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 abortion using intravaginal misoprostol.

OBJECTIVE: To find the effective dose of intravaginal misoprostol to induce second trimester abortion. METHODS: Intravaginal misoprostol in 200-microg, 400-microg and 600-microg doses were applied at 12-h intervals in 150 consecutive pregnancies. RESULTS: The 48-h successful abortion rate was 70.6%, 82% and 96%, respectively, and these rates were unaffected by parity. The mean induction to abortion interval was 45.0 +/- 41.5, 33.4 +/- 34.9 and 22.3 +/- 14.3 h, respectively. The mean dose of misoprostol required to induce abortion was 416.7 microg, 772.8 microg and 1296 microg. The rate of nausea and vomiting was 3.9%, 12% and 20%. The diarrhea occurrence rate was 0%, 6% and 22% with temperature elevation 0%, 2% and 28%, respectively. The rate of incomplete abortion was 35.3%, 28% and 22%, respectively. CONCLUSION: The 600-microg dose is more effective as an abortifacient agent for second trimester abortion in terms of 48-h success rate and the rate of incomplete abortion but with more side effects. However, the side effects were mild and did not warrant any specific treatment.

A comparison of intravaginal misoprostol and intracervical prostaglandin E2 gel for ripening of unfavorable cervix and labor induction.

OBJECTIVE: To study the effectiveness of single application of intravaginal misoprostol versus intracervical prostaglandin E2 gel for ripening the unfavorable cervix and labor induction. METHOD: One hundred and ten patients with indications for induction of labor with unfavorable cervices were randomized to receive either 100 microgram tablets of misoprostol placed in the posterior vaginal fornix or prostaglandin E2 1.5 mg in gel placed into the endocervix. Those, who were not in active labor after 24 hours, had labor induced with amniotomy and oxytocin. RESULTS: Among 110 patients recruited, 60 received misoprostol and 50 received prostaglandin E2 gel. The average interval from start of induction to vaginal delivery was 19.14 +/- 10.64 hours in misoprostol group and 21.37 +/- 13.09 hours in the prostaglandin E2 group (p = 0.33). Five patients (8%) in the misoprostol group had induction of labor after 24 hours of the treatment compared with 13 patients (26%) in the PGE2 group. The difference was significant (p = 0.03). Oxytocin augmentation was 35% in the misoprostol group and 34% in the prostaglandin E2 group (p = 0.86). There were no significant differences between routes of delivery. Nineteen patients (31%) in misoprostol group and 16 patients (32%) in the PGE2 gel group had cesarean deliveries. There was one case (1.7%) of uterine hyperstimulation in the misoprostol group and none in the PGE2 gel group. There were no significant difference in Apgar scores < 7 at 1 and 5 minutes, or admission to the neonatal intensive care unit between the 2 groups. CONCLUSION: Vaginal misoprostol is an effective agent for cervical ripening and induction of labor. Complications associated with prostaglandin administration were not statistically different between the 2 groups, but hyperstimulation occurred more in misoprostol group.

Misoprostol in the management of missed abortion.

OBJECTIVE: To compare the effect of vaginal misoprostol with that of placebo when used prior to dilation and aspiration in women with a missed abortion. METHOD: Eighty-four pregnant women with a missed abortion were randomized to receive either vaginal misoprostol (200 micrograms) or placebo the day before the planned dilatation and aspiration under inhalation anesthesia. RESULT: Thirty-five women (83.33%) in the misoprostol group and 6 women (17.14%) in the placebo group aborted spontaneously prior to the scheduled dilatation and aspiration, P < 0.0001. The mean insertion to spontaneous expulsion time was 11.63 +/- 6.14 h in the misoprostol group compared to 11.95 +/- 5.43 h in placebo. In the misoprostol group two women required intramuscular pethidine for analgesia. In the placebo group there were two cases of blood loss in excess of 500 ml and one woman with a uterine perforation. CONCLUSION: Vaginal administration of misoprostol to women with a missed abortion produced spontaneous expulsion of the pregnancy and reduced the need for surgical treatment.

The use of low dose 1.5 mg prostaglandin E2 gel for cervical ripening and induction of labor at term with unfavorable cervix.

A prospective study was undertaken to evaluate the efficacy and safety of a 1.5 mg prostaglandin E2 gel applied intracervically for the initiation of cervical ripening before the induction of labor. All patients were required to have an initial Bishop score of four or less. There was a total of 220 pregnant women in this study and primipara accounted for 175 or 80 per cent of the pregnant women. The 1.5 mg PGE2 gel was found to be an effective means of cervical ripening in both primipara and multipara with a success rate of 77.7 and 93.3 per cent after the first application to 96 and 100 per cent in the second application, respectively. The mean induction to delivery time was 25.17 hours in primipara and 13.57 hours in multipara. The mean amniotomy to delivery time was 7.55 and 4.65 hours in primipara and multipara, respectively. The cesarean section rate was 48 per cent and 18 per cent in primipara and multipara, respectively. The side-effects were minimal. These results compare well with other reported studies using different dosages and routes.

Comparative study of fluconazole and clotrimazole for the treatment of vulvovaginal candidiasis.

BACKGROUND: The introduction of the triazole antifungal agent fluconazole, which can be used via an oral route and single dose, has had a significant impact on patient compliance. GOAL OF THIS STUDY: To compare the efficacy and safety of a single oral dose of 150 mg fluconazole with that of a 100-mg clotrimazole vaginal suppository twice a day in the morning and at bedtime for 3 days in the treatment of vulvovaginal candidiasis. STUDY DESIGN: A single-blind, randomized controlled trial was conducted at Ramathibodi Hospital between June 1 and September 30, 1993. RESULTS: There were 53 women in the group treated with fluconazole and 50 in the group treated with clotrimazole. There was no significant difference between the two groups regarding clinical characteristics (age and length of follow-up period). Mycological cure rates approximately 1 week after treatment were 79.2% in the fluconazole group and 80.0% in the clotrimazole group. Approximately 4 weeks after treatment, these rates were 60.4% and 66.0%, respectively. The side effects were minimal and did not warrant any treatment. The differences in the results were not statistically significant. CONCLUSION: We recommend that a single oral dose of 150 mg of fluconazole be given as an alternative method of treating vulvovaginal candidiasis, but the cost is higher than for clotrimazole.

PIP: The efficacy and safety associated with use of a single oral dose of 150 mg of fluconazole compared to administration of a 100 mg clotrimazole vaginal suppository twice a day for three days in the treatment of vulvovaginal candidiasis were investigated. Involved in the prospective, double-blind, controlled trial conducted at a Bangkok hospital were 103 women with a confirmed diagnosis of vulvovaginal candidiasis who were randomly assigned to a treatment group. Self-assessed clinical improvement was obtained within 1 week in 88.7% of women in the fluconazole group and 90.0% of those in the clotrimazole group. The mycologic cure rate at the 1-week follow-up visit was 79.2% in the fluconazole group and 80.0% in the clotrimazole group; at 4 weeks, these rates were 60.4% and 68.0%, respectively. 3 (5.7%) fluconazole users experienced nausea and 1 (1.9%) reported dizziness, while 11 (22.0%) clotrimazole acceptors had vaginal burning. This study suggests that fluconazole is equally as effective as the traditionally used antifungal agent clotrimazole. Although the former drug has the advantages of oral administration, single dosage, and minimal side effects, it is more expensive.

Mid-trimester abortion using hypertonic saline or prostaglandin E2 gel: an analysis of efficacy and complications.

A total of 149 mid-trimester termination of pregnancies using hypertonic saline infusion (125) or prostaglandin E2 gel (24) have been analyzed for efficacy and complications. The mean induction to abortion time (I-A) was 31.7 +/- 9.2 hours in hypertonic saline (HSI) group and 28.4 +/- 27.7 hours in prostaglandin (PGE2) group. Retained placenta occurred in 76 (63.3%) in HSI group and 6 (25%) in PGE2 group. Four (3.3%) in HSI group had pyrexia over 38.5 degrees C and the only one case with proven sepsis developed disseminated intravascular coagulation defect (DIC) which accounted for one case (0.8%) of blood loss of more than 500 ml. There was also one case of mildly disturbed electrolytes in HSI group occurring during the instillation. Minor side-effects of nausea and vomiting occurred in 4 (16.7%) in the PGE2 group only.

PIP: Between January 1990 and December 1991, physicians used either intra-amniotic 20% hypertonic saline (HSI) solution (no more than 200 ml) or 3 mg intracervical prostaglandin E2 gel (PGE2) to induce mid-trimester abortion in 149 women at Ramathibodi Hospital in Bangkok, Thailand. 125 women were in the HSI group and 24 were in the PGE2 group. The mean induction to abortion time was 28.4 hours for the PGE2 group and 31.7 hours for the HSI group. The longest induction to abortion time was 73 hours for the HSI group and 127.2 hours for the PGE2 group. Nausea and vomiting only occurred in women in the PGE2 group (16.7%). Only 4 (3.3%) HSI cases developed fever. One of these cases had disseminated intravascular coagulation (DIC) defect which was likely caused by contamination during instillation of HSI. This case lost more than 500 ml of blood. One HSI case experienced increased electrolytes during HSI instillation, which was likely caused by leakage of sodium chloride into the vascular system. Even though many HSI cases (63.3%) experienced a retained placenta, hemorrhaging occurred in only 1 (0.8%) HSI case, the one with DIC. The women in the PGE2 group were less likely to experience a retained placenta (25%). The average length of stay in 70% of cases in both groups was 2 days. Provided clinicians use aseptic techniques and closely observe HSI patients, HSI termination of midtrimester pregnancy is effective and safe. HSI is less expensive than PGE2 and is available in most developing countries. PGE2 can be used as an alternative method instead of hysterotomy.

Control of uterine hyperactivity caused by prostaglandin with intravenous terbutaline: a case report.

Prostaglandin E2 is beginning to be used more widely for the induction of labor in this country. The main concern with vaginal administration is the difficulty in stopping uterine hyperactivity. This report is a case where intravenous terbutaline was given as soon as hyperactivity and fetal heart rate deceleration were detected. Using this treatment, hyperactivity was controlled and the fetal heart rate returned to normal. Unfortunately, cesarean section was necessary for fetal distress which developed two and a half hours later when syntocinon was started intravenously to augment the labor.

Coitus, oral-genital sex and anal intercourse.

Current evidence suggests that there is a change of attitude towards more permissive sex among the young and educated people in Thailand compared to other oriental countries. This study aimed to find the frequency of coitus, oral-genital sex and anal intercourse among new female patients who attended the sexual health clinic, Ramathibodi Hospital in 1990. The gynecologist in charge interviewed the patients using a questionnaire. The total number of participants was 408. Coital frequency ranged from < 1 to 7 times per week with 1, 2, 3 as the first three leading rate. There were 107 women (26.2%) and 150 men (36.8%) who had experienced fellatio and cunnilingus, respectively. Only 5.6 per cent had anal intercourse. These findings add more knowledge about the sexual behavior among Thais and that a certain group of people are not strictly conservative in their attitude towards sex and that males are more permissive than females.

Low birthweight in Thailand: 1982.

Birthweight is sensitive index of social and economic change. The objectives of this study are to establish baseline birthweight, per cent of low birthweight and to determine maternal characteristics on LBW among Thai mothers. The study was based on data from birth records which was collected in 1982. The total number of samples used was 28,952. The lowest mean birthweight occurred in the North and Northeastern regions. These two regions had a mean birthweight of less than 3,000 g. The incidence of LBW was highest in the North at 12.8 per cent. The per cent of birthweight showed the highest with maternal age less than 20 years or parity equal to zero. Unskilled workers showed the highest per cent of LBW in the Northeast, North and the East and housewives in the West and South and farmers in the North.

PIP: Low birth weight and maternal characteristics information was collected among the regions in Thailand in 1982. A 10% sample survey was conducted among 72 provincial hospitals and four regional maternal and child health centers: 28,952 birth records. The mean birthweight was computed as a simple average in grams excluding nonreported weights or missing values. Low birth weight (LBW) was weight under 2500 g. The mean birth weights were as follows: 2933 g in the north, 2980 g in the northeast, 3039 g in the east, 3042 g in the center, 3050 g in the west, and 3044 g in the south; LBW as a percentage of births was respectively 12.8%, 10.4%, 9.6%, 9.3%, 8.7%, and 8.2%. The northern region had the highest incidence of LBW. The highest LBWs were among women aged under 20 years or with no prior children. The exception was the eastern region which had the highest LBWs among mothers aged over 35 years. In the northeast, north, and east, mothers who were unskilled workers had the highest percentage of LBW infants. In the west, south, and among farmers in the north, housewives had the highest percentage of LBW infants. Civil servants had the lowest LBW infants, except in the north. The low birth weights in the north and northeastern regions was attributed to a lower maternal age. The mean birth weight of these two regions was under 3000 g. Further research was suggested in order to determine the influence of socioeconomic factors or nutrition on LBW infants.

Operative obstetrics at Ramathibodi Hospital, 1970-1990.

A 21-year retrospective review of operative obstetrics at the Department of Obstetrics and Gynaecology, Ramathibodi Hospital was reported from January 1, 1970 to December 31, 1990. There were a total of 128,630 deliveries, of which 41,724 (32.4%) were abnormal deliveries. Forceps, vacuum and cesarean section still increased, but vaginal breech deliveries have lost their popularity in this institution.

Ripening of the unfavorable cervix with prostaglandin E2: intracervical versus intravaginal route.

Forty-eight term primiparae women with unripe cervix (Bishop score of 4 or less) were randomly given either 1.5 mg of prostaglandin E2 in 3 ml of gel intracervically or 3 mg prostaglandin E2 tablet intravaginally to ripen the cervix. Intracervical administration caused favorable cervix in 36 per cent compared with 12 per cent in the intravaginal group, and induced spontaneous labor in 41 per cent compared with 69 per cent in the intravaginal group. Oxytocin augmentation was required in 88 per cent in the intracervical group compared to 62 per cent in the intravaginal group. The only significant difference statistically was the mean duration of the insertion of PGE2 to delivery being 16 hours and 23.5 hours in the intracervical and intravaginal routes respectively (P = 0.02). There was one case of hyperstimulation and one case of maternal death from amniotic fluid embolism in this study.

Split-dose metronidazole or single-dose tinidazole for the treatment of vaginal trichomoniasis.

In a double-blind, randomized, controlled trial, efficacy and safety of a single-day split dose of 1.6 g of metronidazole were compared with a single 2-g dose of tinidazole in the treatment of vaginal trichomoniasis. Women with symptomatic vaginal trichomoniasis were randomly assigned to one of the two treatment groups. There were 67 women in the group treated with the single-day split dose and 65 in group treated with the single dose. There was no significant difference between the two groups in terms of clinical characteristics (age, weight, and length of follow-up period). The cure rates, using trypticase yeast extract iron serum (TYI) medium to confirm microbiologic cure, were 98.5% and 100% for the groups treated with a single-day split dose and with a single dose, respectively. The side effects were minimal and did not warrant any treatment. The differences in the results were not statistically significant. We recommend that the single-day split dose of 1.6 g of metronidazole regimen be given as an alternative drug for vaginal trichomoniasis. Its advantages include being highly effective, significantly less expensive, and with minimal side effects.

Intra-cervical prostaglandin E2 gel in management of dead fetus in utero.

During a two and a half year period at this institution, prostaglandin E2 gel was administered intra-cervically in the treatment of 74 cases of dead fetus in utero. Delivery was achieved in all 74 cases. The mean interval from induction to delivery of the fetus was 17.6 hours with a mean total dosage used of 5.2 mg. Seventy percent of the patients spontaneously expelled the fetus and placenta completely. Gastrointestinal side-effects were minimal with no medication needed. Oxytocin was used in 17 (23%) patients mainly to expedite the expulsion of the fetus. Intra-cervical administration appeared to result in fewer side-effects and was more cost effective than vaginal prostaglandin therapy for the treatment of dead fetus.

Induction of labor using intracervical prostaglandin E2 gel: the outcome.

A prospective study was undertaken to evaluate the safety and efficacy of a 3 mg prostaglandin E2 (PGE2) gel applied intracervically for the initiation of cervical ripening before the induction of labor. All patients were required to have an initial Bishop score of 4 or less. The 3 mg PGE2 gel was found to be an effective method of cervical ripening in primigravida and multigravida with a success rate of 76 and 86.8 per cent after the first application to 96.4 and 97.4 per cent after third application respectively. The mean induction to delivery time was 22 hours in primigravida and 13 hours in multigravida. The mean amniotomy to delivery time was 6 hours and 4 hours in primigravida and multigravida respectively. However, the incidence of cesarean section was not improved as expected and there was one instance of uterine hyperstimulation. The only serious complication was one uterine rupture that occurred in multigravida with the prolonged use of oxytocin.

Comparison of intravenous oxytocin with and without vaginal prostaglandin E2 gel in term pregnancy with premature rupture of membranes and unfavorable cervix.

Forty-seven nulliparous term pregnant women with PROM and unfavorable cervix, were randomly divided into 23 patients who were observed for four hours then followed by intravenous oxytocin, and 24 patients who were given 3 mg PGE2 gel intravaginally then followed by intravenous oxytocin four hours later. No statistically significant difference was observed between the two treatment groups with regard to Bishop score four hours after observation, intravenous oxytocin to delivery time, Apgar score at 1 and 5 minutes and maternal puerperal complications in both groups. It can be concluded that PGE2 did not significantly improve Bishop score or shorten the induction to delivery time in cases of PROM with unfavorable cervix. Intravenous oxytocin is still preferable both in terms of cost and effectiveness.

Fetal outcome in term frank breech primipara delivered vaginally and by elective cesarean section.

A retrospective study was carried out over a 3-year period comparing the fetal outcome of primiparous term frank breech delivered vaginally with those by elective cesarean section. There were 87 patients delivered by vaginal route and 176 by abdominal route. The staff delivered 13 per cent by vaginal route against 57 per cent by residents. There were no statistical differences in apgar score at 1 and 5 minutes with regard to the routes of delivery, different fetal birthweights and obstetrical experience of the accoucheur. There were no perinatal deaths. The concept of elective cesarean section in all primiparous term frank breech should be reconsidered.

Hydrops fetalis due to Bart hemoglobinopathy at Ramathibodi Hospital (1978-1987): a 10-year review.

This was a retrospective case-control study of hydrops fetalis due to Bart hemoglobinopathy at Ramathibodi Hospital between 1978-1987. The incidence was 0.61 per 1,000 deliveries. Hydrops fetalis tend to go into labour prematurely with smaller fetuses and larger placentae. When compared with the control group there were statistically significant differences in the history of previous perinatal loss and obstetric complications i.e. hypertensive disorder in pregnancy and postpartum hemorrhage. Early diagnosis and termination of pregnancy will avoid these complications.