Three–dimensional prenatal ultrasonography of thanatophoric dysplasia: Initial experience at Siriraj Hospital.

Objective: To initially report the prenatal diagnosis of thanatophoric dysplasia (TD) by using both 2 dimensional (2D-US) and 3 dimensional (3D-US) ultrasonography. Methods: During January 2004 to December 2006, 10 pregnant women who were referred to our Maternal Fetal Medicine Unit due to abnormal skeletal sonographic findings have been extensively investigated by 2D-US and 3D-US. Results: 3 cases of TD (30%) have been identified with an average gestational age of 26 weeks. Sonographic findings demonstrated short limbs, severe micromelia, telephone receiver like femoral bone, bell shaped small thorax, platyspondyly of vertebrae and normal shaped skull in all cases. Prenatal diagnosis was made earlier by 2D-US analysis and then was confirmed by 3D-US. Conclusion: 3D-US provides additional findings and increases interpreter confidence, It provides additional information in the evaluation of fetal skeletal dysplasia, including thanatophoric dysphasia, compared with 2D-US.

Result of ambulatory diet therapy in gestational diabetes mellitus.

OBJECTIVES: To evaluate the effectiveness of an ambulatory program for glycemic control of women with gestational diabetes mellitus (GDM). MATERIAL AND METHOD: A total of 33 women with GDM whose FBS from OGTT > or = 105 mg/dl were scheduled to attend weekly ambulatory care for dietary therapy with their family. FBS and 2-hour postprandial blood glucose were monitored every visit for a few weeks. At the end of this program, those with poor glycemic control were admitted for further tight dietary control by conventional 3-day course after which insulin was finally started for the women whose glycemic control remained poor. RESULTS: After the ambulatory program, 14 of 33 cases (42.4%) achieved good glycemic control without hospitalization. Another 6 cases (18.2%) did not need insulin therapy after admission for 3-day intensive dietary therapy. Altogether, 20 out of 33 cases (60.6%) of GDM whose FBS from OGTT > or = 105 mg/dl could avoid insulin therapy after attending the ambulatory program alone or with additional 3-day intensive dietary therapy course. Similar effectiveness was observed from the authors' previous study on 3-day intensive dietary therapy alone. CONCLUSION: The authors' current ambulatory dietary therapy program has shown to be effective in achieving good glycemic control and avoiding unnecessary insulin therapy and admission in most cases of women with GDM. In the future, an even more effective ambulatory diet control may ascertain that once a woman is hospitalized, insulin should be started right away.

Efficacy of fetal echocardiography and an evaluation of indications.

Fetal echocardiography has been accepted as a prenatal noninvasive diagnostic tool of cardiovascular diseases in fetuses for more than three decades. There are limited data in Thailand. A retrospective study of prenatal, natal and postnatal data of pregnant women who had fetal echocardiography at Siriraj Hospital, Bangkok, Thailand, from January 1999 to July 2005 was conducted. In total, there were 117 pregnant women who had fetal echocardiography under standard indications. Median age of pregnant women was 30.2 (17.3-44.2) years old. Median gestational age at the first fetal echocardiography was 29 (17-40) weeks. Median number of time the women had fetal echocardiography was 1 (1-10). Indications for fetal echocardiography were; obstetricians suspected of fetal cardiovascular diseases, multiple anomalies, family history of congenital heart diseases, chromosome anomalies, hydrops fetalis, and other indications (53.8%, 12%, 11.1%, 8.5%, 8.5% and 6.0% respectively). There were 49 (41.8%) cases who had abnormal cardiovascular problems, i.e., structural heart diseases 26 cases, rhythm disturbance 15 cases, and cardiac masses 8 cases. Upon comparison with postnatal echocardiography and/or autopsy findings, fetal echocardiography had a sensitivity of 96.9%, specificity of 90.6%, and accuracy of 92.8%. There was various degrees of risk to have cardiovascular problems for each of the indication taking fetal echocardiography and postnatal data into consideration. Fetal echocardiography had an impact on the management in 57.3% of cases. Conclusion: Fetal echocardiography is a reliable prenatal diagnostic tool for cardiovascular problems with high accuracy and has an impact on the management at prenatal, natal and postnatal period. Different indications for fetal echocardiography have an effect on the relative risk of fetal cardiovascular diseases.

Effect of 3-day intensive dietary therapy during admission in women after diagnosis of gestational diabetes mellitus.

OBJECTIVE: To determine the impact of 3-day intensive dietary therapy during admission on glycemic control. MATERIAL AND METHOD: GDM women, with level of fasting blood glucose (FBS) at or above 105 mg/dl on their oral glucose tolerance test (OGTT), were hospitalized. After 3-day intensive dietary therapy, the women were stratified by FBS value and mean 2-hour postprandial blood glucose. Those with poor glycemic control, FBS at or above 105 mg/dl, were prescribed insulin therapy. RESULT: Between 1 August 2001 to 31 December 2002, a total of 9861 pregnant women were screened for clinical risk factors of GDM at their first antenatal visits, and 4663 had at least 1 risk. After 50-gm glucose challenge test and 100-gm OGTT GDM was diagnosed in 300 women. Only 18% (54 in 300 cases) of GDM had level of FBS at or above 105 mg/dl on OGTT. They were admitted in a special ward for further investigation and initial management. After 3 days of intensive dietary therapy, the FBS and mean 2-hour postprandial blood glucose level were monitored and stratified in 3 groups. Only 42.6% of admission group (23 in 54 cases) still had FBS at or above 105 mg/dl and required insulin therapy (group 1). One third (18 in 54 cases) could avoid insulin therapy due to the level of FBS below 105 mg/dl and mean 2-hour postprandial blood glucose below 120 mg/dl (group 2). This second group was discharged, and due to attend the high risk pregnancy clinic a few weeks later The third group (group 3), comprising one fourth (13 in 54 cases), had FBS below 105 mg/dl but had a mean 2-hour postprandial blood glucose at or above 120 mg/dl. This third group were also discharged and were monitored glycemic profile by FBS and 2-hour postprandial blood glucose every time during their visits to the high risk pregnancy clinic. According to criteria of 2-hour postprandial blood glucose at or above 120 mg/dl on two or more occasions within a 1-2 weeks interval, no one in group 3 needed insulin therapy afterward CONCLUSION: GDM women with FBS at or above 105 mg/dl on their OGTT, should be prescribed intensive dietary therapy alone for 3 days inside hospital rather than initiating insulin immediately after diagnosis. One third had a benefit of avoiding insulin therapy. Only 42% failed to achieve good glycemic control and still needed insulin therapy. One fourth showed optimal glycemic control after this intervention (FBS below 105 mg/dl) but had mean 2-hour postprandial blood glucose at or above 120 mg/dl. Longer trial of dietary therapy should be considered in this last group to avoid over treatment of insulin therapy.

The cost analysis of ultrasound screening for fetal anomalies.

Objectives : To determine the effectiveness of ultrasound screening for fetal anomalies at different gestational ages and to define an appropriate cost for each ultrasound screening. Materials and methods: 470 pregnant women participated in our ultrasound screening programme from October 1st, 2002 to September 15th, 2003. 757 scans were appointed throughout the first, second and third trimesters, numbering 240,257 and 260 scans, respectively. The ultrasound cost were reduced to about 30% of the normal price (800 baht for 2-3 scans). Results : out of757 scans, 7 abnormal fetuses were found. All abnormalities were detected around 18-20 weeks of gestation No abnormalities were found at other gestational ages. The abnormalities included infantile polycystic kidney, cleft lip, trisomy 13,gastroschisis and 3 cases of echogenic foci of hearts. Using this reduced cost, these pregnant women were easily able to participate in this research Programme. Conclusion: In order to reduce perinatal morality and morbidity, ultrasound screening for fetal anomalies can be performed between 18-20 weeks gestation. If the fetus is found to be abnormal, proper management and care can be planned before delivery. An important obstacle is the high cost of having a scan performed. Therefore, a reduced cost should be considered to recruit more pregnant women to participate in this policy. A reasonable cost for each ultrasound was found to be 425 baht.

Risk factor-based selective screening program for gestational diabetes mellitus in Siriraj Hospital: result from clinical practice guideline.

A clinical practice guideline for the screening and diagnosis of gestational diabetes mellitus (GDM) is currently implemented at Siriraj Hospital. During the year 2000, a total of 9325 pregnant women were screened for clinical risk factors during their first antenatal visits, and 3770 had at least 1 risk. After the 50 g glucose challenge test and 100 g oral glucose tolerance test, GDM was diagnosed in 235 women. The incidence of GDM was 6.2 per cent (95% CI 5.5-7.1) among high-risk pregnant women, and 2.5 per cent (95% CI 2.2-2.9) of all pregnant women. Significant risk factors identified from the present study were family history of DM (adjusted OR 1.86, 95% CI 1.38-2.51), age > or = 30 years (adjusted OR 2.41, 95% CI 1.72-3.39), history of unexplained intrauterine fetal death (adjusted OR 4.30, 95% CI 2.04-9.04), and obesity (adjusted OR 2.83, 95% CI 1.88-4.25). The risk of developing GDM also increased when more than 1 clinical risk factor was identified. The results support the value of this screening program for GDM. Every obstetrician should be aware of the need to screen for GDM in every pregnant woman and a similar program should also be introduced to other settings.

Prediction of adverse perinatal outcome by umbilical artery to middle cerebral artery resistance index ratio in pregnancies complicated by hypertensive disorder.

This study aimed to evaluate umbilical artery to middle cerebral artery resistance index ratio above 95th percentile (UARI / MCARI 95) was able to predict adverse perinatal outcome in pregnancies complicated by hypertensive disorder. Fitty-three pregnant women with hypertensive disorder were recruited to this study. All of these women gave birth within 7 days of performing the Doppler study. The ability of UARI / MCARI 95 to predict adverse perinatal outcome was as follow: sensitivity 12.5%, specificity 89.2%, positive predictive value 33.3%, negative predictive value 70.2%, false positive rate 10.8%, false negative rate 87.5% and accuracy 66%. This ratio did not qualify as a reliable screening test for prediction of adverse perinatal outcome prediction in pregnancies complicated by hypertensive disorder.

Prenatal diagnosis of cardiovascular diseases.

Fetal echocardiography is a safe means to obtain reliable anatomical and hemodynamic data of the fetal heart. The procedure is essential for prenatal diagnosis of cardiovascular abnormalities. In addition, fetal echocardiography is useful to follow-up the progression, monitoring during treatment and making a plan of treatment especially in life-threatening cardiac conditions. The objective of this study was to find the distribution of indications for fetal echocardiography, fetal cardiac anomalies detected, outcome of the fetuses and to assess the accuracy of the procedure. A retrospective study was done at Siriraj Hospital, Mahidol University, Bangkok, Thailand. Pregnant women whose fetuses had prenatal echocardiographic data and gave birth from January 1999 to December 2001 were included. The total number of pregnant women was 54 cases. The indications for fetal echocardiography were suspicion of fetal cardiovascular disease by the obstetrician 42.6 per cent, family history of congenital heart diseases 14.8 per cent, multiple organ system anomalies 14.8 per cent, chromosomal anomalies 11.1 per cent, hydrops fetalis 9.3 per cent, maternal systemic diseases 5.6 per cent and previous pregnancy with a dead fetus in utero 1.9 per cent. The gestational age at the time of the first fetal echocardiography ranged from 17 to 39 weeks (median 28 weeks). The number of fetal echocardiography done in each case ranged from 1 to 10 (median 1.4). Prenatal diagnosis of the abnormal cardiovascular system in fetuses was found in 19 cases (35.2%). There were abnormal cardiac anatomies in 42 per cent, cardiac tumors or abnormal masses in 37 per cent and rhythm disturbances in 21 per cent. When compared with postnatal echocardiography and/or autopsy finding, fetal echocardiography had a sensitivity of 100 per cent, specificity of 96.3 per cent and accuracy of 97.8 per cent. Conclusion: Fetal echocardiography has good accuracy in the diagnosis of cardiovascular diseases. Obstetrician's suspicion is important in the prenatal diagnosis of heart disease that would have affected the short and long-term outcome of the fetus.

Color Doppler ultrasonography for prediction of malignant ovarian tumors.

The purpose of this cross-sectional study was to evaluate whether the pulsatility index determined by the color Doppler sonography could be used to distinguish between benign and malignant ovarian tumors. A total of 120 patients who had their ovarian tumors removed surgically at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University were included in the study. Each patient had color Doppler sonography performed prior to laparotomy. The Doppler results were compared to the histological diagnosis of the ovarian tumors. Of the 113 patients whose intratumoral blood flow could be evaluated, the pulsatility index was significantly lower in malignant lesions than in benign lesions (0.85 +/- 0.46 vs 1.63 +/- 0.64, p<0.001). The sensitivity, specificity, and accuracy of the pre-operative pulsatility index (< or = 1.0) in detecting malignant ovarian tumors were 82.9 per cent, 80.8 per cent, and 81.4 per cent, respectively; with 65.9 per cent positive predictive value, 91.3 per cent negative predictive value, 19.2 per cent false positive rate, and 17.1 per cent false negative rate. The present results suggest that color Doppler sonography may be a useful clinical tool in the pre-operative evaluation of ovarian masses. However, the pulsatility indexes showed considerable overlap between benign and malignant lesions, indicating that color Doppler sonography has limitations in the differentiation of benign from malignant ovarian masses. The cost of the equipment and experience requirement also limits its use in general gynecologic practice.

Ultrasound measurement of tibia and fibula bone length in Thai fetus.

A prospective cross-sectional study was conducted in order to construct reference centile charts for tibia and fibula bone length of Thai fetuses. A total of 621 normal pregnant women, who attended the antenatal clinic at Siriraj Hospital, Mahidol University, Bangkok, were recruited between 12 and 41 weeks of gestation. We identified pregnant women who had regular menstrual period for at least 3 months without contraception prior to the current pregnancy; and whose uterine size at the time of examination was compatible with menstrual age. Each fetus was measured only once at a randomly assigned gestation age specifically for the purpose of this study. A total of 461 fetal tibia and fibula lengths were measured due to unfavorable fetal position in some cases. Regression models were fitted to estimate the mean and standard deviation for each parameter at each gestational age. The centile charts of both lower limb lengths for Thai fetuses were derived from regression equations and are presented.

Charts of Thai fetal biometry: Head circumference.

The purpose of this study was to develop reference centiles of head circumference (HC) for Thai fetuses, and to compare them with previously published data. Normal pregnant women who attend antenatal clinic at Siriraj Hospital provided the study population. A total of 621 cases between 12 - 41 weeks of gestation were recruited. Gestational age was determined by menstrual history which had been regular for at least 3 months without contraception prior to current pregnancy, and uterine size which was compatible with menstrual age at the first time of examination. Each fetus was measured once at a randomly assigned gestational age specifically for the purpose of this study. Due to unfavorable fetal position in some cases, HC data were only available in 609 measurements. Stepwise linear regression models were fitted separately to estimate the mean and standard deviation as functions of gestational age. A reference centile chart was constructed from both equations, assuming the data were normally distributed. A new reference centile chart for HC is presented and compared with previously published data. Our derived centile were lower than those from Western studies, which may partly be due to racial differences. This emphasizes the need to develop fetal biometric charts specific to each region.

Charts of Thai fetal biometry: Upper extremities.

A cross-sectional study was conducted in order to construct a reference chart for Thai fetal upper extremities long bone (humerus, radius, and ulna). A total of 621 normal pregnant women, who attended the antenatal clinic at Siriraj Hospital, Mahidol University, Bangkok, were recruited between 12 and 41 weeks of gestation. We identified pregnant women who had previous regular menstrual period for at least 3 months without contraception prior to current pregnancy; and uterine size at the time of examination was compatible with menstrual age. Each fetus was measured only once at a randomly assigned gestational age specifically for the purpose of this study. Due to unfavorable fetal position in some cases, data were available in only 482 measurements of the humerus, and 443 measurements of the radius and ulna respectively. Linear regression models were fitted separately to estimate the mean and standard deviation at each gestational age for each parameter. New reference centiles were constructed from both equations, assuming the data were normally distributed. This will provide more reliable reference data to be utilized in the assessment of gestational age and in the diagnosis of upper limb deformities during fetal period.

The occurrence of granulation tissue at vaginal vault from different technique of vault closure following hysterectomy.

A randomized double blind clinical trial was carried out at Siriraj Hospital in order to compare the occurrence of vaginal vault granulations between vaginal vault closure, using interrupted figure-of-eight and interlocked continuous sutures with chromic catgut. Eight healthy patients who underwent total abdominal hysterectomy for benign conditions were randomly assigned to one of the two studied techniques. Six weeks after the operation, the patients were examined blinded to see whether there were vaginal vault granulations. The characteristics of both study groups were comparable. The incidence of vaginal vault granulations in patients was 41.2 percent. The granulations occurred in 27.5 percent in the interlocked continuous and 55 percent in the interrupted figure-of-eight suture group (P<0.05). In patients with vaginal vault granulation, 90.9 percent had abnormal vaginal discharge and/or bleeding, while those without did not (P<0.01). Closure of the vaginal vault with interlocked continuous sutures should be employed in cases of total abdominal hysterectomy in order to decrease the occurrence of vaginal vault granulations later on.