Comparing three cardiothoracic ratio measurement techniques and creating multivariable scoring system to predict Bart's hydrops fetalis at 17-22 weeks' gestation.

To assess the diagnostic performance of three cardiothoracic (CT) ratio techniques, including diameter, circumference, and area, for predicting hemoglobin (Hb) Bart's disease between 17 and 22 weeks' gestation, and to create a multivariable scoring system using multiple ultrasound markers. Before invasive testing, three CT ratio techniques and other ultrasound markers were obtained in 151 singleton pregnancies at risk of Hb Bart's disease. CT diameter ratio demonstrated the highest sensitivity among the other techniques. Significant predictors included CT diameter ratio > 0.5, middle cerebral artery-peak systolic velocity (MCA-PSV) > 1.5 multiples of the median, and placental thickness > 3 cm. MCA-PSV exhibited the highest sensitivity (97.8%) in predicting affected fetuses. A multivariable scoring achieved excellent sensitivity (100%) and specificity (84.9%) for disease prediction. CT diameter ratio exhibited slightly outperforming the other techniques. Increased MCA-PSV was the most valuable ultrasound marker. Multivariable scoring surpassed single-parameter analysis in predictive capabilities.

Decision-to-Delivery Interval After Implementation of a Specific Protocol for Emergency Cesarean Delivery Because of Category III Fetal Heart Rate Tracings.

OBJECTIVE: To assess the frequency of emergency cesarean deliveries with decision-to-delivery intervals (DDIs) of less than 30 minutes after implementation of a code blue protocol following National Institute of Child Health and Human Development (NICHD) category III fetal heart rate (FHR) tracings. The secondary aim was to compare differences in pregnancy outcomes for deliveries completed before and after the 30-minute threshold. METHODS: All women undergoing a code blue emergency cesarean delivery between July 2015 and December 2021 were included. Information from electronic medical records, including baseline demographics, clinical characteristics, and pregnancy outcomes were retrospectively reviewed. RESULTS: Among 254 code blue cesarean deliveries, 246 (96.9%) had a DDI of ≤30 minutes. The median DDI was 17 (14.3-20.0) minutes. No significant differences in adverse maternal and neonatal outcomes were detected between deliveries with DDIs greater than and less than 30 minutes. The incidence of stillbirth was higher in the >30 minute-DDI group than in the ≤30 minute-DDI group (12.5% vs. 2%; P = 0.176). CONCLUSIONS: After implementation of a code blue protocol for emergency cesarean delivery, a DDI within 30 minutes was achieved in 97% of cases with category III FHR tracings. The incidence of stillbirth was dramatically higher in the >30 minutes-DDI group. We encourage all obstetric units to consider every factor that could reduce the DDI by developing specific, local protocols.

Prenatal predisposing factors associated with neonatal lupus erythematosus.

OBJECTIVES: To identify the prenatal predisposing factors related to neonatal lupus erythematosus (NLE). MATERIALS AND METHODS: A retrospective case-control study was made of 131 pregnant women with positive anti-Ro or anti-La autoantibodies and known neonatal outcomes between January 2002 and December 2019 at Siriraj Hospital, Bangkok, Thailand. There were 101 unaffected neonates and 30 NLE cases confirmed postnatally. Demographic and clinical data of the mothers and neonates with and without NLE were statistically compared. RESULTS: NLE was diagnosed in 30 out of 131 cases. A multivariate analysis identified the following significant factors for NLE: maternal anti-La antibodies (odds ratio (OR), 3.591; p = 0.030); and maternal treatment with either hydroxychloroquine (OR, 0.082; p = 0.001) or prednisolone (OR, 0.136; p = 0.017). Of the significant variables examined in the multivariate analysis models, high levels of maternal anti-La antibodies were found to be the strongest predictor of noncardiac NLE (OR, 4.558; p = 0.032), while a female baby was significantly higher in pregnancies complicated by cardiac NLE (OR, 5.374; p = 0.046). Hydroxychloroquine still provided a protective effect for both cardiac and noncardiac NLE (p = 0.039 and 0.032, respectively). CONCLUSIONS: The maternal anti-La antibodies were a beneficial predictor for NLE, especially as their high titers were influentially associated with noncardiac features. A female fetus seemed to present an increased risk for developing a congenital heart block. Nevertheless, the treatment with hydroxychloroquine during the pregnancies demonstrated a potentially protective factor against both cardiac and noncardiac manifestations.

Nomograms of fetal cardiothoracic ratio from 17 to 37 weeks' gestation as assessed by three different measurement techniques and their correlation with gestational age.

OBJECTIVE: To create nomograms for fetal cardiothoracic (CT) ratio as assessed by three different 2-dimensional sonographic measurements, including CT diameter, circumference, and area ratios, in Thai fetuses with a gestational age (GA) of 17-37 weeks, and to evaluate both their correlation with GA or biparietal diameter (BPD) and variability among the three measurement methods. METHODS: Two-dimensional sonographic measurements of fetal CT ratio in 4-chamber view were assessed by three different measurement techniques. The 95% reference intervals and Z-scores of all measurement methods based on GA or BPD were constructed. Intraclass correlation coefficients (ICC) for the reproducibility of each technique were compared. RESULTS: A total of 511 uncomplicated singleton pregnancies were included. The fetal CT ratio values by all measurement techniques gradually and smoothly increased with increasing GA and BPD. The fetal CT circumference ratio showed the least correlation with both GA and BPD. The intraobserver and interobserver reliability coefficients of all techniques demonstrated almost excellent agreement (all ICCs at least 0.87). CONCLUSION: Reference intervals and Z-score reference ranges were developed using three different techniques for fetal CT ratio with a GA of 17-37 weeks. These nomograms are a simple and reliable screening tool for identifying abnormal fetal heart size.

A 10-Year Retrospective Review of Prenatal Applications, Current Challenges and Future Prospects of Three-Dimensional Sonoangiography.

Realistic reconstruction of angioarchitecture within the morphological landmark with three-dimensional sonoangiography (three-dimensional power Doppler; 3D PD) may augment standard prenatal ultrasound and Doppler assessments. This study aimed to (a) present a technical overview, (b) determine additional advantages, (c) identify current challenges, and (d) predict trajectories of 3D PD for prenatal assessments. PubMed and Scopus databases for the last decade were searched. Although 307 publications addressed our objectives, their heterogeneity was too broad for statistical analyses. Important findings are therefore presented in descriptive format and supplemented with the authors' 3D PD images. Acquisition, analysis, and display techniques need to be personalized to improve the quality of flow-volume data. While 3D PD indices of the first-trimester placenta may improve the prediction of preeclampsia, research is needed to standardize the measurement protocol. In highly experienced hands, the unique 3D PD findings improve the diagnostic accuracy of placenta accreta spectrum. A lack of quality assurance is the central challenge to incorporating 3D PD in prenatal care. Machine learning may broaden clinical translations of prenatal 3D PD. Due to its operator dependency, 3D PD has low reproducibility. Until standardization and quality assurance protocols are established, its use as a stand-alone clinical or research tool cannot be recommended.

Seroprevalence of Bordetella pertussis antibodies and anti-pertussis antibody response after a single dose of reduced-antigen combined diphtheria, tetanus, and acellular pertussis vaccine (Tdap) in pregnant Thai women.

BACKGROUND: Maternal immunization with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) has recently been implemented to prevent infant pertussis. Tdap is still not routinely recommended in Thailand, and there are limited data to support or challenge this strategy. OBJECTIVES: The primary aim was to determine the seroprevalence of anti-pertussis toxin antibodies (anti-PT IgG) among pregnant Thai women. The secondary aims were to evaluate antibodies response after Tdap vaccination between seronegative and seropositive mothers and to compare the different antibody titers at delivery among seropositive mothers who received Tdap to those who received tetanus-diphtheria vaccine (Td). METHODS: This randomized clinical trial was conducted during April 2018 to April 2019 at Siriraj Hospital, Bangkok, Thailand. A total of 129 pregnant women were included. Paired blood samples for anti-PT IgG levels were obtained during the first antenatal visit and at delivery. A baseline cut-off value of <5 IU/ml indicated seronegativity. There were 29 exclusions from the original 129 enrollment. All seronegative participants (n = 69) received Tdap, while the seropositive group were randomized 1:1 to receive either Tdap (n = 18) or Td (n = 13) during 27-36 weeks' gestation. The antibody levels from both sera were compared between groups. RESULTS: The seroprevalence of maternal anti-PT IgG was 33.3% (43/129). There was no significant difference in the increment of antibody levels after Tdap vaccination between the seronegative and seropositive groups (30.2 vs. 42 IU/ml; p = 0.183). Among seropositive groups, all Tdap recipients had increased antibody titers at delivery, while all Td recipients showed waning of immunity throughout gestation. (42 IU/ml vs. -7.4 IU/ml; p < 0.001). CONCLUSION: Most pregnant Thai women have seronegative against pertussis. Most seropositive mothers had initial low antibody titers and their immunity significantly decreased before delivery. Our findings highlight the need for universal pertussis immunization in pregnancy regardless of individual baseline immunity.

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

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.

Decision-to-delivery interval in emergency cesarean delivery in tertiary care hospital in Thailand.

OBJECTIVE: To determine the decision-to-delivery interval (DDI) in emergency cesarean delivery and associated factors. METHODS: A total of 431 pregnant women who were indicated for emergency cesarean delivery were included. Clinical information and timing of process after decision until delivery and pregnancy outcomes were evaluated. RESULTS: Mean age was 30 years, and 59.4% were nulliparous. Mean gestational age at delivery was 37.9 weeks. The decision was made during normal office hour in 33.2%. Median decision-to-operating room interval, decision-to-incision interval, and DDIs were 45, 70, and 82 minutes, respectively. Only 3.5% of patients had DDI ≤30 minutes, while 52.0% had DDI >75 minutes. During after office hours, every time interval was significantly shorter and 4.9% had DDI ≤30 minutes compared to 0.7% in normal office hours (P=0.001). Compared to other indications, time intervals were significantly shorter in those with non-reassuring fetal heart rate (FHR), and DDI ≤30 minutes was achieved in 18.8% vs. 0.8% (P<0.001). Shortest DDI was observed among those with non-reassuring FHR during after office hours. Neonatal outcomes were comparable between different DDIs. CONCLUSION: Only 3.5% of emergency cesarean delivery had a DDI ≤30 minutes (median 82 minutes). Significant shorter time intervals were observed in those with non-reassuring FHR during after office hours.

Decision-to-delivery interval in pregnant women with intrapartum non-reassuring fetal heart rate patterns.

RATIONALE, AIMS AND OBJECTIVES: It has been proposed that delivery should be accomplished within 30 minutes after diagnosis of fetal distress. The objective of this study was to determine the decision-to-delivery interval (DDI) in emergency caesarean delivery for non-reassuring fetal heart rate (FHR). METHODS: A total of 272 term, singleton pregnant women who underwent an emergency caesarean section for non-reassuring FHR were included. Patient characteristics and clinical data were reviewed. The timing of the decision-to-delivery process was reviewed. RESULTS: The mean age was 28.7 years; the mean gestational age at delivery was 38.4 weeks; and 93.7% were in FHR category 2. The decision for emergency caesarean delivery was made during normal office hours in 31.6%. Median time for decision-to-operating room, decision-to-incision and decision-to-delivery was 42.3, 48.5 and 56 minutes, respectively. Only 6.6% of women had a DDI of <30 minutes, whereas 30.5% had a DDI of >75 minutes. Significantly shorter intervals were observed for every endpoint among patients in FHR category 3, and they were significantly more likely to deliver within 30 minutes than were those in FHR category 2 (41.2% vs. 4.3%, P < 0.001). Similar results were observed for cases that occurred during normal and after hours. Neonatal outcomes were comparable among different DDI categories. CONCLUSION: Only 6.6% of women with non-reassuring FHR achieved the 30-minute goal for caesarean delivery (median 56 minutes). Better performance was observed among patients in FHR category 3 regardless of diagnosis time, with 41.2% of these patients having a DDI of <30 minutes.