Pharuhas Chanprapaph

Sonographic Markers of Hemoglobin Bart Disease at Midpregnancy

Objective. To evaluate the efficacy of various sonographic markers at midpregnancy in predicting fetal hemoglobin Bart disease. Methods. Four hundred eighty‐eight pregnancies at risk of having fetuses with hemoglobin Bart disease were recruited for prenatal diagnosis with cordocentesis at 18 to 21 gestational weeks. Before cordocentesis, the sonographic markers, including cardiothoracic ratio, placental thickness, pericardial effusion, pleural effusion, ascites, subcutaneous edema, cord edema, dilated umbilical vein, and amniotic fluid index, were assessed and recorded. The definite fetal diagnosis was based on blood analysis. The efficacy of each sonographic marker in predicting hemoglobin Bart disease was evaluated by sensitivity and specificity. Results. Among 488 pregnancies undergoing prenatal diagnosis, 100 fetuses were proved to be affected by hemoglobin Bart disease. The cardiothoracic ratio gave the highest sensitivity, 95.0%, with specificity of 96.1%, followed by placental thickness. Signs of hydrops fetalis were observed in 33.0% of cases; they did not increase the sensitivity of the cardiothoracic ratio but strongly reinforced the diagnosis when they appeared. Conclusions. At midpregnancy, sonographic markers can effectively differentiate normal pregnancies from those with fetal hemoglobin Bart disease. Among couples at risk with no sonographic markers, the risk of having an affected child is nearly eliminated. The most sensitive marker was the cardiothoracic ratio, followed by placental thickness.

Cordocentesis at 16-24 weeks of gestation: experience of 1320 cases

The objective of this study was to assess the safety and efficacy of diagnostic cordocentesis at midpregnancy. 1320 singleton pregnancies with no obvious congenital anomalies, a gestational age of 16–24 weeks, and proper indications underwent cordocentesis using the freehand technique. The results of each procedure was prospectively collected and subsequently analysed for the results and pregnancy outcomes. The mean maternal age was 31.1 years and the mean gestational age at the time of cordocentesis was 19.8 weeks. The most common indication was the risk of severe thalassaemia syndrome (69.8%) and was followed by rapid karyotyping. Of 1320 cordocenteses, 1281 (97%) were done successfully at the first attempt. The mean duration of the procedure was 10.5 min and was significantly longer in the first 50 cases of practice for each operator. The maternal blood contamination rate was higher when the cord insertion was targeted. The procedure‐related complications included transient bleeding at puncture site (20.2%), transient fetal bradycardia (4.3%), chorioamnionitis (two cases), and cord haematoma (one case). Of 1281 successful cases, 184 fetuses had severe disease. The total fetal loss rate was 3.2% and the procedure‐related loss was 1%. The other obstetric complications were comparable with those in the general population. We conclude that cordocentesis at midpregnancy is a useful, relatively safe, and effective procedure for prenatal diagnosis. Copyright

Alcoholization: The choice of intrauterine treatment for chorioangioma

Chorioangioma is a vascular tumor of the placenta. Most are small and asymptomatic, whereas the large tumors are clinically significant and often associated with polyhydramnios and fetal heart failure. To prevent fetal loss from these complications, many interventions have been proposed, including intrauterine transfusion in anemic cases and fetoscopic surgery to ablate the feeding vessels. The case presented herein had large chorioangiomas, 8 and 4 cm in diameter, associated with polyhydramnios and early signs of hydrops fetalis, diagnosed at 27 weeks gestation. After extensive counseling, we performed alcohol ablation of the feeding vessel of the larger tumor. Signs of fetal heart failure and hydrops fetalis disappeared dramatically. The pregnancy was extended for 2 weeks, followed by premature rupture of the membranes and spontaneous labor at 32 weeks gestation and a surviving female baby, weighing 1360 g, was delivered uneventfully. This preliminary experience suggests that alcoholization may be one of the best choices for this condition due to its high efficacy, simplicity, safety and very low cost. To our knowledge, this is the first report using alcoholization for the treatment of hydrops fetalis secondary to chorioangioma.

Sonographic features of trisomy 18 at midpregnancy

Objective:  To evaluate the sonographic characteristics of the fetuses with trisomy 18 at 16–22 weeks of gestation.

Intrauterine treatment for an acardiac twin with alcohol injection into the umbilical artery

An acardiac twin is a unique complication of monochorionic twinning, in which a normal pump twin perfuses the acardiac twin. The mortality rate of the pump twin is greater than 50%. Herein we present the successful treatment of an acardiac twin with alcoholization as follows. An acardiac twin was diagnosed at 24 weeks gestation. Circulation interruption of the acardiac twin was successfully achieved by injection of absolute alcohol (5 mL) into the intra‐abdominal umbilical artery. Serial ultrasound after the procedure revealed normal growth of the pump twin, whereas the acardiac twin was shrinking. Spontaneous premature delivery at 34 weeks gestation resulted in a normal surviving female baby weighing 2410 g and an acardiac female fetus weighing 300 g. This experience suggests that this simple technique may be an alternative treatment for an acardiac twin.

Variability of Nuchal Translucency Measurement

Objectives: To evaluate intra- and inter-observer variations of nuchal translucency (NT) measurements and study the duration of measurements. Subjects: One hundred and forty-seven singleton pregnant women with 10–14 weeks of gestation who had attended antenatal clinic during January 1st, 2000–August 31st, 2001 were included. Methods: Crown-rump length and NT were measured three times for each woman. Then, another examiner who was unaware of the previous results did the other three measurements. The duration of measurements was recorded. Intra-observer and inter-observer variations were analyzed by repeated ANOVA and paired t test, respectively. The correlation of NT measurements within each observer and between paired observers was evaluated by intraclass correlation coefficients (ICC). Kappa statistic was calculated for agreement. Results: Intra-observer variation of all 10 examiners at three institutes was varied from 0.20 ± 0.27 to 0.33 ± 0.41 mm. Inter-observer variation at Chiang Mai University was 0.40 ± 0.37 mm which was the highest value compared with those at Prince of Songkla and Khon Kaen University (p < 0.05). The mean duration of measurements was in range of 8–12 min. The intra-observer repeatability of the first two measurements showed ICCs varying from 0.61 to 0.94. The inter-observer repeatability of paired examiners showed a variation in ICC from 0.28–0.90. The kappa value expressing the intra- and inter-observer repeatability as being >95th or ≤95th percentile was 0.73 and 0.72, respectively. Conclusions: NT measurement was reproducible for small variation and good agreement. The duration of measurements was acceptable.

Distribution of Normal Nuchal Translucency Thickness: A Multicenter Study in Thailand

Aims: To establish the normative data distribution of nuchal translucency (NT) thickness in Thai fetuses. Methods: A cross-sectional multicenter study was conducted among 6,455 women with singleton pregnancies and gestational age between 10 and 14 weeks. For each case, the fetal crown-rump length (CRL) and NT were measured by transabdominal ultrasound. Transvaginal ultrasounds were used in poorly visualized cases. The distribution values of the NT thicknesses and their corresponding 10-mm CRL intervals between 45 and 84 mm were examined to obtain the median and 95th percentiles. Quantile regression modeling across the CRLs was performed to obtain the reference values. Results: Transabdominal ultrasound measurements were successfully done on 6,347 fetuses with 39 cases by the transvaginal route. Fetuses with CRL between 45 and 84 mm and normal outcomes made up a total of 4,352 cases. The mean (SD) gestational age, CRL and NT thickness were 12.5 (0.7) weeks, 60.2 (9.7) mm, and 1.15 (0.38) mm, respectively. The mean normal NT increased linearly with CRL. The quantile regression equation to predict the 95th percentile of the NT thickness (mm) was 0.727 + [0.017 × CRL (mm)]. Conclusions: The NT thickness in normal Thai fetuses was found to be thinner than in both Caucasian and other Asian populations.

Prenatal Diagnosis of Isolated Tricuspid Valve Atresia Report of 4 Cases and Review of the Literature

Objective. To describe the prenatal features of fetal tricuspid atresia. Methods. Four cases of fetal tricuspid atresia were prenatally diagnosed, sonographically described, and followed. Results. On the basis of this small series, the key findings for diagnosis included the demonstration of no patent tricuspid valve on the 4‐chamber view, no flow across the tricuspid valve on pulsed or color Doppler flow mapping, small right ventricles, and associated interventricular septal defects. Increased nuchal translucency thickness may give the first clue leading to follow‐up scans, resulting in a definite diagnosis. Conclusions. Tricuspid atresia can be readily diagnosed prenatally. The key findings and differential diagnoses are provided.

Sonographic Diagnosis of Exencephaly: Omphalocele at 11 Weeks of Gestation

This report presents a sonographic diagnosis of exencephaly combined with omphalocele at 11 weeks of gestation. The transvaginal ultrasound showed frog‐eye appearance face with no skull, abnormal shape of disorganized brain with covering membrane separated from brain mass by anechoic fluid in some area, and omphalocele of 8 mm diameter. Therapeutic abortion was successfully done with misoprostol. Postabortal macroscopic findings confirmed the prenatal diagnosis. The combination of exencephaly and omphalocele is rare, and this is one of the earliest diagnosis of not only exencephaly but also omphalocele. To our best knowledge, this represents the earliest diagnosis of the combination. In conclusion, transvaginal ultrasound proved highly informative for both exencephaly and omphalocele as early as in first trimester.