Rise in cesarean section rate over a 20-year period in a public sector hospital in northern Thailand

OBJECTIVE: To determine a trend of cesarean section rate (CSR) and main contributing factors in a public sector hospital, representing northern part of Thailand. METHODS: A retrospective descriptive analysis was conducted by assessing the database of maternal-fetal medicine unit, which had prospectively been collected for 20 years. Trends were evaluated using data for the years 1992–2011. Private sector patients were excluded. RESULTS: A total of 50,872 public sector patients were available for analysis. The number of deliveries was gradually decreased from 3,802 in 1992 to 1,748 in 2011. Of them, 7,480 underwent cesarean section, CSR of 14.7 %. However, the CSR was significantly increased from 11.3 % in 1992 to 23.6 % in 2011 (p value <0.001). The CSRs indicated by cephalopelvic disproportion (CPD) and previous CSs were mainly responsible for a marked increase over the study period. CSR due to CPD was increased from 3.2 % in 1992 to 7.9 % in 2011 (p value <0.0001). While CSR due to other indications either breech presentation, fetal distress and twin pregnancies were only slightly, but significantly increased in the last decades but they are relatively constant in the recent years. CONCLUSIONS: In our public sector, CSR has gradually increased. The main reasons of such an increase were likely to be associated with over-diagnosis of CPD and subsequent repeated CS, while other indications played only a minimal role. To achieve the appropriate CSR, audit system for diagnosis of CPD must be instituted

Maternal Death at Maharaj Nakorn Chiang Mai Hospital, the 17 Years Experience

Objective: To analyze the characteristics, leading causes and trend of maternal deaths at Maharaj Nakorn Chiang Mai Hospital between the 20th and the 21st centuries. Study design: Retrospective descriptive study. Methods: The database of Maternal-Fetal Medicine unit and medical records, between January 1991 and December 2007, were reviewed for maternal death cases, causes of death and the causes were categorized into subgroups. Results: There were 72,952 live births and 50 cases of maternal deaths. The overall maternal mortality ratio (MMR) was 65:100,000 live births. Thirty-four (68%) were referral cases. Between the 20th century (1991-1999) and the 21st century (2000-2007), MMR had been dropped from 67/100 000 live births to 62 /100 000 live births. The direct maternal death was the most common cause of death and the top five leading causes were postpartum hemorrhage (PPH), amniotic fluid embolism, heart diseases, septic abortion and severe pre-eclampsia, respectively. Direct maternal death was decreased (MMR from 46.1 to 33.5%) but indirect maternal death were increased (MMR from 9.6 to 23.9%). Conclusion: The trend of MMR at Maharaj Nakorn Chiang Mai Hospital appeared to be minimal changed during the 17 years period. The direct maternal death tends to be decreased but the indirect maternal death tends to be significantly increased. PPH was the most common cause of death in both centuries

Comparisons of serum non-transferrin-bound iron levels and fetal cardiac function between fetuses affected with hemoglobin Bart’s disease and normal fetuses

ObjectiveTo compare the levels of Non-transferrin bound iron (NTBI) in fetuses with anemia, using Hb Bart’s disease as a study model, and those in unaffected fetuses and to determine the association between fetal cardiac function and the levels of NTBI.Patients and methodsA prospective study was conducted on pregnancies at risk of fetal Hb Bart’s disease. All fetuses underwent standard ultrasound examination at 18–22 weeks of gestation for fetal biometry, anomaly screening and fetal cardiac function. After that, 2 ml of fetal blood was taken by cordocentesis to measure NTBI by Labile Plasma Iron (LPI), serum iron, hemoglobin and hematocrit. The NTBI levels of both groups were compared and the correlation between NTBI and fetal cardiac function was determined.ResultsA total of 50 fetuses, including 20 fetuses with Hb Bart’s disease and 30 unaffected fetuses were recruited. There was a significant increase in the level of serum iron in the affected group (median: 22.7 vs. 9.7; p-value: 0.013) and also a significant increase in NTBI when compared with those of the unaffected fetuses (median 0.11 vs. 0.07; p-value: 0.046). In comparisons of fetal cardiac function, myocardial performance (Tei) index of both sides was significantly increased in the affected group (left Tei: p = 0.001, Right Tei: p = 0.008). Also, isovolumetric contraction time (ICT) was also significantly prolonged (left ICT: p = 0.00, right ICT: p = 0.000). Fetal LPI levels were significantly correlated inversely with fetal hemoglobin levels (p = 0.030) but not significantly correlated with the fetal serum iron levels (p = 0.138). Fetal LPI levels were also significantly correlated positively with myocardial performance index (Tei) of both sides (right Tei: R = 0.000, left Tei: R = 0.000) and right ICT (R = 0.013), but not significantly correlated with left ICT (R = 0.554).ConclusionAnemia caused by fetal Hb Bart’s disease in pre-hydropic stage is significantly associated with fetal cardiac dysfunction and increased fetal serum NTBI levels which are significantly correlated with worsening cardiac dysfunction. Nevertheless, based on the limitations of the present study, further studies including long-term data are required to support a role of fetal anemia as well as increased fetal serum NTBI levels in development of subsequent heart failure or cardiac compromise among the survivors, possibly predisposing to cardiovascular disease in adult life

Comparing the outcomes of termination of second trimester pregnancy with a live fetus using intravaginal misoprostol between women with and without previous cesarean section

Abstract Objective To compare the outcomes of termination of pregnancy with live fetuses in the second trimester (14–28 weeks), using misoprostol 400 mcg intravaginal every 6 h, between women with previous cesarean section (PCS) and no previous cesarean section (no PCS). Methods A comparative study was conducted on a prospective database of pregnancy termination in the second trimester, Chiang Mai university hospital. Inclusion criteria included: (1) singleton pregnancy; (2) gestational age between 14 and 28 weeks; and (3) pregnancy with a live fetus and medically indicated for termination. The participants were categorized into two groups; PCS and no PCS group. All were terminated using misoprostol 400 mcg intravaginal every 6 h. The main outcomes were induction to fetal delivery interval and success rate, defined as fetal delivery within 48 h. Results A total of 238 women, including 80 PCS and 158 no PCS, were recruited. The success rate of fetal delivery within 48 h between both groups was not significantly different (91.3% vs. 93.0%; p-value 0.622). The induction to fetal delivery interval were not significantly different (1531 vs. 1279 min; p-value > 0.05). Gestational age was an independent factor for the success rate and required dosage of misoprostol. The rates of most adverse effects of misoprostol were similar. One case (1.3%) in the PCS group developed uterine rupture during termination, ending up with safe and successful surgical removal and uterine repair. Conclusion Intravaginal misoprostol is highly effective for second trimester termination of pregnancy with PCS and those with no PCS, with similar success rate and induction to fetal delivery interval. Gestational age was an independent factor for the success rate and required dosage of misoprostol. Uterine rupture could occur in 1.3% of PCS, implying that high precaution must be taken for early detection and proper management. Synopsis Intravaginal misoprostol is highly effective for termination of second trimester pregnancy with a live fetus, with a comparable success rate between women with and without previous cesarean section, with a 1.3% risk of uterine rupture among women with previous cesarean section

Entonox&reg; versus Pethidine in Labor Pain Relief: A Randomized Controlled Trial

Background: Pain relief during labor is a part of standard care in modern obstetrics. Several modalities used for pain relief have their own disadvantages and benefits in terms of side effects, effectiveness, availability, and satisfaction. The objectives of this study are primarily to compare the effectiveness and patients&rsquo; satisfaction for pain relief during labor between pethidine and inhaled 50% nitrous oxide (Entonox&reg;). Methods: Laboring women at 37&ndash;41 + 6 weeks of gestation were randomly allocated to receive pethidine (50 mg intravenously) or Entonox&reg; for reducing labor pain. Pain scores were evaluated at 0, (baseline), 30, 60, 90, and 120 min after initiation, using the visual analog scale (VAS) and also satisfaction score after delivery using the verbal rating scale (VRS). The secondary outcomes were also assessed, including APGAR scores, labor course, side effects, and cesarean section rate. Results: A total of 136 laboring women underwent randomization into two groups, but only 58 and 65 in the pethidine group and the Entonox&reg; group were available for analysis. The median pain scores at baseline, 30, 60, and 90 min were comparable between both groups (p-value &gt; 0.05); however, pain score at 120 min in the pethidine group was significantly higher (p-value: 0.038). The median of satisfaction score was significantly higher in the Entonox&reg; group (4 vs. 3; p-value 0.043). All of the secondary outcomes were comparable between the two groups. Conclusions: Both have comparable effectiveness, but Entonox&reg; has a higher satisfaction score. Entonox&reg; could be an alternative to pethidine for reducing labor pain, because of its efficacy, ease for self-adjustment for satisfaction, and no serious effects on the labor course and newborns

Change in Prevalence of Hepatitis B Virus Infection in Pregnant Women in the Last Two Decades in Thailand

Objectives: In Thailand, there has been a strategy to prevent the mother-to-child transmission of HBV for over 30 years. However, there is still a lack of empirical evidence regarding the effectiveness of this strategy. This study aims to investigate the trends in the prevalence of HBV infection in pregnant women and to identify factors that may be associated with the prevalence of HBV infection in pregnant women. Patients and Methods: A maternal–fetal medicine database was accessed to retrieve the consecutive obstetric records of women giving birth at Chiang Mai University Hospital, Thailand, from January 2003 to December 2022. All women undergoing HBV tests with available results were included for an analysis of the trends and changes in the prevalence of maternal HBV infection. Also, the rates of infection in different age cohorts were compared. Results: During the study period, a total of 36,958 women were eligible for analysis. Overall, the prevalence of HBV infection in pregnant women was found to be 5.3% (1970 cases). Overall, HBV prevalence fell from 6.11% in 2003 to 3.15% in 2022. There was a significant reduction, especially in the adolescent group, decreasing from 8.26% in 2003 to 0% in 2022. In the reproductive age group, the prevalence significantly decreased from 6.41% to 2.01%. However, the prevalence in the elderly group was unchanged. The only significant risk factor was the years in the early timeline of the study period, presumably associated with previous HBV vaccination. Other factors, such as socioeconomic status, residential area, and being a private case, were not correlated with the prevalence of HBV. Conclusion: The prevalence of HBV infection in pregnant women has significantly decreased in the past two decades from 6.11% in 2003 to 3.15% in 2022. The percentage of reduction was very striking in the adolescent group, dropping from 8.6% in 2003 to 0.0% in 2022 or being nearly eradicated in the most recent years. Our results suggest that the overall prevalence of HBV infection among our pregnant women will probably be less than 1.0% in the near future

A retrospective comparison of pregnancy outcomes between women with alpha-thalassaemia 1 trait and normal controls

The objective of this retrospective cohort study was to compare pregnancy outcomes between low-risk pregnant women with alpha-thalassaemia-1 trait and normal controls. The database of the Maternal–Foetal Medicine unit was used to identify low-risk singleton pregnant women complicated by alpha-thalassaemia-1 trait who gave birth between January 2002 and October 2014. The low-risk pregnancies with non-carrier status for thalassaemia were assigned into the control group, with a control-to-case ratio of 10:1. During the study period, 595 women with alpha-thalassaemia-1 trait and 5950 normal controls were identified. There was no significant difference in the incidence of preterm birth and most obstetric outcomes between the two groups. However, a statistically significant difference was detected between them in terms of gestational age at delivery, 37.76 ± 2.81 vs. 38.11 ± 2.50 weeks (p = .001), birth weight, 2876 ± 581 vs. 2948 ± 527 g (p = .002) as well as the rate of low-birth weight, 17.1 vs. 12.8% (p = .002). In conclusion, this study provides new insights that alpha-thalassaemia-1 trait has minimal effect on gestational age at delivery and low-birth weight whereas other common adverse pregnancy outcomes are not increased.Impact statement What is already known on this subject: Thalassaemia trait is associated with some degree of anaemia. What the results of this study add: The prevalence of common adverse outcomes such as preterm birth, stillbirth, low Apgar scores and pregnancy-induced hypertension were not significantly different between both the groups, possibly caused by too small sample size to gain enough power. However, the rate of low-birth weight was significantly increased among pregnancy with alpha-thalassaemia-1 trait. What the implications are of these findings for clinical practice and/or further research: The information may be provided for alpha thalassaemia-1 trait mothers and their families. Physicians should guard against the occurrence of adverse pregnancy in these mothers. Prospective control study should be conducted to overcome the limitation of retrospective nature