Immunolocalization and protein expression of the alpha subunit of the large-conductance calcium-activated potassium channel in human myometrium

Large-conductance calcium-activated potassium (BKCa) channels play an important role in the control of myometrial excitability. The aim of the present study was to determine the localization and protein expression of the alpha subunit of BKCa channels in the pregnant and parturient human uterus. An anti-alpha BKCa channel monoclonal antibody (anti-alpha(995-1113)) was used to localize and quantitate immunoreactive BKCa channel protein in myometrium of singleton term pregnant women undergoing either elective (n=26) or emergency Caesarean section following the onset of spontaneous labour (n=25). Data are presented as medians (interquartile range). Differences between groups were analysed using the Mann-Whitney U test. Immunohistochemistry studies localized the alpha subunit of the BKCa channel to the plasma membrane and the cytosol of myometrial cells with similar reaction end product in pregnant women who were or were not undergoing labour. Expression of this subunit, observed as a 125 kDa band in western blots, was significantly higher in pregnant women who were not undergoing labour (30.6% (20.3, 43.9)) than in those who were undergoing labour (15.7% (11.3, 22.4); P<0.01). Reduced BKCa alpha subunit expression in pregnant women during labour may underlie the initiation of uterine contractility during parturition.

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

OBJECTIVES

To assess the adverse effects of isosorbide mononitrate (IMN) compared with misoprostol for cervical ripening at term.

METHODS

One hundred and seven women with term pregnancies referred for induction of labor with Bishop scores of 6 or less were randomly allocated to receive either a 40-mg IMN tablet vaginally (n = 55) or 50 microg misoprostol vaginally (n = 52) every 6 h for a maximum of three doses. They were sent to the labor ward for amniotomy or oxytocin if either their Bishop scores were more than 6 or their cervices were not ripe 24 h after the treatment. Adverse effects, progress, and outcomes of labor were assessed.

RESULTS

Isosorbide mononitrate was associated with fewer adverse effects especially uterine tachysystole (0 vs. 19.2%, P < 0.01) and hyperstimulation (0 vs. 15.4%, P < 0.01). The time from start of medication to vaginal delivery in IMN group was significantly longer (25.6 +/- 6.1 vs. 14 +/- 6.9 h, P < 0.01). Oxytocin was needed in 51 women (92%) of the isosorbide mononitrate group and six women (11%) of the misoprostol group (P < 0.001). The cesarean rate was not significantly different between the groups, but the major indications were different: dystocia (45%) in the IMN group vs. persistent non-reassuring fetal heart rate pattern (56%) in the misoprostol group.

CONCLUSIONS

Cervical ripening with IMN resulted in fewer adverse effects, but was less effective than misoprostol.

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

OBJECTIVE

To compare the intensity of postcesarean pain between closure and nonclosure of peritoneum in the women with a midline incision and one previous cesarean section.

STUDY DESIGN

The setting was an obstetrics unit of a university teaching hospital. A double-blind randomized trial was performed on 60 pregnant women with a midline incision and one previous cesarean section who underwent elective repeated cesarean section. Thirty women each were allocated to the "closure" group and the "nonclosure" group. The principal outcome measure was the postcesarean pain assessed by visual analog scale (VAS).

RESULTS

There was no difference in postoperative pain for closure and nonclosure of peritoneum groups in repeated cesarean patients; while resting (P=0.8), while moving in bed (P=0.94), and while walking (P=0.52). The use of opiate (P=0.27) and oral analgesics (P=0.37) also suggested no difference. No differences were found in duration of the operation, incidence of postoperative complications, time of returned bowel function, and length of the hospital stay.

CONCLUSION

The VAS showed no difference in postcesarean pain between closure and nonclosure of peritoneum.

Cephalocentesis with the modified Smellie's perforator

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

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

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

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

OBJECTIVE

To compare the efficiency of lidocaine with that of plain saline for paracervical pain relief during fractional curettage.

METHODS

This double-blind, randomized, controlled trial included 140 women who underwent fractional curettage. Seventy women were allocated to the lidocaine group and 70 to the plain saline group. The main outcome measure was the intensity of pain measured by visual analog scale during and after the procedure.

RESULTS

The intensity of pain was significantly lower in the lidocaine group than in the plain saline group over the course of the procedure (P = .02), especially during fractional curettage. There were no serious adverse effects in this study.

CONCLUSION

Lidocaine is more effective than plain saline for paracervical pain relief during fractional curettage. The anesthetic mechanisms of lidocaine are mechanical distention of tissue and peripheral nerve block.

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

OBJECTIVE

To compare the effectiveness of 600 and 800 microg of misoprostol administered intravaginally every 12 hours for termination of second trimester pregnancies.

METHODS

One hundred and forty-three pregnant women at 14-26 weeks' gestation were randomized in 2 groups to receive either 600 microg (N = 67), or 800 microg (N = 76) of intravaginal misoprostol every 12 hours until abortion was induced.

RESULTS

The incidences of abortion within 24 hours after initial drug administration were 82.1% (n = 55) and 78.9% (n = 60), within 48 hours 92.5% (n = 62) and 92.1% (n = 70), the mean abortion intervals were 15.2 (10.5, 20.8) hours and 15.3 (10.2, 21.8) hours, the complete abortion rates 77.6% (n = 52) and 72.4% (n = 55), and body temperature of more than 38 degrees C were 26.9% (n = 18) and 71.1% (n = 54, p = < 0.001) in the 600 and 800 microg group, respectively. All other side-effects were similar between the 2 groups.

CONCLUSION

In consideration of effectiveness and febrile complication, we suggest that 600 microg applied every 12 hours is the most appropriate dose to use for second trimester termination

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

OBJECTIVE

To evaluate the effectiveness of active management of labor in the setting of a developing country.

METHODS

This historical cohort study compared the labor characteristics and outcome of all anti-HIV positive nulliparous pregnant women (n=96), who delivered between January 1991 and March 1999, treated with traditional labor management to all anti-HIV negative nulliparous pregnant women (n=1856), who delivered in 1998, treated with active management of labor in the tertiary center of a developing country. The year 1998 was chosen by using the total cesarean section rate of nulliparous patients from 1991 to 1998 to find the mean, then selected the year with cesarean section rate nearest to the mean as a control. Data were analyzed by the chi-square and t-tests.

RESULTS

The length of labor was significantly shortened in the active management group (6.3+/-3.3 h vs. 8.9+/-6 h, P<0.001). A significantly greater proportion of the traditional management group had prolonged labor (29.3% vs. 4.9%, P<0.001). However, the cesarean section rate was not different between the two groups (active vs. traditional=17% vs. 14.6%, P=0.7) with dystocia as a major indication in both groups. Maternal and fetal complications were not different.

CONCLUSION

The active management of labor shortened the duration of labor and reduced prolonged labor; however, it did not decrease the cesarean section rate.

Postpartum intrauterine pressure studies of the uterotonic effect of oral misoprostol and intramuscular syntometrine

OBJECTIVES

To investigate the effect of oral misoprostol in dosages varying from 200 microg to 800 microg on postpartum uterine contractility and to establish their side effects.

DESIGN

A prospective descriptive study.

PARTICIPANTS

Fifty-seven women who delivered vaginally after spontaneous labours not requiring augmentation.

METHODS

Within 5 minutes of delivery of the placenta, a calibrated Gaeltec catheter with an intrauterine pressure transducer at its tip was inserted transcervically into the uterine cavity. Cumulative uterine activity was recorded for 30 minutes in each woman before administering the oral misoprostol tablets and continued for a further 90 minutes after its administration. Thus each woman acted as her own control regarding changes in uterine contractility. Uterine activity was recorded on a Sonicaid Meridian fetal monitor, which measures active contraction area automatically. The incidence of side effects was also recorded.

RESULTS

There was no statistical difference (P = 0.887) in the adjusted mean difference in cumulative uterine activity following all the doses of oral misoprostol, compared with intramuscular syntometrine, the largest difference being seen in oral misoprostol 200 microg (adjusted mean difference -2282 kPas s, 95% CI -7954 to 3390 kPas s). The mean onset of action of oral misoprostol (6.1, SD 2.1 min) was significantly slower than that of intramuscular syntometrine (3.2, SD 1.5 min; P = 0.002), but their durations of action were similar (P = 0.637). In the misoprostol group the commonest side effects were shivering (36%) and a rise in body temperature above 38 degrees C (40%). In the syntometrine group, the most commonly observed side effect was moderate uterine pain (nine out of ten women) and a rise in diastolic blood pressure of 20 mmHg (two out of ten women).

CONCLUSION

The results of this study show that oral misoprostol has a definite uterotonic effect on the postpartum uterus. At doses of 200 microg to 400 microg, oral misoprostol has a similar uterotonic effect to intramuscular syntometrine. Higher doses of oral misoprostol are associated with significantly more side effects.

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

OBJECTIVE

To estimate the adverse effects of glyceryl trinitrate compared with prostaglandin (PG) E2 vaginal tablet for cervical ripening in term pregnancy.

METHODS

One hundred ten women with term pregnancies referred for induction of labor with Bishop scores of 6 or less were randomly assigned to receive a 500-microg glyceryl trinitrate tablet vaginally (n = 54) or a 3-mg PGE2 tablet vaginally (n = 56), every 6 hours for maximum of two doses. Subjects were sent to the labor ward for amniotomy or oxytocin if their Bishop scores were more than 6 or their cervices were not ripe 24 hours after treatment. Adverse effects, changes in the Bishop scores, progress, and outcomes of labor were assessed.

RESULTS

Glyceryl trinitrate was associated with fewer episodes of uterine tachysystole (0% versus 9%; P =.02). The median Bishop score after 12 hours was lower in women given glyceryl trinitrate compared with those given PGE2. Adverse effects, including headache and palpitations, were more frequent with glyceryl trinitrate than with PGE2. The cesarean rate was not significantly different between groups.

CONCLUSION

Cervical ripening with glyceryl trinitrate resulted in fewer episodes of tachysystole, but there were significantly more minor side effects. It can be used for cervical ripening at term, but it was not as effective as PGE2.

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

OBJECTIVE

To undertake a survey of cesarean section in the general, private and university hospitals in Thailand.

METHODS

Postal questionnaires were sent to all the general, private and university hospitals with 200 beds or more. The questionnaires were prepared to find out the percentage, the indications and the trend of cesarean delivery, the measures taken to decrease cesarean section rate, and the practice of external cephalic version (ECV) and vaginal birth after cesarean section (VBAC) in the hospitals.

RESULTS

The overall response rate was 88%. Mean cesarean section rates were 24, 48, and 22% in the general, private and university hospitals, respectively. Cesarean section rates in most of the hospitals were increased in the past 5 years namely 78% in the general hospitals, 50% in the private hospitals, 66% in the university hospitals. However, only 38% of the hospitals had measures to regulate this operation. Repeated cesarean section was the most common indication in the private (63%) and the university hospitals (88%) while failure to progress was the most common indication in the general hospitals (55%). ECV and VBAC were performed in 26 and 12% of the hospitals. They were, however, not the standard practices.

CONCLUSION

Rising of cesarean section rate without any measure to regulate it is the problem in the developing countries. Standardised labor management and reduction of unnecessary primary cesarean section will automatically reduce repeated operation and overall cesarean section.

Nutrients and hormones in heat-dried human placenta

This cross-sectional study was to assess the nutrients in terms of protein, fat, minerals, and hormones in heat-dried human placenta. Thirty heat-dried human placentas, 15 from male and 15 from female, were analyzed for protein (amino acids), fiber, fat, moisture, minerals (sodium, potassium, phosphorus, calcium, iron, magnesium, zinc, copper, manganese), hormones (estradiol, progesterone, testosterone, growth hormone). Heat-dried female human placentas had slightly higher fiber content than male, but protein and fat components were not different. Mineral levels in placentas were high especially sodium, potassium and phosphorus. There were no significant differences in the amount of minerals and hormonal profile between female and male placentas. However, hormone levels in heat-dried placenta were low compared to physiologic level in human beings. The results of this study suggest that the amount of nutrients particularly protein and minerals in heat-dried human placentas were enriched.

Vaginal misoprostol in termination of second trimester pregnancy

OBJECTIVE

To study the effectiveness and complications of 600 micrograms of intravaginal misoprostol for terminating second trimester pregnancies.

STUDY DESIGN

One hundred and seventy-two patients undergoing termination of pregnancy between March 1997 and April 1999 were studied. Each patient received 600 micrograms of intravaginal misoprostol every 12 hours until abortion occurred.

RESULTS

The mean induction to abortion time was 24.1 +/- 21.6 hours. The percentage of women aborting within 24 and 48 hours was 68.6 and 89.5 respectively. There was no significant difference in the mean induction to abortion time and the percentage of women aborted within 48 hours between nulliparous and multiparous women. The mean amount of misoprostol used was 1405.5 +/- 1084.6 micrograms. Incomplete abortion occurred in 23.3% of women. The most common complication was temperature of more than 38 degrees C occurred in 41% followed by diarrhoea (20%), nausea and vomiting (15%).

CONCLUSION

Six hundred micrograms of vaginal misoprostol is effective, but whether the 48 hours abortion rate can be improved with a large dose or shortened the time interval between doses, requires further study.

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

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

Serum vitamin A and E in pregnant women with hemoglobinopathies

OBJECTIVE

To evaluate the relationship between the status of serum vitamin A, E and hemoglobinopathies among Thai pregnant women.

METHODS

This was a cross-sectional study in which serum vitamin A and E were assessed in 323 pregnant women with normal hemoglobin and 73 with hemoglobinopathies (47 with hemoglobin E and 26 with thalassemia) during the first trimester.

RESULTS

There were no significant differences in the mean serum vitamin A, E concentrations and vitamin E/cholesterol ratio between pregnant women with normal hemoglobin and hemoglobinopathies, while confounding variables that might affect serum vitamin levels i.e. maternal age, gravida, BMI, gestational age, hematocrit, hemoglobin, mean corpuscular hemoglobin concentration and blood group were not different.

CONCLUSION

The results of this study suggest that antenatal care in terms of micronutrients-vitamin A, E in Thai pregnant women with hemoglobinopathies should not be different from normal pregnant women.

Umbilical artery blood gas and lactate in healthy newborns

This study aimed to establish the normal range of umbilical artery pH, pCO2, base deficit and lactate in normal term and preterm newborn. Umbilical artery pH, pCO2, base deficit and lactate was measured in 637 newborn babies. The study included 555 babies at term with Apgar score equal to or more than 7 at 5 minutes, not requiring assisted ventilation and not admitted to the neonatal unit (NNU), as well as 47 preterm babies with Apgar score equal to or more than 7 at 5 minutes who were admitted to the NNU for observation only because of prematurity. Data was presented as mean and SD. Statistical analysis was done by t-test and simple linear regression analysis. In the newborn at term mean umbilical artery blood gas and lactate were as follows; pH = 7.25 (+/- 0.08), pCO2 = 45.66 (+/- 1.88) mmHg, base deficit = 7.69 (+/- 3.88) mEq/L, lactate = 2.96 (+/- 1.8) mMol/L. In preterm newborn the values were; pH = 7.25 (+/- 0.04), pCO2 = 51.78 (+/- 13.00) mmHg, base deficit = 5.29 (+/- 1.87) mEq/L, lactate = 2.55 (+/- 1.87) mMol/L. The range of umbilical artery blood gas and lactate parameters in term and preterm fetuses with good neonatal outcome were derived. There was a statistically significant difference in pCO2 and base deficit between term and preterm newborn. There was no linear correlation between lactate, pH, pCO2, base deficit and fetal glucose respectively in term or preterm infants.

External cephalic version: first report from Thailand

This prospective study was to preliminary report the safety and success rate of external cephalic version (ECV) in patients with breech presentation or transverse lie at 36 weeks of gestation or more. The aim of this procedure was to reduce the cesarean section rate from indication of breech presentation and transverse lie. This procedure was first started in the Obstetrics and Gynecology Department, Ramathibodi Hospital in June 1998. Thirty two patients were enrolled in this study. ECV was 65 per cent successful with the reversion rate of five per cent. There was no maternal or fetal complication related to this procedure. Factors associated with successful outcome in this study were the location of placenta, the position of fetal spine and the amount of amniotic fluid. A larger study is needed before the true success rate and the efficacy of this procedure can be apparent.

Emergency cervical cerclage: Ramathibodi Hospital experience

This retrospective study is to evaluate the outcome of pregnancy after emergency cervical cerclage. Records of patients, who were treated with emergency cervical cerclage in Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, from 1982 to 1997, were reviewed. Maternal age, gravida, parity, past obstetric history, gestational age at cerclage, latency period, complication and outcome were noted. Only one of 7 patients who had this operation performed, aborted. The others continued pregnancy and all the babies were born alive. There was no serious maternal complication. This operation has a favorable outcome in selected cases.

Malignant ovarian germ cell tumours: experience in the National University Hospital of Singapore

Management of thirteen cases of malignant ovarian germ cell tumours was reported. Of these, 5 (38%) were immature teratoma, 3 (23%) were endodermal sinus tumour, 1 (8%) was dysgerminoma and 4 (31%) were mixed germ cell tumour. Eight (61%) had stage I, 1 (8%) had stage II and 4 (31%) had stage III diseases. Six had unilateral salpingo-oophorectomy, 6 had total abdominal hysterectomy and bilateral salpingo-oophorectomy and 1 had bilateral oophorectomy. Ten (77%) had adjuvant chemotherapy predominantly with bleomycin/etoposide/cisplatin combination. All patients with stage I and stage II tumours were alive with no evidence of disease at 1/2 year to 5 years followup. Of the 4 patients with stage IIIC diseases, 2 with optimal debulking surgery were alive and disease free at 4 and 7 years after surgery. The other 2 patients with stage IIIC tumours had multiple bulky residual tumours. One of them with a combination of endodermal sinus tumour and embryonal carcinoma died of progressive disease despite chemotherapy 6 months after surgery and the other with mixed endodermal sinus tumour and dysgerminoma was alive with disease at 6 months. Alpha-fetoprotein levels were raised in all 6 patients with endodermal sinus tumour, either pure or combined with other tumours. Regression of alpha-fetoprotein levels was of important prognostic significance in endodermal sinus tumour.

Cesarean and postpartum hysterectomy

OBJECTIVE

To review the cases of cesarean and postpartum hysterectomy.

METHOD

A retrospective study of all cases of cesarean and postpartum hysterectomy during 1985-1994. Maternal characteristics, method of delivery, indications for hysterectomy and complications were reviewed.

RESULTS

The rate of cesarean and postpartum hysterectomy was 1:1667 deliveries. Half of these cases were delivered by cesarean section. The main indications for hysterectomy were massive bleeding due to uterine atony, abnormal placental adhesions or uterine rupture. Maternal morbidity was high and there was one maternal death.

CONCLUSION

Cesarean and postpartum hysterectomy is a necessary life-saving operation. Although maternal mortality is rare, morbidity remains high. Prevention of complications that give rise to hysterectomy and optimally timed surgery should decrease maternal morbidity and mortality.