The efficacy of postpartum tubal sterilization training program with minilaparotomy approach in Ob/Gyn residents.

Objectives: To evaluate the efficacy of postpartum tubal sterilization training program with minilaparotomy approach (PTSMA). Study design: From September 2020 to November 2021, 24 first-year Obstetrics and Gynecology (Ob/Gyn) residents were randomly allocated into 2 groups of traditional apprenticeship learning (watching video clip) versus apprenticeship learning plus PTSMA attending. The program consisted of didactics followed by self-practicing with 2 stations of postpartum tubal sterilization simulators (PTSS). All participants were allowed to perform their first tubal sterilization under supervision within a few days after training. Their surgical skills were blindly evaluated by 2 experts through the recorded videos. Five domains of direct observation of procedural skills (DOPS) score introduced by Royal Thai College of Obstetricians and Gynecologists were assessed. DOPS score, operative time, blood loss and post-op complication were analyzed and compared. Results: Median of total DOPS score in the PTSMA group was higher than the non-PTSMA group (93 vs. 73, p = 0.020). Concerning 2 domains of DOPS score (tubal fishing and tubal sterilization), the PTSMA group had the higher median score than the non-PTSMA group (36 vs. 24, p = 0.045 and 40 vs. 32, p = 0.020). There was no significant difference observed in the median score of 3 other domains (peritoneal cavity accessing, abdominal wall closure and complication prevention), estimated blood loss and operative time. Conclusion: Postpartum tubal sterilization training program with minilaparotomy approach using instructive simulators significantly improved the total DOPS score especially tubal fishing and tubal ligation skills in Ob/Gyn residents. Implications: The study evidently showed the benefit of PTSMA with an inexpensive and simple to prepare models. In unexperienced operators, practicing in model prior to surgery should be encouraged to improve their operative skills.

Role of Ultrasound and MRI in Diagnosis of Severe Placenta Accreta Spectrum Disorder: An Intraindividual Assessment With Emphasis on Placental Bulge.

BACKGROUND. The "placental bulge" sign (focal area of myometrial-placental bulging beyond the normal uterine contour) on ultrasound (US) or MRI is postulated to represent deeper venous invasion in placenta accreta spectrum (PAS) disorder and may represent severe PAS. OBJECTIVE. The purpose of this study was to evaluate the diagnostic performance and interobserver agreement of US and MRI features for diagnosis of severe PAS, with an emphasis on the placental bulge sign. METHODS. This retrospective study included 62 pregnant women (mean age, 33.2 ± 5.5 [SD] years) with clinically suspected PAS who underwent both US and MRI. Five readers (two maternal-fetal medicine specialists for US, three abdominal radiologists for MRI) independently reviewed images for the given modality, blinded to the final diagnosis, and recorded the presence of a range of findings (nine on US, eight on MRI), including placental bulge. Intraoperative and pathologic findings were used to separate patients into those with and without severe PAS according to International Federation of Gynecology and Obstetrics classification. Diagnostic performance of US and MRI findings for severe PAS was evaluated, multivariable logistic regression was performed, and interob-server agreement was assessed. RESULTS. A total of 58.1% (36/62) of patients had severe PAS. On US, the finding with the highest accuracy for severe PAS was placental bulge (85.5%), which had a sensitivity of 91.7% and specificity of 76.9%. On MRI, the finding with highest accuracy was also placental bulge (90.3%), which had a sensitivity of 94.4% and specificity of 84.6%. In the multivariable regression analysis, placental bulge was an independent predictor of severe PAS on US (odds ratio [OR], 8.94; p = .02) and MRI (OR, 45.67; p = .003). Interobserver agreement analysis showed a kappa value for placental bulge of 0.48 for MRI and 0.40 for US. Given wide 95% CIs, differences among features for a given modality and differences between modalities were not statistically significant. CONCLUSION. The findings suggest a strong performance of placental bulge in diagnosing severe PAS on both US and MRI, with a potentially stronger performance on MRI. Nonetheless, interobserver agreement remains suboptimal for both modalities. CLINICAL IMPACT. Accurate prenatal diagnosis of severe PAS by imaging could help guide maternal counseling and selection of either hysterectomy or uterine-preserving surgery.

Comparison of maternal and perinatal morbidity between elective and emergency caesarean section in singleton-term breech presentation.

The objective of the study was to compare maternal and neonatal adverse outcomes between elective caesarean section (ElCS) and emergency caesarean section (EmCS) for singleton-term breech presentation. This study included women with singleton breech presentation who underwent ElCS or EmCS at term during 2007-2015 at Siriraj Hospital (Thailand). Complete data were collected for 2178 pregnant women. Of those, 1322 (60.7%) women underwent EmCS, and 856 (39.3%) delivered by ElCS. Maternal and perinatal morbidity were compared. There was no maternal or perinatal death in either group. Maternal morbidity was comparable between groups, except for longer hospital stay in the EmCS group (p = .047). One-minute Apgar score was significantly lower in the EmCS group (p = .040). There was no significant difference in 5-min Apgar score between groups. No significant difference was observed for serious maternal and neonatal morbidity between women who underwent ElCS versus those who underwent EmCS for singleton-term breech presentation.IMPACT STATEMENTWhat is already known on this subject? Emergency caesarean section (EmCS) is generally known to be associated with a higher risk of maternal and neonatal complications than elective caesarean section (ElCS).What do the results of this study add? In singleton-term breech presentation, EmCS in tertiary care setting was not associated with an increase in serious maternal and neonatal morbidity compared with EICS. Cord prolapse as an indication for emergency caesarean section was significantly associated with adverse outcomes while advanced cervical dilation ≥7 cm or low foetal station ≥+1 did not have an impact on maternal and neonatal complications.What are the implications of these findings for clinical practice and/or further research? Mean gestational age in both the ElCS and EmCS groups was approximately 38 weeks and 5 d; there were no neonatal cases with respiratory distress syndrome. Our findings suggest further prospective study in planned caesarean section scheduled for 38-39 weeks in patients with term breech presentation. The results of such a study could yield lower rates of both EmCS and potential adverse outcomes.

Previous Adolescent Pregnancy and Breastfeeding Does Not Negatively Affect Bone Mineral Density at the Age of Peak Bone Mass.

PURPOSE: To determine bone mineral density (BMD) at the age of peak bone mass in women who previously experienced pregnancy and breastfeeding during adolescence. MATERIALS AND METHODS: In this retrospective study, female volunteers aged 24-30 years who were pregnant during the age of 15-19 years and have had one to two babies were recruited. All of them experienced breastfeeding without history of bone- or calcium-related problems, such as fracture or low calcium intake. BMD was determined at the femur and L1-L4 spine by dual-energy X-ray absorptiometry. RESULTS: We found that both volunteers who previously experienced breastfeeding and age-matched control volunteers had similar BMD at the L1-L4 spines and femora. Further analysis for site-specific changes of lumbar and femoral BMDs showed that the values of the breastfeeding group were not different from those of the control group except at L1 and L2, where BMD values were greater in breastfeeding group compared with the control group. At both femoral and vertebral sites, T- and Z-scores were apparently similar between the two groups. In addition, the BMD at peak bone mass had no significant correlation with breastfeeding duration. CONCLUSIONS: Teenage pregnancy and breastfeeding did not negatively affect BMD later at the age of peak bone mass. Therefore, breastfeeding can be encouraged in teenage mothers.

Measurement of fetal atrioventricular time intervals: A comparison of 3 spectral Doppler techniques.

OBJECTIVE: To establish nomograms for fetal atrioventricular (AV) time intervals assessed by 3 different pulsed-wave Doppler techniques: left ventricular inflow and outflow tracts (LV in/out), superior vena cava and ascending aorta (SVC/AA), and pulmonary artery and pulmonary vein (PA/PV). METHODS: A cross-sectional study was performed in 311 normal fetuses divided into 5 groups between 16 and 38 weeks. Pulsed-wave Doppler-derived AV intervals were measured by interrogation of flow in LV in/out, SVC/AA, and PA/PV. Linear regression analyses were performed to examine correlations with gestational age (GA) and fetal heart rate (FHR). Intraclass correlation coefficients for reproducibility of each method were compared. RESULTS: Pulmonary artery and pulmonary vein revealed the longest mean AV time intervals (P < .001). The AV intervals in all methods were positively correlated with GA (R2  = 0.20-0.36; P < .001) and negatively correlated with FHR (R2  = 0.09-0.19; P < .001). The SCV/AA time intervals demonstrated the weakest influence of FHR. For LV in/out, SVC/AA, and PA/PV, intraobserver and interobserver reliability coefficients showed excellent agreements (all intraclass correlation coefficients ≥ 0.80). CONCLUSION: All pulsed-wave Doppler-derived AV time intervals increased with advancing GA and decreased with increasing FHR. Fetal AV interval measurements can be obtained in a clinically viable fashion with excellent reproducibility.

Site-Specific Onset of Low Bone Density and Correlation of Bone Turnover Markers in Exclusive Breastfeeding Mothers.

PURPOSE: Lactation often affects calcium metabolism and induces bone loss. Calcium supplementation and a high calcium diet are recommended to prevent bone loss, especially during inadequate calcium intake. Our study aimed at determining bone loss in breastfeeding mothers, and if it occurred, whether it was site specific and there were correlations between serum bone turnover markers. MATERIALS AND METHODS: Since the 6-month exclusive breastfeeding is usually recommended in several countries, our study examined bone mineral density (BMD) in early (1-2 month), mid (3-4 month)-, and late (5-6 month) lactation compared with nonpregnant, nonlactating control women. Site-specific bone loss was monitored in lumbar vertebrae and femora. Bone turnover markers, that is, C-terminal telopeptide of type 1 collagen and N-terminal propeptide of type 1 collagen (P1NP), were determined by electrochemiluminescence immunoassays. RESULTS: The onset of bone loss in exclusive breastfeeding mothers was site specific, for example, in the lumbar bone at mid-lactation and in the femoral bone in late lactation. Serum ionized calcium levels in late lactation were lower than the normal levels. In addition, a correlation was found between bone turnover marker, P1NP, and femoral BMD. CONCLUSIONS: The onset of bone loss in exclusive breastfeeding mothers was site specific, and the lumbar bone was a vulnerable and perhaps better representative site for bone loss detection. It was suggested that the optimal starting time for calcium supplementation should be before the mid-lactation when the bone loss was observed. In addition, the biochemical marker that best predicted the onset of bone loss in lactating women was P1NP.

Sensitivity of multiple first trimester sonomarkers in fetal aneuploidy detection.

BACKGROUND: Multiple first trimester aneuploidy sonomarkers have been introduced recently. OBJECTIVE: To evaluate the efficacy of first trimester sonomarkers in fetal aneuploidy detection without serum markers. METHODS: There were entirely 280 fetuses with 11-13+6 weeks' gestation (crown-rump -length between 45-84 mm) enrolled to assess nuchal translucency thickness (NT), nasal bone (NB), tricuspid regurgitation (TR) and ductus venosus (DV) flow. The performance of each single marker and multiple markers for major fetal aneuploidy screening were determined. RESULTS: Totally, 190 fetuses (67.85%) underwent invasive prenatal diagnosis with 14 major chromosome abnormalities identified including 4 cases of trisomy 21, 4 cases of trisomy 18, 3 cases of trisomy 13 and 3 cases of 45, XO. NT was the most accurate single marker with sensitivity of 71.43% and false-positive rate (FPR) of 4.14% while NB or TR was the most specific marker (99.6%) but lacked sensitivity. Among multiple first trimester-screening sonomarkers, NT plus TR evaluation were the most sensitive test (78.57%) with FPR of 4.76%. CONCLUSION: NT was the most accurate first trimester-screening marker for fetal aneuploidy. NT plus TR assessment as double-screening markers could improve the sensitivity by 7% leading to the lower number of unnecessary invasive prenatal diagnosis.

Short-term outcomes after second-trimester genetic amniocentesis in Siriraj Hospital.

OBJECTIVE: To determine the short-term outcomes of second-trimester genetic amniocentesis at Siriraj Hospital, Bangkok, Thailand. METHODS: In a retrospective descriptive study, data were assessed from women with a singleton pregnancy who underwent genetic amniocentesis between 16 and 21 gestational weeks at the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Siriraj Hospital, from May 2007 to June 2012. The amniocentesis records and medical data of all women were analyzed statistically. RESULTS: During the 5-year period, complete data were collected for 3307 pregnant women. The rate of total pregnancy loss within 4 weeks of testing was 7 out of 3307 (0.2%; 95% confidence interval, 0.1%-0.4%). Advanced maternal age (≥35 years) was the most common indication for amniocentesis (94.6%). The culture failure rate was 0.2%. Chromosomal abnormalities were detected in 109 pregnancies (3.3%); trisomy 21 was the most prevalent abnormality (0.8%). The possible risk factors of fetal loss were early amniocentesis (gestational age, <18 weeks) (P=0.013), abnormal fetal sonography (P=0.004), culture failure (P=0.015), and old-blood- or murky-stained amniotic fluid (P=0.036). CONCLUSION: Second-trimester genetic amniocentesis resulted in 0.2% of total pregnancy loss within 4 weeks of testing. This information is essential for patient counseling before amniocentesis.

Pilot study of normal development of nipples during pregnancy.

BACKGROUND: Numerous factors, both in the mother and in the infant, are involved in achieving breastfeeding. One maternal factor is normality of the nipples. However, no definition of normal nipple length or width or normal range and changes in pregnant women exists. OBJECTIVE: This study aimed to demonstrate the change of nipple length and width and areola width during pregnancy in Thai women. METHODS: This descriptive study was conducted from March 2010 to July 2011. A total of 56 pregnant women with nipple length ≥ 7 mm on both sides were recruited for the study. All women were at 8 to 12 weeks of gestation. The patients were scheduled for nipple and areola measurements up to 9 times, depending on the routine antenatal care appointments and delivery date. Nipple length and width and areola width of all participants were consecutively evaluated in each prenatal visit. RESULTS: The mean nipple length was 9.3 ± 1.5 mm at the first visit and significantly increased to 11.2 ± 1.8 mm by the time of the last visit (P < .001). Similarly, the nipple width was 13.6 ± 1.8 mm in the first trimester and widened to 15.9 ± 2.3 mm at term (P < .001). No differences of nipple length or width change were observed between both sides. The areola width of both sides considerably increased by 12.3 ± 6.1 mm during pregnancy (P < .001). CONCLUSION: During pregnancy, nipple length and width as well as areola width increased significantly.

Outcome of non-protractile nipple correction with breast cups in pregnant women: a randomized controlled trial.

OBJECTIVE: The benefit of antenatal nipple correction remains inconclusive. This study aims to demonstrate the value of breast cups in lengthening of short nipples and to compare the breastfeeding rate between the users and the nonusers. SUBJECTS AND METHODS: Singleton pregnant women with at least one short nipple (<7.0 mm) were enrolled at a gestational age (GA) of 16-20 weeks. All participants were randomly allocated into the breast cup group (BC group) and the expectant group (EX group). The first group was requested to wear breast cups for at least 8 hours during the daytime, whereas the second group was not. The nipple length was evaluated prior to the study and at every visit until GA of 36 weeks by the same blinded evaluator. RESULTS: Among 90 eligible participants (43 in the BC group, 47 in the EX group), the nipple elongation in the BC group was significantly higher than in the EX group (2.37±1.29 mm versus 1.84±0.98 mm; p=0.032), with a mean difference of 0.53±0.24 mm (95% confidence interval 0.05, 1.01). On Day 3, there was an insignificantly higher number of mothers with a LATCH score of ≥7 in the BC group. The 3-month exclusive breastfeeding rate in the BC group was insignificantly greater than that of the EX group (65.39% versus 50.0%; p=0.35). CONCLUSIONS: Breast cups are safe and well tolerated by users and evidently increase the length of short nipples and enhance the exclusive breastfeeding rate.

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.

The correlation in antepartum fetal test between full fetal biophysical profile (FBP) and rapid biophysical profile (rBPP).

OBJECTIVE: To determine the correlation between the rapid biophysical profile (rBPP), the combination of amniotic fluid index (AFI), and sound-provoked fetal movement (SPFM) detected by ultrasound, and the full biophysical profile (FBP) in terms of abnormal and normal result. MATERIAL AND METHOD: A prospective study was performed in 200 singleton pregnancies with no fetal anomalies between 30-42 weeks of gestation indicated for non-stress test (NST). All participants received both the standard (FBP) and the new rBPP examinations. Abnormal fetal test was defined as having a score of < or = 6 for FBP or < or = 2 for rBPP. The main outcome measurement was Spearman's correlation coefficient (r) between both examinations. RESULTS: The incidences of the abnormal tests were 1.5% and 6.0% in FBP and rBPP, respectively. The data showed a positive correlation between the two tests (r(s) = 0.67; p < 0.01). Regarding the operative time, FBP assessment was 25.56 +/- 8.75 times longer than rBPP. The number of abnormal NST was remarked at 1.5% while oligohydramnios and abnormal SPFM were detected at 5% and 2%, respectively. Compared to the standard NST, rBPP test was significantly superior in terms of correlation with FBP (r(s) = 0.67 vs. 0.33) and shorter duration of test (1.21 +/- 0.32 min. vs. 21.65 +/- 5.47). CONCLUSION: The statistically significant positive correlation between rBPP and FBP has been revealed. Due to its simplicity, rapidity, and no need of expensive equipment or experienced interpreter the rBPP may be alternatively used as a primary antepartum fetal test in the overcrowded obstetric center or when fetal surveillance tests are limited.

Specificity of fetal tricuspid regurgitation in prediction of Down syndrome in Thai fetuses at 17-23 weeks of gestation.

OBJECTIVE: To assess the specificity of tricuspid regurgitation (TR) in prediction of Down syndrome in Thai fetuses at 17-23 weeks' gestation and to determine the prevalence of TR among normal chromosome fetuses in a high-risk population. MATERIAL AND METHOD: A prospective study was performed in 395 high-risk pregnant women who underwent amniocentesis or cordocentesis for fetal karyotyping at 17-23 weeks. The presence or absence of TR was determined by pulsed wave Doppler at the time of prenatal diagnosis. TR was diagnosed when the regurgitation flow was observed for at least half of systole or > or = 70 milliseconds with maximum velocity of > or = 100 cm/sec. The diagnostic values of TR for detection of Down syndrome were calculated. RESULTS: The prevalence of TR was 3.8% (14/370) in normal chromosome fetuses and 40% (2/5) in Down syndrome fetuses. Fetuses with TR had a higher chance to be Down syndrome (11.1%) than those without TR (0.8%) (95% CI of the difference, 0.09-32.9, p = 0.036). Specificity, sensitivity, NPV and PPV of TR in prediction of Down syndrome were 95.9%, 40%, 99.2% and 11.1%, respectively. Among normal chromosome fetuses with TR, 14.3% (2/14) had congenital cardiac abnormalities. CONCLUSION: TR is not only a high specificity secondary ultrasound marker at 17-23 weeks to identify fetuses with Down syndrome in high-risk pregnant women but also associates with the risk of cardiac defects in normal chromosome fetuses.

Reverse twin-twin transfusion syndrome after fetoscopic laser photocoagulation of chorionic anastomoses: a case report.

A case of severe twin-twin transfusion syndrome (TTTS) which developed at menstrual age of 17 weeks underwent a fetoscopic laser ablation of the anastomosing vessels. The vascular equator of the anastomoses was noticed to be deviated due to marginal cord insertion of the recipient fetus. The procedure was accomplished uneventfully. However, the recipient fetus died 6 h after the procedure. After the pregnancy was terminated, the donor was found to be counterintuitively plethoric, and the recipient was pale. Similar appearances were noted on the placental territories of each fetus. This is consistent with reverse TTTS. Dye injection study and microscopic examination revealed a residual deep vein-vein anastomosis. This subchorionic vascular connection is still a challenge to coagulate with current placental surgery techniques. To the best of our knowledge, this is the first confirmed case of reverse TTTS as a cause of fetal loss following laser photocoagulation. This report also discusses the technical considerations in the complicated case of in utero placental surgery for TTTS.

Fractional thigh volume by three-dimensional ultrasonography for birth weight prediction.

OBJECTIVE: To determine the correlation between actual birthweight (BW) and fetal weight calculated from fractional thigh volume (ThiV). MATERIAL AND METHOD: The authors have conducted a prospective, cross-sectional study of normal Thai fetal thigh volume. There were 176 eligible pregnant women who met the criteria of singleton with no fetal anomaly were recruited into the present study. Prior to the present study, 3 operators had been trained and standardized for fractional ThiV measurement by an expert for the first 20 cases. To generate the fetal weight calculating formula, fetal ThiV data from the first 100 cases were employed Then, the authors' new prediction formula was compared and validated with the Hadlock's and the Tongsong formula in 56 normal late-third-trimester fetuses. All patients were assessed for 2D fetal biometry and 3D fractional ThiV within one week before delivery. RESULTS: A total of 176 fetuses underwent ultrasound at the gestational age of 38.5 +/- 2.1 weeks. The reproducibility of fractional ThiV measurement technique showned very good correlation in both inter- and intra-observer reliability as observed by the high intraclass correlation (0.971-0.994). By using the regression model, fractional ThiV presents a superior correlation to actual BW (r = 0.965). The fitting formula is characterized by predicted fetal BW (g) = 774.744 + 32.658 x fractional ThiV (ml). The presented new formula shows the smallest absolute percentage error (APE) for BW estimation when compared to that of Hadlock's and Tongsong's. CONCLUSION: Fetal 3D-fractional ThiV is consistent with actual BW The measurement of fractional ThiV can improve the accuracy of fetal weight prediction especially in some eventful conditions.

Antenatal diagnosis of double outlet of right ventricle without extracardiac anomaly: a report of 4 cases.

Four fetuses were diagnosed antenatally with double outlet of right ventricle (DORV) at 17, 20, 26, and 28 weeks' gestation, respectively, using 2-dimensional sonography. Chromosome study was normal in all 4 cases, and there were no extracardiac abnormalities. The sonographic diagnoses were based on the following findings: (1) arising of the 2 great vessels predominantly from the right ventricle; (2) the presence of bilateral coni; and (3) parallel direction of the 2 vessels rather than the normal perpendicular course. Two cases were terminated electively with postnatal autopsy confirmation; the other 2 cases were closely monitored throughout pregnancy and underwent normal vaginal delivery at term and subsequent surgical correction with good outcome. In conclusion, DORV can be readily diagnosed in utero by checking outflow tract even without 3-dimensional sonography and in the absence of obvious risk for congenital heart defects.

Anemia and hydrops in a fetus with homozygous hemoglobin constant spring.

Hemoglobin Constant Spring (Hb CS) is an unstable hemoglobin (Hb) variant that results from a nucleotide substitution at the termination codon of the alpha2-globin gene. The compound heterozygosity of alpha-thalassemia and Hb CS (--/alphaCSalpha) results in a Hb H/CS disease which is clinically more severe than deletional Hb H disease. Homozygosity of Hb CS (alphaCSalpha/alphaCSalpha) is generally characterized with mild hemolytic anemia, jaundice, and splenomegaly. The authors report 1 case with Hb CS homozygosity who presented with fetal anemia and hydrops. Intrauterine transfusions were given which rendered a favorable outcome. This report demonstrates an unusual and serious in utero complication in a fetus with Hb CS/CS.

Comparison of the manual stimulation test and the nonstress test: a randomized controlled trial.

OBJECTIVE: To evaluate manual fetal stimulation (MST) through the maternal abdomen in comparison to standard nonstress test (NST) in terms of nonreactive rates and testing time. MATERIAL AND METHOD: Five hundred and forty high-risk singleton pregnancies at 28 gestational weeks or more were assigned to have either NST or MST using blocked randomization (270 each). All fetal heart rate (FHR) tracings were analyzed blindly using standard NST criteria by one perinatologist. RESULTS: The MST group provided a significantly higher reactive rate than that of the NST group, 98.9% and 84.4% respectively, p < 0.001. Mean testing time of the reactive results of the MST group was also significantly shorter than that of the NST group, 7.94 +/- 6.27 min and 13.91 +/- 9.58 min respectively, p < 0.001. CONCLUSION: This is the first randomized controlled trial (RCT) to demonstrate the distinctive benefit of the simple and less expensive MST. MST significantly reduces the time to reactivity and increases the frequency of reactivity when compared to NST alone.

Prenatal sonographic diagnosis of tetralogy of fallot.

The objective of this report was to emphasize the sonographic findings of tetralogy of Fallot (TOF) during the prenatal period. Four fetuses with TOF were prenatally diagnosed at gestational ages of 25, 28, 25, and 32 weeks. Based on this small series, prenatal sonographic findings suggestive of TOF may be summarized as follows: (1) a large aortic root, which is the most common prenatal sonographic finding, (2) a small pulmonary artery or stenosis of the right ventricular outflow tract, (3) a ventricular septal defect in the outlet portion of the septum, (4) an overriding aorta, which is best seen in the long-axis view, and (5) right ventricular hypertrophy. Other findings such as hydrops fetalis or polyhydramnios may also be helpful especially in the case of dysplastic pulmonary valves. The demonstration of a normal aortic root would render the presence of TOF unlikely. TOF with pulmonary atresia can be confused with truncus arteriosus, in which both pulmonary arteries arise from the ascending aorta. How-ever, with careful examination along the course of the ascending aorta, there are no branches arising from the aorta in TOF.

Variability of nuchal translucency measurement: a multicenter study in Thailand.

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 < 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.