Publications by authors named "Tuangsit Wataganara"

57 Publications

Teaching and training the total percutaneous fetoscopic myelomeningocele repair.

J Perinat Med 2021 Apr 5. Epub 2021 Apr 5.

Hospital Israelita Albert Einstein, Fetal Therapy Program, São Paulo, SP, Brazil.

Skin-over-biocellulose for Antenatal Fetoscopic Repair (SAFER) is a recently developed technique for fully percutaneous fetoscopic repair of myelomeningocele. The formation of a neo-dura mater triggered by the use of a biocellulose patch over the placode obviates the need of primary repair of fetal dura mater, and seems to further improve neurodevelopmental outcome. Insufflation of humidified carbon dioxide into the amniotic cavity requires proper training and a different equipment set from those used in the classic "under-water" fetoscopy. To shorten the learning curve of novice teams, we have developed a structured training course encompassing three critical steps: (1) visiting the proctor center, (2) selection of the first case, and (3) on-site training of the surgical team. Upon the site arrival, there will be: (1) theoretical lecture for all specialists involved in the fetal care, (2) simulation training, and (3) surgical proctoring. Proctor team can take over the surgery if the local team cannot complete. This training course has been successfully used in five different countries: Israel, Chile, Italy, USA and England and all local teams are already performing surgeries solo without any failures or maternal morbidity. Teaching new procedures in fetal medicine is challenging, because of the small number of candidate cases, and the direct relation of good outcomes and the number of cases operated. This proposed training modules may be adopted by other teams that want to embark on this type of novel minimally invasive treatment.
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http://dx.doi.org/10.1515/jpm-2020-0591DOI Listing
April 2021

'Getting to zero' cross transmission of SARS-CoV-2 in obstetric ultrasound during COVID-19 pandemic.

J Perinat Med 2021 03 6;49(3):399-400. Epub 2021 Jan 6.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

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http://dx.doi.org/10.1515/jpm-2020-0579DOI Listing
March 2021

Mentoring a surgical team towards procedural competence in the early learning curve for selective fetoscopic laser photocoagulation.

Singapore Med J 2020 Sep 21. Epub 2020 Sep 21.

Department of Obstetrics and Gynaecology, National University Health System, Singapore.

Introduction: Selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS) is challenging for new surgeons at the start of their learning curve. We described an approach utilising telementoring and team-based training to facilitate rapid attainment of the skills required for safe and efficient practice with a limited caseload.

Methods: We conducted a prospective observational study of SFLP performed by the novice primary surgical team in three stages: under direct on-site supervision from an expert mentor (Group 1), with remote tele-guidance from that mentor (Group 2) and independently (Group 3), at an academic tertiary hospital in Singapore. The primary team undertook regular training on high-fidelity tissue models to accelerate skills acquisition and complement the surgical performance.

Results: Nine patients diagnosed with Stage 2 TTTS were assessed for procedural characteristics, surgical outcomes and perinatal survival following SFLP. There were no significant differences in operative duration, anastomoses ablated, gestational age or birth weight at delivery. The complications observed were: recurrent TTTS (22.2% of pregnancies), twin anaemia polycythaemia sequence (33.3%), preterm prelabour membrane rupture (22.2%) and delivery at < 32 weeks (44.4%). At least one twin was live-born in 88.9% of cases, while postnatal survival to six months of at least one twin occurred in 77.8%.

Conclusion: Systematic mentoring and specialised skills training are useful in aiding new surgeons to negotiate the steep learning curve and achieve good outcomes at the start of a new practice, particularly in the setting of low patient numbers. This is best paired with dedicated model training to achieve and maintain surgical dexterity for this complex procedure.
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http://dx.doi.org/10.11622/smedj.2020137DOI Listing
September 2020

Minimizing cross transmission of SARS-CoV-2 in obstetric ultrasound during COVID-19 pandemic.

J Perinat Med 2020 Nov;48(9):931-942

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated infection (COVID-19) is affecting populations worldwide. This statement may serve as guidance for infection prevention and safe ultrasound practices during the COVID-19 pandemic. Ultrasound examination is a fundamental part of obstetric care, yet it is a potential vector for transmission of SARS-CoV-2. Decontamination methods should always be implemented for ultrasound equipment, especially in the presence of suspected or confirmed COVID-19 cases. There must be workflow policies to protect pregnant women and healthcare providers from nosocomial cross transmission of SARS-CoV-2. Cleaning and disinfecting of equipment must be in accordance with their potential of pathogen transmission. Consider using telemedicine and genetic technologies as an adjunctive of obstetric ultrasound to reduce patient crowding. Patient triage and education of healthcare providers of infection prevention are crucial to minimize cross contamination of SARS-CoV-2 during obstetric ultrasound.
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http://dx.doi.org/10.1515/jpm-2020-0228DOI Listing
November 2020

Clinical Experiences of Intravenous Hydralazine and Labetalol for Acute Treatment of Severe Hypertension in Pregnant Thai Women.

J Clin Pharmacol 2020 12 29;60(12):1662-1670. Epub 2020 Jun 29.

Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

Response to acute treatment of severe hypertension during pregnancy in Asian women was not known. Labor and delivery checklists of Thai women treated with intravenous hydralazine or labetalol for systolic blood pressure (SBP) ≥ 160 or diastolic blood pressure (DBP) ≥ 110 mm Hg from January 2011 to December 2013 were reviewed as parts of an audit. Primary outcome was prompt achievement of SBP 140-150 and DBP 90-100 mm Hg after the first bolus. Secondary outcomes were medication-related undesired effects. The mean ± standard deviation age and prevalence of chronic hypertension in hydralazine (n = 62) versus labetalol (n = 64) groups were 32.5 ± 6 versus 29.9 ± 6.8 years and 50% versus 21.9%, respectively (P < .05). Magnesium sulfate was promptly administered on admission to every woman to prevent seizure. Targeted blood pressure was timely achieved in 41.9% and 67.2% of the hydralazine and labetalol groups, respectively (P < .05). Nonreassuring fetal heart rate occurred in 51.6% and 32.8% of the hydralazine and labetalol groups, respectively (P = .05). The prevalence of cesarean section and Apgar score < 7 were not significantly different (P > .05). Real-life clinical experiences suggested significant advantages of intravenous labetalol over hydralazine in pregnant women with severe hypertension.
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http://dx.doi.org/10.1002/jcph.1685DOI Listing
December 2020

Clinical performance of DNA-based prenatal screening using single-nucleotide polymorphisms approach in Thai women with singleton pregnancy.

Mol Genet Genomic Med 2020 07 24;8(7):e1256. Epub 2020 Apr 24.

Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand.

Background: To review the performance of noninvasive prenatal screening (NIPS) using targeted single-nucleotide polymorphisms (SNPs) approach in mixed-risk Thai women.

Methods: Retrospective analysis of data for detection of trisomy 21 (T21), 18 (T18), 13 (T13), monosomy X (XO), other sex chromosome aneuploidies (SCA), and triploidy/vanishing twins (VT) from a single commercial laboratory.

Results: Mean (±SD) gestational age and maternal weight were 13.2 (±2.1) weeks and 125.7 (±22.4) pounds, respectively (n = 8,572). From 462/8,572 (5.4%) no-calls; 1/462 (0.2%) was uninformative SNPs, and 1/462 chose amniocentesis. Redraw settled 323/460 (70%) samples with low fetal fraction (FF); and 8,434/8,572 (98.4%) were finally reportable, with 131 high risks (1.6%). The median (min-max) FF of reportable (n = 8,434) and unreportable samples (n = 137) samples were 10.5% (2.6-37.9) and 3.8% (1-14.1), respectively (p < .05). Fetal karyotypes were available in 106/131 (80.9%) and 52/138 (37.7%) high risk and repeated no-calls, respectively. The positive predictive values (PPVs) for T21 (n = 47), T18 (n = 15), T13 (n = 7), XO (n = 8), other SCA (n = 7), and triploidy/VT were 94%, 100%, 58.3%, 66.7%, 70%, and 57.1%, respectively. None of repeated no-calls had aneuploidies.

Conclusion: SNP-based NIPS has high PPVs for T21 and T18. Although the proprietary SNPs library is not population-specific, uninformative SNPs are uncommon.
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http://dx.doi.org/10.1002/mgg3.1256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336763PMC
July 2020

Morphology, intrafetal vascular pattern, and umbilical artery Doppler indices of acardiac twins.

Prenat Diagn 2020 07 26;40(8):958-965. Epub 2020 Apr 26.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand.

Background: Twin reversed arterial perfusion (TRAP) sequence consists of acardiac twin (A) paradoxically perfused by pump twin (P) through an umbilical artery (UA). We proposed characterization of acardiac twins with intrafetal vascular pattern (IVP), and assessed its correlation with morphology and UA Doppler indices.

Methods: We prospectively evaluated 21 cases of TRAP sequence. Morphology (acardia vs hemicardia) and IVP (simple vs complex) of acardiac twins were characterized with ultrasound and color Doppler. Twins weight ratio (A/P Wt) and UA Doppler indices of acardiac and pump twins including (1) difference of systolic/diastolic ratio (UA ∆S/D), (2) difference of resistance index (UA ∆RI), and (3) ratio of pulsatility index (UA PI A/P) were calculated.

Results: The median (min, max) gestational age at diagnosis was 18 (11, 27) weeks. Acardia (n = 14) were associated with simple IVP (n = 16) (P < .05). After exclusion of acardia with complex IVP (n = 1), the A/P Wt, UA ∆S/D, UA ∆RI, and UA PI A/P of acardia with simple IVP (n = 13), hemicardia with simple IVP (n = 3), and hemicardia with complex IVP (n = 4) were not significantly different (P > .05).

Conclusions: Most of acardiac twins were acardia with simple IVP. Morphology and IVP of acardiac twins were not associated with UA Doppler indices.
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http://dx.doi.org/10.1002/pd.5710DOI Listing
July 2020

Additional benefits of three-dimensional ultrasound for prenatal assessment of twins.

J Perinat Med 2020 Feb;48(2):102-114

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

Three-dimensional ultrasound (3DUS) may provide additional information for prenatal assessment of twins. It may improve the diagnostic confidence of dating, nuchal translucency (NT) and chorionicity assignment in twin pregnancies. The "virtual 3DUS placentoscopy" can guide selective fetoscopic laser photocoagulation (SFLP) to treat twin-twin transfusion syndrome (TTTS). Volumetric assessment of the dysmorphic acardiac twin with the Virtual Organ Computer-aided Analysis (VOCAL) software is more accurate than the conventional ultrasound measurement. Twin anemia polycythemia (TAP) sequence and selective intrauterine growth restriction (sIUGR) may be clinically monitored with 3DUS placental volume (PV) and power Doppler vascular indices. Congenital anomalies are more common in twins. Evaluation of fetal anomalies with 3DUS could assist perinatal management. The 3DUS power Doppler can provide a better understanding of true and false umbilical cord knots, which are commonly found in monoamniotic (MA) twins. Single demise in monochorionic (MC) twin pregnancies can cause severe neurologic morbidity in the surviving co-twin. Prenatal prediction of brain injury in the surviving co-twin with unremarkable neurosonographic examination is difficult. The 3DUS power Doppler may aid in prenatal detection of subtle abnormal cerebral perfusion. Prenatal assessment of conjoined twins with 3DUS is important if emergency postnatal surgical separation is anticipated. There is no significant additional advantage in using real-time 3DUS to guide prenatal interventions. Assessment of the cervix and pelvic floor during twin pregnancies is enhanced with 3DUS. Due to lack of high-quality studies, routine prenatal 3DUS in twin pregnancies needs to be balanced with risks of excessive ultrasound exposure.
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http://dx.doi.org/10.1515/jpm-2019-0409DOI Listing
February 2020

Simulation-based fetal shunting training.

Prenat Diagn 2019 12 15;39(13):1291-1297. Epub 2019 Nov 15.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

Objectives: To develop a simulation model and assess the learning curve of fetal shunting.

Methods: Three staff and three trainees performed fetal shunting on a model using the fetal bladder stent. The model was evaluated according to various sources of validity evidence. The number of procedures to reach competency was determined by the learning curve-cumulative summation (LC-CUSUM) and CUSUM analysis. The learning and control phases were defined as the periods before and after passing the level of competency, respectively.

Results: The model was validated to be constructive in the educational process. A total of 600 procedures were carried out with an overall success rate of 94.2% and no significant difference between staff and trainees. The average number of procedures to reach competency was 47. Total procedural time decreased after passing the level of competency. Although the trainees required a longer procedural time in the learning phase than the staff did, there was no significant between-group difference in the control phase.

Conclusions: Using this model, the estimated number of procedures to achieve competency was 47, as substantiated by the increased procedural success and reduced procedural time in the control phase. Training on this simulation model may improve technical performance.
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http://dx.doi.org/10.1002/pd.5599DOI Listing
December 2019

Prospective evaluation of screening performance of first-trimester prediction models for preterm preeclampsia in an Asian population.

Am J Obstet Gynecol 2019 12 4;221(6):650.e1-650.e16. Epub 2019 Oct 4.

Chinese University of Hong Kong, Hong Kong SAR, China. Electronic address:

Background: The administration of aspirin <16 weeks gestation to women who are at high risk for preeclampsia has been shown to reduce the rate of preterm preeclampsia by 65%. The traditional approach to identify such women who are at risk is based on risk factors from maternal characteristics, obstetrics, and medical history as recommended by the American College of Obstetricians and Gynecologists and the National Institute for Health and Care Excellence. An alternative approach to screening for preeclampsia has been developed by the Fetal Medicine Foundation. This approach allows the estimation of patient-specific risks of preeclampsia that requires delivery before a specified gestational age with the use of Bayes theorem-based model.

Objective: The purpose of this study was to examine the diagnostic accuracy of the Fetal Medicine Foundation Bayes theorem-based model, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence recommendations for the prediction of preterm preeclampsia at 11-13 weeks gestation in a large Asian population STUDY DESIGN: This was a prospective, nonintervention, multicenter study in 10,935 singleton pregnancies at 11-13 weeks gestation in 11 recruiting centers across 7 regions in Asia between December 2016 and June 2018. Maternal characteristics and medical, obstetric, and drug history were recorded. Mean arterial pressure and uterine artery pulsatility indices were measured according to standardized protocols. Maternal serum placental growth factor concentrations were measured by automated analyzers. The measured values of mean arterial pressure, uterine artery pulsatility index, and placental growth factor were converted into multiples of the median. The Fetal Medicine Foundation Bayes theorem-based model was used for the calculation of patient-specific risk of preeclampsia at <37 weeks gestation (preterm preeclampsia) and at any gestation (all preeclampsia) in each participant. The performance of screening for preterm preeclampsia and all preeclampsia by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, and placental growth factor (triple test) was evaluated with the adjustment of aspirin use. We examined the predictive performance of the model by the use of receiver operating characteristic curve and calibration by measurements of calibration slope and calibration in the large. The detection rate of screening by the Fetal Medicine Foundation Bayes theorem-based model was compared with the model that was derived from the application of American College of Obstetricians and Gynecologists and National Institute for Health and Care Excellence recommendations.

Results: There were 224 women (2.05%) who experienced preeclampsia, which included 73 cases (0.67%) of preterm preeclampsia. In pregnancies with preterm preeclampsia, the mean multiples of the median values of mean arterial pressure and uterine artery pulsatility index were significantly higher (mean arterial pressure, 1.099 vs 1.008 [P<.001]; uterine artery pulsatility index, 1.188 vs 1.063[P=.006]), and the mean placental growth factor multiples of the median was significantly lower (0.760 vs 1.100 [P<.001]) than in women without preeclampsia. The Fetal Medicine Foundation triple test achieved detection rates of 48.2%, 64.0%, 71.8%, and 75.8% at 5%, 10%, 15%, and 20% fixed false-positive rates, respectively, for the prediction of preterm preeclampsia. These were comparable with those of previously published data from the Fetal Medicine Foundation study. Screening that used the American College of Obstetricians and Gynecologists recommendations achieved detection rate of 54.6% at 20.4% false-positive rate. The detection rate with the use of National Institute for Health and Care Excellence guideline was 26.3% at 5.5% false-positive rate.

Conclusion: Based on a large number of women, this study has demonstrated that the Fetal Medicine Foundation Bayes theorem-based model is effective in the prediction of preterm preeclampsia in an Asian population and that this method of screening is superior to the approach recommended by American College of Obstetricians and Gynecologists and the National Institute for Health and Care Excellence. We have also shown that the Fetal Medicine Foundation prediction model can be implemented as part of routine prenatal care through the use of the existing infrastructure of routine prenatal care.
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http://dx.doi.org/10.1016/j.ajog.2019.09.041DOI Listing
December 2019

Comparison of Mannequin Training Satisfaction with a Conventional Box Trainer and a Low-Fidelity Fetoscopic Surgical Simulator for Selective Fetoscopic Laser Photocoagulation.

Fetal Diagn Ther 2020 28;47(1):84-90. Epub 2019 Aug 28.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Background: A low-fidelity fetoscopic surgical simulator (FSS) for training of selective fetoscopic laser photocoagulation (SFLP) was developed.

Objective: To evaluate and compare training satisfaction with an FSS and with a conventional box trainer (BT).

Methods: The BT consisted of a cleaned human placenta attached to the inside of a plastic storage box with a watertight lock cover and an ultrasound-transparent rubber skin. The FSS consisted of the replica of a monochorionic twin placenta attached to the inside of a spherically shaped, ultrasound-transparent phantom. Tap water was used as an ultrasound conduction agent. Evaluation of the mannequin trainings was conducted on 8 junior maternal-fetal medicine (MFM) attending physicians and 22 MFM fellows. Training satisfaction was scored from 0 to 10 on 8 different domains.

Results: The mean satisfaction score (±SD) with the FSS was higher than with the BT in all domains (p < 0.05). The fellows' training satisfaction with the BT was greater than that of the attending physicians in 4 domains: tactile feedback, demonstration of chorionic vessels, feedback on performance, and overall value as learning aid (p < 0.05).

Conclusions: As evaluated by a small group of trainees, our FSS is superior to the BT in mannequin training of SFLP. However, the BT may be more useful for trainees with limited clinical experience.
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http://dx.doi.org/10.1159/000502180DOI Listing
November 2020

Intrapartum prediction of birth weight with a simplified algorithmic approach derived from maternal characteristics.

J Perinat Med 2019 Aug;47(6):643-650

Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkok Noi, Bangkok, Thailand.

Objective To derive and validate a population-specific multivariate approach for birth weight (BW) prediction based on quantitative intrapartum assessment of maternal characteristics by means of an algorithmic method in low-risk women. Methods The derivation part (n = 200) prospectively explored 10 variables to create the best-fit algorithms (70% correct estimates within ±10% of actual BW) for prediction of BW at term; vertex presentation with engagement. The algorithm was then cross validated with samples of unrelated cases (n = 280) to compare the accuracy with the routine abdominal palpation method. Results The best-fit algorithms were parity-specific. The derived simplified algorithms were (1) BW (g) = 100 [(0.42 × symphysis-fundal height (SFH; cm)) + gestational age at delivery (GA; weeks) - 25] in nulliparous, and (2) BW (g) = 100 [(0.42 × SFH (cm)) + GA - 23] in multiparous. Cross validation showed an overall 69.3% accuracy within ±10% of actual BW, which exceeded routine abdominal palpation (60.4%) (P = 0.019). The algorithmic BW prediction was significantly more accurate than routine abdominal palpation in women with the following characteristics: BW 2500-4000 g, multiparous, pre-pregnancy weight <50 kg, current weight <60 kg, height <155 cm, body mass index (BMI) <18.5 kg/m2, cervical dilatation 3-5 cm, station <0, intact membranes, SFH 30-39 cm, maternal abdominal circumference (mAC) <90 cm, mid-upper arm circumference (MUAC) <25 cm and female gender of the neonates (P < 0.05). Conclusion An overall accuracy of term BW prediction by our simplified algorithms exceeded that of routine abdominal palpation.
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http://dx.doi.org/10.1515/jpm-2018-0347DOI Listing
August 2019

Retrospective analysis of 113 consecutive cases of placenta accreta spectrum from a single tertiary care center.

J Matern Fetal Neonatal Med 2020 Oct 29;33(19):3324-3331. Epub 2018 Oct 29.

Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Placenta accreta spectrum (PAS) remains a major cause of maternal morbidity. We sought to assess the characteristics and treatment outcomes of PAS managed at a tertiary care center with high volume of PAS. Electronic medical records of all patients with diagnosis of PAS from June 2010 to October 2016 were reviewed. Details of obstetric backgrounds, predelivery diagnosis, peripartum management, and outcomes were analyzed. One hundred thirteen women with PAS were identified from 50,448 deliveries during the study period. Vaginal delivery, emergency, and elective cesarean section were accomplished in 41.6, 30.1, and 28.3%, respectively. There was no maternal mortality. Approximately 41.6% of women with PAS had peripartum hysterectomy. There was a fair inverse correlation between intraoperative blood loss and gestational weeks at delivery ( = -0.311; =.001), but not gestational weeks at diagnosis ( = .249). Cases with predelivery diagnosis ( = 29) had higher intraoperative blood loss than those diagnosed postdelivery ( = 84) (<.001). Anterior PAS ( = 58) is associated with attachment to previous uterine scar, antepartum bleeding, and intraoperative blood loss compared to posterior PAS ( = 44) (<.05). The PAS patients with previous uterine surgery had the highest chance of peripartum hysterectomy (<.001). Contradictory to previous reports, our data suggest a more severe spectrum of PAS in those with predelivery detection earlier gestational weeks at delivery. Peripartum hysterectomy was highest in anterior PAS that attached to the previous uterine scar.
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http://dx.doi.org/10.1080/14767058.2018.1530757DOI Listing
October 2020

A retrospective review of on-admission factors on attainment of therapeutic serum concentrations of magnesium sulfate in women treated for a diagnosis of preeclampsia.

J Matern Fetal Neonatal Med 2020 Jan 17;33(2):258-266. Epub 2018 Jul 17.

Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

There is little information on the effect of maternal characteristics and on-admission laboratory parameters to the therapeutic serum magnesium sulfate (MgSO) levels in women with preeclampsia (PE). We sought to identify factors that may predict timely attainment of therapeutic serum magnesium levels after intravenous administration for seizure prophylaxis. On-admission factors of 360 women with PE who received intravenous MgSO (4-g loading and 2-g/h maintenance) for seizure prophylaxis were retrospectively reviewed. Parameters of those who attained therapeutic serum concentrations (4.8-8.4 mg/dL) within 2 h (Group A) and those who did not (Group B) were compared. There was no seizure or magnesium toxicity in this cohort. Median (min-max) level of serum magnesium was 4.3 (2.5-8.4) mg/dL. Women in Group A ( = 105) had lower gestational age, body mass index (BMI), and platelets count, higher blood urea nitrogen (BUN), serum creatinine, uric acid, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, prothrombin, and partial thromboplastin times than those in Group B ( = 255) ( < .05). Women with mild PE were less likely to attain therapeutic serum magnesium levels compared with those with severe phenotypes (adjusted OR 23.57, 95% CI 8.20-67.76 versus adjusted OR 14.72, 95% CI 3.56-60.89, respectively;  < .05), which may be explained by their significantly lower serum BUN and uric acid ( < .05). On-admission factors, especially BMI and renal clearance indices, of women with PE may affect timely attainment of therapeutic serum magnesium levels. Validation of its clinical impact requires further study focusing on women with severe PE.
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http://dx.doi.org/10.1080/14767058.2018.1489531DOI Listing
January 2020

Advanced ultrasound for prenatal interventions.

Ultrasonography 2018 Jul 2;37(3):200-210. Epub 2018 May 2.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand.

Ultrasound is an integral part of prenatal interventions. Doppler studies and 3-dimensional ultrasound (3DUS) are frequently used to determine whether fetal surgery is required. The operator's experience remains crucial for reducing procedure-related morbidity. Real-time 3DUS (or 4DUS) can simultaneously display the needle tip in three orthogonal planes, providing reassurance that no fetal parts are in the path. In experienced hands, 4DUS guidance may not be more effective than B-mode, but its value for less-experienced operators remains to be determined. Recent developments in needle, shunt, and video endoscopic technologies may compliment the use of image-guided in utero procedures. Future developments of higher-dimensional transducers and image software may improve the utility of ultrasound for invasive obstetric interventions.
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http://dx.doi.org/10.14366/usg.18011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044223PMC
July 2018

Time and temperature dependence of radiofrequency ablation in the human placenta.

Prenat Diagn 2018 06 22;38(7):504-510. Epub 2018 May 22.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

Objective: The objective of the study is to compare radiofrequency (RF) effects on fresh placentae with varying levels of sustained time (Ts) and degrees of target temperature (°t).

Method: A total of 108 pieces of fresh placentae were coagulated with a 2-cm RF needle at 60 W in an organ bath. The vertical and horizontal diameters (Vd, Hd) of tissue coagulation visualized by ultrasound were measured. The impacts of 12 different Ts-°t combinations on the ablation size ascertained on pathological examination (Vd , Hd ) were compared using 2-way ANOVA. The agreement between sonographic and pathological findings was assessed using Bland-Altman analysis.

Results: Considerable changes in the Vd and Hd were associated with increasing the Ts and °t. The impact of RF on tissue coagulation was greatest when the °t was set at 100°C, with further destruction as the Ts progressed to 7 minutes of exposure. The ablation size estimated by ultrasound exhibited an overestimation by an average of 5.65% and 21.02% for Vd and Hd, respectively.

Conclusion: A prolonged Ts at a higher °t contributes to progressive placental tissue destruction by RF, with maximum destruction at 100°C for 7 minutes in an ex vivo nonperfused placenta. Tissue injury that is apparent on ultrasound may extend beyond pathological damage.
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http://dx.doi.org/10.1002/pd.5276DOI Listing
June 2018

Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators.

J Vis Exp 2018 03 21(133). Epub 2018 Mar 21.

Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore;

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome (TTTS), but is technically challenging and can lead to significant complications. Acquiring and maintaining the necessary surgical skills require consistent practice, a critical caseload, and time. Training on realistic surgical simulators can potentially shorten this steep learning curve and enables several proceduralists to acquire procedure-specific skills simultaneously. Here we describe realistic simulators designed to allow the user familiarity with the equipment and specific steps required in the surgical treatment of TTTS, including fetoscopic handling, approaches to anterior and posterior placenta, recognition of anastomoses, and efficient coagulation of vessels. We describe the skills that are especially important in conducting placental laser coagulation that the surgeon can practice on the model and apply in a clinical case. These models can be adapted easily depending on the availability of materials and require standard fetoscopy equipment. Such training systems are complementary to traditional surgical apprenticeships and can be useful aids for fetal medicine units that provide this clinical service.
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http://dx.doi.org/10.3791/57328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5933233PMC
March 2018

Prediction and prevention of pre-eclampsia in Asian subpopulation.

J Obstet Gynaecol Res 2018 May 14;44(5):813-830. Epub 2018 Feb 14.

Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

The benefit of the early administration of aspirin to reduce preterm pre-eclampsia among screened positive European women from multivariate algorithmic approach (ASPRE trial) has opened an intense debate on the feasibility of universal screening. This review aims to assess the new perspectives in the combined screening of pre-eclampsia in the first trimester of pregnancy and the chances for prevention using low-dose aspirin with special emphasis on the particularities of the Asian population. PubMed, CENTRAL and Embase databases were searched from inception until 15 November 2017 using combinations of the search terms: preeclampsia, Asian, prenatal screening, early prediction, ultrasonography, pregnancy, biomarker, mean arterial pressure, soluble fms-like tyrosine kinase-1, placental growth factor, pregnancy-associated plasma protein-A and pulsatility index. This is not a systematic review or meta-analysis, so the risk of bias of the selected published articles and heterogeneity among the studies need to be considered. The prevalence of pre-eclampsia and serum levels of biochemical markers in Asian are different from Caucasian women; hence, Asian ethnicity needs to be corrected for in the algorithmic assessment of multiple variables to improve the screening performance. Aspirin prophylaxis may still be viable in Asian women, but resource implication needs to be considered. Asian ethnicity should be taken into account before implementing pre-eclampsia screening strategies in the region. The variables included can be mixed and matched to achieve an optimal performance that is appropriate for economical restriction in individual countries.
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http://dx.doi.org/10.1111/jog.13599DOI Listing
May 2018

Serum-free placental growth factor isoform 1 at 11-13-week gestation: effects of maternal factors, mean arterial pressure, placental volume, and uterine artery pulsatility index.

J Matern Fetal Neonatal Med 2018 Nov 25;31(21):2813-2819. Epub 2017 Jul 25.

a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital , Mahidol University , Bangkok , Thailand.

Introduction: To define the effects of maternal factors, mean arterial pressure (MAP), placental volume (PV), and uterine artery Doppler pulsatility index (UtAPI) to serum level of free form of placental growth factor isoform 1 (free PlGF-1) measured with a novel automated assay.

Methods: We enrolled 200 Thai women singleton pregnancy from 11 to 13 weeks gestation with low prior risk maternal factors (age, parity, tobacco use, assisted reproductive technology, and body mass index). MAP was measured. Serum-free PlGF-1, PV, and UtAPI were measured with a new assay, transabdominal three-dimensional, and color Doppler ultrasounds, respectively. Effects of these variables to serum-free PlGF-1 level were assessed.

Results: Data from 195 eligible subjects showed an elevation of serum-free PlGF-1 from 11, 12, and 13 weeks (mean ± SD; 36.89 ± 24.92, 38.71 ± 17.44, and 49.68 ± 22.30 pg/mL, respectively (p < .05)). Serum-free PlGF-1 level showed positive correlation with PV (r = 0.290, p < .01), and negative correlation with right and left UtAPI (r = -0.717, p = .05 and r = -0.221, p < .05, respectively). PV showed negative correlation with right and left UtAPI (r = -0.243, p < .05 and r = -0.372, p < .05, respectively). Serum-free PlGF-1 level had no significant correlation with maternal factors or MAP (p > .05). There was no preeclampsia at <34 weeks in 161 subjects (82.6%) with known pregnancy outcomes.

Conclusions: There was modest correlation of serum-free PlGF-1, PV, and UtAPI, but not with maternal factors or MAP. Adjustment of serum-free PlGF-1 in early preeclampsia screening algorithm should be considered.
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http://dx.doi.org/10.1080/14767058.2017.1357168DOI Listing
November 2018

Circulating soluble fms-like tyrosine kinase-1 and placental growth factor from 10 to 40 weeks' pregnancy in normotensive women.

J Perinat Med 2017 Oct;45(7):895-901

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Introduction: Circulating soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are potential markers for preeclampsia. The objective was to construct and analyse the reference ranges of serum levels of sFlt-1 and PlGF throughout the course of pregnancy in low-risk Thai pregnant women.

Methods: We enrolled 110 low-risk, Thai women singleton pregnancy from 10 to 40 gestational weeks. Serum concentrations of sFlt-1 and PlGF were measured with an automated assay. The reference ranges of serum levels of sFlt-1, PlGF and sFlt-1/PlGF ratio were constructed and assessed for possible correlations with gestational age, maternal factors [age, parity, tobacco use, artificial reproductive technologies (ARTS) and body mass index (BMI)], and pregnancy outcomes (gestational age at delivery, development of preeclampsia, neonatal birth weight and placental weight).

Results: None of the subjects developed preeclampsia. Serum sFlt-1 concentrations significantly elevated from 20 to 40 gestational weeks (P=0.003). Significant elevation and dropping of serum PlGF levels and sFlt-1/PlGF ratios were observed at 10 to 29 and 30 to 40 weeks of gestation, respectively (P<0.001). There was an inversed correlation between serum PlGF levels at 20 to 29 gestational weeks and neonatal birth weights (r=-0.48, P<0.05). There were no associations between serum levels of sFlt-1, PlGF, or sFlt-1/PlGF ratios and maternal BMI, gestational age at delivery, or placental weight (P>0.05). Effects from parity, smoking and ARTS were inconclusive.

Conclusion: Robust change of serum PlGF levels suggests for its broader clinical application compared to sFlt-1. Prediction of preeclampsia using serum analytes may be gestational period specific.
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http://dx.doi.org/10.1515/jpm-2017-0093DOI Listing
October 2017

Three-dimensional ultrasound for prenatal assessment of conjoined twins: additional advantages?

J Perinat Med 2017 Aug;45(6):667-691

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Conjoined twins are a rare, but serious, complication of monozygotic twins. Early prenatal diagnosis of conjoined twins is increasingly made with transvaginal ultrasound and color Doppler studies. Most prenatally diagnosed conjoined twins are terminated due to the high perinatal mortality, but advancement in pediatric surgery has allowed for successful postnatal separation in a small number of cases, and some parents may consider this option over termination of pregnancy. It is important to get a detailed prenatal ultrasound for the site and extent of fusion for an accurate categorization. Three-dimensional ultrasound (3DUS) provides images that can facilitate counselling for the parents. Additional information that impacts on diagnosis, prognostication, and perinatal management of conjoined twins could be obtained from selective use of 3DUS, particularly those with atypical fetal union. Most of the proposed additional benefits of 3DUS are based on case reports. Magnetic resonance imaging (MRI) has been increasingly used for the purpose of identifying intricate organ sharing. Because of the rarity of this condition, and the heterogeneity of fetal fusion, added benefits of either 3DUS or MRI for prenatal diagnosis and perinatal management of conjoined twins have not been demonstrated by well-conducted clinical trials. This article aims to review clinical application of various 3DUS display modes in prenatal assessment of conjoined twins, focusing on their potential additional benefits, risks and misuses. 3DUS may help detecting additional findings that are not possible with 2DUS, but, it has not been scientifically shown to improve the survival rate of the twins or reduce maternal morbidity.
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http://dx.doi.org/10.1515/jpm-2016-0381DOI Listing
August 2017

Establishing Prenatal Surgery for Myelomeningocele in Asia: The Singapore Consensus.

Fetal Diagn Ther 2017 21;41(3):161-178. Epub 2017 Feb 21.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand.

Objectives: The Management of Myelomeningocele Study (MOMS Trial) has inspired many fetal therapy centers (FTCs) to offer open fetal surgery for myelomeningocele (MMC). This is an initial effort to create a candidate model that can be applicable to many parts of Asia.

Material And Methods: A limited selection of specialists from 4 established FTCs in Thailand, Hong Kong, India, and Singapore met for a round table discussion. Experts from Children's Hospital of Philadelphia (CHOP) involved in the Trial moderated the session. The practice suggestions in this statement were from a targeted literature review and expert opinion.

Results: A high prevalence of MMC in Asia supports an effort to adopt the procedure, but only in established FTCs with good maternal and neonatal ancillary supports. The falling incidence of MMCs may affect case volume and maintenance of skill. A regional approach was recommended. Fetal benefits have to be weighed against maternal risks, with a consideration of recent outcome data from the endoscopic approach. Responsible FTCs need standardized diagnosis and management, with their long-term outcome data available for an audit.

Conclusions: It is envisaged that the information presented by this multidisciplinary team would be useful for FTCs in Asia or elsewhere that plan to establish more advanced fetal care in the future.
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http://dx.doi.org/10.1159/000452218DOI Listing
February 2018

Cesarean section: the pediatricians' views.

J Matern Fetal Neonatal Med 2017 Sep 16;30(17):2081-2085. Epub 2016 Oct 16.

c Department of Obstetrics and Gynecology , Division of Maternal Fetal Medicine, Faculty of Medicine Siriraj Hospital , Bangkok , Thailand.

Cesarean sections (CS) have greatly increased and many reasons are often evoked. Safer anesthetics and surgical procedures have rendered CS a popular choice for both professionals and mothers alike. CS on maternal request, for nonmedical reasons, is the subject of scientific, legal and ethical dispute. We shall address the CS issues, primarily, from the pediatrician's point of view. The immediate neonatal problems of the more mature neonate are well recognized. For preterm birth, contradictory results on mid- and long-term outcomes do not confirm the earlier reports on neonatal advantages of CS over vaginal delivery; therefore, their mode of delivery should be based on individual circumstances. The intestinal flora of neonates delivered by CS is often deprived of the normal colonization by maternal vulvovaginal and rectal flora. Whether this adverse microbiome will play a role in the late development of multiple morbidities in children and adults is an interesting possibility open to consideration. The consequences of unnecessary CS demands a reflection for all the involved parties and the decision to perform a CS shall, then, be based on the net clinical benefit to all: the mother, the child and the future adult.
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http://dx.doi.org/10.1080/14767058.2016.1237496DOI Listing
September 2017

Circulating free soluble fms-like tyrosine kinase-1 during late first trimester in relation with placental volume as a surrogate for trophoblastic production: a physiology study in low-risk cohort.

J Matern Fetal Neonatal Med 2017 Aug 5;30(16):1976-1983. Epub 2017 Feb 5.

a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital , Bangkok , Thailand.

Background: Data on first-trimester circulating soluble fms-like tyrosine kinase-1 (sFlt-1) and ischemic placental disease is limited and conflicting. This study aimed to study its physiology in relation to trophoblastic mass as the source of production.

Methods: Low-risk (representing normal placentation) women from 11 0/7 to 13 6/7 weeks' gestation were prospectively enrolled. Selective measurement of serum free sFlt-1 using a new automated assay from 100 eligible subjects was analyzed with gestational age, maternal weight, fetal crown-rump length (CRL), and mean uterine artery Doppler pulsatility index (PI). Placental volume (surrogate for trophoblastic mass) was estimated using 3-dimensional ultrasound and was assessed for its association with serum free sFlt-1.

Results: There was no significant association between serum free sFlt-1 and placental volume in either arithmetic (r = 0.053, p = 0.600), logarithmic (r = 0.005, p = 0.963), or quartile (p = 0.703) scale. There was a significant negative correlation between free sFlt-1 level and maternal weight (r=-0.213, p = 0.033). No significant correlation was found between free sFlt-1 level and gestational age (r = 0.007, p = 0.947), CRL (r = 0.027, p = 0.788), and uterine artery Doppler mean PI (r = 0.020, p = 0.828).

Conclusions: Lack of correlation between circulating free sFlt-1 level and placental volume suggests that trophoblasts are not its major source during first trimester with presumably physiologic placentation.
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http://dx.doi.org/10.1080/14767058.2016.1235697DOI Listing
August 2017

Rapid initiation of fetal therapy services with a system of learner-centred training under proctorship: the National University Hospital (Singapore) experience.

Singapore Med J 2017 Jun 21;58(6):311-320. Epub 2016 Jul 21.

Department of Obstetrics and Gynaecology, National University Health System, Singapore.

Introduction: Management of complicated monochorionic twins and certain intrauterine structural anomalies is a pressing challenge in communities that still lack advanced fetal therapy. We describe our efforts to rapidly initiate selective feticide using radiofrequency ablation (RFA) and selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS), and present the latter as a potential model for aspiring fetal therapy units.

Methods: Five pregnancies with fetal complications were identified for RFA. Three pregnancies with Stage II TTTS were selected for SFLP. While RFA techniques utilising ultrasonography skills were quickly mastered, SFLP required stepwise technical learning with an overseas-based proctor, who provided real-time hands-off supervision.

Results: All co-twins were live-born following selective feticide; one singleton pregnancy was lost. Fetoscopy techniques were learned in a stepwise manner and procedures were performed by a novice team of surgeons under proctorship. Dichorionisation was completed in only one patient. Five of six twins were live-born near term. One pregnancy developed twin anaemia-polycythaemia sequence, while another was complicated by co-twin demise.

Discussion: Proctor-supervised directed learning facilitated the rapid provision of basic fetal therapy services by our unit. While traditional apprenticeship is important for building individual expertise, this system is complementary and may benefit other small units committed to providing these services.
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http://dx.doi.org/10.11622/smedj.2016127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474526PMC
June 2017

Fetal magnetic resonance imaging and ultrasound.

J Perinat Med 2016 Jul;44(5):533-42

Magnetic resonance imaging (MRI) has been increasingly adopted in obstetrics practice in the past three decades. MRI aids prenatal ultrasound and improves diagnostic accuracy for selected maternal and fetal conditions. However, it should be considered only when high-quality ultrasound cannot provide certain information that affects the counseling, prenatal intervention, pregnancy course, and delivery plan. Major indications of fetal MRI include, but are not restricted to, morbidly adherent placenta, selected cases of fetal brain anomalies, thoracic lesions (especially in severe congenital diaphragmatic hernia), and soft tissue tumors at head and neck regions of the fetus. For fetal anatomy assessment, a 1.5-Tesla machine with a fast T2-weighted single-shot technique is recommended for image requisition of common fetal abnormalities. Individual judgment needs to be applied when considering usage of a 3-Tesla machine. Gadolinium MRI contrast is not recommended during pregnancy. MRI should be avoided in the first half of pregnancy due to small fetal structures and motion artifacts. Assessment of fetal cerebral cortex can be achieved with MRI in the third trimester. MRI is a viable research tool for noninvasive interrogation of the fetus and the placenta.
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http://dx.doi.org/10.1515/jpm-2015-0226DOI Listing
July 2016

Delivery modes in case of fetal malformations.

J Perinat Med 2017 Apr;45(3):273-279

1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw.

An estimated 276,000 babies die within 4 weeks of birth every year, worldwide, from congenital anomalies. Better quality ultrasound screening can increase the detection of these fetal malformations in the prenatal period. Prenatal counseling for the pregnant woman and her family, regarding the nature of the disease and prognosis is necessary. Options for management in prenatal, perinatal, intrapartum, neonatal, and childhood periods need to be thoroughly discussed, so that the family can make an informed decision. A multidisciplinary approach is usually needed once a decision has been made to optimize fetal outcome, to plan for the timing and location as well as the mode of delivery. In most of the cases, vaginal delivery can be attempted. An elective cesarean delivery should be reserved for maternal concern of dystocia, certain fetal conditions that cesarean delivery will optimize perinatal outcome, or if the parents have a psychosocial determination to have a live-born infant.
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http://dx.doi.org/10.1515/jpm-2015-0364DOI Listing
April 2017

Maternal and neonatal outcomes in women with severe pre-eclampsia undergoing cesarean section: a 10-year retrospective study from a single tertiary care center: anesthetic point of view.

J Matern Fetal Neonatal Med 2016 Dec 29;29(24):4096-100. Epub 2016 Mar 29.

b Department of Obstetrics and Gynecology , Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand.

Objective: This study is aiming to determine an actual incidence and characteristics of complications in cesarean section for severe pre-eclampsia (PE) by analysis of a large cohort from a single tertiary care center according to two choices of anesthesia.

Methods: Electronic medical records of pregnant women complicated with severe PE delivered by cesarean section from January 2002 to December 2011 were retrospectively reviewed. Medical records of their corresponding neonates were also identified and reviewed.

Results: A total of 701 women and 740 neonates (28 twin pairs) were identified. Anesthetic techniques were spinal anesthesia (SA) (88%) and general anesthesia (GA) (12%). Total maternal and neonatal deaths were 0.3% and 1.2%, respectively. Patients in GA group had a higher incidence of coagulopathy, immediate postpartum hemorrhage, intensive care unit admission, renal failure, respiratory complications, and death (p < 0.05). Neonates born from women in GA group had a higher incidence of lower birth weight, birth asphyxia, prematurity, neonatal intensive care admission, respiratory complications, and death (p < 0.05).

Conclusion: Spinal anesthesia can be safely administered to severely pre-eclamptic parturients undergoing cesarean section. General anesthesia is associated with more untoward outcomes, as it has been chosen in patients with more severity of the disease.
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http://dx.doi.org/10.3109/14767058.2016.1159674DOI Listing
December 2016

Controversial ultrasound findings in mid trimester pregnancy. Evidence based approach.

J Perinat Med 2016 Mar;44(2):131-7

Mid trimester fetal anatomy scan is a fundamental part of routine antenatal care. Some U/S soft markers or controversial U/S signs are seen during the scan and create some confusion regarding their relation to fetal chromosomal abnormalities. Example of these signs: echogenic focus in the heart, echogenic bowel, renal pyelectasis, ventriculomegaly, polydactely, club foot, choroid plexus cyst, single umbilical artery. We are presenting an evidence based approach from the literature for management of these controversial U/S signs.
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http://dx.doi.org/10.1515/jpm-2015-0223DOI Listing
March 2016

Ultrasound in Africa: what can really be done?

J Perinat Med 2016 Mar;44(2):119-23

Today we are living in a globalized world in which information on what is happening in one part of the world is easily communicated to other parts of the world. This happens thanks to advancement in science and technology. One area where technology has made the greatest impact is heath care provision. Ultrasound technology is now playing a critical role in health care provision particularly in Obstetrics and Gynaecology. This has significantly assisted in provision of quality health care to pregnant women and their unborn infants and in reducing maternal and neonatal morbidity and mortality in the developed world. Africa the continent with greatest health care challenges and with the highest maternal and neonatal mortalities is yet to fully utilize this important technology. The need for this technology is great as the conditions requiring its application abound. The effective application of Ultrasound however faces serious challenges in Africa. To successfully entrench Ultrasound in quality Obstetrics and Gynaecology care various approaches must be adopted to overcome the challenges. The aim of this paper is to identify the benefits and the challenges inimical to the application Ultrasound in Obstetrics and Gynecology in Africa. It also examines what needs to be done to achieve better application of Ultrasound in Obstetrics and Gynecology.
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http://dx.doi.org/10.1515/jpm-2015-0224DOI Listing
March 2016