Fetal ocular distance in normal pregnancies.

OBJECTIVE: To construct reference ranges of fetal ocular distance (interocular and binocular distance) and to evaluate the relationships between the gestational ages and fetal ocular distance. MATERIAL AND METHOD: Six hundred and two normal pregnant women were evaluated from the 15th to 40th week of gestation. Fetal ocular distance (interocular and binocular distances) was added to routine biometric measurements for normal fetuses. The fetal ocular distance (interocular and binocular distances) was also related to gestational age. RESULTS: Five hundred and ninety five measurements were used for analyses. A linear regression and correlation were observed between gestational age (GA) and interocular distance (y = 2.304 + 0.510 x GA, R2 = 0.887; p < 0.0001), and binocular distance (y = 2.590 + 1.420 x GA, R2 = 0.953; p < 0.0001). A linear growth function was observed between biparietal diameter (BPD) and both interocular distance (y = 2.854 + 0.203 x BPD, R2 = 0.888; p < 0.0001), and binocular distance (y = 3.893 + 0.568 x BPD, R2 = 0.965; p < 0.0001). CONCLUSION: The present study provides normative data of fetal interocular distance and binocular distance. These data may be helpful in detection of fetal hypotelorism or hypertelorism.

Cardiac and hemodynamic changes during carbon dioxide pneumoperitoneum for laparoscopic gynecologic surgery in Rajavithi Hospital.

OBJECTIVE: To study the effects of intraperitoneal CO2 insufflation on cardiopulmonary variables in gynecological laparoscopic patients. MATERIAL AND METHOD: A prospective descriptive study of BP, HR, End tidal CO2, and Sat O2 in 30 gynecologic patients who underwent laparoscopic surgery between 1 September 2006 and 30 July 2007. RESULTS: Blood pressure increased in the early state. The End tidal CO2 significant increased during surgery. Heart rate and Sat O2 did not change. At completion of the laparoscopic intervention, physiological variables exhibited a trend to baseline values. CONCLUSIONS: This prospective descriptive study documents significant changes in systemic hemodynamic variables that seem to be directly associated with the insufflation of CO2 during gynecologic intraperitoneal laparoscopic surgery. This ongoing evaluation confirms the effect of gynecological laparoscopic surgery and CO2 insufflation on cardiopulmonary function in patients.

Oral potassium chloride and oral rehydration solution supplement to prevent hypokalemia in sodium phosphate regimen for bowel preparation prior to gynecological laparoscopic surgery.

OBJECTIVE: To evaluate the efficacy of oral potassium chloride and oral rehydration solution (ORS) supplement for hypokalemia prevention after sodium phosphate (NaP) bowel preparation. MATERIAL AND METHOD: A comparative historical study of patients who underwent gynecological laparoscopic surgery between June 2005 and December 2007 and received NaP for bowel preparation prior to surgery. In the experiment group, a 10% Potassium chloride (KCl) elixir and ORS supplement was introduced to 47 of the patients. The control group of 42 patients received only pure water Age, body mass index, and time of defecation after NaP bowel preparation were recorded. Serum potassium level before NaP (K0), 4 hours (K4), and 10 hours (K10) after last dose of NaP were measured in both groups. RESULTS: It was found that the experiment group could maintain serum potassium level well. The mean +/- SD of serum potassium level before NaP (K0), at 4 hours after NaP (K4) and at 10 hours after NaP (K10) were 3.99 +/- 0.35, 4.09 +/- 0.43, 4.03 +/- 0.63, respectively. In the control group, the K0 was similar to that in the experiment group but the K4 decreased to 3.50 +/- 0.35 and K10 was 3.76 +/- 0.40 which had a significant difference (p = 0.011). Serum hypokalemia (K < 3.5 mmol/L) was found in 22 patients (52.38%) of the control group. CONCLUSION: Oral KCl elixir and ORS supplement for sodium phosphate bowel preparation regimen can prevent hypokalemia prior to surgery.

Risk assessment of preeclampsia in advanced maternal age by uterine arteries Doppler at 17-21 weeks of gestation.

OBJECTIVE: To assess the risk of preeclampsia development in elderly gravidarum by uterine arteries Doppler at 17-21 weeks' gestation. MATERIAL AND METHOD: Pulsatility index (PI) of the uterine arteries was measured by color Doppler transabdominal sonography in 298 elderly gravida women at 17-21 weeks of gestation. The criterion for abnormal results was PI > 95th percentile of each gestational age and/or the presence of bilateral notches. The major end point was preeclampsia. RESULTS: Ten woman (3.4%) developed preeclampsia. Two hundred and eighty-four women (95.3%) had a normal Doppler flow of uterine arteries (PI < or =95th percentile of each gestational age), and 14 woman (4.7%) had abnormal Doppler flow of uterine arteries. The sensitivity, specificity, and positive and negative predictive values for detecting preeclampsia were 20%, 95.8%, 14.3%, and 97.2%, respectively. CONCLUSION: Women with mean PI > 95th of each gestational age have a high risk of developing preeclampsia. With the high negative predictive value, this test may be useful to minimize unnecessary interventions.

Effect of a new oral contraceptive with drospirenone on vital signs, complete blood count, glucose, electrolytes, renal, and liver function.

OBJECTIVE: To evaluate the effect of a new oral contraception formulation with drospirenone (Yasmin) on vital signs, complete blood count, glucose, electrolytes, and renal and liver function. MATERIAL AND METHOD: An open-label non-comparative clinical trial was conducted. One hundred women who were planning to use oral contraception for at least six months were recruited. The subjects received a blister pack which contained 21 tablets of 3 mg drospirenone /30 tg ethinyl estradiol for the first four cycles (1 cycle = 28 days). Cycle 5 and 6 blister packs were dispensed during the visit in cycle 4. Heart rate and blood pressure of each subject were checked at baseline and each visit. Serum from each subject was collected and sent for complete blood count, glucose, electrolytes, and renal and liver function tests at baseline and at cycle 6. Mean differences in these tests at cycle 6 compared to baseline were assessed. RESULTS: Ninety-two of the 100 subjects (92%) completed the present study. There was no significant change in heart rate, blood pressure, complete blood count, glucose, electrolytes, and renal and liver function tests at cycle 6 when compared to baseline. CONCLUSION: Oral contraception formulation with drospirenone (Yasmin) is well tolerated and has good contraceptive efficacy. It is safe, as it has no effect on heart rate, blood pressure, complete blood count, glucose, electrolytes, and renal and liver function.

Obstetric outcomes in nulliparous young adolescents.

The objective of this study was to determine whether pregnant young adolescents under 15 years of age developed more obstetric complications than adult women. A retrospective case control study was undertaken. The pregnancies of 121 nulliparous women under age 15 delivered at Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University between January 1994 and December 2004 were compared to 121 nulliparous controls age 20-29. Multiple gestations were excluded. Young adolescents were more likely to develop anemia, preterm delivery, preeclampsia and deliver low birth weight neonates. More cases in the young adolescent group did not have antenatal care. Cephalopelvic disproportion occurred less often in the young adolescent group. No differences were observed between the groups regarding the prevalence of premature rupture of membranes, cesarean section, low Apgar score and fetal demise. Adolescents under 15 years of age experienced more obstetric complications than adult women. Development of appropriate education, pregnancy prevention and antenatal care programs is invaluable for adolescents. These programs should target young adolescents who are at increased risk for adverse pregnancy outcomes.

Effects of demineralized bone matrix on proliferation and osteogenic differentiation of mesenchymal stem cells from human umbilical cord.

BACKGROUND: Mesenchymal stem cells or mesenchymal progenitor cells are defined as self-renewable, multipotent progenitor cells with the unlimited capacity to differentiate into multiple lineage-specific cells that form bone, cartilage, fat, and muscle tissues. Demineralized bone matrix (DBM) has been extensively utilized in orthopaedic, periodontal, and maxillofacial applications and widely investigated as a biomaterial to promote new bone formation. OBJECTIVE: To isolate and characterize umbilical cord mesenchymal stem (UCMS) cells and examine the biological activity of DBM in the UCMS cells MATERIAL AND METHOD: UCMS cells were obtained from human umbilical cord culture. Cells were treated with or without DBM over 7 days of culture. Cell proliferation was examined by direct cell counting. Osteogenic differentiation of the UCMS cells was analysed with alkaline phosphatase staining assay. RESULTS: Phenotypic characteristics ofhuman UCMS cells were spindle and stellate shapes with fine homogenous cytoplasm, typically associated with fibroblast-like cells. The control cells (without DBM treatment) exhibited a spindle shape with little extracellular matrix, whereas the DBM treated cells appeared shortened and flattened, and they were surrounded by extracellular matrix. DBM inhibited the growth of the UCMS cells by 50%, as determined by direct cell counting. Morphologic and histochemical studies confirmed that DBM had a strong stimulatory effect on the alkaline phosphatase activities of UCMS cells, a very early marker of cell differentiation into the osteogenic lineage. CONCLUSION: Mesenchymal progenitor cells derived from umbilical cord could differentiate along an osteogenic lineage and thus provide an alternative source for cell-based therapies and tissue engineering strategies.

Prenatal exclusion of Pompe disease by electron microscopy.

Pompe disease is a lysosomal storage disorder caused by alpha-glucosidase deficiency. The disease is characterized by accumulation of glycogen in the lysosomes. The accumulation has unique ultrastructural features which enable a prenatal diagnosis by electron microscopy. We describe prenatal electron microscopic testing in a fetus of a mother whose previous child died of Pompe disease. The disease in the affected child was diagnosed by a decrease in alpha-glucosidase activity of his skin fibroblasts. Electron microscopy of the chorionic villus sample and amniocytes revealed normal findings, thus predicting an unaffected fetus. The study was confirmed by the birth of a normal neonate who was still healthy at the age of 12 months. Electron microscopy is useful in the first and second trimesters to exclude Pompe disease prenatally. This test can be use prenatally and provides families with reassurance.

Spontaneous reseal of ruptured membranes after genetic amniocentesis.

BACKGROUND: Rupture of membranes is an uncommon complication of genetic amniocentesis. The risk of ruptured membranes is reported as 1-1.2%. CASE: Genetic amniocentesis complicated by ruptured membranes was diagnosed in a 31-year-old woman. The membranes resealed after 48 hours with conservative management and the pregnancy ended with a favorable outcome. CONCLUSION: Spontaneous reseal of ruptured membranes after genetic amniocentesis can occur with conservative management and end with a favorable pregnancy outcome.

An increase of the cardiothoracic ratio leads to a diagnosis of Bart's hydrops.

BACKGROUND: Thalassemia is a common single gene disorder in Southeast Asia. a-thalassemia is a group of syndrome characterized by deficient production of the alpha-globin chain. Individuals with heterozygous alpha-thalassemia-1 are at risk of having a fetus that has Hemoglobin Bart's hydrops fetalis (Hb Bart's). Usually, when the hemoglobin electrophoresis in heterozygous alpha-thalassemia-1 is normal, the Mean Corpuscular Volume (MCV) is lowered. We report a case of increased cardiothoracic ratio that led to a diagnosis of Hb Bart's in a couple who had normal hemoglobin electrophoresis and low MCV. CASE REPORT: A 23-year-old woman, gravida 2, Para 0-0-1-0, initially presented for antenatal care at 13 weeks pregnancy. Her MCV was 67 fentolitre, DiChlorophenol-IndolPhenol (DCIP) test was negative and hemoglobin electrophoresis was normal. Her husbands MCV was 67 fentolitre, and hemoglobin electrophoresis was normal. Cardiomegaly (an increased of the cardiothoracic ratio) was detected by ultrasonogram at 25 weeks of gestation. She and her husband were comprehensively counseled after an Hb Bart's was suspected. A cordocentesis was performed and the fetal blood was tested for hemoglobin electrophoresis. The result was later known and confirmed as Hb Bart's. The couple decided to terminate the pregnancy. The induced abortion was successful and the patient was discharged on the second day after the abortion. She was well at the 4-week follow-up. CONCLUSION: A prenatal ultrasonographic screening should be conducted in couples who are suspected of being alpha-thalassemia-1 carriers when DNA study of alpha-globin gene cannot be performed. The increase of cardiothoracic ratio will help detect an early stage of Hb Bart's.

Pregnancy outcomes in adolescents < or = 15 years old.

OBJECTIVE: The authors' purpose was to assess the occurrence of specific complications of adolescent < or = 15 years old in a tertiary hospital population. MATERIAL AND METHOD: A retrospective study was conducted in a population of adolescents (age < or = 15 years) delivered at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University from January 1, 1994 to December 31, 2004. Subgroup analysis was also conducted according to the total number of antenatal visits. Group 1 had total antenatal visits less than four times during their gestation; group 2 had total antenatal visits at least four times during their gestation. RESULTS: During an 11-year study period, a total of 340 adolescent pregnancies aged < or = 15 years old, were delivered. The patients' mean age was 14.5 years, and their mean gestational age was 37.5 weeks. Most cases (95.6%) were nulliparous. 12.3% of the cases had no antenatal care. The newborns' mean birth weight was 2819.2 g. Cesarean section rate was 12.1%. The most frequent obstetric complications were: anemia (22.6%), preterm delivery (16.5%), preeclampsia (7.4%), and small for gestational age infants (4.4%). Preterm delivery was the only obstetric complication that was significantly different between the two groups (22.1% in group 1 versus 12.0% in group 2, p < 0.05). CONCLUSION: Pregnancy in adolescents < or = 15 years poses many obstetric complications. These complications are reduced when they have a total antenatal care visit at least four times during their gestations. This information can be used to counsel adolescents who are pregnant to be concerned about their antenatal care.

Ethics and the comprehensive application of epistemology in medical practice.

Our simple definition of ethics is good thought, speak and action. Epistemology means the hypothesis of facts about thought, speech and action. Medical practice is all means of medicine. Medicine classifies people into normal and abnormal. The abnormal are the sick. They loose some organs or those normal looking organs are dysfunctional. They are social problems, some can be treated, and some do not get the appropriate care. The problems of society of normal people are overeating and obesity, abortion, drug abuse, promiscuity, torture, terrorism, disobeying rules and order, corruption, brain-washing and unethical advertisements, etc. On the other hand, the social problems of the abnormal are down, deafness, blindness, dumb, hypertension, hypercholesterolemia, diabetes mellitus and cancer, etc. An example of the social-doctor problem is the mal distribution of doctors in rural areas. It was reported by the ministry of public health that the ratio of doctor to population to be 1:800 in Bangkok and 1:5, 700 in some rural areas in the north eastern part of Thailand. The doctors, themselves, are at a high grade of worker and intelligent quotient. They know all the problem and, at the same time, create problems, both, faster than the general population can do. It affects good and bad in the society. In the past, present and the foreseeable future the medical students get their studies in the western style. Their medical schools are situated in big cities. These schools are old and famous. They learn their medical procedure in a big hospital of more than 400 beds in the inpatient department wards. Their instructors and professors are highly qualified, are middle class people and well accepted in the society. Their families are lovely and warm. Their children study in the first class schools in town. The medical students feel very happy and appreciate seeing their professors in television routinely at prime time. In conclusion, their professors are an example of role model for them to follow. Everyone looks for security in her/his profession. Facts need no proof and reference. People with justice in mind should believe and understand the above mentioned. This leads to the problem of mal distribution of doctors in rural areas, why do doctors live in big cities or wish to be in the private sector? In fact, not many a number of doctors serve in the rural area. About 4-5 of them, their name will be announced yearly as the best rural doctor award. After the big ceremony, lasted not longer than a month, it is hard to remember their name. They are proud to be praised, it pushes them into stress intentionally with all the best of their intelligence and the total of their body strength to work harder in rural. Unfortunately their earning, the security of their profession, the increased chance of being sued, to get caught in the medical litigation, the expenses of their family social status and the study of their children cannot be compared to of those doctors in big city and/or in the private sector. Mal distribution of doctors in remote rural areas has been a persisting unresolved problem in many parts of the world, why not apply the principles of ethics and epistemology? They have been left, untouched forever.

Primary ovarian pregnancy.

BACKGROUND: Primary ovarian pregnancy is a relatively rare form of ectopic pregnancy with an incidence of 1/6000 - 1/40000 pregnancies. CASE REPORT: A 25-year-old woman, gravida 1, parity 0, presented with vaginal bleeding after 8 weeks of amenorrhea. Pelvic examination revealed a left adnexal mass and transvaginal ultrasound confirmed a left adnexal echocomplex mass with free fluid in the cul-de-sac. Serum beta hCG was 3441 mIU/mL. Emergency exploratory laparotomy was performed with a preoperative diagnosis of left ectopic pregnancy, suspected of ovarian pregnancy. Ruptured left ovarian pregnancy was intraoperatively diagnosed. Left salpingo-oophorectomy was performed. The histopathology confirmed ovarian pregnancy. She was well at discharge and throughout a 4-week period of follow-up. CONCLUSION: Although primary ovarian pregnancy is rare and difficult to diagnose clinically and even intraoperatively, it can be detected early with the use of combined transvaginal ultrasonography and serum beta hCG The standard of care is conservative treatment in order to preserve the patient's fertility.

Prenatal exclusion of Crouzon syndrome by mutation analysis of FGFR2.

Crouzon Syndrome is an autosomal dominant syndromic craniosynostosis characterized by premature closure of cranial sutures, exophthalmos, and midface hypoplasia. It is caused by multiple mutations in the fibroblast growth factor receptor 2 (FGFR2). We describe prenatal genetic testing of FGFR2 in a fetus of a mother whose previous child had Crouzon Syndrome due to an apparently de novo mutation, S351C. Sequence electropherograms of the exon 10 of FGFR2 encompassing the codon 351 revealed only the normal sequence, thus predicting a very high likelihood of an unaffected fetus. The study was confirmed by the birth of a normal neonate. We report the use of molecular genetic testing to exclude Crouzon Syndrome due to FGFR2 mutation prenatally. Prenatal diagnostic testing for a known mutation is a reasonable option for couples at risk for having a child with Crouzon Syndrome due to germline mosaicism. Molecular testing is more accurate and reliable than ultrasonography and provides families with reassurance.