiography had a sensitivity of 96.9%, specificity of 90.6%, and accuracy of 92.8%. There was various degrees of risk to have cardiovascular problems for each of the indication taking fetal echocardiography and postnatal data into consideration. Fetal echocardiography had an impact on the management in 57.3% of cases. Conclusion: Fetal echocardiography is a reliable prenatal diagnostic tool for cardiovascular problems with high accuracy and has an impact on the management at prenatal, natal and postnatal period. Different indications for fetal echocardiography have an effect on the relative risk of fetal cardiovascular diseases.

Toxemia of pregnancy in teenage orphan girl: A case report.

A 13 year old adopted girl who was 6 months pregnant was presented with altered consciousness and bleeding from the vagina. Based on the signs and symptoms of edema, severe hypertension and heavy proteinuria, accompanied by the abdominal ultrasound results, she was diagnosed with severe pre-eclampsia /eclampsia complicated by an abruption of the placenta and a dead fetus in utero. These serious conditions resulted in acute renal failure due to both pre-renal and renal causes. With proper management of hypertension and fluid therapy, the renal function returned to normal. Neurological manifestation was transient but complete recovery through psychological testing was in doubt. A multidisciplinary team, including psychiatrist, pediatrician, social worker and legal consultant, was established to address the issue of child abuse and neglect.

Effect of 3-day intensive dietary therapy during admission in women after diagnosis of gestational diabetes mellitus.

OBJECTIVE: To determine the impact of 3-day intensive dietary therapy during admission on glycemic control. MATERIAL AND METHOD: GDM women, with level of fasting blood glucose (FBS) at or above 105 mg/dl on their oral glucose tolerance test (OGTT), were hospitalized. After 3-day intensive dietary therapy, the women were stratified by FBS value and mean 2-hour postprandial blood glucose. Those with poor glycemic control, FBS at or above 105 mg/dl, were prescribed insulin therapy. RESULT: Between 1 August 2001 to 31 December 2002, a total of 9861 pregnant women were screened for clinical risk factors of GDM at their first antenatal visits, and 4663 had at least 1 risk. After 50-gm glucose challenge test and 100-gm OGTT GDM was diagnosed in 300 women. Only 18% (54 in 300 cases) of GDM had level of FBS at or above 105 mg/dl on OGTT. They were admitted in a special ward for further investigation and initial management. After 3 days of intensive dietary therapy, the FBS and mean 2-hour postprandial blood glucose level were monitored and stratified in 3 groups. Only 42.6% of admission group (23 in 54 cases) still had FBS at or above 105 mg/dl and required insulin therapy (group 1). One third (18 in 54 cases) could avoid insulin therapy due to the level of FBS below 105 mg/dl and mean 2-hour postprandial blood glucose below 120 mg/dl (group 2). This second group was discharged, and due to attend the high risk pregnancy clinic a few weeks later The third group (group 3), comprising one fourth (13 in 54 cases), had FBS below 105 mg/dl but had a mean 2-hour postprandial blood glucose at or above 120 mg/dl. This third group were also discharged and were monitored glycemic profile by FBS and 2-hour postprandial blood glucose every time during their visits to the high risk pregnancy clinic. According to criteria of 2-hour postprandial blood glucose at or above 120 mg/dl on two or more occasions within a 1-2 weeks interval, no one in group 3 needed insulin therapy afterward CONCLUSION: GDM women with FBS at or above 105 mg/dl on their OGTT, should be prescribed intensive dietary therapy alone for 3 days inside hospital rather than initiating insulin immediately after diagnosis. One third had a benefit of avoiding insulin therapy. Only 42% failed to achieve good glycemic control and still needed insulin therapy. One fourth showed optimal glycemic control after this intervention (FBS below 105 mg/dl) but had mean 2-hour postprandial blood glucose at or above 120 mg/dl. Longer trial of dietary therapy should be considered in this last group to avoid over treatment of insulin therapy.

Reference centile chart for fetal liver length of Thai fetuses.

OBJECTIVE: To create a reference centile chart for fetal liver length of Thai fetuses. DESIGN: Prospective, cross-sectional study. SETTING: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University. MATERIAL AND METHOD: A total of 752 pregnant women, who attended the antenatal clinic at Siriraj Hospital, Mahidol University, Bangkok, were recruited between 13-40 weeks of gestation. Each fetus was measured only once for the purpose of this study. Using real-time ultrasound with a 3.5 MHz convex transducer; the authors measured fetal liver length. The mean and standard deviation (SD) were estimated at each week of gestation using linear regression modeling. RESULTS: A total of 750 fetuses were measured for fetal liver length. Linear regression models were fitted to estimate the mean and 95% confidence interval for liver length at each gestation age. The centile chart of liver length was also presented CONCLUSION: A reference centile chart for fetal liver length of Thai fetuses has been created.

Correlation of uterine cervical length measurement from transabdominal, transperineal and transvaginal ultrasonography.

OBJECTIVE: To investigate the feasibility of transperineal ultrasonography for uterine cervical assessment by determining the correlation of uterine cervical length measurement from transabdominal, transperineal and transvaginal ultrasonography and comparing discomfort arising from each technique. MATERIAL AND METHOD: Fifty pregnant women of 37 weeks' gestation or later who gave consent participated in this research. They had no exclusion criteria, which were listed as the following: preterm premature rupture of membranes, previous cervical surgery, undiagnosed vaginal bleeding, and true labor pain. They all underwent transabdominal (3.5-MHz curvilinear transducer), transperineal (3.5-MHz curvilinear transducer) and transvaginal ultrasonography (7.5-MHz curvilinear endovaginal transducer). The uterine cervical length was measured from the straight line between the external and internal os. If either of the external or internal os was not clearly demonstrated, the authors would justify the cervical length as non-measurable. Measurement in each technique was performed twice and the mean cervical length was used for data analysis. Discomfort arising from each technique was evaluated by visual analog scale. RESULTS: Uterine cervical length was measurable in 23 (46%), 49 (98%) and in all cases by transabdominal, transperineal and transvaginal ultrasonography respectively. In the transabdominal technique, no significant differences in woman's age, weight, body-mass index and parity were observed between measurable and non-measurable cases. Significant correlation was demonstrated between transperineal and transvaginal ultrasound (r = 0.73, p < 0.01). A significantly higher discomfort score was demonstrated in transvaginal ultrasonography, but no significant difference in discomfort score was found between transabdominal and transperineal ultrasonography. CONCLUSION: Transperineal ultrasonography is feasible for acceptable uterine cervical visualization with only slight discomfort to the patients.

Laparoscopic cystectomy of an ovarian mucinous cystadenoma in a 12-year-old girl: a possible role of operative laparoscopy for a huge benign adnexal mass.

The case of an obese 12-year-old girl with a huge and mobile pelvic cystic mass is presented. After ultrasonography and determination of tumor markers, a right huge benign adnexal mass was suspected. In order to avoid exploratory laparotomy because severe pain and a large operative scar were expected, an operative laparoscopy was performed. No intra-operative and post-operative complications were observed. With the uneventful recovery, only a one-day hospital stay was needed. Neither residual nor recurrent evidence was suspected after 2-, 6-, 12-, 18- and 24-months follow-up. With proper case selection, good pre-operative counseling and the operation performed under familiarity and good training in laparoscopy, laparoscopic management of a huge suspected benign adnexal mass is technically feasible. The benefits are reducing hospital stay, lowering morbidity, especially less pain and cosmetic acceptance of the operative scar.

Accuracy of transvaginal ultrasound for the evaluation of myometrial invasion in endometrial carcinoma.

OBJECTIVE: To evaluate the accuracy of transvaginal ultrasound for the evaluation of myometrial invasion in endometrial carcinoma in comparison with standard paraffin section. METHOD: A total of 111 patients with endometrial carcinoma diagnosed from fractional curettage underwent pre-operative transvaginal ultrasonography to assess myometrial invasion. Operation for surgical staging was subsequently performed and the hysterectomy specimen was evaluated for depth of myometrial invasion by standard paraffin section blinded from transvaginal ultrasound results. Final histopathologic diagnosis and depth of myometrial invasion were obtained from standard paraffin section. Ultrasonographic assessment was compared with the histopathological results. RESULTS: In evaluation of myometrial invasion, transvaginal ultrasound yielded the sensitivity of 69.4 per cent, specificity of 70.6 per cent, positive predictive value of 53.2 per cent, negative predictive value of 82.8 per cent, and accuracy of 70.3 per cent. The accuracy, sensitivity, specificity, negative predictive value, false positive and negative rates were comparable between grade 3 and grade 1 and 2 tumors. However, the positive predictive value was significantly higher among grade 3 than grade 1 and 2 tumors. The Kappa coefficients were 0.57 and 0.22 for grade 3 and grade 1 and 2 tumors respectively. CONCLUSION: Transvaginal ultrasound for assessment of depth of myometrial invasion in endometrial carcinoma provided acceptable accuracy compared with standard paraffin section. This technique might be of value for the decision making in the intra-operative management of endometrial carcinoma.

Uterine artery resistance index above 95 percentile: prevalence and adverse perinatal outcome prediction in pregnancies complicated by hypertensive disorders.

Uterine artery resistance index (UARI) was determined in a cohort of pregnant women complicated by a hypertensive disorder. The prevalence of the value above 95 percentile (UARI95) and its prediction of adverse perinatal outcomes were evaluated. Fifty-eight women were included in the study. The prevalence of UARI95 in this group of women was 27.6 per cent. The correlations between mean UARI95 and adverse perinatal outcomes were: 31.6 per cent sensitivity, 74.4 per cent specificity, with only 60.3 per cent accuracy. The mean UARI95 does not qualify as a reliable screening test for adverse perinatal outcomes in pregnancies complicated by hypertensive disorders.

A model for malignancy probability prediction of adnexal masses.

OBJECTIVE: To develop a model for pre-operative malignancy probability determination in a patient with an adnexal tumor or tumors by the application of multivariate logistic regression analysis to variables at the time of pelvic sonography. METHOD: Pre-operative ultrasound examination including Doppler analysis was performed on 117 consecutive women scheduled for surgery because of an adnexal mass or masses. Each tumor was classified as probably benign or malignant using a subjective evaluation system on the gray-scale morphological images. Then, Doppler sonography was carried out. The resistance index (RI) and pulsatility index (PI) of the vessel with the highest velocity were recorded. Multivariate logistic regression analysis was performed with the histological outcome as the dependent variable. Independent variables included patient's age, menopausal status, gray-scale morphological data, RI and PI. The probability of malignancy was formulated from statistical analysis. RESULTS: There were 117 women included in the study, 83 (71%) with histologically benign and 34 (29%) with histologically malignant ovarian tumors. Regression analysis on the five variables resulted in the retention of only patient's age, morphological data and RI as significant contributing factors for malignancy prediction. The probability of malignancy was 1/(1+e(-z)) where e was the base value for natural logarithms and z was the regression equation: -3.6355 + 1.8028 (age) + 2.1047 (morphological data) + 2.9816 (RI). CONCLUSION: A model for estimation of probability of malignancy for an adnexal tumor was derived using multivariate logistic regression analysis. The prediction should be more accurate than that from either gray-scale ultrasound imaging or Doppler velocimetry alone. The test of the model is now on-going.

Risk factor-based selective screening program for gestational diabetes mellitus in Siriraj Hospital: result from clinical practice guideline.

A clinical practice guideline for the screening and diagnosis of gestational diabetes mellitus (GDM) is currently implemented at Siriraj Hospital. During the year 2000, a total of 9325 pregnant women were screened for clinical risk factors during their first antenatal visits, and 3770 had at least 1 risk. After the 50 g glucose challenge test and 100 g oral glucose tolerance test, GDM was diagnosed in 235 women. The incidence of GDM was 6.2 per cent (95% CI 5.5-7.1) among high-risk pregnant women, and 2.5 per cent (95% CI 2.2-2.9) of all pregnant women. Significant risk factors identified from the present study were family history of DM (adjusted OR 1.86, 95% CI 1.38-2.51), age > or = 30 years (adjusted OR 2.41, 95% CI 1.72-3.39), history of unexplained intrauterine fetal death (adjusted OR 4.30, 95% CI 2.04-9.04), and obesity (adjusted OR 2.83, 95% CI 1.88-4.25). The risk of developing GDM also increased when more than 1 clinical risk factor was identified. The results support the value of this screening program for GDM. Every obstetrician should be aware of the need to screen for GDM in every pregnant woman and a similar program should also be introduced to other settings.

Ultrasonographic prenatal diagnosis of Treacher Collins syndrome: a case report.

A case of Treacher Collins syndrome (TCS) diagnosed prenatally using ultrasonography is reported. The pregnant woman was gravida 2, para 0. Her husband had stigmata of the syndrome. Ultrasonography revealed polyhydramnios, abnormal fetal ears and marked micrognathia. Abortion occurred spontaneously at 26 weeks of gestation. The abortus bore clinical features of the syndrome.

Placental ratio and fetal growth pattern.

INTRODUCTION: Placental hypertrophy and reduced fetal growth have been postulated to be an adaptation to maintain placental function in pregnant women with complications such as malnutrition. If this is true, a pregnancy with impaired fetal growth, resulting in a small for gestational age (SGA) infant, should have an increased placental weight to birthweight ratio (placental ratio) compared to those with appropriate for gestational age (AGA) or large for gestational age (LGA) infants. OBJECTIVES: To determine the relationship between placental ratio and fetal growth pattern. MATERIAL AND METHOD: Labour and delivery data of 1000 deliveries in the Department of Obstetrics & Gynecology, Siriraj Hospital from January 2001 to June 2001 were retrospectively studied to compare the placental ratios among pregnancies with SGA, appropriate for gestational age (AGA) and large for gestational age (LGA) infants. RESULTS: From 96 SGA, 804 AGA and 100 LGA cases, a higher placental ratio was found in the SGA group compared to AGA (0.2074 and 0.1985 respectively, p = 0.013). However, actual placental hypertrophy was not found as demonstrated by a lower placental weight in SGA compared with AGA pregnancies of the same birthweight range. There was no significant difference in placental ratio between the LGA and AGA group, the ratios being 0.2020 and 0.1985 respectively (p = 0.260). Although a positive correlation between placental weight and birthweight was observed in the AGA and LGA groups, it was not demonstrated in the SGA infants. This might influence the placental ratio in the SGA group. CONCLUSION: SGA pregnancies are associated with an increased placental ratio which appears not to be due to placental hypertrophy. As reduced birthweight has been shown to be correlated to diseases in adult life, whether this association between SGA and an increased placental ratio will have an implication in future obstetric care and prediction of diseases in adult life remains to be elucidated.

Comparison of newborn’s birth weight between twin pregnancy in adolescents and adults.

A retrospective study was done to compare infant mean birth weight between twin pregnancy in 60 adolescent and 120 adult gravidas who delivered at Siriraj Hospital during January, 1985 to December 1993. Adolescent twin pregnant women had significantly (p <0.01) lower infant mean birth weight (2,040.0 + 520.7 and 1,963.8+ 695.3 grams of the first and second twins respectively) than did adults (2,311.0+ 432.5 and 2,226.6+ 496.1 grams of the first and second twins respectively). However, the mean infant birth weight of the first and second twins of each group was not significantly different (p >0.05). Length of gestation was the predominant contributor to effect birth weight of the first and second twins while parity was the predominant contributor to effect only birth weight of the second twins.