Thitima Suntharasaj

Etiology and Outcome of Non-Immune Hydrops fetalis in Southern Thailand

Objective: To study the etiology and outcome of non-immune hydrops fetalis in southern Thailand. Methods: The medical records and videotape recordings of all pregnant women diagnosed with non-immune fetal hydrops, from January 1993 to December 2002 were reviewed. Results: Non-immune hydrops fetalis was documented in 71 cases. The causes of fetal hydrops were identified in 87.3%. Homozygous α-thalassemia-1 dominated as the cause of non-immune fetal hydrops (28.2%), followed by structural abnormalities (15.5%) and infection (12.7%). The underlying etiology remained unknown in 9 cases (12.7%). The overall survival rate of non-immune hydrops fetalis cases was 4.2%. Spontaneous regression occurred in 2 cases. Two cases were lost to follow up after initial evaluation. Termination of pregnancy was performed in 47 cases. There were 12 dead fetuses in utero, 2 stillbirths, 5 early neonatal deaths and only 3 cases survived. Conclusions: Homozygous α-thalassemia-1 is the most common cause of non-immune hydrops fetalis in southern Thailand, and the overall prognosis of non-immune hydrops fetalis is poor. We suggest that an effective thalassemia-screening program for prevention and control of homozygous α-thalassemia-1 be established in all areas where the α-thalassemia-1 gene is prevalent.

Pregnancy with Scrub Typhus and Vertical Transmission: A Case Report

Scrub typhus is a rickettsian disease which is seldom found in pregnancy. A 31‐year‐old, 34 weeks pregnant woman presented with fever, chill and cough for 6 weeks. Fetal jeopardy was found then a cesarean section was performed to deliver a 2,200 g male with hepatosplenomegaly. The mothers diagnosis was confirmed by positive Weil‐Felix (OXK titer 1: 320) and scrub typhus (titer 1: 1600) tests. Vertical transmission was also demonstrated by a positive scrub typhus IgM in her child.

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.

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.

Three-Dimensional Ultrasonographic Bladder Volume Measurement Reliability of the Virtual Organ Computer-Aided Analysis Technique Using Different Rotation Steps

Objective. The purpose of this study was to investigate the reliability of Virtual Organ Computer‐Aided Analysis (VOCAL; GE Healthcare, Kretztechnik, Zipf, Austria) using the 4 standard rotation steps to measure the bladder volume with 3‐dimensional (3D) ultrasonography. Methods. Using the 4 standard rotation steps of VOCAL, 2 independent observers made 3D volume measurement data sets from the urinary bladder (n = 180). Sets of 30, 20, 12, and 6 planes were obtained from the sequential rotations of 6°, 9°, 15°, and 30°, respectively. The internal contours of the bladders were determined manually. Reliability was evaluated with the intraclass correlation coefficient (ICC), and Bland‐Altman plots were generated to examine bias and agreement. One‐way analysis of variance was used to compare bladder volume measurements between the angles. P < .05 was considered statistically significant. Results. A high degree of reliability was observed between pairs of different rotation angles (ICC, 0.994–0.999). There was good agreement between all pairs of different rotation angles, with percentages of the mean difference ranging from −0.9% to 1.8%. No significant difference was found for bladder volume measurements by the VOCAL technique with varying rotation steps. Intraobserver and interobserver reliabilities were high (ICC, 0.994–0.998). Conclusions. Urinary bladder volume measurement by the VOCAL technique using different rotation steps is highly reliable. A plane rotation of 30° produces the fastest result.

Outcomes of multifetal pregnancies

Aim:  To determine the outcomes of multifetal pregnancies and to compare maternal and neonatal complications between spontaneously conceived and assisted reproductive therapy.

Comparison of the Five Sonographic Morphology Scoring Systems for the Diagnosis of Malignant Ovarian Tumors

Objective: To evaluate the accuracy of the 5 sonographic morphology scoring (SMS) systems (Sassone, DePriest, Lerner, Vera and Kawai and Valentin) for prediction of malignant ovarian tumors. Methods: A diagnostic study was conducted at Songklanagarind Hospital during November 2008 to June 2009. All of the patients scheduled for elective surgery due to ovarian tumors underwent transabdominal or transvaginal sonography within 72 h before the operation. The pictures were recorded. Attention was given to volume, wall and septal thickness, locularity, echogenicity, and papillary and internal surface of the tumor. The 5 SMS systems were applied later by the first author, who was not aware of the clinical data. The final diagnosis was determined by a histopathological report and was categorized into benign or malignant ovarian tumor. Borderline tumors were included in the malignant group. Results: One hundred and forty-six patients were recruited; 82 benign (56.2%), 14 borderline (9.6%), and 50 malignant tumors (34.2%). The sensitivities of the SMS by Sassone, DePriest, Lerner, Vera and Kawai and Valentin were 75, 89.1, 82.8, 79.7 and 82.8% and the specificities were 79.3, 73.2, 68.3, 82.9 and 85.4%, respectively. Conclusions: Among the 5 systems, the DePriest system is the most sensitive SMS for the prediction of ovarian cancer.

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.

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.