Ninlapa Pruksanusak

Reliability of fetal nasal bone length measurement at 11–14 weeks of gestation

BackgroundNasal bone assessment has been incorporated into Down syndrome screening in first trimester. Several studies have established the normal reference values for fetal nasal bone length in the first trimester, which were found to be varied by population. However, the study on reliability of nasal bone length measurement was limited with contradictory results. This study aimed to investigate the reliability of fetal nasal bone length measurement at 11–14 weeks of gestation in the Thai population.MethodsA total of 111 pregnant women at 11–14 weeks of gestation attending for the routine first-trimester ultrasound examination were recruited. Each case was measured separately by two examiners. Examiner 1 performed the first measurement in all cases; any of the other 5 examiners consecutively performed the second measurement. Three independent measurements were performed by each examiner and they were blinded to the results of the others. Intraobserver and interobserver variabilities were evaluated with the intraclass correlation coefficient (ICC).ResultsNasal bone measurement was successfully performed in 106/111 cases (95.5%) by at least one examiner; 89 cases were performed by two examiners. The intraobserver variability was excellent for all examiners (ICC, 0.840-0.939). The interobserver variability between different pairs of examiners varied from moderate to excellent (ICC, 0.467-0.962). The interobserver variability between examiner 1 and any other examiner was good (ICC, 0.749). The Bland-Altman plot of the interobserver differences of nasal bone length measurements between examiner 1 and any other examiner showed good agreement.ConclusionsThe reliability of the fetal nasal bone length measurement at 11–14 weeks of gestation was good. The nasal bone length measurement was reproducible. Ethnicity has an effect on fetal nasal bone length, but reliability of nasal bone length measurement is critical to accuracy of screening and should be audited on an ongoing basis.

A survey of the knowledge and attitudes of pregnant Thai women towards Down syndrome screening

Aim:  To determine the knowledge and attitudes of pregnant Thai women towards Down syndrome screening.

Fetal Cardiac Rhabdomyoma With Hydrops Fetalis Report of 2 Cases and Literature Review

Rhabdomyoma is the most common cardiac tumor in fetuses, often associated with the tuberous sclerosis complex, especially when multiple tumors and a positive family history of tuberous sclerosis are noted. The tumor is often benign and has a tendency to regress but may increase in size until the early third trimester. Fetal cardiac rhabdomyoma complicated by hydrops fetalis and leading to fetal death is rare. We report 2 cases of fetal cardiac rhabdomyoma with hydrops fetalis and provide a review of the literature.

A reference for ductus venosus blood flow at 11-13+6 weeks of gestation.

Objective: To establish reference ranges for ductus venosus (DV) blood flow assessment obtained transabdominally at 11-13+6 weeks of gestation. Methods: A cross-sectional study was conducted on singleton pregnancies with a crown-rump length (CRL) ranging from 45 to 84 mm, normal fetus, and subsequent newborn birth weight appropriate for gestational age. Measurements of DV Doppler variables were performed by experienced sonographers: peak velocity during ventricular systole (S-wave) and diastole (D-wave), nadir during atrial contraction (A-wave), time-averaged maximum velocity (TAmax), pulsatility index for veins (PIV), and peak velocity index for veins (PVIV). Results: A total of 304 fetuses were included. The mean CRL was 60.7 ± 7.2 mm (range: 45.9-75.5). The mean nuchal translucency measurement was 1.4 ± 0.4 mm. The S-wave, D-wave, A-wave, and TAmax values varied significantly with gestational age (p < 0.05) and regression models were constructed for each variable. The remaining variables, systolic/atrial wave ratio, preload index, PVIV, and PIV, did not vary significantly with gestational age within this CRL range. Conclusion: Reference ranges for DV Doppler assessment were established in normal fetuses. These ranges may be a useful tool for evaluation of anueploidy and fetal cardiac function.

A Thai Reference for Normal Fetal Nasal Bone Length at 11–13(+6) Weeks Gestation

Aim: The purpose of this study was to establish a Thai reference for normal fetal nasal bone length (NBL) at 11–13+6 weeks gestation. Methods: The fetal nasal bone was measured by sonography in pregnant women at 11–13+6 weeks gestation. All neonates who showed normal karyotypes were examined after delivery to confirm the absence of congenital abnormalities. Results: A total of 255 pregnant women were recruited. Forty-seven pregnant women were excluded from the analysis because of technically unsatisfactory examination or absent nasal bone and chromosomal abnormalities. The mean ± SD of NBL was 1.79 ± 0.33 mm and increased significantly with crown–rump length (CRL) and gestational age (p < 0.001). The best-fit equation for NBL in euploid fetuses in relation to CRL was: NBL (mm) = (0.030 × CRL (mm)) – 0.016. Conclusion: NBL in Thai fetuses at 11–13+6 weeks was found to be on average shorter than that in Caucasian, African-American and Chinese populations, but similar to those reported in Korean and Latin-American populations.

Combined maternal-associated risk factors with intrapartum fetal heart rate classification systems to predict peripartum asphyxia neonates

OBJECTIVE To improve the predictive ability for identification of peripartum asphyxia neonates by using the 3-tier and 5-tier fetal heart rate (FHR) classification systems. STUDY DESIGN A retrospective case-control study comparing peripartum asphyxia neonates and no asphyxia neonates was conducted. The FHR tracings were classified into the 3-tier and 5-tier systems by the two reviewers. Pearsons X2 or Fishers exact tests was used for comparisons between the groups. Logistic regression models were used to identify factors associated with peripartum asphyxia neonates. Odds Ratios (OR) and Likelihood Ratios (LR) with 95% confidence intervals (CI) were calculated from the regression coefficients. RESULTS A total of 36 peripartum asphyxia fetuses (5.0%) were enrolled. Overall, the performance of category II and suspicious tracings to detect peripartum asphyxia neonates was higher than the yellow and orange tracings with 61% and 67% sensitivity, respectively. The 5-tier FHR classification had higher specificity than the 3-tier system (82-99%). The predictive ability to detect peripartum asphyxia neonates by the 5-tier FHR classification was highest when combined with maternal-associated risk factors (AUC 0.67-0.72). CONCLUSION Maternal-associated risk factors combined with an abnormal 5-tier FHR classification had high predictive ability and specificity to detect peripartum asphyxia neonates.

Prenatal diagnosis of complete trisomy 9 with a novel sonographic finding of heart calcification.

Complete trisomy 9 is a rare chromosomal disorder. The prenatal sonographic features of fetuses with complete trisomy 9 are nonspecific. There are also some reports showing rare features such as abnormal calcification in the liver and hypochondral region.1–4 Complete trisomy 9 was first described in 1973 from cultured lymphocytes in an infant with congenital heart defects, skeletal abnormalities, and severe dysmorphism.5 Most cases of complete trisomy 9 result in spontaneous first-trimester abortion. Fetuses who survive to term generally have a mosaic state.6,7 Since the prognosis of fetuses with complete trisomy 9 is poor, and the survival rate is very low, prenatal diagnosis of this condition is beneficial to provide useful information for genetic counseling and prenatal care. Sonography is a noninvasive and helpful tool in detecting this condition, especially when fetal karyotyping is unavailable. Although there are overlapping prenatal sonographic findings between trisomy 9 and trisomy 18, the main characteristic findings of complete trisomy 9 are cardiovascular defects, intrauterine growth restriction, genitourinary abnormalities, and limb anomalies. Craniofacial dysmorphism and a single umbilical artery can also be detected in some cases.8,9 Most reported cases were confirmed by fetal karyotyping, either from amniotic fluid or lymphocyte cultures. Here we report a new sonographic finding in a complete trisomy 9 case, which was confirmed postnatally by autopsy along with fetal karyotyping. This finding provides useful information, which will help in prenatal diagnosis of this lethal condition. A 37-year-old woman, gravida 4, para 2012, was referred to our institution at a gestational age of 16 weeks 5 days for amniocentesis due to advanced maternal age and a history of a child with trisomy 21. The first fetal sonographic examination showed a singleton fetus with a strawberry head shape, a moderately hyperechoic bowel, overlapping fingers, and a single umbilical artery. A fetal echocardiogram revealed situs solitus and abnormal left-axis deviation. Interestingly, abnormal cardiac calcification was also detected in both ventricular walls and the interventricular septum (Figure 1). The estimated fetal weight was appropriate for gestational age. Amniocentesis was subsequently performed, and fetal karyotyping showed 47,XX,+9 by the standard G-banding technique. The second sonographic examination was performed at 19 weeks’ gestation. Intrauterine growth restriction was not observed, and no additional physical anomalies were detected. Genetic counseling was provided to the family. Cordocentesis was performed, which confirmed the complete trisomy 9 female karyotype. Termination of pregnancy was performed at 21 weeks 5 days, after which an autopsy report indicated a female abortus weighing 270 g with multiple dysmorphic features, including a broad-based nose, hypertelorism, micrognathia, low-set ears, clenched hands, a 2-vessel cord, and an imperforate anus. The heart with calcification in both ventricular walls and interventic-

Comparison of reliability between uterocervical angle and cervical length measurements by various experienced operators using transvaginal ultrasound

Abstract Purpose: To compare the reliability between uterocervical angle (UCA) and cervical length (CL) measurements by various experienced operators. Methods: Transvaginal ultrasonographies (TVS) were performed in 102 pregnant women between 16°/7–24°/7 gestational weeks by different levels of experienced operators. For both CL and UCA measurements, intraobserver variability was assessed for each operator by examining the range between maximum and minimum measurements in each participant, compared to the mean of all three measurements. Interobserver variabilities were explored using Bland–Altman analysis. Intraclass correlation coefficients were used for both intraobserver and interobserver reliability. Results: For intraobserver variability of the UCA, the ranges between maximum and minimum UCA measurements in operator 1 and 3 were 1.5º–34º and 2º–36º (n = 51), and in operators 2 and 3 were 0º–61º and 1º–25º (n = 51). Intraclass correlation coefficients (ICC) for intraobserver reliability were 0.90 for operator 1, 0.67 for operator 2 and 0.93 for operator 3. For interobserver variability of the UCA, the limits of agreement for mean UCA were −37.53º–38.41º and −36.27º–26.17º, and for maximum UCA were −39.47º–41.38º and −44.24º–22.9º in comparisons between operators 1 and 3, and operator 2 and 3, respectively. Intraclass correlation coefficients for mean UCA were 0.73 and 0.74, and for maximum UCA were 0.71 and 0.67 in comparisons between operators 1 and 3, and operator 2 and 3, respectively. Conclusions: The UCA measurements had a higher intra- and interobserver reliabilities than the CL measurements.

Normative weight-adjusted models for the median levels of first trimester serum biomarkers for trisomy 21 screening in a specific ethnicity

Objective To establish normative weight-adjusted models for the median levels of first trimester serum biomarkers for trisomy 21 screening in southern Thai women, and to compare these reference levels with Caucasian-specific and northern Thai models. Methods A cross-sectional study was conducted in 1,150 normal singleton pregnancy women to determine serum pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG) concentrations in women from southern Thailand. The predicted median values were compared with published equations for Caucasians and northern Thai women. Results The best-fitting regression equations for the expected median serum levels of PAPP-A (mIU/L) and free β- hCG (ng/mL) according to maternal weight (Wt in kg) and gestational age (GA in days) were: median PAPP−A=e[8.4454 − 0.01950 (Wt-55)+ 0.05747 (GA-87)], and median free β−hCG=e[3.6409 − 0.01703 (Wt-55)– 0.03345 (GA-87)]. Both equations were selected with a statistically significant contribution (p< 0.05). Compared with the Caucasian model, the median values of PAPP-A were higher and the median values of free β-hCG were lower in the southern Thai women. And compared with the northern Thai models, the median values of both biomarkers were lower in southern Thai women. Conclusion The study has successfully developed maternal-weight- and gestational-age-adjusted median normative models to convert the PAPP-A and free β-hCG levels into their Multiple of Median equivalents in southern Thai women. These models confirmed ethnic differences.

Agreement of three interpretation systems of intrapartum foetal heart rate monitoring by different levels of physicians

Abstract A prospective study was conducted in centre in Southern Thailand, to evaluate agreement in EFM interpretation among various physicians in order to find out the most practical system for daily use. We found strong agreement of very normal FHR tracings among the FIGO, NICHD 3-tier and 5-tier systems. The NICHD 3-tier was more compatible with the FIGO system than 5-tier system. Overall inter-observer agreement was moderate for the NICHD 3-tier system while inter-observer agreement of 5-tier system was fair also the intra-observer agreement was higher in the NICHD 3-tier system. So the 3-tier systems are more suitable than the 5-tier system in general obstetric practice. Impact statement What is already known on this subject: The 3-tier and 5-tier systems were widely used in general obstetrics practice. What the results of this study add: The inter- and intra-observer agreement of NICHD 3-tier system was higher than the 5-tier system. What the implications are of these findings for clinical practice and/or further research: The 3-tier systems were more suitable than the 5-tier systems in general obstetrics practice.