Laparoscopic surgery for presumed benign ovarian tumor during pregnancy.

BACKGROUND: The surgical management of ovarian tumors in pregnancy is similar to that of non-pregnant women. The procedures include resection of the tumor (enucleation), removal of an ovary or ovaries (oophorectomy), or surgical excision of the fallopian tube and ovary (salpingo-oophorectomy). The procedure can be done by open surgery (laparotomy) or keyhole surgery (laparoscopy) technique. The benefits of laparoscopic surgery include shorter hospital stay, earlier return to normal activity, and reduced postoperative pain. However, conventional laparoscopic surgery techniques required the infusion of gas carbon dioxide in the peritoneum to distend the abdomen and displace the bowel upward to create the room for surgical manipulation. Serious complications such as abnormally high levels of carbon dioxide in the circulating blood (hypercarbia) and perforation of internal organs have also been reported. These serious complication may be harmful to the fetus. OBJECTIVES: To compare the effects of using laparoscopic surgery for benign ovarian tumor during pregnancy on maternal and fetal health and the use of healthcare resources. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 June 2006). SELECTION CRITERIA: Randomized controlled trials with reported data that compared outcomes of laparoscopic surgery for benign ovarian tumor in pregnancy to conventional laparotomy technique. DATA COLLECTION AND ANALYSIS: Two review authors planned to independently assess trial quality and extract data. MAIN RESULTS: There were no randomized controlled trials identified. AUTHORS' CONCLUSIONS: The practice of laparoscopic surgery for benign ovarian tumour during pregnancy is associated with benefits and harms. However, the evidence for the magnitude of these benefits and harms is drawn from case series studies, associated with potential bias. The results and conclusions of these studies must therefore be interpreted with caution. The available case series studies of laparoscopic surgery for benign ovarian tumour during pregnancy provide limited insight into the potential benefits and harms associated with this new surgical technique in pregnancy. Randomized controlled trials are required to provide the most reliable evidence regarding the benefits and harms of laparoscopic surgery for benign ovarian tumour during pregnancy.

The impact of overactive bladder, stress and mixed urinary incontinence on quality of life in Thai postmenopausal women.

OBJECTIVE: To assess the quality of life (QOL) of Thai postmenopausal women with overactive bladder (OAB), stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). MATERIAL AND METHOD: A total of 420 Thai postmenopausal women (120 had SUI, 60 MUI, 120 OAB and 120 controls) were recruited QOL was assessed by the Thai version short form 36 (SF-36). RESULTS: There was no significant difference in the patients's characteristics. All domains of SF-36 in women with OAB, SUI and MUI were statistically significantly lower than the control group. OAB and MUI had lower SF-36 scores than SUI in all domains except the role of physical health. When compared between OAB and MUI, the women with MUI had lower SF-36 scores than OAB in all domains (except the physical functioning and general health). CONCLUSION: OAB, SUI and MUI had more significant impaired QOL than control. The author found a greater impact on QUL in OAB and MUI in Thai postmenopausal women.

Diagnostic hysteroscopy at King Chulalongkorn Memorial Hospital: 7 years experience.

We reported our experience and results of diagnostic hysteroscopy performed on 294 patients between June 1994 and May 2000 at the Gynecologic Endoscopy Unit, King Chulalongkorn Memorial Hospital. Diagnostic hysteroscopy was performed successfully in 286 patients (97.3%), allowing thorough inspection of the uterine cavity. Cervical dilatation was required in 146 patients (49.6%). The most common indication was endometrial polyps (34.4%) followed by infertility (19.4%) and abnormal uterine bleeding (14.9%), respectively. Each of the hysteroscopic findings accounted for 103 patients (35%) in endometrial polyps and normal endometrium. The procedure failed in 8 patients (2.71%) due to uterine perforation. In conclusion, diagnostic hysteroscopy should be considered as a safe, effective and successful investigation procedure for suspected intrauterine pathology.

Pipelle versus fractional curettage for the endometrial sampling in postmenopausal women.

The experimental and cross over design study was performed to compare the pain, ability to sample the endometrial issue, and pathological results from pipelle and fractional curettage in post menopausal patients. Thirty naturally menopausal patients who visited King Chulalongkorn Memorial Hospital with abnormal bleeding per vagina from June 1 to December 31, 1997, were enrolled in the study. In group A,endometrial tissue sampling was first conducted by Pipelle and followed by fractional curettage. In group B, the fractional curettage was performed before Pipelle. The results showed that the pain derived by the visual analogue scale of Pipelle and fractional curettage were 3.34 +/- 1.44 (mean +/- SD) and 6.58 +/- 1.75 respectively (p<0.01). The sensitivity and specificity of Pipelle in endometrial tissue samplings compared with fractional curettage were 87.5 and 100 per cent, respectively. One from 3 cases of adeneocarcinoma of the endometrium could not be detected by Pipelle. In conclusion, Pipelle significantly produced less pain than fractional curettage. Even though Pipelle is a simple and easy method for endometrium sampling, the use of Pipelle to replace fractional curettage in the management of postmenopausal bleeding should be done with caution. False negative could occur in the focal disease of malignancy of the endometrium.

Accuracy of hysteroscopic diagnosis of endometrial polyps.

OBJECTIVE: To evaluate the diagnostic accuracy of endometrial polyps by hysteroscopy. MATERIAL AND METHOD: One hundred and sixty five women undergoing diagnostic hysteroscopy between January 1996 and December 1998 at the Gynecologic Endoscopy Unit, King Chulalongkorn Memorial Hospital were recruited in this study. The hysteroscopic diagnosis was compared with the histopathology by endometrial curettages performed after hysteroscopy. RESULTS: Endometrial polyps were diagnosed by hysteroscopy in 54 patients (32.73%). When compared to tissue pathology, we found an accuracy of 81.21 per cent, sensitivity of 92.59 per cent, specificity of 78.98 per cent, positive predictive value of 46.29 per cent, negative predictive value of 98.19 per cent, false positive of 17.57 per cent and false negative of 1.21 per cent. CONCLUSION: For endometrial polyps, diagnostic hysteroscopy yields a high accuracy but low positive predictive value. Therefore, endometrial biopsy is necessary to confirm diagnosis of endometrial polyps by hysteroscopy.

The metabolic and bone density effects of continuous combined 17-beta estradiol and noresthisterone acetate treatments in Thai postmenopausal women: a double-blind placebo-controlled trial.

OBJECTIVE: To compare the changes of lipid parameters, liver function tests, fasting plasma glucose and bone density in Thai postmenopausal women who received this combined hormonal treatment and placebo. STUDY DESIGN: Double-blinded, randomized controlled trial study. MATERIAL AND METHOD: Sixty postmenopausal women attending the menopause clinic at Chulalongkorn Hospital from July, 1996 to December, 1996, were enrolled in the study. The patients were randomized to receive the placebo or drug (17 beta-estradiol 2 mg and norethisterone acetate 1 mg) continuously. Patient characteristics, physical examination, liver function tests, fasting plasma glucose, lipid parameters (fasting total cholesterol, low density lipoprotein cholesterol (LDL), high density lipoprotein (HDL) and triglyceride level) and bone densitometry were performed before beginning the study. The lipid parameters were repeated at 3, 6 and 12 months. Fasting plasma glucose, liver function tests and bone densitometry were repeated at 12 months. RESULTS: In the drug group, there were significant changes in the cholesterol at 3, 6 and 12 months when compared to the baseline. There were significant differences at 3, 6 and 12 months when compared between groups. The HDL values were not significantly different within groups. The LDL values at 3, 6, 12 months were significantly lower than the baseline in the drug group when compared within groups and at 6, 12 months in the placebo group. The triglyceride values were not significantly different between groups and within groups. There was no significant change between groups and within groups of fasting plasma glucose, total bilirubin, direct bilirubin, AST, ALT, albumin and globulin. The alkaline phosphatase values were significantly decreased at 12 months in the drug group. The bone density of total BMD and T-score at the spine of the drug group increased significantly at 12 months. The per cent change per year was +5.1. In contrast, the values in the placebo group decreased significantly, the per cent change per year was -0.9. The same pattern was also found in the bone density of the total hip. But when focused to the femoral neck, we found no significant change in both groups. CONCLUSION: This continuous combined treatment resulted in beneficial changes of bone density and lipid profiles. The therapy prevented bone loss and the changes in serum lipoprotein were concordant with a lipid profile associated with a decreased risk of coronary heart disease in Thai postmenopausal women.

Prevalence of osteopenia and osteoporosis in Thai women.

OBJECTIVE: To determine the age-specific and age-adjusted prevalence of osteopenia and osteoporosis in pre- and postmenopausal Thai women. METHODS: This was a descriptive study of 1,935 Thai women ranging in age from 40 to 80 years, with randomly selected strata using multistage sampling and stratifying from six representative provinces of the country. After recruiting, all the women were interviewed by a well-trained interviewer using structured questionnaires. Bone mineral density (BMD) of lumbar spine 1-4 and nondominant hip was measured by a dual energy photon absorptiometer. The investigators were trained and standardized; inter- and intraobserver variations were measured periodically. Every BMD outcome was re-examined by the specialist. Age-specific prevalence of osteoporosis and osteopenia were determined using both Thai and Western standard BMD values. Age-adjusted prevalence of osteopenia and osteoporosis was calculated using the age-adjusted direct method. RESULTS: Using the Thai BMD reference, the age-specific prevalence of osteoporosis among Thai women rose progressively with increasing age to more than 50% after the age of 70. The age-adjusted prevalence of osteoporosis also rose progressively. It was 19.8%, 13.6%, and 10% for lumbar spine, femoral neck, and intertrochanteric. The age-adjusted prevalence of osteoporosis indicates the overall magnitude of that condition in the population or country. In our study, using a Western BMD reference resulted in a misleadingly high prevalence of osteoporosis in the population of Asian countries. CONCLUSION: It is important to calculate the age-adjusted prevalence of osteopenia and osteoporosis to address the overall magnitude of the problem in Thai women. This will allow us to predict the socioeconomic impact of preventable chronic conditions such as osteoporosis. The results obtained from this study are important data for public health policy: maximizing bone mass throughout life as well as detection of important risk factors is essential.

Bone mineral density of lumbar spine and proximal femur in normal Thai women.

OBJECTIVE: To find the reference data for age-specific normal bone mineral density in a Thai female population. STUDY DESIGN: Cross-sectional, Descriptive study. MATERIAL AND METHOD: 1773 Thai women aged between 11-80 years were recruited, using multistage cluster sampling and stratifying from six represented provinces in the country, each strata was randomly selected. After recruiting, the women were interviewed by well-trained personnel using structured questionnaires. Bone mineral density of the lumbar spine 1-4 and nondominant hip were measured by Dual Energy Photon Absorptiometer. The scientists, X-rays technician were trained and standardized inter and intra observers variation. Quality control of examination was measured periodically. Every BMD outcome was re-examined by a specialist. RESULTS: The peak bone mineral density of both spines and hips was between the age of 30 to 34 years old. Mean Value for spine and femoral neck was 0.957 and 0.814 g/cm2 respectively. The BMD of spine and hip was significantly decreased after the age of 35 and the loss was accelerated at age 50. Osteoporosis for spine and femoral neck is considered when BMD are below 0.682 and 0.569 g/cm2 respectively. CONCLUSION: The results are important data for public health policy, by maximizing bone mass during skeletal growth before menopause and minimizing bone loss throughout life as well as for detection of important risk factors.

Clinical effects of 17 beta-estradiol and norethisterone acetate in postmenopausal Thai women.

OBJECTIVE: To compare the climacteric symptoms, the bleeding patterns, side effects, endometrial thickness, serum follicular stimulating hormone (FSH) and estradiol level in postmenopause Thai women who received this drug and placebo. STUDY DESIGN: Double blind, randomized placebo controlled trial. MATERIAL AND METHOD: Sixty postmenopausal women attending the menopause clinic at Chulalongkorn Hospital from July, 1996 to December, 1996, were enrolled in the study. The patients were randomized to receive the placebo or drug (17 beta-estradiol 2 mg and norethisterone acetate 1 mg) continuously. After 12 months, 13 patients in the drug group were switched to have placebo and 13 patients in the placebo were switched to the drug group. Recording of patient characteristics, physical and gynecologic examination, pap smear, breast examination and mammogram, climacteric symptom scores, transvaginal ultrasonography, serum FSH and Estradiol level were performed prior to the study. Physical examinations, breast palpitations, measurement of body weight and blood pressure, climacteric symptom scores and side effects were repeated at 3, 6, 12, 18 months. Gynecologic examination, pap smear, serum FSH and estradiol, transvaginal ultrasonography, were repeated at 12 months. RESULTS: The women in the drug group had fewer climacteric symptoms than baseline after 6 months. The incidence of amenorrhea was 74.0 per cent at 12 months. The incidence of abnormal uterine bleeding (spotting and breakthrough bleeding) was 37.0 per cent at 3 months, 29.6 per cent at 6 months, 25.9 per cent at 12 months and 7.1 per cent at 18 months. The women in the drug group had fewer climacteric symptoms than baseline after 6 months. Breast tenderness was the most common side effect. The endometrial thickness decreased significantly in the drug group. Serum FSH decreased and serum estradiol increased significantly in the drug group. CONCLUSION: This combined regimen was more effective in relieving the climacteric symptoms in women who used the drug than those who used the placebo. There was a high incidence of amennorhoea after 12 months. But there was also a high frequency of abnormal bleeding in the first 3 months of treatment. Counseling on the bleeding pattern and common side effects should be conducted before starting the treatment to increase the compliance. This combined regimen proved to be a useful alternative for postmenopausal Thai women who prefer to avoid cyclic bleeding from sequential therapy.

Effects of the etonogestrel-releasing contraceptive implant (Implanon on parameters of breastfeeding compared to those of an intrauterine device.

Eighty healthy single births born at a gestational age of 259-294 days were studied in an open, non-randomized, group comparative fashion. The mothers were on average 6 weeks postpartum, healthy, and fully breastfeeding at the start of treatment. Forty-two mothers elected to use the etonogestrel-releasing implant, Implanon, while 38 chose use of a non-hormone medicated intrauterine device (IUD). One month after implant placement, the dose of etonogestrel ingested by the infants via breast milk was 19.86 ng/kg/day, which decreased to 10.45 ng/kg/day at the end of the study period (month 4). The volume of breast milk production was not affected by the use of Implanon. There were no significant differences between groups in milk content of total fat, total protein, and lactose. The timing and quantity of supplementary feedings did not differ between the two groups. Growth of the infants was analyzed by treatment and gender. For the girls, no differences between groups were seen for body weight, body length, and head circumference. The same applied to the boys except for a somewhat larger, although not statistically significant, increase in body weight for boys whose mother used Implanon. There was a low incidence of intercurrent illnesses in the infants of both groups. None of the conditions was of a serious nature. From the present study, we conclude that Implanon did not change the volume and composition of breast milk. The low concentration of etonogestrel ingested by the infant was not associated with adverse effects.

Ruptured tuboovarian abscess in late pregnancy. A case report.

BACKGROUND: Tuboovarian abscess is an unusual obstetric complication that causes maternal and fetal morbidity and mortality. CASE: A woman, G1, P0, with a 32-week pregnancy presented with abdominal pain. Physical examination on admission revealed fever and unremarkable abdominal signs. Eleven hours after admission, signs of peritonitis became prominent, necessitating emergency laparotomy. Surgical findings included an 8-cm, right, ruptured tuboovarian abscess with massive purulent contamination of the abdominal cavity. Cesarean hysterectomy with bilateral salpingo-oophorectomy was performed. Neither the newborn nor the mother had postoperative complications. CONCLUSION: Since there are discrepancies in the incidences of tuboovarian abscess in pregnant and nonpregnant groups, the pathogenesis of tuboovarian abscess may be different in the two populations. In pregnancy, diagnosis and management are also more difficult than in the nonpregnant state. Clinical data may not reveal the diagnosis until surgery is mandatory. Because most pregnant women with tuboovarian abscesses are young, conservative surgery should be attempted if the pathology is limited to only one side of the adnexa and further reproduction is desired.

Similarity of bone mass measurement among hip, spines and distal forearm.

From January-December 1995, bone mineral density (BMD) of lumbar spine, hip and distal forearm were studied in 325 healthy women visiting the menopause clinic, Chulalongkorn Hospital. This retrospective analysis was conducted to assess the correlation of BMD among various measurement sites. Bone mass measurement at hip and spine were performed utilizing dual energy X-ray absorptiometer (DEXA), Hologic QDR 2000 and at distal forearm by single energy X-ray absorptiometer (SEXA), Hologic DTX 100. By canoconical correlation, the results revealed a significant correlation of BMD of distal and ultra-distal part of forearm with various sites of hip (r = 0.602, p < 0.001). There was also significant correlation of distal and ultra-distal part of forearm with various sites of spines (r = 0.619, p < 0.001). Though there is some heterogeneity of bone mass density among different measurement sites, practically with this fairly good level of correlation, bone mass measurement of distal forearm might be used to predict the BMD of hip and spine in Thai women. The accuracy of predicting the BMD of hip and spine by BMD of distal forearm in the mass screening programme in Thailand is now going on. The results will be followed.

Premarital counseling clinic at Chulalongkorn Hospital.

BACKGROUND: The premarital counseling clinic at Chulalongkorn Hospital was established in 1978. The characteristics and sexual background were reviewed. AIM: To study characteristics, sexual background and choices of contraceptions of premarital couples attending the premarital counseling clinic at Chulalongkorn Hospital during the past ten years, (1988-1998). DESIGN: Descriptive study. MATERIAL AND METHOD: Two hundred couples (men (M) and women (W)) attending the premarital clinic at Chulalongkorn Hospital from July 1988 to January 1998 were recruited in the study. The counseling program included medical counseling, sex education and family planning counseling. The information of couples was recorded by the Family Planning Unit staff and the residents. RESULTS: The mean age was 31.5 +/- 4.3 yrs. (M), 28.9 +/- 3.8 yrs. (W). Most of the couples had a bachelor's degree education (61.5%--M; 72%--W). Most of them were employees (64.0%--M; 60.0%--W), had an income of 10,000-20,000 baht per month (39.0%--M; 38.0%--W) were Buddhist 97.0 per cent (M), 93.0 per cent (W). There were only 4 couples who had an abnormal physical examination. 85.5 per cent of the men had had sexual experience before while it was only 23.0 per cent in women. Most of the men had frequent masturbation 3-4 times/month (31.5%) and most of the women had no masturbation (86.0%) at all. Most of the couples (71.5%) chose to have contraception (contraceptive pill 57.5% and condom 20.0%). CONCLUSION: Premarital counseling should be adjusted to the background of the couples. Most couples had a high income and education. Sex counseling is important for couples especially women. The propagation of premarital clinic encourages further study and to outreach the general population of Thailand.

PIP: This study aims to review the characteristics, sexual background, and the choice of contraception among premarital couples attending the premarital counseling clinic at Chulalongkorn Hospital in Thailand. The study recruited 200 couples attending the premarital clinic from July 1988 to January 1998, which had a counseling program that included medical counseling, sex education, and family planning counseling. Most of the participants had a bachelor's degree education and a Buddhist religion. 39% of males and 38% of females had an income of 10,000-20,000 baht per month. Some couples had abnormal physical examinations such as undescended testes and cases of varicococle. About 85.6% of men had sexual experiences before marriage compared to 23% of females. Most couples (71.5%) chose to have contraception, such as contraceptive pill (57.5%) and condom (20%). Findings suggest that premarital counseling should be adjusted to the background of the couples, and sex education should focus more on women since they have lesser sexual experience before marriage as compared to men.

Dengue hemorrhagic fever during pregnancy: antepartum, intrapartum and postpartum management.

Dengue hemorrhagic fever is a common tropical disease in Thailand that nowadays has an increasing incidence during adulthood. We managed three cases of dengue hemorrhagic fever during pregnancy which developed during the antepartum, intrapartum and postpartum periods. We diagnosed dengue hemorrhagic fever during pregnancy with clinical pictures of fever, hemoconcentration and thrombocytopenia with serological proof in all cases. All cases were treated conservatively except for the second one, in which cesarean delivery was inevitable due to severe preeclampsia with unfavorable cervix. All patients and their babies were in good condition before discharge. With increasing incidence during adulthood, more cases of dengue hemorrhagic fever in pregnancy can be found. Conservative treatment should be conducted in all cases. We believe that this is the first case report of intrapartum dengue hemorrhagic fever during pregnancy.