Entrapment of after-coming head in cesarean breech delivery of term pregnancy: A case report.

Nowadays, the majority of breech deliveries are by cesarean section. In Siriraj Hospital, planned vaginal breech delivery is not our current practice. Compared with vaginal breech delivery, cesarean section can significantly reduce neonatal complications, with a trivial increase in maternal complications. However, cesarean section cannot alleviate all of the complications. In the present report, a case with entrapment of after-coming head in cesarean breech delivery of a term fetus was described, and the management of this emergency condition was reviewed.

Comparison between Siriraj liquid-based and conventional cytology for detection of abnormal cervicovaginal smears: a split-sample study.

This study aimed to evaluate the correlation and agreement between Siriraj liquid-based cervical cytology (Siriraj -LBC) and conventional cytology. A total of 479 women who attended the Department of Obstetric and Gynaecology Siriraj Hospital for cervical cancer screening were enrolled. For each woman collection of cervical cells was performed using VCE technique. After smearing cells on a glass slide for conventional cytology, both broken ends of wooden spatula and cotton swabs were then placed into a plastic vial containing a specific preservative solution for Siriraj-LBC. All specimens were prepared and interpreted by experienced cytotechnologists at the Gynecologic Cytology Unit. Interpretations of the results from one technique were made without knowledge of those from the other technique. The results from both techniques were compared for agreement and correlation. Colposcopy or histology was used as the gold standard. The overall detection rate of abnormal cervicovaginal cells was higher by Siriraj-LBC than by conventional cytology (11.1% vs. 1.67%, P <0.001). These two techniques had high diagnostic agreement of 89.77%, and minimal to fair correlation with a Kappa of 0.128 (P<0.001) and a Spearman rho correlation coefficient of 0.394 (P <0.001). There were 49 cases whose Siriraj-LBC revealed higher cytologic grading than did the conventional cytology; there were no cases of the opposite result. The gold standard was available in 45 cases with abnormal cytology by Siriraj-LBC, revealing a positive predictive value (PPV) of 71.1% for Siriraj-LBC and 97.8% for conventional cytology, and a negative predictive value (NPV) of 42.2% for the conventional cytology. In conclusion, The results from Siriraj-LBC and conventional cytology have high diagnostic agreement and minimal to fair correlation. The Siriraj-LBC increases detection rate of abnormal cervicovaginal cells with probable decrease in false negatives but increase in false positives from the baseline values by conventional cytology. Therefore the screening performance of Siriraj-LBC is not inferior to the conventional cytology and this approach may be used as an alternative screening method for cervical cancer.

Blood absorption capacity of various sanitary pads available in Thailand.

Objective: To assess the blood absorption capacity of various sanitary pads available in Thailand. Methods: Forty-eight models of sanitary pads, 10 pads per each model, were tested. Whole blood was poured into the center of each pad. Three volumes were recorded: volume-A, the volume recorded when the seeping blood reached at least one lateral rim of the pad, volume-B, when it reached at least one longitudinal end, and volume-C, when it showed the maximal absorption capacity of the pad. Results: The blood volume absorbed in each model ranged from 2.4+0.5 to 23.5+2.9 mL for volume-A, 4.9+0.9 to 40.7+2.1 mL for volume-B, and 7.9+1.2 to 90.0+16.9 mL for volume-C, respectively. Some models did not allow blood to reach either a lateral rim or a longitudinal end of the pad. Conclusion: The blood absorption capacity of sanitary pads largely varied on model and brand. Therefore, in order to use pad counting for estimating the volume of excess menstrual blood loss, it is necessary to know the exact model of sanitary pad used by the patient.

Gynecological endocrinology patients attending Siriraj Hospital at the beginning of the new millennium.

Objective: The purpose of this study was to analyse the spectrum of new patients with gynecological endocrine abnormalities presenting to a teaching hospital in Bangkok at the beginning of the new millennium. The data obtained may help policy makers, involved health care providers and medical educators plan for the future to best suit the Thai new health care system, medical research or contemporary medical education in a teaching hospital. Methods: Only new patients attending the Gynecologic Endocrinology Clinic at Siriraj Hospital in the year 2000 (excluding natural and surgical menopause patients who separately attended the Menopause Clinic at that time) were included in the analysis. There were 492 new patients attending the clinic including newly referred patients from other departments at Siriraj Hospital or from other hospitals. Of these, 464 (94.3%) had complete records, full follow up and a conclusive final diagnosis. The data was analysed and presented in a descriptive manner. Results: Among 464 patients, the most common presenting symptom was abnormal uterine menstruation (85.5% of cases). The five most common final diagnoses were: endometrial hyperplasia (18.9%), Anovulatory DUB (14.4%), Endometriosis with histodiagnosis (13.7%), Polycystic ovary syndrome (5.1%) and premature ovarian failure (3.0%). Other uncommon diagnoses such as primary amenorrhea, which needs complicated investigations, caused by different etiologies (e.g. Mullerian agenesis, gonadal dysgenesis, androgen insensitivity syndrome), rare cases of secondary amenorrhea (e.g. late onset congenital adrenal hyperplasia, hypogonadotropic hypogonadism, pseudocyesis) were also seen at our clinic in the year 2000. Conclusion: The gynecologic endocrinology clinic of Siriraj Hospital had a great variety of number of cases and diagnoses, both common and uncommon. In most cases, problems could be evaluated and investigated at the outpatient clinic without admission. Treatments were also given and monitored effectively there. Only a few special investigations, such as chromosome analysis, CT or MRI were needed to obtain a final diagnosis. We expect to see a lower number of less complicated cases in the future who may be managed at a primary or a secondary care hospital. Nevertheless, knowledge about gynecological endocrinopathies are still of major importance for both undergraduates and postgraduates.

Health check-up program for pre/postmenopausal women at Siriraj Menopause Clinic.

OBJECTIVE: To determine the general health status of pre/postmenopausal women attending the menopause clinic. STUDY DESIGN: Retrospective descriptive study. SETTING: Siriraj Menopause Clinic, Gynecologic Endocrinology Unit, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University. Study population: Pre/postmenopausal women (i) presumed to have no medical disease (no disease group) or (ii) with unknown status of medical disease (no record group) and undergoing health check-up program at the time of registration without prior hormone therapy. MATERIAL AND METHOD: Medical records of new patients registering at the menopause clinic from January 1999 to December 2005 were reviewed. RESULTS: Among 1,020 patients undergoing health check-up program, there were 366 patients in the no disease group. They had abnormal health parameters listing by frequency of prevalence including hypercholesterolemia (62.3%), suboptimal blood pressure (49.3%), overweight to obese (30.2%), suboptimal fasting blood sugar (2 7.9%), hypertriglyceridemia (21.3%), abnormal liver function tests (5.4-6.9%), and abnormal kidney function tests (0.5%). The prevalence of dyslipidemia was statistically higher in the no record group compared to the no disease group; such abnormal parameters included hypercholesterolemia (> or =200 ml/dL), high blood level of low density lipoprotein cholesterol (LDL-C > or = 130 mg/dL), and high ratio between LDL-C and high density lipoprotein cholesterol (LDL-C/HDL-C ratio >3). Osteoporosis was found in 6.6% of the patients. Abnormal mammographic findings that needed close follow-up or breast biopsy were found in 13.5%. Twelve patients had breast biopsy and none had breast cancer. CONCLUSION: Abnormal health parameters are common in pre/postmenopausal women presumed to have no medical disease. The similar or even worse findings are also found in those whose status of medical diseases was unknown. Therefore, a routine health screening program, especially for metabolic diseases, should be offered to pre/postmenopausal women regardless of their medical history.

Serum follicle stimulating hormone and estradiol in peri/postmenopausal women attending Siriraj Menopause Clinic: a retrospective study.

OBJECTIVES: To determine serum levels of Follicle Stimulating Hormone (FSH) and Estradiol (E) in peri/postmenopausal women attending the menopause clinic. STUDY DESIGN: Retrospective descriptive study. SETTING: Siriraj Menopause Clinic, Gynecologic Endocrinology Unit, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital. Study population: Peri/postmenopausal women attending Siriraj Menopause Clinic from January 1994 to December 2003. MATERIAL AND METHOD: Medical records of women who had a blood test for FSH and/or E2 prior to hormonal therapy were reviewed. RESULTS: During a 10 year period, there were 116 eligible patients who could be classified into perimenopausal (31 cases), natural postmenopausal (43 cases), and surgical postmenopausal (32 cases) groups. Age at registration of perimenopausal (47.87 +/- 4.38 yr) and surgical postmenopausal (48.06 +/- 6.49 yr) groups were younger than that of the natural postmenopausal group (55.74 +/- 6.80 yr). The perimenopausal group, who still had regular menstruation, was the youngest. The average FSH level of 60.46 +/- 33.15 mIU/mL was not different among groups. The estradiol level of perimenopausal (79.05 +/- 83.62 pg/mL) and surgical postmenopausal (63.05 +/- 136.39 pg/mL) groups were significantly higher than that of natural postmenopausal (25.05 +/- 37.663 pg/mL) group (p = 0.001). Serum level of FSH or E2 was not correlated with age or years since menopause. There was significant but minimal negative correlation between serum levels of FSH and E2. CONCLUSION: Serum FSH and/or E2 levels are not accurate enough by themselves to rule in or rule out perimenopause. The authors suggested that clinicians should diagnose perimenopause based on menstrual history and age, without relying on laboratory testing.

Effectiveness and safety of very low dose combined oral contraceptive for the treatment of non-atypical endometrial hyperplasia: A pilot study.

Objective: A randomized control study to compare the effectiveness and the safety of very low dose oral contraceptive (OC) with progestin for the treatment of endometrial hyperplasia. Methods: Ten patients with non-atypical endometrial hyperplasia who did not have contraindications for OC were randomized to receive either OC (Mercilon®) or progestin (Medroxy progesterone acetate: MPA) for 6 months at the Gynecologic Endocrinology Unit, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital. Their main measured outcomes were endometrial histopathology and adverse events. Results: Sixty percent (3 of 5) of the progestin group and 80% (4 of 5) of the OC group completed the 6-month therapy. All of them had normal endometrium by the end of the 6th cycle of treatment. Two cases in the progestin group and one case in the OC group withdrew from the study by the end of 1st cycle of treatment. No serious adverse event was detected during the study period. Conclusion: OC may be as effective and safe as progestin for the treatment of non-atypical endometrial hyperplasia.

Health economic evaluation of CDC s recommendation (1996 and 2002) for prevention of early onset group B streptococcal disease in Thailand

Background: Group B streptococcus (GBS) infection is one of the leading causes of morbidity and mortality in the neonatal period in the USA. The Centers for Disease Control and Prevention (CDC) issued a recommendation to prevent early-onset GBS infection in 1996 and a revised recommendation in 2002. Objectives: To perform a health economic analysis of the CDC recommendation using clinical data currently available in Thailand. Study design: Health economic analysis. Materials and Methods: After reviewing the literature regarding clinical data I Thailand, a decision analysis was performed to evaluate the outcomes of 3 strategies: universal culture screening, intrapartum risk factors assessment, and no prevention. Outcomes: The medical care cost for each strategy and incremental medical care cost for the prevention of one GBS case were analyzed. Results: Under the present conditions in Thailand and using the cost estimated from Siriraj Hospital’s charge in the year 2005, the no prevention practice was the most cost-effective strategy. The incremental medical care cost to prevent one GBS case for the universal culture screening and the intrapartum risk assessment were 594,754.17 Baht and 83,677.78 Baht, respectively. Conclusion: Although neither of the preventive strategies recommended by the CDC was cost-effective in general clinical practice in the present situation in Thailand, the intrapartum risk assessment strategy may be reasonable because the incremental cost to prevent one GBS case was less than 100,000 Baht.

Hormonal replacement therapy in surgical menopause with underlying endometriosis.

OBJECTIVE: To evaluate the effect of hormonal replacement therapy (HRT) regimens in surgical menopause patients with underlying endometriosis. DESIGN: Observational retrospective study. MATERIAL AND METHOD: 123 women with endometriosis after definite surgery (total abdominal hysterectomy with bilateral salpingo-oophorectomy) were followed in the Gynecologic Endocrinology and Menopause clinics. Patients were classified into 4 groups according to HRT regimens, i.e. control (no HRT, n=17), estrogen only (ERT, n=50), cyclic estrogen/progestin regimen (cyclic E/P, n=16), and continuous combined estrogen/progestin (ccE/P, n=24). 12 patients who received more than one regimen and 4 patients who received less than 6 months of HRT were excluded from the study. The information was obtained from the medical records. RESULTS: Mean age at surgery of all patients was 38.9 years old. Mean duration of HRT was 41.2 months. There was no difference in age at surgery or duration of follow-up in each group. There was 1 (2%) case of recurrent endometriosis and 3 (6%) cases of recurrent symptoms in the estrogen only group; none of them required additional surgical treatment. Malignant transformation was not found. CONCLUSIONS: Although the present series is small, it seems that HRT is safe for postmenopausal women with underlying endometriosis. Recurrence of endometriosis has rarely been a problem with HRT, especially in those who received the combination of estrogen and progestin regimens.

Sexuality in menopausal Thai women.

Objective : To evaluate the type and incidence of sexual problems and their relationship to vaginal problems and hormonal replacement therapy (HRT) in menopausal Thai women. Design : Cross-sectional study. Patients : 96 women, who were followed-up at the Menopause Clinic, Department of Obstetric Gynecology, Faculty of Medicine Siriraj Hospital from September 2001 to August 2002. Methods : All women were interviewed about sexual problems. The questionnaires requested demographic data, reproductive history, history of hormonal replacement therapy, postmenopausal complaints of sexual experience and responsiveness. Main outcome measurement : Types of sexual problems, the relationship between sexual and vaginal problems and the effect of HRT on sexuality. Results : Common sexual problems encountered after menopause were loss of libido, orgasmic dysfunction and dyspareunia. Both sexual desire and sexual activity decreased in the premenopausal period. Forty-three percent of natural menopausal women had sexual activity less than once a month. Similar results were found in the surgical groups. Only 24% of the subjects occasionally reached orgasm. Vaginal problems were found to have a significant relationship to the loss of sexual desire, whereas the decrease in vaginal secretion had significant relationship to the lack of orgasm. About 45.2% of menopausal women with HRT did not have a significant change in libido and sexual response. Conclusion : There is a decline in sexual response and activity in menopausal Thai women. Women with surgical menopause demonstrated a similar kind of sexual dysfunction as women with natural menopause. HRT cannot alleviate all the symptoms of sexual dysfunction but it is beneficial for vaginal complaints . Counseling and health education in which a positive attitude towards menopause is portrayed is important.

Increasing trend of illicit drug abuse in Thai parturient at Siriraj Hospital.

OBJECTIVE: To report the magnitude of the problem and to evaluate the outcome of maternal illicit drug use in Thai parturients. DESIGN: Retrospective case-control study. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University. SUBJECT: The subjects were 44,640 parturients who had deliveries at Siriraj Hospital from January 1998 to December 2001 and were divided into two groups. The study group consisted of 66 parturients with a history of illicit drug use and the control group consisted of 44,574 parturients without a history of illicit drug use. INTERVENTION: Medical records of 66 parturients with a history of illicit drug use were reviewed. Obstetric statistics of the department were retrieved from the computerized database in the Division of Obstetric and Gynecologic Registry. The data were analyzed using descriptive statistics. MAIN OUTCOME MEASURE: Characteristics of parturients, pregnancy outcome, type and incidence of illicit drug. RESULTS: Within the study period, 66 cases of maternal illicit drug use were identifiable during the intrapartum period; 65 cases used amphetamine or derivatives and 1 case used an opioid derivative. The number had risen from 1 case in 1998 to 58 cases in 2001. Mean age of the patients was 23.30 +/- 6.04 years. Compared to the control group which included 44,574 parturients, the patients had a lower incidence of antenatal care (ANC rate = 21.21% vs 94.35%; RR = 0.23, 95% CI = 0.14-0.26), a higher incidence of HIV infection (10% vs 2%; RR = 6.09, 95% CI = 2.83-13.12), a higher incidence of birth before arrival (BBA rate = 9.09% vs 1.06%; RR = 8.59, 95% CI = 3.98-18.51), and a lower cesarean section rate (10.60% vs 26.36%; RR = 0.40, 95% CI = 0.20-0.81). There were no serious intrapartum, immediate postpartum and neonatal complication. Fetal outcome included a higher incidence of low birth weight infants (22.73% vs 10.23%; RR = 2.22, 95% CI = 1.42-3.46) and a smaller head circumference than the normal range of Thai fetal biometry (31.85 +/- 1.47 cm). CONCLUSION: There is an increasing trend of illicit drug use in Thai parturients. Although the present case series of drug abuse in Thai parturients cannot give the whole picture of maternal drug abuse in the Thai population, the dramatic increase in the identifiable cases during the past 4 years is very alarming. Currently, the outcome of pregnancy in case detected during intrapartum is not much different from that in the general population. However, there are potential risks for the patients and their babies. All medical staffs should be aware of this condition. Careful clinical data gathering and laboratory testing are suggested for prevention of complications and the potential hazards of this problem.

Distal radius bone mineral density and grip strength in peri/postmenopausal Thai women.

To determine the relationship between distal radius bone mineral density (BMD) and grip strength (GS) in peri/post menopausal Thai women. 177 healthy volunteers, > or = 40 years old, were included. Distal radius BMD of the non-dominant side was measured using dual energy X-ray absorptiometry. GS of both dominant and non-dominant sides was measured using a Jamar dynamometer. The association between BMD and GS was determined by correlation analysis. Other factors possibly affecting the BMD or GS including age, years since menopause (YSM), body weight (BW), height (Ht) and body mass index (BMI) were analyzed by the multiple regression method. It was found that BMD had statistically significant but weak, positive correlation to GS (r = 0.262, p < 0.001 for the dominant side, r = 0.193, p < 0.001 for non-dominant side). Age and YSM had a negative correlation, whereas, BW and Ht had a positive correlation to either BMD or GS. After multiple regression analysis, the significant predictors of BMD were age and BW, of dominant GS were age and Ht, and of non-dominant GS was YSM. In conclusion, decrements in distal radius BMD and in GS were found in peri/postmenopausal women. Aging seems to be the most important factor for these features. Although the GS has statistically significant correlation to the corresponding BMD, the clinical significance might not be obvious. Furthermore, the stronger correlation of BMD to the contralateral dominant GS than to the ipsilateral non-dominant GS implies that the influence of muscular strength on BMD, if present, is not due to a direct effect in this age group.

Minor side effects of hormonal replacement therapy in menopausal Thai women.

Objective : To evaluate type and incidence of minor side effects of hormonal replacement therapy (HRT). Design : Cross-sectional, descriptive study. Patients : 114 women, who were follow up at Menopause Clinic in July 2001. Methods: All women were interviewed about their experience in various symptoms possibly related to HRT side effects. The symptoms before and during HRT were recorded. The symptoms that were present only during HRT but not before HRT were considered as side effects. Results : The study showed that breast pain was the most common side effect of both cyclic HRT (40%) and continuous HRT (38.1%) groups; whereas the complaint of weight gain was more pronounced in the estrogen only (31.8%). Conclusion : Although minor side effects of HRT are not life threatening, they may have influence on the compliance of HRT. The incidence of minor side effects of HRT is varied depending on the HRT regimens. However, the symptoms similar to the HRT side effects are already present prior to HRT in a certain number of patients.