Atrial flutter in fetuses and early childhood: a report of eight cases.

Atrial flutter is an uncommon arrhythmia in children. The presenting features and treatment responses of two fetuses and six children with atrial flutter were presented. Two patients were diagnosed prenatally at 31 and 35 weeks' gestation. One patient was successfully controlled in utero by maternal administration of digoxin and the other by direct current cardioversion after delivery. Two fetuses and 2 of 6 children had normal cardiac structure by echocardiogram. Three patients had right atrial enlargement due to atrial primun septal defect, secundum atrial septal defect with primary pulmonary hypertension, and endomyocardial fibrosis. One patient developed atrial flutter with sinus node dysfunction after surgical correction of total anomalous pulmonary venous connection. Four cases presented as atrial flutter with regular atrioventricular conduction (2:1 or 3:1 conduction) while the remainder presented with irregular atrioventricular conduction. Heart failure was presented in two patients and improved after the arrhythmias were controlled. Successful termination of atrial flutter was accomplished by using DC cardioversion in 4 patients and one patient converted to normal sinus rhythm following combination of digoxin and amiodarone administration. Digoxin was administered for one year as the prophylactic medication in six patients. None had recurrence of atrial flutter during the follow-up period of one to four years. Two patients required chronic digoxin and amiodarone therapy. We concluded that atrial flutter in fetuses and early childhood carries a good prognosis. Acute treatment with direct current cardioversion is sufficient in most patients, combination of digoxin and amiodarone may be an alternative therapy to convert atrial flutter.

Fetal transverse cerebellar diameter in Thai population.

We developed a nomogram for transverse cerebellar diameter (TCD) in Thai fetuses by recruitment of 153 normal pregnant women in the first trimester. The gestational age calculated by the certain last menstrual period and the first trimester ultrasound were in agreement. The pregnant women were stratified into 4 groups and scanned at four weekly intervals: group A was first scanned at 14 weeks, group B at 15 weeks, group C at 16 weeks, and group D at 17 weeks. A total of 699 measurements from 14 to 40 weeks of gestation were obtained. The data were analyzed for mean and standard deviation; and the best fit mathematical model was derived. The TCD grew progressively along gestational age. The growth rate was slightly less than that of a Western study after 28 weeks of gestation. This could serve as the basis for gestational dating in fetuses with aberrant fetal growth.

Sonographic findings in clinically diagnosed threatened abortion.

OBJECTIVE: To determine the sonographic appearances in pregnant women who presented with vaginal bleeding in the first 20 weeks of gestation. METHOD: Pregnant women of under 20 gestational weeks diagnosed clinically as threatened abortion were recruited for ultrasound scan at the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University. The sonographic findings were reported as viable pregnancy, anembryonic pregnancy, embryonic death, incomplete abortion, complete abortion, ectopic pregnancy, molar pregnancy and inconclusive findings. Patients with inconclusive findings were followed weekly until final diagnoses were established. All patients were followed-up to 20 weeks or until the final outcomes were revealed. RESULTS: Two hundred and sixty eight pregnant patients were enrolled. Ultrasound scans demonstrated 100 viable fetuses (37.3%), 73 embryonic deaths (27.3%), 46 anembryonic pregnancies (17.2%), 6 molar pregnancies (2.2%), 3 ectopic pregnancies (1.1%), 14 complete abortions (5.2%) and 26 inconclusive findings (9.7%). Follow-up scan on patients with inconclusive findings revealed 9 anembryonic pregnancies (3.3%), 9 incomplete abortions (3.3%), 1 embryonic death (0.4%) and 1 viable pregnancy (0.4%). Six patients (2.3%) were lost to follow-up. The viable pregnancy rate according to maternal age was highest at the maternal age of 25 to 29 years old (49%), whereas, it was lowest at the maternal age of 40 to 44 years old (0%). The viable pregnancy rate according to gestational age was highest at 6 to 8 weeks (61.2%), whereas, it was lowest at 18 to 20 weeks (20%). CONCLUSION: Sonographic findings in patients with clinically diagnosed threatened abortion demonstrated viable pregnancies in around one-third of the cases. Use of ultrasound in clinically diagnosed threatened abortion may assist clinicians in establishing a definite diagnosis so that appropriate care could be offered to the patients.

Transvaginal sonography for fetal crown-rump length measurement in a Thai population.

A prospective descriptive cross-sectional study was undertaken at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University to establish a reference interval for fetal crown-rump length (CRL) in a Thai population using transvaginal ultrasound. This study was performed on normal pregnant women registered at the antenatal clinic in their first trimester. All had a good menstrual history. CRL measurement was obtained by a 5 MHz vaginal probe. All of the newborns were proved to be normal at birth. We constructed and compared CRL (mm) relating to gestational age (GA) (days). Five hundred and forty seven cases were enrolled into the study. CRL was correlated with gestational age. The best fit regression equation was the quadratic model: CRL (mm) = -13.872 - 0.014 GA (day) + 0.0097 GA (day)2, R = 0.92, p < 0.0001). Centiles and a chart for CRL derived from the regression equation are presented. In conclusion, a reference interval for fetal crown-rump length in a Thai population has been established. This data may be useful in the early detection of genetic or environmental disorders affecting fetal growth in the first trimester of pregnancy.

Prenatal ultrasound diagnosis in Thailand.

Ultrasound technology has been extensively employed in obstetric and gynecologic practice for several decades. It has been used not only in gestational age estimation, placental location, amniotic fluid assessment but also in antenatal diagnosis of fetal abnormalities of various systems. The incidence of Congenital Heart Disease (CHD) is currently estimated to be 8 to 9 out of every 1,000 live births. Congenital heart disease is thought to be a multifactorial disorder in over 90% of the cases. Pioneer studies on the ultrasound investigation of the heart were reported in the early 1970s. Since the introduction of high resolution real-time ultrasound in the late 1970s, reports on ultrasound assessment of fetal cardiac anatomy and function have been appearing with increasing frequency in both the obstetric and cardiologic literature. At present, fetal echocardiography is a well established technique for the prenatal diagnosis of CHD. However, the distribution of the technique is still limited as it requires both a very experienced operator and meticulous scanning. Screening the entire obstetric population does not appear possible at present. Therefore fetal echocardiography is as necessarily directed toward selected pregnancies carrying a higher-than-normal risk of fetal cardiac anomalies. The progressive developments in cardiac ultrasound during the past two decades have substantially altered the practice of perinatologists, obstetricians and cardiologists. Total cardiac ultrasound studies are now becoming the primary armamentarium in the diagnosis of fetal congenital heart diseases. Since a 92% sensitivity of 4-chamber view in screening fetal heart diseases was first reported in 1987, 4-chamber view has been widely recommended for routine use in fetal sonographic examinations. Recent studies have demonstrated somewhat variable results and have suggested incorporation of the out flow should thoroughly understand the advantages and limitations of fetal cardiac scanning especially the 4-chamber view in order that the appropriate information and management plan can be offered to the patients. Fetal cardiac scanning is well recognized as one of the most tedious scanning of all fetal organ systems. With a tremendous advancement in ultrasound resolution including color imaging capacity several kinds of fetal cardiac anomalies could be diagnosed antenatally which inevitably allows more proper management plan for couples engaged in these.

Fetal hematology.

The objective of this study was to establish normal fetal hematological parameters throughout gestation. Samples of pure fetal blood from 35 fetuses of 21-38 weeks' gestation were obtained by fetal blood sampling under continuous ultrasound guidance. The hematological parameters were determined with automated cell counter within 30 minutes after the procedures. Fetal red blood cell and granulocyte counts rose significantly with advancing gestation, whereas, the mean corpuscular volume fell. There were no significant changes in fetal hemoglobin, hematocrit, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, red cell distribution width, total white blood cell count, lymphocyte count, mid-cell count, platelet count, mean platelet volume, and platelet distribution width with increasing gestation. The growing application of fetal blood sampling to the prenatal diagnosis renders mandatory a knowledge of normal fetal blood values. These results may provide useful reference values for prenatal diagnoses of hematological disorders.

Fetal complete heart block: an expectant management.

Fetal complete heart block is a rare cardiac arrhythmia occurring in prenatal life. The diagnosis usually requires a multimodality approach of imaging technology especially M-mode and Doppler ultrasound. The management guideline is not conclusive. We presented 2 cases of fetal complete heart block diagnosed prenatally. The fetuses were closely monitored conservatively and delivered at term. Permanent cardiac pacemakers were performed neonatally with satisfactory outcomes.

Transvaginal hysterosalpingo-contrast sonography (HyCoSy) compared with chromolaparoscopy: a preliminary report.

Fifteen infertile women who required tubal passage evaluation by chromolaparoscopy were recruited. Those who had lower genital tract infection or abnormal uterine bleeding were excluded from the study. Transvaginal HyCoSy was performed during the first half of the menstrual cycle at least 24 hours prior to chromolaparoscopy. The results from both transvaginal HyCoSy and chromolaparoscopy were compared in assessing tubal patency and uterine pathology. A high correlation was noted regarding uterine examination using transvaginal HyCoSy compared with chromolaparoscopy (sensitivity, specificity, PPV and NPV were 91.7%, 33.3%, 84.6% and 50%, respectively). The correlation of the outcome between the two procedures in assessing tubal patency, when combining both tubes, was also high (sensitivity, specificity, PPV and NPV were 100%, 55.6%, 80% and 100%, respectively). The most common adverse event was only mild pelvic pain which did not necessitate any treatment. These preliminary results reveal the potential value of transvaginal HyCoSy as an alternative in infertility investigations. It seems to be as effective but less invasive than conventional chromolaparoscopy. The adverse events reported in this study relate more to the procedure (catheter insertion) rather than the trial substance.

Nomogram of nuchal fold thickness of Thai fetuses.

The aim of the study was to establish normal values of nuchal fold thickness during 14-21 weeks of pregnancy. Three hundred Thai pregnant women before 12 weeks of gestation were recruited. Gestational age was determined by last menstrual period and confirmed by crown-rump length. Subjects with date-size discrepancy of more than 7 days were excluded from the study. Nuchal fold thickness was measured twice, first during 14-17 weeks, and then during 18-21 weeks. Five hundred and nine measurements were obtained. Nomogram of nuchal fold thickness was constructed. Mean values of nuchal fold thickness increased steadily from 2.59 +/- 0.77 millimeters (mm) at 14 weeks to 4.12 +/- 0.98 mm at 21 weeks. Average rate of increase were 0.22 mm per week. In conclusion, nuchal fold thickness increased with advancing gestational age from 14 to 21 weeks of pregnancy. Different normal cut-off levels for each gestational week may be more appropriate for screening of fetal Down syndrome in Thai pregnant women.

Evaluation of current antepartum fetal tests.

Three hundred high-risk pregnancies of at least 28 weeks' gestation were included in this prospective descriptive study. Fetal movement count was performed daily. Maternal perception of sound provoked fetal movement (MPSPFM), fetal acoustic stimulation test (FAST), amniotic fluid index (AFI) and doppler umbilical artery pulsatility index were tested weekly until delivery. All fetal testing performed within a week of delivery was compared with fetal outcome. Fetal outcome was considered poor when there was perinatal death, intrapartum fetal distress, a five minute Apgar score of less than 7, thick meconium-stained amniotic fluid or admission to the neonatal intensive care unit. Seventeen pregnancies were considered poor outcome (prevalence of 5.7%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Kappa index (KI) of each test to predict poor fetal outcome were evaluated. A combination of FAST and AFI is the most reliable antepartum fetal test. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and Kappa index of the combination of FAST and AFI were 70.0%, 99.6% 87.5%, 98.8%, 98.5% and 0.77%, respectively.