Predictors and a scoring model for maternal near-miss and maternal death in Southern Thailand: a case-control study.

PURPOSE: To identify predictors and develop a scoring model to predict maternal near-miss (MNM) and maternal mortality. METHODS: A case-control study of 1,420 women delivered between 2014 and 2020 was conducted. Cases were women with MNM or maternal death, controls were women who had uneventful deliveries directly after women in the cases group. Antenatal characteristics and complications were reviewed. Multivariate logistic regression and Akaike information criterion were used to identify predictors and develop a risk score for MNM and maternal mortality. RESULTS: Predictors for MNM and maternal mortality (aOR and score for predictive model) were advanced age (aOR 1.73, 95% CI 1.25-2.39, 1), obesity (aOR 2.03, 95% CI 1.22-3.39, 1), parity ≥ 3 (aOR 1.75, 95% CI 1.27-2.41, 1), history of uterine curettage (aOR 5.13, 95% CI 2.47-10.66, 3), history of postpartum hemorrhage (PPH) (aOR 13.55, 95% CI 1.40-130.99, 5), anemia (aOR 5.53, 95% CI 3.65-8.38, 3), pregestational diabetes (aOR 5.29, 95% CI 1.27-21.99, 3), heart disease (aOR 13.40, 95%CI 4.42-40.61, 5), multiple pregnancy (aOR 5.57, 95% CI 2.00-15.50, 3), placenta previa and/or placenta-accreta spectrum (aOR 48.19, 95% CI 22.75-102.09, 8), gestational hypertension/preeclampsia without severe features (aOR 5.95, 95% CI 2.64-13.45, 4), and with severe features (aOR 16.64, 95% CI 9.17-30.19, 6), preterm delivery <37 weeks (aOR 1.65, 95%CI 1.06-2.58, 1) and < 34 weeks (aOR 2.71, 95% CI 1.59-4.62, 2). A cut-off score of ≥4 gave the highest chance of correctly classified women into high risk group with 74.4% sensitivity and 90.4% specificity. CONCLUSIONS: We identified predictors and proposed a scoring model to predict MNM and maternal mortality with acceptable predictive performance.

Reliability of measurements of facial profile parameters by operators with different levels of experience at 15 to 23 weeks of gestation.

PURPOSE: To compare the reliability of measurements of five fetal facial profile parameters by operators with different levels of experience, at 15 to 23 weeks of gestation in Thai fetuses. METHODS: An observational study was conducted. The inferior facial angle, anteroposterior mandibular diameter, mandible width, maxilla width, and mandible length were measured in 123 normal fetuses, using 2D ultrasonography, by three operators with different levels of experience. Each participant was examined by two operators. Each operator performed three independent measurements for each parameter and was blinded to the results of the other. Reliability of measurement was evaluated using intraclass correlation coefficient. Bland-Altman analysis was used to evaluate agreement. RESULTS: The ability to obtain a mandible length measurement was highest (100%) among the five parameters. Intraobserver variabilities of anteroposterior mandibular diameter, mandible width, maxilla width, and mandible length measurements were excellent for all operators (ICC 0.958-0.986), while those of inferior facial angle measurements were moderate to excellent (ICC 0.560-0.923), depending on the operators' experience. Interobserver variabilities varied between pairs of operators; only two parameters, anteroposterior mandibular diameter and mandible length, showed excellent interobserver variabilities (ICC >0.9), with good agreement. CONCLUSIONS: The mandible length measurement was the best parameter in terms of feasibility and reliability.

Distribution of uterocervical angles in the second trimester of pregnant women at low risk for preterm delivery.

The uterocervical angle (UCA) has recently been studied as a parameter to identify women at risk for spontaneous preterm birth (sPTB). This study aimed to investigate the distribution of UCA values by transvaginal sonography (TVS) in the second trimester of women at low risk for sPTB. TVS was performed in 450 low-risk pregnant women at gestational age (GA) 160/7-240/7 weeks. The UCA distribution by GA was visualised using a scatter plot. The range of UCA values and their relationship with GA were assessed using quantile regression analysis. p < .05 was considered statistically significant. A total of 242 participants with anteflexed uterus, no history of caesarean section and term delivery were analysed. The normal range of UCA (5th and 95th percentiles) was from 63.0 degrees (95% CI, 53.1-72.9) to 148.8 degrees (95% CI, 139.5-158.0) with no significant changes during this GA period (-0.3 degrees per week, p = .757).Impact statementWhat is already known on this subject? Spontaneous preterm birth (sPTB) is a major problem in obstetrics. A screening strategy using history of sPTB and cervical length (CL) measurement is the current standard to identify women at risk for sPTB and provide adequate prevention. However, a third of women who are identified as low risk go on to have sPTB, so a better means needs to be found to more reliably identify women at risk. Various studies have found that a wide uterocervical angle (UCA) was associated with sPTB, and thus the UCA has been proposed as a potential sPTB screening parameter. However, to date there is a lack of prospective studies evaluating this proposal, and no consensus about the proper gestational age to perform UCA measurements to identify women at risk of sPTB.What do the results of this study add? This study reports the distribution of UCA at the GA of 160/7-240/7 weeks of low-risk singleton pregnancy women who delivered at term. The mid-90% values ranged from 63.0 degrees to 148.8 degrees with no significant differences in this GA period.What are the implications of these findings for clinical practice and/or further research? Because of the wide range of UCA values at GA 160/7-240/7 weeks, more studies regarding UCA values in various gestational ages are required to fully understand the trend of UCA values along pregnancy and confirm whether or not the UCA would be a useful parameter for sPTB prediction and if so at what gestational age it would have to be assessed.

Perinatal management for fetal oral epignathus with duplication of the pituitary gland (DPG)-plus syndrome: A case report and literature review.

The prenatal diagnosis of epignathus presents a unique challenge for physicians. Differential diagnosis is usually based on the anatomic location of the tumor. Typical prenatal ultrasound characteristics of epignathus include a mixed solid and cystic lesion with vascularity in the solid component, originating from the hard or soft palate, and it is often associated with other anomalies such as craniofacial clefts or trans-sphenoidal intracranial extension. Herein, we present a case of prenatal diagnosis of epignathus with rare ultrasonographic findings, prenatal management requiring collaborative efforts of a multidisciplinary team, and a well-planned innovative ex utero intrapartum treatment procedure. In addition, this report highlights the evolving postnatal diagnosis of the rare developmental anomaly, duplication of the pituitary gland-plus syndrome, which includes various midline craniofacial, central nervous system, spinal, and endocrine abnormalities.

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.

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.

Reference ranges of fetal mandible measurements: Inferior facial angle, jaw index, mandible width/maxilla width ratio and mandible length in Thai fetuses at 15 to 23 weeks of gestation.

OBJECTIVES: To determine the normal distribution of 1) inferior facial angles (IFA), 2) jaw index, 3) mandible width/maxilla width ratio (MD/MX ratio), and 4) mandible length (ML) in second trimester Thai fetuses. METHODS: A prospective study was performed between April 1 and October 31, 2020, at the Maternal-Fetal Medicine Unit of Songklanagarind Hospital. Transabdominal ultrasonography was performed on Thai singleton pregnant women at 150/7 to 236/7 weeks of gestation to measure IFA, jaw index, MD/MX ratio and ML. All women received standard antenatal care and were followed up until delivery. The exclusion criteria were multifetal gestation, congenital anomaly, chromosomal abnormality, fetal growth restriction, abnormal amniotic fluid volume, suspected abnormality of fetal mandible, maxilla or jaws based on the proposed criteria from previous studies and suspected neonatal structural or genetic abnormalities postnatally. Quantile regression was used to estimate changes in the median, 5th and 95th percentiles of each parameter across gestational ages and to generate formulas for predicting the 5th percentile value for each parameter. RESULTS: The results of 291 women were analyzed. Scatter plots and reference ranges of each parameter were generated. IFA, jaw index and ML values significantly increased, while the MD/MX ratio value significantly decreased, with increasing gestational age. The formulas calculated for predicting the 5th percentile value for each parameter were IFA = 55.12 + 0.045*(GA in days-136) jaw index = 37.272 + 0.01693*(GA in days-136) MD/MX ratio = exp(0.027-0.00110*(GA in days-136)) ML = 20.83 + 0.243*(GA in days-136). CONCLUSIONS: The reference ranges and formulas to calculate the 5th percentile values of mandible parameters in Thai fetuses were developed. TRIAL REGISTRATION: This study has been reviewed and approved by the Thai Clinical Trials Registry with identification number TCTR20210602003.

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.

Uterocervical angle measurement for preterm birth prediction in singleton pregnant women with no history of preterm birth and normal cervical length: A prospective cohort study.

OBJECTIVE: To evaluate the ability of second trimester uterocervical angle (UCA) to predict spontaneous preterm birth (sPTB) in low-risk singleton pregnant women. STUDY DESIGN: Transvaginal sonographies were performed in the second trimester of 450 singleton pregnant women with no history of sPTB and no history of second trimester miscarriage with normal cervical length (CL) who attended antenatal care at Songklanagarind Hospital, a tertiary teaching hospital in southern Thailand. Gestational ages at delivery were recorded then the UCA values were evaluated according to sPTB occurrence. The differences in mean values of UCA between sPTB and full-term groups were evaluated using t-test. A receiver operating characteristics (ROC) curve was used to assess the ability of UCA to predict sPTB. RESULTS: After excluding women with unknown pregnancy outcomes or missing UCA images, the sPTB rate was 34/421 (8.1 %). In women with anteflexed uterus, the mean UCA value was wider in the sPTB group compared to those with term birth if the measurements were performed at GA 19.5-24 weeks (sPTB group, 123.4°vs controls, 104.3°; P = 0.017). The ROC curve showed an area under the curve (AUC) of 0.7045. The optimal UCA cut-off value was ≥110 degrees, which gave a sensitivity of 83.3 % and a specificity of 61.2 %. The positive predictive value (PPV) was 16.7 %, negative predictive value (NPV) 97.5 %, positive likelihood ratio (LR+) 2.2 and negative likelihood ratio (LR-) 0.3. CONCLUSION: The UCA in the second trimester is not a good predictor of sPTB in low risk pregnant women.

Comparison of reliability between uterocervical angle and cervical length measurements by various experienced operators using transvaginal ultrasound.

Purpose: To compare the reliability between uterocervical angle (UCA) and cervical length (CL) measurements by various experienced operators.Methods: Transvaginal ultrasonographies (TVS) were performed in 102 pregnant women between 16°/7-24°/7 gestational weeks by different levels of experienced operators. For both CL and UCA measurements, intraobserver variability was assessed for each operator by examining the range between maximum and minimum measurements in each participant, compared to the mean of all three measurements. Interobserver variabilities were explored using Bland-Altman analysis. Intraclass correlation coefficients were used for both intraobserver and interobserver reliability.Results: For intraobserver variability of the UCA, the ranges between maximum and minimum UCA measurements in operator 1 and 3 were 1.5º-34º and 2º-36º (n = 51), and in operators 2 and 3 were 0º-61º and 1º-25º (n = 51). Intraclass correlation coefficients (ICC) for intraobserver reliability were 0.90 for operator 1, 0.67 for operator 2 and 0.93 for operator 3. For interobserver variability of the UCA, the limits of agreement for mean UCA were -37.53º-38.41º and -36.27º-26.17º, and for maximum UCA were -39.47º-41.38º and -44.24º-22.9º in comparisons between operators 1 and 3, and operator 2 and 3, respectively. Intraclass correlation coefficients for mean UCA were 0.73 and 0.74, and for maximum UCA were 0.71 and 0.67 in comparisons between operators 1 and 3, and operator 2 and 3, respectively.Conclusions: The UCA measurements had a higher intra- and interobserver reliabilities than the CL measurements.