Thai Preeclampsia Guideline

30 (-)
Standard and Ethics to Improve Womens Health
Merging Knowledge and Practice in OB-GYN 2015
30 (-)
.. 2558

5 2 2558
THEME: Merging Knowledge and Practice in OB-GYN 2015
18 - 21 2558

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Merging knowledge and Practice
Precogress workshops 4 Main congress 2
scientific lecture 14 Special lecture 10

Parallel lecture 20 2558 speaker
AC 10

RTCOG Cowboy Night Party 2015 20 2558

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1) Thai Journal of Obstetrics and Gynaecology
Maternal-fetal medicine, Reproductive medicine Gynecologic oncology Female
pelvic medicine and reconstructive surgery 1

2) Maternal-fetal medicine, Reproductive medicine,
Gynecologic oncology Female pelvic medicine and reconstructive surgery
1

3) Meta analysis 4 Maternal-fetal medicine,
Reproductive medicine Gynecologic oncology Female pelvic medicine and reconstructive
surgery 1

4)

5)

6)

7) Clinical Practice Guideline (CPG)

8)

9)
Thai Journal of Obstetrics and Gynaecology
(Thai-Journal Citation Index Centre : TCI)

10) ..
1 .. 2558
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International Federation of Obstetrics and Gynaecology (FIGO), Asia and Oceania Federation of
Obstetrics and Gynaecology (AOFOG) ASEAN Association of Obstetrics and Gynaecology
(ASEAN)
XXI FIGO World Congressof of
Gynecology and Obstetrics 4-9
.. 2558 . . FIGO
Awards in Recognition of Women Obstetricians/Gynaecologists
4

Asia and Oceania Federation of Obstetrics and
Gynaecology (AOFOG) 23rd Asian & Oceanic
Congress of Obstetrics & Gynaecology (AOCOG 2013) 20-23 ..2556

AOCOG 2013 (Organizing Committee) (Scientific Committee)
(Hospitality Committee)
1,223 55

24th Asian & Oceanic Congress of Obstetrics & Gynaecology (AOCOG
2014) 3-6 .. 2558
3 .
. .
Shan S. Ratnam Young Gynaecologist Awards

German Society of Obstetrics and Gynaecology
THAI-GERMAN Society of Obstetrics and Gynaecology
(MOU)
2 20 ..
2558 Prof. Rudy Leon De Wilde 6
30 (-)

5 2 2558 .. 2558 18-21 .. 2558
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Harmony of Womens Life : Basic & Beyond
-

Fellow

25 45
898 42 1 Major Sponsors 10 Sponsor
lectures

7,922,900.00 ( ) 4,441,137.55
( ) 3,481,762.45
()

6.2 .. 2558 22 24 .. 2558

www.wonderwoman@rtcog.or.th

-
electronic book e-Book

17 31
CME 17 CNEU 10 474
43 1 Major Sponsors 8 Sponsor lectures

3,382,914.00 ()
895,584.16 ()
2,487,329.84 ()
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1.3 Quality assurance

1.4 International Classification of Disease (ICD) Thai Modification Diagnosis Related Group (DRG)

1.5
2.

2.1 / /

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9

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(patient information)

2.5 / /

2.5.1 / /
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2.6.1 / /

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10

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2.8 International Classification of Disease (ICD) Thai Modification Diagnosis Related Group (DRG)

2.8.1 standard
coding guideline 2

2.8.2 DRG version
-

2.8.3
3. 2558

3.1
(Primary dysmenorrhea: Diagnosis and Treatment)

23 8 2557

3.2
(Intrapartum Fetal Monitoring) 1

24 3 2558

3.3
(Prevention of mother to child: transmission of HIV)

3.4
(Antepartum fetal surveillance)

3.5
(Management of Preeclampsia and Eclampsia) 1

30 .. 2558
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3.6
(Management of Atonic Postpartum Hemorrhage)
1

3.7 CPG 2 8
8 (Consent form and information sheet) 2
CPG website www.rtcog.or.th
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1. Thai Journal of Obstetrics and Gynaecology 4

2. /

3. (Thai J. Obstet Gynaecol: Best papers awards)
Thai Journal of Obstetrics and Gynaecology

4. Thai Journal Obstetrics and Gynaecology
SCOPUS PUBMED

5.

6.

7.

1. 1
60

2. ..2558 (1 15 ) Thai Journal of
Obstetrics and Gynaecology 32
15

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3. Thai Journal of Obstetrics and Gynaecology Vol.23 No.4 ( )

4. Thai Journal of Obstetrics and Gynaecology

5.
(Thai Journal Citation Index (TCI)) Thai Journal Citation Index Center Thai
Journal Impact Factors 2555-2557 0.078 SCOPUS

6.

(Reviewer)

7. International Editorial Board 3

8. Thai Journal of
Obstetrics and Gynaecology .. 2557 2558
5,000
.. 2557
21 (Obstetrics 16 , Gynaecology 5 ) 5
(Obstetrics 3 , Gynaecology 2 )
A Correlation between First-void Morning Urinary Protein to Creatinine
Ratio (UPCR) and 24 Hours Urinary Protein in Pregnancy with Suspected Preeclampsia
Thai Journal of Obstetrics and Gynaecology Vol.22 No.4 (OCTOBER - DECEMBER 2014)
. The Correlation of
Body Mass Index and Waist-Hip Ratio to Insulin Resistance in Reproductive-aged Thai Women
with Polycystic Ovary Syndrome Thai Journal of Obstetrics and Gynaecology
Vol.22 No.4 (OCTOBER - DECEMBER 2014) .


(www.rtcog.or.th)

MailChimp 1,472 2,700
e-mail address

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1.4 clinical science 4 ( )
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2.1 Basic Science 12 .. 2557

2.2 2 3 Basic Science 111

2.3 Basic Science 111

1.
109

2.
1 - .. 2558

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1
3. OSLER .. 2558

3.1 OSLER 3-27 .. 2557

3.2 OSLER 11

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3 ( 4) OSCE 110
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4 .. 2558 . -
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Basic Science 8 .. 2558
24
Basic Science 265

(1) 1 1 124

(2) 2 2 140

(3) .. 2557 1
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10 .. 2558 2
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1.2.2 Interinstitute conference
2 108
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28

-
(Treatment in ovarian tumors
of low malignant potential) ( 2558)

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2558)
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22-24 2558

2.2.2 30 ..2558
18-21 2558

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2.3.1 Refresher course 2015 11 13-14 2558

2.3.2 Theme Thai Gynecologic
Cancer Society : Optimal management for gynecologic cancer patient
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- Basic Course on Colposcopy 2015 26-28 2558
.

2.5

-

-

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3.1 Ovaries & fallopian tubes : To remove or to preserve during
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2. Fellows
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3.3.2

-
22-24 2558

- 30 ..2558
18-21 2558

3.4 (CPG)
Guideline for the management of Uterine Leiomyoma in Infertility
30 ..2558 1821
2558

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33
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.. 2558 2

5.3 ..2558
2

1. -
36

2. -

2

5.4 Pre-congress workshop Diagnosis and repair of acute 3rd and 4th
degree Obstetrics Anal Sphincter Injuries (OASIS) 18 2558 13.00-15.30
.

5.5 Pelvic Organ Prolapse and Urinary Incontinence: Update
and management for general OB-GYN 18 2558 89
4 89
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- .. 2558 Update in Family
Medicine 2015

(7) (.)

- Down syndrome screening
39

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6. . ( .. 2558)

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Cesarean section cesarean delivery cesarean birth
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1.

1.1 Low transverse cesarean section

1.2 Low vertical cesarean section

1.3 Classical cesarean section

2. ( ICD10)

2.1 Planned Elective cesarean section
39
primary
genital herpes
121

2.2 Emergency cesarean section

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section emergency cesarean section
(acute fetal compromise) 30
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3.1 Primary (first) cesarean section

3.2 Repeat cesarean section 2

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external cephalic
version VBAC (vaginal birth after cesarean delivery)
Absolute indications

1. (feto-pelvic disproportion)
(failure to progress during labor)

2. (malpresentation)
mento-posterior

3.

4. Placenta previa

5. Vasa previa

6.

7. repair stress urinary incontinence fistula
122
Relative Indications

1.

2. (nonreassuring fetal status)

3.

4.

5.
Patient choice cesarean, maternal request cesarean cesarean on demand

(4-6)
2 (7)

(7)
maternal request cesarean section
maternal
request cesarean section

1 2(4-12)
1

(4-12)

1. Maternal mortality

- -
elective

123

2. Infection

3. Anesthetic complications

4. Hemorrhage / Blood
transfusion

5. Hysterectomy
6. Thromboembolism
7. Surgical complications

8. Breastfeeding

9. Postpartum pain
10. Postpartum depression
- elective -

-

-
-

- Elective -

-
-
-
-
- elective -

- elective

- -

-

-

-
-
-
-
124
11. Psychological outcomes - -

elective

12. Maternal length of stay - -

13. Urinary incontinence
- elective -

1

2 5

-

14. Anorectal function
- Elective -

15. Pelvic organ prolapse
-
-
16. Sexual function
-
-

1. Subsequent fertility
- -

2. Subsequent uterine rupture - -

125
3. Subsequent placenta previa, -

-
placenta accreta

-

4. Subsequent bladder and -
-
bowel injuries
5. Subsequent stillbirth
- -

-

2

(4-12)

1. Fetal mortality
2. Neonatal mortality

3. Iatrogenic prematurity

4. Respiratory morbidity

5. Neonatal asphyxia,
encephalopathy

-
-
- -

-

- -

- -
-

-
meconium
aspiration syndrome
- elective -

126

6. Intracranial hemorrhage

7. Fetal nerve injury

8. Brachial plexus injury

9. Fetal lacerations

10. Neonatal infection

-

- -

-

- -

-

- -

-

- elective -

- elective -

127

11. Neonatal length of stay

12. Long-term outcomes
- elective -

-
-

elective

elective

(8-12)

1.

2.

3.
39-40

4.

hydrocephaly
cystic Hygroma sacrococcygeal teratoma
omohalocele nonlethal osteogenesis imperfecta
nonlethal hydrops fetalis(13)

herpes simplex virus, HIV, hepatitis C,
hepatitis B, human papilloma virus group B streptococcus
128

herpes simplex virus
HIV 1,000
copies (14)
(1,15)

Fetal lung maturity

elective cesarean section 39
neonatal respiratory distress
39 respiratory distress syndrome
transient tachypnea of newborn
elective cesarean section 38 ( 38 +0
38 +6 ) 39 ( 39 +0 39 +6 )
38
20-50 (16)

(Anesthesia)

-

-

-

-

-

-

-

-

-

-

-

-

CBC 1

placenta previa, placenta accreta, placental abruption, eclampsia, HELLP syndrome, hematocrit
25 5
129
patient safety checklist 1(17)

Patient Safety ChecklistP
Preoperative Planned cesarean delivery
Date______________ Patient ___________________ Date of birth___________ MR #____________
Physician__________________________________ Gravidity/Parity____________________________
Best estimated gestational age___________________ Indication____________________________
q Patient has a complete medical history and physical examination
q Known allergies identified
q Medical factors that could affect anesthetic choices identified
q Patient counseled about risks and benefits of cesarean delivery versus trial of labor and vaginal delivery
q Consent form signed as required by institution
q Appropriate preoperative and pertinent prenatal laboratory test results (eg, group B streptococci
or hematocrit) available
q Antibiotic prophylaxis administered within 60 minutes before incision
q Appropriate deep vein thrombosis prophylaxis administered
q Yes
q No: Reason:____________________________________________________________________
q Presence of fetal heart tones documented before incision
q Yes
q No: Reason:____________________________________________________________________
q Risk factors identified:
130
q If at risk of bleeding more than 1,000 mL, adequate intravenous access and fluids planned
and packed cells and blood products available
q Airway
q Allergies
q Notification of neonatal or pediatric departments if necessary
q A time out is conducted before the start of surgery to confirm the patients name,
allergies, and consent; to confirm the surgery to be performed; and to identify team member
names and roles
q Surgical counts performed before incision (surgical counts are reconfirmed postoperatively)
(1,18)

(lateral tilt) 10 15
inferior vena cava
Apgar score
umbilical artery pH (19) regional anesthesia

100
(20)

7.5% povidone-iodine scrub
10% povidone-iodine solution 2-3
iodine
4% chlorhexidine gluconate scrub 10% chlorhexidine
gluconate solution

povidone-iodine

(21)

povidone-iodine
131

adhesive drapes
(22)

(skin incision)

(transverse incision)
incisional hernia (vertical incision)

Pfannenstiel incision ( 2-3
symphysis pubis pubic hair )
Joel-Cohen incision ( anterior superior iliac spines
3 Pfannenstiel incision)

2 Joel-Cohen incision
Pfannenstiel incision
(23)

Maylard incision Cherney incision
hematoma

suprafascial
subfascial hematoma perforating capillary
sensory nerve
(adhesion)

(skin incision length)

15 ( Allis clamp )

Subcutaneous incision / opening

subcutaneous tissue
blunt
dissection subcutaneous tissue
inferior epigastric vessel

Fascial incision

rectus sheath

2
132

rectus muscle

3 rectus muscle

rectus sheath rectus muscle

parietal peritoneum

blunt sharp dissection
blunt expansion

Bladder flap formation

visceral peritoneum (bladder
flap formation)
hematuria

(
1-3 1000 )(24)
40,000

bladder flap
lower uterine segment
bladder flap

bladder blade
bladder blade

(low transverse incision) lower uterine segment
28
classical vertical low-vertical incision
133

blunt dissection

(25,26)
blunt dissection
blunt dissection 2

forceps, vacuum manual extraction

3
vacuum extraction
(27) forceps
forceps

manual delivery
+2

delayed cord clamping 60

(prophylactic antibiotic)

planned cesarean section
emergency cesarean section

60-70(28,29)

ampicillin first-generation cephalosporin cefazolin
ceftriaxone

cefazolin 2 120
cefazolin 3 120 penicillin
clindamycin 900 gentamicin 5 / 1 (1)

ampicillin first-generation cephalosporin
134

(prevention of uterine atony)

oxytocin 20 normal saline solution
1000 carbetocin 100 methylergometrine 0.2
oxytocin 10

cord traction (spontaneous placental
removal) (manual placental removal)
(endometritis)
(feto-maternal hemorrhage)

(30)

sponge

(30)

(uterine exteriorization)

3
(31)

sponge holding forceps

(closure of uterine incision)

2 (2-layer closure) submucosal muscular
layer musculo-muscular layer (1-layer closure)
submucosal muscular layer 2

4 (32)
135
decidua serosa

unlocked continuous sutures

systematic review meta-analysis .. 2557

locking sutures
(33)

chromic catgut,
polyglactin polyglycolic acid

blunt sharp
(32) . 2 chromic catgut 1
monocryl 1

visceral peritoneum

visceral peritoneum

(34) visceral peritoneum
subperitoneal pocket
pocket hematoma

visceral peritoneum
5-6 peritoneum regenerate

500-1000

(35)

parietal peritoneum

parietal peritoneum

parietal peritoneum
(34)

parietal peritoneum
raw surface peritoneum
omentum

rectus muscle

rectus muscle
rectus muscle
136

fascia (rectus sheath)

delayed-absorbable suture continuous unlocking suture

10% povidone-iodine solution

subcutaneous tissue

subcutaneous tissue 2
seroma (36)

interrupted stitch plain catgut No. 3-0 vicryl No.3-0 (drainage)
drain

staple polyglycolic acid 4-0 subcuticular suture Pfannenstiel
incision staple
subcuticular suture staple 6
staple 3
absorbable sutures(37)

subcuticular
suture (37)

1. Pfannenstiel incision Joel-Cohen incision

2. bladder flap

3. low transverse incision blunt expansion

4.

5. 2

6. visceral parietal peritoneum

7.
137
(incidental procedures)

fecalith
pedunculated myoma
biopsy

(early ambulation)
4-8

Hemoglobin
(1,38)

(emergency peripartum hysterectomy)

0.20-5.09 1000

3(39)

endomyometritis
35-40 4-5
85
60

2.5 - 6 4 7
1-2 group A group B beta-hemolytic streptococcus
staphylococcus epidermidis aureus, E.coli, Proteus mirablis

meta-analysis ..2558

Joel-Cohen subcutaneous
tissue 2 cord traction(29)

uterine artery
1 2

138

1 0.28
0.1

deep vein thrombosis 178 100,000

pulmonary embolism 19 36,470

0.13 1000

0.4 - 3
transient tachypnea of the newborn (TTN) elective
3.1

placenta previa 1 200
1 2 3

placenta accreta 1 0.2 , 2
0.3, 3 0.6 4 2.1 placenta previa
placenta accreta 1 3.3, 2
11, 3 40 4 61

(cesarean scar pregnancy)

1 2226 6
70
(40)

second stage of labor
first stage of laber

second stage of labor
intensive care unit 7.41 2.6 5.20
intensive care unit 1.63 Apgar score
7 5 2.77 first stage of labor (41)
inflammatory bowel disease

bacterial colonization
inflammatory bowel disease Crohn disease ulcerative colitis
systematic review meta-analysis
Crohn disease ulcerative colitis
(42) observational studies systematic review
139
meta-analysis inflammatory
bowel disease (43)
(1,44,45)

1. low transverse

(birth plan)

2.

3.

4.

5. epidural analgesia

6. 30

7. continous electronic monitoring

8.

9. oxytocin

10. oxytocin

11. prostaglandin E2 (dinoprostone)

12. prostaglandin E1 (misoprotol)

13. Foley catheter

14. 1

15.
low transverse 1

16.
140

17. (fetal macrosomia)

18. 18 24

19.

20.

low transverse incision

maternal request cesarean delivery

1. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dasshe JS, Hoffman BL, et al. Williams
Obstetrics. 24 ed. New Yolk:McGraw-Hill, 2014:1218-69.
2. National Institute for Health and Clinical Excellence. CG132 Caesarean Section. Available
at: http://guidance.nice.org.uk/ CG132 accessed March 2012.
3. The American College of Obstetricians and Gynecologists and The Society for Maternal
and Fetal. Obstetric care consensus: Safe prevention of the primary cesarean delivery. No
1:March 2014.
4. Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice cesarean: an evidence-based
review. Obstet Gynecol Surv 2004;59:601-16.
5. Visco AG, Viswanathan M, Lohr KN, Wechter ME, Gartlehner G, Wu JM, et al. Cesarean
delivery on maternal request. Obstet Gynecol 2006;108:1517-29.
6. Norwitz ER. Cesarean delivery on maternal request. UpToDate 2015.
7. The American College of Obstetricians and Gynecologists. ACOG committee opinion no.
559: Cesarean delivery on maternal request. Obstet Gynecol 2013; 121:904.
8. Williams HO. The ethical debate of maternal choice and autonomy in cesarean delivery.
Clin Perinatol 2008;35:455-62.
141
9. Wax JR. Maternal request cesarean versus planned spontaneous vaginal delivery: maternal
morbidity and short term outcomes. Semin Perinatol 2006; 30:247.
10. Hansen, AK, Wisborg, K, Uldbjerg, N, Henriksen, TB. Risk of respiratory morbidity in term
infants delivered by elective caesarean section: cohort study. BMJ 2008; 336:85.
11. MacDorman, MF, Declercq, E, Menacker, F, Malloy, MH. Neonatal mortality for primary
cesarean and vaginal births to low-risk women: application of an intention-to-treat model.
Birth 2008; 35:3.
12. Declercq E, Barger M, Cabral HJ, Evans SR, Kotelchuck M, Simon C, et al. Maternal outcomes
associated with planned primary cesarean births compared with planned vaginal births.
Obtet Gynecol 2007;109:669-77.
13. Hamrick S. Cesarean delivery and its impact on the anomalous infant. Clin Perinatol
2008;35:395406.
14. Sharma D, Spearman P. The impact of cesarean delivery on transmission of infectious agents
to the neonate. Clin Perinatol 2008;35:407-20.
15. Berghella V. Cesarean delivery: preoperative issues. UpToDate 2015.
16. Glavind J, Uldbjerg N. Elective cesarean delivery at 38 and 39 weeks: neonatal and m aternal
risks. Curr Opin Obstet Gynecol 2015;27:121-7.
17. The American College of Obstetricians and Gynecologists. Patient Safety Checklist no. 4:
preoperative planned cesarean delivery. Obstet Gynecol 2011; 118:1471.
18. Berghella V. Cesarean delivery: technique. UpToDate 2015.
19. Wilkinson C, Enkin MW. Lateral tilt for caesarean section. Cochrane Database of Systematic
Reviews 2006, Issue 3. Art. No.: CD000120. DOI:10.1002/14651858.CD000120.pub2.
20. Hadiati DR, HakimiM, Nurdiati DS Ota E. Skin preparation for preventing infection
following caesarean section. Cochrane Database of Systematic Reviews 2014, Issue 9. Art.
No.: CD007462. DOI: 10.1002/14651858.CD007462.pub3.
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22. Ward HRG, Jennings OGN, Potgieter P, Lombard CJ. Do plastic adhesive drapes prevent
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(CORONIS): a fractional, factorial, unmasked, randomised controlled trial. Lancet 2013;
382:234.
26. CAESAR study collaborative group. Caesarean section surgical techniques: a randomised
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27. Bofill JA, Lencki SG, Barhan S, Ezenagu LC. Instrumental delivery of the fetal head at the
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Infections Among Women Undergoing Cesarean Section: A Review. Infect Control Hosp
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30. Atkinson MW, Owen J, Wren A, Hauth JC. The effect of manual removal of the placenta on
post-cesarean endometritis. Obstet Gynecol 1996;87:99-102.
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144
Placenta accreta
..
-

Placenta accreta placenta
increta placenta percreta placenta accreta
placental adhesion disorder (PAD), abnormal
placentation placenta accreta ..1982-2002
1:533 1970 1980
1: 4,027 1:2,510 (1-3)
(previous cesarean section) (placenta previa) (1,4)
placenta previa
placenta accreta 40(5) placenta accreta
7(3)

placenta accreta

placenta previa
placenta
accreta Comstock (6) placenta
accreta

1. Irregulary shaped placental lacunae within placenta

2. Thining of the myometrium overlying the placenta

3. Loss of retroplacental sonolucence space

4. Protusion of the placenta into bladder

5. Increased vascularity of the uterine serosa-bladder interface

6. Doppler ultrasonography, turbulent flow through the lacunae

Intraplacental lacunae vascular lake placental
parenchyma intraplacental lacunae intraplacental
lacunae placental invasion(7-9) Kerr de Mendoca(7) .. 1988
Finberg HJ(8) Yang JL(9) lacunae Grade 0 3 Grade 0
lacunae, Grade 1 1-3 small lacunae, Grade 2 4-6 lacunae Grade 3 lacunae
placenta accreta lacunae Grade 1
86.9,78.6,76.9 88.0
lacunae Grade 2 100, 97.2, 93.8 100 Cumstock
(10) intraplacental lacunae 15
145
placenta accreta 79 92

invasion trophoblastic tissue
hypoechoic space placenta myometrium
placenta accreta thining of myometrium overlying placenta loss of retroplacental
sonolucence space uterine lower
segment 3 interface myometrium
placenta (11) placental invasion outer third
myometrium uterine serosa
myometrium normal echogenic
protusion mass placenta percreta(6)

placenta accreta diffuse or focal intraplacental
lacuna flow, vascular lake with turbulent flow, hypervascular of serosa-bladder interface
prominent subplacental venous complex(12-14)

.. 2013 D Antonio F meta-analysis 23
placenta accreta
90.72 (95% CI 87.2-93.6) 96.94 (95%
CI 96.3-97.5) positive likelihood ratio 11.01 (6.1-20) negative likelihood ratio 0.16 (0.11-0.23)
diagnostic odds ratio 98.59 (48.8-199)
placenta accreta (11)
placenta accreta
(lower segment)
(fundus) (15-16)

(magnetic resonance
imaging, MRI) placenta accreta heterogenous signal intensity within placenta, presence of intraplacental bands on T2W imaging
abnormal placental vascularity MRI
placenta-myometrium interface
myometrium parametrium invasion(17-18) MRI
MRI
placenta accreta

placenta accreta

intervention

34-36 (19-20) midline vertical incision
146
classical uterine incision

uterine vessels conservative
51 22
radio-intervention
methotrexate (5)
1. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet

Gynecol 2005;192:1458-61.
2. Read JA, Cotton DB, Miller FC. Placenta accreta: changing clinical aspects and outcome.
3. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta.
Am J Obstet Gynecol 1997;177:210-4.
4. Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery.
Am J Obstet Gynecol 2011;205:S2-10.
5. Placenta Accreta ACOG Committee opinion No. 529. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2012.
6. Comstock CH. Antenatal diagnosis of placenta accrete:areview .Ultrasound Obstet Gynecol
2005;26:89-96.
7. Kerr de Mendona L.Sonographic diagnosis of placenta accreta. Presentation of six cases. J
Ultrasound Med 1988;7:211-5.
8. Finberg HJ, Williams JW. Placenta accreta: prospective sonographic diagnosis in patients
with placenta previa and prior cesarean section. J Ultrasound Med 1992;11:333-43.
9. Yang JI, Lim YK, Kim HS, Chang KH, Lee JP, Ryu HS. Sonographic findings of placental lacunae
and the prediction of adherent placenta in women with placenta previa totalis and prior
cesarean section. Ultrasound Obstet Gynecol 2006;28:178-82.
10. Comstock CH, Love JJ Jr, Bronsteen RA, Lee W, Vettraino IM, Huang RR, et al. Sonographic
detection of placenta accreta in the second and third trimesters of pregnancy. Am J Obstet
Gynecol 2004;190:1135-40.
11. DAntonio F, Iacovella C, Bhide A. Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2013;42:509-17.
147
12. Chou MM, Ho ES, Lee YH.Prenatal diagnosis of placenta previa accreta by transabdominal
color Doppler ultrasound. Ultrasound Obstet Gynecol 2000;15:28-35.
13. Twickler DM, Lucas MJ, Balis AB, Santos-Ramos R, Martin L, Malone S, et al. Color flow
mapping for myometrial invasion in women with a prior cesarean delivery. J Matern Fetal
Med 2000;9:330-5.
14. Shih JC, Palacios Jaraquemada JM, Su YN, Shyu MK, Lin CH, Lin SY, et al. Role of
three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison
with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol 2009;33:193-203.
15. Comstock CH, Lee W, Vettraino IM, Bronsteen RA. The early sonographic appearance of
placenta accreta. J Ultrasound Med 2003;22:19-23.
16. Stirnemann JJ, Mousty E, Chalouhi G, Salomon LJ, Bernard JP, Ville Y. Screening for placenta
accreta at 11-14 weeks of gestation.Am J Obstet Gynecol 2011;205:547.e1-6.
17. Maldjian C, Adam R, Pelosi M, Pelosi M 3rd, Rudelli RD, Maldjian J. MRI appearance of
placenta percreta and placenta accreta. Magn Reson Imaging 1999;17:965-71.
18. Kirkinen P, Helin-Martikainen HL, Vanninen R, Partanen K. Placenta accreta: imaging by
gray-scale and contrast-enhanced color Doppler sonography and magnetic resonance
imaging.J Clin Ultrasound 1998;26:90-4.
19. Shamshirsaz AA, Fox KA, Salmanian B, Diaz-Arrastia CR, Lee W, Baker BW,et al.
Maternal morbidity in patients with morbidly adherent placenta treated with and without a
standardized multidisciplinary approach.Am J Obstet Gynecol. 2015;212:218-9.
20. Eller AG, Bennett MA, Sharshiner M, Masheter C, Soisson AP, Dodson M, et al. Maternal
morbidity in cases of placenta accreta managed by a multidisciplinary care team compared
with standard obstetric care. Obstet Gynecol 2011;117:331-7.
148
:
(Polycystic ovary syndrome: Diagnosis)
..

Stein Leventhal ..1935(1) 7

Polycystic ovaries
10 Pneumoroentgenography
(2) Stein
(Syndrome) (Anovulation)

(Ovarian cortex) Fibrosis (Stroma)
Primordial follicle
(2)

50 LH
Leventhal LH
Stein-Leventhal
Stein-Leventhal

(2)

70 Radio-immunoassay (RIA)
Gonadotropins LH FSH
LH Follicle
LH FSH

FSH LH FSH
LH FSH LH/FSH 3 2.5
(2) (3)

LH
LH LH

149
LH/FSH
1990(4)

70 Pneumography
(2) 80
Adams 5

LH FSH
Dopamine Opioid GnRH Prolactin
GnRH LH
Gonadotropin releasing hormone (GnRH)
LH (2)

80-90

..
1980 1983(6, 7)
(8)

Burghen (6)
Bruno (9)
Acanthosis Nigricans Oral glucose
tolerance test (OGTT) 23 Fasting
insulin (r=0.458, p<0.01), (r=0.419, p<0.02) (r=0.425,
p<0.02) LH

(10, 11)
(12)

(12) Diazoxide
Metformin Troglitazone
(12)
GnRH agonist
(12)

(12) Mutation
150

(12)

Tyrosine
Phosphorylation Tyrosine
Insulin receptor substrate (IRS) (12)
Tyrosine Serine Serine autophosphorylation
Tyrosine- autophosphorylation

(12)

Theca
LH
(11, 13)
(12) Sex hormone binding globulin (SHBG)
SHBG
IGF binding protein IGF-1
(14) Follicle
2-9 . 2-5 . (15) Follicle
Primary, Secondary follicle Antral follicle
(14)

AMH Follicle
AMH AMH Primodial follicle Primary
follicle(14) AMH Granulosa Follicle
AMH (16)
AMH Follicle
Antral follicle AMH Follicle Antral follicle
Follicle
(16)

(17, 18) 30
30 (18, 19)
30(19)
(20)
Theca
151
(19, 20)
35-40 (21, 22)

(23) (Menarche)
Primary amenorrhea(24)
( 35 )
( 3-6 )

20-74(23)

(23)

(23)
60-80 (23)

80(23)

(14)
Balen (25) 10
(0.5 x x x /
12 2-9

Follicle
8-33
70-100(23)

Acanthosis nigricans(23)
30-50(23) Acanthosis nigricans Hyperkeratosis Papillomatosis

(23) Acanthosis nigricans
(26, 27)

(17)
152
(19, 20)
follicle(28)

(12, 29)
(29, 30) ?

..1990
National Institute of Health (NIH)
NIH .. 1990(4) NIH
European Society for Human Reproduction and Embryology (ESHRE) American Society of Reproductive Medicine (ASRM) Rotterdam
.. 2003(31) Rotterdam

(Androgen Excess Society)
AES-2006 .. 2006(32)

NIH
+
+
-
Rotterdam
+/-
+/-
+/-
AES-2006
+/+
+/-

NIH ()
Rotterdam 2
3 AES-2006 () 1 2
Rotterdam

(4, 31, 32)
Hyperprolactinemia
153
Late-onset (non-classical) congenital adrenal hyperplasia (NCAH),

Cushings syndrome
TSH, Prolactin, Estradiol (E2) FSH
17-hydroxyprogesterone NCAH

1. Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet
Gynecol 1935;29:181-91.
2. , .
. : , .
Polycystic Ovary Syndrome. :
; 2551. p. 1-31.
3. Rojanasakul A, Chailurkit L, Sirimongkolkasem R, Chaturachinda K. Serum lipids and
lipoproteins in women with polycystic ovarian disease with different body mass index. Int
J Gynaecol Obstet 1988;27:401-6.
4. Zawadzwi JK, Dunaif, A. Diagnostic criteria for polycystic ovary syndrome: toward a rational
approach. In: Dunaif A, Givens, J.R., Haseltine, F.P., Merriam, G.R., editor. Polycystic ovary
syndrome. Boston: Blackwell Scientific Publications; 1992. p. 377-84.
5. Adams J, Franks S, Polson DW, Mason HD, Abdulwahid N, Tucker M, et al. Multifollicular
ovaries: clinical and endocrine features and response to pulsatile gonadotropin releasing
hormone. Lancet 1985;2:1375-9.
6. Burghen GA, Givens JR, Kitabchi AE. Correlation of hyperandrogenism with hyperinsulinism
in polycystic ovarian disease. J Clin Endocrinol Metab 1980;50:113-6.
154
7. Pasquali R, Casimirri F, Venturoli S, Paradisi R, Mattioli L, Capelli M, et al. Insulin resistance

in patients with polycystic ovaries: its relationship to body weight and androgen levels. Acta
Endocrinol (Copenh) 1983;104:110-6.
8. Dunaif A, Segal KR, Futterweit W, Dobrjansky A. Profound peripheral insulin resistance,
independent of obesity, in polycystic ovary syndrome. Diabetes 1989;38:1165-74.
9. Bruno B, Poccia G, Fabbrini A. Insulin resistance and secretion in polycystic ovarian disease.
J Endocrinol Invest 1985;8:443-8.
10. Poretsky L, Grigorescu F, Seibel M, Moses AC, Flier JS. Distribution and characterization of
insulin and insulin-like growth factor I receptors in normal human ovary. J Clin Endocrinol
Metab 1985;61:728-34.
11. Poretsky L, Smith D, Seibel M, Pazianos A, Moses AC, Flier JS. Specific insulin binding sites
in human ovary. J Clin Endocrinol Metab 1984;59:809-11.
12. . : . :
, . Polycystic Ovary Syndrome. :
; 2551. p. 77-90.
13. Samoto T, Maruo T, Ladines-Llave CA, Matsuo H, Deguchi J, Barnea ER, et al. Insulin receptor
expression in follicular and stromal compartments of the human ovary over the course of
follicular growth, regression and atresia. Endocr J 1993;40:715-26.
14. .
. : , . Polycystic Ovary Syndrome. :
; 2551. p. 61-76.
15. Jonard S, Robert Y, Cortet-Rudelli C, Pigny P, Decanter C, Dewailly D. Ultrasound examination
of polycystic ovaries: is it worth counting the follicles? Hum Reprod 2003;18:598-603.
16. Chang RJ, Cook-Andersen H. Disordered follicle development. Mol Cell Endocrinol
2013;373:51-60.
17. hSU MI. Changes in the PCOS phenotype with age. Steroids 2013;78:761-6.
18. Johnstone EB, Davis G, Zane LT, Cedars MI, Huddleston HG. Age-related differences in the
reproductive and metabolic implications of polycystic ovarian syndrome: findings in an
obese, United States population. Gynecol Endocrinol 2012;28:819-22.
19. Panidis D, Tziomalos K, Macut D, Delkos D, Betsas G, Misichronis G, et al. Cross-sectional
analysis of the effects of age on the hormonal, metabolic, and ultrasonographic features
and the prevalence of the different phenotypes of polycystic ovary syndrome. Fertil Steril
2012;97:494-500.
155
20. Hudecova M, Jan H, Christian B, Poromaa IS. Long-term reproductive and metabolic
consequences of PCOS. Curr Diabetes Rev 2012;8:444-51.
21. de Guevara AL, Crisosto N, Echibur B, Preisler J, Vantman N, Bollmann J, et al. Evaluation
of ovarian function in 35-40-year-old women with polycystic ovary syndrome. Eur J Obstet
Gynecol Reprod Biol 2013;170:165-70.
22. Markopoulos MC, Valsamakis G, Kouskouni E, Boutsiadis A, Papassotiriou I, Creatsas G, et
al . Study of carbohydrate metabolism indices and adipocytokine profile and their relationship with androgens in polycystic ovary syndrome after menopause. Eur J Endocrinol.
2012;168:83-90.
23. , . .:
; 2551. p. 113-32.
24. Deligeoroglou E, Atanasopoulos N, Tsimaris P, Dimopoulos KD, Vrachnis N,Creatsas G.
Evaluation and management of adolescent amenorrhea. Ann N Y Acad Sci 2010;1205:23-32.
25. Balen AH, Laven JS, Tan SL, Dewailly D. Ultrasound assessment of the polycystic ovary:
international consensus definitions. . Hum Reprod Update 2003;9:505-14.
26. Charnvises K, Weerakiet S, Tingthanatikul Y, Wansumrith S, Chanprasertyothin S, Rojanasakul
A. Acanthosis nigricans: clinical predictor of abnormal glucose tolerance in Asian women
with polycystic ovary syndrome. Gynecol Endocrinol 2005;21:161-4.
27. Weerakiet S, Bunnag P, Phakdeekitcharoen B, Wansumrith S, Chanprasertyothin S,
Jultanmas R, et al. Prevalence of the metabolic syndrome in Asian women with polycystic
ovary syndrome: using the International Diabetes Federation criteria. Gynecol Endocrinol
2007;23:153-60.
28. Hudecova M, Holte J, Olovsson M, Poromaa IS. Long-trerm follow-up of patients with
polycystic ovary syndrome: reproductive outcome and ovarian reserve. Hum Reprod
2009;24:1176-83.
29. .
. : , . Polycystic Ovary Syndrome. :
;2551. p. 147--66.
30. . . :
;2551. p. 177-92.
31. Revised 2003 consensus on diagnostic criteria and long-term health risks related to
polycystic ovary syndrome. Fertility and Sterility 2004;81:19-25.
156
32. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et

al. Positions statement: criteria for defining polycystic ovary syndrome as a predominantly
hyperandrogenic syndrome: an Androgen Excess Society guideline. J Clin Endocrinol Metab
2006;91:4237-45.
157
Management of Polycystic Ovary Syndrome (PCOS)

..
..
-

Polycystic ovary syndrome (PCOS)
4-7 (1)

PCOS

(endometrial cancer) (metabolic syndrome)
(cardiovascular disease)

PCOS

-

- (hyperandrogenism)

- (insulin resistance) (diabetes mellitus:
DM) (carbohydrate and lipid metabolism)

-

(life style modification)

159
(central obesity or android fat distribution)

(2, 3) PCOS
5
(4)
(hyperandrogenism)(5)

(chronic anovulation) oligomenorrhea ( 35 )
amenorrhea ( 3 ) estrogen
breakthrough bleeding
3 (6)

- (oral combined contraceptive pill: OCP)

- progestin (cyclic progestin)

- levonorgestrel (Levonorgestrel intrauterine system (IUS))

(OCP)

hyperandrogenism progestins
3rd 4th generation progestins 1st
2nd generation norethisterone, levonorgestrel, medoxy-progesterone acetate androgenic
glucocorticoid effect
(lipid and carbohydrate metabolism)(7)
progestins
progestins 3rd generation gestrodene, desogestrel, norgestimate 4th generation
chlomadione acetate, cypoterone acetate, drospirenone progestin
anti-androgenic anti-mineralo-cortocoid effect
hyperandrogenism progestin
1(8)
160
1 progestin
Progestin
Progesto- Estro- Andro-
Anti-
Gluco-
Anti
genic
genic genic androgenic cortocoid mineralo-

corticoid
Progesterone
+
-
-
+
+
+
Dydrogesterone
+
-
-
+
-
+
Medroxy-
+
-
+
-
+
progesteroneacetate
Cypoterone acetate
+
-
-
++
+
Chlomadione acetate +
-
-
+
+
Norethisterone
+
+
+
+
-
Levonorgestrel
+
-
+
-
-
Drospirenone
+
-
-
+
-
+
Schindler AE, Campagnoli C, Druckmann R, Huber J, Pasqualini JR, Schweppe KW, et
al. Classification and pharmacology of progestins.Maturitas 2003;46Suppl 1:S7-16.

OCP PCOS
(thromboembolism) ethinyl estradiol (EE)
(9) OCP
40
(liver function impairment) EE
EE 50 (high dose OCP)
30-35 (low dose pill) EE 15-20
(ultralow dose pill) OCP ultralow dose EE Mercilon (EE 20
+ Desogestrel 0.15 ), Meliane (EE 20 + Gestodene 75 ),
Minidoz (EE 15 + Gestodene 60 ), Yaz (EE 20 + Drospirenone
3 ) Minidoz Yaz 24 4 (24/4)

(vaginal ring)
hepatic first pass effect

progestin (cyclic progestin)

progestin
progestin
progestogen withdrawal bleeding

161
medroxyprogesterone 10 progestin (equivalent dose)

7-10 (10)
hyperandrogenism PCOS
hyperandrogenism

(Levonorgestrel IUS)

(11) hepatic first pass effect PCOS

(hyperandrogenism)

(OCP)

progestin 3rd 4th generation

- Ethinyl estradiol 35 + Cypoterone acetate 2 (Diane-35)

- Ethinyl estradiol 30 + Drospirenone 3 21 active pills (Yasmin)

- Ethinyl estradiol 20 + Drospirenone 3 24 active pills (YAZ)

- Oilezz

7 EE 40 Desogestrel 25

15 EE 30 Desogestrel 125

- Ethinyl estradiol 30 + Chlormadinone acetate 2 (Belara)

- Ethinyl estradiol 20 + Desogestrel 150 (Mercilon)

progestin antiandrogenism Cyproterone acetate
(CPA) Dienogest,Drosperinone, Chlormadinone acetate(12) progestin EE
sex hormone blinding globulin (SHBG) free
testosterone free testosterone hyperandrogenism
OCP hyperandrogenism
OCP OCP (terminal hair)
terminal hair
3
(plucking) (shaving) wax
laser

- Androgen receptor antagonists flutamide,

- Androgen synthesis inhibitors

5-reductase inhibitors finasteride

CYP17A1 (17-hydroxylase, 17, 20-lyase) inhibitors cyproterone acetate,

spironolactone, danazol, gestrinone, ketoconazole, abiraterone acetate
162

3b-Hydroxysteroid dehydrogenase inhibitors gestrinone

17b-Hydroxysteroid dehydrogenase inhibitors simvastatin

CYP11A1 (cholesterol side-chain cleavage enzyme) inhibitors aminoglutethimide

HMG-CoA reductase inhibitors statins atorvastatin, simvastatin

cypoterone acetate
OCP cypoterone acetate 25-50
OCP 10 OCP (13)

spironolactone
(hirsutism score) 40 50(14) spironolactone
OCP 75(15)


(insulin resistance) (diabetes mellitus:

DM) (carbohydrate and lipid metabolism)

PCOS
-
PCOS 20(16)
21.2(17)
insulin insensitizing agent Metformin
PCOS ( 80 )
acanthosisnigricans (AN) 75 gram oral glucose tolerance test
(OGTT) 75 gram OGTT

(i) impaired fasting glucose (IFG), that is, fasting blood glucose (FBG) 100 and <126mg/dL

(ii) impaired glucose tolerance test (IGT), that is, 2-hr glucose 140 and <200mg/dL

(iii) type 2 DM, that is, FBG 126mg/dL or 2-hr glucose 200mg/dL

insulin insensitizing agent
metformin
500
1,000
2,500-2,550 (18) metformin II
31
58(19) metformin
5-18(20-22) statin
(23)
163

PCOS 75 30-50(10)
PCOS
(ovulation induction)

(gestational diabetic: GDM) (preeclampsia)
5
(4)

PCOS clomiphene citate (CC)
50 5 5 (24)
150
(25) 75-80 CC(26)
22 (27) 6
(24) CC metformin
CC metformin (28)

aromatase inhibitors letrozole

Gonadotrophins GnRH analogues
CC (CC resistance)
PCOS (ovarian hyperstimulation
syndrome: OHSS) PCOS

(laparoscopic ovarian drilling)
CC, metformin, gonadotrophins GnRH analogues(24)
CC CC
(29, 30)

PCOS

hyperandrogenism

164
1. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med. 2005;352:1223-36.

2. Pasquali R, Casimirri F. The impact of obesity on hyperandrogenism and polycystic ovary
syndrome in premenopausal women. Clin Endocrinol (Oxf) 1993;39:1-16.
3. Legro RS. Obesity and PCOS: implications for diagnosis and treatment. Semin Reprod Med
2012;30:496-506.
4. Kiddy DS, Hamilton-Fairley D, Bush A, Short F, Anyaoku V, Reed MJ, et al. Improvement in
endocrine and ovarian function during dietary treatment of obese women with polycystic
ovary syndrome. Clin Endocrinol (Oxf) 1992;36:105-11.
5. Moran LJ, Hutchison SK, Norman RJ, Teede HJ. Lifestyle changes in women with polycystic
ovary syndrome. Cochrane Database Syst Rev 2011:CD007506.
6. Coulam CB, Annegers JF, Kranz JS. Chronic anovulation syndrome and associated neoplasia.
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of oral contraceptive use with serum lipids and lipoproteins in young women: the Bogalusa
Heart Study. Ann Epidemiol 1997;7:561-7.
8. Schindler AE, Campagnoli C, Druckmann R, Huber J, Pasqualini JR, Schweppe KW, et al.
Classification and pharmacology of progestins. Maturitas. 2003;46 Suppl 1:S7-S16.
9. Risk of thromboembolic disease in women taking oral contraceptives. A preliminary
communication to the Medical Research Council by a Subcommittee. Br Med J 1967;2:355-9.
10. Sheehan MT. Polycystic ovarian syndrome: diagnosis and management. Clin Med Res
2004;2:13-27.
11. Gallos ID, Shehmar M, Thangaratinam S, Papapostolou TK, Coomarasamy A, Gupta JK. Oral
progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia:
a systematic review and metaanalysis. Am J Obstet Gynecol 2010;203:547 e1-10.
12. Schneider HP. Androgens and antiandrogens. Ann N Y Acad Sci. 2003;997:292-306.
13. Belisle S, Love EJ. Clinical efficacy and safety of cyproterone acetate in severe hirsutism:
results of a multicentered Canadian study. Fertil Steril 1986;46:1015-20.
165
14. Crosby PD, Rittmaster RS. Predictors of clinical response in hirsute women treated with
spironolactone. Fertil Steril 1991;55:1076-81.
15. Erenus M, Yucelten D, Gurbuz O, Durmusoglu F, Pekin S. Comparison of spironolactone-oral
contraceptive versus cyproterone acetate-estrogen regimens in the treatment of hirsutism.
Fertil Steril 1996;66:216-9.
16. Wongwananuruk T, Rattanachaiyanont M, Indhavivadhana S, Leerasiri P, Techatraisak K, Tanmahasamut P, et al. Prevalence and clinical predictors of insulin resistance in reproductiveaged thai women with polycystic ovary syndrome. Int J Endocrinol 2012;2012:529184.
17. Indhavivadhana S, Wongwananuruk T, Rattanachaiyanont M, Techatraisak K, Leerasiri P,
Tanmahasamut P, et al. Prevalence of metabolic syndrome in reproductive-aged polycystic
ovary syndrome Thai women. J Med Assoc Thai 2010;93:653-60.
18. Nestler JE. Metformin for the treatment of the polycystic ovary syndrome. N Engl J Med
2008;358:47-54.
19. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J
Med 2002;346:393-403.
20. Pirwany IR, Yates RW, Cameron IT, Fleming R. Effects of the insulin sensitizing drug metformin
on ovarian function, follicular growth and ovulation rate in obese women with oligomenorrhoea. Hum Reprod 1999;14:2963-8.
21. Velazquez E, Acosta A, Mendoza SG. Menstrual cyclicity after metformin therapy in polycystic
ovary syndrome. Obstet Gynecol 1997;90:392-5.
22. Diamanti-Kandarakis E, Kouli C, Tsianateli T, Bergiele A. Therapeutic effects of metformin
on insulin resistance and hyperandrogenism in polycystic ovary syndrome. Eur J Endocrinol
1998;138:269-74.
23. Puurunen J, Piltonen T, Puukka K, Ruokonen A, Savolainen MJ, Bloigu R, et al. Statin therapy worsens
insulin sensitivity in women with polycystic ovary syndrome (PCOS): a prospective, randomized,
double-blind, placebo-controlled study. J Clin Endocrinol Metab 2013;98:4798-807.
24. Consensus on infertility treatment related to polycystic ovary syndrome. Hum Reprod
2008;23:462-77.
25. Dickey RP, Taylor SN, Curole DN, Rye PH, Pyrzak R. Incidence of spontaneous abortion in
clomiphene pregnancies. Hum Reprod 1996;11:2623-8.
26. Homburg R. Clomiphene citrate--end of an era? A mini-review. Hum Reprod 2005;20:204351.
166
27. Eijkemans MJ, Imani B, Mulders AG, Habbema JD, Fauser BC. High singleton live birth rate
following classical ovulation induction in normogonadotrophic anovulatory infertility (WHO
2). Hum Reprod 2003;18:2357-62.
28. Lord JM, Flight IH, Norman RJ. Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone,
pioglitazone, D-chiro-inositol) for polycystic ovary syndrome. Cochrane Database Syst Rev
2003:CD003053.
29. Pelosi MA, Pelosi MA, 3rd. Laparoscopic electrosurgical furrowing technique for the treatment of polycystic ovaries. J Am Assoc Gynecol Laparosc 1996;4:57-62.
30. Barisic D, Grizelj V, Corusic A. Pregnancy following the laparoscopic bipolar electrocoagulation of polycystic ovaries resistant to medicamentous ovulation induction--a case report.
Eur J Obstet Gynecol Reprod Biol 1999;83:225-6.
167
..
-

2

3-4

- 500

-

-
(active transport) (electrolyte)
(facilitated transport)

- pKa pH

pH 7-7.2 pKa 7.2

- (colostrums)

(mature milk)

(relative infant dose RID)
10
169

(NSAIDs) (opioids)
0.5-8.1(1, 2) ibuprofen
0.65(3) naproxen 3.3(4)
codeine 16.7(2) morphine
9-35(5)

dimenhydrinate ondansetron domperidone
metoclopramide
(6-10) dimenhydrinate antihistamine
(11)
(12)
dimenhydrinate
ondansetron domperidone
0.1 metoclopramide 4.7
domperidone metoclopramide (galactogogue) (13, 14)

ondansetron ondansetron domperidone
metoclopramide dimenhydrinate
(15, 16) (17) domperidone (18)

antacid
alginic acid simethicone
170
(19) H2 antagonist famotidine

ranitidine cimetidine famotidine 1.9(20)
ranitidine 1.3-4.6(21) cimetidine
9.8-32.6 famotidine ranitidine
proton-pump inhibitors (PPIs) omeprazole
pantoprazole omeprazole 1.1(22)
pantoprazole 0.95(23)

antacid (24)
H. pyroli
(24)

chlorpheniramine loratadine fexofenadine
chlorpheniramine (12) antihistamine
(11, 25)
pseudoephedrine pseudoephedrine
2.2-6.7 24(26)
bromhexine N-Acetylcysteine
bromhexine bromhexine
(27)

cephalosporin
loratadine fexofenadine

171

cephalosporin
(28) 0.18-4.1
(29) tetracycline
(30) fluoroquinolone
(31)
metronidazole (mutation)
metronidazole
9-13
(metallic) (32, 33)

cephalosporin fluoroquinolone
metronidazole 400
2 (33)
tetracycline
(34)
3

4.9
97.5
3-5 14 2.6
1 50-150
1-2
(relative infant dose) 52(35)
(36)

(cocktail)
(37)
2 ( 10
172
40 1.5 5% 12 8-12% 5 )
(38, 39)
(40)
(41)
1-2 (42)

(43)

(phthalates) (dioxin) (44, 45)

50000 (46)

- Hale ( H) 5 L1
L2 L3 L4 L5

- Weiner ( W) 3 S
(safe) US (unsafe) U (unknown)(47, 48)

- (The American Academy of Pediatrics
AAP) 7 1
2 3
4
5
6 7
173

H: L1 W: S AAP: 6

LactMed http://toxnet.nlm.nih.gov/newtoxnet/lactmed.
htm LactMed application
android iOS Medications and Mothers Milk Drugs in
Pregnancy and Lactation Micromedex LexiComp Epocrates
Physicians Desk Reference (PDR)
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human breast milk. Eur J Clin Pharmacol 1981;20:123-5.
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6. Babaei AH, Foghaha MH. A randomized comparison of vitamin B6 and dimenhydrinate in the
treatment of nausea and vomiting in early pregnancy. Iran J Nurs Midwifery Res 2014;19:199202.
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8. da Silva OP, Knoppert DC, Angelini MM, Forret PA. Effect of domperidone on milk production in mothers of premature newborns: a randomized, double-blind, placebo-controlled
trial. CMAJ 2001;164:17-21.
9. Czeizel AE, Vargha P. A case-control study of congenital abnormality and dimenhydrinate
usage during pregnancy. Arch Gynecol Obstet 2005;271:113-8.
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11. Messinis IE, Souvatzoglou A, Fais N, Lolis D. Histamine H1 receptor participation in the control
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population-based cohort study. Eur J Clin Pharmacol 2013;69:269-77.
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Am J Gastroenterol 1985;80:912-23.
20. Anderson PO. Drug use during breast-feeding. Clin Pharm. 1991 Aug;10:594-624.
21. Kearns GL, McConnell RF, Jr., Trang JM, Kluza RB. Appearance of ranitidine in breast milk
following multiple dosing. Clin Pharm 1985;4:322-4.
22. Marshall JK, Thompson AB, Armstrong D. Omeprazole for refractory gastroesophageal reflux
disease during pregnancy and lactation. Can J Gastroenterol 1998;12:225-7.
23. Plante L, Ferron GM, Unruh M, Mayer PR. Excretion of pantoprazole in human breast. J
Reprod Med 2004;49:825-7.
24. Richter JE. Review article: the management of heartburn in pregnancy. Aliment Pharmacol
Ther 2005;22:749-57.
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effect of histamine and H1 and H2 receptors on prolactin and luteinizing hormone release
in humans: sex differences and the role of stress. J Clin Endocrinol Metab 1981;52:924-8.
26. Aljazaf K, Hale TW, Ilett KF, Hartmann PE, Mitoulas LR, Kristensen JH, et al. Pseudoephedrine:
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27. Eichler VD, Kreuzer H. [Bromhexine residues in calves, pigs, and in the milk of cows]. Arzneimittelforschung 1975;25:615-22.
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amoxicillin into the breast milk. Acta Paediatr Scand 1981;70:285-8.
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of three newer quinolones in pregnant and lactating women. Am J Med 1989;87:49S-51S.
32. Passmore CM, McElnay JC, Rainey EA, DArcy PF. Metronidazole excretion in human milk
and its effect on the suckling neonate. Br J Clin Pharmacol 1988 ;26:45-51.
33. Erickson SH, Oppenheim GL, Smith GH. Metronidazole in breast milk. Obstet Gynecol
1981;57:48-50.
34. Morganti G, Ceccarelli G, Ciaffi G. [Comparative concentrations of a tetracycline antibiotic
in serum and maternal milk]. Antibiotica 1968;6:216-23.
35. Tyrala EE, Dodson WE. Caffeine secretion into breast milk. Arch Dis Child 1979;54:787-9.
36. Ryu JE. Caffeine in human milk and in serum of breast-fed infants. Dev Pharmacol Ther
1985;8:329-37.
37. Mennella JA, Beauchamp GK. The transfer of alcohol to human milk. Effects on flavor and
the infants behavior. N Engl J Med 1991;325:981-5.
38. Little RE, Anderson KW, Ervin CH, Worthington-Roberts B, Clarren SK. Maternal alcohol use
during breast-feeding and infant mental and motor development at one year. N Engl J Med
1989;321:425-30.
39. Streissguth AP, Barr HM, Martin DC, Herman CS. Effects of maternal alcohol, nicotine, and
caffeine use during pregnancy on infant mental and motor development at eight months.
Alcohol Clin Exp Res 1980;4:152-64.
40. Cobo E. Effect of different doses of ethanol on the milk-ejecting reflex in lactating women.
Am J Obstet Gynecol 1973;115:817-21.
41. Ho E, Collantes A, Kapur BM, Moretti M, Koren G. Alcohol and breast feeding: calculation
of time to zero level in milk. Biol Neonate 2001;80:219-22.
42. Mennella JA. Regulation of milk intake after exposure to alcohol in mothers milk. Alcohol
Clin Exp Res 2001;25:590-3.
176
43. Ilett KF, Hale TW, Page-Sharp M, Kristensen JH, Kohan R, Hackett LP. Use of nicotine patches
in breast-feeding mothers: transfer of nicotine and cotinine into human milk. Clin Pharmacol
Ther 2003;74:516-24.
44. LaKind JS, Berlin CM, Mattison DR. The heart of the matter on breastmilk and environmental chemicals: essential points for healthcare providers and new parents. Breastfeed Med
2008;3:251-9.
45. Geraghty SR, Khoury JC, Morrow AL, Lanphear BP. Reporting individual test results of
environmental chemicals in breastmilk: potential for premature weaning. Breastfeed Med
2008;3:207-13.
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48. Buhimschi CS, Weiner CP. Medications in pregnancy and lactation: Part 2. Drugs with minimal
or unknown human teratogenic effect. Obstet Gynecol 2009;113:417-32.
177
Management Ovarian Cancer in Pregnancy

..

1:2000 .. 1964 1:1,000
.. 2000
(1)

(1)

(leukemia
lymphoma) melanoma
(2)
4-8 : 100,000 2.3-4.1
90 6

epithelial tumors 49-75 sex cord stromal tumors 9-16 germ
cell tumor 6-40(3)

70 ultrasound
cesarean section(4,5) Gui (5)
41 31.7
2 17.1 3 46.3
(6)
Imaging

Imaging pelvic ultrasound
ultrasound solid areas,
179
multi-loculated masses, internal septum, papillary projections, 2 , ascites

Doppler ultrasound (6) IOTA (International Ovarian Tumor
Analysis) ultrasound model
1(7)
1 : IOTA simple rule(7)
ultrasound
(M features)
M 1 irregular solid tumor
M 2 presence of ascites
M 3 At least 4 papillary structures
M 4 Irregular multilocular solid tumor with largest diameter 100 mm
M 5 Very strong blood flow (colour score 4)
(B features)
B1 unilocular
B2 presence of solid components, of which largest solid component has larger diameter < 7 mm
B3 presence of acoustic shadows
B4 smooth multilocular tumor with largest diameter < 100 mm
B5 No blood flow (colour score 1)
Rule 1: If one or more M features are present in absence of B feature, mass is classified as malignant.
Rule 2: If one or more B features are present in absence of M feature, mass is classified as benign.
Rule 3: If both M features and B features are present, or if no B or M features are present, result
is inconclusive and second stage test is recommended.

ultrasound epithelial
germ cell tumors (8)

Dysgerminoma germ cell tumor 2
ultrasound solid lobule heterogeneous echogenicity
Doppler ultrasound

Yolk sac tumor mixed solid cystic
hemorrhage solid heterogeneous echogenicity
cystic space septum

Immature teratoma heterogeneous solid mass calcification

180
Magnetic resonance imaging (MRI)

MRI 2 3 gadolinium-based
contrast MRI 3
leiomyoma, endometriomas complex mass solid
compound (7) MRI ultrasound
Tumor marker

tumor marker
tumor marker CA125 tumor marker
epithelial tumor CA125
decidual amnion cells 7-13 3
48 . trophoblastic invasion placental detachment
CA125 112 U/ml(9,10) CA125
(7-11)
tumor marker germ cell tumor alpha-fetoprotein (AFP)
B-hCG inhibin B antimullerian hormone (AMH)
(7) tumor marker carcinoembryonic antigen (CEA), CA19-9
lactate dehydrogenase (LDH)(1)

counseling

(6)

2
corpus luteum
2 3
(6)
20

3
181

1.

2.
34

3. (neoadjuvant chemotherapy)

borderline tumor non-epithelial tumors
(germ cell, sex-cord stromal tumors) 1 midline
(unilateral salpingo-oophorectomy), omentectomy, peritoneal cytology
peritoneal biopsy
invasive epithelial tumor advanced stage
complete surgical staging
(12) advanced stage
residual tumor
(13)

low malignant potential tumor
stage IA grade 1

neural tube defects, cleft lip, amelia, cardiac defects

(ototoxic)

plasma
volume, renal clearance hepatic metabolism pharmacokinetics

35
3

epithelial ovarian tumors

epithelial tumor
platinum paclitaxel stage IB early stage
platinum cisplatin carboplatin 6 3-4
182
Azim Jr (14) epithelial tumor 20

19 platinum-based regimens 1 single paclitaxel 17 20
2 3 3 3
39 2
premature rupture of membranes 30 cisplatin
cyclophosphamide 3
preeclampsia 1

paclitaxel Cardonick (15)
12 3 paclitaxel based
paclitaxel 117
6 2 3 2

paclitaxel 1 6.25 pyloric stenosis
4
paclitaxel 2 3
non-epilthelial tumor

germ cell sex cord stromal tumor
stage IA dysgerminama immature teratoma grade 1 early stage granulosa cell
sex cord stromal group(16) BEP regimen (bleomycin, etoposide,
cisplatin) 4-6 BEP
1 BEP BEP 1 cycle
1 28 ventriculomegaly, cerebral atrophy,
anemia neutropenia etoposide
(13)
183
1. Salani R, Billingsley CC, Crafton SM. Cancer and pregnancy: an overview for obstetricians
and gynecologists. Am J Obstet Gynecol 2014;211:7-14.
2. Morice P, Uzan C, Gouy S, Verschraegen C, Haie-Meder C. Gynaecological cancers in
pregnancy. Lancer 2012;379:558-69.
3. Gezgin K, Karatayl R, Yazc F, Acar A, Celik C, Capar M. Ovarian cancer during pregnancy.
Int J Gynaecol Obstet 2011;115:140-3.
4. Machado F, Vegas C, Leon J, Perez A, Sanchez R, Parrilla JJ ,et al. Ovarian cancer during
pregnancy: analysis of 15 cases. Gynecol Oncol 2007;105:446-50.
5. Gui T, Cao D, Shen K, Yang J, Fu C, Lang J,et al. Management and outcome of ovarian
malignancy complicating pregnancy: an analysis of 41 cases and review of the literature.
Clin Transl Oncol 2013;15:548-54.
6. Minig L, Otao L, Diaz-Padilla I, Alvarez Gallego R, Patrono MG, Valero de Bernab J.
Therapeutic management of epithelial ovarian cancer during pregnancy. Clin Transl Oncol 2013 ;
15:259-64.
7. de Haan J, Verheecke M, Amant F. Management of ovarian cysts and cancer in pregnancy.
Facts Views Vis Obgyn 2015;7:25-31.
8. Shaaban AM, Rezvani M, Elsayes KM, Baskin H Jr, Mourad A, Foster BR, et al. Ovarian
malignant germ cell tumors: cellular classification and clinical and imaging features.
Radiographics 2014;34:777-801.
9. Aslam N, Ong C, Woelfer B, Nicolaides K, Jurkovic D. Serum CA125 at 11-14 weeks of
gestation in women with morphologically normal ovaries. BJOG 2000;107:689-90.
10. Szecsi PB, Andersen MR, Bjrngaard B, Hedengran KK, Stender S. Cancer antigen 125 after
delivery in women with a normal pregnancy: a prospective cohort study. Acta Obstet
Gynecol Scand 2014;93:1295-301.
11. Amant F, Brepoels L, Halaska MJ, Gziri MM, Calsteren KV. Gynaecologic cancer complicating
pregnancy: an overview. Best Pract Res Clin Obstet Gynaecol 2010;24:61-79.
12. Han SN, Verheecke M, Vandenbroucke T, Gziri MM, Van Calsteren K, Amant F. Management
of gynecological cancers during pregnancy. Curr Oncol Rep 2014;16:415.
13. Brewer M, Kueck A, Runowicz CD. Chemotherapy in pregnancy. Clin Obstet Gynecol 2011;
54:602-18.
14. Azim HA Jr, Peccatori FA, Pavlidis N. Treatment of the pregnant mother with cancer: a
systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy
during pregnancy. Part I: Solid tumors. Cancer Treat Rev 2010;36:101-9.
184
15. Cardonick E, Bhat A, Gilmandyar D, Somer R. Maternal and fetal outcomes of taxane
chemotherapy in breast and ovarian cancer during pregnancy: case series and review of
the literature. Ann Oncol 2012;23:3016-23.
16. Colombo N, Peiretti M, Garbi A, Carinelli S, Marini C, Sessa C,et al. Non-epithelial ovarian
cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol
2012;23:vii20-6.
185
Adnexal mass in pregnancy:

How to approach and Laparoscopic treatment for benign condition
..

-

incidence 1:1,000

2529-2544 (15 )(1)
118 116,323 (1:986) Elective operation
81.6% Emergency operation 18.4% Mature cystic teratoma 39.4% Endometrioma 19.2% Serous cystadenoma 11.5% Mucinous cystadenoma 8.6% Hemorrhagic corpus
luteal cyst 8.6% Leiomyoma 1.9% Ovarian malignancy 1.9% Borderline tumor 0.9%
(2-6)
3 3 1 elective
emergency

Endometriotic cyst

- ovarian
tumor, par tubal cyst, myoma, appendiceal abscess

- functional cyst pathological cyst
functional cyst corpus luteal cyst 16
theca lutein cyst
follicle
187
luteoma of pregnancy

- pathological cyst malignancy

(2)
myoma, par tubal cyst pelvic organ tumor

teratoma solid part soft tissue
mural nodule immature teratoma low
malignant potential ( epithelial tumor) benign

MRI ionizing radiation
pedunculated myoma, red degeneration of myoma, endometrioma, massive
ovarian edema Gadolinium-based contrast CT
scan 0.035-0.05 Gy

iodinated contrast transient suppression fetal thyroid

Tumor marker

-

-

-

-

14 6.1-8.8%
(resolution) 69-89% (2,7-8)

2 1-15%(2)
5-10 . 6-8 .
< 6 . > 10 . 60% 10-17 36.7%
15-16 6% 20 (9)

2-17%
188

2 3
6 .
8 . 10 .
2
functional cyst organogenesis drug-induced
teratogenesis spontaneous pregnancy loss
corpus luteum

benign counselling
Dermoid cyst
()
Cul-de-sac endometriotic cyst

set

(3,5,10)
189
2
Midline

port

Lithotomy uterine elevator

port
16 port port
( port )
port open technique Verres needle port blind
technique
15 mmHg End-tidal CO2 (Capnogram)
Endotracheal tube reflex CO2 acidosis

( 5
10 . 3.3 . 30 0
) port under visual

port & trocar port &
trocar accessory ports
benign
malignant
ovarian cystectomy salpingo-oophorectomy

(Laparoscopic Allis forceps non-tooth graspers
) graspers suction
(
) 10
15 (
)
190
( Single port surgery

)

Endobag spillage
content ovarian cystectomy

Ramathibodi laparscopic endobag(11,12)
5, 7, 10 15 .

Bipolar current
plate
Carbonmonoxide

ovarian cystectomy oophorectomy
port
training box
coagulation

specimen umbilical port port
endobag
suction content
endobag endobag

Dermoid cyst Endometriotic
cyst

1.
2
2. 3. 4. 5.
specimen calcification solid part
port 6.
3.3 . 30
accessory ports 5 . port 5 . 1 port

191

1a
1b
1c
1a, 1b, 1c:

1, 2
3
2: 2 ()

Single port laparoscopic surgery
port multi-channel
Robotic surgery
(docking)

-
2546(13-15)

Laparoscopic
surgery for adnexal masses during pregnancy, 10 years experience in Ramathibodi Hospital
Retrospective comparative study(16) ..2546-2556 case
control 2:1 Laparoscopy 42 Explor laparotomy 21
28.8 31.4 Dermoid
cyst 32.2%
ovarian cystectomy oophorectomy

192
Acknowledgement : .. .. ..
.. .. .. ..
.. .. . .
. OPD ANC & GYN Ward 6SE OROB ORSK
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Assoc Thai 2005;88:37-40.
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laparotomy. J Reprod Med 1997;42:551-8.
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surgical management. Am J Obstet Gynecol 1999;181:19-24.
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laparotomy in the management of adnexal masses during pregnancy. Fertil Steril 1999;71:955-60.
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Rajavithi Hospital: 2002-2005. Thai J Obstet Gynecol 2009;17:37-42
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Maternal-Fetal Medicine, Principles and Practice. Creasy RK, Resnik R, Iams JD, Lockwood
CJ, Moore TR, Greene MF, editors, Elsevier Saunders, 7th ed, 2014;1156-66.
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pregnancy. Obstet Gynecol 1999;93:585-9.
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193
10. Yeun PM, Chanf AM. Laparoscopic management of adnexal mass during pregnancy. Acta
Obstet Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal
masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol 2003;108:217-22.
11. Kaewjai N, Chumphoochanapai K, Vajiratanakorn S, Tingthanatikul Y, Srisombut C, Weerakiet
S. Ramathibodi endobag for ovarian tumor. Annual Meeting of the Royal Thai College of
Obstetricians and Gynecologists. 2010, p 225.
12. Kaewjai N, Permpech R. Ramathibodi endobag for ovarian tumor in laparoscopic surgery.
The Thai Perioperative Nurse Association Journal 2010;3.
13. Srisombut C, Tingthanatikul Y. Laparoscopic management of ovarian tumor in pregnancy.
A report of two cases. Annual Meeting of the Royal Thai College of Obstetricians and
Gynecologists 2003, p 238.
14. Tingthanatikul Y, Srisombut C, Lertvikool S, Satirapod C, Preutthipan S, Promsonthi P,
Pitukkijronnakorn S, Jaovisidha A, Wilailak S, Weerakiet S. Laparoscopic management of
ovarian tumor in pregnancy, Ramathibodi Experience. XVIII Annual Congress of International
Society for Gynecologic Endoscopy 2009, p 80.
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A, Jultanmas R, Weerakiet S. Laparoscopic surgery for ovarian mass in pregnancy. Annual
Meeting of the Royal Thai College of Obstetricians and Gynecologists. 2009, p 239.
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M, Rojanasakul A. Laparoscopic surgery for adnexal masses during pregnancy, 10 years
experience in Ramathibodi Hospital. Annual Meeting of the Royal Thai College of
Obstetricians and Gynecologists 2013.
194
RTCOG Clinical Practice Guideline

Management of Preeclampsia and Eclampsia

5-10
..2555
141 17.6
100,000
25 3.1 100,000 (
..2556)(1)

(preeclampsia)

(2-7)

systolic 140
diastolic 90 2 4 systolic
160 diastolic 110
()

10 cuff
1.5 80 ( mid-arm
195
circumference 33 cuff )
diastolic Korotkoff phase V
Korotkoff phase IV systolic Korotkoff phase I

preeclampsia

Proteinuria protein 300 24 protein:creatinine
ratio 0.3 (dipstick)
1+ ( quantitative )
Classification(7)

4
1. Preeclampsia eclampsia
2. Chronic hypertension ()
3. Chronic hypertension superimposed preeclampsia
4. Gestational hypertension
1 (7)
Preeclampsia

systolic 140 diastolic 90

20

Proteinuria

proteinuria

(new-onset) new-onset

Thrombocytopenia : 100,000/

Renal insufficiency : serum creatinine 1.1 /

2 serum creatinine

Impaired liver function : liver transaminase 2

Pulmonary edema

Cerebral visual symptoms
Eclampsia

196
Chronic hypertension

20

20 12

Chronic hypertension with superimposed preeclampsia

Chronic hypertension preeclampsia
Gestational hypertension


20 systemic

finding

proteinuria

12

(2, 3, 7) preeclampsia
severe features (3)

2 4 (
)

Thrombocytopenia : 100,000/

Impaired liver function : liver transaminase 2
(severe persistence)
2

Progressive renal insufficiency: serum creatinine 1.1 /
2 serum creatinine

Pulmonary edema

(new-onset)

severe preeclampsia
preeclampsia without severe features mild
preeclampsia () preeclampsia dynamic process
severe preeclampsia
(7)
1 2

preeclampsia without severe features mild gestational hypertension

1. 37 0/7

2. 37 0/7 expectant management

197

- strict bed rest

-

-

- 2

- gestational hypertension proteinuria

- magnesium sulfate (MgSO4) universally eclampsia

- liver enzyme

- preeclampsia without severe features
2-4

- fetal growth restriction umbilical artery
Doppler velocimetry

3.

- 72 7-10

-

o systolic 150 diastolic 100
2 4-6

o systolic 160 diastolic 110
1

- new-onset hypertension preeclampsia
severe hypertension parenteral MgSO4
severe preeclampsia

-

- stabilize MgSO4

- ( systolic 160
diastolic 110 )

- stable

- stable

1. 34 0/7 stabilize

2. 24 0/7 (previable) stabilize
expectant management

3. 24 1/7 33 6/7

corticosteroid (expectant management)
intensive care
198

MgSO4 48

corticosteroid 48 ()

preterm premature rupture of membranes

( 100,000 )

hepatic enzymes (2 )

( 5 )

severe oligohydramnios (amniotic fluid index 5 )

umbilical artery Doppler studies reversed end-diastolic flow

new-onset renal dysfunction

corticosteroid ( delay) stabilize

uncontrollable severe hypertension

eclampsia

pulmonary edema

abruptio placenta

disseminated intravascular coagulation

evidence of non-reassuring fetal status

intrapartum fetal demise

-

-

- parenteral MgSO4

-
neuraxial anesthesia (spinal epidural anesthesia)

- severe preeclampsia MgSO4

- eclampsia parenteral MgSO4
HELLP syndrome

-
-
-

stabilize MgSO4
stabilize
1. 34 0/7
2. 24 0/7 (previable)
3. 24 1/7 33 6/7 stable
199

- delay 24-48 corticosteroid course
24 1/7 33 6/7 stable
Chronic hypertension

- chronic hypertension
38 0/7

- Chronic hypertension with superimposed preeclampsia severe features

1. stable expectant management
37 0/7

2. 34 0/7 corticosteroid

- Chronic hypertension with superimposed preeclampsia severe features

1. MgSO4

2. 34 0/7

3. 34 0/7 corticosteroid
expectant management stable
34 0/7

- Chronic hypertension with superimposed preeclampsia
stabilize
corticosteroid course

uncontrollable severe hypertension

eclampsia

pulmonary edema

abruptio placenta

disseminated intravascular coagulation

non-reassuring fetal status

200
1 Preeclampsia without severe features
201
HT = hypertension
DIC = disseminated intravascular coagulation
2 Severe preeclampsia (SPE)

202

eclampsia
12
3 eclampsia
203
severe preeclampsia/ eclampsia(8-10)

1. MgSO4 ()

1.1 IM regimen

- Initial dose 10% MgSO4 4-6
1 / 50% MgSO4 10 5

- Maintenance dose 4 50% MgSO4
5 4

1.2 IV regimen infusion pump MgSO4

1.3 10% MgSO4 2

2. systolic 160 diastolic
110

3. LRS 80 /

4.

5.

6. endotracheal tube,
ambu bag, calcium gluconate
(7)

(60-80 . )

1. early-onset preeclampsia 34

2. preeclampsia 2
204
(2, 3, 4, 9, 10)
(Anticonvulsant
drugs)

1-2

patellar reflex 100 /
25/
14 /
dose

. . . 30

Mg
205

creatinine 1.3 / maintenance
dose 50 1 / Mg
maintenance dose MgSO4 phenytoin 125
( 250 3-5 ) diazepam 5
Mg

Mg

Effect
Therapeutic level
Loss of patellar reflex
Respiratory paralysis
Cardiac arrest
* 2
# 3
mg/ dL *
4.8-8.4
8-10
12-25
25-30
mEq/ L #
4-7
10
15
> 25

maintenance 1 / Mg level

MgSO4 bolus MgSO4 2 rate
infusion 1.5 / bolus 2
conventional anticonvulsant Mg
cranial imaging scan stabilize
(5)

15
first line

1. First line
1.1 Hydralazine
25 /2

Test dose 1 1 5

Treatment dose 5-10 2 20
10

20 labetalol 20
2 10 labetalol
40 2
206
1.2 Labetalol
25
/5
IV bolus
4 ampoules
(100
/20
+
80
100
10
20
40 2 10
80
hydralazine
10
10
2
20
heart
block
first degree,
peripheral

shock
sick
sinus
syndrome,
Prinzmetals
angina, severe
arterial
disease,
cardiogenic
heart failure
congestive
207

1.3 Nifedipine
10,
20

/
Treatment
dose
10
20
20
20
20

20 labetalol 40

MgSO

4

10
1 15 1 30 1
30
labetalol
200
oral
nifedipine
therapy

2. Second-line
2.1 Nicardipine
pump

infusion
2
/2
10
/10

nicardipine
+ NSS

IV drip
(10
/10)1ampoule
IV
25-50
/
100

0.1
90

/

(2.5-5 /) titrate 2.5 / 15
15 /
cardiogenic
shock,
recent MI acute unstable angina, severe aortic

stenosis
208

2.2 Labetalol infusion pump

IV drip 20 ampoules (500 /100 ) +
400 500 1 / drip 20 /
20 / 30 total dose 160 /
0.9%NSS, 5% D/NSS, 5% D/N/2, 5% D/RLS, RLS
1. .
.. 2556.
2. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield
JS. Williams Obstetrics. 24thed. New York: McGraw Hill 2014;728-79.
3. Creasy RK, Resnik R, Iams JD, Lockwood CJ, Moore TR, Greene MF. Creasy & Resniks
Maternal- Fetal Medicine. Principles and Practice. 7th ed. Philadelphia: Elsevier 2014;756-84.
4. Report of the National High Blood Pressure Education Program Working Group on High Blood
Pressure in Pregnancy. Am J Obstet Gynecol 2000;183:S1-S22.
5. American College of Obstetricians and Gynecologists. Emergency therapy for acute-onset,
severe hypertension during pregnancy and the postpartum period. Committee Opinion
No.623. Obstet Gynecol 2015;125:521-5.
6. National Heart, Lung, AND Blood Institute. The seventh report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
NIH Publication No. 04-5230. Bethesda(MD):NHLBI;2004. Available at: http://www.nhlbi.nih.
gov/files/docs/guidelines/jnc7full.pdf. Retrieved October 14, 2014.
7. American College of Obstetricians and Gynecologists. Task Force on Hypertension in
Pregnancy. Report of the American College of Obstetricians and Gynecologists Task Force
on Hypertension in Pregnancy Executive Summary. Obstet Gynecol 2013;122:1122.
8. Institute of Obstetricians and Gynaecologist. Royal College of Physicians of Ireland and
Clinical Strategy and Programmes Directorate, Health Service Executive. Clinical Practice
Guideline. The Diagnosis and Management of pre-eclampsia and eclampsia. Version 1.0.
Guideline No.3. Date of publication September 2011. Revision date- September 2013.
9. National Institute for Health and Clinical Excellence. Hypertension in pregnancy: the
management of hypertensive disorder during pregnancy. NICE clinical guideline. Available
at: http://www.guideline.gov/content.aspx?id=24122. (Accessed on January 11, 2012)
10. World Health Organization. WHO recommendations for prevention and treatment of
pre-eclampsia and eclampsia. 2011.
209
()
:
Ovaries & Fallopian Tubes: To Remove or to Preserve during Hysterectomy

(prophylactic salpingo-oophorectomy ) 2
risk-reducing bilateral salpingo-oophorectomy (RRSO)

incidental elective bilateral salpingo-oophorectomy (BSO)

(1, 2)
Risk-Reducing Bilateral Salpingo-oophorectomy

(hereditary cancer syndrome)
breast-ovarian cancer syndrome BRCA
BRCA1 BRCA2
hereditary cancer syndrome
211
13 (3) 17 41
(4, 5)

65-82(6, 7)
13 BRCA1 7
BRCA2 10 (6, 7)

1.5 BRCA1 39-54
BRCA2 11-23(6, 7)
0.6 1.3 (4)

serous carcinoma(8, 9) Lynch syndrome
(hereditary nonpolyposis colorectal cancer syndrome: HNPCC)
40-60 6-12(10)

hereditary cancer syndrome
/
(11)

1. 20-25

2

Ashkenazi Jewish

< 50

Ashkenazi Jewish 40

BRCA1 BRCA2

2. 5-10

40

serous carcinoma

2 50

50

Ashkenazi Jewish 50

2
1 50

212

1 (, , ) 2 (-,
/-)

(1)

CA125
BRCA1 BRCA2 30-35 5-10
(12)

BRCA1 BRCA2
(13-18)

(19) BRCA

2
(20)

1.

2. (21)
(19, 22, 23)

3. mesovarium
fimbria
(8)

RRSO
80-90 BRCA1 BRCA2(13-15, 24)
(hazard ratio: HR) 0.04 0.25(14, 15)
0.19 0.21 (17, 18) RRSO
BRCA1(25)
213

BRCA
40-70(14, 15, 25)
BRCA
BRCA1(25)

RRSO
0.21(13) 0.32
0.31 0.36 BRCA1 BRCA2 (18)

(peritoneal carcinoma) 2-4(5, 16, 26) serous carcinoma
III

BRCA1 BRCA2(16, 26) 1-2 BRCA1
BRCA2 (13)

RRSO

BRCA

hereditary ovarian cancer 40
30 (27, 28)
BRCA1 50
35 2-3 40
10-21 50 BRCA2 BRCA1
10 60
2-3 50 BRCA2
(6, 7, 27, 29)
0.3-2.6 (30, 31)
60 30
40 BRCA2 26-34
50 (7, 29)
(14, 30, 32)

BRCA RRSO
35 40

(30, 32)
214

1.

(11)

2.

(32, 33)

3.

pelvic ultrasound

4.

omentum para-colic gutter

ovarian artery vein 2 . pelvic
brim (34)

interstitium
92 ampulla isthmus 8
infundibulum fimbria interstitium (35)
RRSO 0.6 fimbria(28)

(frozen section)

(36)

omental biopsy (34, 37)

(8, 38, 39)

HNPCC
(10) BRCA tamoxifen
(32)
215

5.

12-64 (24, 28, 36-41)
50 4 (39)
2-3 .

BRCA 2 0.7
0.7 0.2
40 RRSO (24)
(pre-invasive lesions) (28)
fimbria (longitudinal)
fimbria (8)

6.

RRSO

CA125
CA125 (42)

1. BRCA

2. HNPCC

3.

Elective Bilateral Salpingo-oophorectomy

(hysterectomy)

(salpingo-oophorectomy, SO)
45

20
21 50 hysterectomy SO
abdominal laparoscopic hysterectomy SO
vaginal hysterectomy(43-45)
216

bilateral SO
(bilateral salpingectomy)
elective bilateral SO
Elective Salpingo-oophorectomy

(anovulatory cycle)

FSH estrogen
10
estrogen estradiol estrone
androgen testosterone, androstenedione, and dehydroepiandrosterone
70-80 androgen estrogen
aromatization (40, 46, 47)

bilateral SO
FSH estrogen
estrogen androgen (48-51)

hysterectomy bilateral SO

hysterectomy(52, 53) prospective cohort
( FSH 40 IU/L)
hysterectomy hysterectomy
5 20.6 7.3 hysterectomy
hysterectomy 3.7 hysterectomy(54)

3
bilateral SO
The Nurses Health Study (NHS)(55,56), The Womens Health Initiative Observational
Study (WHI)(57) The Mayo Clinic Cohort Study of Oophorectomy and Aging(58, 59)
217
Elective Bilateral Salpingo-oophorectomy (BSO)

serous adenocarcinoma
(21)

BSO
(primary peritoneal carcinoma)
94-96%
hysterectomy
0.1-0.75 BSO 220-323 1 (55, 56)

meta-analysis BSO
hysterectomy tubal ligation
34 (57, 58)

serous, endometrioid, clear cell
(9, 59-62)
bilateral salpingectomy

40 45
BSO
estrogen BSO
45 (55)

3-4 hysterectomy
(residual ovary syndrome) 5
(63, 64)
functional cysts 50 benign ovarian neoplasms 40 malignant
ovarian neoplasms 10(64)

(65)
218
Elective BSO

oophorectomy hysterectomy

elective BSO hysterectomy
BSO

elective
BSO
(All-Cause Mortality)

elective BSO
estrogen

BSO
1 24 BSO 24
50

(66) BSO
(66)
WHI BSO(56)

BSO

BSO
50 50 (68)

NHS (coronary heart disease)
BSO 45 BSO
50 (55)

Mayo Clinic study BSO 45
45 (69)
WHI BSO(56)
BSO
219

BSO 48 50
cognitive impairment dementia
BSO(70, 71)

BSO BSO(55, 56, 72)

BSO

androgen androgen estrogen
(73)

BSO

elective BSO

- 94-96
0.1-0.75

- 40 45

- residual ovary syndrome
3-4

-
45-50

(cognitive impairment/ dementia) /
/

- elective BSO

220
elective bilateral
salpingectomy

- elective BSO

residual ovary syndrome pelvic endometriosis, tubo-ovarian
abscess, chronic pelvic pain

- elective BSO
50-51
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..
..

227
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(Intrauterine insemination, IUI)

..
.
.
..
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:
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2. (Intrauterine insemination with donor sperm, IUI-D)

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1.2

1.3

1.4

2. (4)

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2.3

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229
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2.

3.

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4.

5.

6.
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7.

(Level IV)(14,15)

8.

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8.2

8.3

8.4

8.5

8.6

8.7

8.8

8.9 10
(16) (Level IV)
230

8.10

8.11 6
(Level III)(17)

8.12

(18)

9. (19)

10. 5 (19)

11.
(3)

12.

(19)

13.
20 (20)

1. gonadotrophin antiestrogen
(Level II-a)(21)

2. total motile sperm
count 5 (Level II-b)(22,23)

3. 2 1
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4. 3-6 (Level II-a)(26-28)

5.
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6.

: 15.8 % 35

: 11.0 % 35 - 39

: 4.7 % 40 - 42

: 1.2 % 43 - 44

: 0 % 44 (30)

7. 2 - 4 % (31)
231
1. .. 2558.
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4. 7/...
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19. 9/...

20. 2/...
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234
Abnormal labor curve / labor progression

..

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(2)
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active phase 5 .
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2 ./.

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deceleration phase (artifact)

deceleration phase of labor

1.3.2 Secondary arrest of dilatation

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2 . secondary arrest of dilatation
238

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1

. 6 .

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2

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1.

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arrest of descent 1 .

1.3.4 Failure of descent

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failure of descent deceleration phase 2
2. 2

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2 2 .
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239

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block malrotation
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Contemporary patterns of spontaneous vaginal delivery

..

sigmoid curve
(protraction and arrest disorders) Friedman 1950s(1)

(2-5)
Friedman (latent phase) deceleration
(active phase) (nulliparaous)(6-9)
Zhang (10)

(American College of Obstetricians and
Gynecologiests Society for Maternal-Fetal Medicine) 2014(11)
Friedman Zhang

Friedman

Friedman 2
3-5
3-5
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8
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2 4
243
protraction arrest
(12)
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(12)

Zhang

Zhang .. 2002(13)

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Zhang
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62,415
.. 2002-2008
5 6
2)(10)
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epidural
244

(13)
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Zhang
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245
Knowledge and Practice in OB-GYN 2015

Merging

2
( ) (spontanerous onset of labor)(10)

3 (10) (P0; P1; 1 P2+;

2 )

Friedman Zhang
Friedman
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curve (14)

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246
10 (15) Zhang
(10,16) repeated measures eighth-degree polynomial model
interval-censored regression labor curves

(continuous monitoring)
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2. Zhang (10)
3-4

exponential curve
deceleration deceleration
(13, 17-19) 6

(20) (body mass index)
(21, 22)

3.
epidural oxytocin
1950s Friedman
(16, 17)

3-6

4-6

247
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18. Nguyen T, Handa VL, Hueppchen N, Cundiff GW. Labour curve findings associated with fourth
degree sphincter disruption: the impact of labour progression on perineal trauma. J Obstet
Gynaecol Can 2010;32:21-7.
19. Gross TL, Sokol RJ, Williams T, Thompson K. Shoulder dystocia: a fetal-physician risk. Am J
20. Vahratian A, Troendle JF, Siega-Riz AM, Zhang J. Methodological challenges in studying
labour progression in contemporary practice. Paediatr Perinat Epidemiol 2006;20:72-8.
21. Kominiarek MA, Zhang J, Vanveldhuisen P, Troendle J, Beaver J, Hibbard JU. Contemporary
labor patterns: the impact of maternal body mass index. Am J Obstet Gynecol 2011;205:244.
e1-8.
22. Chin JR, Henry E, Holmgren CM, Varner MW, Branch DW. Maternal obesity and contraction
strength in the first stage of labor. Am J Obstet Gynecol 2012;207:129.e1-6.
249
(Gynecologic Ultrasound)
.

(ultrasound)

10
diagnostic imaging
CT (computed tomography) MRI (magnetic resonance imaging)
(1-2)

1.

2. /

3.

4.
(1,3-5)

(transabdominal ultrasound) (transvaginal ultrasound)
2 2

(transrectal ultrasound)
(transvaginal probe) (
)
251
(Transabdominal ultrasound)

(probe)

(resolution)

()

(pubic symphysis)

(
)
(
)

1. ()

2. ()

3. ( )

(focus)

2-5
(megahertz, MHz) 2 MHz
5 MHz
(multifrequency probe)
252

(linear)
(curve-linear/convex) -
()

crystal (piezoelectric crystal)
electronic (
)
()

coupling agent ultrasonic gel

-
Coupling agent gel
gel
gel
gel gel

Coupling agent gel

gel
gel
(Transvaginal ultrasound)

(resolution)

253

(
)
()

/
artifact

2

--
--
(focus)

2 ()

(1)

()
(spermicides)

()
coupling agent gel
254
) gel

anatomy

anatomy
sagittal
plane
sagittal plane

transverse
plane

2
transverse
plane

(6-7)

255
(1)
diagram
sagittal plane ( AP pelvic plane)
4 :

Diagram
A
( 70% )
Diagram
diagram
A
180
)
antevert
sagittal
plane
diagram
A
antevert
sagittal
plane
diagram
256

Diagram C D

-
(mirror
image)
diagram

A B
(1)
diagram
antevert
sagittal
plane
diagram
C
coronal
plane
trans-pelvic
plane)
coronal
plane
(
)(7)
transverse
plane
7.5x3x 5
(
x
x
)

257
)
(4,8)

proliferative phase 3-5
isoechoic 3 (triple layers)
(echogenic line) endometrium
functionalis (hypoechoic) endometrium basalis
(echogenic) 8-12 secretory
phase 14

2
3 x 2 x 2 follicles
( follicles )

()
(2)
(fimbria)

sonoprinter
X-rays multi-format ()

- sonoprinter
DVD

hard disk
electronic media MO disk,
CD-ROM, DVD-ROM, USB flash drive, external hard disk
DICOM (Digital Imaging and Communications in Medicine)
(10)

body mark

258
1. , , . , .
. :
, 2544.
2. . . : , ,
, , . . 2. :
- , 2548:426-41.
3. Timor-Tritsch IE. Conducting the gynecologic ultrasound examination. In: Timor-Tritsch IE,
Goldstein SR, editors. Ultrasound in gynecology. 2nd edition. Philadelphia. Churchill Livingstone,2007:45-50.
4. , . . : ,
, , , , . .
4. : - ,
2547:542-51.
5. Levi CS, Lyons EA, Holt SC, Dashefsky SM. Normal anatomy of the female pelvis and transvaginal sonography. In: Callen PW, editor. Ultrasonography in obstetrics and gynecology. 5th
edition. Philadelphia. Saunders 2008:887-918.
6. Bernaschek G, Deutinger J. Endosonography in obstetrics and gynecology: the importance
of standardized image display. Obstet Gynecol 1989;74:817-20.
7. Fleischer AC, Kepple DM. Normal pelvic anatomy and scanning techniques. In: Fleischer AC,
Kepple DM, editors. Transvaginal sonography: a clinical atlas. 2nd ed. Philadelphia: Lippincott
1995:21-35.
8. Timor-Tritsch IE. Relevant pelvic anatomy. In: Timor-Tritsch IE, Goldstein SR, editors. Ultrasound in gynecology. 2nd edition. Philadelphia. Churchill Livingstone, 2007:53-85.
9. Hricak H, Akin O, Sala E, Ascher SM, Levine D, Reinhold C. Diagnostic imaging gynecology.
Salt lake city. Amirsys Inc, 2007.
10. Peisner DB. Instrumentation, modality selection, and documentation. In: Timor-Tritsch IE,
Goldstein SR, editors. Ultrasound in gynecology. 2nd edition. Philadelphia. Churchill Livingstone 2007:33-44.
259
CT imaging in ovarian disease

..

ultrasound (US)
ultrasound
ultrasound

CT

(appendicitis), diverticulitis,
pyelonephritis CT
neoplasm CT

peritoneal implant

CT (treatment response) recurrent
tumor (surveillance) CT
CT

Magnetic Resonance Imaging (MRI) US CT
MR
US CT
follicular cyst endometrioma hemorrhagic cyst fat
teratoma MR CT MR
MR MR
US CT US CT
CT Follicular cyst

3-8 . 25 .

261
2015
Merging
Knowledge
and Practice
in OB-GYN

CT

enhancement attenuation
15 HU enhancement 1-2

Cystic
corpus
luteum
luteinizing
follicular bed
corpus luteum
neoangiogenesis

corpus
luteum
first
trimester
corpus
luteum
(cystic corpus luteum) 2
(hemorrhagic
cystic corpusluteum)
cystic
(1)

corpus
luteum

CT
unilocular

(crenulated wall)
enhancement
(
1)
attenuation
follicular

cyst
corpus luteum cyst
1
Cystic corpus luteum 2
Hemorrhagic cyst
Hemorrhagic
ovarian cyst

follicular cyst corpus luteal cyst CT
-hCG
unilocular
attenuation
25-100 HU(1)
CT
fluid-fluid level ( 2)
(rupture)
CT
(hemoperitoneum)
Endometriomas

10 80 (1)
CT endometrioma
endometriosis
(implant) malignant disease abscess
262

CT unilocular multilocular
US CT
MR
(rupture) ( 3)
Torsion

(benign)

CT adnexa 5 .
target liked mass
adnexa 40

enhancement (1-3)
Tubo-ovarian abscess (TOA) and Pyosalpinx

Pelvic inflammatory disease (PID)
(cervicitis)
(endometritis) (salpingitis) (TOA)

US
CT

CT(2-3) ( 4)

1. adnexa septa

2. mesosalpinx

3. round ligament
omentum mesentery

4. (satellite lesion)

5.
3 Endometrioma with rupture 4

TOA
263
Neoplasm
Teratomas
15
mature
benign
15-20
(1)
(malignancy)

CT

fat
(1)
90
enhancement

( 5)
immature
cystic teratoma
enhancement

fat
mature
teratoma
cystic
( 6)

6
Immature teratoma
Fibrotic
tumor
(4)

4 neoplasm

(4)
fibroma,
thecoma
fibrothecoma

ascites
Meig

pleural
effusion
syndrome

CT
(solid
mass)
hypoattenuation

enhancement enhancement
pedunculated uterine leiomyoma

5
Mature cystic teratoma
Epithelial Neoplasm

60 neoplasm 85
serous mucinous tumors clear cell, endometrioid
Brenner tumor epithelial tumor 50-70
serous carcinoma 40 mucinous cystic neoplasm
(5)
264
Merging
2015
Knowledge
andPractice
in OB-GYN

CT
unilocular multilocular

septa
papillary
projection
benign

malignancy

benign
unilocular
multilocular
septa
papillary projection
malignancy
papillary
projection

enhancement
multilocular
septa (> 3 .)

Serous cystadenoma
unilocular
mucinous cystadenoma
multilocular

locule ( 7)
serous

cystadenocarcinoma mucinous cystadenocarcinoma multilocular

( 8)
7 Mucinous cystadenoma 8 Serous cystadenocarcinoma
(local
extension)
cul-de-sac, sigmoid colon, omentum, uterus, pelvic peritoneum
structure 3 (6)

1. Intraperitoneal

ascites
implant
implantation
omentum
mesentery
peritoneal
implantation
mucinous tumor
mucin
pseudomyxoma peritonei ( 9-11)

2.
gonadal vein
Lymphatic
invasion
para-aortic
pericaval chain
(short
axis) lymphatic invasion ( 12)

3. Hematogenous dissemination

CT MR MR
75-78 CT
265
Merging
Knowledge
Practice
in OB-GYN
and
2015
9 Peritoneal seeding
10 Omental caking

11 Pseudomyxoma peritonei
12 Lymph node metastasis

1. Potter
AW,
Chandrasekhar
CA. US and CT evaluation of acute pelvic pain of gynecologic
origin
in nonpregnant
premenopausal
patients.
2008;28:1645-1659.

RadioGraphics

2. Bennett
GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain:
RadioGraphics

spectrum
of CT
findings.
2002;22:785-801.

3. Yitta
S,
Hecht
EM,
CM, Bennett
GL. Added
of multiplanar

Slywotzky

value

reformation
in the
multidetector
CT
evaluation
of
the
female
pelvis:
a
pictorial
review.
RadioGraphics

2009;29:1987-2005.
Jeong YY, Outwater EK, Kang HK. Imaging evaluation of ovarian masses. RadioGraphics
4.
2000;20:1445-1470.
5. Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR imagings of ovarian tumors
with emphasis on differential diagnosis. RadioGraphics 2002;22:1305-1325.
6. Kawamoto S, Urban BA, Fishman EK. CT of epithelial ovarian tumors. RadioGraphics
1999;19:S85-S102.
266
Emergency management in GYN

..
-

1. (ectopic pregnancy)

2. (pelvic inflammatory disease; PID)

3. (complications of adnexal mass)

4. (abnormal uterine bleeding; AUB)

(ovarian hyperstimulation syndrome; OHSS)

3

1. /

- (medical imaging techniques)

(transvaginal ultrasound; TVUS)(1)
87-99 94-99 (2)

1(3)
267
1:

Tubal

Interstitial

Cornual

Cervical

Cesarean scar

Ovarian

Intramural

Abdominal

1. Empty uterine cavity

2. An inhomogeneous adnexal mass or, an empty extra-uterine
gestation sac or a yolk sac or fetal pole cardiac activity in an
extra-uterine sac
2. Products of conception/gestation sac located in the interstitial
(intramyometrial) portion of the tube surrounded by a continuous
rim of myometrium
3. Interstitial line sign (thin echogenic line extending from a central
uterine cavity echo to the periphery of the interstitial sac)
1. A single interstitial portion of the Fallopian tube in the main uterine body
2. Products of conception/gestation sac mobile and separate from
the uterus surrounded by the myometrium
3. Vascular pedicle joining the gestational sac to the unicornuate uterus
2. Barrel shaped cervix
3. Products of conception/gestation sac below the level of the internal
cervical os
4. Negative sliding organ sign
2. Products of conception/gestation sac located anteriorly at the level
of the internal os covering the presumed site of the previous lower
segment Caesarean section scar
3. Negative sliding organ sign
4. Evidence of peritrophoblastic flow on color Doppler examination
2. Cystic structure with a wide echogenic ring on or within the ovary,
generally seen surrounded by ovarian cortex and separate from the
corpus luteum
2. Products of conception/gestation sac completely surrounded by
myometrium and separate from the endometrial cavity
2. No evidence of a dilated Fallopian tube or complex adnexal mass
3. Gestation sac surrounded by loops of bowel and separated by peritoneum
4. Wide mobility similar to fluctuation of the sac
268

(CT) (MRI)

CT
2
(non-tubal ectopic pregnancies) interstitial cornual, ovarian, cervical,
abdominal cesarean scar pregnancies (heterotopic pregnancy)(4)

-

-hCG
(serial measurement)
(3) -hCG
( 1,500-2,000 mIU/ml) (discriminatory zone)
-hCG
(3,5-6)
-hCG (3)

(6)

-hCG
salpingostomy (6-7)

- (biochemical markers)

metalloprotease 12, fibronectin cell-free pregnancy-associated microRNAs(3,8)

- (diagnostic laparoscopy)

TVUS
TVUS
(3)
(pregnancy of unknown location; PUL)(3,6)

2. /

(6)

-

( )
2 salpingectomy salpingostomy
(6) (laparoscopy)
(laparotomy) (6,9)
269

(salpingostomy) -hCG
(6)
33.5
fimbria isthmus (10)

-

methotrexate single-dose
80-90(7,11)
-hCG 2,000 mIU/ml(6,11)
(hemoperitoneum) (12)

- (expectant management)

-hCG
TVUS
-hCG -hCG
(6)

1. /

-

(13-14) 75
(13)
(13-14)
(minimum criteria) Centers
for Disease Control and Prevention (CDC) 2(14)

-

1) TVUS 2)
TVUS (Doppler studies) 3) CT 4) MRI
(14-15)
(13-14)

CDC (specific criteria)
2(14)
270
2:
Levels of criteria
Minimum (1 or
more for
presumptive
diagnosis)
Additional

Specific

Findings
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness

Oral temperature >101F (>38.3C)
Abnormal cervical mucopurulent discharge or cervical friability
Presence of abundant numbers of WBC on saline microscopy of
vaginal fluid
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Laboratory documentation of cervical infection with N.
gonorrhoeae or C. trachomatis
Endometrial biopsy with histopathologic evidence of endometritis
Transvaginal sonography or magnetic resonance imaging techniques
showing thickened, fluid-filled tubes with or without free pelvic
fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic
infection (e.g., tubal hyperemia)
Laparoscopic findings consistent with PID

-

(16)
osteopontin
(tubo-ovarian abscess; TOA) (17)

2. /

CDC .. 2015 3(14)
271
3 :
Regimens
Parenteral

Intramuscular/Oral

Options
1. Cefotetan 2 g IV every 12 hours PLUS Doxycycline 100 mg orally or
IV every 12 hours
2. Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV
every 12 hours
3. Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose
IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every
8 hours. Single daily dosing (35 mg/kg) can be substituted.
1. Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg
orally twice a day for 14 days WITH or WITHOUT Metronidazole
500 mg orally twice a day for 14 days
2. Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally
administered concurrently in a single dose PLUS Doxycycline
100 mg orally twice a day for 14 days WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
3. Other parenteral third-generation cephalosporin (e.g., ceftizoxime
or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for
14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day
for 14 days

parenteral
72 (18) TOA
TOA 1) 2) 6-10
3) 72 (18)

(minimally-invasive drainage) transvaginal ultrasound-guided aspiration
(18)

1. /

(torsion)
(hemorrhage/rupture) (19)
58(20)
272

-

(19)
(color Doppler)
(21)
(19) CT MRI

color Doppler hemorrhagic infarction
(22)

(19)
(functional
ovarian cysts) hemorrhagic corpus luteum (pathological cysts)
dermoid cyst, endometriotic cyst (19)

-

(leukocytosis)
(19)
interleukin-6(23)

endometriotic
cyst C-reactive protein D-dimer

(24)

2. /

(19)
(ischemia) (detorsion)
(thrombo-embolism)(25)

(cystectomy)
(26-27)

(19)
273
1. Oron G, Tulandi T. A pragmatic and evidence-based management of ectopic pregnancy. J

Minim Invasive Gynecol 2013;20:446-54.
2. Kirk E, Bourne T. Diagnosis of ectopic pregnancy with ultrasound. Best Pract Res Clin Obstet
Gynaecol 2009;23:501-8.
3. Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the
management of pregnancy of unknown location. Hum Reprod Update 2014;20:250-61.
4. Kao LY, Scheinfeld MH, Chernyak V, Rozenblit AM, Oh S, Dym RJ. Beyond ultrasound: CT
and MRI of ectopic pregnancy. Am J Roentgenol 2014;202:904-11.
5. Doubilet PM, Benson CB. Further evidence against the reliability of the human chorionic
gonadotropin discriminatory level. J Ultrasound Med 2011;30:1637-42.
6. Barash JH, Buchanan EM, Hillson C. Diagnosis and management of ectopic pregnancy. Am
Fam Physician 2014;90:34-40.
7. Atkinson M, Gupta S, Mcgee T. hCG monitoring after single-dose methotrexate treatment
of tubal ectopic pregnancy: is the Day 4 hCG necessary? A retrospective cohort study.
Aust N Z J Obstet Gynaecol 2014;54:475-9.
8. Miura K, Higashijima A, Mishima H, Miura S, Kitajima M, Kaneuchi M, et al. Pregnancy-associated microRNAs in plasma as potential molecular markers of ectopic pregnancy. Fertil
Steril 2015;103:1202-8.
9. Cohen A, Almog B, Satel A, Lessing JB, Tsafrir Z, Levin I. Laparoscopy versus laparotomy in
the management of ectopic pregnancy with massive hemoperitoneum. Int J Gynecol Obstet
2013;123:139-41.
10. Kayatas S, Demirci O, Kumru P, Mahmutoglu D, Saribrahim B, Arinkan SA. Predictive factors
for failure of salpingostomy in ectopic pregnancy. J Obstet Gynecol Res 2014;40:453-8.
11. Helmy S, Bader Y, Pablik E, Tiringer D, Pils S, Laml T, et al. Cut-off value of initial serum
-hCG level predicting a successful MTX therapy in tubal ectopic pregnancy: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2014;179:175-80.
12. Gnisci A, Stefani L, Bottin P, Ohannessian A, Gamerre M, Agostini A. Predictive value of hemoperitoneum for outcome of methotrexate treatment in ectopic pregnancy: an observational
comparative study. Ultrasound Obstet Gynecol 2014;43:698-701.
13. Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med
2015;372:2039-48.
14. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64:1-137.
274
15. Lee MH, Moon MH, Sung CK, Woo H, Oh S. CT findings of acute pelvic inflammatory disease.
Abdom Imaging 2014;39:1350-5.
16. Yang SF, Wu TF, Tsai HT, Lin LY, Wang PH. New markers in pelvic inflammatory disease. Clin
Chim Acta 2014;431:118-24.
17. Tee YT, Wang PH, Yang SF, Tsai HT, Lee SK, Ko JL, et al. Correlation of plasma osteopontin
and neutrophil gelatinase associated lipocalin levels with the severity and clinical outcome
of pelvic inflammatory disease. Taiwan J Obstet Gynecol 2014;53:158-61.
18. Mitchell C, Prabhu M. Pelvic Inflammatory Disease: current concepts in pathogenesis, diagnosis and treatment. Infect Dis Clin North Am 2013;27:793-809.
19. Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract
Res Clin Obstet Gynaecol 2009;23:711-24.
20. Bouguizane S, Bibi H, Farhat Y, Dhifallah S, Darraji F, Hidar S, et al. Adnexal torsion: a report
of 135 cases. J Gynecol Obstet Biol Reprod (Paris) 2003;32:535-40.
21. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics
2008;28:1355-68.
22. Rha SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS, et al. CT and MR imaging features of
adnexal torsion. Radiographics 2002;22:283-94.
23. Cohen SB, Weisz B, Seidman DS, Mashiach S, Lidor AL, Goldenberg M. Accuracy of the
preoperative diagnosis in 100 emergency laparoscopies performed due to acute abdomen
in nonpregnant women. J Am Assoc Gynecol Laparosc 2001;8:92-4.
24. Tanaka K, Kobayashi Y, Dozono K, Shibuya H, Nishigaya Y, Momomura M, et al. Elevation
of plasma D-dimer levels associated with rupture of ovarian endometriotic cysts. Taiwan J
25. McGovern PG, Noah R, Koenigsberg R, Little AB. Adnexal torsion and pulmonary embolism:
case report and review of the literature. Obstet Gynecol Surv 1999;54:601-8.
26. Mathew M, Mubarak SA, Jesrani SK. Conservative management of twisted ischemic adnexa
in early pregnancy. Ann Med Health Sci Res 2015;5:142-4.
27. Li YT, Kuon LC, Lee PN, Kuo TC. Laparoscopic detorsion of twisted ovary. J Chin Med Assoc
2005;68:595-8.
275

..

30

()

(17 )

( 10-12)(1)
(2)

()

277

1) ()

(basic service) (2)

bag (mask)

(comprehensive service)

(
)

(3)

19 14 ( )

(4)

2)

(5)
(WHO) UNICEF UNFPA
278
5 (5)
5
20-25

( )

1.
(

)

()

learning curve

(
)

2.

(
)
()

(
) (poor circulation poor contraction)

3.

( condom-balloon
279
( SOS Bakri balloon

)
bimanual compression

4.
DIC
DIC

(
recombinant factor VII ) Pack and Go back ( 1)(6)
( Kocher clamp Kocher
) umbrella packing ( 2)(7,8) ( SOS
Bakri balloon )

5.

( ) Mc Roberts

( )
4
(

)

6.
learning curve Mauriceau-Smellie-Veit

1)
(AP) 2)

3) 4)
5) Piper forceps 1-4
Piper forceps ( Piper
forceps )
280
1
Pack
Go Back
and
2 Umbrella pack
281
(1) Charoenweerakul P, Srisupundit K, Tongsong T. Maternal death at Maharaj Nakorn Chiang

Mai hospital, the 17 years experience. Thai J Obstet Gynaecol 2009;17(4):230-6.
(2) World Health Organization UNPFUMSoPH. Monitoring emergency obstetric care : a handbook.
2009.
(3) Goldie SJ, Sweet S, Carvalho N, Natchu UC, Hu D. Alternative strategies to reduce maternal
mortality in India: a cost-effectiveness analysis. PLoS Med 2010 Apr;7(4):e1000264.
(4) Hussein J, Kanguru L, Astin M, Munjanja S. The effectiveness of emergency obstetric referral
interventions in developing country settings: a systematic review. PLoS Med 2012;9(7):e1001264.
(5) AbouZahr C, Wardlaw T. Maternal mortality at the end of a decade: signs of progress? Bull
World Health Organ 2001;79(6):561-8.
(6) Finan MA, Fiorica JV, Hoffman MS, Barton DP, Gleeson N, Roberts WS, et al. Massive pelvic
hemorrhage during gynecologic cancer surgery: pack and go back. Gynecol Oncol 1996
Sep;62(3):390-5.
(7) Burchell RC. The umbrella pack to control pelvic hemorrhage. Conn Med 1968 Oct;32(10):
734-6.
(8) Dildy GA, Scott JR, Saffer CS, Belfort MA. An effective pressure pack for severe pelvic
hemorrhage. Obstet Gynecol 2006 Nov;108(5):1222-6.
282
Prevention of Thalassemia : Obstetric Approaches

..

Thalassemia refers to a group of inherited hematological disorders. They occur most
commonly among Asian people, especially of Southeast Asian, Southern Asian and Mediterranean
populations. Complications of thalassemia can be prevented when patient with thalassemia
major are treated with regular blood transfusions to keep their hemoglobin level around or
more than 10 g/dl. But frequent blood transfusions also lead to an accumulation of iron in the
body, which can damage the heart, liver, and other organs. Iron chelator can helps the body
to eliminate excess iron and prevent or delay problems related to iron overload. While these
conventional therapy involving blood transfusions and iron chelation are expensive, prenatal
approaches by prenatal diagnosis and selective abortion are more economical, which should
not be carried out indiscriminately. This approach needs an accurate diagnosis and very good
understanding of the disease.

In Thailand, the type and frequencies of thalassemia are heterogenous, both a and
b thalassemia and some abnormal hemoglobins such as Hb E and Hb Constant Spring. The
frequencies are 20-30% for a thalassemia, 3-9% for b thalassemia, 10-50% for Hb E and 1-8%
for Hb Constant Spring. These abnormal genes in different combinations lead to over 60 thalassemia
syndromes. Due to the large number of thalassemic patients and limited medical service
resources, it is not possible to give optimal blood transfusions and iron chelating agents to
the majority of patients. The best approach to cope with thalassemia in developing countries,
including Thailand, is to prevent birth of new cases with major thalassemic disease.

In 2004, our team reported the prevalence of thalassemia in pregnant women in
northern area of Thailand, with the overall prevalence of thalassemia trait or heterozygote
being 25.4%; which classified as a thalassemia 1 trait were 6.6%, b thalassemia trait 3.75, Hb E
trait 11.6%, homozygous Hb E 0.8%. The combination of a thalassemia 1 trait and b thalassemia
trait was 1.2%, combination of a thalassemia 1 trait and Hb E traits were 1.5% and also found
b thalassemia/Hb E disease as 0.2%. This high prevalence of thalassemia trait leads to many
births of severe thalassemia as previously described. Before the prevention and control program
283
by prenatal approach was initiated in 1994, our department encountered about 20 cases of
homozygous b thalassemia, 30-40 cases of b thalassemia/Hb E disease and 20-30 cases of Hb
Barts hydrops each year, from the total births of 6000-8000.
Chiangmai Strategy for The Prevention and Control of Severe Thalassemia

Since 1998, the Chiangmai team developed a feasible method and have had great
success in control of severe thalassemia, simply and at much lower cost. Later, we have
modified the original strategy to be more accurate and effective. The strategy includes:

1. Genetic counseling

2. Identification of pregnancies at risk by:

a. Retrospective screening (history review of known risk)

b. Prospective screening for asymptomatic women

1. Screening test: OF test and Hb E screening

2. Diagnostic test (if both partners of the couple are positive according to the

screening test):

a. Hb A2 level and PCR for a thal 1 if OFT positive

b. Hb A2 level if OFT negative but Hb E positive

3. Prenatal diagnosis for pregnancy at risk

a. Prenatal counseling

b. Cordocentesis at 18-22 weeks gestation

c. Fetal blood analysis with high performance liquid chromatography (HPLC)

4. Termination of the affected pregnancy
The prospective screening consisted of OF test and Hb E screening tests in women with no
risk and testing the husbands of the women with a positive result. Subsequently, the OF test
was replaced by MCV when the automated cell counters became available nationwide. If
both partners had a positive result, the further diagnostic test (Hb A2 and PCR) for the carrier
was needed. A pregnancy in which both partners of the couple were carriers was considered a
couple at risk (CAR), the further in-detail counseling and cordocentesis was offered for prenatal
diagnosis of the severe thalassemia syndrome. (Figures 1 and 2)
284
Figure 1 Main scheme for the screening of thalassemia carriers, Chiangmai strategy
Figure 2 Outline of thalassemia screening techniques.

Presently, we introduced the IC strip test (immunochromatographic strip test) for

inthe

detection
a thalassemia
1 (SEA type)
area
which
PCR test was not available.

Since the program was started the number of new cases of severe thalassemia at
our
institute is gradually decreasing. In the very first few year of program, we evaluated the

and
that
among

of
cost-effectiveness
of
the
program
found
the
total
pregnant
population
21,000

individuals
that
we
screened,
affected
fetuses
had
been
terminated.
The total
80
detected
and
cost of the prevention program was about US$ 257,140 and the cost of management of these
affected cases, if they had been born, would be US$ 7,200,000. The cost-benefit ratio is 1:28,
which is a very highly cost-effective project.

Once the couple at risk is identified, the prenatal diagnosis will offer for the couple as
the flow in figures 3-5

285

Figure 3-5 Flow chart which offer prenatal diagnosis for the couple at risk in b thalassemia,

b thal/Hb
E and
Hb Barts hydrops
286

Conclusion

Thalassemia is one of the major public health problems in Asia and Thailand. The
strategy for a control program consists of treatment and prevention; treatment of existing cases
in the most cost-effective way, and reducing the new cases. This should define the methods of
treatment and prevention appropriate to each individual area and individual country. To achieve
success in the prevention and control of thalassemia needs continuity and holistic approach. It
is expected that with optimal collaboration and support, effective prevention and control can
be achieved. This will lead to better quality of life for the next generation.
Table
1 Effectiveness of the prevention and control program at Faculty of Medicine, Chingmai

University, between 2003-2013.
287
Reference:
1. Fucharoen S, Winichagoon P, Thonglairoam V, et al.(1991). Prenatal diagnosis of thalassemia
and hemoglobinopathies in Thailand: experience from 100 pregnancies. Southeast Asian J
Trop Med Public Health 22, 16-29.
2. Fucharoen S, Winichagoon P.(1987). Hemoglobinopathies in Southeast Asia. Hemoglobin 11,
65-88.
3. Tongsong T, Wanapirak C, Sirivatanapa P, et al.(2000). Prenatal control of severe thalassemia:
Chiang Mai strategy. Prenat Diagn 20, 229-234.
4. Tongsong T, Wanapirak C, Sirivatanapa P, et al.(2001). Prenatal eradication of Hb Barts
hydrops fetalis. J Reprod Med 46, 18-22.
5. Wanapirak C, Muninthorn W, Sanguansermsri T, Dhananjayanonda P, Tongsong T.(2004).
Prevalence of thalassemia in pregnant women at Maharaj Nakorn Chiang Mai Hospital.
J Med Assoc Thai 87, 1415-1418.
6. Wanapirak C, Tongsong T, Sirivatanapa P, Sanguansermsri T, Sekararithi R, Tuggapichitti
A.(1998). Prenatal strategies for reducing severe thalassemia in pregnancy. Int J Gynaecol
Obstet 60, 239-244.
7. Wasi P, Na-Nakorn S, Pootrakul S, et al.(1969). Alpha and beta thalassemia in Thailand. Ann
NY Acad Sci 165, 60-82.
8. Wasi P.(1981). Hemoglobinopathies including thalassemia. Part I: Tropical Asia. Clin Haematol
10, 707-729.
288
:
HPV Testing
(Cervical Cancer Screening with Primary HPV Testing)
..
HPV
HPV HPV testing
HPV testing
HPV testing
HPV testing

(morbidity)
(mortality)

precancerous/preinvasive lesions CIN 2, CIN 3 AIS
HPV

HPV testing HPV-based screening cytology-based
screening

30-59 131,746
3 (1)

1. HPV (HPV testing)

2. (cervical cytology)
289

3. (visual inspection with acetic acid, VIA)

3
3

HPV testing
1 8
HPV testing 1
1 3 (1)

HPV testing
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VIA

*
12.7
21.5
20.9
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14%

**
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15.5
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3.5 5.5 (2) 2

2 HPV-based screening cytology-based
screening
HPV test
(screening interval) 5 (2)
290
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15.4
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Kaiser Permanente 8
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Pap smear CIN
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HPV Testing
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(2,5-9)
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cytology
cytology HPV testing CIN3+
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0.5% 0.1% (12) 3 Katki
300,000 HPV-negative CIN3 3
cytology-negative(13) negative HPV test
negative cytology
291
and Practice
in OB-GYN 2015
Merging
Knowledge
176,000
Ronco

HPV testing

cytology
relative
risk(RR)
= 0.45(95%
CI : 0.25-0.81)

HPV
testing adenocarcinoma squamous cell carcinoma pooled

(2)
rate
ratio
=
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(95%
CI
:
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CI
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negative
cytology
HPV Testing
HPV Testing Cytology Co-testing

HPV-negative CIN3+
co-testing-negative HPV testing 3
co-testing 5
25 42,000
HPV testing cytology HPV testing CIN3+
cytology 92% 53% (14) HPV-negative 3-year
CIR of CIN3+ co-testing-negative cytology-negative 3-year CIR
2 4

1
CIN3+ 3 5 negative HPV testing negative
co-testing co-testing
HPV testing 3 negative HPV testing
5 negative co-testing
3 negative cytology(10) 5
292
MergingKnowledge
and Practice
in
OB-GYN
2015
4 3-Year Cumulative Incidence Rate (CIR) CIN3+ (11)
CIN3+ Cancer 3 5 Negative Screening Test(10)
HPV16
HPV18

HPV16 HPV18 70%
HPV
(15)
squamous
cellcarcinoma
adenocarcinoma
HPV16
55%-60%
(16)
HPV18
adenocarcinoma

(15) HPV16/18-positive cytology
CIN2+
CIN2+

30 cytology-negative HPV-positive
HPV16 /18-positive CIN2 11.7%
1 10 HPV 4.7%(17)

HPV-positive cytology-negative 10 HPV16/18positive CIN3+ HPV-positive
14-17% 3% (18) HPV16-positive / HPV18-positive
CIN3+ normal cytology (19)

HPV16/18-positive 3-year CIR CIN3+ 21.6%
HPV 3-year CIR CIN3+ 5.4%(11)
Rijkaart HPV16/18 3-year CIR CIN3+
26% HPV 3-year CIR CIN3 6.6%(5)
293

HPV 16/18
HPV-positive HPV 16/18-positive
cytology HPV16/18 cytology
( ASCUS) cytology 1 co-testing

HPV testing
cytology
HPV testing HPV 16/18 genotyping
CIN3 (20)

ASC-US cytology HPV-positive CIN2
14.0% HPV-negative
CIN2 0.8% 1 (21)
HPV test

HPV testing
co-testing cytology
1 HPV testing(22)

1. Negative: 3

2. Positive: HPV 16/18 genotyping

- HPV16/18 positive

- HPV positive non 16/18 cytology

co-testing 12

ASCUS

3. HPV16/18 genotyping cytology

- co-testing 12

- ASCUS
294
HPV testing

HPV testing 25

ATHENA
CIN3+
30%
37%
25-29
30-39
50%
25-29
(22)
testing
25
CIN3+
cytology
HPV
CIN3+ colposcopy
30

CIN3+
25-29
295
HPV testing
HPV testing
3
Ronco HPV screening 5
cytology 3
3 (2)
ATHENA 3-year CIR CIN3+ negative HPV testing
1%(11) HPV-negative 3 CIR
3
3 negative HPV testing
3 (22)
Negative HPV Testing

HPV testing
(false negative) HPV testing
(23-27) 777 HPV
91% HPV
(25)
136 14 (10%) HPV-negative
Hybrid Capture 2 PCR assays 3 SPF10, GP5+/6+
E7-specific assay 8 136 (5.8%) HPV-negative 6 HPV11,
16 (2 ), 18, 45 68 HPV-negative adenocarcinoma
squamous cell carcinoma (15.6% 2.9% p = 0.017) HPV-negative
disease-free survival HPV-positive(26)

HPV testing
(internal controls)
primary HPV screening
HPV

1.
- HPV
- HPV 90-95 % 5-10%

(persistent)
296
- HPV

- HPV

HPV

2. cytology HPV
12 HPV

3.
HPV HPV
HPV

4. HPV
5

5.

6. HPV HPV 60%

HPV testing
HPV testing (automated)
Pap smear human errors
HPV testing
(reproducible) HPV testing

mass screening
-

-
20-70 HPV 7-10 %(28-30) HPV testing
(burden/workload)
Pap smear

297
HPV testing
Pap smear 7-10 % HPV-negative
3-5
HPV testing
cytology
HPV testing
Pap smear

HPV-based screening cytology-based screening
HPV-negative CIN3+
cytology-negative HPV-negative CIN3+
co-testing-negative HPV testing 3
co-testing 5

HPV testing
25 3 HPV-positive
HPV 16/18 genotyping HPV16/18-positive
HPV cytology cytology co-testing
12 cytology ASCUS HPV16/18 genotyping
cytology cytology ( ASCUS ) cytology
co-testing 12
1. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R, Budukh AM, et al. HPV
screening for cervical cancer in rural India. N Engl J Med 2009;360:1385-94.
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3. Leyden WA, Manos MM, Geiger AM, Weinmann S, Mouchawar J, Bischoff K, et al. Cervical
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preventable cervical cancer risks: evidence from a nationwide audit in Sweden. J Natl Cancer
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8. Gyllensten U, Gustavsson I, Lindell M, Wilander E. Primary high-risk HPV screening for
cervical cancer in post-menopausal women. Gynecol Oncol 2012;125:3435.
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10. Gage J, Katki HA, Schiffman M, Castle PE, Fetterman B, Poitras NE, et al. Reassurance against
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Natl Cancer Inst 2014;106:14.
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panel. http://www.fda.gov/AdvisoryCommittees /CommitteesMeetingMaterials/ Medical
Devices/MedicalDevicesAdvisoryCommittee/MicrobiologyDevicesPanel/ucm388531.htm;
March 12, 2014. (Accessed January 2015)
12. Dillner, J., Rebolj, M., Birembaut, P., Petry, K.U., Szarewski, A., Munk, C. et al. Long term
predictive values of cytology and human papillomavirus testing in cervical cancer screening:
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13. Katki HA, Kinney WK, Fetterman B, Lorey T, Poitras NE, Cheung L, et al. Cervical cancer risk
for women undergoing concurrent testing for human papillomavirus and cervical cytology:
a population-based study in routine clinical practice. Lancet Oncol 2011;12: 66372.
14. Castle PE, Stoler MH, Wright TC Jr, Sharma A, Wright TL, Behrens CM.et al.Performance of
carcinogenic human papillomavirus (HPV) testing and HPV16 or HPV18 genotyping for cervical
cancer screening of women aged 25 years and older: a subanalysis of the ATHENA study.
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15. Herzog TJ, Monk BJ. Reducing the burden of glandular carcinomas of the uterine cervix.Am
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cancer. Am J Clin Pathol 2012;137:516-42.
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genotyping for the triage of women with high-risk HPV+ cytology-negative results. Am J Clin
Pathol 2011;136:578-86.
18. Khan MJ, Castle PE, Lorincz AT, Wacholder S, Sherman M, Scott DR, et al. The elevated
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type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. J Natl
Cancer Inst 2005;97:1072-9.
19. Berkhof J, Bulkmans NW, Bleeker MC, Bulk S, Snijders PJ, Voorhorst FJ, et al.Human
papillomavirus type-specific 18-month risk of high-grade cervical intraepithelial neoplasia in
women with a normal or borderline/mildly dyskaryotic smear. Cancer Epidemiol Biomarkers
Prev 2006;15:1268-73.
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Comparison of cervical cancer screening strategies incorporating different combinations of
cytology, HPV testing, and genotyping for HPV 16/18: results from the ATHENA HPV study.
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papillomavirus testing in women with ASC-US cytology: results from the ATHENA HPV study.
Am J Clin Pathol 2011;135:468-75.
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high-risk human papillomavirus testing for cervical cancer screening: Interim clinical
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301
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( Thai Journal of Obstetrics and Gynaecology)
A Correlation between First-void Morning Urinary Protein to Creatinine Ratio

(UPCR) and 24 Hours Urinary Protein in Pregnancy with Suspected Preeclampsia
Pimchanok Pariyaeksut MD,
Tripop Lertbunnaphong MD,
Jarunee Leetheeragul B.N.S., M.N.S., A.P.N.,
Dittakarn Boriboonhirunsarn MD, MPH, PhD.
Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700,
Thailand
Abstract
Objective: To evaluate a correlation between first-void morning urinary protein to creatinine ratio
(UPCR) and 24-hour urine protein in pregnant women suspected of preeclampsia.
Materials and Methods: A total of 40 pregnant women suspected of preeclampsia were enrolled
and admitted for 24-hour urine collection. Collected urine was divided into 2 parts, first-void
morning urine and the remaining. First-void morning UPCR was determined and 24-hour urine protein
was calculated by a combination of protein from both specimens. Significant proteinuria was diagnosed
if the total 24-hour urine protein was greater than 300 mg. A correlation between first-void morning
UPCR and 24-hour urine protein was estimated using Pearson product-moment correlation coefficient (r).
Results: Mean age was 31.0 7.0 years and mean gestational age was 33.2 4.6 weeks. Eight patients
(20%) had significant proteinuria and were diagnosed as preeclampsia. A correlation between first-void
morning UPCR and 24-hour urine protein showed a significant positive correlation with coefficient (r)
of 0.76, p < 0.001. At the cut-off value of 0.3, first-void morning UPCR had sensitivity of 87.5% (95%
CI 46.7 99.3) specificity of 96.9% (95% CI 82.0 99.8) for diagnosis of significant proteinuria.
Conclusions: First-void morning UPCR significantly correlated with 24-hour urine protein. It should
be considered as an alternative method for detecting significant proteinuria in women suspected of
preeclampsia.
Keywords:
preeclampsia, urine protein to creatinine ratio, 24-hour urine protein
303
Free Communication
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Incidence of fetal bradycardia and effect of placental injury on fetal heart rate
during second-trimester genetic amniocentesis
Tharangrut Hanprasertpong**, Chusana Petpichetchian*, Surachai Ponglopisit*, Manaphat Suksai*,
Ounjai Kor-anantakul*, Alan Geater*, Ninlapa Pruksanusak*, Jitti Hanprasertpong.*
*Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University
**Department of Obstetrics and Gynaecology, Faculty of Medicine, Srinakharinwirot University
Abstract
Objective: To compare the incidence of fetal bradycardia and level of fetal heart rate change
following a second-trimester genetic amniocentesis with and without placental injury.
Methods: A prospective study was performed in singleton pregnancies that were scheduled for
second-trimester genetic amniocentesis in order to compare the incidence of fetal bradycardia
between injured and non-injured placenta during amniocentesis
Results: A total of 257 and 495 participants in injured and non-injured groups were analyzed.
The incidence of fetal bradycardia following amniocentesis was not statistically different between the
two groups. (1.17% and 0.20% in injured and non-injured placenta groups, respectively; p=0.095). The
mean change of baseline fetal heart rate before and after amniocentesis was also not significantly
different between the two groups. (p = 0.84) No fetal death or pregnancy loss occurred within 4 weeks
after the procedure. All 4 bradycardia participants were normal and healthy and had an appropriate
weight for their gestational age. Additionally no fetal gross structural malformations at birth or
additional composite maternal pregnancy complications were observed.
Conclusion: Placental injury during a second-trimester genetic amniocentesis due to advanced
maternal age had no effect on the incidence of bradycardia and the change of fetal heart rate
baseline values.
304
Free Communication
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Accuracy of ultrasonography performed by Maternal Fetal Medicine fellowship

in developing country as Thailand for fetal sex determination during second
trimester genetic amniocentesis
Tharangrut Hanprasertpong*, Ounjai Kor-anantakul#, Alan Geater*, Chitkasaem Suwanrath#, Surachai
Ponglopisit#, Chusana Petpichetchein#, Manaphat Suksai#
# Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University
* Department of Obstetrics and Gynaecology, Faculty of Medicine, Srinakharinwirot University
Abstract
Objective: To evaluate the accuracy of fetal sex determination during second trimester amniocentesis and also identify the factors of inaccurate determination
Methods: A prospective study was conducted to evaluate the accuracy of fetal sex determination
during second trimester amniocentesis and identify the possible factors of inaccurate determination
Results: 560 women were enrolled. The sex of 11/552 (1.99%) fetuses could not be adequately
determined. Overall, 491 of the 541 diagnose were correct an accuracy of 90.8% (CI88.0-93.1) given
an ultrasonographic diagnosis could be made. Among phenotypic females, the accuracy was 226/246,
(91.9%; 95% CI 87.7-95.0) and among phenotypic males, the accuracy was 276/295, (89.9%; 95% CI
85.8-93.0). The diagnosis of female sex was correct in 226/256, (88.3%; 95% CI 84.0-92.0), and the
ultrasonographic diagnosis of male sex was correct in 265/285, (93.0%; 95% CI 89.4-95.7). For both
sexes combined and for female fetuses, year of fellowship was only significant variable associated
with correct sex determination. [2nd year vs1st year: overall OR 2.55, (95% CI 1.44 4.61); female
fetuses OR 6.54, (95% CI 2.48- 17.26)].
Conclusion: Fetal sex determination using ultrasonography during amniocentesis is possible. Less
experienced physicians should be had increased awareness especially in case
305
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Case Report of Transient Abnormal Myelopoiesis in Down Syndrome fetuses.

Wirada Hansahiranwadee, MD, Chayada Tangshewinsirikul, MD, Sommart Bumrungphuet, MD, Panyu
Panburana, MD.
Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok 10400, Thailand
Abstract
Objective: To report the ultrasound findings and clinical course of transient abnormal myelopoiesis
(TAM) in Down syndrome fetuses which were prenatally diagnosed in Ramathibodi hospital.
Material and Methods: Medical records of 2 cases with confirmed TAM in Down syndrome were
retrospectively reviewed for prenatal ultrasonographic findings, fetal blood analysis, flow cytometry
and postnatal clinical course.
Result: From May 2010 to September 2013, 2 cases of TAM associated with Down syndrome were
confirmed. Sonographic presentations of non-immune hydrops fetalis were initially manifested at
late second trimester to early third trimester including fetal ascites, hepatomegaly and cardiomegaly.
Congenital infection was precluded. Complete blood count from cord bloods in both cases
showed with abnormal leukocytosis with blast cells and fetal anemia. The platelet counts showed
thrombocytosis in one case whilst thrombocytopenia was found in the other. Preterm births were
the only adverse obstetric outcome found in both cases. TAM resolved spontaneously after birth.
Conclusion: Fetal TAM is one of hematologic conditions causing non-immune hydrops fetalis in
fetuses with Down syndrome. Liver failure and anemic induced high-output heart failure could be the
supposed pathogenesis of hydrops.
306
Free Communication
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Uthaithanee Hospital steps for control severe hemorrhage after placental

removal in case of placenta previa
Permkiat Tangcharoensilp MD, Poutthaporn Tovivut MD, Jutharut Photiwan, Chudapa Wimonpun.
Department of Obstetric and Gynecology, Uthaithanee Hospital, Thailand. Permkiat.280103@gmail.com
Abstract
Objective: To describe the new policy (Uthaithanee hospital steps) contained with 6-steps such
as antenatal ultrasound diagnosis, classification, 3 tourniquet technique (uterine-ovarian vessels
ligation), bilateral uterine vessels ligation, direct suture at endometrium implantation site, and loosen
tourniquets for hemostasis check as steps 1-6 subsequently, for control severe hemorrhage in 4 cases
of placenta previa
Materials and methods: In Uthaithanee hospital, every placenta previa cases were classified as
complicated or not at ANC. Cases with uncontrolled bleeding after placental removal were treated
with the last four Uthaithane hospitals steps.
Result: During May 2013 to May 2015, two of four cases (50%) could be successfully controlled even
though subtotal hysterectomy was performed in one case due to suspected abnormal placental
adherence and complete family. Subtotal hysterectomy and B-Lynch uterine compression suture were
used in the failure cases. In the postpartum period, all parturient and their baby were uneventful.
Conclusion: Uthaithanee hospital steps was a fair policy for control severe hemorrhage after placental
removal in case of placenta previa
Keywords: placenta previa, placental removal, 3-tourniquets, severe hemorrhage
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Dusit 6
Pregnancy Outcomes among Women with Hemoglobin E trait

Walairat Kemthong, M.D., Phudit Jatavan, M.D., Kuntharee Traisrisilp, M.D., Theera Tongsong, M.D.
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
Abstract
Objective: To compare the maternal and fetal outcomes between pregnant women complicated
with hemoglobin E (HbE) trait and normal controls
Patients and methods: A retrospective cohort study was conducted by assessment of the database
of maternal-fetal medicine units from January 2003 to December 2013 to identify singleton pregnant
women complicated by HbE trait. Pregnancies with medical complications or fetal anomalies were
excluded. The normal controls were low risk pregnancies and were non-carrier status for thalassemia
and hemoglobinopathy.
Result: During the study period, 1,073 women with HbE trait and 2,146 normal controls were included.
The baseline characteristics of the two groups were comparable except that the number of prenatal
visit was statistically higher in study group (8.553.03 vs.7.854.33, p=<0.001). Most pregnancy
outcomes were not significantly different. However, the rate of asymptomatic bacteriuria was
minimally higher in the study group, 3.5% vs 2.3%; P=0.042 (relative risk 1.19; 95%CI: 0.98-1.43). Note
that the rates of gestational diabetes tended to be higher in the group of HbE trait (7.6% vs 6.8%),
but did not reach a statistical level.
Conclusion: The HbE trait does not significantly increase risk of common adverse pregnancy outcomes,
except for minimal increase in asymptomatic bacteriuria.
Keywords:
Hemoglobinopathy, Hemoglobin E, Pregnancy, Outcomes, Trait
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MFM
Dusit 6
Hemodynamic studies of isolated absent ductus venosus

Phudit Jatavan, M.D.*, Walairat Kemthong, M.D.*, Chitrakan Charoenboon, M.D.*, Fuanglada
Tongprasert, M.D.*, Kornkanok Sukpan, M.D.**, Theera Tongsong, M.D.*
* Department of Obstetrics and Gynecology,** Department of Pathology, Faculty of Medicine Chiang Mai University,
Thailand
Abstract
Objective: To evaluate hemodynamic changes among fetuses with isolated absent ductus venosus
(IADV) diagnosed by prenatal ultrasonography
Patients and Methods: Fetuses with prenatal diagnosis of IADV were recruited and followed-up.
Hemondynamic assessment was performed in all cases, including measurement of cardiac
dimensions, shortening fraction, myocardial performance index, preload index in the IVC and the
presence of venous pulsations in the UV. Fetuses with structural or chromosomal abnormalities were
excluded.
Results: Nine fetuses of IADV were assessed, including six cases with umbilical extra-hepatic drainage
(liver bypass) and three with intra-hepatic drainage. All fetuses with liver bypass showed an elevated
preload index in the IVC, venous pulsations in the UV and cardiomegaly. Of them, four had hydrops
fetalis, two showed poor cardiac function and three resulted in perinatal mortality. Three cases with
intra-hepatic drainage had continuous flow in the UV, normal in all hemodynamic parameters and all
survived.
Conclusion: Hemodynamic assessment of fetuses with IAPD was helpful in predicting the
development of hydrops fetalis and perinatal mortality. The poor prognostic factors included cardiac
overload, cardiomegaly, poor myocardial performance, increased preload, the presence of venous
pulsations and liver bypass.
Keywords: Cardiac function, Ductus venosus, Hydrops fetalis, Preload index, Venous pulsation
309
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MFM
Dusit 7
Strong influence of Thai ethnicity on the levels of first trimester serum markers, a
prospective study of 15,380 screenings
Theera Tongsong, MD., Chanane Wanapirak, MD., Wirawit Piyamongkol, MD., Supatra Sirichotiyakul,
MD., Fuanglada Tongprasert, MD., Kasemsri Srisupundit, MD., Suchaya Luewan, MD., Kuntharee Traisrisilp, MD., Phudit Jatavan, MD.
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand
Abstract
Objective: 1) To construct Thai-specific reference ranges of the first trimester serum markers,
pregnancy-associated plasma protein A (PAPP-A), and free beta-human chorionic gonadotropin (b-hCG),
as well as to compare with Caucasian-specific model, 2) To determine the discriminatory power of
both markers in differentiating fetal Thai Down syndrome
Materials and Methods: Thai pregnant women at gestational age of 11-98 days were prospectively
recruited to determine serum PAPP-A and free-beta hCG levels and were followed-up for pregnancy
outcomes. The main outcomes were percentage of difference between median MoMs of Thai specific
model and those of Caucasian specific model as well as comparisons of median MoMs between fetal
Thai Down syndrome and unaffected fetuses.
Results: A total of 15,380 singleton pregnancies were recruited, including 34 cases with fetal Down
syndrome and 15,346 unaffected fetuses. Thai reference ranges of free-beta hCG and PAPP-A were
established based on the best fitted equation derived from 13,506 normal pregnancies. After weight
correction, the medians based on Thai models were still significantly higher than those derived from
Caucasian models. The medians MoM of b-hCG and PAPP-A of Thai model after weight correction
were 12.5% and 12.8% higher than those of Caucasian models. Nevertheless, the effectiveness of
both markers in discriminating affected and unaffected pregnancies was as good as that studied on
Caucasian population. Median MoM of affected fetuses was 1.86 and 0.55 for b-hCG and PAPP-A
respectively. Mahalanobis distance was 1.1 and 1.2 SD for b-hCG and PAPP-A, respectively.
Conclusions: Both maternal serum b-hCG and PAPP-A could effectively differentiate fetal Thai Down
syndrome from unaffected fetuses but, in addition to weight correction, Thai ethnicity correction is
also mandatory.
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MFM
Dusit 7
Effectiveness of serum markers screening for fetal Down syndrome in Northern

Thai population, using Thai-specific model
Chanane Wanapirak, MD., Theera Tongsong, MD., Wirawit Piyamongkol, MD., Supatra Sirichotiyakul,
MD., Fuanglada Tongprasert, MD., Kasemsri Srisupundit, MD., Suchaya Luewan, MD., Kuntharee
Traisrisilp, MD., Phudit Jatavan, MD.
Abstract
Objective: To determine the effectiveness of fetal Down syndrome screening by serum markers
among northern Thai pregnant women based on Thai-specific model.
Methods: A prospective study on pregnant women attending antenatal clinics at 32 our network
hospitals, meeting the inclusion criteria. The recruited women underwent first trimester (11-14 weeks)
or second trimester (16-20 weeks) serum markers screening (placental-associated protein-A and freebeta hCG for first trimester screen and alpha-fetoprotein, free beta-hCG and unconjugated estriol for
second trimester screen). Women undergoing the first trimester screening were approached as the
contingent sequential screening. Pregnancies at high risk (> 1:250) were referred for invasive diagnoses.
All neonates were finally evaluated for chromosome status. Effectiveness of the screening test based
on Thai-specific and western reference ranges were evaluated.
Results: A total of 21,744 singleton pregnancies meeting inclusion criteria were screened with
complete data. Of them, 43 pregnancies had fetal Down syndrome (prevalence 1:506). With Thai
model, 37 out of 43 were prenatally diagnosed, detection rate of 86.0%, at false positive rate of 8.0%
(1744 cases), compared to that using western model, detection rate of 86.0% at false positive rate of
12.8 % (2775 cases). When maternal age-based screening was applied, only 11 (25.6%) fetuses with
Down syndrome were prenatally detected with 12.7% false positive rate. When considering only the
first trimester screening (15,380 women), the detection rate and false positive rate based on Thai and
Western model were 88.2% vs 88.2% and 7.7% vs 13.6%, respectively.
Conclusion: Based on Thai-specific model of biochemical markers, a significant number of fetuses
with Down syndrome were prenatally detected, whereas the false positive rate reflexive of the
unnecessary invasive procedures could be avoided nearly 5% (more than 1000 procedures). This
experience indicates that each population should develop its own reference ranges of the serum
markers. Maternal age-based screening yielded unacceptably low detection rate and high false
positive rate, suggesting no longer use even in the low socio-economic population.
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MFM
Dusit 7
Cost-benefit analysis of prenatal control of Down syndrome using Thai model

Kasemsri Srisupundit, MD., Piyaluk Buddhawongsa, PhD*, Woraluck Himagalasa, PhD*, Theera
Tongsong, MD., Chanane Wanapirak, MD., Wirawit Piyamongkol, MD., Supatra Sirichotiyakul, MD.,
Fuanglada Tongprasert, MD., Suchaya Luewan, MD., Kuntharee Traisrisilp, MD., Phudit Jatavan, MD.
Department of Obstetrics and Gynecology, Faculty of Medicine, and * Faculty of Economics, Chiang Mai University,
Thailand
Abstract
Objective: To assess the cost-benefit of prenatal Down syndrome screening based on Thai-specific
model.
Methods: A prospective study on pregnant women attending antenatal clinics at 32 our network
hospitals, meeting the inclusion criteria. The recruited women underwent first trimester (11-14 weeks)
or second trimester (16-20 weeks) serum markers screening (placental-associated protein-A and freebeta hCG for first trimester screen and alpha-fetoprotein, free beta-hCG and unconjugated estriol for
second trimester screen). Women undergoing the first trimester screening were approached as the
contingent sequential screening. Pregnancies at high risk (> 1:250) were referred for invasive diagnoses.
Results: In screening 15731 women, 83.3% of fetal Down syndrome were detected in early
gestation and were controlled. During the study period, the prevalence of Down syndrome was
decreased in more than 80% and the number of invasive diagnoses was 50% decreased, when
compared to maternal age based screening. If this strategy was applied to Thai population in the year
2014 in which 800,000 pregnant women were included, the number of unnecessary invasive diagnoses
was decreased in 31,180 cases (4.7%) when compared to the western model. In cost-benefit analysis
(CBA), using discount rate of 3% on the basis of the year 2011, net present value (NPV) was 287.79
million baht and benefit cost ratio (B/C) was 18.17 baht. In the analysis of sensitivity to change, the
NPV could be varied between 131.58 - 1,061.96 baht and the B/C ratio was 8.85 - 64.36 baht. The
variable, which had the greatest influence on NPV, was the rate of acceptance in screening.
Conclusion: Screening fetal Down syndrome using Thai model is highly cost-effective.
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MFM
Dusit 7
Prenatal diagnosis of a Morgagni hernia with massive pericardial effusion: A case

report
Wirada Dulyaphat MD, Sommart Bumrungphuet MD, Wirada Hansahiranwadee MD, Chayada
Tangshewinsirikul MD, Panyu Panburana MD.
Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital,
Mahidol University
Abstract
Background: Morgagni hernia is a rare form of congenital diaphragmatic hernia, resulting from
anterior defect in the diaphragm. Prenatal diagnosis may be difficult because of unfamiliar sonographic
features.
Objective: To report sonographic features and neonatal outcome in a case of Morgagni hernia with
massive pericardial effusion
Case: A 36-year-old primigravida was referred to Ramathibodi hospital at 38 weeks gestation due
to fetal severe pulmonary hypoplasia. Sonographic examination revealed a single alive fetus with
massive intrathoracic fluid and anteriorly located homogeneous hypoechoic mass compressing both
lungs. Congenital diaphragmatic hernia with herniated lobe of liver with massive pericardial effusion
was diagnosed. Neither associated anomalies nor hydrops fetalis was detected. Differential diagnosis
might be pericardial effusion with intrapericardial teratoma and intrapericardial extrapulmonary
sequestration. MRI was performed to confirm the diagnosis. Planned delivery by cesarean section was
done at 41 weeks gestation. After birth, chest x-ray and echocardiography were done to confirm the
diagnosis. Early sign of cardiac tamponade was observed and resolved by pericardiocentesis. Surgical
correction was accomplished at 5 days of life, herniated left lobe of liver through anterior defect in
a diaphragm (Morgagni type) was detected during the operation. The newborn developed pulmonary
hypoplasia and was discharged 3 months later with home oxygen therapy.
Conclusion: A case of Morgagni hernia with massive pericardial effusion was diagnosed in utero by
sonography and MRI at 38 weeks gestation. After surgical correction postnatally, newborn developed
pulmonary hypoplasia and needed home oxygen therapy.
Keywords: congenital diaphragmatic hernia, Morgagni hernia, fetal pericardial effusion
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MFM
Dusit 7
Ultrasonographic simulation system for training of screening examination of the

fetal heart
Surasak Jantarasaengaram*, Pizzanu Kanongchaiyos**, Chonlatit Prateepmanovong** and
Sitthiya Lertwiram**
*Maternal-fetal medicine unit and Ultrasound unit, Rajavithi Hospital, Bangkok, Thailand
**Department of computer science, Faculty of engineering, Chulalongkorn University, Bangkok, Thailand
Abstract
Objective: To evaluate virtual reality performance of an ultrasonographic scanning simulation system
for training of screening examination of the fetal heart.
Methods: We developed an ultrasonographic simulation system that comprised of a mockup probe
module, a pregnant abdominal manikin and computer software for projection of dynamic 2D fetal
heart image from 4D STIC volume. The mockup probe was equipped with orientation sensors set
up with the manikin and was connected to a laptop for spatial calculation. The laptop monitor
was used as system monitor. The system had additional real-time 3D-orientation-guided graphics
displaying the corresponded fetal orientations and scanning planes for trainees practice and had
ability to save dynamic images of 4CH, LVOT, RVOT and 3V for subsequent evaluation by trainers. The
system was evaluated by experienced sonologists using pre-installed normal STIC volumes acquiring
in apical and transverse cardiac orientations. Volume standardization towards virtual cephalic and
breech fetal orientation was carried out in every volume prior to system evaluation. After practicing
with the simulator for 20 minutes, each sonologist rated the system in a scale of 1-10 evaluation form.
Results: Ten sonologists participated in system evaluation. All of them were able to display the 4CH,
LVOT, RVOT and 3V during practicing in all cardiac (apical/transverse) and fetal orientation (cephalic/
breech). The rated scales (median, range) for virtual reality of the dynamic 2D images, probe-images
correlation and overall virtual reality performance of the system were 9 (8,10), 10 (9,10) and 9 (8,10),
respectively. The orientation-guided graphics had a rated scale for the respective dynamic display of
8 (8,10) and for detailing 3D perception while practicing of 8 (7,10). Rated scale for the potential of
using the system for training of fetal heart screening was 10 (9,10).
Conclusions: The ultrasonographic simulation system offers a respectable virtual reality performance
and has potential in the training for ultrasonographic fetal heart screening.
Keywords: Fetal echocardiography, fetal heart, STIC, ultrasound simulator, ultrasound training.
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MFM
Dusit 7
Distinctive 2- and 3-dimensional sonographic features of genital tuberculosis

Surasak Jantarasaengaram*, Niphon Praditphol** and Kanate Thanakumtorn*
Department of obstetrics and gynecology, Rajavithi Hospital, Bangkok **Department of pathology, Rajavithi Hospital,
Bangkok, Thailand
Abstract
Objective: To present findings from 2- and 3-dimensional sonography in a woman with genital
tuberculosis
Method: A woman presented with 3-months lower abdominal pain and mild abdominal distension.
Ascites was suspected on physical examination without palpable abdominal mass. Transabdominal
and transvaginal ultrasound examination was performed using 2- and 3-dimensional sonography.
Results: Septated ascites, enlarged fallopian tubes and thick peritoneum were depicted by 2-dimensional
sonography. Three-dimensional reconstruction images of pelvic organs revealed bead-liked fallopian
tube and diffuse peritoneal seedings. Endometrial sampling showed granulomatous inflammation in
endometrial tissue with positive AFB stain.
Conclusion: Distinctive sonographic features can lead to diagnosis of genital tuberculosis that
precludes the need for laparotomy.
Keywords: bead-liked fallopian tube, septated ascites, thick peritoneum, tuberculous peritoneal
seedings
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VDO Surgical Techniques
Dusit 8
Effective use of umbrella pack and Bakri postpartum balloon for posthysterectomy pelvic floor hemorrhage
Kittipat Charoenkwan, MD
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
Abstract
Objective: Massive pelvic floor hemorrhage sometimes occurs following hysterectomy especially
in patients who have gone through difficult surgery and/or who are in complicated situations. These
usually include radical pelvic surgery for gynecologic malignancies and peripartum hysterectomy for
obstetric hemorrhage. When happen, control of the hemorrhage by using conventional methods is
frequently unsuccessful. The aim of this presentation is to demonstrate the effectiveness of applying
the umbrella pack or the Bakri balloon as a pressure pack for hemorrhage control in these circumstances.
Materials and Methods: Video presentation of one case of umbrella packing and one case of Bakri
balloon placement
Results: Ten patients had the umbrella packing and three patients had the Bakri balloon placement
as a mean of bleeding control. All hemorrhage was successfully controlled by these measures.
Conclusion: Transvaginal pressure packing employing the umbrella pack or the Bakri balloon is
effective in controlling posthysterectomy pelvic floor hemorrhage. This method is simple, safe, and
readily applicable. There is no need for re-exploration to remove the pack after the bleeding has
been controlled.
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Dusit 8
Laparoscopic Sacro - colpopexy with mesh graft material: experience and results
Kulvanitchaiyanunt A MD.
Department of Obstetrics and Gynecology, Pranungkloa Hospital, Nonthaburi, Thailand
Abstract
Objective: To report the feasibility, efficacy and safety of laparoscopic sacro-colpopexy with mesh
as graft material.
Design: Retrospective analytic study of 45 first consecutive cases.
Setting: Gynecologic endoscopy unit, department of Obstetrics and Gynecology, Pranungkloa Hospital, Nonthaburi, Thailand.
Methods: During October 2010 until June 2015, forty-five patients with severe uterine prolapsed
stage III and IV were underwent the laparoscopic sacro-colpopexy using a gyne mesh as graft material.
The outcomes were intraoperative complications,operating time, post-operative complications and
satisfaction of the patients.
Results: The average operating time was 193.9 minutes (138- 240 min) with mean blood loss 85.5
cc. No complications occurred during the procedure and early postoperative course, except 2 cases
(4.4%) had been converted to open surgery. During a median follow-up at 15.4 months (range : 3 - 48
months). The was no recurrence case of vaginal prolapsed during follow-up time. However, 11 out of
45 patients had worsen of stress urinary incontinence in mild degree. Overall the patient satisfaction
rate was 91%.
Conclusion: The laparoscopic sacro-colpopexy seems to be feasibility, highly safe and effective
at short and intermediate term. This procedure is needed to compare with other conventional
treatments and evaluate in the long term efficacy.
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Dusit 8
Laser vaporization of the vagina: surgical technique

Sathone Boonlikit MD.
Department of Obstetrics and Gynecology, Rajavithi Hospital, Medical College, Rangsit University,
Bangkok, Thailand
Abstract
Objective: To demonstrate the surgical technique of vaginal laser vaporization
Materials and methods: Laser vaporization was used to treat women with histology-proved VAIN 3
at Rajavithi hospital, Bangkok, Thailand. Treatment was performed using a carbon dioxide laser unit
attached to colposcopy. All patients had general anesthesia. A CO2 laser with a focused spot size
of 2 mm ,a power of 15-20W, continuous wave was used. Vaginal wall destruction was intentionally
accomplished to a depth of 1.5 to 3 mm depending on the case. Depth of vaporization was assessed
intraoperatively by recognition of proper surgical plane through colposcopy.
Results: The video presentation shows the surgical techniques of laser vaporization. Because of
thinning of valvovaginal epithelium, it is difficult to control the depth of ablation by actual measurement.
The most reliable method of depth control is the intraoperative recognition of vaginal wall
microanatomy layer by layer. To ensure complete ablation of the full thickness of vaginal epithelium,
submocosal stromal fibers must be observed through colposcopic view. This video demonstrates how
to reach the correct surgical depth and how to set the laser parameter i.e. beam diameter, power
and mode to produce various tissue effect.
Conclusion: The CO2 laser is regarded as the treatment of choice for most VAIN cases. It provides
a surgeon with complete removal of lesion and precisely controlled depth. Minimal morbidity and
the ability of repeated treatment are the major advantage as the recurrent rate of this disease is high
regardless of method of treatment.
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Dusit 8
Management of ectopic pregnancy by laparoscopy and laparotomy, practically

use in regional hospital of Thailand
Prateung Liamponsabuddhi,MD.
Obstetrician and Gynecologist, Lampang Hospital
Abstract

Laparoscopic surgery new trend approach to cure ectopic pregnancy (EP) as a minimal invasive
technic that left small scar and less adhesion, with rapid recovery.
Objective: To compare laparotomy and laparoscopy management underwent in EP at Lampang
Hospital.
Material and Methods: A retrospective analytical study of EP 149 cases that were admitted to
Lampang hospital between Oct 1st, 2012 and Sept 30th, 2014. There were 44 cases of laparoscopy
and 105 cases of Laparotomy. The operation time, length of stay in hospital, volume of blood intraabdominal cavity, and postoperative analgesic drug used were compared. Student test of means and
Fishers exact probability test were calculated.
Results: The incidence of EP was 1.38% (95%CI=1.16-1.61) of total life births in Lampang hospital.
Among 44 cases of laparoscopy, 40cases or 90.91 percents were laparoscopic salpingectomy, 3 or
6.82 percents were salpingo-oophorectomy (SO), and only 1 case or 2.27 percent was laparoscopic
cornuectomy. While the laparotomy group
Keywords; ectopic pregnancy, laparoscopic salpingectomy, bipolar forceps
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Dusit 8
Laparoscopic treatment in massive bleeding ruptured tubal pregnancy with an

open entry technique.
Watcharin Chirdchim MD., Thitichaya Perksanusak MD., Chanya Thamrongwuttikul MD.
Phrapokklao hospital, Chantaburi, Thailand
Abstract
Objective: To demonstrate surgical technique of laparoscopic treatment in massive bleeding ruptured
tubal pregnancy with an open entry technique.
Case presentation: A Chinese woman presented with acute pelvic pain and 7-8 weeks missed period.
Her vital signs were impending shock, mark pale, and abdominal distention with voluntary guarding
when palpated at pelvic region. Pelvic examination show minimal bleeding per os and cervical motion tenderness. Investigation results were positive urine pregnancy test, no intrauterine gestational
sac with massive free fluid in cul-de-sac by transvaginal ultrasound and low level hematocrit (29%).
Ruptured ectopic pregnancy is the provisional diagnosis.
Materials and Methods: After initial resuscitation, emergency laparoscopic surgery was
performed. Vertical intraumbilical skin incision open entry technique with balloon port was used.
Left ruptured tubal pregnancy and 900 ml of hemoperitoneum were found. Left salpingectomy was
done and old blood was removed by suction irrigation. Piece of tubal pregnancy was removed within
endobag via balloon umbilical port.
Results: Timing from skin incision to assess pelvic cavity was 2 minutes 40 seconds and timing from
assess pelvic cavity to salpingectomy was 15 minutes. The patient was discharged in 2 days after
operation without complication.
Conclusion: Ruptured tubal pregnancy with impending shock can be safely treated by laparoscopic
surgery with open entry technique.
Keywords: Rupture tubal pregnancy, laparoscopic surgery, open entry technique.
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Dusit 8
Maylard Incision in Gynaecologic Surgery:4-year Experience in Thammasat University Hospital

Sakol Manusook MD*, Komsun Suwannarurk MD*,
Densak Pongrojpaw MD*, Kornkarn Bhamarapravatana PhD**
* Department of Obstetrics and Gynaecology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
** Department of Preclinical Science, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
Abstract
Objective: To present the results of Maylard incision for gynaecologic surgery in Thammasat University
Hospital during the past four years.
Material and Method: A retrospective study of gynaecologic surgery performed via the Maylard
muscle cutting incision compare to Pfannenstiel muscle splitting and midline incision. Data came
from subjects who underwent gynecologic surgery at Thammasat University Hospital, Pathumthani,
Thailand from January 2010 to December 2013.
Results: Two hundred and eighty three cases were recruited during the study period. Average age
of all cases was 42.7 years (range 16-89). Patients of Maylard cases were older and heavier than Pfannenstiel cases. Body mass index of all groups were not statistically different. Forty seven cases
(16.6%) underwent surgery due to malignant indication while the remaining 236 cases (83.4%) were
benign condition.

Operative time of Pfannenstiel was shorter than Maylard incision while Maylard and midline
incision had similar operative time. Hysterectomy and conservative surgery were performed at 67.8
and 32.2 percent respectively. Maylard, Pfannenstiel and midline incisions were performed in 106, 59
and 118 cases. The anesthetic method in all types of incision are not significantly different.

Half of patients who required vacuum drainage usage belong to Maylard group. Estimated
blood loss of all groups were not statistically different. Length of stay of Maylard group was shorter
than midline group but slightly longer than Pfannenstiel group. Time for first meal was not statistically
different in all groups.

The time to first dose analgesia was measured from time of finished surgery to time for first
analgesia requirement. TFA of Maylard group was shorter than midline but longer than Pfannenstiel
group. Postoperative pain scores in first three days from surgery were not statistically different except
in the second day postoperative pain of midline group that was greater than Maylard group.

Complications from surgery, namely reoperation rate, blood transfusion, bowel and urinary
bladder injuries were not significantly different in all groups.
Conclusion: Maylard incision provides similar operative results with midline and Pfannenstiel
technique. Even though it takes more time for abdominal entry but it gives more operative exposure
than Pfannenstiel incision. Maylard incision could be an optional technique that provides cosmetic
and successful results.
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MFM & RM; PND
Dusit 11
Fetal bladder outlet obstruction with a good outcome but remained hydronephrosis and hydroureter: A case report
Sirinat Sirilert, MD., Theera Tongsong, MD., Kasemsri Srisupundit, MD., Suchaya Luewan, MD.,
Kuntharee Traisrisilp, MD.
Abstract
Background: Fetal bladder outlet obstruction is characterized by dilatation of bladder and proximal
urethra, termed keyhole appearance, and thickened bladder wall. Hydroureter and hydronephrosis
are also found from vesico-ureteric reflux. The prognosis of fetal bladder outlet obstruction is poor,
especially with oligohydramnios that cause pulmonary hypoplasia but the outcome may be poor
even with normal amniotic fluid volume. Termination of pregnancy is one of the treatment options.
Objective: To describe a unique case of fetal bladder outlet obstruction (megacystis) followed by
spontaneous resolution after mid-gestation but persistent megaureter
Case: A 19-year-old primigravid woman presented at 19 weeks of gestation and underwent
sonographic anomaly screening. Ultrasound examination revealed fetal megacystis with dilated
proximal urethra (keyhole appearance), bilateral hydroureter and bilateral hydronephrosis. All other
findings were unremarkable. The prenatal diagnosis of fetal bladder outlet obstruction was made and
options for termination of pregnancy or fetal therapy were offered. However, expectant management
with serial ultrasound was chosen by the couple. At 34 weeks of gestation, the normal bladder size
with markedly thickened bladder wall and normal amount of amniotic fluid was noted whereas the
megaureter were progressive and more tortuous. After birth at term, the baby could urinate normally
without complications and hydroureter as well as hydronephrosis gradually improved.
Conclusion: We described a case of fetal bladder outlet obstruction with spontaneous release but
the megaureter had a progressive change in utero, probably secondary to mechanical uretero-vesical
obstruction caused by markedly thickened bladder wall of the shrunken bladder.
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MFM & RM; PND
Dusit 11
Prenatal ultrasound features of Pena-Shokier sequence: A case report

Sirida Pittyanont, M.D.*, Phudit Jatavan, M.D.*, Theera Tongsong, M.D.* , Songkiat Suwansirikul, M.D.**
* Department of Obstetrics and Gynecology,** Department of Pathology, Faculty of Medicine Chiang Mai University
Abstract
Background: Pena-Shokeir syndrome is rare autosomal recessive disease characterized by intrauterine
growth retardation, facial anomalies, multiple congenital joint contractures, pulmonary hypoplasia and
polyhydramnios. Its estimated incidence is 1:12,000 births. Prenatal sonography can identify typical
findings. The differential diagnoses may include Trisomy 18, lethal multiple pterygium syndrome and
Neu-Laxova syndrome.
Objective: To describe prenatal ultrasound of Pena-Shokier sequence with autopsy confirmation
Case: A 25-year-old primigravid women presented at 23 weeks of gestation. She was referred for
sonographic anomaly screening. The ultrasound findings showed polyhydramnios, micrognathia, fixed
flexion of the bilateral wrists, persistent abnormal postures of both upper and lower extremities as
well as scoliosis. No fetal movement, even with stimulation by pseudo-laryngeal stimulator. Fetal
akinesia or lack of movement in the utero persisted on serial ultrasound examinations. Chromosomal
study revealed normal, 46 XY. Spontaneous labor and delivery occurred at 30 weeks of gestation and
gave birth to a stillborn fetus with autopsy confirmation for Pena-Shokeir sequence.
Conclusion: We described a rare case of prenatal diagnosis of Pena-Shokier sequence. The important
prenatal ultrasound clues are persistent akinesia, abnormal limb postures without change on serial
ultrasound. However this sequence is usually lethal because of pulmonary hypoplasia secondary to
no respiratory muscular movement.
Keywords: Pena-Shokier sequence, Fetal akinesia, Prenatal diagnosis, Ultrasound
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MFM & RM; PND
Dusit 11
Pregnancy outcomes among women with beta-thalassemia trait

Chitrakan Charoenboon, M.D., Phudit Jatavan, M.D., Kuntharee Traisrisilp, M.D., Theera Tongsong, M.D.
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
Abstract
Objective: To compare the obstetric outcomes between pregnant women affected by beta-thalassemia trait and normal controls
Methods: A retrospective cohort study was conducted on singleton pregnant women complicated
by beta-thalassemia trait and normal controls, randomly selected with the controls-to-case ratio
of 2:1. All were low-risk pregnancies without underlying medical diseases and fetal anomalies. The
pregnancies undergoing invasive prenatal diagnosis were excluded.
Results: A total of 597 pregnant women with beta-thalassemia trait and 1194 controls were recruited.
Baseline characteristics and maternal outcomes in the two groups were similar. The prevalence of
fetal growth restriction and preterm birth tended to be higher in the study group but not reached the
significant levels but the rate of low birth weight was significantly higher in the study group (relative
risk 1.25; 95% CI,1.001.57). Additionally, abortion rate was also significantly higher in the study group
(relative risk, 3.25; 95% CI: 1.35-7.80).
Conclusion: Beta-thalassemia trait could minimally, but significantly, increase risk of low birth weight
but did not increase rates of maternal adverse outcomes.
Keywords: Beta-thalassemia, Pregnancy, Outcomes, Trait
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Prenatal diagnosis and management of twin pregnancy consisting of a complete

hydatidiform mole with co-existing live fetus: two case reports and literature
review
Manaphat Suksai, MD,1 Ounjai Kor-anantakul, MD,1 Chitkasaem Suwanrath, MD, M.Med.Sci.,1 Tharangrut
Hanprasertpong MD,1 Thiti Atjimakul, MD,2 Aroontorn Pichatechaiyoot, MD,2 Anupong Nitiruangjaras, MD3
Maternal and Fetal Medicine Unit, 2 Oncology Unit, Department of Obstetrics and Gynecology,
Department of Pathology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
Abstract
Objective: The aim of this study was to present the prenatal ultrasonographic findings, management
and outcome of multiple gestation complicating with complete hydatidiform mole and co-existent
fetus (CHMCF).
Case report: We reported two cases with prenatal ultrasound scans demonstrated a normally live
fetus compatible with gestational age without gross anomaly alongside a normal placenta and adjacent
numerous vesicular tissue with a snowstorm appearance consistent with hydatidiform mole. Both
cases were termination during second trimester of pregnancy due to several maternal complication.
Cytogenetic analysis illustrated diploid set of chromosomes. Histopathological examination confirmed
the diagnosis. Nonmetastatic gestational trophoblastic neoplasm was complicated in one case with
successful treatment with chemotherapy.
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Successful preimplantation genetic diagnosis for beta thalassemia with HLA

matching in Siriraj Hospital
Japarath Prechapanich MD*, Chidchanok Kaewjunun MSc*, Kamonrat Phokhao MSc**, Monchan
Sirikong MSc**, Chompunut Kanjanakorn MSc**, Chanin Limwongse MD**, Roungsin Choavaratana MD*.
*Infertility unit, Department of Obstetris and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University.
**Thalassemia center, Faculty of Medicine Siriraj Hospital, Mahidol University.
Abstract
Objective: To develop the technique of preimplantation genetic diagnosis (PGD) for beta
thalassemia with human leukocyte antigen (HLA) matching.
Materials and Methods: 33 year old woman with previous child suffering from thalassemia
major (beta 41/42 with HbE) was stimulated and collected the oocytes by standard ovarian
stimulation and then fertilized by intracytoplasmic sperm injection (ICSI) process. Blastocyst biopsy
was performed on day 5 of good quality embryo and genetic testing techniques were DNA sequencing
for beta thalassemia mutation and short tandem repeats (STR) analysis for HLA matching.
Results: From total 9 retrieved oocytes, 5 blastocysts were biopsied for beta thalassemia mutation
checking. Three unaffected blastocysts underwent STR analysis and one of blastocyst that matched
with previous daughter was transferred to uterine cavity. Pregnancy was uneventful and the genetic
result was confirmed with cordocentesis on GA 19 weeks.
Conclusion: The technique of PGD for beta thalassemia with HLA matching was developed in Siriraj
Hospital.
Keywords: PGD, beta thalassemia, HLA matching.
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Infertile couples greatly divided on the 2015 law on assisted reproductive

technology
S. Kiatpongsan,1 P. Virutamasen,1 K. Pruksananonda.1
Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand 10330.
Abstract
Objective: To evaluate infertile couples opinions on being a legally married couple as a prerequisite
for assisted reproductive technology (ART).
Materials and methods: We invited infertile couples who attended a monthly educational
session at King Chulalongkorn Memorial Hospital to participate in a survey. Each couple anonymously
completed the survey in private before the session. The survey asked whether they know that being
legally married is required for ART and whether they think it should be a must prerequisite.
Additionally, they reported if they are willing to lawfully obtain a marriage certificate in order to
access ART. We analyzed results in aggregate and then stratified by participants demographics
(multiple logistic regression models). Statistical significance was determine at p < 0.05.
Results: Ninety-eight couples completed the survey (response rate = 100%). Median ages of male
and female partners were 37.0 and 36.0, respectively. Median duration of partnership was 6.0 years.
76.3% of couples were legally married.
47.4% of couples knew that legally married status is required for ART by the law and 48.0% agreed with
the law. 91.7% of couples were willing to get married legally in order to gain access to ART. Opinions
and willingness to comply with the law did not differ by participants age, income and education.
Conclusion: The requirement to be a legally married couple by the 2015 law is not well known
among infertile couples and about half of them do not agree with the law. However, most couples
are willing to follow the law.
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( Thai Journal of Obstetrics and Gynaecology)
The Correlation of Body Mass Index and Waist-Hip Ratio to Insulin Resistance in
Reproductive-aged Thai Women with Polycystic Ovary Syndrome
Warangkana Apiwattanasavee MD,
Kitirat Techatraisak MD,Ph.D.
Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Abstract
Objective: To compare the correlation of body mass index (BMI) and waist-hip ratio (WHR) to insulin
resistance (IR) in reproductive-aged Thai women with polycystic ovary syndrome (PCOS).
Material and methods: A retrospective cross-sectional study was conducted among 205 reproductiveaged women who attended the Gynecologic Endocrinology Unit of the Department of Obstetrics and
Gynecology, Siriraj Hospital during July 2005 - December 2010. Reviewed data included age, body
weight, height, waist circumference, hip circumference, HOMA-IR.
Results: Among 205 cases of PCOS women, 97 women had IR (47.3%) and 108 women did not have
IR (52.7%). By a forward stepwise multiple logistic regression analysis, mean BMI and WHR in IR group
were significant higher than non-IR group (P < 0.001). Area under an ROC curve of IR for BMI was 0.9
and for WHR was 0.82. Both BMI and WHR correlate to insulin resistance. In comparison, BMI had better correlation than WHR (P = 0.006).
Conclusion: Reproductive-aged Thai PCOS women with IR had higher BMI and WHR than those who
did not have IR. Both BMI and WHR correlate to insulin resistance. BMI correlates better to IR than WHR.
Keywords: Body mass index, Waist-Hip ratio, Insulin resistance, Polycystic ovary syndrome,
Correlation
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Effect of DMPA on cell apoptosis and proliferation in eutopic endometrium of

women with endometriosis
Lertvikool S1, Sophonsritsuk A1, Tawarasumia Y1, Tingthanatikul Y1, Wongkulab A1, Weerakiet S1*,
Poljaroen J2,3, Sroyraya M2,3, Chansela P2,4, Changklungmoa N5, Songkoomkrong S2, Sobhon P2
Department of Obstetrics & Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok,
10400, Thailand.
2
Department of Anatomy, Faculty of Science, MahidolUniversity,Bangkok, 10400, Thailand.
3
NakhonsawanCampus,Mahidol University, Nakornsawan Province, 60130, Thailand.
4
Department of Anatomy, Phramongkutkloa College of Medicine, Bangkok, 10400, Thailand.
5
Department of Pathobiology, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.
1
Abstract
Objective: to investigate the effect of depot medroxyprogesterone acetate (DMPA) on apoptosis and
proliferation activity of the eutopic endometrium in women with endometriosis.
Material and Methods: A randomized controlled trial was conducted at department of Obstetrics and
Gynecology, Ramathibodi hospital and department of Anatomy, Faculty of Science, Mahidol University.
Fourteen women were randomly allocated to receive either 150 mg of DMPA for 3 months (DMPA
group) or nothing (non-DMPA group). Ten women with uterine fibroid were included as controls. All
women had an endometrial biopsy done. The cell proliferation was evaluated by an immunohistochemical technique for PCNA while TUNEL technique was done for apoptosis.
Results: There was no significant difference of basic characteristics between the DMPA and non-DMPA
groups. There was a significant difference of cell proliferation in the glands and stroma of
endometrium between groups. The cell proliferation rates both in the glands and stroma seemed to
be lower in the DMPA group. There was also a difference of cell apoptosis in the glands and stroma
between groups. The apoptosis in the stroma was much higher in the DMPA group than the one in
the non-DMPA and control groups.
Conclusion: 12 weeks of DMPA administration enhanced apoptosis in the stromal cells, but not
in the glandular cells of the eutopic endometrium. The medication simultaneously suppressed
proliferation of both glandular and stromal cells in the eutopic endometrium of women with
endometriosis.
Keywords: cell apoptosis, cell proliferation, depo-medroxyprogesterone, eutopic endometrium,
endometriosis.
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Beneficial effect of Curcuma comosa extract (Wan chak motluk) on vasomotor

symptoms and menopausal quality of life
Areepan Sophonsritsuk, M.D., PhD1,2, Ongard Bovornsakulvong MD1., Mayuree Jirapinyo M.D1.,
Pawinee Piyachaturawat PhD3
Gynecologic Endocrinology Unit, Department of Obstetrics & Gynecology, Ramathibodi Hospital, Faculty of
Medicine, Mahidol University
2
Translational Medicine PhD program, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
3
Department of Physiology, Faculty of Science, Mahidol University
1
Abstract
Objective: Wann chak motluk or Curcuma comosa is a very popular Thai herb and widely
dispensed in market. It has been used in traditional medicinal remedies in Thailand for relief
dysmenorrhea, treating leucorrhea and endometritis, promoting uterine involution after baby
delivery, and reducing vasomotor symtptom. Crude extract of C.comosa exerts the estrogenic effects
in vitro. We studied the effect of C.comosa crude extract on vasomotor symptom and quality of life
in peri- and menopausal women.
Material and Methods: We conducted a clinical trial which included 40 peri- and menopausal
women with menopausal symptoms at Ramathibodi hospital from September 2014 to August 2015.
The participants were treated with either 250 mg or 500 mg per day of C.comosa crude extract for
3 months. 20 womens were recruited into each group. Daily number of mild, moderate, and severe
hot flushes were recorded. Quality of life was evaluated by the Menopause-Specific Quality of Life
(MENQOL) and Kupperman index questionnaires each visit at 0, 1, and 3 months.
Results: Participants receiving 500 mg/d C.comosa had statistically significant reduction in hot flush
frequency after 3 months of treatment (p<0.036). A significant improvement of quality of life demonstrated by MENQOL at 3 months in women receiving 250 and 500 mg/d C.comosa (p<0.015, 0.008,
respectively).
Conclusion: Wann chak motluk could relief vasomotor symptom and improve quality of life in peri- and
menopausal women. However, larger clinical trials still are needed before introducing it into the clinic.
Keywords: Curcuma comosa Roxb., Wann chak motluk, vasomotor symptom, quality of life, menopause
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The Effect of Cissus Quadrangularis on Bone Markers in Osteopenia Women: A

Randomized Double-Blind Placebo Control Trial
Olarik Musigavong, MD*
*Abhaibhubejhr hospital, Prachinburi, Thailand
Abstract
Background: Osteoporosis is one of the problems in elderly Thai women. The cost of treatment is
very high. Cissus quadrangularis is traditionally used for treatment of bone disease in Hindu and Thai
herbal medicine.
Objective: to investigate the effect of Cissus quadrangularis on bone marker levels in postmenopausal women with osteopenia
Material and methods: Subjects were 38 postmenopausal women with osteopenia age 45-75 years.
19 women were randomized into treatment group received Cissus quadrangularis capsule (400 mg) oral
twice a day for 3 months and the other 19 women were received nothing. Blood was drawn before
and after treatment. Pre-treatment and post-treatment values of liver function test, creatinine, P1NP,
and CTX were measured in both groups.
Results: P1NP was statistically significant decreased compared with pre-treatment level in treatment
group. CTX was increased but not statistically significant. No significant change of liver enzyme and
creatinine level was demonstrated.
Conclusions: Cissus quadrangularis may mediate either bone formation or combined bone formation
and resorption effects. There was also no effect of Cissus quadrangularis on liver enzyme and
creatinine level. Further study are needed to clarify the anti-osteoporotic effect of Cissus
quadrangularis and fracture prevention.
Keywords: Osteopenia, bone marker, Cissus quadrangularis
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Comparison of Pueraria mirifica Gel and Conjugated Equine Estrogen Cream

Effects on Vaginal Health in Postmenopausal Women
Narathorn Suwanvesh, M.D.1, Jittima Manonai, M.D.2, Areepan Sophonsritsuk, M.D., Ph.D.1,3
Reproductive Endocrinology and Infertility Unit, Department of Obstetrics & Gynaecology, Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand.
2
Reproductive Health Unit, Department of Obstetrics & Gynaecology, Ramathibodi Hospital, Mahidol University,
Bangkok, Thailand.
3
Research centre, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
1
Abstract
Objective: To study the effect of 12-week of Pueraria mirifica gel preparation on vaginal maturation
index, vaginal symptom score, vaginal health assessment score and vaginal flora in postmenopausal
women and compare with conjugated estrogen cream.
Design: A prospective, non-inferiority, randomized controlled study
Setting: Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital.
Patients: Eighty-two healthy postmenopausal women (age 45-70 years old) with at least one of
vulvovaginal symptoms.
Interventions: Patients were randomly assigned into two groups. First group applied Pueraria
mirifica gel 0.5 g intravaginally daily for 2 weeks, then decreased to 3 times per week for 10 weeks.
The other group applied conjugated estrogen cream 0.5 g intravaginally in the same frequency as the
first group. Both groups were appointed for follow-up at 6-week and 12-week periods for assessing
vaginal cytology, signs, symptoms and vaginal flora changes after the treatment.
Main Outcome Measures: 1. Vaginal maturation index 2. Vaginal symptoms score 3. Vaginal health
assessment score 4. Lactobacillus grading
Results: The vaginal maturation index increased significantly at 6 and 12 weeks after treatment in
both groups (p<0.05), but it significantly higher in the conjugated estrogen group (p <0.05). The vaginal
symptom score decreased significantly after treatment in both groups (p<0.05), there were no
statistically significant different between the two groups (p>0.05). The number of lactobacillus
significantly increased after 12 weeks of treatment in both groups (p<0.05) while the mean endometrial
thickness did not change in both groups (p>0.05). No serious adverse event was reported.
Conclusions: A12-week period of 0.5 gram of Pueraria mirifica gel treatment has been proven
to be efficacious and safe for the treatment of symptoms and signs of vulvovaginal atrophy in
postmenopausal women. The superiority of conjugated estrogen cream over Pueraria mirifica gel
was shown in improving signs of vaginal atrophy and restoring vaginal epithelium at 6 and 12 weeks.
Clinical Trial Registration Number: TCTR20150219001
Keywords: Pueraria mirifica, Conjugated estrogen cream, Vaginal health, Vaginal cytology,
Vulvovaginal atrophy
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Prevalence and Co-Occurrence of Pelvic Floor Disorders in Postmenopausal

Women
Chuleekorn Sritonchai M.D,* Jittima Manonai M.D*.
*Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok
10400, Thailand
Abstract
Objectives: To report the prevalence and co-occurrence of pelvic floor disorders in postmenopausal
women, and explore the effect of menopause on pelvic floor disorders.
Materials and Methods: In this retrospective study, we reviewed the medical records of consecutive women who had attended a tertiary urogynaecology clinic between January 2011 and December
2012. Initial evaluation records included age, parity, and menopausal status. Pelvic floor symptoms
(stress urinary incontinence, urinary urgency and frequency, urgency incontinence, dysuria, pelvic
organ prolapse, obstructed defecation, and fecal incontinence) were evaluated using the Pelvic Floor
Bother Questionnaire. All subjects were examined in the lithotomy position by three urogynecologists
according to the pelvic organ prolapse quantification system.
Results: Of 467 women, 394 were postmenopausal. The prevalence of stress urinary incontinence,
urinary urgency, urinary frequency, urgency incontinence, dysuria, pelvic organ prolapse, obstructed
defecation, and fecal incontinence were 60.7%, 78.2%, 57.1%, 49.2%, 51.5%, 62.9%, 40.6%, and
43.1%, respectively. Three hundred and fifty six women (90.4%) reported at least two symptoms of
pelvic floor disorders. Pelvic organ prolapse at least stage II was found in 55 (75.3%) and 340 (86.3%)
of premenopausal and postmenopausal women, respectively. Menopausal status seems to be a
protective effect on stress urinary incontinence (p= 0.009; 95%CI -0.28 to -0.40). On multivariate analysis,
controlling for age and parity, there was no effect of menopause on pelvic floor disorders (p> 0.05).
Conclusion: There was a high prevalence of pelvic floor disorders in postmenopausal women. The
menopausal status did not affect pelvic floor symptoms.
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Isolated torsion of the hydrosalpinx in an infertile woman

Nujaree Leelasuwattanakul MD., Ratchanee Daungrideeswat MD., Sawaek Weerakiet MD.
Bangkok Hospital- UDON, Udonthani Province
Abstract
Objective: Aim of the current study was to report a rare case of the torsion of a hydrosalpinx in an
infertile woman.
Methods and Results: We reported a case of 28 year-old infertile woman who presented with left
lower abdominal pain, nausea, vomitting and fever for 2 days. Bilateral hydrosalpinges have been
diagnosed for a year, but she denied to undergo salpingectomy before IVF treatment. Physical and
pelvic examinations revealed T 39.0 c, and tender palpation at LLQ and the left adnexum.
Ultrasound and CT scan showed the bilateral hydrosalpinges and free fluid in the cul de sac.
CBC showed WBC of 10400/mm3, N of 67%. The diagnosis was infected hydrosalpinx. Parenteral
antibiotics were administrated. There was no improvement of the clinical signs and symptoms after
48 h of treatment. Diagnostic laparoscopy showed the isolated gangrene left hydrosalpinx with the
torsion at the isthmus and the right hydrosalpinx. Laparoscopic salpingectomy of both tubes was
performed. The woman was discharged from the hospital 2 days after surgery.
Conclusion: This was a rare case of the isolated torsion of hydrosalpinx presenting with common
clinical manifestations. Laparoscopic surgery could be used to make diagnosis and to treat this
condition.
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Age independent of body mass index negatively affects semen quality

J. Ngeamvijawat,1 A. Sawangchaeng,1 S. Kiatpongsan,2 P. Virutamasen,2 K. Pruksananonda.2
1
2
Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
Department of Obstetrics and Gynecology, The faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
Abstract
Objective: To find effects of age and body mass index on semen quality.
Materials and methods: We investigated the effects of age and body mass index (BMI) on
semen quality via a retrospective cohort study in male patients attending a fertility clinic at King
Chulalongkorn Memorial Hospital in Bangkok, Thailand. One thousand three hundreds and
seventy-seven patients were included in the study. We used multivariate regression models
to test for effects of age and BMI concurrently on each of sperm analysis parameters (volume,
concentration, total number, motility, rapid movement, progressive movement, normal morphology).
Statistical significance was determine at p < 0.05.
Results: Participants mean age was 36.8 years (SD = 6.4). Mean BMI was 24.9 (SD = 3.6).

Controlled for BMI, age was significantly and negatively associated with semen volume
(coefficient = - 0.15; p < 0.001), total number (coefficient = - 0.07; p = 0.018), motility (coefficient =
- 0.16; p < 0.001), rapid movement (coefficient = - 0.19; p < 0.001) and progressive movement (coefficient = - 0.19; p < 0.001) but not with concentration and normal morphology.

Controlled for age, BMI was not associated with any semen parameters.
Conclusion: Age but not BMI negatively affects semen quality. With advantages of multivariate
regression models, our study showed that, independent of BMI, age is negatively associated with
semen quality. This information can be helpful in patient education and counselling.
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Clinical and Laboratory Comparison between Obese and Non-obese Reproductiveaged Thai women with Polycystic Ovary Syndrome
Panicha Chantrapanichkul, M.D., Pichai Leerasiri, M.D.,Thanyarat Wongwananuruk, M.D., Manee
Rattanachaiyanont, M.D., Suchada Indhavivadhana, M.D., Kitirat Techatraisak, M.D., Surasak Angsuwathana, M.D.
Gynecologic Endocrinology unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital,
Mahidol University, Bangkok 10700, Thailand
Abstract
Objectives: To compare the clinical and laboratory findings of obese and non-obese of Thai polycystic
ovary syndrome (PCOS) women.
Study design: cross-sectional study
Material and method: The total of two hundred and fifty Thai PCOS women who attended at
Gynecologic Endocrinology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj
Hospital during May 2007 to January 2009. All subjects were interviewed and examined for weight,
height, waist circumference, blood pressure, presence of acanthosis nigricans and hyperandrogenism.
The venous blood samples were drawn twice, first at 12-hour fasting period for fasting plasma glucose,
insulin, lipid profile, hormonal level and second at 2 hours after 75 gram glucose loading for plasma
glucose and insulin level.
Results: The mean age was 26.5+ 6.6 and 24.4+4.9 years in the obese and non-obese PCOS. The
clinical manifestations, such as oligomenorrhea and hyperandrogenism were similar in both groups
but the non-obese group had significant more presence of polycystic ovaries. The obese group had
more significant women presence of acanthosis nigricans. The laboratory findings in obese population
showed all carbohydrate profile, triglyceride and free testosterone had more significantly level than
those of non-obese group while high density lipoproterin (HDL-C) and sex hormone blinding globulin
(SHBG) had significant lower level in obese group. Finally, the obese PCOS also had more significant
hypertension, dyslipidemia, glucose intolerance, and metabolic syndrome than those of non-obese
group.
Conclusion: Metabolic disorders were found significantly more in the Thai obese PCOS women
compare with non-obese PCOS women.
Keywords: PCOS, obese, metabolic disorder
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The success of Methotrexate in treatment of ectopic pregnancy: 10-year experience

Chananya Tatitham MD*, Chatchai Treetampinich MD*, Matchuporn Sukprasert MD* Chonthicha
Satirapod MD*, Wicharn Choktanasiri MD*
*Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok,
Thailand 10400
Abstract
Objective: To report the success and failure rates of Methotrexate used in ectopic pregnancy treatment
from the clinical practice of Ramathibodi hospital in past 10 years.
Material and method: The medical record data from July 2005 to June 2015 were reviewed. All
cases with the diagnosis of ectopic pregnancy that initially treated with single dose Methotrexate were
included. The cases that did not know the final outcome would be excluded. The success and failure
rate of Methotrexate treatment were reported in percentage. Therefore we analyzed the parameters
that can be the effect of treatment in terms of baseline -hCG, size of mass from ultrasonography
and location of ectopic pregnancy.
Results: There were 550 patients diagnosed with ectopic pregnancy. 94 patients were given single
dose Methotrexate as initial treatment. However only 89 cases were included into the study due to
data loss. We found that 68.5% (61/89) of cases were given with only one dose of methotrexate and
9.0% (8/89) needed one more repeat dose. Therefore overall success rate was 77.5% (69/89) and the
rest 22.5% (20/89) needed surgical intervention. Interestingly, the patients with -hCG 5,000 mIU/ml
showed medical treatment success rate of 87.3 % (62/71). Whereas, patients with -hCG >5,000 needed
surgical treatment 61.1% (11/18). There was only 9.0% (8/89) of cases with the ectopic pregnancy
mass size more than 4 cm from ultrasonography. Still our data found success rate was 87.5% (7/8). In
terms of the location of ectopic pregnancy medical treatment success rate among tubal pregnancy
group was 74.6% (50/67) , pregnancy of unknown location was 100% (16/16), cornual pregnancy was
40% (2/5) and cervical pregnancy was 100% (1/1).
Conclusion: We concluded that the Methotrexate treatment is helpful in the patients who have
tubal pregnancy or pregnancy of unknown location with -hCG levels 5,000. The success rates in
this group were conformable to the previous studies.
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The effect of different timing after ejaculation on sperm motility and viability
in semen analysis at laboratory room temperature
Sirisuk Ouitrakul M.D.1, Matchuporn Sukprasert M.D.1, Chonthicha Satirapod M.D.1, Wicharn
Choktanasiri M.D.1, Aram Rojanasakul M.D.1, Chatchai Treetampinich M.D.1, Worawan Lupthalug
M.D.1, Sunanta Jarupoonpol M.D.2, Suda Natrchalayuth M.S.2, Supaporn Moonphol B.S.2, Sudaporn
Chamnankran B.S.2, Suteera Waiprib B.S.2, Duangchanok Salee B.S.2
Infertility Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok,
2
In vitro fertilization laboratory, Infertility Unit, Department of Obstetrics and Gynecology, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University, Bangkok,
1
Abstract
Objective: To determine the effect of time post ejaculation (30, 60, 120, 180 and 240 minutes) on
sperm motility and viability for samples kept at laboratory room temperature
Design: Observational Study
Setting: Infertility Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi
Hospital, Mahidol University, Bangkok, Thailand
Subjects: Semen samples from ninety-eight patients attending the infertility clinic from February 17,
2015 to March 15, 2015.
Methods: Semen samples were kept at laboratory room temperature (25-26C) and were analyzed
for sperm motility by a Computer aided sperm analysis (CASA) system and for sperm viability by
eosin exclusion test at 30, 60,120, 180, 240 minutes post ejaculation. Samples were stained for sperm
morphology by Diff-Quick rapid test at 30 and 180 minutes.
Main outcome measurement: Sperm motility and viability
Results: In this study a total of 98 semen samples were analyzed. Our data show that the
percentage of sperm motility underwent a statistically significant decrease after being kept at laboratory
room temperature for 60 minutes post ejaculation (p<0.004) with a concomitant statistically significant
decrease in the percentage of sperm viability after being kept at laboratory room temperature for 120
minutes post ejaculation (p<0.000).
Conclusions: We conclude that sperm motility begins to significantly decrease after 60 minutes while
viability becomes affected after 120 minutes. Therefore we suggest that semen samples for analysis
can be kept at laboratory room temperature but should be evaluated for acceptable sperm motility
within 60 minutes after ejaculation
Keywords: sperm motility, sperm viability, laboratory room temperature, time post ejaculation
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Body mass index (BMI) and abdominal obesity index as screening test for
abnormal glucose metabolism in patient with polycystic ovarian syndrome women
Nipawan Attawattanakul MD.1, Sawaek Weerakiet, MD.1, Areepan Sophonsritsuk, MD., PhD.1,2
Reproductive Endocrinology and Infertility Unit, Department of Obstetrics & Gynecology, Ramathibodi Hospital,
Faculty of Medicine, Mahidol University
2
Translational Medicine PhD program, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
1
Abstract
Objective: Women with polycystic ovarian syndrome (PCOS) are at increased risk for developing
abnormal glucose metabolism due to increased insulin resistance. Screening by oral glucose tolerance
test (75g OGTT) has been recommended by the Androgen Excess Society to western obese patients
with PCOS and lean PCOS women age >40 years with either family history of T2DM or personal
history of GDM. BMI and abdominal obesity indexes were associated with increased insulin resistance
in previous study. We aim to test if BMI and abdominal obesity index could be used as screening test
to predict abnormal glucose metabolism in order to avoid unnecessary 75g OGTT.
Material and Methods: We conducted a cross-sectional study which included 268 women diagnosis
of PCOS at Ramathibodi hospital based on Rotterdam criteria from 2002-2009. Data collected was
age, BMI, waist circumference(WC), hip circumference(HC), weight-height ratio(WHtR) and weight-hip
ratio(WHR). We operated curve analysis for their ability to predict abnormal glucose metabolism and
then calculated the cut point at approximately 90% and 95% sensitivity.
Results: The Area Under the receiver operating characteristic(ROC) for BMI, WC, HC, WHtR and WHR
were all significantly different(p<0.05). At sensitivity of 91.1%, 1)the BMI cut-off was 19.5 kg/m2 with
21.2% specificity, 2)the WC cut-off was 64cm with 13.8% specificity, 3)the HC cut-off was 85cm with
22.2% specificity,4)the WHtR cut-off was 0.41 with 22.2% specificity and 5)the WHR cut-off was 0.75
with 20.1% specificity.
Conclusion: By applying these cut-off values, only 12.31-18.28% of patients could be omitted from
75g OGTT, which is approximate to only 7 new PCOS cases diagnosed within year in our hospital. Our
findings had a little benefit for abnormal glucose metabolism screening of PCOS women since a few
patients could avoid 75g OGTT explained by poor specificity of the metabolic parameters..
Keywords: BMI, abdominal obesity, abnormal glucose metabolism, polycystic ovarian syndrome
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Chromosomal Characteristics of Human Preimplantation Embryos Assess by

Comparative Genomic Hybridization
Sukprasert M, M.D.1, Satirapod C, M.D.1, Lupthalug W, M.D.1, Theetumpinit C, M.D.1, Choktanasiri W, M.D.1
The Reproductive Endocrinology and Infertility unit, Department of Obstetrics and Gynecology, Faculty of Medicine
Ramathibodi hospital, Mahidol university
1
Abstract
Objective: To investigate the prevalence of chromosomal abnormalities of embryos in Thai
populations by array CGH techniques.
Design: Retrospective study
Setting: Academic medical center
Patient(s): 2066 cells from 281 patients
Intervention(s): Single cell was load into 0.2 ml PCR tube. The DNA was generated by whole genome
amplification and tested by array CGH
Main Outcome Measure(s): The percentage of normal/abnormal embryo according to age group
Result(s): Chromosome aneuploidy in embryos showed the euploidy rate for all embryos was
42.23%. Trophectoderm had a higher euploidy rate than blastomere especially in the young patient
group (70.53%). Complex chromosome abnormalities (more than one chromosome abnormality) were
demonstrated to be the most common abnormalities of this study (66.44%) while monosomy and
trisomy were minor (18.16% and 15.40%)
Conclusion(s): aneuploidy screening in preimplantation embryos by array CGH technique detected
more chromosome abnormalities than previous method
Keywords: preimplantation embryo, whole genome amplification, comparative genomic hybridization

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Recurrent cervical cancer after radical hysterectomy: a study of clinicopathologic

features, relapse patterns, methods of detection and clinical outcome
Ingporn Jiamset MD, Jitti Hanprasertpong MD.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla
University, Hat Yai, Songkhla 90110, Thailand
Abstract
Objective: To investigate the clinicopathologic features, pattern of recurrence, methods of
detection and clinical outcome of patients with recurrent cervical cancer after radical surgery.
Material and methods: The records of consecutive patients with recurrent cervical cancer
after radical hysterectomy with pelvic node dissection between 1987 and 2014 at Songklanagarind
Hospital were retrospectively reviewed. Clinicopathologic features, pattern of recurrence, methods of
detection, salvage treatment and outcome were analyzed.
Results: Of 689 patients, 82 (11.9%) had recurrences. According to the recurrence pattern, 58
(70.7%) patients had locoregional, 18 (22.0%) had distance and 6 (7.3%) had combined recurrence.
No correlation between clinicopathologic features and recurrence patterns were observed. Most of
these patients (62.2%) complained of symptoms prior to examination. The majority of patients with
asymptomatic recurrence were diagnosed by physical and pelvic examinations (71.4%) and Pap smear
(21.4%). Successful imaging consisted of chest X-ray in only 1 case (3.6%) and CT scan/ultrasound in
only 1 case (3.6%). The median follow-up time after recurrence was 12.7 months. The 1-year overall
survival (OS) for the whole study population was 73.00%. Multivariate analysis showed age (P=0.045),
modality of treatment after recurrence (P=0.001), hemoglobin (Hg) level (P=0.041) and white blood
cell (WBC) count (P=0.007) were independent adverse prognostic factors for OS.
Conclusion: Physical and pelvic examinations and Pap smear can detect asymptomatic patients with
recurrent cervical cancer after radical surgery. Age, modality of treatment, Hg level and WBC counts
are significant prognostic factors for recurrent cervical cancer.

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Do ABO blood groups have effect on oncological outcome of radical hysterectomy

for early-stage cervical cancer?
Abstract
Objective: To evaluate the prognostic value of ABO blood groups in surgical patients with
early-stage cervical cancer.
Material and methods: The cohort included 413 patients diagnosed with stages IA2-IB1cervical cancer
who received radical hysterectomy between 2002 and 2014. The prognostic impact of ABO blood
groups on recurrence-free survival (RFS) and overall survival (OS) were analyzed.
Results: The 5-year RFS and OS were 93.13% and 96.81% for blood group O, 87.68% and 88.22%
for blood group A, 81.66% and 89.40% for blood group B, and 83.12% and 94.12% for blood group
AB groups, respectively. Blood group O was associated with a smaller tumor size (P=0.014). Patients
were stratified for analysis as either blood group O or non-O. The 5-year RFS and OS were 93.13% and
96.81% for blood group O and 83.66% and 89.76% for blood group non-O, respectively. In multivariate
analysis, age (P= 0.025), histology (P=0.020) and deep stromal invasion (P=0.006) were independent
adverse prognostic factors for RFS, while the statistically significant independent prognostic factors
for OS were age (P=0.007) and parametrial involvement (P<0.001). The Cox model did not show any
significant effects of non-O blood group on survival outcome. However, a time varying effect Cox
model revealed that non-O blood group was associated with a worse RFS (HR 2.69, 95% CI 1.12-6.46,
P=0.017) and OS (HR 3.13, 95% CI 0.88-11.16, P=0.053) during the first 5 years.
Conclusion: Early-stage cervical cancer patients with non-O blood group have poorer RFS and OS
during the first 5 years than the O blood group.
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Skin metastasis from cervical cancer: report of 7 cases and literature review
Athithan Rattanaburi MD, Jitti Hanprasertpong MD.
University, Songkhla 90110, Thailand
Abstract
Objective: To describe clinical manifestations and outcome of patients with skin metastasis from
cervical cancer.
Material and methods: The patients diagnosed skin metastasis from cervical cancer between 2004
and 2013 were reviewed. The clinical presentations, histopathology, characteristic of lesions including
sites of metastasis, treatment modalities and clinical outcome were described.
Results: We describe 7 patients who developed skin lesions with biopsy proved for metastasis from
cervical cancer. Median age was 47 years (range 36-53). Six out of seven patients found skin metastasis
in recurrent disease range 3-36months after remission from primary treatment. The histologic types
were squamous cell carcinoma and adenocarcinoma in 4 and 3 patients, respectively. The patterns
of skin metastasis were nodules, plaque and mass. The common sites of metastasis were abdominal
wall, vulva, lower extremities and scalp. There were different modalities for treatment such as
radiation, systemic chemotherapy or palliative care. Even intensive therapy, the survival was poor
(range 3-15months).
Conclusion: There are various cutaneous lesions of skin metastasis from cervical cancer and
usually found in the advanced disease or recurrent setting. This presentation is a sign of grave prognosis.
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Impact of diabetes mellitus on oncological outcome after radical hysterectomy

for early stage cervical cancer
Abstract
Objective: To evaluate the relationship between type 2 diabetes mellitus (DM) and oncologic
outcome in early stage cervical cancer patients who underwent radical hysterectomy with pelvic
node dissection.
Material and methods: Patients with early stage cervical cancer diagnosed between January 2001
and December 2014 were retrospectively enrolled. We assessed the outcomes of 402 non-DM and
42 DM patients with cervical cancer. We tested the prognosis value of DM in the patients by Cox
proportional hazard modeling.
Results: Of 444 patients, the median age was 46 years. Patients with DM were more likely to be
older and overweight. The patients with DM compared with those without DM had lower
lymphovascular space invasion. In the DM group, 20 patients took metformin and 22 patients did not
take metformin. The 5-year recurrence-free survival (RFS) and 5-year overall survival (OS) for the whole
study population were 88.49% (95% CI = 84.42-91.55) and 96.34% (95% CI = 93.20-98.05), respectively.
In the DM group, metformin use did not affect the 5-year RFS (P=0.553) or the 5-year OS (P=0.429).
In multivariate analysis, age (P=0.007), histology (P=0.006) and deep stromal invasion (P=0.007) were
independent adverse prognostic factors for RFS, while there was a borderline significant association
for increased RFS with DM (P=0.051). DM (P=0.008), age (P=0.009) and node status (P=0.001) were the
only 3 independent prognostic factors for OS.
Conclusions: Early stage cervical cancer patients with type 2 DM have poorer oncologic outcome
than patients without DM. Metformin use did not affect oncologic outcome.
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Serum Human Chorionic Gonadotropin (hCG) Ratios for Early Detection of Drug
Resistance to EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide
and vincristine)
Nathapol Sirimusika MD*, Sathana Boonyapipat MD.*
*Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla
University, Hat Yai, Songkhla, Thailand
Abstract
Background: Gestational trophoblastic neoplasia (GTN) is highly sensitive to chemotherapy. EMA/
CO is an effective chemotherapeutic regimen used for the high-risk GTN. Currently, there is no
consensus guideline to define the criteria for resistance to chemotherapy. An hCG ratios were
developed to assess the response of chemotherapy and early detect drug resistance which can avoid
the risk of ineffective cycles of chemotherapy.
Objectives: To identify the optimal hCG ratio in predicting EMA/CO resistance in the high-risk GTN
and compare detection rate to the FIGO 2000 criteria
Materials and Methods: Seventy seven women with primary high-risk GTN treated with EMA/CO in
Songklangarind Hospital between 2002-2013 were included. The hCG ratio was determined by serum
pretreatment hCG level divided by hCG level before each cycle of chemotherapy. The hCG ratios and
their corresponding sensitivities with ROC were compared at the different specificities in predicting
chemoresistance classified the FIGO 2000 criteria. The detection rates using optimal hCG ratios were
compared with those using the FIGO criteria.
Results: Among the specificity of 90%, 92.5 %, and 95%, the 90% specificity yielded the best ROC.
At a 90% specificity, the sensitivity of cycle 2 to 6 were 33%, 50%, 75%, 48.5%, and 50% respectively.
The optimal hCG ratio of cycle 2 to 6 were 6.1, 18.7, 31.9, 41.9, and 100.22 respectively. The hCG
ratios obtained at cycle 2-5 detected chemoresistance of 33.3%, 58.3%, 75%, and 75% respectively,
while FIGO2000 detected 8.3%, 33.3%, 41.7%, and 66.7%, respectively.
Conclusion: The hCG ratios should be used in prediction EMA/CO resistance in early course of
treatment (before cycle 5). Women with hCG ratio of less than 31.9 at cycle 4 should be considered
as at high-risk for the chemoresistance and may need second-line chemotherapy.
Keywords: drug resistance, EMA/CO, gestational trophoblastic neoplasia, human chorionic gonadotropin,
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Pulmonary Benign Metastasizing Leiomyoma Coincident with Estrogen Producing

Tumor in Aging Woman: A Case Report
Kanokwaroon Watananirun MD, Nalat Sompagdee MD.
Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Mahidol University
Abstract
A 54-year-old woman suffering from dyspnea for 7 months. The patient underwent open lung biopsy.
The tumor nodules comprised fascicles of bland appearing smooth muscle cells. Immunostaining
positive for vimentin, SMA, desmin, HHF35, while negative for AE1/AE3, CD34, HMB45, S100. All pathological findings were compatible with benign metastasizing leiomyoma. Pelvic organ evaluation by CT
abdomen showed hypodensity lesions at both ovaries measuring 2.9 x 2.6 cm on the left and 1.6 X
1.6 cm on the right. According to her aging might be menopausal period. So, reproductive hormonal
profile was evaluated. The result of FSH was 10.25 mIU/mL. Thus the patient underwent laparoscopic
bilateral salpingo-oophorectomy. The pathological reported adult granulosa cell tumor of one ovary.
From all finding suggested this tumor might produce estrogen and stimulated this metastasis
pulmonary leiomyoma in this delude herself into reproductive period.
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Standard and Ethics to Improve Womens Health

Merging Knowledge and Practice in OB-GYN 2015

THEME: Merging Knowledge and Practice in OB-GYN 2015

THEME: Merging Knowledge and Practice in OB-GYN 2015

Pre-congress Workshops 18 Main Congress

Management Ovarian Cancer in Pregnanacy

Adnexal mass in pregnancy: How to approach and Laparoscopic treatment for

Abnormal labor curve/labor progression

CT imaging i ovarian disease

Emergency management in GYN

Prevention of Thalassemia : Obstetric Approaches

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