Prevalence of gestational diabetes mellitus and pregnancy outcomes in Asian women with polycystic ovary syndrome.

The aim of this study was to determine the prevalence of gestational diabetes mellitus (GDM) and the pregnancy outcomes in Asian women with polycystic ovary syndrome (PCOS). The retrospective cohort study was performed to compare pregnancy outcomes of 47 pregnancies in 41 PCOS women with 264 pregnancies in 222 women with normal menstruation. Logistic regression was used to assess the risk of PCOS on GDM, hypertensive disorder in pregnancy (HDP) and premature delivery. The mean age of both groups was 31 years. The mean body mass index (BMI) and proportion of BMI of > 25 kg/m2 were significantly higher in the PCOS than in the control group. There was no difference in the prevalence of GDM between the PCOS women and the high-risk group of the controls. The prevalence of HDP and premature delivery was significantly greater in PCOS women (21.3 and 13.3%) than in the controls (6.4 and 5.4%), respectively. PCOS was demonstrated as a risk factor for GDM and HDP with borderline statistical significance, but not for premature birth. The Cesarean section rate was higher in the PCOS than in the control group. In conclusion, the prevalence of GDM in Asian women with PCOS is high and comparable to those of a high-risk group.

Induction of labor with vaginal misoprostol for second trimester termination of pregnancy in the scarred uterus.

OBJECTIVES: To assess the safety of vaginal misoprostol for second trimester pregnancy termination in patients with a history of cesarean section. METHODS: A consecutive series of 593 women with pregnancies of 14-26 weeks were studied. A cohort of 56 cases had undergone previous cesarean section delivery. The 528 cases who had no history of prior uterine surgery served as the controls. The termination was carried out according to the regimen used at the time of enrollment, either 600 microg applied at every 6 or every 12 h, or 800 microg applied at every 12 h using the vaginal route. RESULTS: The median induction to abortion time in the previous cesarean section group (15.1 h) was not significantly different from that of the controls (15.8 h). The median total dosage of misoprostol used was the same for both groups (1200 microg). The rates of incomplete abortion and analgesia usage were significantly higher in the previous cesarean section group as compared with the controls. CONCLUSIONS: Vaginal misoprostol was effective for the second trimester pregnancy termination but the safety of misoprostol in the scarred uterus cannot be assumed from this study. A large series is needed to reach the power to see the difference.

Randomized trial of isosorbide mononitrate versus misoprostol for cervical ripening at term.

OBJECTIVES: To assess the adverse effects of isosorbide mononitrate (IMN) compared with misoprostol for cervical ripening at term. METHODS: One hundred and seven women with term pregnancies referred for induction of labor with Bishop scores of 6 or less were randomly allocated to receive either a 40-mg IMN tablet vaginally (n = 55) or 50 microg misoprostol vaginally (n = 52) every 6 h for a maximum of three doses. They were sent to the labor ward for amniotomy or oxytocin if either their Bishop scores were more than 6 or their cervices were not ripe 24 h after the treatment. Adverse effects, progress, and outcomes of labor were assessed. RESULTS: Isosorbide mononitrate was associated with fewer adverse effects especially uterine tachysystole (0 vs. 19.2%, P < 0.01) and hyperstimulation (0 vs. 15.4%, P < 0.01). The time from start of medication to vaginal delivery in IMN group was significantly longer (25.6 +/- 6.1 vs. 14 +/- 6.9 h, P < 0.01). Oxytocin was needed in 51 women (92%) of the isosorbide mononitrate group and six women (11%) of the misoprostol group (P < 0.001). The cesarean rate was not significantly different between the groups, but the major indications were different: dystocia (45%) in the IMN group vs. persistent non-reassuring fetal heart rate pattern (56%) in the misoprostol group. CONCLUSIONS: Cervical ripening with IMN resulted in fewer adverse effects, but was less effective than misoprostol.

A randomized comparison of postcesarean pain between closure and nonclosure of peritoneum.

OBJECTIVE: To compare the intensity of postcesarean pain between closure and nonclosure of peritoneum in the women with a midline incision and one previous cesarean section. STUDY DESIGN: The setting was an obstetrics unit of a university teaching hospital. A double-blind randomized trial was performed on 60 pregnant women with a midline incision and one previous cesarean section who underwent elective repeated cesarean section. Thirty women each were allocated to the "closure" group and the "nonclosure" group. The principal outcome measure was the postcesarean pain assessed by visual analog scale (VAS). RESULTS: There was no difference in postoperative pain for closure and nonclosure of peritoneum groups in repeated cesarean patients; while resting (P=0.8), while moving in bed (P=0.94), and while walking (P=0.52). The use of opiate (P=0.27) and oral analgesics (P=0.37) also suggested no difference. No differences were found in duration of the operation, incidence of postoperative complications, time of returned bowel function, and length of the hospital stay. CONCLUSION: The VAS showed no difference in postcesarean pain between closure and nonclosure of peritoneum.

Cephalocentesis with the modified Smellie's perforator.

A 37-year-old pregnant woman, gravida 2, para 0, was referred to Ramathibodi Hospital at 31 weeks of gestation with the diagnosis of hydrocephalus and polyhydramnios. Repeated ultrasound scans revealed hydrocephalus with macrocephaly (BPD=10.3 cm), polyhydramnios (AFI=31.5), and a suspected esophageal atresia. After counseling, both parents decided not to pursue the pregnancy and requested vaginal delivery. They decided against transabdominal, ultrasonic-guided cephalocentesis because of its invasiveness, patient's awareness, and pain. Skull decompression with the modified Smellie's perforator was performed after five 400-microg doses of misoprostol were applied to dilate the cervix. The post-partum condition was uneventful. Fetal skull decompression with the modified Smellie's perforator and misoprostol for cervix dilation is a useful, simple, and safe procedure that can be performed with no previous experience.

Lidocaine versus plain saline for pain relief in fractional curettage: a randomized controlled trial.

OBJECTIVE: To compare the efficiency of lidocaine with that of plain saline for paracervical pain relief during fractional curettage. METHODS: This double-blind, randomized, controlled trial included 140 women who underwent fractional curettage. Seventy women were allocated to the lidocaine group and 70 to the plain saline group. The main outcome measure was the intensity of pain measured by visual analog scale during and after the procedure. RESULTS: The intensity of pain was significantly lower in the lidocaine group than in the plain saline group over the course of the procedure (P = .02), especially during fractional curettage. There were no serious adverse effects in this study. CONCLUSION: Lidocaine is more effective than plain saline for paracervical pain relief during fractional curettage. The anesthetic mechanisms of lidocaine are mechanical distention of tissue and peripheral nerve block.

Second trimester pregnancy termination: a comparison of 600 and 800 micrograms of intravaginal misoprostol.

OBJECTIVE: To compare the effectiveness of 600 and 800 microg of misoprostol administered intravaginally every 12 hours for termination of second trimester pregnancies. METHODS: One hundred and forty-three pregnant women at 14-26 weeks' gestation were randomized in 2 groups to receive either 600 microg (N = 67), or 800 microg (N = 76) of intravaginal misoprostol every 12 hours until abortion was induced. RESULTS: The incidences of abortion within 24 hours after initial drug administration were 82.1% (n = 55) and 78.9% (n = 60), within 48 hours 92.5% (n = 62) and 92.1% (n = 70), the mean abortion intervals were 15.2 (10.5, 20.8) hours and 15.3 (10.2, 21.8) hours, the complete abortion rates 77.6% (n = 52) and 72.4% (n = 55), and body temperature of more than 38 degrees C were 26.9% (n = 18) and 71.1% (n = 54, p = < 0.001) in the 600 and 800 microg group, respectively. All other side-effects were similar between the 2 groups. CONCLUSION: In consideration of effectiveness and febrile complication, we suggest that 600 microg applied every 12 hours is the most appropriate dose to use for second trimester termination

Active management of labor: is it suitable for a developing country?

OBJECTIVE: To evaluate the effectiveness of active management of labor in the setting of a developing country. METHODS: This historical cohort study compared the labor characteristics and outcome of all anti-HIV positive nulliparous pregnant women (n=96), who delivered between January 1991 and March 1999, treated with traditional labor management to all anti-HIV negative nulliparous pregnant women (n=1856), who delivered in 1998, treated with active management of labor in the tertiary center of a developing country. The year 1998 was chosen by using the total cesarean section rate of nulliparous patients from 1991 to 1998 to find the mean, then selected the year with cesarean section rate nearest to the mean as a control. Data were analyzed by the chi-square and t-tests. RESULTS: The length of labor was significantly shortened in the active management group (6.3+/-3.3 h vs. 8.9+/-6 h, P<0.001). A significantly greater proportion of the traditional management group had prolonged labor (29.3% vs. 4.9%, P<0.001). However, the cesarean section rate was not different between the two groups (active vs. traditional=17% vs. 14.6%, P=0.7) with dystocia as a major indication in both groups. Maternal and fetal complications were not different. CONCLUSION: The active management of labor shortened the duration of labor and reduced prolonged labor; however, it did not decrease the cesarean section rate.

Effect of lower uterine segment sweeping on progress of labor in nullipara.

Previous studies have shown that sweeping between the membranes and lower uterine segment was an effective procedure for reducing prolonged pregnancy. However, there has been no study to show the effect of lower uterine segment sweeping to the progress of the active phase of labor. This study was to determine the effect of lower uterine segment sweeping on the progress of the active phase of labor in nullipara. A total of four hundred nulliparous term pregnant women with spontaneous labor were randomized to one of two groups; the control group had routine vaginal examination while the study group had lower uterine segment sweeping at the time of each examination. Oxytocin infusion was given if there was dysfunctional labor. Progression of labor and the need for oxytocin augmentation were reviewed. Data were analyzed by chi square and Student t-test. Oxytocin was used in 67 per cent of the sweeping group and 62 per cent of the control group (p=0.3). The duration of the first stage (0.46), the second stage (0.38), and the third stage (0.28) of labor were not significantly different between the two groups. In conclusion, lower uterine segment sweeping did not reduce the need for oxytocin augmentation or lessen the duration of labor in nullipara.

Vaginal misoprostol for cervical priming before operative hysteroscopy: a randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of vaginal misoprostol for cervical priming before operative hysteroscopy and to assess the cervicouterine complications related to cervical dilatation and hysteroscopic surgery in nulliparous women. METHODS: One hundred fifty-two women with definite intrauterine lesions were randomly assigned to receive either 200 microg vaginal misoprostol or placebo. Cervical response and outcome and complications of operative hysteroscopy were assessed. RESULTS: Thirty-five subjects were needed in each arm to detect a type I error of 0.01 with a power of 0.99. The mean cervical dilatation estimated by Hegar dilator was significantly different between the treated group (7.3 +/- 0.7 mm) and the control group (3.8 +/- 1.1 mm, P <.001). In the misoprostol group, 55 (75.3%) patients needed cervical dilation, compared with 75 (94.9%, P =.001) in the placebo group. The median time of cervical dilation to Hegar number 9 was significantly shorter in the treated group (40 seconds) compared with the control group (120 seconds, P <.001). The mean operative time was significantly shorter in the treated group (36.4 +/- 10.9 minutes) compared with the control group (45.9 +/- 14.2 minutes, P <.001). Cervical tears occurred in nine (11.4%) patients in the control group and in one (1.4%, P =.018) in the misoprostol group. Creation of a false tract was more common in the control group. Two uterine perforations occurred in the placebo group. CONCLUSION: Vaginal misoprostol applied before operative hysteroscopy reduced the need for cervical dilation, facilitated hysteroscopic surgery, and minimized cervical complications.

Randomized comparison of glyceryl trinitrate and prostaglandin E2 for cervical ripening at term.

OBJECTIVE: To estimate the adverse effects of glyceryl trinitrate compared with prostaglandin (PG) E2 vaginal tablet for cervical ripening in term pregnancy. METHODS: One hundred ten women with term pregnancies referred for induction of labor with Bishop scores of 6 or less were randomly assigned to receive a 500-microg glyceryl trinitrate tablet vaginally (n = 54) or a 3-mg PGE2 tablet vaginally (n = 56), every 6 hours for maximum of two doses. Subjects were sent to the labor ward for amniotomy or oxytocin if their Bishop scores were more than 6 or their cervices were not ripe 24 hours after treatment. Adverse effects, changes in the Bishop scores, progress, and outcomes of labor were assessed. RESULTS: Glyceryl trinitrate was associated with fewer episodes of uterine tachysystole (0% versus 9%; P =.02). The median Bishop score after 12 hours was lower in women given glyceryl trinitrate compared with those given PGE2. Adverse effects, including headache and palpitations, were more frequent with glyceryl trinitrate than with PGE2. The cesarean rate was not significantly different between groups. CONCLUSION: Cervical ripening with glyceryl trinitrate resulted in fewer episodes of tachysystole, but there were significantly more minor side effects. It can be used for cervical ripening at term, but it was not as effective as PGE2.

Vaginal misoprostol in termination of second trimester pregnancy.

OBJECTIVE: To study the effectiveness and complications of 600 micrograms of intravaginal misoprostol for terminating second trimester pregnancies. STUDY DESIGN: One hundred and seventy-two patients undergoing termination of pregnancy between March 1997 and April 1999 were studied. Each patient received 600 micrograms of intravaginal misoprostol every 12 hours until abortion occurred. RESULTS: The mean induction to abortion time was 24.1 +/- 21.6 hours. The percentage of women aborting within 24 and 48 hours was 68.6 and 89.5 respectively. There was no significant difference in the mean induction to abortion time and the percentage of women aborted within 48 hours between nulliparous and multiparous women. The mean amount of misoprostol used was 1405.5 +/- 1084.6 micrograms. Incomplete abortion occurred in 23.3% of women. The most common complication was temperature of more than 38 degrees C occurred in 41% followed by diarrhoea (20%), nausea and vomiting (15%). CONCLUSION: Six hundred micrograms of vaginal misoprostol is effective, but whether the 48 hours abortion rate can be improved with a large dose or shortened the time interval between doses, requires further study.

Epidemic of cesarean section at the general, private and university hospitals in Thailand.

OBJECTIVE: To undertake a survey of cesarean section in the general, private and university hospitals in Thailand. METHODS: Postal questionnaires were sent to all the general, private and university hospitals with 200 beds or more. The questionnaires were prepared to find out the percentage, the indications and the trend of cesarean delivery, the measures taken to decrease cesarean section rate, and the practice of external cephalic version (ECV) and vaginal birth after cesarean section (VBAC) in the hospitals. RESULTS: The overall response rate was 88%. Mean cesarean section rates were 24, 48, and 22% in the general, private and university hospitals, respectively. Cesarean section rates in most of the hospitals were increased in the past 5 years namely 78% in the general hospitals, 50% in the private hospitals, 66% in the university hospitals. However, only 38% of the hospitals had measures to regulate this operation. Repeated cesarean section was the most common indication in the private (63%) and the university hospitals (88%) while failure to progress was the most common indication in the general hospitals (55%). ECV and VBAC were performed in 26 and 12% of the hospitals. They were, however, not the standard practices. CONCLUSION: Rising of cesarean section rate without any measure to regulate it is the problem in the developing countries. Standardised labor management and reduction of unnecessary primary cesarean section will automatically reduce repeated operation and overall cesarean section.

Prevention and control of thalassemia in Ramathibodi Hospital, Thailand.

Eight thousand seven hundred and thirty-six pregnant women were screened for thalassemia and hemoglobinopathies by mean corpuscular volume less than 80 femtolitres (fl). Three thousand six hundred and seventy women (42%) were MCV less than 80 fl. In this group there were 2,390 women (70%) who had positive Hb typing by high performance liquid chromatography (HPLC) such as beta-thalassemia major, beta-thalassemia hemoglobin E disease, beta-thalassemia trait, heterozygous and homozygous hemoglobin E, alpha-thalassemia-1 trait and hemoglobin H disease and 77% of their partners came and had hemoglobin typing done. Seventy-five couples at risk for having severely affected thalassemia fetuses were detected from this screening program. Prenatal diagnosis was performed in 58 couples (77.3%). Eight affected fetuses were detected. All pregnancies with affected fetuses except one with beta-thalassemia/HbE were terminated. There were 3 fetal losses (6%) as the result of prenatal diagnosis procedure.

The epidemiology of cervical incompetence in Ramathibodi Hospital between 1982-1997.

Cervical incompetence is an important cause of midtrimester abortion. However, the etiology and diagnostic method have still not been established. This retrospective study was aimed to review epidemiology, management and outcome of cervical incompetence in Ramathibodi Hospital, Mahidol University, Thailand, from 1982 to 1997. Fifty seven patients were diagnosed as having cervical incompetence during this period. Fifty patients had elective cerclage. Seven patients had emergency cerclage. Success rate in this study was 94.6 per cent. Only 7 per cent of patients had complications such as chorioamnionitis and suture displacement. There was no other serious complication after treatment. Nowadays, there is still no established method to diagnose cervical incompetence in pregnancy. Treatment is usually based on past obstetric history. Cervical cerclage is an established treatment for this problem. Emergency cerclage is still controversial. The prevention is to avoid any procedure which can cause cervical trauma leading to cervical incompetence.