Reliability of the sonographic evaluation for cervical length and elastography with pelvic parameters in term pregnancy by experienced operators with varying levels of experience.

OBJECTIVE: To assess the reliability of sonographic measurements of six cervical and pelvic parameters by three sonographers with varying levels of experience. METHODS: A cross-sectional study was conducted in pregnant women with a gestational age of ≥39 weeks. Each pregnant woman was examined by two sonographers with different levels of experience. Six parameters were measured: cervical length (CL), cervical strain elastography (extrinsic type), posterior cervical angle (PCA), fetal head-to-perineum distance (FHPD), fetal head-to-pubic symphysis distance (FHSD), and angle of progression (AOP). Intra- and interobserver reliabilities were assessed using the intraclass correlation coefficient with a 95% confidence interval. Pearson pairwise correlation coefficients were used to analyze the correlation between the parameter values. RESULTS: In all, 66 pregnant women were enrolled in this study. We found excellent intraobserver reliability for measurements of CL, PCA, FHPD, FHSD, and AOP and good-to-excellent intraobserver reliability for cervical strain values in the cross-sectional view of the endocervix in the internal os area and cross-sectional view of the entire cervix in the internal os area. Interobserver reliability was excellent for all pelvic parameters, except for the FHPD. Strain values were moderate to excellent in the area of the internal os. A significant negative correlation between CL and strain values at the internal os was observed. CONCLUSIONS: Pelvic parameters, except for FHPD, have excellent intra- and interobserver reliabilities. The high reproducibility of CL and cervical strain elastography at the internal os level, with a negative correlation between these two parameters, may play an important role in predicting successful induction of labor.

Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country.

OBJECTIVE: The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand. METHODS: This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016. RESULTS: Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001). CONCLUSION: The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.

An in-depth analysis of maternal mortality in a quaternary university hospital in Southern Thailand: A 16-year experience.

OBJECTIVE: To perform an in-depth analysis and evaluate the causes of maternal deaths in a university hospital in Southern Thailand. METHODS: A retrospective descriptive study was conducted. Medical records of all women who died during pregnancy or within 42 days of termination of pregnancy at Songklanagarind Hospital from January 2006 to December 2021 were reviewed. RESULTS: There were 51 910 live births during the 16-year period and 68 maternal deaths (31 of direct cause, 36 of indirect cause, and one of unknown cause). The maternal mortality ratio was 131 per 100 000 live births. There was a decreasing trend in the maternal mortality ratio, especially during the past 4 years. The leading causes of death were cardiac disease (n = 17), hypertensive disorders in pregnancy (n = 9), and postpartum hemorrhage (n = 7). The most common indirect causes of maternal death were cardiac disease, hematologic disease, and dengue hemorrhagic fever. There was a decreasing trend in indirect to direct deaths ratios during three study periods. Ratios in 2006 to 2010, 2011 to 2015, and 2016 to 2021 were 1.6, 1.4, and 0.5, respectively. CONCLUSIONS: The three leading causes of death were cardiac disease, hypertensive disorders in pregnancy, and postpartum hemorrhage. Improvements in the quality of obstetric care at all hospital levels are required.

Predictors of adverse perinatal outcomes in fetal growth restriction using a combination of maternal clinical factors and simple ultrasound parameters.

OBJECTIVE: To identify predictors of adverse perinatal outcomes in pregnancies with fetal growth restriction (FGR) using a combination of maternal clinical factors and simple ultrasound parameters and develop a risk-scoring model for predicting adverse perinatal outcomes. METHODS: A retrospective study of 370 non-anomalous singleton pregnancies with FGR was conducted. Multivariate logistic regression analysis was used to identify factors associated with adverse perinatal outcomes; P < 0.05 was considered statistically significant. The discriminative ability was measured with the area under the receiver operating characteristic curve (AUC). A weighted score for each predictor was calculated. RESULTS: Adverse perinatal outcomes occurred in 165/370 (44.6%) cases. There were eight predictive factors, including a history of pregnancy-induced hypertension (PIH) (score = 1), chronic hypertension (score = 3), PIH (score = 2), maternal weight gain less than 8 kg (score = 1), early-onset FGR (score = 1), estimated fetal weight less than 5th percentile (score = 2), amniotic fluid index less than 5 cm (score = 3), and abnormal umbilical artery Doppler (score = 2), with total scores ranging from 0 to 15. AUC for the eight-item predictive model was 0.799 (95% confidence interval 0.753-0.845). CONCLUSION: A combination of maternal clinical factors and simple ultrasound parameters showed acceptable predictive performance for adverse perinatal outcomes in FGR.

Comparison of the predictive ability for perinatal acidemia in neonates between the NICHD 3-tier FHR system combined with clinical risk factors and the fetal reserve index.

BACKGROUND: Electronic fetal monitoring alone is a poor screening test for detecting fetuses at risk of acidemia or asphyxia. We aimed to evaluation of predictive ability of the National Institute of Child Health and Human Development (NICHD) 3-tier fetal heart rate (FHR) system combined with the maternal, obstetric, and fetal risk factors for predicting perinatal acidemia, and to compare this with the predictive of the NICHD 3-tier system alone, and the Fetal Reserve Index (FRI). METHODS: A retrospective cohort study was conducted among singleton term pregnant women. Fetal heart rate tracings of the last two hours before delivery were interpreted into the NICHD 3-tier FHR classification system by two experienced obstetricians. Demographic data were compared using the χ2 or Fisher's exact test for categorical variables and the Student's t test for continuous variables. Logistic regression model was used to identify factors associated with perinatal acidemia in neonates. The Odds ratios (OR) and probabilities with 95% confidence intervals (CI) were calculated. RESULTS: A total of 674 pregnant women were enrolled in this study. Using the NICHD 3-tier FHR categories I and II combined with the selected risk factors (AUC 0.62) had a better performance for perinatal acidemia prediction than the NICHD 3-tier FHR alone (AUC 0.55) and the FRI (AUC 0.52), (P<0.01). Improvement of predicting perinatal acidemia was found when NICHD category I was combined with preeclampsia or arrest disorders of labor (OR 3.2, 95% CI 1.30‒7.82) or combined with abnormal second stage of labor (OR 6.19, 95% CI 1.07‒36.06) and when NICHD category II was combined with meconium-stained amniotic fluid (OR 4.73, 95% CI 2.17‒10.31). CONCLUSIONS: The NICHD 3-tier FHR categories I or II combined with selected risk factors can improve the predictive ability of perinatal acidemia in neonates compared with the NICHD 3-tier system alone or the FRI.

Secondary postpartum hemorrhage: Incidence, etiologies, and clinical courses in the setting of a high cesarean delivery rate.

OBJECTIVES: To evaluate the incidence, etiologies, and clinical outcomes of secondary postpartum hemorrhage in a hospital with a high cesarean section rate and to compare the etiologies of secondary postpartum hemorrhage following cesarean delivery versus vaginal delivery. MATERIALS AND METHODS: This retrospective study included 123 women with secondary postpartum hemorrhage who were treated at a tertiary-level hospital between January 2004 and June 2018. Descriptive statistics and the chi-square test were used for data analysis. RESULTS: The incidence of secondary postpartum hemorrhage was 0.21%. The median onset of bleeding was 12 days after delivery. Fifty-two percent of the deliveries were by cesarean section. The most common etiology of secondary postpartum hemorrhage was endometritis (67.5%), followed by retained placental tissue (21.1%). Women who delivered by cesarean section had a higher rate of endometritis (80.0% vs 53.4%) and a lower rate of retained placental tissue (10.8% vs. 32.8%) than those who delivered vaginally. Surgical intervention included uterine evacuation in 29.3% and hysterectomy in 8.1% of the patients. Five percent of women were treated by embolization. CONCLUSIONS: Endometritis was the most common cause of secondary postpartum hemorrhage. Women who delivered by cesarean section were less likely to have retained placental tissue but were at higher risk for endometritis and uterine pseudoaneurysm than those who delivered vaginally.

Persistent reversed end-diastolic flow of the middle cerebral artery: A rare and concerning finding.

Fetal reversed end-diastolic flow of the middle cerebral artery is a rare ultrasound finding associated with pathological fetal conditions. Herein, we report the case of a fetus presenting with reversed end-diastolic flow of the middle cerebral artery caused by extensive intracranial hemorrhage from maternal warfarin therapy. From a literature review, we present the clinical findings, etiologies, and outcomes of cases with fetal reversed end-diastolic flow of the middle cerebral artery.

Etiology and outcome of non-immune hydrops fetalis in relation to gestational age at diagnosis and intrauterine treatment.

OBJECTIVE: To determine the etiology and outcome of non-immune hydrops fetalis (NIHF) according to gestational age at diagnosis and intrauterine treatment. STUDY DESIGN: A total of 122 NIHF cases were included. Medical records and ultrasonographic images were reviewed. The etiology, outcome, and intrauterine treatment were assessed. RESULTS: The etiology was determined in 100 cases, and Hb Bart's disease was the most common. Two cases each of homozygous Southeast Asian ovalocytosis (SAO) and hemoglobin Constant Spring (Hb CS) were found. NIHF diagnosed in early gestation (<24 weeks) had a higher rate of chromosomal abnormalities and fetal demise. Intrauterine treatment was given in 18 cases, and 50% had successful live births. CONCLUSION: Hb Bart's disease was the most common cause of NIHF. SAO and Hb CS were associated with hydrops. NIHF in gestational age <24 weeks was associated with chromosomal abnormalities and fetal demise. Intrauterine treatment should be offered in selected cases.

Ethnic-specific reference range affects the efficacy of quadruple test as a universal screening for Down syndrome in a developing country.

OBJECTIVE: To evaluate the efficacy of the quadruple test for potential use as a Thai national policy for Down syndrome (DS) screening and establish an accurate equation for risk estimation of Down syndrome based on gestational age, weight and the ethnic-specific reference range of our population. METHODS: A prospective study was conducted on singleton pregnancies at 14 to 21 weeks of gestation to evaluate the efficacy of quadruple DS screening using the automatically calculated Western European descent factor (WF) in our population and the impact of screening using a specific Thai ethnic factor as well as to establish an equation for the risk estimation of DS based on gestational age, weight and a local Thai ethnic factor to correct for the impact of ethnic factor on the screening efficacy. RESULTS: Of a total of 5,515 women, 12 cases of DS and 8 cases of other aneuploidies were found. The detection rate, false positive rate and specificity were 75.0%, 9.1% and 90.9%, respectively, by automatic calculation with the widely used WF; the screening efficacy was lower when used in Asian populations than in other studies. The best-fitted regression equation of serum quadruple screening of AFP, free ß-hCG, uE3 and inhibin A was established by adjustment for gestational age (GA) in days, maternal weight and our Thai-specific ethnic reference range which was created for this study. Calculations with our Thai-specific ethnic model gave a better detection rate of 83.3%, a false positive rate of 9.6% and specificity of 90.4%. CONCLUSION: The serum quadruple test had a lower detection rate than expected when the risk estimation was based on the WF reference range. The serum quadruple test using WF had significantly different levels when corrected with our ethnic-specific factor. Using our local ethnic specific model could increase the detection rate of DS screening in Thailand with a minimal increase in false positive rates. Our findings indicate that DS screening should be adjusted with an appropriate individual ethnic factor when used for national screening.

The relationship between intrapartum cerebroplacental ratio and adverse perinatal outcomes in term fetuses.

OBJECTIVES: The cerebroplacental ratio (CPR) Doppler has been proposed as an instrument for predicting adverse perinatal outcomes particularly during antepartum period. Abnormal CPR is associated with non-reassuring fetal status requiring operative delivery, low Apgar score and neonatal complications. The aim of this study was to assess the role of CPR Doppler in the labor triage suite, so as to identify fetuses at risk for non-reassuring status as well as other adverse perinatal outcomes. METHODS: This was a prospective cohort study of term pregnancies who attended the labor room during the latent phase of labor. Both fetal Middle Cerebral Artery Pulsatility Index (MCA-PI) and Umbilical Artery Pulsatility Index (UA-PI) were measured and these values were converted to CPR values. Non-reassuring fetal status requiring operative delivery and other adverse perinatal outcomes were compared between women with normal and abnormal CPR values. Accuracy of CPR for predicting non-reassuring fetal status and abnormal fetal heart rate patterns were calculated. RESULTS: A total of 384 women were recruited. Lower CPR values were observed in women who underwent operative delivery for non-reassuring fetal status. However, when dividing women into normal and abnormal CPR groups, using 3 different cut-off values, the rate of non-reassuring fetal status was not significantly different between the groups. There was a significantly higher rate of abnormal fetal heart rate monitoring in fetuses with CPR < 5th percentile and CPR < 1. CPR appeared to have a low positive predictive value (PPV) for predicting non-reassuring fetal heart rate patterns, however, the negative predictive value (NPV) was high. CONCLUSIONS: In term fetuses, lower CPR is associated with non-reassuring fetal status. CPR measurement during the intrapartum period with currently available CPR cut-off values is not a good predictor for adverse perinatal outcomes, with the exception of abnormal fetal heart rate patterns. However, the high NPV may be used to stratify pregnant women who may benefit from continuous fetal heart rate monitoring.

Agreement of three interpretation systems of intrapartum foetal heart rate monitoring by different levels of physicians.

A prospective study was conducted in centre in Southern Thailand, to evaluate agreement in EFM interpretation among various physicians in order to find out the most practical system for daily use. We found strong agreement of very normal FHR tracings among the FIGO, NICHD 3-tier and 5-tier systems. The NICHD 3-tier was more compatible with the FIGO system than 5-tier system. Overall inter-observer agreement was moderate for the NICHD 3-tier system while inter-observer agreement of 5-tier system was fair also the intra-observer agreement was higher in the NICHD 3-tier system. So the 3-tier systems are more suitable than the 5-tier system in general obstetric practice. Impact statement What is already known on this subject: The 3-tier and 5-tier systems were widely used in general obstetrics practice. What the results of this study add: The inter- and intra-observer agreement of NICHD 3-tier system was higher than the 5-tier system. What the implications are of these findings for clinical practice and/or further research: The 3-tier systems were more suitable than the 5-tier systems in general obstetrics practice.