Indonesian Journal of Obstetrics and Gynecology (INAJOG)
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Effect of Ovarian Stimulation with Recombinant FSH for In Vitro Fertilization (IVF) on Anti Müllerian Hormone (AMH) Levels as an Early Marker of Ovarian Reserve
Get PDFObjective: To analyze the effect of ovarian stimulation with recombinant FSH on AMH levels as a marker of ovarian reserve in patients undergoing IVF.
Method: This study is an intervention study which compares AMH levels pre- and post-ovarian stimulation with recombinant FSH in IVF participants to determine the effect of ovarian stimulation on ovarian reserve. This study was conducted at Dr. Cipto Mangunkusumo Hospital, Jakarta, from January to July 2010. AMH levels measured are AMH levels pre- and post-stimulation taken on the day of hCG evaluation.
Result: Of 56 patients undergoing IVF treatment, 20 subjects were eligible for study. The mean age of the patients was 35. 3 ± 4.0 years, the mean duration of infertility 9.1 ± 5.7 years, the mean BMI 21.9 ± 3.4 kg/m2, the median AMH level pre-stimulation was 4.0 ng/ml and the total dosage of FSH used was 2747.5 ± 1076.3 IU/
day, the mean duration of ovarian stimulation was 9 ± 3 days. Of the 20 subjects recruited, 11 patients (55%) had a decrease in AMH levels, and the remaining 9 patients (45%) did not. Data analysis showed that the decrease in AMH levels was not statistically significant (p = 0.295) [AMH1; median 4.0 ng/ml (range 2.2 - 5.9) and AMH2; median 3.2 ng/ml (range 1.6 - 4.8)].
Conclusion: AMH levels decrease following ovarian stimulation with recombinant FSH is not statistically significant, so it can be concluded that ovarian stimulation in IVF has no effect on ovarian reserve.
[Indones J Obstet Gynecol 2011; 35-2: 70-3]
Keywords: ovarian reserve, AMH, recombinant FSH, ovarian
stimulation, IV
Early Experience of Laparoscopic Radical Hysterectomy and Lymphadenectomy
Get PDFI have had a basic laparoscopy skill during my residency
in the Department of Obstetrics and Gynecology
University of Indonesia back in 1974. At that
time this procedure only for diagnostic purpose especially
to determine the patency of the fallopian tube.
Time goes on and laparoscopy now becomes very
popular surgical procedure as a minimal invasive surgery
in almost all of the surgical procedure not only
in gynecologic field but also has expanded to digestive
surgery, orthopedic, ENT, thorax surgery. Prof.
Joo-Hyun Nam, MD (Prof. Nam) from Korea suggested
me to develop this kind of surgery. Gynecologic
oncologist should have competency for doing
this minimal invasive surgery such radical surgery in
cervical cancer, endometrium and early ovarian cancer
or just for surgical staging includes paraaortic
lymphadenectomy and omentectomy.
Before I involved deeply in laparascopic gynecologic
oncology surgery, I have learned much form
dr. Wachyu Hadisaputra, as the chairman of the gynecologic
endoscopy working group from POGI (Indonesian
Society of Obstetrician and Gynecology), in
laparoscopic gynecologic non oncology surgery.
In late 1990 I attended a symposium Laparoscopy
in Gynecologic Oncology in Philadelphia organized
by the late Prof. Dargent under IGCS (International
Gynecology Cancer Society). In 2005 I followed a
workshop for radical hysterectomy and lymphadenectomy
on unbalmed cadaver (fresh cadaver) in Florida
during Annual Meeting Society of Gynecologic Oncology,
and I joined for the next year workshop. The
trainer came from prominent countries such as USA,
Germany and France. Since then I practiced total hysterectomy
with laparoscopic surgery, even in small
number of cases. In early 2009 I had an opportunity
to visit Prof. Nam hospital in Seoul and watched him
doing live radical surgery in the operating theatre. In
the same year I practiced paraaortic lymphadenectomy
on swine in Shanghai. Back from Seoul I and
dr Chamim started doing radical surgery at Fatmawati
Hospital and months later I followed an unbalmed cadaver
Laparoscopic Symposium in Oncology in
Taichung Taiwan. Another case done at Omni Hospital
to fullfil dr. Boy Busmar’s invitation.
From what I had been experienced I can suggest
that we have set a solid team which is very important
and supported by good equipment such colpotomy device,
bipolar dissection, scissor, hormonic and ligaclip
are very helpful if possible but if is available enough
with bipolar dissection. The first step to assess the
internal genital, if there is a massive adhesion it
would prolong the surgery time.
We then opened or incised the peritoneum between
round ligamentum and fimbria and extended medially
and laterally to exposed psoas muscle and ureter
which cross the common iliac artery. The round ligament
should stay intact to ease the surgery and prevent
the uterus not to distort. Vesico-uterine fold was
opened and we made a space such as paravesical and
pararectal spaces. Then the procedure was done medially
to extract fat and node ventral to common iliac
until the wall of the artery was noted and we did lymphadenectomy
along the external iliac artery. By doing
this procedure, the iliac vein, internal iliac and
uterine artery will be exposed and obturator nerve as
well. The nodes was then put in the plastic bag made
of plastic drug so it is very cheap instead of special
bag sold by the supplier. Ureter was disected and
pushed aside and ureteric canal was opened.
Vagina was amputated by direction of colpotomy device
and top of the vagina sutured through the vagina
as suggested by Prof. Nam. By doing this if we think
that vagina cut was inadequate, we can cut it more.
The beginning of the procedure took more than 4
hours and as mentioned by the literatures that the
learning curve will decrease by the amount of surgery.
We have done 5 cases, 1 of those with serosal laceration
of the sigmoid and repaired the lacerated serosal
with few stitches and 1 case with iliac vein and the
bleeding could be controlled using ligaclip. I hope
that this minimal invasive surgery will enrich our modality
in handling the malignancy in gynecologic surgery
and we can positioned to the level of developed
countries in Asia.
The Asian Society of Gynecologic Oncology has
planned to train Young Gynecologic Oncologist in
this kind of surgery. In July 2010 there will be a
workshop laparoscopy in gynecologic Oncology in
Seoul and Indonesian Society of Gynecologic Oncology
(Himpunan Onkologi Ginekologi Indonesia) is
asked to propose candidates. Accommodation and
transportation while in Korea will be covered by
ASGO. I hope, this invitation can be responded well
by our young gynecologic oncologist
The Identification of Placental Alpha Micro Globulin-1 (Amnisure®) as a Method to Identify Rupture of Membrane
Get PDFObjective: We aimed to do a study in the use of the identification of Placental Alpha Micro Globulin-1 or PAMG-1, in the form of Amnisure ® test, as a method to diagnose rupture of membrane (ROM), compared with other conventional method (direct visualization and
nitrazine test).
Method: We used a cross-sectional design. Every pregnant woman who came to our hospital with gestational age of 14 to 42 weeks complaining of membrane rupture was recruited. Sterile speculum
examination and nitrazine test was performed for every patient. Amnisure ® was utilized, using vaginal swab from posterior fornices. Data analysis was performed with SPSS version 17.
Results: We recruited 20 patients to join our study. Mean age, parity and gestational age was 28.5 years, parity one and 35.5 ± 3.4 weeks of gestation. Amnisure® test was positive in 14 patients. With nitrazine as standard for ROM diagnosis, the sensitivity for Amnisure® was 85% and the specificity was 83.3%. The positive predictive
value was 92.3% and negative predictive value was 71.4%.
Conclusion: For every positive vaginal pooling, nitrazine and Amnisure ® will be tested positive. Several studies using Amnisure® have shown similar results. Role of Amnisure® seemed evident in cases of uncertainty such as chronic ROM and severe oligohydramnios due to ROM. Positive results in presence of intact membranes which suggested micro-perforations of the membrane still need further research. Much still needed to be done before implementing Amnisure® in our country, especially in the matter of cost effectiveness.
[Indones J Obstet Gynecol 2012; 36-1:20-3]
Keywords: amnisure®, PAMG-1, RO
Adhesion Prevention in Operative Laparoscopy
Get PDFObjective: To know the modalities used for prevention of adhesion
formation in operative laparoscopy.
Method: Literature study.
Results: Methods of prevention of adhesion in laparoscopy include:
modification of surgical technique, anti-inflammatory agents,
peritoneal instillates and barrier adjuvants. Modification of surgical
techniques such as adherence to basic principles of microsurgery,
the use of electrothermal bipolar vessel sealer, liberal irigation of
the abdominal cavity and instillation of a large amount of Ringer’s
lactate at the completion of the procedure. This technique alone,
eventhough seems effective, is insufficient. The anti-inflammatory
agents used are the NSAIDs, corticosteroids, antihistamines, progestogens, GnRH agonists and calcium channel blocker. But none
of them demonstrated to be significantly effective. Barrier adjuvants
consist of: oxidized regenerated cellulose (ORC) and expanded polytetrafluoroethylene (ePTFE) and peritoneal instillates are the crystalloids, icodextrin, hyaluronic acid (HA), solution of HA, viscoelastic gel, hydrogel, and fibrin sealent. There is insufficient evidence data regarding the methods above for the prevention of adhesiogenesis in laparoscopy. But one study evaluating the use of viscoelastic gel did significantly reduce adnexal adhesion in laparoscopy.
Conclusion: Laparoscopy does not trully eliminate the adhesiogenesis
problem. No single therapy is effective for prevention of adhesion
formation. The multimodal methods shall be used to increase
the successful rate in adhesion prevention.
[Indones J Obstet Gynecol 2010; 34-4: 204-7]
Keywords: laparoscopy, adhesion, microsurgery, anti-inflammatory,
peritoneal instillates, barrier adjuvant
Diagnostic Value of IGFBP-1 Rapid Test and Combined IGFBP-1-AFP in Vaginal Fluid from Premature Rupture of Amniotic Membranes
Get PDFObjective: To compare the diagnostic value of IGFBP-1 and combined
IGFBP-1-AFP rapid tests in diagnosing premature rupture of
membranes (PROM).
Method: This study was conducted in Dr. Soetomo Hospital in Surabaya
from July to November 2013. The subjects were 52 pregnant
women with presumed PROM diagnosis, which was recorded by
clinical data and sampling of vaginal discharge swab. The diagnostic
value was obtained by comparing the results of IGFBP-1 and combinated
IGFBP-1-AFP rapid tests by standard PROM examination
namely vaginal pooling, litmus paper test and ferning test.
Result: A difference between the diagnostic value of IGFBP-1 and
combined IGFBP-1-AFP rapid tests in diagnosing PROM was
shown, where the sensitivity and specificity of IGFBP-1 rapid test was
85% and 95%, compared to combined IGFBP-1-AFP rapid test,
which was 91% and 95%. The correlation coefficient of combined
IGFBP-1-AFP rapid test with standard PROM examination
(r=0.841, p=0.000) was higher than the correlation coefficient of
IGFBP-1-AFP rapid test with standard PROM examination
(r=0.772, p=0.000).
Conclusion: Combined IGFBP-1-AFP rapid test has a better diagnostic
value than IGFBP-1 rapid test alone.
Keywords: combined IGFBP-1-AFP, IGFBP-1, PRO
IIIB-IV Degree Perineal Rupture Repair Using Overlapping and End-to-End Techniques with Pudendal Block Anesthesia
Get PDFObjective: To compare the incidence of persistent sonographic anal
sphincter defect, fecal urgency, anal and fecal incontinence after IIIb-
IV degree perineal rupture repair using overlapping and end-to-end
technique.
Method: An open clinical trial with randomization was carried out in
July 2010-April 2012. The population consisted of the patients who
underwent vaginal delivery in Dr. Sardjito Central General Hospital,
Sleman District General Hospital, as well as Tegalrejo, Jetis and Mergangsan
Community Health Centers who did no have complaints of
fecal urgency, anal incontinence, and/or fecal incontinence, and suffered
IIIb-IV degree perineal rupture repaired within less than 24
hours of rupture. The exclusion criteria included conditions in which
patients could not undergo repair at the moment (shock, uncooperative
patient). Fourty-eight research samples were divided into 2
groups, 24 samples for each of the treatment group (overlapping repair)
and the control group (end-to-end repair). Local anesthesia was
performed in a pudendal-block manner.
Result: Success of the repair was assessed based on the presence of
persistent sonographic anal sphincter defects in the 6-week evaluation
after repair. Successful repair was higher in the overlapping group
than that of the end-to-end group (94.74% vs 81.25%, p=0.31).
Clinically and based on the Fecal Continence Scoring Scale (FCSS),
evaluation at weeks II and VI indicated successful repair in both
groups.
Conclusion: There was no difference in the incidence of persistent
sonographic anal sphincter defects, fecal urgency, anal incontinence,
and fecal incontinence, after IIIb-IV degree perineal rupture repair
using overlapping technique in comparison with end-to-end technique.
Keywords: end-to-end technique, III-IV degree perineal rupture,
obstetric perineal rupture, overlapping techniqu
A Case of Prenatal Diagnosis of Trisomy 18 with Ultrasound
Get PDFObjective: To report a case of trisomy 18 diagnosed in prenatal care. Methods: Case report. Case: A 24 years old primigravida woman was diagnosed with term pregnancy (37-38 weeks) with an intrauterine singleton live fetus with Edwards syndrome. In 15-16 weeks of pregnancy the omphalocele was discovered using ultrasound. Subsequently, amniocentesis was performed and the chromosome analysis result showed Edwards syndrome (47, XX +18). The patient chose to continue the pregnancy until term. In this patient, elective CS was performed at term pregnancy, involving teamwork between obstetrics and perinatology. A female baby was born weighing 1720 grams, 40 cm body length, and APGAR score of 5/7. The congenital anomalies discovered include umbilical hernia, rocker bottom feet, clenched hands, low set malformed ears, and a single umbilical artery. The baby was born with asphyxia, improved after resuscitation, and required treatment in the NICU. Pediatric surgeons planned umbilical hernia repair. Furthermore, because of the presence of suspected esophageal atresia, the baby was planned for gastrotomy, which was delayed because the baby was experiencing desaturation. Because of the unstable condition of the baby, echocardiography and gastrotomy were not done until the 18th day of treatment. At the 18th day, the baby’s condition deteriorated and the baby died with metabolic acidosis. Conclusion: Edwards syndrome can be diagnosed in the prenatal period by risk factors consideration, maternal serum markers, and ultrasonographic identification of organ abnormalities. [Indones J Obstet Gynecol 2015; 3-4: 234-238] Keywords: Edwards syndrome, prenatal diagnosis, trisomy 18, ultrasoun
Helminth Infection in Pregnancy: Effect on Serum Albumin Level and Pregnancy outcome
Get PDFObjective: To determine the prevalence of helminth infection in
pregnant women and its effect on albumin levels and pregnancy outcome.
Method: A prospective cohort study was conducted on third trimester
pregnant women presenting for antenatal care in several hospitals
in Makassar. Information on subject demography was recorded
using short questionnaire. Stool samples were collected to determine
the presence of helminth infection. Albumin levels were measured
from maternal blood and cordâ€blood. Outcome of pregnancy
was assessed upon delivery.
Result: The prevalence of helminth infection in our subjects was
22.8%. Among 21 infected women, 17 were infected with Ascaris
lumbricoides (80.9%), one with Trichuris trichiura and three with
both Ascaris and Trichuris. The mean Ascaris lumbricoides intensity
was 1769.3 epg (Range = 24â€11.688 epg). Helminth infections have
no effect on either maternal or neonatal albumin levels (p=0.748 and
p=0.480, respectively). Although it was not found to be significant
(p>0.05), helminth infection seems to affect gestational age (OR 2.06,
95% CI 1.48â€2.86) and birth weight (OR 2.18, 95% CI 1.52â€3.14).
Neonatal albumin level and pregnancy outcome were not affected by
maternal albumin level.
Conclusion: Helminth infection seems to affect pregnancy outcome
in pregnant women in Makassar, but not through influence of albumin.
Factors other than albumin level may responsible for such condition
