Publications by authors named "Kuntharee Traisrisilp"

57 Publications

New genetic and clinical evidence associated with fetal Beckwith-Wiedemann syndrome.

Prenat Diagn 2021 May 3. Epub 2021 May 3.

Department of Obstetrics and Gynecology, Faculty of Medicine Chiang Mai University, Meaung, Chiang Mai, Thailand.

Early detection of Beckwith-Wiedemann syndrome (BWS) is very important since it is very useful regarding counseling of parents concerning the risk of developing embryonic tumors, selection of the mode of delivery due to potential adrenal cysts that might bleed during labor, prevention of neonatal hypoglycemia and even options of pregnancy termination in non-viable fetuses. This report describes the prenatal classic sonographic triad of fetal BWS (omphalocele, macrosomia, macroglossia) and other supporting findings (hepatomegaly, adrenal enlargement) as well as additional postnatal evidence. Also, it demonstrates new molecular genetic evidence potentially associated with the disease (the presence of a novel heterozygous c.358G>T variant of the CDKN1C gene). Importantly, we provide new evidence indicating that elevated levels of the four serum biomarkers (alpha-fetoprotein, beta-human gonadotropin, unconjugated estriol, and inhibin-A) in late first or early second trimester might be strongly suggestive of BWS which may facilitate early detection especially in cases of no obvious anomaly. In conclusion, this study emphasizes on early detection of BWS as early as at 14 weeks of gestation, based on the abnormal rise of the four serum biomarkers together with omphalocele. To the best of our knowledge, this is the earliest prenatal detection of BWS ever reported. Finally, we provide new molecular genetic evidence that is, potentially associated with BWS.
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http://dx.doi.org/10.1002/pd.5956DOI Listing
May 2021

May-Thurner Syndrome Is Aggravated by Pregnancy.

Medicina (Kaunas) 2021 Mar 1;57(3). Epub 2021 Mar 1.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand.

This study aims to emphasize that asymptomatic patients with undiagnosed and asymptomatic May-Thurner syndrome (MTS) may firstly develop severe compression during pregnancy. A 40-year-old woman, G1P0, at 22 weeks of twin gestation presented with left lower extremity edema and pain. One twin was structurally normal while the other had bilateral renal agenesis with oligohydramnios. Magnetic resonance venography (MRV) revealed severe compression of the left iliac vein by the right iliac artery without evidence of deep vein thrombosis (DVT). Conservative treatment with anticoagulant prophylaxis was instituted throughout the rest of pregnancy and postpartum period. She was also complicated with severe pre-eclampsia, a cesarean section was performed due to a prolapsed cord at 27 weeks of gestation, and she gave birth to a surviving baby weighing 1100 g. In conclusion, this case report provides evidence that pregnancy can disclose a subtle May-Thurner anatomy to be symptomatic without DVT. Successful pregnancy outcomes could be achieved with conservative treatment and anticoagulant prophylaxis.
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http://dx.doi.org/10.3390/medicina57030222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7999580PMC
March 2021

Prenatal Sonographic Features of CHARGE Syndrome.

Diagnostics (Basel) 2021 Feb 28;11(3). Epub 2021 Feb 28.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand.

CHARGE syndrome is a rare autosomal dominant disorder, associated with coloboma (C), heart defects (H), choanal atresia (A), retardation of growth and/or central nervous system (R), genitourinary anomalies (G) and ear abnormalities (E). Prenatal diagnosis of the syndrome is very rare but may be suspected when a combination of such abnormalities is identified. We describe a prenatally suspected case of CHARGE syndrome due to unique findings of cardiac defects (DORV) in combination with minor clues, including a structurally malformed ear with persistent non-response to an acoustic stimulation (which has never been prenatally described elsewhere), renal malrotation and growth restriction. Postnatal diagnosis was made based on confirmation of the prenatal findings and additional specific findings of bilateral coloboma, choanal atresia and ear canal stenosis. Finally, molecular genetic testing by whole exome sequencing of the neonate and her parents revealed a novel de novo heterozygous frameshift c.3506_3509dup variant in the gene, confirming the clinical diagnosis of CHARGE syndrome. In conclusion, we describe unique prenatal features of CHARGE syndrome. Educationally, this is one of the rare examples of CHARGE syndrome, comprising all of the six specific anomalies as originally described; it is also supported by the identification of a specific genetic mutation. The identified genetic variant has never been previously reported, thereby expanding the mutational spectrum of . Finally, this case can inspire prenatal sonographers to increase awareness of subtle or minor abnormalities as genetic sonomarkers.
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http://dx.doi.org/10.3390/diagnostics11030415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997219PMC
February 2021

Comparison of pregnancy outcomes after second trimester amniocentesis between procedures performed by experts and non-experts.

J Perinat Med 2021 May 9;49(4):474-479. Epub 2020 Dec 9.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Objectives: To compare the rate of fetal loss in pregnancy after second trimester amniocentesis between procedures performed by experts and non-experts and to assess other pregnancy complications as secondary outcomes.

Methods: A retrospective cohort study was performed on singleton pregnancies that underwent mid-trimester amniocenteses in a single institution. The fetal loss rates of procedures performed by experts and non-experts were collected and analyzed. Other adverse pregnancy outcomes were also examined.

Results: In total, 14,450 amniocenteses were performed during the study period. These included 11,357 (78.6%) procedures in the group expert operators and 3,093 (21.4%) procedures in the group non-expert operators. In the non-expert group, the fetal loss rate was slightly increased but not significantly (p=0.24).In addition, the higher number of spontaneous abortions was associated with blood-stained amniotic fluid sample (p<0.001; RR=9.28). Multiple needle insertions also increased in the non-expert group significantly. However, no difference in pregnancy outcomes was found between in single and multiple needle insertions.

Conclusions: The amniocentesis procedures performed by the non-experts was not increase the fetal loss rate. However, the other adverse pregnancy outcomes, including preterm birth, low birth weight and fetal growth restriction were significantly increased in the non-expert group.
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http://dx.doi.org/10.1515/jpm-2020-0430DOI Listing
May 2021

Quad test for fetal aneuploidy screening as a predictor of small-for-gestational age fetuses: a population-based study.

BMC Pregnancy Childbirth 2020 Oct 15;20(1):621. Epub 2020 Oct 15.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.

Background: To identify the relationship between quadruple test for aneuploidy screening (alpha-fetoprotein: AFP; free beta-human chorionic gonadotropin: b-hCG; unconjugated estriol: uE3 and inhibin-A: IHA) and fetal growth restriction and to construct predictive models for small-for-gestational-age (SGA) fetuses.

Methods: Women who underwent quadruple test for aneuploidy were followed-up for final outcomes. The multiples of the median (MoMs) of the four biochemical markers for the SGA group and those of normal fetuses were compared. The models for predicting SGA by the individual biomarkers and their combination were constructed using binary logistic regression analysis, and their diagnostic performances in predicting SGA were determined.

Results: Of 10,155 eligible pregnant women, 578 (5.7%) and 9577 (94.3%) had SGA and normal growth, respectively. High levels of AFP, b-hCG and IHA but low levels of uE3 significantly increased the risk of SGA. The constructed predictive equations had predictive performance for SGA, with areas under the receiver-operated characteristic curve of 0.724, 0.655, 0.597, 0.664 and 0.754 for AFP, b-hCG, uE3, IHA, and the combination, respectively.

Conclusion: The quad test for aneuploidy screening could also be used as a predictor of SGA, without extra-effort and extra-cost.
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http://dx.doi.org/10.1186/s12884-020-03298-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7559175PMC
October 2020

Comparisons of pregnancy outcomes between twin pregnancies with and without second-trimester amniocentesis.

Prenat Diagn 2020 09 4;40(10):1330-1337. Epub 2020 Aug 4.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Objective: To assess the amniocentesis-related pregnancy loss rate and preterm birth rate among twin pregnancies undergoing amniocentesis.

Methods: A retrospective cohort study was conducted at a tertiary center. The study group included twin pregnancies undergoing amniocentesis during 16 to 22 weeks of gestation. The control group was those not undergoing amniocentesis. All amniocenteses were performed by the MFM specialists. The main outcomes were the rate of pregnancy loss (before 24 weeks) and preterm birth.

Results: A total of 332 cases in the study group and 1188 controls were analyzed. The percentages of maternal age ≥35 years, high parity, and cases complicated with medical diseases were significantly higher in the study group. The pregnancy loss rate after the procedure tended to be higher, but not significant, in the study group (3.0% vs 2.2% P = .383). Likewise, the rate of preterm birth in the study group was higher, but not significant (70.5% vs 66.0% P = .130). Logistic regression analysis to adjust confounding factors showed no significance of amniocentesis on pregnancy loss and preterm birth.

Conclusion: Though amniocentesis in twin pregnancies has theoretical risk of pregnancy loss, it is relatively safe when performed by maternal-fetal medicine specialists. This information is useful for counseling, especially when performed by experienced hands.
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http://dx.doi.org/10.1002/pd.5783DOI Listing
September 2020

Fetal hydrometrocolpos with pre-axial mirror polydactyly as a new variant of McKusick-Kaufman syndrome.

J Clin Ultrasound 2021 Jan 14;49(1):62-65. Epub 2020 Jun 14.

Faculty of Medicine, Department of Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand.

This report describes a variant of McKusick-Kaufman syndrome presenting with a large fetal abdominal cyst of hydrometrocolpos at 37 weeks of gestation. The diagnosis was based on the ultrasound findings of a large homogeneous hypoechoic cyst (diameter of >10 cm) with incomplete septum, thickened wall, superiorly connecting to the dilated uterus, consistent with hydrometrocolpos. Additionally, pre-axial mirror polydactyly of the left foot was suspected. Postnatal examination/work-up confirmed the prenatal findings. This is the first report of prenatal diagnosis of hydrometrocolpos with complex polydactyly of mirror image pre-axial duplications containing nine toes instead of six-toe postaxial polydactyly.
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http://dx.doi.org/10.1002/jcu.22882DOI Listing
January 2021

Prenatal sonographic features of fetal mediastinal teratoma.

J Clin Ultrasound 2020 Sep 7;48(7):419-422. Epub 2020 Jun 7.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand.

Mediastinal teratoma can cause severe hydrops fetalis, which worsens the effects of the mass compression on the vital mediastinal organs. A careful sonographic examination is mandatory to demonstrate the characteristic features suggestive of this congenital tumor. We describe these features at 20 weeks gestation. The most prominent finding was the heterogeneous echogenicity of a large cystic-solid mass with hyperechoic dots, seen as a part of the anterior mediastinum immediately posterior to the sternum. Additional diagnostic features included posterior displacement of the heart, low cardiac output, and hypoplasia of the normally structured heart and lungs due to the direct mass compression. These sonographic findings were confirmed at autopsy which confirmed a nonmetastatic immature teratoma. Sonography may enable accurate diagnosis of mediastinal teratoma considering the anterior location and heterogeneous appearance of the mass, posterior displacement of the heart, normal lung morphology, and compression effects on these organs.
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http://dx.doi.org/10.1002/jcu.22876DOI Listing
September 2020

Prenatal screening of DiGeorge (22q11.2 deletion) syndrome by abnormalities of the great arteries among Thai pregnant women.

Obstet Gynecol Sci 2020 May 14;63(3):330-336. Epub 2020 Apr 14.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Objective: 22q11.2DS (deletion syndrome) is one of the common serious anomalies resulting in high perinatal morbidity and mortality rate. Nevertheless, prenatal diagnosis of 22q11.2DS in Southeast Asia has never been described and its prevalence in prenatal series has never been explored. The objective of this study was to describe the experience of prenatal diagnosis of 22q11.2DS in the Thai population and to determine its prevalence among fetuses prenatally diagnosed with abnormalities of the great arteries.

Methods: A prospective study was conducted on pregnant Thai women prenatally diagnosed with abnormalities of the great arteries in the second trimester. The recruited cases were investigated for fetal 22q11.2 deletion by in situ hybridization with a probe specific to the DiGeorge/VCFS TUPLE 1 region located on chromosome 22 for the locus D22S75, and 22qter for a telomere specific sequence clone as the control region.

Results: Five out of the 42 (11.9%) fetuses with abnormalities of the great arteries meeting the inclusion criteria were proven to have 22q11.2DS. The most common abnormalities were the tetralogy of Fallot (or variants) and right-sided aortic arch, followed by a thymic hypoplasia.

Conclusion: As observed in the western countries, we have documented that, among pregnant Thai women, 22q11.2DS is highly prevalent in fetuses with abnormalities of the great arteries (approximately 12%). This information is important when counselling couples to undergo prenatal testing for 22q11.2DS, since this information is vital in the patients' decision of termination or continuation of pregnancy and in a well-prepared management of the affected child.
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http://dx.doi.org/10.5468/ogs.2020.63.3.330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231935PMC
May 2020

A comparison of pregnancy outcomes after second-trimester amniocentesis between cases with penetration of the placenta and nonpenetration.

J Matern Fetal Neonatal Med 2020 Apr 16:1-6. Epub 2020 Apr 16.

Faculty of Medicine, Department of Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand.

To compare the fetal loss rate associated with second-trimester amniocentesis between the procedures with penetration and nonpenetration of the placenta, as a primary outcome and to compare the rates of adverse pregnancy outcomes including preterm birth, fetal growth restriction and low birth weight, as secondary outcomes. A retrospective cohort study was conducted on women undergoing second-trimester amniocentesis. Our prospective database of amniocentesis, from January 1989 to December 2018, was accessed to retrieve the records meeting the inclusion criteria consisting of singleton pregnancies, gestational age of 16-22 weeks, and known obstetric outcomes. The patients were categorized into two groups: placental penetration and nonpenetration. The rates of fetal loss, including abortion (<24 weeks of gestation) and fetal death (>24 weeks of gestation), and other adverse pregnancy outcomes were compared between the two groups. A total of 21,566 procedures were performed during the study period. Of them, 8601 were excluded due to chromosomal/structural abnormalities, various underlying medical diseases and incomplete data or unavailability of final outcomes. Finally, 12,965 cases were available for analysis including 4692 (36.2%) in the group of placental penetration and 8273 (63.8%) in the group of nonpenetration. The abortion rate after amniocentesis trended to be increased in the placental penetration group (0.6 versus 0.4%,  = .064; RR: 1.60, 95%CI 0.97-2.64). Likewise, the fetal loss rate trended to be increased in the placental penetration group (1.0 versus 0.7%,  = .121; RR: 1.35 95%CI 0.92-1.98). Interestingly, preterm birth rate was significantly increased in the placental penetration group (13.8 versus 12.6%,  = .043; RR: 1.10 95%CI 1.00-1.20). Fetal loss rate was slightly increased, but not statistically significant, among the procedures with placental penetration. However, penetration of the placenta was slightly but significantly associated with an increase in rates of preterm birth.
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http://dx.doi.org/10.1080/14767058.2019.1702017DOI Listing
April 2020

Comparison of the Effectiveness of Universal and Targeted Iodine Supplementation in Pregnant Women: A Randomized Controlled Trial.

Gynecol Obstet Invest 2020 11;85(2):189-195. Epub 2020 Mar 11.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand,

Objective: To compare the effectiveness of universal and targeted iodine supplementation strategies.

Methods: A randomized controlled trial involving low-risk Thai pregnant women was carried out. The participants were categorized into either the study group, in which iodine supplementation was varied based on median urine iodine concentration, or the control group, which received universal supplementation. Urine samples were collected before the start of treatment and at delivery. The primary outcome was iodine status after each supplementation regime.

Results: Two hundred and eight women were randomly categorized into 2 groups, 104 control-group participants and 104 study-group participants. Baseline iodine status in both groups was not significantly different. More than half of the pregnant women were classified as having iodine insufficiency. After supplementation, the proportions of iodine insufficiency in the control and study groups (27.9 and 33.3%, respectively; p value = 0.508) and those of excessive level (19.1 and 11.7%, respectively; p value = 0.247) were not significantly different between the 2 groups. However, iodine level above the requirement was statistically significantly higher in the control group (47.1%) compared with the study group (30.0%; p value = 0.048).

Conclusions: The 2 strategies, universal and targeted supplementation, have comparable effectiveness in prevention of iodine deficiency, but the evidence suggests that targeted supplementation is better in avoiding over-supplementation.
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http://dx.doi.org/10.1159/000506800DOI Listing
September 2020

Fetal Down syndrome screening models for developing countries; Part I: Performance of Maternal Serum Screening.

BMC Health Serv Res 2019 Nov 27;19(1):897. Epub 2019 Nov 27.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.

Background: To identify the performance of fetal Down syndrome (DS) screening for developing countries.

Methods: A prospective study on MSS (maternal serum screening) with complete follow-ups (n = 41,924) was conducted in 32 network hospitals in the northern part of Thailand. Various models of MSS were tested for performance.

Results: MSS based on Caucasian reference range resulted in very high false positive rate (FPR; 13%) in our country, compared to the rate of 7.8% with our own (Thai) reference range, whereas the detection rate was comparable. As individual screening, C-S (contingent first trimester screening including PAPP-A, and free beta-hCG, classified as a) high risk [> 1:30], indicated for invasive diagnosis; b) intermediate risk [1:30-1500], indicated for STS; and c) low risk [< 1:1500], need no further tests.) was the most effective model (sensitivity 84.9%, FPR 7.7%) but nearly one-third needed the second trimester test (STS) because of intermediate results. Additionally, about one-third had their first visits in the second trimester and had no chance of FTS (first trimester screening). C-S plus STS had a sensitivity of 82.4% and FPR 8.1% whereas independent first and second trimester screening model (I-S) gave the sensitivity of 78.4% and FPR of 7.5% but was much more convenient and practical.

Conclusion: C-S plus STS was the most effective models while I-S model was also effective and may be better for developing countries because of its simplicity and feasibility.
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http://dx.doi.org/10.1186/s12913-019-4446-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880541PMC
November 2019

Early prenatal detection of anterior uterine sacculation resulting from previous cesarean sections.

J Clin Ultrasound 2020 Feb 13;48(2):111-114. Epub 2019 Nov 13.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Anterior uterine sacculation was diagnosed at 15 weeks of gestation in a woman with two previous cesarean sections, based on hourglass appearance of two distinct uterine segments, namely the empty upper segment and the large thinned wall lower segment containing a fetus with posteriorly attached placenta. The pregnancy developed through the bulging weakened anterior wall instead of growing toward the upper segment. Urgent hysterectomy was performed. The operative and pathological findings confirmed the prenatal ultrasound findings. This is the first report of prenatal diagnosis of sacculation due to cesarean section, which prevented the catastrophic event of uterine rupture.
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http://dx.doi.org/10.1002/jcu.22789DOI Listing
February 2020

Giant choledochal cyst and infantile polycystic kidneys as prenatal sonographic features of Caroli syndrome.

J Clin Ultrasound 2020 Jan 4;48(1):45-47. Epub 2019 Oct 4.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Caroli syndrome is a developmental disorder caused by complete or partial arrest of ductal plate remodeling, leading to dilated bile ducts along with fibrosis surrounding the portal tracts. It is most commonly associated with autosomal recessive polycystic kidney (ARPKD). We report a unique case of Caroli syndrome, diagnosed prenatally at 24 weeks of gestation in a 29-year-old Thai woman. Ultrasound findings revealed the association of a fetal giant choledochal cyst with ARPKD. Autopsy findings showed ductal plate malformation, typical of Caroli syndrome, associated with giant choledocal cyst and ARPKD.
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http://dx.doi.org/10.1002/jcu.22778DOI Listing
January 2020

Z Score Reference Ranges of Fetal Cardiac Output From 12 to 40 Weeks of Pregnancy.

J Ultrasound Med 2020 Mar 12;39(3):515-527. Epub 2019 Sep 12.

Department of Obstetrics and Gynecology, Faculty of Medicine Chiang Mai University, Chiang Mai, Thailand.

Objectives: To develop the Z score reference ranges of fetal cardiac output (CO) in healthy fetuses from 12 to 40 weeks of pregnancy.

Methods: A cross-sectional descriptive study was undertaken among low-risk singleton pregnancies with healthy fetuses between 12 and 40 weeks. The right ventricular cardiac output (RCO), left ventricular cardiac output (LCO), and combined cardiac output (CCO) were measured by 2-dimensional ultrasound with the Doppler velocity of the aorta and pulmonary arteries. The pregnancies were followed until delivery RESULTS: The RCO, LCO, and CCO were determined in 700 fetuses. The predictive models of the CO as a function of gestational age (GA) and biparietal diameter were identified, and the Z score reference ranges were constructed. The means and standard deviations of CO on both sides were increased with GA and biparietal diameter as power models. Nomograms for the LCO, RCO, and CCO were established (ie, RCO = 0.000148 × GA ; SD = 0.000131 × GA ; LCO = 0.000514 × GA ; SD = 0.000169 × GA ). The RCO was much more increased than the LCO with advancing GA.

Conclusions: The Z score reference ranges and percentile charts of fetal CO were constructed throughout gestation with a large sample size. This may be helpful in detection of cardiac disorders, especially cardiomyopathy, cardiac anomalies, fetal anemia, and fetal growth restriction.
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http://dx.doi.org/10.1002/jum.15128DOI Listing
March 2020

Pregnancy-induced progressive change of prolactin-secreting macroadenoma with the development of bitemporal hemianopia and severe headache.

Clin Case Rep 2019 Jul 3;7(7):1365-1369. Epub 2019 Jun 3.

Department of Obstetrics and Gynecology, Faculty of Medicine Chiang Mai University Chiang Mai Thailand.

In a difficult case of macroadenoma with progressive change during pregnancy, timely cesarean delivery, avoidance of breastfeeding, and intensive conservative treatment after birth could have satisfactory results, in terms of fetal outcomes, regression of tumor, and resumption of visual activity.
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http://dx.doi.org/10.1002/ccr3.2244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637432PMC
July 2019

The performance of cardio-biparietal ratio measured by 2D ultrasound in predicting fetal hemoglobin Bart disease during midpregnancy: A pilot study.

Prenat Diagn 2019 07 29;39(8):647-651. Epub 2019 May 29.

Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Objective: The aim of this study was to assess the performance of cardio-biparietal ratio measured by real-time two-dimensional ultrasound in predicting hemoglobin (Hb) Bart disease among fetuses at risk.

Method: This prospective diagnostic study recruited pregnancies at risk for Hb Bart disease at 17 to 22 weeks' gestation. Cardio-biparietal ratio and cardiothoracic ratio were measured before cordocentesis for Hb typing. The performance of the cardio-biparietal ratio and cardiothoracic ratio for identifying affected fetuses was evaluated.

Results: Among 72 fetuses at risk, 31 were diagnosed as affected by Hb Bart disease. By using a cutoff 0.45, cardio-biparietal ratio had a sensitivity of 83.9%, specificity of 92.7%, positive predictive value of 89.7%, and negative predictive value of 88.4%, whereas cardiothoracic ratio using cutoff 0.5 had a sensitivity of 94.3%, specificity of 65.1%, positive predictive value of 68.8%, and negative predictive value of 93.3%.

Conclusion: Cardio-biparietal ratio is a new sonomarker to predict Hb Bart disease among fetuses at risk. This sonomarker is relatively effective and may be useful in areas of high prevalence of alpha thalassemia disease, limited number of experts in prenatal ultrasound, and difficult access to prenatal diagnosis.
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http://dx.doi.org/10.1002/pd.5478DOI Listing
July 2019

The best cutoff value of middle cerebral artery peak systolic velocity for the diagnosis of fetal homozygous alpha thalassemia-1 disease.

Prenat Diagn 2019 02 6;39(3):232-237. Epub 2019 Feb 6.

Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Objective: To determine the best cutoff value of middle cerebral artery peak systolic velocity (MCA-PSV) for the diagnosis of fetuses with homozygous alpha thalassemia-1 disease.

Methods: Pregnancies at risk for fetal homozygous alpha thalassemia-1 disease at 18 to 22 weeks were recruited. MCA-PSV was measured before cordocentesis for hemoglobin typing and complete blood count. The performance of the MCA-PSV for identifying affected fetuses was evaluated using a best cutoff value derived from the receiver operating characteristic (ROC) curve.

Results: Among 142 fetuses at risk, 46 (32.4%) fetuses were diagnosed as affected by homozygous alpha thalassemia-1 disease and were categorized as mild anemia (16.3%), moderate anemia (58.1%), and severe anemia (25.6%). With the best cutoff point of MCA-PSV > 1.30 multiples of the median (MoM) or >30.0 cm/s, the sensitivity for predicting fetal homozygous alpha thalassemia-1 was 100%.

Conclusions: MCA-PSV > 1.30 MoM is the best cutoff value for the diagnosis of all degrees of fetal anemia from homozygous alpha thalassemia-1 fetuses. Because of its simplicity for interpretation and high efficacy, a cutoff value of MCA-PSV > 30 cm/s can also be used as an alternative marker for fetal anemia screening during 18 to 22 weeks of gestation.
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http://dx.doi.org/10.1002/pd.5419DOI Listing
February 2019

Chorionic villous sampling-related complications: a cohort study.

J Matern Fetal Neonatal Med 2020 Jun 20;33(11):1901-1905. Epub 2018 Dec 20.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

To compare the adverse pregnancy outcomes between the pregnant women undergoing chorionic villous sampling (CVS) and those without CVS. A cohort study was conducted on low risk pregnancies attending Chiang Mai University Hospital between years 2003 and 2017 and identify the database of women undergoing CVS (study group) and control group. Each case in study group was matched for 10 cases of the control by maternal age and year of procedure. Of 1384 pregnancies undergoing CVS, 776 cases met criteria and were matched with 7760 controls. The gestational age at delivery and actual birth weight were significantly different between two groups (38.02 versus 38.96 weeks, value <.001 and 3025 versus 3092 g, value .001). Moreover, CVS group had significantly higher preterm birth (9.4 versus 7.3%, value .037; RR 1.287, 95% CI 1.017-1.629). However, there was no significant difference in fetal loss rate before 24 weeks (1.16 versus 1.9%, value .14), small for gestational age (SGA); SGA (4 versus 4%, value .948) and low birth weight (LBW); LBW (8.9 versus 8.0%, value .41). Pregnancies undergoing CVS tend to deliver earlier and has significantly higher preterm birth. However, the incidences of fetal loss, SGA and LBW are not significantly increased.
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http://dx.doi.org/10.1080/14767058.2018.1533943DOI Listing
June 2020

Reply to the letter to the Editor.

Arch Gynecol Obstet 2018 08 27;298(2):455. Epub 2018 Jun 27.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.

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http://dx.doi.org/10.1007/s00404-018-4826-1DOI Listing
August 2018

Second-trimester maternal serum screening for fetal Down syndrome: As a screening test for hemoglobin Bart's disease: A prospective population-based study.

Prenat Diagn 2018 08 3;38(9):700-705. Epub 2018 Jul 3.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Purpose: The purpose of this study is to determine the effectiveness of second-trimester maternal serum screening for Down syndrome as a screening test for fetal hemoglobin (Hb) Bart's disease among an unselected population.

Methods: A secondary analysis of a large prospective database (20 254 pregnancies) was conducted to compare the levels of maternal serum screening, alpha-fetoprotein (AFP), free beta-human chorionic gonadotropin, and unconjugated estriol between pregnancies with Hb Bart's disease and unaffected pregnancies.

Results: The median AFP levels were much higher among affected fetuses (1.96 vs 1.12 multiple of the median; P < .001), yielding a sensitivity of 81.6% and specificity of 86.4%. Thus, AFP measurement is effective in predicting fetal Hb Bart's disease among an unselected population when using a cutoff value of 1.5 multiple of the median. The serum free beta-human chorionic gonadotropin levels were slightly, but significantly, higher in the affected pregnancies, while the serum unconjugated estriol levels were minimally, but significantly, lower among the affected pregnancies.

Conclusion: Second-trimester maternal serum AFP levels were significantly elevated in cases of fetal Hb Bart's disease. Pregnancies with unexplained elevated serum AFP levels in areas of high prevalence of Hb Bart's disease should always undergo a detailed ultrasound examination to detect any early signs of fetal anemia before development of hydrops fetalis.
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http://dx.doi.org/10.1002/pd.5316DOI Listing
August 2018

The effectiveness of iodine supplementation during pregnancies in geographical areas of high prevalence of iodine insufficiency.

J Obstet Gynaecol 2018 Aug 12;38(6):756-761. Epub 2018 Mar 12.

a Department of Obstetrics and Gynecology, Faculty of Medicine , Chiang Mai University , Chiang Mai , Thailand.

The objective of this study was to determine the effectiveness of routine iodine supplementation among pregnant women in areas of high prevalence of an iodine insufficiency, using WHO criteria to determine the iodine status. A longitudinal study was conducted on pregnant women attending antenatal care at a tertiary hospital. The urine iodine concentration was measured in the first trimester and after 150 μg of iodine supplementation in the third trimester. A total of 327 pregnant women met the inclusion criteria with a complete follow-up. The prevalence of an iodine insufficiency was significantly lower in the third trimester, when compared to the first trimester (21.41% vs 55.35%, p < .001). However, 21.4% of cases still had an iodine insufficiency and 35.17% had an 'above-requirement' in the third trimester. In the areas of high prevalence of iodine insufficiency, an iodine supplementation significantly reduces the number of women with insufficiency; however, it was associated with unnecessarily high UICs, leading to the risk of excess iodine. Impact statement What is already known on this subject: Iodine insufficiency is highly prevalent in many geographical areas. Half of the pregnant women in the northern part of Thailand had an iodine insufficiency in the first trimester. What do the results of this study add: Iodine supplementation (daily 150-mcg of potassium iodide) could significantly reduce the number of women with the insufficiency. About one-fifth of women still had an iodine insufficiency in spite of iodine supplementation. Universal supplementation could be associated with unnecessarily high UICs, potentially at risk of iodine excess. What are the implications of these findings for clinical practice and/or further research: Physicians should guard against the occurrence of adverse effect from an iodine excess when there is routine iodine supplementation for pregnant women. Further study is required to establish the best strategy for an iodine supplementation in pregnancy.
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http://dx.doi.org/10.1080/01443615.2017.1410534DOI Listing
August 2018

Fetal Cardiac Remodeling in Response to Anemia: Using Hemoglobin Bart's Disease as a Study Model.

Ultraschall Med 2020 Apr 7;41(2):186-191. Epub 2018 Feb 7.

Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand.

Objective:  To assess fetal cardiac remodeling in response to anemia, by comparing the fetal cardiac dimensions and global sphericity index (GSI) of normal fetuses and fetuses with anemia using fetal Hb Bart's disease as a study model.

Methods:  Fetuses at risk for Hb Bart's disease undergoing cordocentesis at 18 to 22 weeks of gestation were recruited. Fetal cardiac dimensions including GSI (cardiac length to cardiac width ratio), interventricular septum thickness (IVST), left ventricular wall thickness (LVWT) and right ventricular wall thickness (RVWT) were measured.

Results:  215 pregnancies at risk met the inclusion criteria, including 54 affected fetuses and 161 normal fetuses. The mean GSI was significantly lower in the affected group (1.11 ± 0.06 vs. 1.26 ± 0.09, p-value 0.017). The GSI of the normal group was relatively constant regardless of gestational age. The IVST and LVWT tended to increase, but not significantly, in the affected group, whereas the RVWT was minimally but significantly increased. The ROC curve for GSI had an area under curve of 0.844. The best cut-off of GSI was 1.17, giving a sensitivity of 74.1 % and a specificity of 88.2 %.

Conclusion:  Fetal cardiac remodeling in response to anemia causes a marked decrease in global GSI with minimal hypertrophy as an adaption to volume overload. Importantly, GSI is a new maker for anemia and may play a role in clinical application for early detection of fetal anemia, possibly due to any cause. Additionally, GSI measurement is simple and gestational age-independent.
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http://dx.doi.org/10.1055/s-0044-101253DOI Listing
April 2020

Efficacy of aromatherapy for reducing pain during labor: a randomized controlled trial.

Arch Gynecol Obstet 2018 May 3;297(5):1145-1150. Epub 2018 Feb 3.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.

Background: Many strategies for labor pain management have been studied, including aromatherapy, which is a noninvasive, alternative medicine used as an adjunct for labor pain control. Nevertheless, the results were contradictory. Therefore, we conducted this study to determine the effectiveness of aromatherapy for reducing pain during labor.

Methods: A randomized controlled trial was carried out on Thai laboring primigravidae who were a low-risk singleton pregnancy undergoing vaginal delivery. All participants, both study and control group, received standard obstetric care. Aromatherapy was only provided to the study group during the first stage of labor. The women rated their pain intensity by rating scales at different stages of labor. The primary outcome was pain scores and the secondary outcomes were necessity of painkiller usage, labor time, aromatherapy-associated complications, route of delivery, and Apgar scores.

Results: A total of 104 women were recruited, 52 in each group. Baseline characteristics and baseline pain scores were comparable. The median pain score of latent and early active phase was lower in the aromatherapy group, 5 vs 6 and 7 vs 8, respectively. The mean differences of pain scores between latent and early active phase and the baseline were significantly lower in the aromatherapy group, 1.88 vs 2.6 (p = 0.010) and 3.82 vs 4.39 (p = 0.031), respectively. Late active phase pain scores and other perinatal outcomes were not significantly different.

Conclusion: Aromatherapy is helpful in reducing pain in latent and early active phase, and can probably be used as an adjunctive method for labor pain control without serious side effects.
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http://dx.doi.org/10.1007/s00404-018-4700-1DOI Listing
May 2018

Intracranial fetus-in-fetu with numerous fully developed organs.

J Clin Ultrasound 2018 Sep 28;46(7):487-493. Epub 2017 Nov 28.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand.

Fetus in fetu (FIF) is an extremely rare anomaly featuring a monozygotic, diamniotic, parasitic twin, enclosed within its host twin. It is characterized by the presence of vertebrae and well-developed organs in a fetiform mass. Only 18 cases of intracranial FIF have been published. Of them, only five cases were prenatally detected. This study prenatally demonstrated triplet FIFs at 31 weeks within amniotic-like sac in the fetal skull, consisting of multiple well-defined organs. The FIF attached to the host twin via body stalk containing a single main feeding artery and vein, representing umbilical vessels. Surgical removal was performed at the age of two months. Pathological examination showed the triplet FIF, consisting of numerous well-developed organs (musculocutaneous-skeletal, nervous, respiratory, gastrointestinal systems etc.), with soft tissue/skin coverings, but no vertebral body was seen. Molecular genetic analysis revealed identical genetic mapping among the three FIFs and the host. This case provides strong evidence against Willis's hypothesis but supports Spencer's theory of abnormal twinning.
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http://dx.doi.org/10.1002/jcu.22566DOI Listing
September 2018

Fetal isovolumetric time intervals as a marker of abnormal cardiac function in fetal anemia from homozygous alpha thalassemia-1 disease.

Prenat Diagn 2017 Oct 11;37(10):1028-1032. Epub 2017 Sep 11.

Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Objective: To determine whether fetal isovolumetric time intervals can be an early sonographic marker of fetal anemia in fetuses with homozygous alpha thalassemia-1.

Methods: Pregnancies at risk for fetal homozygous alpha thalassemia-1 disease at 18-22 weeks were recruited before cordocentesis for hemoglobin typing. Isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) intervals were measured by placing pulsed wave Doppler sample volume within the left ventricle to obtain the mitral and aortic waveform. Time intervals were compared between the affected group of homozygous alpha thalassemia-1 fetuses and the unaffected group.

Results: Among 70 fetuses at risk, 28 cases were diagnosed as affected by homozygous alpha thalassemia-1 disease. Mean ICT and ICT + IRT intervals in the affected group were significantly longer than in the unaffected group (47.9 ± 12.5 ms vs 35.0 ± 6.7 ms, p < 0.001; and 96.2 ± 13.6 ms vs 80.9 ± 10.6 ms, p < 0.001. ICT effectively predicted affected fetuses with 71.4% sensitivity and 78.6% specificity using a cutoff value ≥40 ms.

Conclusions: Isovolumetric contraction time was significantly prolonged in fetal anemia from homozygous alpha thalassemia-1 during the early stage of hydropic changes. Because of its simple measurement and high efficacy, ICT can be a useful marker for prenatal screening of abnormal cardiac function in fetal anemia. © 2017 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/pd.5140DOI Listing
October 2017

Huge cardiac myxoma in pregnancy.

BMJ Case Rep 2017 Jul 31;2017. Epub 2017 Jul 31.

Department of Anesthesiology, Chiang Mai University, Chiang Mai, Thailand.

A 28-year-old pregnant woman presented at 28 weeks of gestation. She was diagnosed to have a left atrial myxoma 2 years earlier, but was lost to follow-up. During this pregnancy, the transthoracic echocardiography showed a 9 cm mass in the left atrium obstructing mitral valve inflow, interfering with mitral valve closure, causing severe mitral regurgitation and severe pulmonary hypertension. However, there were no clinical signs of pulmonary and systemic congestion or obstruction. Based on the clinical symptoms of the patient, the echocardiographic findings and the term of her pregnancy, the patient decided to schedule for a vaginal delivery with surgical correction after delivery. She gave birth at 32 weeks of gestation. During labour, pulmonary oedema developed but was detected early and it responded to therapy. Two weeks after delivery, a right anterior thoracotomy was performed to facilitate the removal of the left atrial myxoma and repair of the mitral valve.
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http://dx.doi.org/10.1136/bcr-2017-219624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5612290PMC
July 2017

A retrospective comparison of pregnancy outcomes between women with alpha-thalassaemia 1 trait and normal controls.

J Obstet Gynaecol 2017 Nov 9;37(8):1000-1003. Epub 2017 Jun 9.

a Department of Obstetrics and Gynecology, Faculty of Medicine , Chiang Mai University , Chiang Mai , Thailand.

The objective of this retrospective cohort study was to compare pregnancy outcomes between low-risk pregnant women with alpha-thalassaemia-1 trait and normal controls. The database of the Maternal-Foetal Medicine unit was used to identify low-risk singleton pregnant women complicated by alpha-thalassaemia-1 trait who gave birth between January 2002 and October 2014. The low-risk pregnancies with non-carrier status for thalassaemia were assigned into the control group, with a control-to-case ratio of 10:1. During the study period, 595 women with alpha-thalassaemia-1 trait and 5950 normal controls were identified. There was no significant difference in the incidence of preterm birth and most obstetric outcomes between the two groups. However, a statistically significant difference was detected between them in terms of gestational age at delivery, 37.76 ± 2.81 vs. 38.11 ± 2.50 weeks (p = .001), birth weight, 2876 ± 581 vs. 2948 ± 527 g (p = .002) as well as the rate of low-birth weight, 17.1 vs. 12.8% (p = .002). In conclusion, this study provides new insights that alpha-thalassaemia-1 trait has minimal effect on gestational age at delivery and low-birth weight whereas other common adverse pregnancy outcomes are not increased. Impact statement What is already known on this subject: Thalassaemia trait is associated with some degree of anaemia. What the results of this study add: The prevalence of common adverse outcomes such as preterm birth, stillbirth, low Apgar scores and pregnancy-induced hypertension were not significantly different between both the groups, possibly caused by too small sample size to gain enough power. However, the rate of low-birth weight was significantly increased among pregnancy with alpha-thalassaemia-1 trait. What the implications are of these findings for clinical practice and/or further research: The information may be provided for alpha thalassaemia-1 trait mothers and their families. Physicians should guard against the occurrence of adverse pregnancy in these mothers. Prospective control study should be conducted to overcome the limitation of retrospective nature.
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http://dx.doi.org/10.1080/01443615.2017.1313822DOI Listing
November 2017

Left Atrial Myxoma in Pregnancy: Management Strategy Using Minimally Invasive Surgical Approach.

Case Rep Cardiol 2017 16;2017:8510160. Epub 2017 Apr 16.

Cardiology Unit, Department of Internal Medicine, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand.

This case report concerns a young woman who, during her pregnancy, suffered severe mitral regurgitation. It was discovered at the same time that she had a left atrial myxoma. During the early postpartum period she successfully underwent an anterior minithoracotomy to remove the left atrial myxoma in conjunction with repair of the mitral valve. The thoracotomy approach in this specific patient was chosen as it would give a better chance of successful mother-child bonding because the patient would be able to avoid the precautions which would have been necessary following a sternotomy, especially the limitation of her ability to hold her child during the first 4-6 weeks postoperatively.
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http://dx.doi.org/10.1155/2017/8510160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5439244PMC
April 2017

Fetal megaureters caused by involuted bladder after spontaneous resolution of bladder outlet obstruction.

J Clin Ultrasound 2016 Nov 13;44(9):595-596. Epub 2016 Sep 13.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand.

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http://dx.doi.org/10.1002/jcu.22391DOI Listing
November 2016