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1 Tongsong T, Wanapirak C, Siriwattanapa P, Pongsuthirak P. Sonographic evaluation of clinical suspicion for ectopic pregnancy. Asia Oceania J Obstet Gynaecol 1992 Jun;18(2):115-20.

Abstract: Analysis of transabdominal ultrasonic findings of 167 patients presented with clinical suspicion of extrauterine pregnancies (EUP), all with measurable serum HCG, has been undertaken. Patients were divided into two main groups, namely those with demonstrable typical intrauterine gestational sac (46.7%), and those without (53.3%). This later group of patients, i.e., without intrauterine sac, was further subdivided into four other groups depending on whether or not they have adnexal mass and/or fluid in cul-de-sac. In this first subgroup of patients (21 cases), without any demonstrable mass or fluid, a positive predictive value (PPV) for EUP of only 28.6% was obtained. With ultrasound showing fluid but no mass, the PPV was 55.6%, while those with both mass and fluid, the PPV as high as 95.7% was possible. Characterization of the adnexal mass or cul-de-sac findings among those with empty uterus may further improve PPV. The results of this study indicates that ultrasonic examination can help to provide a more correct diagnosis in the investigation of EUP. EUP can be easily excluded, in the great majority of cases, with sonographic visualization of intrauterine pregnancy. In the case of empty uterus with no mass or fluid, patients should be closely followed up with HCG titer and ultrasonic examination. For those with empty uterus with fluid, culdocentesis may be indicated; whereas in the case of empty uterus with mass, laparoscopy should be considered as additional investigative procedures

2 Tongsong T, Wanapirak C, Jesadapornchai S, Tathayathikom E. Fetal binocular distance as a predictor of menstrual age. Int J Gynaecol Obstet 1992 Jun;38(2):87-91.

Abstract: The relation between fetal binocular distance and menstrual age was determined by cross-sectional analysis of 555 normal fetuses (14-40 weeks) using real-time sonography. Mathematical modelling of the data demonstrated that the binocular distance growth curve, similar to the biparietal diameter, is nonlinear. Predicted binocular values at various points in gestation were comparable to the results of other investigators. Predicted menstrual age in weeks for specific binocular distance measurements in millimeters were calculated and are reported in tabular form. The variability (+/- 2 SD) associated with predicting menstrual age from binocular distance is +/- 14 days between 14 and 27 weeks, but between 29 and 40 weeks the variability is +/- 24 days. Binocular distance can be used as an adjunct in estimating menstrual age and may be useful in the diagnosis of some abnormalities, e.g. hypotelorism or hypertelorism

3 Pongsuthirak P, Tongsong T, Srisomboon J. Rupture of a noncommunicating rudimentary uterine horn pregnancy with a combined intrauterine pregnancy. Int J Gynaecol Obstet 1993 May;41(2):185-7.

No abstract available

4 Tongsong T, Simaraks S, Sirivatanapa P, Sudasna J, Wanapirak C, Kunavikatikul C, et al. Study of intrauterine growth from birthweight at Maharaj Nakhon Chiang Mai Hospital. J Med Assoc Thai 1993 Sep;76(9):482-6.

Abstract: Intrauterine growth curve and normogram for newborns at Maharaj Nakhon Chiang Mai Hospital are constructed. Birthweight at various gestational weeks of deliveries were determined within 24 hrs after birth. All 1,311 Thai pregnant women selected, fitted the criteria of inclusion deliveries at Maharaj Nakhon Chiang Mai Hospital from May 1983 to April 1991 (8 yrs). Their gestational age distribution was between 28 wks to 42 wks. Clinical status at birth was satisfactory. There were no obstetric or medical complications during pregnancy. Mean birthweight and standard deviation of newborns for each gestational age at delivery were calculated and presented in tabular and graphic form. Mean birthweight for 40 wks of gestation was 3.144 +/- 382 g. In addition, normogram of 10th, 50th, 90th percentile ranks of birthweight for each gestational age was constructed. These values may be useful as baseline data of intrauterine growth curve to evaluate fetal growth in our population

5 Tongsong T, Pongsatha S. Transvaginal sonographic features in diagnosis of ectopic pregnancy. Int J Gynaecol Obstet 1993 Dec;43(3):277-83.

Abstract: OBJECTIVES: To evaluate the efficacy of pelvic transvaginal sonography (TVS) in patients with clinical presentation of extrauterine pregnancy (EUP) and positive beta-hCG. METHODS: Three hundred and twenty-one patients with clinical suspicion of EUP were subjected to TVS at Maharaj Nakorn Chiang Mai Hospital. The criteria for entry to the study were (1) clinical suspicion of EUP, with stable hemodynamic condition, (2) correct final diagnosis must be known, (3) serum beta-hCG must be determined, by assay sensitivity of 10 mIU/ml (4) TVS was examined by the same sonographer. Frequencies of each TVS feature in EUP and IUP were determined. Among the patients with positive beta-hCG and empty uterus, the accuracy indices of various TVS features in predicting EUP were calculated. RESULTS: Patients with measurable beta-hCG were divided into two main groups, namely those with demonstrable typical intrauterine gestational sac (52/201), and those without (149/201). None of the subjects in the first group had EUP. Among the latter group of patients, with empty uterus, TVS signs could be further divided into 3 subgroups: (1) Direct sign, clear evidence of extrauterine gestational sac. This group had positive predictive value 100%, but low sensitivity (26%). (2) Indirect signs of EUP, i.e. adnexal mass and pelvic fluid, especially echogenic fluid. Echogenic fluid, adnexal mass and their combination had positive predictive value for EUP 92.3%, 92.8% and 95.0%, respectively. Complex adnexal mass gave the highest sensitivity (85.7%). (3) No positive sign on TVS, which is very unlikely to be EUP, and was found in only 2.8% of EUP. CONCLUSIONS: The results of this study indicate that TVS can help to facilitate the diagnosis of EUP in most cases. EUP can be confidently diagnosed by demonstration of adnexal ring, and excluded by visualization of intrauterine sac. Complex adnexal mass and echogenic fluid are extremely helpful in making the diagnosis

6 Tongsong T, Wanapirak C, Takapijitra A. Ultrasonic measurement of the fetal head to abdominal circumference ratio in normal pregnancy. J Med Assoc Thai 1993 Mar;76(3):153-8.

Abstract: The relation between fetal HC/AC ratio and menstrual age was determined from 14th-40th weeks gestations by analysis of 1,211 measurements examined with real-time ultrasound scanner Aloka 630, 650. The mean HC/AC ratio with +/- 2SD and percentile ranks were determined and presented in both graphic and tabular forms. The mean ratio was 1.207 at 14 week’s but decreased slowly until 30 week’s when the ratio was 1.110 thereafter there was a rather sharp fall in the mean ratio 1.010 at 36 weeks and 0.967 at 40 weeks and then the variability decreases. Interestingly, HC/AC ratio value for each gestational week in this study was not so different from those of western studies. We hope that the value from this large series is important baseline data for evaluation of fetal growth in our population and is more appropriate for application with Thai women than caucasian data

7 Tongsong T, Srisomboon J. Amniotic fluid volume as a predictor of fetal distress in intrauterine growth retardation. Int J Gynaecol Obstet 1993 Feb;40(2):131-4.

Abstract: OBJECTIVE: To determine the efficacy of sonographic assessment of amniotic fluid volume (AFV) in predicting intrapartum fetal distress in pregnancies with intrauterine growth retardation (IUGR) compared with the nonstress test (NST). METHOD: A prospective study of 242 pregnancies with IUGR who underwent antepartum assessment of AFV and NST with intrapartum continuous FHR monitoring was conducted and analyzed. RESULT: AFV was a reliable predictor of intrapartum fetal distress with sensitivity, specificity, positive and negative predictive values of 84.0%, 83.41%, 36.84% and 97.84%, respectively. The efficacy of AFV was comparable with that of the NST. CONCLUSION: Sonographic assessment of AFV is an effective predictor of intrapartum fetal distress in pregnancies with IUGR

8 Tongsong T, Wanapirak C, Pongsuthirak P. Ultrasonic fetal transverse trunk diameter in normal northern Thai women. J Med Assoc Thai 1993 Feb;76(2):79-84.

Abstract: Fetal transverse trunk diameter (TTD) were measured by two obstetric sonographers, using Aloka model SSD 630 and 650. The measurements were performed on 1,009 occasions in 235 women during normal pregnancies between the 14th and 40th weeks (age range 17-37 years) (4.5 measurements per pregnancy, on average). The relation between TTD and menstrual age was determined and mathematical modeling of the data demonstrated that the linear quadratic function was optimal (r2 = 0.973). The most fitted regression equation was obtained by regression analysis. 1.) TTD = -2.69055 + 0.38326 G.A – 0.00140137 GA2 2.) GA = 7.222585 + 2.82632 TTD + 0.02605 TTD2. Interestingly, TTD value for each gestational week in this study is not so different from that of the European data. Predicted TTD values for a given gestational week were determined and presented in tabular form. The values from this study may be important baseline data for evaluation of fetal growth in our population

9 Tongsong T, Srisomboon J. Amniotic fluid volume as a predictor of fetal distress in postterm pregnancy. Int J Gynaecol Obstet 1993 Mar;40(3):213-7.

Abstract: OBJECTIVE: To determine the efficacy of amniotic fluid volume (AFV) assessment in predicting intrapartum fetal distress in postterm pregnancy compared with the conventional nonstress test (NST). METHOD: A prospective study of 252 postterm patients who underwent antepartum assessment of AFV and NST with intrapartum continuous FHR monitoring was conducted and subjected to analysis. RESULT: AFV was significantly more accurate in predicting intrapartum fetal distress than the NST with sensitivity, specificity, positive and negative predictive values of 72.73%, 90.87%, 26.67% and 98.65%, respectively. CONCLUSION: AFV assessment was an effective method in predicting fetal distress in postterm pregnancy

10 Tongsong T, Wanapirak C, Srisomboon J, Sirichotiyakul S, Polsrisuthikul T, Pongsatha S. Transvaginal ultrasound in threatened abortions with empty gestational sacs. Int J Gynaecol Obstet 1994 Sep;46(3):297-301.

Abstract: OBJECTIVE: To determine whether transvaginal ultrasound criteria alone can distinguish viable from non-viable gestational sacs at a single examination. METHOD: A prospective descriptive study was undertaken and analysis performed on 211 pregnancies complicated by threatened abortion and empty gestation sacs diagnosed by transvaginal ultrasound. The main outcome measure was the final diagnosis of viable or non-viable gestation on subsequent transvaginal sonography. RESULTS: The study shows that a single transvaginal ultrasound examination is useful in differentiating viable from non-viable gestation sacs. The mean sac diameter (MSD) was found to be the most useful criterion for determining non-viability. An MSD of > or = 17 mm that lacked an embryo and an MSD of > or = 13 mm without visible yolk sac were reliable predictors of non-viable gestation sacs at a single examination with 100% specificity and 100% positive predictive value. An MSD > or = 13 mm without visible yolk sac was the most sensitive criterion. Using MSD criteria, 73% of non-viable gestations could be reliably identified without any false-positive diagnoses. Deformed shape, low position and thin decidual reaction are strong indicators of non-viable gestations but are not 100% accurate. There is still a significant proportion of empty sacs, where no accurate distinction between viable and non-viable can be made according to one criterion at a single examination and in these cases serial examinations should be carried out before any active management is advocated. CONCLUSION: In most cases, transvaginal sonographic criteria alone can distinguish viable from non-viable empty gestational sacs at a single examination

11 Tongsong T, Pongnarisorn C, Mahanuphap P. Use of vaginosonographic measurements of endometrial thickness in the identification of abnormal endometrium in peri- and postmenopausal bleeding. J Clin Ultrasound 1994 Oct;22(8):479-82.

Abstract: One hundred and seventy seven women with peri- and postmenopausal bleeding were subjected to vaginosonographic examination followed by thorough pathological examination of the uterine curetting samples. A mean endometrial thickness (double layer) of 13.2 +/- 3.6 mm and 8.2 +/- 4.8 mm were found in those with and without histological abnormalities, respectively. Endometrial thickness of less than 7 mm, however, was found to be predictive of normal endometrium (100% sensitivity, 46% specificity) and can, therefore, be used to separate those who require diagnostic curettage from those who do not. These findings suggest that this relatively simple, noninvasive procedure can be used as a screening test for patients with peri- or postmenopausal bleeding

12 Tongsong T, Wanapirak C, Piyamongkol W. Prenatal diagnosis of twin reversed arterial perfusion (TRAP) syndrome. J Clin Ultrasound 1994 Jul;22(6):405-7.

No abstract available

13 Tongsong T, Piyamongkol W. Comparison of the acoustic stimulation test with nonstress test. A randomized, controlled clinical trial. J Reprod Med 1994 Jan;39(1):17-20.

Abstract: The nonstress test (NST) is a helpful adjunct in the management of high-risk pregnancies. It has high predictability and a low false-negative rate but unfortunately has fairly high false-positive results. Attempts have been made to find a suitable stimulant to help decrease nonreactive results as well as to shorten the duration of testing: the recently introduced fetal acoustic stimulation test (AST) may have such attributes. This prospective, randomized clinical trial was carried out to assess the new test. A total of 1,300 individual tests were performed on high-risk pregnancies. Cases were randomized to receive either the AST or NST. All tracings were interpreted blindly by an independent perinatologist. The incidence of nonreactive tests was 6.8% in the AST group and 13.8% in the NST group (P < .001). There was a significant reduction in the time needed for a reactive test to occur. It can be concluded, therefore, that AST offers a greater advantage over NST by lowering both the incidence of nonreactive tests and testing time, thereby resulting in less of a need for the contraction stress test and biophysical profile

14 Tongsong T, Piyamongkol W, Sreshthaputra O. Accuracy of ultrasonic fetal weight estimation: a comparison of three equations employed for estimating fetal weight. J Med Assoc Thai 1994 Jul;77(7):373-7.

Abstract: This study was conducted to compare the accuracy in estimating the fetal weight of three equations with ultrasound in 104 pregnant women. Equation I log 10 (EFW) = 1.85479 + 0.09008 (BPD) + 0.02466 (AC) Equation II log 10 (EFW) = 2.24784 + 0.09122 (FL) + 0.002798 (BPD x AC) -0.0010112 (AC x FL) Equation III log 10 (EFW) = -1.7492 + 0.166 (BPD) + 0.046 (AC) – 2.646 (AC x BPD)/1000 There was no difference in either the overall mean errors of 95 per cent CI among the three equations, except in the least error for equation II in these with birthweight of less than 2,000 grams and for equation III in these with birthweight of more than 3,000 grams. It was concluded, therefore, that predictions based on either equation I or II developed from local Thai population, which have an almost identical overall mean error when compared with one another or with Shepard’s (i.e. equation III), can be used in our clinical

15 Lallemant M, Le CS, McIntosh K, Brennan T, Gelber R, Lee TH, et al. AZT trial in Thailand. Science 1995 Nov 10;270(5238):899-900.

No abstract available

16 Tongsong T, Srisomboon J, Wanapirak C, Sirichotiyakul S, Pongsatha S, Polsrisuthikul T. Pregnancy outcome of threatened abortion with demonstrable fetal cardiac activity: a cohort study. J Obstet Gynaecol 1995 Aug;21(4):331-5.

Abstract: Pregnancy with visible fetal heart beat complicated by first trimester threatened abortion had significant increased risk of subsequent spontaneous abortion compared with normal pregnancy. OBJECTIVE: To compare pregnancy outcomes in cases complicated by first trimester threatened abortion with those that were not. METHODS: Prospective cohort study of 255 cases of first trimester threatened abortions but with visible heart beat and 265 other normal pregnancies. RESULTS: Spontaneous abortion rates of 5.5% (with relative abortal risk of 2.91) was found for study group, compared to 1.88% for controls (p < 0.05). Preterm delivery was also higher, but was not statistically significant. CONCLUSIONS: First trimester bleeding with visible fetal heart beat appears to associate significantly with higher subsequent spontaneous abortion rate than those without

17 Tongsong T, Kamprapanth P, Srisomboon J, Wanapirak C, Piyamongkol W, Sirichotiyakul S. Single transvaginal sonographic measurement of cervical length early in the third trimester as a predictor of preterm delivery. Obstet Gynecol 1995 Aug;86(2):184-7.

Abstract: OBJECTIVE: To evaluate the accuracy of a single sonographic measurement of cervical length early in the third trimester as a predictor of preterm delivery. METHODS: A total of 771 women attending the antenatal clinic at the Maharaj Nakorn Chiang Mai Hospital between January 1, 1990, and November 30, 1993, with singleton gestations, cervical competence, accurate dates of last menstrual period, and gestational ages between 28-30 weeks, were recruited into the study. Forty-one were excluded, ten because of induced preterm delivery, 24 because of measurement problems, and seven because they were lost to follow-up. We analyzed the remaining 730 women. RESULTS: Ninety-one (12.5%) women ended with preterm births and the remaining 639 (87.5%) delivered at term. The mean (+/- standard deviation) cervical lengths of the term and preterm groups were statistically significantly different at 37 +/- 5 and 34 +/- 6 mm, respectively (P < .001). The likelihood ratio of cervical length at various cutoff points was calculated. The appropriate cutoff point based on the receiver operating characteristic curve (35 mm) was associated with a significantly increased likelihood of preterm delivery (20 versus 7%) and was detected in two-thirds of preterm births. This cutoff point gave a sensitivity and specificity of 65.9 +/- 5.1% (95% confidence interval [CI]) and 62.4 +/- 5.2% (95% CI), respectively. CONCLUSION: A single transvaginal sonographic measurement of cervical length at 28-30 gestational weeks can be used to predict the risk of preterm delivery, using a cutoff point of 35 mm, but its cost-effectiveness should be assessed further

18 Tongsong T, Sirichotiyakul S, Siriangkul S. Prenatal diagnosis of congenital hypophosphatasia. J Clin Ultrasound 1995 Jan;23(1):52-5.

No abstract available

19 Tongsong T, Srisomboon J, Sudasna J. Prenatal diagnosis of Langer-Saldino achondrogenesis. J Clin Ultrasound 1995 Jan;23(1):56-8.

No abstract available

20 Manorot M, Tongsong T, Khettglang T. A comparison of serum magnesium sulfate levels in pregnant women with severe preeclampsia between intravenous and intramuscular magnesium sulfate regimens: a randomized controlled trial. J Med Assoc Thai 1996 Feb;79(2):76-82.

Abstract: The frequency of blood samples that achieved therapeutic level was lower in the group of maintenance with intravenous regimen than the intramuscular regimen significantly at 15, 30, 60, 120 and 240 minutes after loading dose. The mean level of serum magnesium sulfate in the intravenous group was significantly lower than intramuscular group. This study supported to choose the maintenance by intramuscular regimen. However, further study is required to analyse the effect of higher level of magnesium sulfate in Thai patients

21 Srisomboon J, Tongsong T, Tosiri V. Preinduction cervical ripening with intravaginal prostaglandin E1 methyl analogue misoprostol: a randomized controlled trial. J Obstet Gynaecol Res 1996 Apr;22(2):119-24.

Abstract: OBJECTIVE: To evaluate the efficacy of intravaginal prostaglandin E1 methyl analogue misoprostol in cervical ripening in patients with unfavorable cervix (Bishop score < 4) requiring labor induction. METHOD: A randomized controlled clinical trial of 62 women in the third trimester with various indications for induction of labor were randomly allocated to receive either 100 micrograms misoprostol inserted vaginally (32) or placebo similarly applied (30). Transvaginal sonography was performed to measure the cervical length before and 12 hrs after insertion. RESULTS: The mean change in cervical length and Bishop score was significantly greater in the misoprostol group (24 mm and score 8) compared with in the placebo group (2.2 mm and score 1) (p = 0.001). All but one patients receiving misoprostol went into labor while only one in the placebo group did so. The interval from insertion to vaginal delivery was significantly shorter in the misoprostol group (12.0 vs 25.5 hrs, p < 0.001). Delivery occurred within 24 hrs in 75% and 30% of patients in the misoprostol and placebo groups respectively. Uterine tachsystole occurred more frequently in the misoprostol group (38%) than in the placebo group (0%) (p < 0.001). All could be rapidly reversed by tocolytics without apparent untoward intrapartum effects. No significant differences were noted in the 2 groups in terms of perinatal outcomes and mode of delivery. CONCLUSION: Intravaginal misoprostol is an effective, cheap and safe method for cervical ripening. The higher frequency of uterine tachysystole in the misoprostol group did not increase the risk of adverse intrapartum and neonatal outcomes

22 Tongsong T, Wanapirak C, Srisomboon J, Piyamongkol W, Sirichotiyakul S. Antenatal sonographic features of 100 alpha-thalassemia hydrops fetalis fetuses. J Clin Ultrasound 1996 Feb;24(2):73-7.

Abstract: OBJECTIVE: To characterize the sonographic findings of alpha-thalassemia hydrops fetalis. METHODS: Descriptive study of the ultrasound findings in 100 women with antenatal diagnosis of hydrops fetalis due to alpha-thalassemia. RESULTS: Mean (+/- SD) maternal age was 27.5 + 5.7 years (17-41 years). Mean menstrual age was 31.3 +/- 4.7 weeks (22-42 weeks). All fetuses were stillborn or died very shortly after birth. The indications for sonographic examination included early onset of pre-eclampsia, large for date, decreased fetal movement and nonreactive NST, or bradycardia and premature contractions. The sonographic features found in more than 90% of cases included hepatosplenomegaly, cardiac enlargement, edematous placenta, and ascites. Other common findings were oligohydramnios (82%), subcutaneous edema (75%), decreased fetal movement (74%), cord edema (63%), and enlarged umbilical vessel (62%). Pericardial or pleural effusion was seen in only 15% of cases. None of the fetuses showed any morphological abnormality. Early findings (22-28 weeks) included evidence of a thickened placenta and/or minimal ascites and/or slight cardiomegaly. CONCLUSIONS: The sonographic characteristics of alpha-thalassemia hydrops fetalis ranged from no obvious morphological abnormalities to evidence of fluid retention. These typical abnormal findings generally did not appear until the late second trimester or early third trimester

23 Nagachinta T, Duerr A, Suriyanon V, Nantachit N, Rugpao S, Wanapirak C, et al. Risk factors for HIV-1 transmission from HIV-seropositive male blood donors to their regular female partners in northern Thailand. AIDS 1997 Nov 15;11(14):1765-72.

Abstract: OBJECTIVE: To describe risks for HIV transmission from male blood donors to their regular female sex partners in Chiang Mai, Thailand. DESIGN: Cross-sectional study. METHODS: From March 1992 through September 1995, 405 HIV-seropositive male blood donors (index cases) and their regular female partners were enrolled in the study. Women with risk factors for HIV infection other than sexual contact with the index male were excluded. Couples were interviewed and examined; specimens were collected for laboratory analysis. RESULTS: Overall, 46% of the 405 women enrolled were HIV-positive. Ninety-eight per cent of male index cases had a history of sex with a female prostitute; 1.5% reported always using condoms with their regular partner. History of sexually transmitted disease (STD) and swollen inguinal lymph nodes in the female partner were associated with an increased risk of HIV infection in the female. History in the female of genital herpes [odds ratio (OR), 3.46; 95% confidence interval (CI), 1.50-8.78], gonorrhea or chlamydia infection (OR, 2.71; 95% CI, 1.39-5.53), and stable relationship of longer than 24 months (OR, 2.28; 95% CI, 1.02-5.09) were associated with an increased risk of HIV infection in the female. Consistent condom use in the past 2 years (OR, 0.10; 95% CI, 0.01-0.79) was associated with a decreased risk of HIV infection in the female. CONCLUSIONS: Married women in northern Thailand who appear otherwise to be at low risk for HIV infection may be exposed to this virus by their husbands. High rates of sex with commercial sex workers among men and low use of condoms within stable relationships may be important factors promoting the transmission of HIV in married couples. Programs to increase the regular use of condoms among married couples could be an important public health intervention to prevent transmission of HIV and other types of STD in northern Thailand

24 Rugpao S, Wanapirak C, Sirichotiyakul S, Yutabootr Y, Prasertwitayakij W, Suwankiti S, et al. Sexually transmitted disease prevalence in brothel-based commercial sex workers in Chiang Mai, Thailand: impact of the condom use campaign. J Med Assoc Thai 1997 Jul;80(7):426-30.

Abstract: One hundred and ninety five (195) brothel-based commercial sex workers (CSW) in Chiang Mai, Thailand, were screened for sexually transmitted disease (STD) between October 1994 and April 1995, prior to their enrollment in a multi-center comparative trial of the effectiveness of two strategies using male and female condoms. These CSW had a mean age of 22.2 (SD 4.3) years. Forty-seven per cent were Thai and 57.4 per cent had no formal education. Median duration of prostitution was 16 months and median cost for sexual service was 50 baht (US$ 2) per client. Ninety-four per cent of CSW reported always using condoms with clients. There were 63 (32.3%) CSW infected with at least one type of the STD screened. The prevalence of STD included chlamydial infection (16.9%), gonococcal infection (14.4%), condyloma accuminata (4.6%), moluscum contagiosum (2.6%) and trichomoniasis (1.0%). There was no statistically significant risk factor for STD found in this study. Despite an active programme for prevention of STD in CSW and the provision of free condoms, STD were diagnosed in one-third of the screened CSW in Chiang Mai. The programme needs to be strengthened by more intensive education and practice in the correct and consistent use of condoms and integrated with other STD prevention programmes

25 Srisomboon J, Piyamongkol W, Aiewsakul P. Comparison of intracervical and intravaginal misoprostol for cervical ripening and labour induction in patients with an unfavourable cervix. J Med Assoc Thai 1997 Mar;80(3):189-94.

Abstract: OBJECTIVE: To compare the efficacy of intracervical versus intravaginal misoprostol for cervical ripening and labour induction at term in patients with an unfavourable cervix. METHOD: A total of 100 pregnant women with indications for induction of labour and unfavourable cervix (Bishop score < or = 4) were randomly assigned to receive either 100 ug misoprostol administered intracervically (50 cases) or intravaginally (50 cases). RESULTS: No significant differences were noted between intracervical and intravaginal misoprostol in terms of Bishop score change, (score 7.2 vs score 7.5), interval from gel insertion to vaginal delivery (17.0 hours vs 16.4 hours), meperidine as analgesic requirement (80% vs 76%), route of delivery and perinatal outcome. Uterine tachysystole occurred in 24 per cent and 32 per cent in the intracervical and intravaginal groups respectively which did not significantly differ, however, all could be rapidly resolved by terbutaline injection. No evidence of fetal distress was noted in these events. Spillage of gel out of the cervix was observed in 70 per cent of patients receiving intracervical misoprostol. Fever was observed in one patient of each group. No other serious side effects were found in both groups. One patient in the intravaginal group had postpartum hemorrhage due to delayed placental separation and uterine atony. CONCLUSION: The two routes of misoprostol gel application appear to be safe and equally effective in ripening cervix and inducing labour, however, the intravaginal application is more convenient to administer practically compared with the intracervical

26 Srisomboon J, Tongsong T, Pongpisuttinun S. Termination of second-trimester pregnancy with intracervicovaginal misoprostol. J Med Assoc Thai 1997 Apr;80(4):242-6.

Abstract: To evaluate the efficacy and side effects of intracervicovaginal misoprostol in termination of second-trimester pregnancy in women with live fetuses. A total of 50 pregnant women between 14 and 27 week’s gestation undergoing termination of pregnancy for medical, obstetrical and genetic reasons were recruited to receive 200 ug misoprostol gel administered intracervicovaginally every 12 hours. The rates of successful abortions within 24 hours and 48 hours were 54 per cent and 92 per cent respectively. The mean time from induction to abortion was 27.5 hours. The rate of complete abortion, defined as the passage of the fetus and placenta without operative assistance was 80 per cent. Side effects were fever (8%), nausea and vomiting (6%) and diarrhea (2%). Thirty one patients (62%) required meperidine as analgesia. Two patients (4%) had postpartum hemorrhage. Intracervicovaginal misoprostol is an effective, cheap, safe and relatively convenient method for termination of second-trimester pregnancy with a live fetus

27 Tongsong T, Kamprapanth P, Pitaksakorn J. Cervical length in normal pregnancy as measured by transvaginal sonography. Int J Gynaecol Obstet 1997 Sep;58(3):313-5.

No abstract is available

28 Rugpao S, Nagachinta T, Wanapirak C, Srisomboon J, Suriyanon V, Sirirojn B, et al. Gynaecological conditions associated with HIV infection in women who are partners of HIV-positive Thai blood donors. Int J STD AIDS 1998 Nov;9(11):677-82.

Abstract: Women who were partners of HIV-positive blood donors were enrolled in a study of heterosexual HIV transmission between March 1992 and December 1996 and were interviewed and examined. Gynaecological conditions, including cervical dysplasia, human papillomavirus (HPV) infection, gonorrhoea, chlamydial infection, trichomoniasis, bacterial vaginosis, vaginal candidiasis and syphilis were assessed in addition to HIV status and CD4 level. Of 481 women enrolled, 224 (46.6%) were HIV seropositive. HIV-infected women were more likely to have abnormal vaginal discharge on physical examination (OR=2.6, P <0.01), HPV infection with a high-risk type (OR=6.9, P <0.01), and cervical dysplasia (OR=5.3, P <0.01). The prevalence of other gynaecological conditions detected at the enrolment visit did not differ by HIV status. History of prior STD (OR=2.0, P <0.01) was more common among HIV-infected women. The median CD4 count was 400 cells/microl among HIV-infected women. The prevalence of abnormal vaginal discharge and bacterial vaginosis increased significantly with decreasing CD4 count. The prevalence of ectopy, vaginal candidiasis, and cervical dysplasia increased with decreasing CD4 count, but these trends were not significant. We conclude that HIV-infected Thai women appear to have increased prevalences of abnormal vaginal discharge, squamous intraepithelial lesions and self-reported history of STD

29 Srisomboon J, Piyamongkol W, Sahapong V, Mongkolchaipak S. Comparison of vacuum extraction delivery between the conventional metal cup and the new soft rubber cup. J Med Assoc Thai 1998 Jul;81(7):480-6.

Abstract: To compare the effectiveness and complications of vacuum extraction delivery between the conventional metal cup and the silicone rubber cup. A prospective randomized clinical trial of 90 pregnant women requiring assisted vaginal delivery who met the predetermined criteria for vacuum extraction were allocated to delivery by the Malstrom metal cup (46 cases) or the silicone rubber cup (44 cases). The two groups were similar in respect of age, parity gestational age and indications for assisted vaginal delivery. The mean and median numbers of tractions and time from cup application to delivery were not significantly different between the groups. The overall success rate was higher in the metal cup (89.1%) than in the rubber cup (79.5%) but not significantly different. The silicone cup was more likely to fail in cases of occiput posterior position, excessive caput, and severe degree of molding. There were no significant differences between groups in terms of Apgar scores, birth canal injury, and maternal blood loss. Scalp injuries occurred more frequently with the metal than with the rubber cup (P = 0.006). Vacuum extraction delivery with the silicone rubber cup is associated with reduced scalp injuries but has a greater tendency to fail when the fetus presents in occiput posterior position, has excessive caput or severe degree of molding

30 Tongsong T, Wanapirak C, Sirivatanapa P, Piyamongkol W, Sirichotiyakul S, Yampochai A. Amniocentesis-related fetal loss: a cohort study. Obstet Gynecol 1998 Jul;92(1):64-7.

Abstract: OBJECTIVE: To assess the risk of fetal loss attributable to second-trimester amniocentesis. METHODS: A cohort study was undertaken among singleton pregnant women undergoing genetic amniocentesis and controls matched prospectively on a one-to-one basis, matched strictly for maternal age, parity, and socioeconomic status. Both groups were recruited at 15-24 weeks’ gestation and observed until delivery. The fetal loss rates of the groups were compared. RESULTS: A total of 2256 pairs were recruited to the study. After excluding those pairs lost to follow-up, those with fetal malformation, and those later proven to have major chromosomal abnormalities, 2045 matched pairs were compared by pregnancy outcomes. There were no significant differences in fetal loss rates, premature deliveries, or placental abruptions between the study and control groups (P > .05). However, this study did not have enough statistical power to identify differences of less than 1%. CONCLUSION: Second-trimester amniocentesis is probably not associated with a greater fetal loss rate than that of matched controls

31 Tongsong T, Wanapirak C, Siriangkul S. Prenatal diagnosis of osteogenesis imperfecta type II. Int J Gynaecol Obstet 1998 Apr;61(1):33-8.

Abstract: OBJECTIVE: To characterize the prenatal sonographic features of osteogenesis imperfecta (OI) type II. DESIGN: Descriptive (case series). SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. SUBJECTS: Six fetuses with prenatal diagnosis of OI were evaluated. RESULTS: Six fetuses were prenatally diagnosed as OI type II in five mothers without familial history of the disease. One mother had two consecutive pregnancies complicated with this condition. The first five cases were classified as OI type IIA, while the last one was OI type IIB. All of subtype A exhibited typical triad of bone shortening, diffuse hypomineralization and multiple fractures of long bones including beaded ribs whereas the subtype B showed shortening of only femurs, normal bone echodensity and isolated fractures of long bones. The postnatal radiography and autopsy confirmed the prenatal diagnosis in all cases. Other findings may occasionally be found, including polyhydramnios, oligohydramnios, hydrop fetalis and small for gestational age. CONCLUSION: The triad of bone shortening, decreased bone density and numerous fractures including beaded ribs permits a confident diagnosis of OI type IIA. Furthermore, sonographic features may differentiate the subtype of OI type II, depending on degree of bone shortening and echodensity

32 Tongsong T, Wanapirak C, Sirichotiyakul S, Siriangkul S. Prenatal sonographic diagnosis of holoprosencephaly. J Med Assoc Thai 1998 Mar;81(3):208-13.

Abstract: The purpose of this series was to describe the sonographic features of fetal holoprosencephaly prenatally. The study was undertaken at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. A total of 12 fetuses with prenatal diagnosis of holoprosencephaly were sonographically evaluated and followed-up. The study revealed that all showed monoventricular cavity, fused thalami, no falx and cavum septum pellucidum. Eight of them were correctly diagnosed sonographically in the first two trimesters. Extrafacial anomalies were also identified in half of the fetuses and all of them had facial abnormalities. Twenty-five per cent (3 cases) had polyhydramnios and only one case had oligohydramnios. Chromosome study revealed that 70 per cent had normal chromosomes, 30 per cent were aneuploidy, trisomy 13; 2 cases and trisomy 18; 1 case. In conclusion, this series indicates that ultrasound has a high predictive value in the diagnosis of holoprosencephaly. The most valuable clue to the diagnosis is the demonstration of the single ventricle. Additionally, demonstration of facial abnormalities may add confidence to the diagnosis. Conversely, should any of these facial features be serendipitously encountered, a careful examination of the intracranial contents is recommended

33 Wanapirak C, Tongsong T, Sirivatanapa P, Sa-nguansermsri T, Sekararithi R, Tuggapichitti A. Prenatal strategies for reducing severe thalassemia in pregnancy. Int J Gynaecol Obstet 1998 Mar;60(3):239-44.

Abstract: OBJECTIVE: To describe the prenatal strategy in reducing new cases of severe thalassemia at Maharaj Nakorn Chiang Mai Hospital. The study design involved a prospective descriptive analysis set in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. SUBJECTS: Pregnant women attending antenatal clinic. METHODS: The strategy included: (1) carrier identification by retrospective (history review) and prospective screening program; (2) the couples at risk were counseled and offered cordocentesis; (3) analysis of fetal blood with high performance liquid chromatography (HPLC) or electrophoresis; and (4) counseling for termination of pregnancy in case of affected fetus. The prospective screening consisted of testing for a carrier by a simple erythrocyte osmotic fragility test (EOFT) in women with no risk and testing the husbands of the women with abnormal tests. A pregnancy in which both of the couple were carriers was considered a risk. RESULTS: Cordocentesis was performed in 554 pregnancies at risk, 252 and 302 from retrospective and prospective screening, respectively. Sixty of 252 of the first group had severe thalassemia. In the prospective screening program of 12 680 women, 459 risk couples were identified, 302 pregnancies underwent cordocentesis and 53 (17.5%) had severe thalassemia. This strategy enabled us to identify 113 cases of severe thalassemia (Hb Bart’s; 60, beta-thal entities; 53) from 554 cases at risk. CONCLUSION: The strategy proves valuable in the control of severe thalassemia. This extensive experience suggests the strategy be considered an effective way in the control of severe thalassemia in high prevalence areas

34 Tongsong T, Wanapirak C, Sirichotiyakul S, Piyamongkol W, Chanprapaph P. Fetal sonographic cardiothoracic ratio at midpregnancy as a predictor of Hb Bart disease. J Ultrasound Med 1999 Dec;18(12):807-11.

Abstract: The objective of this study is to evaluate the efficacy of sonographic cardiothoracic ratio at midpregnancy in predicting fetal hemoglobin Bart disease. Among 17,254 pregnant women screened for severe thalassemia between June 1994 and November 1998, 345 pregnant women at risk for having a fetus with hemoglobin Bart disease underwent ultrasonographic examination and cordocentesis at 18 to 21 weeks’ gestation. Before cordocentesis, the cardiothoracic ratio was determined and recorded. The definite fetal diagnosis was based on fetal blood analysis with high performance liquid chromatography. Among 345 pregnancies in which sonographic examination and cordocentesis were performed, 70 fetuses were affected by hemoglobin Bart disease. The mean cardiothoracic ratio was significantly higher than that of unaffected fetuses (0.55 versus 0.45, Student’s t-test, P<0.001). The sensitivity and specificity of the cardiothoracic ratio in prediction were calculated for various cutoff values. On the basis of the receiver operating characteristic curve, the best cutoff value was 0.50 (greater than 0.50 considered abnormal), giving the sensitivity of 98.6% and a specificity of 98.9%. In conclusion, the cardiothoracic ratio has very high accuracy in predicting hemoglobin Bart disease in pregnancies at risk. This finding suggests that invasive diagnostic method should be reserved for only the fetuses who have a cardiothoracic ratio of 0.5 or more; however, further studies are needed to confirm this observation

35 Tongsong T, Wanapirak C, Sirichotiyakul S. Placental thickness at mid-pregnancy as a predictor of Hb Bart’s disease. Prenat Diagn 1999 Nov;19(11):1027-30.

Abstract: The measurement of placental thickness can effectively differentiate normal pregnancies from affected pregnancies requiring invasive work-up. The objective was to evaluate the efficacy of placental thickness at mid-pregnancy in predicting fetal Hb Bart’s disease in pregnancies at risk. Among 17 254 pregnant women screened for severe thalassaemia between June 1994 and December 1998, 345 pregnancies at risk for having a fetus with Hb Bart’s disease underwent ultrasound examinations and cordocentesis at 18-21 gestational weeks. Before cordocentesis, the placental thickness was measured and recorded.The definite fetal diagnosis was performed with high performance liquid chromatography. The efficacy of placental thickness in predicting Hb Bart’s disease was evaluated by sensitivity and specificity. Various cut-off values of the placental thickness were used for calculation and the best cut-off value was determined by a receiver-operating characteristic (ROC) curve. Of 345 pregnancies at risk, 70 fetuses with Hb Bart’s disease were finally diagnosed. The mean placental thickness (+/-SD) of the normal pregnancies and pregnancies with Hb Bart’s fetuses were significantly different, 24.6+/-5.2 mm and 34. 5+/-6.7 mm, respectively (Student’s t-test, p<0.001). The sensitivity and specificity of placental thickness in prediction were calculated for various cut-off values. Based on the ROC curve, the best cut-off value was 30 mm (>30 mm considered abnormal), giving a sensitivity of 88.57 per cent, specificity of 90.18 per cent, positive-predictive value of 78.48 per cent and negative-predictive value of 96.87 per cent. For couples at risk, when sonographic placental thickness is normal, the risk of having an Hb Bart’s fetus is markedly decreased. The measurement of placental thickness can effectively, though not absolutely, differentiate the normal pregnancies from affected ones requiring invasive work-up

36 Tongsong T, Piyamongkol W, Pongsatha S. Prenatal diagnosis of Meckel syndrome: a case report. J Obstet Gynaecol Res 1999 Oct;25(5):339-42.

Abstract: OBJECTIVE: To demonstrate the major sonographic findings associated with Meckel syndrome and to emphasize the importance of prenatal sonography in helping to establish the correct diagnosis. SUBJECTS: Two fetuses with prenatal diagnosis of Meckel syndrome were sonographically evaluated. RESULTS: Both fetuses were demonstrated to have evidence of renal cystic dysplasia, occipital cephalocele and postaxial polydactyly. One case was diagnosed at 16 weeks of gestation whereas the other was detected at 36 weeks. Of interest, the first case had only unilateral renal cystic dysplasia and contralateral renal agenesis and mild degree of oligohydramnios. The other related anomalies which were not detected prenatally included cerebellar hypoplasia in case 1 and micrognathia in case 2. CONCLUSION: The main sonographic findings included renal cystic dysplasia, occipital cephalocele and postaxial polydactyly

37 Tongsong T, Wanapirak C, Piyamongkol W, Sudasana J. Prenatal sonographic features of sacrococcygeal teratoma. Int J Gynaecol Obstet 1999 Nov;67(2):95-101.

Abstract: OBJECTIVE: To describe the potential role of ultrasound in prenatal diagnosis of fetal sacrococcygeal teratoma (SCT). SUBJECTS: A total of four fetuses with prenatal diagnosis of SCT were sonographically evaluated and followed-up. RESULTS: Fetal SCT was diagnosed at 13, 17, 26 and 27 weeks of gestation. Three of them had predominantly solid tumors with scattered cystic areas, whereas the other one had an entirely cystic tumor. One had a rapid growth tumor and finally developed early hydrops. Three had polyhydramnios and delivered prematurely. The diagnosis was posnatally confirmed in all cases. In the case with the large tumor, a cesarean section was done to avoid traumatic delivery. Two cases survived and the tumors were successfully resected, whereas the others died due to heart failure secondary to hydrops in one case and prematurity in the other one. CONCLUSION: This small series suggests that SCT be readily diagnosed in utero, possibly as early as first trimester. The important clue was an abnormal mass in the sacrococcygeal area. The prenatal diagnosis can contribute to changes in clinical decision

38 Tongsong T, Piyamongkol W, Anantachote A, Pulphutapong K. The rapid biophysical profile for assessment of fetal well-being. J Obstet Gynaecol Res 1999 Dec;25(6):431-6.

Abstract: OBJECTIVE: To determine the efficacy of the rapid biophysical profile (BPP), the combination of amniotic fluid index (AFI) and sound-provoked fetal movement (SPFM) detected by ultrasound, in predicting intrapartum fetal distress in high-risk pregnancies, compared with the nonstress test (NST). STUDY DESIGN: The prospective study of diagnostic tests was conducted on a total of 1,069 high-risk singleton pregnancies, undergoing antepartum assessment of both the standard NST and the new rapid BPP, including AFI and SPFM detected by ultrasound. Intrapartum continuous fetal heart rate (FHR) monitoring was performed in all of them. The diagnostic indices of the NST and the rapid BPP was calculated in term of predicting intrapartum fetal distress. RESULTS: The rapid BPP was a reliable predictor of intrapartum fetal distress with higher sensitivity and specificity. Its accuracy was better than that of the NST. The incidence of fetal compromise among positive, equivocal, and negative tests of the rapid BPP are 78.57, 15.82 and 0.9%, respectively, whereas the incidence among nonreactive and reactive NST are 31.63 and 2.52%, respectively. CONCLUSIONS: The rapid BPP is an effective predictor of intrapartum fetal distress in high-risk pregnancies. It may suffice as an inexpensive and less time-consuming method of evaluating antepartum fetal well-being

39 Tongsong T, Chanprapaph P, Pongsatha S. Omphalopagus conjoined twins. Ultrasound Obstet Gynecol 1999 Dec;14(6):439.

No abstract is available

40 Tongsong T, Chanprapaph P, Pongsatha S. First-trimester diagnosis of conjoined twins: a report of three cases. Ultrasound Obstet Gynecol 1999 Dec;14(6):434-7.

No abstract is available

41 Tongsong T, Wanapirak C, Piyamongkol W. Prenatal ultrasonographic findings consistent with fetal warfarin syndrome. J Ultrasound Med 1999 Aug;18(8):577-80.

No abstract is available

42 Tongsong T, Wanapirak C, Thongpadungroj T. Sonographic diagnosis of intrauterine growth restriction (IUGR) by fetal transverse cerebellar diameter (TCD)/abdominal circumference (AC) ratio. Int J Gynaecol Obstet 1999 Jul;66(1):1-5.

Abstract: OBJECTIVE: To evaluate the validity of TCD/AC ratio in predicting IUGR. STUDY DESIGN: Prospective descriptive analysis. SETTING: Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. SUBJECTS: Women meeting the inclusion criteria consisting of: (1) singleton pregnancies after 28 weeks of gestation; (2) known accurate gestational age; and (3) clinically suspected IUGR. METHODS: The patients were sonographically examined for TCD/AC ratio. The best cut-off value of TCD/AC ratio in predicting IUGR was determined by a receiver operating characteristic (ROC) curve. The fetus with a TCD/AC ratio greater than the cut-off value would be antenatally diagnosed as IUGR for every gestational week. Standard definition of IUGR was a low birthweight, less than the 10th percentile. RESULTS: One hundred and sixty-seven pregnancies with suspected IUGR were analyzed. The prevalence of IUGR among the study group was 51.5%. The best cut-off value of the TCD/AC ratio for predicting IUGR was 15.4%, giving the sensitivity, specificity, positive predictive value and negative predictive value of 73.26%, 80.25%, 79.75%, and 73.86%, respectively. CONCLUSION: The sonographic fetal TCD/AC ratio as a gestational age-independent method can be helpful in antenatal diagnosis of IUGR, especially in pregnancy with uncertain gestational age

43 Tongsong T, Wanapirak C, Piyamongkol W, Sudasana J. Prenatal sonographic diagnosis of VATER association. J Clin Ultrasound 1999 Sep;27(7):378-84.

Abstract: PURPOSE: We examined the potential role of sonography in the prenatal diagnosis of the VATER association, a spectrum of fetal anomalies that includes vertebral defects, imperforate anus, tracheoesophageal fistula, and radial and renal dysplasia. METHODS: The sonographic findings in 4 fetuses with prenatal diagnoses of VATER association were prospectively recorded, along with information on outcome and postnatal radiographic findings. RESULTS: VATER association was diagnosed in 4 fetuses at 20, 17, 21, and 29 weeks’ menstrual age. All showed bilateral radial atresia and tracheoesophageal fistula, visible sonographically as a collapsed or absent stomach with polyhydramnios. Two fetuses had vertebral defects. Postnatal radiographic and macroscopic findings confirmed the prenatal diagnosis in all cases. Other associated anomalies detected prenatally included single umbilical arteries (2 cases), ventricular septal defect (1 case), and renal abnormalities (2 cases). Anal atresia, present in 3 of the 4 fetuses, was not detected prenatally. CONCLUSIONS: This small series suggests that the VATER association can be readily diagnosed in utero. Important clues include radial atresia, absent or collapsed stomach, and polyhydramnios. Prenatal diagnosis can contribute to clinical decisions regarding pregnancy and neonatal management

44 Tongsong T, Chanprapaph P, Thongpadungroj T. Prenatal sonographic findings associated with asphyxiating thoracic dystrophy (Jeune syndrome). J Ultrasound Med 1999 Aug;18(8):573-6.

No abstract is available

45 Tongsong T, Wanapirak C, Chanprapaph P, Siriangkul S. First trimester sonographic diagnosis of holoprosencephaly. Int J Gynaecol Obstet 1999 Aug;66(2):165-9.

Abstract: OBJECTIVE: To describe our experience with sonographic diagnosis of fetal holoprosencephaly in first trimester. SUBJECTS: A total of three fetuses with early prenatal diagnosis of holoprosencephaly were sonographically evaluated and followed up. RESULTS: The study revealed that all showed monoventricular cavity, fused thalami, no falx and cavum septum pellucidum. All of them were correctly diagnosed sonographically in the first trimester. Extracranial anomalies had also been identified in all three fetuses and all of them had facial abnormalities. Cytogenetic studies were successfully carried out in only one case. No polyhydramnios was demonstrated in all cases. CONCLUSION: This small series indicates that holoprosencephaly can be diagnosed in the first trimester. The most valuable clue to the diagnosis is the demonstration of the single ventricle

46 Tongsong T, Wanapirak C, Sirivatanapa P, Wongtrangan S. Prenatal sonographic diagnosis of ectopia cordis. J Clin Ultrasound 1999 Oct;27(8):440-5.

Abstract: PURPOSE: We present a small series of prenatally diagnosed cases of ectopia cordis. METHODS: Four fetuses with prenatally diagnosed ectopia cordis were sonographically evaluated and followed up. RESULTS: The fetuses were diagnosed with ectopia cordis at 9, 13, 21, and 29 weeks’ menstrual age. The case diagnosed at 9 weeks is the earliest prenatal diagnosis reported, to our knowledge. The diagnoses were based on the demonstration of a fetal heart outside the thoracic cavity with Doppler waveforms typical of intracardiac flow. One fetus had isolated ectopia cordis, and 3 had other associated anolmalies. The diagnosis was postnatally confirmed in all cases. Therapeutic abortion was done in 2 cases. One infant survived, and the fourth died shortly after birth. Chromosome study was successfully performed in 2 cases and was normal in both of them. CONCLUSIONS: This small series suggests that ectopia cordis can be readily diagnosed in utero as early as the first trimester. Later in pregnancy, sonography provides important information for planning surgical correction

47 Tongsong T, Chanprapaph P. Picture of the month. Evolution of umbilical cord entanglement in monoamniotic twins. Ultrasound Obstet Gynecol 1999 Jul;14(1):75-7.

No abstract is available

48 Chanprapaph P, Tongsong T, Wongtra-ngan S. Sonographic diagnosis of exencephaly: omphalocele at 11 weeks of gestation. J Obstet Gynaecol Res 2000 Oct;26(5):363-6.

Abstract: This report presents a sonographic diagnosis of exencephaly combined with omphalocele at 11 weeks of gestation. The transvaginal ultrasound showed frog-eye appearance face with no skull, abnormal shape of disorganized brain with covering membrane separated from brain mass by anechoic fluid in some area, and omphalocele of 8 mm diameter. Therapeutic abortion was successfully done with misoprostol. Postabortal macroscopic findings confirmed the prenatal diagnosis. The combination of exencephaly and omphalocele is rare, and this is one of the earliest diagnosis of not only exencephaly but also omphalocele. To our best knowledge, this represents the earliest diagnosis of the combination. In conclusion, transvaginal ultrasound proved highly informative for both exencephaly and omphalocele as early as in first trimester

49 Sirivatanapa P, Tongsong T, Wanapirak C, Sirichotiyakul S, Chanprapaph P, Yampochai A, et al. Prenatal diagnosis: 10-year experience. J Med Assoc Thai 2000 Dec;83(12):1502-8.

Abstract: To evaluate the indications and results of prenatal diagnosis of the high risk pregnant women attending the antenatal care clinic at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University during 1988-1998, we analysed 2,315 amniocenteses, 1,000 cordocenteses, and 11,895 obstetric ultrasound examinations. Among the amniocentesis group, 2,017 cases (87%) were done with the indication of advanced maternal age. The prevalence of major abnormal fetal chromosomes among high risk pregnancies was 1:58. Of 1,000 cases with cordocentesis, the most common indication was fetal risk of severe thalassemia (658 cases; 65.8%) and followed by fetal risk of chromosome abnormalities (272 cases; 27.2%). In the group of cordocentesis for diagnosis of thalassemia, 99 and 49 pregnancies were affected with Hb Bart’s disease and homozygous beta-thalassemia, respectively. Thirty three cases with indication of chromosome analysis had fetuses with abnormal chromosomes. The major indications of ultrasonography included suspicion of intrauterine growth restriction (IUGR), determination of gestational age and screening anomalies, respectively. In conclusion, our extensive experience has enabled us to prenatally detect most fetuses with severe thalassemia, and fetuses with abnormal chromosomes as well as anomalies in a significant number, contributing a great deal to our population. Therefore, we recommend that systematic prenatal diagnosis, either amniocentesis, cordocentesis or ultrasound should be provided to every high risk pregnant woman for a healthy newborn

50 Tongsong T, Pongsatha S. Early prenatal sonographic diagnosis of congenital hypophosphatasia. Ultrasound Obstet Gynecol 2000 Mar;15(3):252-5.

Abstract: A pregnant woman of 14 weeks’ gestation was sonographically examined due to large-for-dates uterine size. The ultrasound examination showed poor ossification of all bony structures. All limbs were shortened with no evidence of fractures. The echodensity approximated that of the surrounding organs. No acoustic shadowing was observed. Based on these sonographic findings, skeletal dysplasia and short-limb dwarfism were diagnosed, the most likely condition being congenital hypophosphatasia. Early cordocentesis was successfully performed at 15 weeks’ gestation to determine fetal alkaline phosphatase concentration. This was undetectable. The prenatal diagnosis of congenital hypophosphatasia was made. After counselling, the woman decided to opt for termination of pregnancy which was performed vaginally. Post-abortion findings confirmed the prenatal diagnosis. To our knowledge, this is the earliest sonographic diagnosis of this condition reported

51 Tongsong T, Wanapirak C, Pongsatha S, Sudasana J. Prenatal sonographic diagnosis of Larsen syndrome. J Ultrasound Med 2000 Jun;19(6):419-21.

No abstract is available

52 Tongsong T, Wanapirak C, Pongsatha S. Prenatal diagnosis of campomelic dysplasia. Ultrasound Obstet Gynecol 2000 May;15(5):428-30.

Abstract: A pregnant woman of 24 weeks’ gestation underwent ultrasound examination for fetal anomaly screening. The ultrasound findings revealed a single fetus with biparietal diameter of 61 mm, which was consistent with menstrual dates. The thoracic cage was small compared to the abdomen with hypoplastic scapulae and normally ossified unfractured ribs. All bony structures demonstrated normal echogenicity. The upper long bones were normal length and shape. Both femurs and tibiae were obviously bowed anteriorly, and slightly shortened. Bilateral talipes equinovarus were clearly demonstrated. A prenatal diagnosis of campomelic dysplasia was made and was confirmed by postnatal radiography and autopsy. The sonographic diagnosis in this case was based on the findings of small thorax, hypoplastic scapulae and bowed tibiae and femurs

53 Tongsong T, Sirichotiyakul S, Chanprapaph P. Prenatal diagnosis of thrombocytopenia-absent-radius (TAR) syndrome. Ultrasound Obstet Gynecol 2000 Mar;15(3):256-8.

Abstract: The prenatal diagnosis of thrombocytopenia-absent-radius (TAR) syndrome using ultrasound and cordocentesis in the 16th week of gestation is established. The sonographic findings detected in this case included bilateral absence of the radius and club hands with normal thumbs and metacarpals. Because of a high index of suspicion for the syndrome, cordocentesis for fetal blood analysis was performed. Thrombocytopenia, with a platelet count of 14,000/mm3, was identified. The pregnancy was electively terminated and subsequent findings confirmed the sonographic diagnosis. This report, to our knowledge, is one of a very limited number of cases published in the literature, in which the prenatal diagnosis of TAR syndrome was made

54 Tongsong T, Chanprapaph P. Triple bubble sign: a marker of proximal jejunal atresia. Int J Gynaecol Obstet 2000 Feb;68(2):149-50.

No abstract is available

55 Tongsong T, Chanprapaph P. Prenatal sonographic diagnosis of ellis-van creveld syndrome. J Clin Ultrasound 2000 Jan;28(1):38-41.

Abstract: Ellis-van Creveld syndrome (chondroectodermal dysplasia) is a rare autosomal recessive disorder characterized by a narrow thorax with short ribs, short extremities with polydactyly, and heart defects. A woman underwent sonographic examination at 27 weeks’ menstrual age to rule out anomalies because of premature labor. Sonography revealed a live fetus with short long bones, polydactyly in the hands and feet, a narrow thorax with short ribs, and an atrial septal defect. All bony structures were of normal hyperechogenicity. The placenta appeared normal and was located at the posterior uterine wall; the amniotic fluid volume was also normal. These findings led to the diagnosis of short-rib dysplasia, most likely Ellis-van Creveld syndrome. The preterm labor stopped but spontaneously recurred at 35 weeks, when a 2,320-g female infant was vaginally delivered. The infant died of pulmonary insufficiency shortly after birth. Postmortem examination confirmed the prenatal findings. We conclude that Ellis-van Creveld syndrome can be readily diagnosed by prenatal sonography in the third trimester

56 Tongsong T, Chanprapaph P. Prenatal sonographic diagnosis of Holt-Oram syndrome. J Clin Ultrasound 2000 Feb;28(2):98-100.

Abstract: Holt-Oram syndrome is an autosomal dominant disorder characterized by heart defects in combination with characteristic upper-limb abnormalities. A woman with no family history of genetic diseases underwent prenatal sonography at 25 weeks’ menstrual age to screen for fetal anomalies. Sonography revealed abnormalities in the upper limbs and heart. The limb abnormalities included bilateral absence of radii and thumbs: the left hand had no carpal or metacarpal bones, and each of the 4 fingers on that hand had only 1 phalangeal bone. Cardiac malformations included an atrial septal defect and Ebstein’s anomaly. Other structures were normal. Prenatal cytogenetic analysis by cordocentesis revealed a normal 46,XY karyotype. Spontaneous labor and delivery at 34 weeks’ menstrual age produced a 1,960-g male infant who died of cardiac insufficiency shortly after birth. The postnatal appearance and autopsy findings confirmed the prenatal findings. In this case, Holt-Oram syndrome was readily diagnosed by prenatal sonography

57 Tongsong T, Chanprapaph P, Khunamornpong S. Prenatal ultrasound of regional akinesia with Pena-Shokier phenotype. Prenat Diagn 2000 May;20(5):422-5.

Abstract: This report describes sonographic features of the Pena-Shokeir phenotype secondary to regional akinesia at 28 weeks of gestation with maternal perception of good fetal movement. The diagnosis was based on the findings of no fetal activity in some parts of the body (upper limbs, a part of the face, and thorax), with deformation sequence of fixed flexion at wrist, elbow, and shoulder joints, fixed open mouth, fetal growth restriction, lung hypoplasia, polyhydramnios and normal chromosome study. Surprisingly, fetal akinesia involved only the upper limbs, a part of the face, and chest, whereas the lower limbs were completely normal in both morphology and activity. With vibroacoustic stimulation, the response of fetal heart rate acceleration, gross body movement including fetal head, spine and lower limb movement were observed, but the movement of the upper limbs and fetal breathing were completely absent. Spontaneous labour and delivery occurred at 29 weeks’ gestation. Postnatal autopsy confirmed the prenatal findings. In conclusion, prenatal sonography plays an important role not only in detecting Pena-Shokeir phenotype but also in providing the detailed pattern of fetal akinesia. Finally, this case reaffirms the concept that function is an integral part of normal development

58 Tongsong T, Wanapirak C, Sirivatanapa P, Sanguansermsri T, Sirichotiyakul S, Piyamongkol W, et al. Prenatal control of severe thalassaemia: Chiang Mai strategy. Prenat Diagn 2000 Mar;20(3):229-34.

Abstract: Prenatal diagnosis of severe thalassaemia is conventionally diagnosed by fetal DNA analysis but it can not be widely used due to its drawbacks of high cost and technical effort. This prospective study describes a new prenatal strategy in preventing severe thalassaemia by a more simple and inexpensive way. The strategy included: (1) genetic counselling; (2) identification of pregnancies at risk by retrospective screening (history of known risk) and prospective screening for asymptomatic women; (3) cordocentesis at 16-22 weeks’ gestation; (4) fetal blood analysis with high performance liquid chromatography (HPLC); (5) termination of affected pregnancy. The prospective screening consisted of 2 min osmotic fragility (OF) and HbE screening test in women with no risk, and testing the husbands of the women with a positive result. If both of the couple had a positive result, the diagnostic test (HbA(2) level and PCR alpha-thal 1) for the carrier was needed. A pregnancy in which both of the couple were carriers was considered at risk. This strategy identified 181 and 108 couples at risk by prospective (from 7954 pregnancies) and retrospective screening, respectively. Two hundred and forty-two underwent cordocentesis, 108 from retrospective screening and 134 from prospective screening, and 62 were proven to have severe thalassaemia (29 and 33 in retrospective and prospective screening, respectively). The strategy identified nearly all, if not all, fetuses with severe thalassaemia without false positives among the screened couples. In conclusion, the strategy proves to be highly effective in the control of severe thalassaemia

59 Tongsong T, Wanapirak C, Kunavikatikul C, Sirirchotiyakul S, Piyamongkol W, Chanprapaph P. Cordocentesis at 16-24 weeks of gestation: experience of 1,320 cases. Prenat Diagn 2000 Mar;20(3):224-8.

Abstract: The objective of this study was to assess the safety and efficacy of diagnostic cordocentesis at midpregnancy. 1,320 singleton pregnancies with no obvious congenital anomalies, a gestational age of 16-24 weeks, and proper indications underwent cordocentesis using the freehand technique. The results of each procedure was prospectively collected and subsequently analysed for the results and pregnancy outcomes. The mean maternal age was 31.1 years and the mean gestational age at the time of cordocentesis was 19.8 weeks. The most common indication was the risk of severe thalassaemia syndrome (69.8%) and was followed by rapid karyotyping. Of 1,320 cordocenteses, 1,281 (97%) were done successfully at the first attempt. The mean duration of the procedure was 10.5 min and was significantly longer in the first 50 cases of practice for each operator. The maternal blood contamination rate was higher when the cord insertion was targeted. The procedure-related complications included transient bleeding at puncture site (20.2%), transient fetal bradycardia (4. 3%), chorioamnionitis (two cases), and cord haematoma (one case). Of 1,281 successful cases, 184 fetuses had severe disease. The total fetal loss rate was 3.2% and the procedure-related loss was 1%. The other obstetric complications were comparable with those in the general population. We conclude that cordocentesis at midpregnancy is a useful, relatively safe, and effective procedure for prenatal diagnosis

60 Wanapirak C, Onishi Y, Wada-Kiyama Y, Ohyama T, Kiyama R. Conservation of DNA bend sites with identical superhelical twists among the human, mouse, bovine, rabbit and chicken beta-globin genes. DNA Res 2000 Aug 31;7(4):253-9.

Abstract: We reported previously that DNA bend sites appear in the human beta-globin locus at an average distance of 680 bp. The relative locations of the sites were conserved among the five active beta-like globin genes and one pseudogene. Here, we mapped the sites in the beta-like globin genes from various species and examined their conservation. The locations of the bend sites in the bovine, rabbit and chicken beta-globin genes mapped here showed marked conservation in their locations relative to the cap site and showed similar locations to the previously mapped sites in the human beta- and mouse betamaj-globin genes. Further analysis of the first bend sites from the cap site (B-1 sites) indicated that they contained tracts of adenines and thymines longer than or equal to two bases. This sequence feature contributed mostly to the curvature profiles revealed by gel assays and/or by computer-based TRIF analysis. TRIF analysis indicated that most of the B-1 sites showed right-handed superhelical twists accompanied by left handed twists. This was confirmed by the effect of ethidium bromide on the superhelical twists in the assays

61 Kitisomprayoonkul N, Tongsong T. Neural tube defects: a different pattern in northern Thai population. J Med Assoc Thai 2001 Apr;84(4):483-8.

Abstract: The objective of this descriptive study was to describe the demographic and sonographic patterns of fetal neural tube defects (NTDs) in Thai pregnant women. The study was conducted at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. The subjects included all pregnancies with diagnosis of fetal neural tube defects. Basic clinical data of the subjects was prospectively collected at the time of diagnosis for NTDs and followed-up until delivery. Antenatal diagnosis was based on sonographic criteria. The results showed that the incidence of NTDs was 0.66/1,000 births, however, spina bifida was very rare, found in only 0.06/1,000 births, similar to encephalocele. All anencephalic fetuses had no concurrent spina bifida, and only a few cases had other associated anomalies. Ultrasound was able to diagnose NTDs with very high accuracy. All cases of antenatal diagnosis were electively terminated. In conclusion, NTDs in the Thai population were rather rare when compared to that of the Europeans and spina bifida was extremely rare. The accuracy of antenatal diagnosis of NTDs with ultrasound was highly reliable

62 Piyamongkol W, Harper JC, Delhanty JD, Wells D. Preimplantation genetic diagnostic protocols for alpha- and beta-thalassaemias using multiplex fluorescent PCR. Prenat Diagn 2001 Sep;21(9):753-9.

Abstract: Haemoglobinopathies including alpha- and beta-thalassaemia are the world’s most common class of single gene disorder. Prenatal diagnosis (PND) for beta-thalassaemia has been proven to be an effective strategy for controlling the incidence of new cases and is widely used in several countries where the disease is common. Successful preimplantation genetic diagnosis (PGD) protocols for beta-thalassaemia have been introduced using restriction fragment length polymorphism (RFLP), single-stranded conformation polymorphism (SSCP) and denaturing gradient gel electrophoresis (DGGE). However, contamination and allele dropout (ADO) remain an important concern for all of these strategies. In the present study two PGD protocols for detecting beta-thalassaemia mutations (codon 41-42 and IVSI-110) and one for alpha-thalassaemia (SEA mutation) have been designed and tested. These methods contain failsafe mechanisms to reduce the risk of misdiagnosis due to ADO or contamination and utilise multiplex fluorescent PCR (F-PCR). Interestingly, amplification efficiency and ADO were significantly affected by the choice of DNA polymerase and the freshness of the single cells used. The close similarity between the DNA sequences of beta-globin and delta-globin was also found to be an important issue that necessitated careful design of primers for the beta-globin gene

63 Piyamongkol W, Harper JC, Sherlock JK, Doshi A, Serhal PF, Delhanty JD, et al. A successful strategy for preimplantation genetic diagnosis of myotonic dystrophy using multiplex fluorescent PCR. Prenat Diagn 2001 Mar;21(3):223-32.

Abstract: The most common form of inherited muscular dystrophy in adults is myotonic dystrophy (DM), an autosomal-dominant disease caused by the expansion of an unstable CTG repeat sequence in the 3′ untranslated region of the myotonin protein kinase (DMPK) gene. Expanded (mutant) CTG repeat sequences are refractory to conventional PCR, but alleles with a number of repeats within the normal range can be readily amplified and detected. Preimplantation genetic diagnosis (PGD) of DM has been successfully applied. However, a misdiagnosis using the reported protocol was recently documented. Two new PGD protocols for DM have been developed which utilise multiplex fluorescent PCR. Ideally a linked polymorphic marker, APOC2, is amplified in addition to the normal DMPK alleles, thus providing a back-up diagnostic result. However, the two couples reported in the present study were not fully informative at the APOC2 locus and so an unlinked short tandem repeat (STR) marker, D21S1414, was substituted. The highly polymorphic nature of the D21S1414, DMPK and APOC2 loci means that a very simple genetic fingerprint can be generated by analyses of these loci. This allows most DNA contaminants to be detected. Contamination is a significant problem for PGD and is the primary reason for the inclusion of D21S1414 and APOC2 in this protocol. This paper reports the first clinical experience and pregnancies following PGD for DM using a multiplex fluorescent PCR protocol

64 Piyamongkol W, Harper JC, Delhanty JD, Wells D. PGD protocols using multiplex fluorescent PCR. Reprod Biomed Online 2001;2(3):212-4.

No abstract is available

65 Pongsatha S, Tongsong T. Second trimester pregnancy termination with 800 mcg vaginal misoprostol. J Med Assoc Thai 2001 Jun;84(6):859-63.

Abstract: OBJECTIVE: To demonstrate the efficacy of 800 microgram vaginal misoprostol tablet for second trimester pregnancy termination. DESIGN: Prospective descriptive study. SETTING: Maharaj Nakorn Chiang Mai Hospital, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. SUBJECT: Pregnant women meeting the inclusion criteria including (1) singleton pregnancy with live fetus, (2) gestational age of 14-28 weeks, (3) indication for therapeutic termination, (4) closed and uneffaced cervix, (5) absence of uterine contraction and leakage of amniotic fluid, (6) no previous classical uterine scar, (7) no contraindication for misoprostol such as hypersensitivity. INTERVENTION: 800 microgram misoprostol tablet intravagina every 12 hours. MAIN OUTCOME MEASURES: Mean induction delivery time, mean abortion time, maternal side effects. RESULTS: The mean induction delivery time was 21.38 + 13.68 hours, mean abortion time was 21.56 +/- 13.68 hours. Diarrhea was the most common side effect occuring in 40 per cent of patients. CONCLUSIONS: 800 mcg vaginal misoprostol every 12 hours is effective but if we want high efficacy along with fewer side effects, lower dose and interval should be further studied

66 Pongsatha S, Tongsong T, Suwannawut O. Therapeutic termination of second trimester pregnancy with vaginal misoprostol. J Med Assoc Thai 2001 Apr;84(4):515-9.

Abstract: OBJECTIVE: To evaluate the efficacy of vaginal misoprostol in therapeutic termination of second trimester pregnancy with a live fetus. DESIGN: Prospective descriptive study. SETTING: Maharaj Nakorn Chiang Mai Hospital, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. SUBJECTS: Pregnant women meeting the inclusion criteria including 1) pregnancy with a live fetus, 2) gestational age of 14-28 weeks, 3) having an indication for therapeutic termination, 4) Bishop’s score of < or = 4, 5) absence of uterine contraction and leakage of amniotic fluid, 6) no previous classical uterine scar and 7) no contraindication for misoprostol such as hypersensitivity. INTERVENTION: 400 microgram misoprostol gel intravagina every 12 hours. MAIN OUTCOME MEASURES: Mean induction-delivery time, mean abortion time, maternal side effects. RESULTS: Sixty eight pregnant women were recruited into the study. The mean induction-delivery time was 35.58 +/- 34.13 hours, mean abortion time was 35.80 +/- 34.13 minutes. Fever was the most common side effect occuring in about two-third of the patients, but no serious maternal complication was observed. CONCLUSION: 400 microgram vaginal misoprostol is effective for therapeutic termination of second trimester pregnancy with no serious side effects. However, the response to this treatment was markedly varied from patient to patient

67 Pongsatha S, Tongsong T, Somsak T. A comparison between 50 mcg oral misoprostol every 4 hours and 6 hours for labor induction: a prospective randomized controlled trial. J Med Assoc Thai 2001 Jul;84(7):989-94.

Abstract: OBJECTIVE: To compare the effectiveness and safety between 50 mcg oral misoprostol every 4 hours and 6 hours for labor induction. DESIGN: A prospective randomized controlled trial. SETTING: Department of Obstetrics & Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. SUBJECTS: Eighty nine pregnant women of at least 34 weeks’ gestation with indications for labor induction in the condition of unfavourable cervix (Bishop score < or = 4) and no contraindication to prostaglandin therapy. INTERVENTIONS: All pregnant women were randomized to receive either 50 mcg misoprostol orally every 4 hours or 6 hours. MAIN OUTCOME MEASURES: Treatment interval from induction to vaginal delivery, maternal and neonatal complication. RESULTS: The mean treatment intervals from induction to vaginal delivery were 22.10 +/- 18.49 hours and 20.91 +/- 11.98 hours in the misoprostol group every 4 hours and 6 hours, respectively. The treatment intervals between the two groups were not statistically significant. There was also no significant difference between both groups with regard to maternal and neonatal complications. CONCLUSION: The effectiveness in terms of treatment interval from induction to vaginal delivery were comparable between the two groups, but administration of misoprostol every 6 hours was found to have a slightly shorter interval, although it did not reach statistical significance. No serious maternal and neonatal complication was demonstrated in both groups. Either regimen in this study can be an alternative for labor induction

68 Sanguansermsri T, Thanaratanakorn P, Steger HF, Tongsong T, Sirivatanapa P, Wanapirak C, et al. Prenatal diagnosis of hemoglobin Bart’s hydrops fetalis by HPLC analysis of hemoglobin in fetal blood samples. Southeast Asian J Trop Med Public Health 2001 Mar;32(1):180-5.

Abstract: Since HbF and HbA are not found in fetuses with Hb Bart’s hydrops fetalis the feasibility of prenatal diagnosis of homozygous alpha-thalassemia 1 by fetal hemoglobin typing was examined. Blood samples were obtained from fetuses at 18 to 22 weeks of gestation by cordocentesis in 32 pregnant women at risk of having a child with homozygous alpha-thalassemia 1 (alpha-thal-1). The samples were analyzed by a PCR-based method for the diagnosis of alpha-thal-1 (SEA type) and the proportion of hemoglobin fractions were determined by automated HPLC. DNA analysis showed that 8 of the 32 fetuses were homozygotes for alpha-thal-1, 17 were heterozygous for alpha-thal-1 (alpha-thal-1 trait), and a normal complement of four a-globin genes was found in 7 cases. The Hb typing in fetuses with homozygous alpha-thal-1 showed a peak of unbound Hb (Hb Bart’s and Hb Portland) and no HbF, HbA and HbA The alpha-thal-1 trait chromatograms showed unbound Hb, pre HbF, HbF and HbA peaks. The chromatogram of normal fetuses showed HbF and HbA peaks without HbA2. In these cases the HbA proportion is between 3% and 10% with no apparent differences between the 18h and 22nd week of gestation. As the analysis of fetal Hb types by HPLC is facile and speedy and the results correspond with those obtained by DNA analysis, fetal Hb typing by automated HPLC is a convenient prenatal diagnostic method for homozygous alpha-thal-1. The method is recommended for prenatal diagnosis in populations with a high frequency of alpha-thal-1

69 Sanguansermsri T, Thanarattanakorn P, Steger HF, Tongsong T, Chanprapaph P, Wanpirak C, et al. Prenatal diagnosis of beta-thalassemia major by high-performance liquid chromatography analysis of hemoglobins in fetal blood samples. Hemoglobin 2001 Feb;25(1):19-27.

Abstract: In Thailand and adjacent countries, most of the beta-thalassemia genes are beta(0)-thalassemia mutations that prevent the production of Hb A. We propose the quantitation of the Hb A fraction in fetal blood in the mid-trimester of pregnancy by automated high performance liquid chromatography as a reasonable prenatal diagnostic method to be applied in areas with limited laboratory facilities. Forty pregnant women at risk of delivering a child with beta-thalassemia major were identified using an erythrocyte osmotic fragility test and quantitation of Hb A2. Cordocentesis was performed at the gestational age of 18-22 weeks and fetal blood was analyzed for hemoglobin fractions by automated high performance liquid chromatography. The beta-globin gene mutations were characterized by beta-globin gene sequencing. The 4 bp deletion at codons 41/42 (-TTCT) was the most frequent of the 40 beta-thalassemia mutations observed (20/40 = 50%), followed by the splice site mutation IVS-I-1 (G–>T) (7/40 = 17.5%), the nonsense mutation at codon 17 (A–>T) (7/40 = 17.5%), the nonsense mutation at codon 35 (C–>A) (3/40 = 7.5%), and the beta(+)-thalassemia promoter mutation at -28 (A–>G) (3/40 = 7.5%). High performance liquid chromatography revealed nine fetuses which had only Hb F and no Hb A. All were homozygotes or compound heterozygotes for beta(0)-thalassemia mutations. In the remaining 31 fetuses, a Hb A peak was present in the chromatograms. One fetus with 0.5% Hb A was a compound heterozygote for the -28 (A–>G) and codons 41/42 (-TTCT) mutations. In the remaining 30 fetuses, the Hb A values ranged between 0.8 and 7.4%. Twenty of these, with a Hb A concentration of 1.82 +/- 0.49% (range 0.8-2.8%), were beta-thalassemia heterozygotes. The remaining 10 fetuses had Hb A values of 4.89 +/- 1.47% (range 2.9-7.4%) and normal beta-globin genes. The absence of Hb A in homozygotes or compound heterozygotes for beta(0)-thalassemia mutations and the presence of measurable amounts of Hb A in heterozygotes and normal homozygotes, permits the diagnosis of fetuses expected to develop postnatal beta-thalassemia major

70 Tongsong T, Chanprapaph P. Prenatal diagnosis of isolated anorectal atresia with colonic perforation. J Obstet Gynaecol Res 2001 Oct;27(5):241-4.

Abstract: We report here a case of prenatal diagnosis of isolated anorectal atresia with intrauterine colonic perforation at 34 weeks of gestation, characterized by the presence of a bilobed cystic pelvic mass with a V-shape appearance separated from the bladder with changing features during observation. Mild ascites was also visualized. Other structures were normal on detailed ultrasound. The patient had spontaneously delivered a male infant weighing 2,100 g at 34 weeks of gestation. The infant died one day after birth, before surgical correction secondary to respiratory distress syndrome. Autopsy revealed isolated anorectal atresia, and high (supraelevator) lesions. In conclusion, the findings of bilobed cystic pelvic mass with a V-shape were useful to diagnose anorectal atresia in this case. Prenatal ultrasound can facilitate early diagnosis and treatment

71 Tongsong T, Chanprapaph P, Khunamornpong S. Prenatal diagnosis of VACTERL association: a case report. J Med Assoc Thai 2001 Jan;84(1):143-8.

Abstract: A prenatal diagnosis of VACTERL association, a combination of vertebral (V), anal (A), cardiac (C), tracheoesophageal (TE), renal (R) and limb (L) anomalies was made at 30 weeks of gestation, based on the sonographic demonstration of vertebral defects, bilateral renal agenesis, and left lower limb defects. Additionally, severe oligohydramnios and fetal growth restriction were also documented. After proper counseling, elective termination of pregnancy was done, resulting in a stillborn infant with multiple malformations compatible with the VACTERL association. The postnatal X-ray and autopsy revealed verterbral defects, anorectal atresia with undetermined sex, cardiac defect of ventricular septal defect, tracheal agenesis with distal atresia of esophagus, bilateral renal agenesis, and limbs defects. The chromosomal study revealed normal, 46,XY. This report emphasizes the important role of prenatal ultrasound in the diagnosis and management of this disorder

72 Tongsong T, Wanapirak C, Kunavikatikul C, Sirirchotiyakul S, Piyamongkol W, Chanprapaph P. Fetal loss rate associated with cordocentesis at midgestation. Am J Obstet Gynecol 2001 Mar;184(4):719-23.

Abstract: OBJECTIVE: The aim of this study was to assess the risk of fetal loss attributable to cordocentesis at midgestation. STUDY DESIGN: A cohort study was conducted during the period 1989-1999. Women undergoing cordocentesis between 16 and 24 weeks’ gestation with singleton pregnancies without obvious fetal anomaly were recruited into the study group. The control subjects were selected prospectively on a one-to-one basis with strict matching for maternal age, parity, gestational age at recruitment, and socioeconomic status. Both groups were prospectively followed up until delivery. RESULTS: A total of 1281 women with successful cordocentesis and their matched control subjects were recruited to the study. After exclusion of some pairs because of loss to follow-up or fetal malformations or severe disease necessitating termination of pregnancy, 1020 matched pairs were available to be compared with respect to fetal loss rate and pregnancy outcomes. The fetal loss rate was significantly higher among the study group (3.2% vs. 1.8%; P <.05, McNemar test). However, there were no significant differences in other obstetric complications between the study and control groups. CONCLUSION: The incremental fetal loss rate associated with cordocentesis at midgestation was about 1.4%

73 Tongsong T, Wanapirak C, Sirivatanapa P, Sa-nguansermsri T, Sirichotiyakul S, Piyamongkol W, et al. Prenatal eradication of Hb Bart’s hydrops fetalis. J Reprod Med 2001 Jan;46(1):18-22.

Abstract: OBJECTIVE: To evaluate the effectiveness of prenatal prevention of Hb Bart’s hydrops fetalis. STUDY DESIGN: The study was a prospective descriptive analysis of pregnant women attending an antenatal clinic between June 1990 and June 1998. The study consisted of two periods, the first half with no prenatal diagnosis (PND) (1990-1994) and the second half with PND. During the study period, all cases of Hb Bart’s hydrops fetalis were prospectively collected and postnatally confirmed. In the second period, prenatal strategy to control severe thalassemia was introduced. The strategy included (1) carrier identification by retrospective (history review for known risk) and prospective screening (simple erythrocyte osmotic fragility test) in women without known risks, (2) the couples at risk were offered genetic counseling and cordocentesis, (3) analysis of fetal blood for diagnosis, and (4) counseling for termination of pregnancy. RESULTS: During the first half of the study, the prevalence of Hb Bart’s hydrops fetalis was 0.305 (89 in 29,399 deliveries). There were no fetuses with Hb Bart’s hydrops fetalis among 16,360 screened pregnancies in the second half. However, of 6,856 pregnancies in the second half not screened due to a late first visit, 10 (0.15%) fetuses had Hb Bart’s hydrops fetalis. Among the screened group, cordocentesis was performed in 361 pregnancies at risk, 170 and 191 from retrospective and prospective screening, respectively; and 75 (20.8%) were proven to have Hb Bart’s disease, which was diagnosed before hydropic changes occurred. CONCLUSION: The strategy proved effective in preventing Hb Bart’s hydrops fetalis, and extensive experience with it suggests that it be considered an effective way to control severe thalassemia

74 Tongsong T, Wanapirak C, Sirichotiyakul S, Sirivatanapa P. Prenatal sonographic markers of trisomy 21. J Med Assoc Thai 2001 Feb;84(2):274-80.

Abstract: OBJECTIVE: To describe the sonographic characteristics of fetuses with trisomy 21. DESIGN: A prospective descriptive analysis. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. SUBJECTS: Pregnancies at risk of trisomy 21 between 14-27 weeks’ gestation. RESULTS: Thirty-six fetuses with subsequently proven trisomy 21 were prenatally evaluated by ultrasound in the second trimester. The main indications for detailed ultrasound examinations were advanced maternal age and abnormal findings on routine ultrasound. All of them had chromosome analysis by amniocentesis or cordocentesis. Nineteen (52.78%) had one or more abnormal findings. The common sonographic findings included thickened nuchal fold (33.33%), short femur (19.44%), and mild pyelectasis (22.22%). The other uncommon abnormalities included major anomalies (cardiac malformations, ventriculomegaly, duodenal atresia, esophageal atresia), hyperechoic bowel, echogenic intracardiac foci, abnormalities of extremities. In this study, rare minor markers but more specific markers including sandal gap, clinodactyly and mid-phalanx hypoplasia of the fifth finger were demonstrated. CONCLUSION: About half of the fetuses with trisomy 21 had abnormal sonographic findings in the second trimester. The most common marker was thickened nuchal fold. Although prenatal ultrasound can not permit a definite diagnosis of trisomy 21, about half of them have sonographic markers, warranting cytogenetic testing

75 Wanapirak C, Nimitwongsakul S, Tongsong T. Sonographic morphology scores (SMS) for differentiation between benign and malignant ovarian tumor. J Med Assoc Thai 2001 Jan;84(1):30-5.

Abstract: The objectives of this cross-sectional descriptive analysis are to determine the sensitivity and specificity of sonographic morphology scores (SMS) in distinguishing between benign and malignant ovarian tumors and to determine the best cut-off score. The study was conducted at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. Two hundred and forty eight nonpregnant patients scheduled for elective surgery for ovarian tumors between July, 1996 and March, 1998 were recruited into the study and were sonographically examined in 24 hours of surgery by the same sonographer to evaluate inner wall structure, wall thickness, septum, echogenicity and score of the tumors. The final diagnosis was pathologically confirmed as the gold standard. It was found that the score of 9 from reciever operating characteristic curve was the best cut-off score, giving the sensitivity of 93.1 per cent and specificity of 75.6 per cent. In conclusion, the SMS system is probably useful in distinguishing ovarian malignancy from benign ovarian tumor

76 Weerachatyanukul W, Rattanachaiyanont M, Carmona E, Furimsky A, Mai A, Shoushtarian A, et al. Sulfogalactosylglycerolipid is involved in human gamete interaction. Mol Reprod Dev 2001 Dec;60(4):569-78.

Abstract: Recent results from our laboratory have revealed the role of sulfogalactosylglycerolipid (SGG) in mouse sperm-zona pellucida (ZP) binding. In this report, we demonstrated the presence of SGG in Percoll-gradient centrifuged (PGC) human sperm by high performance thin layer chromatography with orcinol and Azure A staining, specific for glycolipids and sulfolipids, respectively. SGG in human PGC sperm was quantified by its affinity to Azure A to be 12-15 mol% of sperm lipids. Indirect immunofluorescence revealed that SGG existed on both live and aldehyde fixed human sperm in the head region. Pretreatment of human PGC sperm with affinity purified antiSGG Fab markedly inhibited sperm binding to the ZP in a concentration dependent manner, without any changes in the spontaneous acrosome rate or sperm motility parameters. Fluorescently labeled SGG liposomes also bound uniformly to isolated human ZP, while fluorescently labeled galactosylglycerolipid (GG, SGG’s parental lipid) or phosphatidylserine (PS, negatively charged like SGG) liposomes did not. All of these results suggested the role of human sperm SGG in ZP binding

77 Chanprapaph P, Tongsong T, Wanapirak C, Sirichotiyakul S, Sanguansermsri T. Prenatal diagnosis of alpha-thalassemia-1 (SEA type) by chorionic villus sampling. J Med Assoc Thai 2002 Oct;85(10):1049-53.

Abstract: OBJECTIVE: To describe the experience of prenatal diagnosis for Hb Bart’s disease, by chorionic villus sampling (CVS) with DNA analysis. DESIGN: Descriptive study SETTINGS: Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. SUBJECTS: Sixteen high risk pregnancies at risk of Hb Bart’s disease who were eligible for CVS criteria between 1 January, 1999 and May 31, 2000. MATERIAL AND METHOD: Fetal villi were obtained by either transcervical (TC) or transabdominal (TA) CVS route to extract DNA and detect for alpha-thal-1 gene deletion (SEA type) with modified Chang’s method. The CVS results were confirmed by either serial ultrasound or cordocentesis or diagnosis after pregnancy termination. MAIN OUTCOME MEASURES: The efficacy, safety and pregnancy outcomes. RESULTS: CVS was successfully done in all of 16 cases (5 with TC and 11 with TA), The mean gestational age was 13.25 +/- 2.9 weeks. The procedure time for TA was shorter than that of TC (4.64 +/- 5.4 vs 10.4 +/- 11.3 min). The CVS result showed as follows: 3 normal fetuses, 7 alpha-thal-1 carriers, 4 fetal Hb Bart’s, 1 misdiagnosis and 1 failure to diagnosis due to technical error. The sensitivity and specificity were 100 per cent (4/4) and 90.91 per cent (10/11), respectively. One case of Hb Bart’s misdiagnosis and one failure case were later confirmed for alpha-thal-1 trait and alpha-thal-1/ Hb E trait by cordocentesis, respectively. The pregnancy outcomes included 11 livebirths, 4 terminated cases and 1 fetal loss of continuing pregnancies. No serious complications occurred. CONCLUSION: This preliminary experience suggests that CVS is an effective method for early prenatal diagnosis of fetal Hb Bart’s

78 Harper JC, Wells D, Piyamongkol W, bou-Sleiman P, Apessos A, Ioulianos A, et al. Preimplantation genetic diagnosis for single gene disorders: experience with five single gene disorders. Prenat Diagn 2002 Jun;22(6):525-33.

Abstract: We report our experience of 14 preimplantation genetic diagnosis (PGD) cycles in eight couples carrying five different single gene disorders, during the last 18 months. Diagnoses were performed for myotonic dystrophy (DM), cystic fibrosis (CF) [Delta F508 and exon 4 (621+1 G>T)], fragile X and CF simultaneously, and two disorders for which PGD had not been previously attempted, namely neurofibromatosis type 2 (NF2) and Crouzon syndrome. Diagnoses for single gene disorders were carried out on ideally two blastomeres biopsied from Day 3 embryos. A highly polymorphic marker was included in each diagnosis to control against contamination. For the dominant disorders, where possible, linked polymorphisms provided an additional means of determining the genotype of the embryo hence reducing the risk of misdiagnosis due to allele dropout (ADO). Multiplex fluorescent polymerase chain reaction (F-PCR) was used in all cases, followed by fragment analysis and/or single-stranded conformation polymorphism (SSCP) for genotyping. Embryo transfer was performed in 13 cycles resulting in one biochemical pregnancy for CF, three normal deliveries (a twin and a singleton) and one early miscarriage for DM and a singleton for Crouzon syndrome. In each case the untransferred embryos were used to confirm the diagnoses performed on the biopsied cells. The results were concordant in all cases. The inclusion of a polymorphic marker allowed the detection of extraneous DNA contamination in two cells from one case. Knowing the genotype of the contaminating DNA allowed its origin to be traced. All five pregnancies were obtained from embryos in which two blastomeres were biopsied for the diagnosis. Our data demonstrate the successful strategy of using multiplex PCR to simultaneously amplify the mutation site and a polymorphic locus, fluorescent PCR technology to achieve greater sensitivity, and two-cell biopsy to increase the efficiency and success of diagnoses

79 Pongsatha S, Sirisukkasem S, Tongsong T. A comparison of 100 microg oral misoprostol every 3 hours and 6 hours for labor induction: a randomized controlled trial. J Obstet Gynaecol Res 2002 Dec;28(6):308-12.

Abstract: OBJECTIVE: To compare the efficacy and safety of 100 microg oral misoprostol for induction of labor between the regimen of 3 hour and 6 hour interval administration. METHODS: Singleton pregnancies indicated for induction of labor between 34 and 42 weeks of gestation in the condition of unfavorable cervix (Bishop score < or = 4) and no contraindication for prostaglandins therapy were recruited into the study. All pregnant women were randomly assigned to receive 100 microg oral misoprostol every 3 hours or 6 hours until the cervix was favorable for amniotomy, spontaneous rupture of membranes or active labor occurred. RESULTS: The mean time interval from induction to vaginal delivery was significantly shorter in the 3 hour interval group, compared with the 6 hour interval group (13.82 +/- 6.98h and 17.66 +/- 7.48h, P = 0.0019). There was no significant difference between the groups with regard to mode of delivery, analgesic requirement, maternal complication and neonatal outcome. CONCLUSIONS: 100 microg oral misoprostol every 3 hours is more effective for labor induction than every 6 hours but there was no difference in mode of delivery, analgesic requirement, maternal complications and neonatal outcome. A dose of 100 microg misoprostol orally every 3 hours seems to be the optimum regimen and the new option for labor induction. However, further study should be performed

80 Pongsatha S, Morakot N, Tongsong T. Demographic characteristics of women with self use of misoprostol for pregnancy interruption attending Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2002 Oct;85(10):1074-80.

Abstract: OBJECTIVE: To ascess the demographic characteristics of pregnant women and their partners including details of self use of misoprostol for pregnancy interruption. STUDY DESIGN: Prospective descriptive study. SETTING: Department of Obstetrics and Gynecology, Maharaj Nakorn Chiang Mai Hospital. SUBJECTS: 103 pregnant women with self use of misoprostol for pregnancy interruption from June 1999 to June 2001. METHOD: All subjects were interviewed use the same set of questionnaires. RESULTS: The mean age of the women and their partners were 20.81 +/- 4.10 and 22.46 +/- 5.05 years old respectively. The mean gestational age was 13.85 +/- 5.37 weeks. The most common reason for pregnancy interruption was that they wanted to continue studying. The number of misoprostol tablets used ranged from 1-11 and 87.4 per cent of the women applied this drug via the vaginal route. The main source of drug purchasing was from friends, while the mean total cost was 663.16 +/- 711.32 Baht. No major side effect was detected in the present study. CONCLUSION: Misoprostol, the agent primarily used for gastric and duodenal ulcer prevention, is now used by pregnant women to interrupt their pregnancies. The present study is only the evidence reflecting the tip of the iceberg in this society, changing in sexual behavior, change in abortion techniques, and knowledge on contraception. Though major complications were not found in this study, misoprostol should not be considered safe, because several patients have encountered bleeding or incomplete abortion and required hospital stay

81 Sirichotiyakul S, Tongsong T, Wanapirak C, Chanprapaph P. Prenatal sonographic diagnosis of Majewski syndrome. J Clin Ultrasound 2002 Jun;30(5):303-7.

Abstract: Majewski syndrome is an autosomal recessive disorder characterized by short ribs, polydactyly, short limbs, and a cleft lip. A 26-year-old woman with no family history of genetic diseases presented at 31 weeks’ menstrual age with preterm labor and underwent prenatal sonography to screen for fetal anomalies. Sonography revealed a small thorax, markedly short ribs, micromelia, polydactyly, a cleft lip, dolichocephaly, and severe oligohydramnios. The other structures appeared normal. The most likely diagnosis was Majewski syndrome. Vaginal breech delivery was allowed to proceed. The 1,850-g male newborn died of respiratory failure shortly after birth. The postnatal appearance and radiographs confirmed the prenatal diagnosis

82 Tongsong T, Sirichotiyakul S, Wanapirak C, Chanprapaph P. Sonographic features of trisomy 18 at midpregnancy. J Obstet Gynaecol Res 2002 Oct;28(5):245-50.

Abstract: OBJECTIVE: To evaluate the sonographic characteristics of the fetuses with trisomy 18 at 16-22 weeks of gestation. METHODS: The subjects were recruited from pregnant women undergoing prenatal sonographic examinations at 16-22 weeks of gestation and subsequently proven to be trisomy 18. The results of ultrasound findings were retrospectively reviewed in 25 cases with chromosomes which were confirmed as trisomy 18. RESULTS: All cases had at least one abnormal sonographic finding. There was only one case that had no structural abnormality, but fetal growth restriction was documented. The common sonographic findings included fetal growth restriction, choroid plexus cysts, cardiac anomalies, clenched hand, omphalocele and cleft lip. Fetal growth restriction was the most common finding demonstrated in nearly half of all cases. Other less common findings were diaphragmatic hernia, abnormal head shape, polyhydramnios, single umbilical artery. CONCLUSION: Nearly all fetuses with trisomy 18 had characteristic sonographic patterns of abnormalities demonstrated at midpregnancy. Detailed ultrasound at midpregnancy could effectively screen fetuses with trisomy 18 for further genetic testing

83 Tongsong T, Wanapirak C, Sirichotiyakul S, Chanprapaph P. Intrauterine treatment for an acardiac twin with alcohol injection into the umbilical artery. J Obstet Gynaecol Res 2002 Apr;28(2):76-9.

Abstract: An acardiac twin is a unique complication of monochorionic twinning, in which a normal pump twin perfuses the acardiac twin. The mortality rate of the pump twin is greater than 50%. Herein we present the successful treatment of an acardiac twin with alcoholization as follows. An acardiac twin was diagnosed at 24 weeks gestation. Circulation interruption of the acardiac twin was successfully achieved by injection of absolute alcohol (5 mL) into the intra-abdominal umbilical artery. Serial ultrasound after the procedure revealed normal growth of the pump twin, whereas the acardiac twin was shrinking. Spontaneous premature delivery at 34 weeks gestation resulted in a normal surviving female baby weighing 2410g and an acardiac female fetus weighing 300g. This experience suggests that this simple technique may be an alternative treatment for an acardiac twin

84 Tongsong T, Sirichotiyakul S, Wanapirak C, Chanprapaph P. Sonographic features of trisomy 13 at midpregnancy. Int J Gynaecol Obstet 2002 Feb;76(2):143-8.

Abstract: OBJECTIVES: To evaluate the sonographic characteristics, at 16-22 weeks of gestation, of fetuses later diagnosed with trisomy 13. METHODS: This descriptive analysis of a case series was conducted from June 1989 to May 2001 at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand. Women with abnormal sonographic findings at midpregnancy (16-22 weeks of gestation) underwent amniocentesis or cordocentesis for karyotyping, and the inclusion criterion was proven trisomy 13. RESULTS: Indications for sonographic examination at midpregnancy were a genetic risk, large- or small-for-date fetus, and other suspected anomalies. Fifteen fetuses were later diagnosed with trisomy 13. In all of these cases there was at least one abnormal sonographic finding. In only one case did the fetus show no structural abnormality (at 17 weeks), but polyhydramnios and fetal growth restriction were observed. Common sonographic findings included holoprosencephaly with associated facial anomalies, and abnormal feet and/or hands, especially polydactyly. Non-structural abnormal findings such as polyhydramnios or fetal growth restriction were seen in less than one third of the fetuses. CONCLUSIONS: Nearly all the fetuses with trisomy 13 had sonographic characteristics of abnormalities at midpregnancy although common findings had often not yet appeared or the findings were low-sensitive. Detailed ultrasound at midpregnancy could effectively screen for further genetic testing pregnancies at risk for trisomy 13

85 Tongsong T, Wanapirak C, Sirichotiyakul S, Chanprapaph P. Prenatal sonographic diagnosis of diastrophic dwarfism. J Clin Ultrasound 2002 Feb;30(2):103-5.

Abstract: A healthy 27-year-old pregnant woman underwent sonographic examination because her uterine size was large for 20 weeks’ menstrual age. Sonograms showed short fetal limbs with hitchhiker thumbs and toes, thoracic scoliosis, clubbed feet, and polyhydramnios. The ossification of all bony structures appeared normal, and there was no evidence of fractures. On the basis of these sonographic findings, we diagnosed skeletal dysplasia and short-limbed dwarfism, most likely diastrophic dwarfism. We counseled the parents, and the pregnancy was continued. At 37 weeks menstrual age, the patient vaginally delivered a male infant that weighed 2,560 g. The infant survived with respiratory support during his first few days of life. Postnatal physical and radiologic examinations confirmed the prenatal diagnosis of diastrophic dwarfism. Sonography is the modality of choice for prenatal detection of diastrophic dwarfism

86 Wanapirak C, Tongsong T, Sirichotiyakul S, Chanprapaph P. Alcoholization: the choice of intrauterine treatment for chorioangioma. J Obstet Gynaecol Res 2002 Apr;28(2):71-5.

Abstract: Chorioangioma is a vascular tumor of the placenta. Most are small and asymptomatic, whereas the large tumors are clinically significant and often associated with polyhydramnios and fetal heart failure. To prevent fetal loss from these complications, many interventions have been proposed, including intrauterine transfusion in anemic cases and fetoscopic surgery to ablate the feeding vessels. The case presented herein had large chorioangiomas, 8 and 4cm in diameter, associated with polyhydramnios and early signs of hydrops fetalis, diagnosed at 27 weeks gestation. After extensive counseling, we performed alcohol ablation of the feeding vessel of the larger tumor. Signs of fetal heart failure and hydrops fetalis disappeared dramatically. The pregnancy was extended for 2 weeks, followed by premature rupture of the membranes and spontaneous labor at 32 weeks gestation and a surviving female baby, weighing 1360g, was delivered uneventfully. This preliminary experience suggests that alcoholization may be one of the best choices for this condition due to its high efficacy, simplicity, safety and very low cost. To our knowledge, this is the first report using alcoholization for the treatment of hydrops fetalis secondary to chorioangioma

87 Bermudez MG, Piyamongkol W, Tomaz S, Dudman E, Sherlock JK, Wells D. Single-cell sequencing and mini-sequencing for preimplantation genetic diagnosis. Prenat Diagn 2003 Aug;23(8):669-77.

Abstract: There is increasing interest in the use of preimplantation genetic diagnosis (PGD) as an alternative to routine prenatal diagnosis. However, the costs associated with development and testing of new PGD protocols have forced some PGD centres to limit the number of diseases for which PGD is offered. One of the main factors in the design of new protocols, which affects cost and accuracy, is the choice of the mutation-detection technique. We have assessed the reliability of DNA sequencing and mini-sequencing for clinical diagnosis at the single-cell level and have found them to be rapid and accurate. Extensive optimisation for individual mutations is not usually necessary when employing these versatile techniques and consequently a smaller investment of time and resources should be required during development of new protocols. Additionally, we report single-cell protocols for the diagnoses of cystic fibrosis, sickle cell anaemia and beta-thalassaemia, which utilise mini-sequencing. Unlike most mutation-detection techniques, mini-sequencing permits analysis of very small DNA fragments. Small amplicons experience low allele dropout (ADO) rates, and consequently this approach could potentially improve the reliability of PGD

88 Piyamongkol W, Bermudez MG, Harper JC, Wells D. Detailed investigation of factors influencing amplification efficiency and allele drop-out in single cell PCR: implications for preimplantation genetic diagnosis. Mol Hum Reprod 2003 Jul;9(7):411-20.

Abstract: Preimplantation genetic diagnosis (PGD) of single gene disorders relies on PCR-based tests performed on single cells (polar bodies or blastomeres). Despite the use of increasingly robust protocols, allele drop-out (ADO; the failure to amplify one of the two alleles in a heterozygous cell) remains a significant problem for diagnosis using single cell PCR. In extreme cases ADO can affect >40% of amplifications and has already caused several PGD misdiagnoses. We suggest that an improved understanding of the origins of ADO will allow development of more reliable PCR assays. In this study we carefully varied reaction conditions in >3000 single cell amplifications, allowing factors influencing ADO rates to be identified. ADO was found to be affected by amplicon size, amount of DNA degradation, freezing and thawing, the PCR programme, and the number of cells simultaneously amplified. Factors found to have little or no affect on ADO were local DNA sequence, denaturing temperature (94 or 96 degrees C) and cell type. Consideration of the causal factors identified during this study should permit the design of PGD protocols that experience little ADO, thus improving the accuracy of PGD for single gene disorders

89 Pongsatha S, Tongsong T. Misoprostol for second trimester termination of pregnancies with prior low transverse cesarean section. Int J Gynaecol Obstet 2003 Jan;80(1):61-2.

No abstract is available

90 Sirichotiyakul S, Saetung R, Sanguansermsri T. Analysis of beta-thalassemia mutations in northern Thailand using an automated fluorescence DNA sequencing technique. Hemoglobin 2003 May;27(2):89-95.

Abstract: A total of 218 beta-thalassemia (thal) genes from 109 beta-thal major patients were characterized using an automated fluorescence DNA sequencing technique. Eight different mutations were identified in all 218 alleles (100%). Four common mutations accounted for 96.8% [49.5% were codons 41/42 (-TTCT), 34.4% were codon 17 (A –> T), 6.9% were IVS-I-1 (G –> T) and, 6.0% were codons 71/72 (+A)]. There were three cases of -28 (A –> G) and one of IVS-II-654 (C –> T), mutations that have been previously described in Thai subjects. We also identified two mutations in the beta-globin promoter region which have not been reported in Thailand before [-31 (A –> G) and -87 (C –> A)]. Although these mutations are described as beta+-thal, the compound heterozygote with one of the common beta(o)-thal mutations exhibits the phenotype of beta-thal major. The frequency of beta-thal genes in northern Thailand were similar to the northeastern region, but different from those reported in southern and central Thailand, where IVS-I-5 (G –> C) and IVS-II-654 (C –> T) were the second most common anomalies, respectively. The spectrum of beta-globin gene mutations from this study will be useful for planning a prenatal diagnosis program especially for this region of Thailand

91 Tongsong T, Jitawong C. Success rate of vaginal birth after cesarean delivery at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2003 Sep;86(9):829-35.

Abstract: OBJECTIVE: To study the success rate of vaginal birth after cesarean delivery (VBAC) in pregnant women with prior cesarean scar who delivered at Maharaj Nakorn Chiang Mai Hospital. STUDY DESIGN: Prospective descriptive study. SETTING: Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. SUBJECT: One hundred and seventy-seven pregnant women with one or two prior cesarean deliveries, who attended the antenatal clinic and delivered at Maharaj Nakorn Chiang Mai Hospital between January, 2000 and September, 2002 were recruited with written informed consents. INTERVENTION: Systematic non-directive counseling concerning VBAC compared with elective repeated cesarean delivery was given to the pregnant women. Couples freely chose their preferred route of delivery and were informed that they could change their mind at anytime. Subjects attended the high risk antenatal care clinic. Patients who requested repeated cesarean deliveries were scheduled for the operation at 38 weeks of gestation. All VBAC patients were admitted to the labor unit when in labor and were closely monitored. Labor and postpartum information was prospectively recorded. MAIN OUTCOME MEASURE: Success rate of VBAC. RESULT: Of 177 counselled women, 118 chose VBAC, 54 chose repeated cesarean and 5 could not make a decision. Thirty-three of the 177 cases were excluded, leaving 98 in the VBAC group and 46 in the repeated cesarean group. Baseline characteristics of the patients in both groups were not significantly different. Nineteen of the 98 cases were delivered by cesarean section because of obstetric indications (12/19) and changed their minds during the antenatal period (7/19). Forty-three of 79 cases had successful vaginal delivery, and 36 underwent repeated cesarean deliveries due to obstetric indications (19/36) and changed their minds during labor (17/36). The success rate of VBAC after trial of labor was 54.4 per cent (43 in 79). No uterine rupture or serious complication occurred in the present study. CONCLUSION: The attitude for VBAC was 66.7 per cent and the success rate of VBAC after trial of labor was 54.4 per cent in the present series. Several cesarean deliveries could be avoided by the VBAC policy. Unlike other previous reports, the failure rate of VBAC was rather high. This was associated with many factors such as change of mind due to labor pain

92 Wanapirak C, Kato M, Onishi Y, Wada-Kiyama Y, Kiyama R. Evolutionary conservation and functional synergism of curved DNA at the mouse epsilon- and other globin-gene promoters. J Mol Evol 2003 Jun;56(6):649-57.

Abstract: Human and mouse globin genes were separated approximately 200 million years ago but still share homology and synergism in many aspects including DNA structure. We first mapped DNA bend sites in the mouse epsilon-globin gene and found that these sites were distributed in a regular manner except in the coding region and their overall average distance was 650.7 bp. The first bend site upstream of the cap site (MepsilonB-1, -334 to -147 bp) was found to contain A + T-rich sequences and features contributing to DNA curvature by computer analysis. Transcription assays using deletion constructs indicated strong promoter activity up to bp -215 in erythriod K562 cells. Therefore, the MepsilonB-1 site was located immediately upstream of the promoter region. A reporter gene assay using a series of constructs containing the promoter region revealed that the MepsilonB-1 site showed repressor activity, and on replacement of the DNA curvature with one from another source the activity was retained. A similar feature was found in the other conserved B-1 sites in the human, bovine, and rabbit beta-like globin genes, with the exception of an unconserved B-1 site in the chicken beta-globin gene. A common feature of these conserved B-1 sites was not the nucleotide sequences but the DNA curvature. Furthermore, a unique nucleosome phase at the MepsilonB-1 site was likely to be directed by DNA curvature. Based on these results, DNA curvature is one of the major features of these promoter regions which might influence transcription through nucleosome positioning

93 Chanprapaph P, Tongsong T, Siriaree S. Validity of antenatal diagnosis of intrauterine growth restriction by umbilical Doppler waveform index. J Med Assoc Thai 2004 May;87(5):492-6.

Abstract: OBJECTIVE: To evaluate the validity of systolic/diastolic (S/D) ratio of the umbilical artery in predicting intrauterine growth restriction (IUGR). STUDY DESIGN: Diagnostic test study. SETTING: Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. SUBJECTS: Two hundred and twelve singleton pregnancies between 30 and 42 weeks’ gestation with clinical suspicion of IUGR were recruited and followed-up between December 1st 1995 and June 30th 1998. They were sonographically examined for routine fetal biometry and S/D ratio of umbilical artery Doppler waveform measurement within 14 days of delivery. All of them had an accurate date of last menstrual period and were between 30-42 weeks’ gestation. MATERIAL AND METHOD: The umbilical artery S/D ratio was obtained by the same experienced sonographer, using the same ultrasound machine, Aloka 680EX, (Tokyo, Japan). The S/D ratio of 3 or greater was considered abnormal, predicting IUGR prenatally for every gestational week. IUGR was defined as low birth weight of less than the 10th percentile of the standard birth weight curve of Maharaj Nakorn Chiang Mai Hospital. MAIN OUTCOME MEASURES: Sensitivity specificity positive predictive value and negative predictive value. RESULTS: The prevalence of IUGR among the study group was 50.9%. The S/D ratio of 3 or greater for predicting of IUGR gave the sensitivity, specificity, positive predictive value, and negative predictive value of 52.96%, 78.85%, 74.42% and 65.08%, respectively. CONCLUSION: The umbilical artery S/D ratio has relatively low sensitivity and is not a suitable test for IUGR screening. However, the specificity is rather high and it may be helpful in combination with other parameters

94 Chaovisitsaree S, Piyamongkol W, Pongsatha S, Kunaviktikul C, Morakote N, Chandarawong W. Immediate complications of laparoscopic tubal sterilization: 11 years of experience. J Med Assoc Thai 2004 Oct;87(10):1147-50.

Abstract: OBJECTIVE: To evaluate the complications of laparoscopic tubal sterilization. METHOD: A retrospective study of laparoscopic tubal sterilization performed at Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai, Thailand was conducted. The details of the operation, including complications and operation time were collected from the operative and family planning registry. RESULTS: Between January 1987 and December 1997, 948 cases of laparoscopic tubal sterilization were performed as an outpatient setting. The combination of intravenous sedation and local anesthesia was employed in all cases. Minor intra-operative complications were found in 4.6% of cases. The most frequent complications were meso-salphingeal and meso-ovarian bleeding. No serious complication was found in this study. The mean operation time was 19.3 minutes (range 5-75 minutes). CONCLUSION: The present study suggested that out-patient laparoscopic tubal sterilization under the combination of intravenous sedation and local anesthesia is a convenient and relatively safe procedure

95 Ding C, Chiu RW, Lau TK, Leung TN, Chan LC, Chan AY, et al. MS analysis of single-nucleotide differences in circulating nucleic acids: Application to noninvasive prenatal diagnosis. Proc Natl Acad Sci U S A 2004 Jul 20;101(29):10762-7.

Abstract: The analysis of circulating nucleic acids has revealed applications in the noninvasive diagnosis, monitoring, and prognostication of many clinical conditions. Circulating fetal-specific sequences have been detected and constitute a fraction of the total DNA in maternal plasma. The diagnostic reliability of circulating DNA analysis depends on the fractional concentration of the targeted sequence, the analytical sensitivity, and the specificity. The robust discrimination of single-nucleotide differences between circulating DNA species is technically challenging and demands the adoption of highly sensitive and specific analytical systems. We have developed a method based on single-allele base extension reaction and MS, which allows for the reliable detection of fetal-specific alleles, including point mutations and single-nucleotide polymorphisms, in maternal plasma. The approach was applied to exclude the fetal inheritance of the four most common Southeast Asian beta-thalassemia mutations in at-risk pregnancies between weeks 7 and 21 of gestation. Fetal genotypes were correctly predicted in all cases studied. Fetal haplotype analysis based on a single-nucleotide polymorphism linked to the beta-globin locus, HBB, in maternal plasma also was achieved. Consequently, noninvasive prenatal diagnosis in a mother and father carrying identical beta-thalassemia mutations was accomplished. These advances will help in catalyzing the clinical applications of fetal nucleic acids in maternal plasma. This analytical approach also will have implications for many other applications of circulating nucleic acids in areas such as oncology and transplantation

96 Panpanit A, Muttarak M, Pongsatha S, Chaovisitsaree S, Piyamongkol W, Truengthawatchai S, et al. Mammographic change in hysterectomized women on 0.625 mg/day of conjugated equine estrogen. J Med Assoc Thai 2004 Feb;87(2):126-30.

Abstract: OBJECTIVE: To compare the mammographic change before and after conjugated equine estrogen (CEE) 0.625 mg/day in hysterectomized women. DESIGN: A retrospective descriptive study. SETTING: Menopause clinic, Maharaj Nakorn Chiang Mai Hospital. MATERIAL AND METHOD: Dedicated mammograms and demographic data of 66 women who had been hysterectomized were reviewed. Post surgical menopausal women were recruited for the study. CEE 0.625 mg/day was given just after the operation. The baseline mammography was done before the initiation of HRT and they were compared with the follow-up mammography performed 12-18 months after therapy. The degree of increase in mammographic density was classified as follows: minimal changes (10-25% increased density), moderated change (26-50% increased density), and marked change (> 50% increased density). RESULTS: The mean age +/- SD was 47 +/- 4.3 years old. The mean duration +/- SD of hormone used was 13.5 +/- 2.4 months. The most common indication for operation was myoma uteri (43.9%). On the baseline mammogram, 5 cases had cystic change and one case had a small circumscribed solid mass suspected to be fibroadenoma. On the follow-up mammograms, there were 2 cases (3.0%) detected to have significantly increased breast density. One was moderately increased and the other was markedly increased, but cystic changes and one fibroadenoma were not changed. CONCLUSION: CEE has little effect on increased mammographic density

97 Pongsatha S, Tongsong T. Therapeutic termination of second trimester pregnancies with intrauterine fetal death with 400 micrograms of oral misoprostol. J Obstet Gynaecol Res 2004 Jun;30(3):217-20.

Abstract: OBJECTIVE: To assess the efficacy and maternal side-effects of oral misoprostol for second trimester termination of pregnancies with intrauterine fetal death. METHODS: A prospective descriptive study was conducted on 63 pregnant women who had intrauterine fetal death with unfavorable cervix (Bishop scores </=4). All received 400 micro g of misoprostol orally every 4 h until favorable cervix was achieved. Main outcome measures included success rate of termination within 12, 24, 36 and 48 h, mean induction to delivery time and maternal side-effects. RESULTS: The success rates of termination within 12, 24, 36, 48 h were 50.8%, 84.1%, 88.9% and 92.1%, respectively. Mean induction to delivery time in cases of delivery within 48 h was 13.2 +/- 8.4 h, range 2.25-22.9 h. The most common maternal side-effect was chill (33.3%). No serious maternal complication was detected. CONCLUSION: 400 micro g oral misoprostol every 4 h is effective for pregnancy termination in cases of intrauterine fetal death and may be an alternative regimen because of its ease and convenience

98 Pongsatha S, Tongsong T. Intravaginal misoprostol for pregnancy termination. Int J Gynaecol Obstet 2004 Nov;87(2):176-7.

No abstract is available

99 Sirichotiyakul S, Tongprasert F, Tongsong T. Screening for hemoglobin E trait in pregnant women. Int J Gynaecol Obstet 2004 Sep;86(3):390-1.

No abstract is available

100 Sirichotiyakul S, Tantipalakorn C, Sanguansermsri T, Wanapirak C, Tongsong T. Erythrocyte osmotic fragility test for screening of alpha-thalassemia-1 and beta-thalassemia trait in pregnancy. Int J Gynaecol Obstet 2004 Sep;86(3):347-50.

Abstract: OBJECTIVES: To evaluate the sensitivity and specificity of osmotic fragility test (OFT) as a screening test in predicting the severe thalassemia trait (alpha-thalassemia-1 & beta-thalassemia). METHODS: A descriptive analysis and diagnostic test of non-anemic pregnant women attending antenatal care clinic, Maharaj Nakorn Chiang Mai, during April, and July 2002 was made. Blood samples were collected from 446 singleton pregnancies with no obvious medical complication such as iron deficiency anemia. OFT was performed in the same day, using 0.45% glycerin saline solution and the cut-off value of less than 60% was used for an abnormal test. Quantitative HbA2 test and PCR (SEA type) were done as a gold standard to confirm the diagnosis of beta-thalassemia trait and alpha-thalassemia-1 trait, respectively. RESULTS: The main outcome measures were sensitivity, specificity, positive and negative predictive value of OFT. If the OFT cut-off value of less than 60% was considered positive, the test had a sensitivity, specificity, positive and negative predictive value of 97.6%, 72.9%, 33.6%, and 99.5%, respectively. CONCLUSION: OFT has high sensitivity in detection of alpha-thalassemia-1 trait or beta-thalassemia trait and due to its simplicity with very low cost it may, therefore, be considered as a screening test in a wide population

101 Tongsong T, Sirichotiyakul S, Sukpan K, Sittiwangkul R. Prenatal features of a truncus arteriosus with pulmonary atresia and pulmonary circulation derived from the ductus arteriosus. J Ultrasound Med 2004 Sep;23(9):1221-4.

No abstract is available

102 Tongsong T, Tatiyapornkul T. Cardiothoracic ratio in the first half of pregnancy. J Clin Ultrasound 2004 May;32(4):186-9.

Abstract: PURPOSE: The present study was conducted to establish the nomogram of fetal cardiothoracic (C/T) ratio in the first half of normal pregnancies (eg, 11-20 weeks of gestation), using conventional sonographic techniques. METHODS: Two hundred thirty-eight normal pregnant women enrolled in our prenatal care were recruited into this study. All the patients had singleton fetuses whose gestational age could be accurately determined by the patient’s last menstrual period and sonographic measurements. All the newborns were proven to be normal at birth. The sonographic measurements used to calculate the C/T ratio were obtained from axial scans at the level of the four-chamber view. All measurements were made by the same examiner using a single high-resolution machine. RESULTS: A total of 238 C/T ratio measurements were made. The mean C/T ratio values increased slightly with gestational age, rising from 0.38 at 11 weeks to 0.45 at 20 weeks. The mean C/T value at each gestational week was never greater than 0.50, and no fetus had a C/T ratio greater than 0.50 at 11-15 weeks of gestation. The means and 5th, 50th, and 95th percentiles of the C/T ratio were calculated for each week of gestation and the nomogram was established. CONCLUSIONS: Calculation of the C/T ratio is a simple, reliable, reproducible, and time-efficient means of assessing the size of the fetal heart. By comparing the C/T ratio with the normal values presented here, physicians should be able to more easily identify cases of cardiomegaly early in their patients’ pregnancies

103 Tongsong T, Wanapirak C, Sirichotiyakul S, Chanprapaph P. Sonographic markers of hemoglobin Bart disease at midpregnancy. J Ultrasound Med 2004 Jan;23(1):49-55.

Abstract: OBJECTIVE: To evaluate the efficacy of various sonographic markers at midpregnancy in predicting fetal hemoglobin Bart disease. METHODS: Four hundred eighty-eight pregnancies at risk of having fetuses with hemoglobin Bart disease were recruited for prenatal diagnosis with cordocentesis at 18 to 21 gestational weeks. Before cordocentesis, the sonographic markers, including cardiothoracic ratio, placental thickness, pericardial effusion, pleural effusion, ascites, subcutaneous edema, cord edema, dilated umbilical vein, and amniotic fluid index, were assessed and recorded. The definite fetal diagnosis was based on blood analysis. The efficacy of each sonographic marker in predicting hemoglobin Bart disease was evaluated by sensitivity and specificity. RESULTS: Among 488 pregnancies undergoing prenatal diagnosis, 100 fetuses were proved to be affected by hemoglobin Bart disease. The cardiothoracic ratio gave the highest sensitivity, 95.0%, with specificity of 96.1%, followed by placental thickness. Signs of hydrops fetalis were observed in 33.0% of cases; they did not increase the sensitivity of the cardiothoracic ratio but strongly reinforced the diagnosis when they appeared. CONCLUSIONS: At midpregnancy, sonographic markers can effectively differentiate normal pregnancies from those with fetal hemoglobin Bart disease. Among couples at risk with no sonographic markers, the risk of having an affected child is nearly eliminated. The most sensitive marker was the cardiothoracic ratio, followed by placental thickness

104 Tongsong T, Boonyanurak P. Placental thickness in the first half of pregnancy. J Clin Ultrasound 2004 Jun;32(5):231-4.

Abstract: PURPOSE: This study was conducted to establish normal values of placental thickness during the first half of pregnancy. METHODS: Normal pregnant women with singleton pregnancies between 8 and 20 weeks of gestation were recruited into the study. All the newborns were normal at birth. Placental thickness was measured perpendicularly through the thickest part of the placenta on transabdominal scans. The placental thickness data were analyzed for mean, standard deviation, 95% confidence interval, and 2.5(th), 5(th), 50(th), 95(th), and 97.5(th) percentile for each week of gestational age. The best-fit mathematical model was derived by regression analysis. RESULTS: The total number of measurements was 333 and the number of measurements for each week of gestational age ranged from 9 to 37. Regression analysis yielded the following linear equation of the relationship: placental thickness (in mm) = gestational age (in weeks) x 1.4-5.6 (r = 0.82). CONCLUSION: We have established a nomogram for placental thickness. This resource may be a useful aid in the early detection of placental abnormalities, such as hydropic placenta secondary to hemoglobin Bart’s disease

105 Tongsong T, Sittiwangkul R, Wanapirak C, Chanprapaph P. Prenatal diagnosis of isolated tricuspid valve atresia: report of 4 cases and review of the literature. J Ultrasound Med 2004 Jul;23(7):945-50.

Abstract: OBJECTIVE: To describe the prenatal features of fetal tricuspid atresia. METHODS: Four cases of fetal tricuspid atresia were prenatally diagnosed, sonographically described, and followed. RESULTS: On the basis of this small series, the key findings for diagnosis included the demonstration of no patent tricuspid valve on the 4-chamber view, no flow across the tricuspid valve on pulsed or color Doppler flow mapping, small right ventricles, and associated interventricular septal defects. Increased nuchal translucency thickness may give the first clue leading to follow-up scans, resulting in a definite diagnosis. CONCLUSIONS: Tricuspid atresia can be readily diagnosed prenatally. The key findings and differential diagnoses are provided

106 Tongsong T, Sirichotiyakul S, Sittiwangkul R, Wanapirak C. Prenatal sonographic diagnosis of cardiac hemangioma with postnatal spontaneous regression. Ultrasound Obstet Gynecol 2004 Aug;24(2):207-8.

No abstract is available

107 Wanapirak C, Muninthorn W, Sanguansermsri T, Dhananjayanonda P, Tongsong T. Prevalence of thalassemia in pregnant women at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2004 Dec;87(12):1415-8.

Abstract: OBJECTIVE: To determine the prevalence of thalassemia including alpha-thalassemia-1 trait (SEA type), beta-thalassemia trait, hemoglobin E (HbE) trait, homozygous HbE, the combination of alpha-thalassemia-1 (SEA type) and beta-thalassemia trait, alpha-thalassemia-1 (SEA type) and hemoglobin E trait, and beta-thalassemia hemoglobin E disease in pregnant women. METHOD: A cross-sectional descriptive study was conducted on pregnant women who attended the antenatal clinic at Maharaj Nakorn Chiang Mai Hospital, from 1 August to 31 October 2001. All subjects had blood taken for diagnosis of thalassemia trait or diseases, based on quantitative electrophoresis, and PCR (polymerase chain reaction) technique RESULTS: 516 pregnant women were recruited 81.0% resided in Chiang Mai province, and the remainder were in other northern provinces of Thailand. The mean (+/-SD) age was 27.7+/-6.3 years old. 5.6% of cases had anemia. Overall prevalence of thalassemia trait was 25.4% which were classified as follows: alpha-thalassemia-1 (SEA type) trait 6.6%, beta-thalassemia trait 3.7%, hemoglobin E trait 11.6%, homozygous hemoglobin E 0.8%, the combination of alpha-thalassemia-1 (SEA type) and beta-thalassemia trait 1.2% and the combination of alpha-thalassemia-1 (SEA type) and hemoglobin E trait 1.5%. Additionally, the authors also found beta-thalassemia hemoglobin/E disease 0.2%. CONCLUSION: The prevalence of thalassemia carriers among pregnant women at Maharaj Nakorn Chiang Mai hospital was high, indicating the necessity of a screening thalassemia program aimed at prevention and control of this disease

108 Bhoopat L, Khunamornpong S, Sirivatanapa P, Rithaporn T, Lerdsrimongkol P, Thorner PS, et al. Chorioamnionitis is associated with placental transmission of human immunodeficiency virus-1 subtype E in the early gestational period. Mod Pathol 2005 Oct;18(10):1357-64.

Abstract: The frequency and the cellular basis for HIV-1 transmission from mother to child in the early gestational period are poorly understood. We compared the placentas of 24 women seropositive for HIV-1 subtype E and who had not received any antiretroviral drugs, to placentas of 25 seronegative women. All placentas were obtained during therapeutic abortion at 6-23 weeks gestation. Placentas and fetal organs were examined by routine light microscopy, immunostaining for p24 capsid protein, and in situ PCR to localize which cells were infected with HIV-1 subtype E. The number of previous abortions was not a factor in placental HIV infection since this number was higher in seronegative women (P < 0.01). There were no significant differences between the placentas of the two groups with respect to presence of chorioamnionitis, villitis, villous stromal fibrosis, infarction, abnormal villous maturation, deciduitis or decidual necrosis. HIV-1 subtype E was detected in up to 83% of placentas, either by immunostaining or in situ PCR, in trophoblast, villous stromal cells, Hofbauer cells, decidual and decidual glandular epithelium. Fetal organs were positive for HIV in 30% (6/20) of cases. There was a significant association between transmission of HIV to the fetus and the histologic findings of chorioamnionitis, plasmacellular deciduitis and decidual cell necrosis. This is the first report showing an association of chorioamnionitis with early in utero transmission of HIV-1 subtype E. This may help explain the cases of in utero transmission that persist despite antiretroviral prophylaxis, given that therapy is started in the late gestational period

109 Bhoopat L, Khunamornpong S, Lerdsrimongkol P, Sirivatanapa P, Sethavanich S, Limtrakul A, et al. Effectiveness of short-term and long-term zidovudine prophylaxis on detection of HIV-1 subtype E in human placenta and vertical transmission. J Acquir Immune Defic Syndr 2005 Dec 15;40(5):545-50.

Abstract: Antiretroviral treatment with zidovudine (ZDV) from the 14th week until the end of pregnancy has markedly reduced the vertical transmission rate of HIV-1 in Europe and North America. A shorter duration of treatment has reduced this rate in Africa and Southeast Asia to a lesser degree. In Southeast Asia, subtype E is the major subtype rather than subtype B as in Western countries. The goals of this study were to determine the optimal duration of ZDV prophylaxis for subtype E and to confirm its effectiveness at the histologic level. Fifty pregnant women seropositive for HIV-1 subtype E were given ZDV prophylaxis consisting of 300 mg administered twice daily, switching to 300 mg administered every 3 hours from the onset of labor until delivery. Twenty-seven received “short-term” ZDV lasting 14 to 35 days before delivery, whereas the other 23 received “long-term” ZDV lasting 62 to 92 days. The effectiveness of ZDV prophylaxis was assessed by detection of HIV-1 in the placenta using in situ polymerase chain reaction (PCR). All babies in this study were tested up to one year of age. Three were not positive until after one month of age, but one was positive as a neonate. Four neonates were positive for HIV-1 as detected by PCR on peripheral blood, including one in the neonatal period. All cases were from the short-term prophylaxis group. Decidual glandular epithelial cells were the only cell type in the placenta that expressed HIV proviral DNA under ZDV prophylaxis. Sixty-seven percent of placentas in the short-term ZDV group showed more than occasional positive cells compared with 22% in the group receiving long-term ZDV prophylaxis (P < 0.02). This is first study to compare the effectiveness of short-term and long-term ZDV prophylaxis with respect to the presence of HIV in the placenta. Our study shows that longer (at least 60 days) prophylaxis is more effective in reducing HIV expression in the placenta and is associated with reduced transmission to neonates

110 Chaovisitsaree S, Piyamongkol W, Pongsatha S, Morakote N, Noium S, Soonthornlimsiri N. One year study of Implanon on the adverse events and discontinuation. J Med Assoc Thai 2005 Mar;88(3):314-7.

Abstract: OBJECTIVE: To determine adverse events and discontinuation of Implanon in healthy Thai women between 16 and 45 years of age. DESIGN: Prospective descriptive study. SETTING: Family Planning Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. SUBJECTS: Ninety-two female volunteers with eligible criteria, no contraindication for hormonal contraceptive and wished to have long-term contraception were recruited. MAIN OUTCOME MEASURES: Determination of adverse events was done three months after Implanon insertion. Discontinuation of Implanon use was reviewed during the study period of one year RESULTS: Amenorrhea (40.2%) and infrequent bleeding (39.1%) were the most menstrual adverse events. While most non-menstrual adverse events were headache/dizziness (27.2%) and lower abdominal pain (23.9%). Severe non-menstrual side effect was rare (1-2%). Seven subjects (7.6%) discontinued using Implanon during the one year period of study. CONCLUSION: Implanon demonstrated a high continue rate at the first year of insertion. It produced similar adverse events like other progestin-only contraceptives. Counseling before insertion is important for increased client satisfaction and a higher continuation rate

111 Charoenkwan P, Wanapirak C, Thanarattanakorn P, Sekararithi R, Sae-Tung R, Sittipreechacharn S, et al. Hemoglobin E levels in double heterozygotes of hemoglobin E and SEA-type alpha-thalassemia. Southeast Asian J Trop Med Public Health 2005 Mar;36(2):467-70.

Abstract: Coinheritance of alpha-thalassemia and hemoglobin E (Hb E) is prevalent in Thailand, where the gene frequencies of thalassemia and hemoglobinopathies are high. Hb E carriers with, concomitant inheritance of alpha-thalassemia 1 are known to have a lower level of Hb E. In this study, we reviewed the Hb E levels in Hb E carriers, who either had or did not have Southeast Asian (SEA)-type alpha-thalassemia, in order to seek a Hb E level that may be used as a predictor for concomitant alpha-thalassemia carrier status. The Hb E levels as measured by microcolumn chromatography in 844 Hb E carriers detected during a prenatal screening program for severe thalassemia at Chiang Mai University Hospital were reviewed. Hb E levels ranged from 12.3-35.0% (23.3 +/- 3.1%) in 751 Hb E carriers without SEA-type alpha-thalassemia and from 11.6-32.0% (17.0 +/- 3.7%) in 93 concomitant Hb E and SEA-type alpha-thalassemia carriers. The difference was significant (p < 0.01). However, the absence of SEA-type alpha-thalassemia could not be predicted by the higher Hb E level alone, as 3% of double heterozygotes demonstrated a level of more than 25%. Our study confirms a lower Hb E level in double heterozygotes with Hb E and SEA-type alpha-thalassemia. Nevertheless, the difference does not provide sufficient discriminatory power for the reliable exclusion of alpha-thalassemia status

112 Pongsatha S, Vijittrawiwat A, Tongsong T. A comparison of labor induction by oral and vaginal misoprostol. Int J Gynaecol Obstet 2005 Feb;88(2):140-1.

No abstract is available

113 Rujiwetpongstorn J, Tongsong T, Wanapirak C, Piyamongkol W, Sirichotiyakul S, Chanprapaph P, et al. Feto-maternal hemorrhage after cordocentesis at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2005 Feb;88(2):145-9.

Abstract: OBJECTIVE: To evaluate the incidence and volume of feto-maternal hemorrhage following cordocentesis. STUDY DESIGN: Descriptive study. MATERIAL AND METHOD: One hundred and sixteen asymptomatic non-anemic pregnant women with an indication for cordocentesis at 18-22 weeks of gestation between January and June 2004 were recruited. Maternal blood samples were obtained immediately before and 30 minutes after cordocentesis. Fetal cells in the maternal blood were counted using Kleihauer Betke test. About 25,000 maternal cells per slide were scanned by the same examiner. Feto-maternal hemorrhage was considered significant if the fetal bleeding was more than 0.25 ml. RESULTS: There was a significant increase in fetal blood volume in maternal circulation after cordocentesis (Paired Students t test, p < 0.001). A significant hemorrhage (> 0.25 ml) occurred in 63 from 116 women (54. 7%). Only one had marked hemorrhage of more than 5.0 ml and none had massive hemorrhage (> 15 ml). CONCLUSION: Cordocentesis at 18-22 weeks of gestation can be associated with feto-maternal hemorrhage in more than half of the cases but nearly all cases had only minimal hemorrhage and none had massive hemorrhage

114 Sirichotiyakul S, Maneerat J, Sa-nguansermsri T, Dhananjayanonda P, Tongsong T. Sensitivity and specificity of mean corpuscular volume testing for screening for alpha-thalassemia-1 and beta-thalassemia traits. J Obstet Gynaecol Res 2005 Jun;31(3):198-201.

Abstract: AIM: To evaluate the sensitivity, specificity, positive predictive value and negative predictive value of mean corpuscular volume (MCV) testing for screening for both alpha-thalassemia-1 and beta-thalassemia traits. METHODS: A diagnostic test was conducted on 439 pregnant women attending the antenatal care (ANC) clinic at Maharaj Nakorn Chiang Mai Hospital between April 2002 and July 2002. Blood samples were collected from the pregnant women after they were counseled and gave informed consent. The MCV was measured in all samples using an automated hematology analyzer. The hemoglobin (HbA2) level and polymerase chain reaction (PCR) were measured in all cases to test for the beta-thalassemia trait and the alpha-thalassemia-1 gene (South-East Asian [SEA] type), respectively. The data were collected and analyzed for sensitivity, specificity, positive predictive value and negative predictive value for evaluating the efficacy of MCV testing for screening for both alpha-thalassemia-1 and beta-thalassemia traits. RESULTS: Positive MCV tests (</=80 fl) showed a sensitivity of 92.9% and specificity of 83.9% in screening for alpha-thalassemia-1 and beta-thalassemia traits, respectively. The positive predictive value and negative predictive value were 37.9% and 99.1%, respectively. CONCLUSION: MCV evaluation is a useful tool for screening for alpha-thalassemia-1 and beta-thalassemia traits during pregnancy because of its simplicity, low cost and high sensitivity

115 Suntharasaj T, Ratanasiri T, Chanprapaph P, Kengpol C, Kor-anantakul O, Leetanaporn R, et al. Variability of nuchal translucency measurement: a multicenter study in Thailand. Gynecol Obstet Invest 2005;60(4):201-5.

Abstract: OBJECTIVES: To evaluate intra- and inter-observer variations of nuchal translucency (NT) measurements and study the duration of measurements. SUBJECTS: One hundred and forty-seven singleton pregnant women with 10-14 weeks of gestation who had attended antenatal clinic during January 1st, 2000-August 31st, 2001 were included. METHODS: Crown-rump length and NT were measured three times for each woman. Then, another examiner who was unaware of the previous results did the other three measurements. The duration of measurements was recorded. Intra-observer and inter-observer variations were analyzed by repeated ANOVA and paired t test, respectively. The correlation of NT measurements within each observer and between paired observers was evaluated by intraclass correlation coefficients (ICC). Kappa statistic was calculated for agreement. RESULTS: Intra-observer variation of all 10 examiners at three institutes was varied from 0.20 +/- 0.27 to 0.33 +/- 0.41 mm. Inter-observer variation at Chiang Mai University was 0.40 +/- 0.37 mm which was the highest value compared with those at Prince of Songkla and Khon Kaen University (p < 0.05). The mean duration of measurements was in range of 8-12 min. The intra-observer repeatability of the first two measurements showed ICCs varying from 0.61 to 0.94. The inter-observer repeatability of paired examiners showed a variation in ICC from 0.28-0.90. The kappa value expressing the intra- and inter-observer repeatability as being >95th or < or = 95th percentile was 0.73 and 0.72, respectively. CONCLUSIONS: NT measurement was reproducible for small variation and good agreement. The duration of measurements was acceptable

116 Tongprasert F, Tongsong T, Sittiwangkul R. Prenatal sonographic diagnosis of congenital ductus arteriosus aneurysm: a case report. J Med Assoc Thai 2005 Apr;88(4):541-4.

Abstract: The objective of this report was to demonstrate prenatal sonographic features of congenital ductus arteriosus aneurysm (DAA), a rare, but possibly fatal abnormality. It is characterized by a saccular or fusiform dilatation of the ductus arteriosus. The majority of affected neonates are clinically asymptomatic and tend to progressively diminish in size of DAA and spontaneous closure. However, serious complications can occur during waiting periods, including spontaneous rupture or thromboembolism. Case: A 35 year-old Thai woman, G2P1, underwent ultrasound examination at 34 weeks’ gestation. Fetal echocardiography revealed markedly enlarged and tortuous ductus arteriosus with saccular dilation at the distal end, just before joining the descending aorta. The cross-sectional diameter of the saccular portion of the ductus arteriosus was 10 mm. The active female baby was vaginally delivered at 34 weeks’ gestation, weighing 1050 grams. Postnatal echocardiography confirmed the prenatal findings. The DAA was gradually decreased in size and finally spontaneously closed without medical or surgical intervention

117 Tongprasert F, Tongsong T, Wanapirak C, Sirichotiyakul S, Piyamongkol W, Chanprapaph P. Experience of the first 50 cases of cordocentesis after training with model. J Med Assoc Thai 2005 Jun;88(6):728-33.

Abstract: OBJECTIVE: To describe the experience of the first 50 cases of cordocentesis after practicing with cordocentesis model. MATERIAL AND METHOD: Cordocentesis model consisted of a water-filled transparent glass box covered with a rubber latex sheet with or without piece of pork skin. A 30-cm umbilical cord filled with mercurochrome, hung inside the container, was the target for the puncture. As in real practice, the trainee had to try to aspirate the red mercurochrome from the umbilical cord using a spinal needle under ultrasonographic guidance. After practicing with the model for 300 procedures, the trainee was allowed to perform cordocentesis on pregnant women at gestational age of 18-22 weeks by herself under expert supervision with time limit of 30 minutes. The procedure not successful in 30 minutes was considered failure. Duration of procedures, placental site, puncture site, and related complications were recorded for subsequent analysis. RESULTS: After practicing with model for 300 procedures, real cordocentesis was performed by the trainee on 50 pregnant women. The success rate in obtaining fetal blood within 30 minutes was 100%. Most of them (92%) took less than 10 minutes to complete the procedure. Puncture site bleeding and fetal bradycardia were the most common immediate complications, found in 30% and 8% respectively, and spontaneously resolved within few minutes. CONCLUSION: Without any fetal and maternal jeopardy, cordocentesis model is simple, inexpensive but highly effective for the beginner to gain their experience, skill and prepare themselves for cordocentesis with confidence. However, the reduction of fetal loss rate with the training program remains to be further tested

118 Tongsong T, Sittiwangkul R, Khunamornpong S, Wanapirak C. Prenatal sonographic features of isolated hypoplastic left heart syndrome. J Clin Ultrasound 2005 Sep;33(7):367-71.

Abstract: Hypoplastic left heart syndrome (HLHS) is a spectrum of fetal conditions associated with severe hypoplasia of the left ventricle and left ventricular outflow tract. The purpose of this series was to focus on the sonographic prenatal features of isolated HLHS. Based on the 5 cases presented here, the prenatal sonographic features of HLHS include small-sized left ventricle, atretic or hypoplastic mitral valves with restricted motion and a small amount of antegrade flow or regurgitation, and hypoplastic ascending aorta. Retrograde flow in the transverse aortic arch strongly suggests inadequate systemic output from the left heart. Tricuspid regurgitation is common and increases the chance for the development of hydrops. Other findings may be helpful, including left ventricular hyperechoic endocardium and increased nuchal translucency at 11-14 weeks. With careful fetal echocardiography, HLHS may be readily observed on a 4-chamber view as either a small or even absent left ventricle

119 Tongsong T, Chanprapaph P, Khunamornpong S, Sirichotiyakul S. Sonographic features of Ebstein anomaly associated with hydrops fetalis: a report of two cases. J Clin Ultrasound 2005 Mar;33(3):149-53.

Abstract: Ebstein anomaly, an abnormally low insertion of the tricuspid valve, occurs in 0.5% of patients with congenital heart disease. In rare cases, this disorder may be complicated by congestive heart failure in utero and hydrops fetalis. This article reports the prenatal sonographic features of 2 cases of Ebstein anomaly associated with hydrops fetalis. In both cases, fetal echocardiography was performed at 34 weeks of gestation. The 4-chamber view showed fetal cardiomegaly and pericardial effusion. In both cases, the annular attachment of the tricuspid valve leaflets was difficult to demonstrate and so distal that it could easily be confused with papillary muscle in the right ventricular wall. Poor fetal cardiac hemodynamics with severe tricuspid regurgitation was demonstrated by pulsed Doppler imaging. Pulmonary regurgitation was also clearly demonstrated in both cases. Preterm delivery with stillbirth occurred in both cases. Autopsies confirmed the very distal displacement of the tricuspid valve insertion, close to the apex, and enlargement of the right atrium

120 Tongsong T, Khunamornpong S, Piyamongkol W, Chanprapaph P. Prenatal sonographic delineation of the complex cardiac anatomy of thoraco-omphalopagus twins. Ultrasound Obstet Gynecol 2005 Feb;25(2):189-92.

Abstract: We describe a case of thoraco-omphalopagus twins diagnosed at 18 weeks’ gestation. Each twin had a separate set of anatomical structures except for a shared heart, upper liver and anterior chest wall. The heart was located at the center of the juncture, and consisted of three atria and two ventricles, each twin having a single ventricle and right atrium but a fused left atrium. A set of great arteries originated from each single ventricle and there was juxtaposition of the aortic and pulmonary valves. One twin had transposition of the great arteries, whereas in the other these were normal in configuration. There was only one umbilical cord which contained four vessels (two arteries and two veins). This case report demonstrates the possibility of using fetal echocardiography to delineate the cardiovascular complex of the conjoined heart

121 Tongsong T, Sittiwangkul R, Chanprapaph P, Sirichotiyakul S. Prenatal sonographic diagnosis of tetralogy of fallot. J Clin Ultrasound 2005 Oct;33(8):427-31.

Abstract: The objective of this report was to emphasize the sonographic findings of tetralogy of Fallot (TOF) during the prenatal period. Four fetuses with TOF were prenatally diagnosed at gestational ages of 25, 28, 25, and 32 weeks. Based on this small series, prenatal sonographic findings suggestive of TOF may be summarized as follows: (1) a large aortic root, which is the most common prenatal sonographic finding, (2) a small pulmonary artery or stenosis of the right ventricular outflow tract, (3) a ventricular septal defect in the outlet portion of the septum, (4) an overriding aorta, which is best seen in the long-axis view, and (5) right ventricular hypertrophy. Other findings such as hydrops fetalis or polyhydramnios may also be helpful especially in the case of dysplastic pulmonary valves. The demonstration of a normal aortic root would render the presence of TOF unlikely. TOF with pulmonary atresia can be confused with truncus arteriosus, in which both pulmonary arteries arise from the ascending aorta. How-ever, with careful examination along the course of the ascending aorta, there are no branches arising from the aorta in TOF

122 Tongsong T, Khunamornpong S, Wanapirak C, Sirichotiyakul S. Prenatal sonographic diagnosis of truncus arteriosus associated with holoprosencephaly. J Clin Ultrasound 2005 May;33(4):193-6.

Abstract: We present the case of a truncus arteriosus associated with holoprosencephaly detected in a fetus in the first trimester and the sonographic findings that established this diagnosis. A physical exam was performed on a 35-year-old pregnant woman, gravida 2, para 1. At 20 weeks, sonography showed large-for-date uterine size. Fetal biometry was consistent with menstrual age. Amniotic fluid volume was elevated to 25 AFI cm. Fetal echocardiography revealed a single common artery arising from the heart, a ventricular septal defect, and other cardiac defects. Abnormalities of the fetal brain and face were also shown via sonography, including the presence of a common lateral ventricle without falx cerebri. Alobar holoprosencephaly, the most severe form of holoprosencephaly, was diagnosed. Prenatal chromosomal analysis was offered and the patient elected to have cordocentesis. The chromosome study was normal. Success in surgical repair of truncus arteriosus is established, but alobar holoprosencephaly is associated with neonatal death. Continuation of the pregnancy carried risks for the mother. After proper counseling, the parents of this fetus were offered and accepted termination of pregnancy. A male abortus weighing 320 grams was delivered. Postnatal findings and autopsy confirmed the diagnosis

123 Tongsong T, Chanprapaph P, Sittiwangkul R, Sirichotiyakul S. Rupture of fetal ductus arteriosus aneurysm. Obstet Gynecol 2005 May;105(5 Pt 2):1275-8.

Abstract: BACKGROUND: Ductus arteriosus aneurysm is a rare fetal disorder. CASE: A 35-year-old primigravida had an uneventful antenatal course. Ultrasound examination at 30 weeks of gestation revealed hydramnios. The fetal ductus arteriosus became saccular and dilated with turbulent flow and diameter of 2.5 cm. It was located at the left upper thorax, just distal to the pulmonic valve and extended to the thoracic aorta. A ductus arteriosus aneurysm was diagnosed prenatally. Five days after diagnosis, preterm labor occurred, and dexamethasone and terbutaline were administered. Six hours after initiation of terbutaline, the fetal heart rate suddenly dropped to 90 beats per minute (bpm). A bedside ultrasound examination performed immediately showed profound bradycardia. The aneurysm became a heterogeneous hypoechoic mass with no pulsation, and the fetal heart rate suddenly disappeared. CONCLUSION: Ductus arteriosus aneurysm can be diagnosed prenatally, and terbutaline or dexamethasone may be associated with a risk for rupture

124 Tongsong T, Iamthongin A, Wanapirak C, Piyamongkol W, Sirichotiyakul S, Boonyanurak P, et al. Accuracy of fetal heart-rate variability interpretation by obstetricians using the criteria of the National Institute of Child Health and Human Development compared with computer-aided interpretation. J Obstet Gynaecol Res 2005 Feb;31(1):68-71.

Abstract: AIM: To evaluate the accuracy of fetal heart rate variability interpretation by obstetricians using the criteria of the National Institute of Child Health and Human Development (NICHD), compared with computer-aided analysis as a gold standard. METHODS: One hundred and fourteen panels of fetal heart-rate tracings derived from electrocardiogram via scalp electrodes obtained from women with high-risk pregnancies during the intrapartum period. The tracings were interpreted using computer analysis and recorded as a gold standard. The same tracings were distributed to six observers: three residents in the third year of training and three faculty members. All observers blindly interpreted the fetal heart-rate variability without the knowledge of the computer analysis. The main outcome measures were: (i) the accuracy of fetal heart-rate variability interpretation by obstetricians using the NICHD criteria compared with computer-aided analysis was presented as a percentage value; and (ii) the agreement of fetal heart-rate variability interpretation between the obstetricians and the computer analysis using the NICHD criteria was presented as a kappa-value. RESULT: When using the computer analysis as a gold standard, the accuracy of fetal heart-rate variability interpretation in the residents group was 81.58%, 86.84% and 82.46%, respectively, with a mean of 83.62%, whereas the accuracy of the faculty members was 79.82%, 67.54% and 79.82%, respectively, with a mean of 75.73%. kappa-values, representing the agreement of interpretation, were 0.70, 0.78 and 0.72, with a mean of 0.73 +/- 0.04 among the residents, and 0.67, 0.50 and 0.68, with a mean of 0.62 +/- 0.10 among the faculty members. Agreements in the two groups were not significantly different (Student’s t-test, P=0.14). CONCLUSION: Using the NICHD criteria, the accuracy and agreement of fetal heart-rate variability interpretation in the third-year residents and faculty members are substantial. There was no difference between the groups with regard to the agreement of fetal heart-rate variability interpretation

125 Tongsong T, Sittiwangkul R, Wanapirak C, Sirichotiyakul S. Prenatal diagnosis of transposition-like double-outlet right ventricle with mitral valve atresia in heterotaxy syndrome. J Clin Ultrasound 2005 May;33(4):197-200.

Abstract: We present a case of heterotaxy syndrome with right isomerism detected in a twin fetus, with the sonographic findings that established this diagnosis. At 24 weeks’ menstrual age, ultrasound detected anomalies in the heart suggestive of heterotaxy syndrome. Intrauterine fetal echocardiography demonstrated that the heart of the affected twin was located on the left side with a normal cardiac axis. The right ventricle was much larger than the left ventricle. The appearance of the mitral valve was dysplastic with restricted motion. The ascending aorta exited from the right ventricle, anterior to, right to, and parallel to the smaller pulmonary trunk, which also arose from the right ventricle. Double-outlet right ventricle (DORV) was clearly demonstrated. Cesarean section was performed at 38 weeks’ menstrual age. Both twins were healthy and survived. Postnatal echocardiography and MRI confirmed the prenatal findings. At the age of 4 months, the affected infant had no evidence of cardiac decompensation. This report shows that conventional ultrasound can be used to detect heterotaxy syndrome and that intrauterine fetal echocardiography can delineate the cardiac complex in heterotaxy syndrome. Postnatal surgery with complex Fontan procedures was planned for the affected twin

126 Charoenkwan P, Sirichotiyakul S, Chanprapaph P, Tongprasert F, Taweephol R, Sae-Tung R, et al. Anemia and hydrops in a fetus with homozygous hemoglobin constant spring. J Pediatr Hematol Oncol 2006 Dec;28(12):827-30.

Abstract: Hemoglobin Constant Spring (Hb CS) is an unstable hemoglobin (Hb) variant that results from a nucleotide substitution at the termination codon of the alpha2-globin gene. The compound heterozygosity of alpha-thalassemia and Hb CS (–/alphaCSalpha) results in a Hb H/CS disease which is clinically more severe than deletional Hb H disease. Homozygosity of Hb CS (alphaCSalpha/alphaCSalpha) is generally characterized with mild hemolytic anemia, jaundice, and splenomegaly. The authors report 1 case with Hb CS homozygosity who presented with fetal anemia and hydrops. Intrauterine transfusions were given which rendered a favorable outcome. This report demonstrates an unusual and serious in utero complication in a fetus with Hb CS/CS

127 Piyamongkol W, Vutyavanich T, Piyamongkol S, Wells D, Kunaviktikul C, Tongsong T, et al. A successful strategy for Preimplantation Genetic Diagnosis of beta-thalassemia and simultaneous detection of Down’s syndrome using multiplex fluorescent PCR. J Med Assoc Thai 2006 Jul;89(7):918-27.

Abstract: OBJECTIVES: Preimplantation Genetic Diagnosis (PGD) is an alternative to prenatal diagnosis providing couples the chance to start a pregnancy with an unaffected fetus. The objective of the present study was to develop and apply quick, sensitive and accurate single cell PCR protocols for PGD of beta-thalassemia and Down’s syndrome detection. MATERIAL AND METHOD: Two couples carrying beta-thalassemia codon41-42 mutation underwent routine IVF procedures. Embryo biopsy was performed on Day-3 post-fertilisation and single cell multiplex fluorescent PCR was employed for mutation analysis, contamination detection and diagnosis of trisomy 21 cases. RESULTS: Seventeen embryos were tested in two clinical PGD cycles. This resulted in the first birth following PGD for a single gene disorder in Thailand and South East Asia, confirmed by prenatal testing. Two embryos were shown to be affected by Down’s syndrome. CONCLUSION: Successful strategy for PGD of beta-thalassemia and Down’s syndrome detection using multiplex fluorescent PCR was introduced

128 Piyamongkol W. Role of molecular biology in obstetrics–modern single gene disorders diagnosis techniques. J Med Assoc Thai 2006 Oct;89 Suppl 4:S186-S191.

Abstract: Single gene mutations may lead to an inherited disorder with Mendelian inheritance patterns, of which over 8,000 disorders have been catalogued. The strategy of population screening, offering genetic counseling, prenatal diagnosis and termination of affected pregnancy has been successfully applied worldwide to reduce the number of new patients. Common fetal sampling techniques in utero include chorionic villous sampling, amniocentesis, and fetal blood sampling. Then appropriate analysis is applied for diagnosis, where karyotyping is mainly for chromosome abnormalities and PCR is for single gene disorders. Several modern molecular techniques are useful for identification of defects in single genes. Preimplantation genetic diagnosis is an advanced alternative giving the couple the chance to start a pregnancy ensuring that the baby is free from the genetic disease. It is the role of obstetricians to make most use of the advance molecular biology knowledge to have a healthy community

129 Piyamongkol W, Trungtawatchai S, Chanprapaph P, Tongsong T. Comparison of the manual stimulation test and the nonstress test: a randomized controlled trial. J Med Assoc Thai 2006 Dec;89(12):1999-2002.

Abstract: OBJECTIVE: To evaluate manual fetal stimulation (MST) through the maternal abdomen in comparison to standard nonstress test (NST) in terms of nonreactive rates and testing time. MATERIAL AND METHOD: Five hundred and forty high-risk singleton pregnancies at 28 gestational weeks or more were assigned to have either NST or MST using blocked randomization (270 each). All fetal heart rate (FHR) tracings were analyzed blindly using standard NST criteria by one perinatologist. RESULTS: The MST group provided a significantly higher reactive rate than that of the NST group, 98.9% and 84.4% respectively, p < 0.001. Mean testing time of the reactive results of the MST group was also significantly shorter than that of the NST group, 7.94 +/- 6.27 min and 13.91 +/- 9.58 min respectively, p < 0.001. CONCLUSION: This is the first randomized controlled trial (RCT) to demonstrate the distinctive benefit of the simple and less expensive MST. MST significantly reduces the time to reactivity and increases the frequency of reactivity when compared to NST alone

130 Pongsatha S, Tongsong T. Second-trimester pregnancy interruption with vaginal misoprostol in women with previous cesarean section. J Med Assoc Thai 2006 Aug;89(8):1097-100.

Abstract: OBJECTIVE: To describe the experience of misoprostol use for pregnancy interruption in the second trimester of women with previous cesarean section. MATERIAL AND METHOD: Seventeen pregnant women with viable fetuses and with previous cesarean section indicated for second trimester pregnancy interruption attending Maharaj Nakorn Chiang Mai Hospital were recruited. All received the same regimen of 400 mcg intravaginal misoprostol every 6 hours. The data was analyzed for demographic characteristics, the adverse outcomes, success rate, and time interval to fetal expulsion. RESULTS: The incidences of adverse outcomes were as follows, fever (47.1%), chill (23.5%), and nausea (17.6%). No uterine rupture occurred in this series at all. The rate of oxytocin use and analgesia requirement was 29.4%. Success rate of pregnancy interruption was 100%, though two of them had an abortion time of more than 48 hours. Time interval from misoprostol administration to fetal expulsion was 25.9 +/- 34. 1 hours (range 4.0-142.7 hours). CONCLUSION: This case series reaffirms the efficacy of misoprostol and suggests that misoprostol may relatively be safe even in cases with previous cesarean section. Therefore, misoprostol may be an option of pregnancy interruption in the second trimester to avoid unnecessary surgical procedure including hysterotomy. However, the safety should be tested by further studies with a larger sample size

131 Pongsatha S, Muttarak M, Chaovisitseree S, Luewan S, Panpanit A. Mammographic changes related to different types of hormonal therapies. J Med Assoc Thai 2006 Feb;89(2):123-9.

Abstract: OBJECTIVES: To determine the effects of different types of hormone therapies (HT) on mammographic breast density changes. MATERIAL AND METHOD: Between 1999 and 2002, mammograms obtained before and 12-18 months after different types of HT in 170 women were evaluated Estrogen alone (n = 66), or estrogen in cyclic (n = 59) or continuous (n = 45) combination with progesterone were used. The baseline mammographic density was classified according to the Breast Imaging Reporting and Data Systems (BI-RADS). The serial changes observed mammographically were categorized as follows; no change, minimal change (10-25% increased density), moderate change (26-50% increased density), and marked change (> 50% increased density). Results: Twelve (7%) of the women developed an increase in parenchymal density after HT: Mammographic changes were minimal change in five (2.9%) of the women, moderate change in four (2.3%), and marked change in three (1.8%). No mammographic change was observed in women receiving cyclic estrogen-progesterone. A greater percentage of women who had undergone continuous estrogen-progesterone therapy (22.2%, 10 of 45) demonstrated more change than those who had estrogen alone (3%, 2 of 66). The difference was statistically significant (p < 0.01). Conclusion: Changes of increased density after HT was seen in only 7% of mammograms and depended on the selected hormone regimen

132 Srisupundit K, Tongsong T, Sirichotiyakul S, Chanprapaph P. Fetal structural anomaly screening at 11-14 weeks of gestation at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2006 May;89(5):588-93.

Abstract: OBJECTIVE: To determine the detection rate by ultrasound scanning of fetal anomaly by first trimester (11-14 weeks of gestation). MATERIAL AND METHOD: A prospective descriptive study of 597 pregnant women undergoing Nuchal Translucency (NT) measurement at 11-14 weeks of gestation at Maharaj Nakorn Chiang Mai Hospital. The sonographic examinations focused on NT thickness and fetal structural survey. The final diagnoses were based on neonatal outcomes assessed by the pediatricians and abortuses evaluated by the pathologists. The main outcome measure was the detection rate of fetal anomaly using ultrasonographic examination. RESULTS: Of 597 pregnant women recruited into the present study, the mean age was 29.41 +/- 5.8 years, the incidence of fetal anomaly was about 4% (24 from 597 cases). The detection rate by first ultrasound scans was 58% (14 from 24 cases) and the most common detected structural anomaly was cystic hygroma and exencephaly. The rate of undetected fetal anomalies was 42% (10 from 24 cases). Abnormal NT was found in 16 from a total of 597 cases (2.7%), most of them, however, had normal karyotype and no gross anomaly at birth. CONCLUSION: First trimester (11-14 weeks) ultrasound scan is probably a useful method for detection of fetal structural anomalies with a relatively high detection rate, and may be a good adjunct to the conventional examination

133 Srivichai K, Uttavichai C, Tongsong T. Medical treatment of ectopic pregnancy: a ten-year review of 106 cases at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2006 Oct;89(10):1567-71.

Abstract: OBJECTIVE: To evaluate the effectiveness of single-dose intramuscular methotrexate in the treatment of ectopic pregnancy at Maharaj Nakorn Chiang Mai Hospital MATERIAL AND METHOD: A retrospective review of the patient records was performed on the patients with diagnosis of ectopic pregnancy and treatment with single-dose methotrexate according to the protocol of Stovall et al between 1996 and 2005. The successful treatment was defined as no need for surgical intervention. RESULTS: As many as 96 out of 106 (90.6%) were successfully treated with methotrexate, though four required a second dose. Pretreatment /f-human chorionic gonadotropin (beta-hCG) levels were significantly lower in women who responded to single-dose therapy than either in those who required two doses or who had a failure of medical management (p < 0. 01). The mean pretreatment level of beta-hCG was 873 mlU/ml. The median time to resolution of beta-hCG was 21 days. In addition, all cases with failed medical treatment had adnexal masses larger than 3.5 centimeters in diameter CONCLUSION: In the present series, treatment of ectopic pregnancy with single-dose methotrexate was as high as 90% successful. Women with a high pretreatment beta-hCG level and large sonographic adnexal masses had a greater probability of requiring either surgical intervention or multiple doses of methotrexate

134 Sukrat B, Sirichotiyakul S. The prevalence and causes of anemia during pregnancy in Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2006 Oct;89 Suppl 4:S142-S146.

Abstract: OBJECTIVE: To determine the prevalence and causes of anemia during pregnancy in Maharaj Nakorn Chiang Mai Hospital. MATERIAL AND METHOD: The pregnant women were screened with hemoglobin, hematocrit, osmotic fragility test, hemoglobin E test and serology for hepatitis B, syphilis and HIV at first antenatal visit. In anemic cases, serum ferritin, serum iron/total iron binding capacity, or therapeutic trial with iron supplementation were performed to assess the iron status. The cases of abnormal thalassemia screening were followed by hemoglobin A2 level, PCR for alpha-1 (SEA type) and hemoglobin electrophoresis. Additional tests were stool exam, stool occult blood and red blood cell indices. Anemia was defined as a hemoglobin level less than 11.0 g/dl in the first and third trimester or less than 10.5 g/dl in the second trimester of pregnancy. The data was presented as mean, standard deviation and percentage. RESULTS: Six hundred and forty eight pregnant women were recruited. The prevalence of anemia was 20.1 percent (128 cases). Classified in each trimester the prevalence was 17.3%, 23.8% and 50.0% in the first, second and third trimester, respectively. Thalassemia carriers and diseases were detected in 56 from 102 anemic pregnant women (54.9%). Iron status was assessed in 58 cases and iron deficiency anemia was found in 25 cases (43.1%). Other causes of anemia were parasitic infection (8.7%) and anemia of chronic disease (2.7%). In 37 anemic pregnant women (33.0%), the causes of anemia were not found. CONCLUSION: The prevalence of anemia in pregnant women who first attended at the antenatal clinic was 20.1%. The main causes of anemia were thalassemia carriers/diseases and iron deficiency anemia

135 Tongprasert F, Jinpala S, Srisupandit K, Tongsong T. The rapid biophysical profile for early intrapartum fetal well-being assessment. Int J Gynaecol Obstet 2006 Oct;95(1):14-7.

Abstract: OBJECTIVE: To determine the efficacy of the rapid biophysical profile (rBPP), which uses sound-provoked, ultrasonographically detected fetal movement and amniotic fluid index, for early intrapartum fetal well-being assessment and prediction of adverse perinatal outcomes. METHODS: Rapid BPP was performed in 330 women admitted to the labor unit of Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand, from January 2005 to July 2005. Those who were delivered later than 24h after the rBPP, or who required emergency cesarean section because of placenta previa, abruptio placentae or prolapsed cord were to be excluded. Perinatal outcomes were prospectively assessed and recorded for subsequent analysis. The predicting accuracy of rBPP was calculated according to poor outcomes, which included fetal distress, low Apgar score, admission to the neonatal intensive care unit and perinatal death. RESULTS: Among the 330 pregnancies, there were 6 adverse perinatal outcomes (1.8%). The rBPP had a sensitivity of 50.0%, a specificity of 99.07%, a positive predictive value of 50.0%, a negative predictive value of 99.07% and an accuracy of 98.18%. CONCLUSION: With its simplicity, low cost and high specificity but its low sensitivity and low negative predictive value, the rBPP may be used as a back-up test to confirm fetal well-being during the early intrapartum period in developing countries

136 Tongsong T, Chanprapaph P, Wanapirak C, Sirichotiyakul S. Intrauterine intravenous transfusion therapy for hydrops fetalis due to anemia of uncertain causes. Int J Gynaecol Obstet 2006 Aug;94(2):128-30.

No abstract is available

137 Tongsong T, Sirichotiyakul S, Chaisen R, Wanapirak C. Sensitivity and specificity of dichlorophenol–indophenol precipitation test to screen for the hemoglobin E trait in pregnant women. Int J Gynaecol Obstet 2006 Nov;95(2):149-50.

No abstract is available

138 Tongsong T, Wanapirak C, Khunamornpong S, Sukpan K. Numerous intracystic floating balls as a sonographic feature of benign cystic teratoma: report of 5 cases. J Ultrasound Med 2006 Dec;25(12):1587-91.

Abstract: OBJECTIVE: The purpose of this series was to describe the unusual but unique sonographic pattern of mature cystic teratoma. METHODS: Five patients of reproductive age with clinical manifestations of a pelvic mass were evaluated with sonography for treatment planning. RESULTS: All 5 cases showed the similar sonographic pattern of a large cystic tumor filled with multiple echogenic spherical structures floating in the cystic background. Of the 5 patients, 3 had rather large balls varying in size between 1 and 4 cm in the same tumor masses, whereas the other 2 had numerous smaller balls of about 0.5 cm in diameter. The numerous crowded very small echogenic balls in the last 2 cases mimicked solid nodules representing malignancy. However, there was no vascularization in the balls, which suggested a benign nature. The postoperative pathologic diagnosis was mature cystic teratoma without any malignant component in all cases. CONCLUSIONS: The sonographic feature of intracystic floating echogenic balls is probably pathognomonic for mature teratoma and is easily detected in most cases. Color Doppler sonography is helpful in differentiating these benign nodules (small balls) from malignant tumors

139 Wanapirak C, Srisupundit K, Tongsong T. Sonographic morphology scores (SMS) for differentiation between benign and malignant adnexal masses. Asian Pac J Cancer Prev 2006 Jul;7(3):407-10.

Abstract: OBJECTIVE: To determine the sensitivity and specificity of a scoring system for distinguishing between benign and malignant adnexal masses and to detect threshold scores for prediction of malignant ovarian tumors. STUDY DESIGN: Cross-sectional diagnostic testing. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University. SUBJECTS: A total 158 patients scheduled for elective surgery due to ovarian tumors at Maharaj Nakorn Chiang Mai Hospital between June 16, 2002 and August 8, 2004 were recruited into the study. METHODS: All patients were sonographically examed within 72 hours before surgery by the same sonographer to evaluate the morphology including wall structure, shadowing, septum, echogenicity and score the tumors. The final diagnosis was based on either pathological or operative findings. MAIN OUTCOME MEASURE: Sensitivity and specificity of the best cut-off score. RESULTS: A score of 5 from the receiver operating characteristic curve was found to be the best cut-off score, giving a sensitivity and a specificity of 85% and 70%, respectively. CONCLUSION: Sonographic morphology scores are useful in distinguishing adnexal malignancies from benign lesions in some selected cases

140 Chaovisitsaree S, Namwongprom SN, Morakote N, Suntornlimsiri N, Piyamongkol W. Comparison of osteoporosis self assessment tool for Asian (OSTA) and standard assessment in Menopause Clinic, Chiang Mai. J Med Assoc Thai 2007 Mar;90(3):420-5.

Abstract: OBJECTIVE: To compare osteoporosis self assessment tool for Asian (OSTA) with the standard measurement of bone mineral density (BMD) by dual energy x-rays absorptiometry (DXA) in- identifying the prevalence of osteopenia and osteoporosis in Thai menopausal women who attended the Menopause Clinic, Faculty of Medicine, Chiang Mai University. MATERIAL AND METHOD: The data was retrospectively collected from the medical records of women who had lumbar femoral neck and radius BMD t-score measurement by DXA (Hologic, QDR-4500C) between January 2004 and December 2005. The body weight and age ofpatients were calculated for the OSTA index score. The women with OSTA score < -1 and > or = -1 were classified as “moderate to high risk” and “low risk” for fracture, respectively. The BMD T-scores of < -1 and > or = -1 were classified as “osteopenia to osteoporosis ” and “normal” respectively. RESULTS: Three hundred and fifteen menopausal women of the age of 45-87 years were included. The BMD T-scores assessment revealed that more than half of the subjects had osteopenia to osteoporosis (T-score < or = -1), 196 women (62%) at lumbar spine, 133 women (42.2%) at femur and a third, 114 women (36.2%) at radius respectively. The OSTA index at the standard cut-point of < -1 had a sensitivity and specificity of 36.2% and 71.4% respectively for the lumbar spine and 40.6% and 72.0% respectively for the neck of the femur in predicting osteopenia to osteoporosis status. CONCLUSION: The OSTA index score had a low sensitivity (36-48%) but a high specificity (71-75%) for identifying osteopenic to osteoporotic women among population of menopausal period Nevertheless, it is a useful screening tool in old age women (> 65 years)

141 Luewan S, Srisupundit K, Tongsong T. A comparison of sonographic image quality between the examinations using gel and olive oil, as sound media. J Med Assoc Thai 2007 Apr;90(4):624-7.

Abstract: OBJECTIVE: To compare the quality of real-time sonographic images obtained from the examinations using two different sound media, ultrasound gel and olive oil. MATERIAL AND METHOD: A randomized controlled trial was conducted on the study population recruited from the routine ultrasound service with written informed consent. Each patient underwent scan using both ultrasound gel and olive oil as sound media, but only one media at a time. During each patient examination, the first type of sound media was randomly used and then followed by the other media. The sonographic images of the same plane were recorded as video clips for each type of sound media. The quality of images were blindly evaluated by one experienced sonographer and the quality of ultrasound images was rated as 0 (very poor), 1 (poor), 2 (fair), and 3 (good), respectively. RESULTS: Of 346 cases (692 video clips), the image quality scores in ultrasound gel group and olive oil group were poor, fair, and good quality in 7, 182, and 157 and 9, 190, and 147 cases, respectively. The difference of quality scores between both groups was not statistically significant. (Chi square test; p = 0.687). CONCLUSION: The quality of images obtained from the scan using olive oil is similar to that using ultrasound gel. Therefore, the olive oil may be used as alternative sound media for ultrasound examination. Furthermore, it could possibly be a preferred media because of its lower cost, pleasant smell, and it facility of cleaning

142 Phadungkiatwattana P, Sirivatanapa P, Tongsong T. Outcomes of pregnancies complicated by systemic lupus erythematosus (SLE). J Med Assoc Thai 2007 Oct;90(10):1981-5.

Abstract: OBJECTIVE: To assess the outcomes of pregnancies complicated by systemic lupus erythematosus (SLE) and evaluate the clinical course of the disease during pregnancy. MATERIAL AND METHOD: The database of high-risk pregnancies between 1995 and 2006 was prospectively collected and searched for pregnancies with SLE. The medical records were reviewed RESULTS: Sixty-eight pregnant women were identified during the period of the present study. Of 61 (89.7%) live births, 27 (39.7%) had preterm delivery and 20 (29.4%) had fetal growth restriction. Mean gestational age was 35.6 +/- 4.2 weeks. Mean neonatal birth weight was 2322 +/- 781 grams. There were seven (10.3%) perinatal deaths. Maternal SLE flares occurred in 20 (29.4%), seven in the first trimester, eight in the second trimester five in the third trimester, and none in the post partum period. Preeclampsia is the most common maternal complication (20.6%). There was a higher rate of flares if the pregnancy occurred while the disease was active. The predictor of poor pregnancies outcomes included flare-up of the disease, renal involvement, hypertension, and conception while the disease is active. CONCLUSION: Active SLE prior to pregnancy is associated with a less favorable maternal and fetal outcome. Hypertension increased the risk of fetal loss and adverse outcome

143 Tongprasert F, Tongsong T, Wanapirak C, Sirichotiyakul S, Piyamongkol W. Cordocentesis in multifetal pregnancies. Prenat Diagn 2007 Dec;27(12):1100-3.

Abstract: OBJECTIVE: To describe the experiences in diagnostic cordocentesis in twin pregnancies at midpregnancy METHODS: The database and medical records of pregnant women attending Maternal Fetal Medicine Unit of the hospital for diagnostic cordocentesis at midpregnancy between January 1989 and September 2006 were retrospectively reviewed. RESULTS: During 17 years of experience, 4,241 cordocenteses at midpregnancy were performed for prenatal diagnosis, including 59 procedures in 30 multiple pregnancies (29 twins and 1 triplet). The mean gestational age at the time of cordocentesis was 19.5 +/- 1.6 weeks. Success rate of the samplings was 98.3% with one sample was maternal blood contamination. Averaged-time used of the procedures was 8.2 minutes (range 1-45 minutes). The procedure-related complications included transient bleeding at puncture site (8.5%) and transient fetal bradycardia (22.0%). The total fetal loss rate was 10.5% but there was no cordocentesis-related fetal loss (0.0%), defined as a fetal loss within 2 weeks after the procedure. CONCLUSION: This study may provide a new insight on the safety of cordocentesis in multifetal pregnancies at midpregnancy. The procedure-related fetal loss is not as high as reported in the past. This study suggests cordocentesis be a relatively safe and highly successful in obtaining fetal blood samples

144 Tongsong T, Chanprapaph P, Sittiwangkul R, Khunamornpong S. Antenatal diagnosis of double outlet of right ventricle without extracardiac anomaly: a report of 4 cases. J Clin Ultrasound 2007 May;35(4):221-5.

Abstract: Four fetuses were diagnosed antenatally with double outlet of right ventricle (DORV) at 17, 20, 26, and 28 weeks’ gestation, respectively, using 2-dimensional sonography. Chromosome study was normal in all 4 cases, and there were no extracardiac abnormalities. The sonographic diagnoses were based on the following findings: (1) arising of the 2 great vessels predominantly from the right ventricle; (2) the presence of bilateral coni; and (3) parallel direction of the 2 vessels rather than the normal perpendicular course. Two cases were terminated electively with postnatal autopsy confirmation; the other 2 cases were closely monitored throughout pregnancy and underwent normal vaginal delivery at term and subsequent surgical correction with good outcome. In conclusion, DORV can be readily diagnosed in utero by checking outflow tract even without 3-dimensional sonography and in the absence of obvious risk for congenital heart defects

145 Tongsong T, Sukpan K, Wanapirak C, Sirichotiyakul S, Tongprasert F. Sonographic features of female pelvic tuberculous peritonitis. J Ultrasound Med 2007 Jan;26(1):77-82.

Abstract: OBJECTIVE: The purpose of this study was to evaluate the sonographic features of tuberculous peritonitis in an attempt to facilitate the recognition of this disorder preoperatively. METHODS: The sonographic findings of 16 patients who had tuberculous peritonitis were reviewed. RESULTS: The sonographic findings showed that 14 of the 16 patients had ascites; 10 of these had fine, complete and incomplete mobile septations. Of these 10 patients, 4 had ascites with a latticelike appearance, and 2 had ascites with a parallel violin string appearance, which to our knowledge has not been described previously; 3 had particulate ascites. Peritoneal and omental thickening or nodules were identified in 9 patients. Two patients showed bilateral complex adnexal masses with multiloculated fluid with a thick wall-like tubo-ovarian abscess. CONCLUSIONS: Tuberculous peritonitis seems to have characteristic sonographic features, especially the findings of peritoneal and omental thickening and ascites with fine, mobile septations. These sonographic findings may provide valuable information to help with further investigations and may prevent unnecessary laparotomies

146 Tongsong T, Wanapirak C, Sirichotiyakul S, Tongprasert F, Srisupundit K. Middle cerebral artery peak systolic velocity of healthy fetuses in the first half of pregnancy. J Ultrasound Med 2007 Aug;26(8):1013-7.

Abstract: OBJECTIVE: The purpose of this study was to establish normative data of middle cerebral artery (MCA) peak systolic velocity (PSV) in the first half of normal pregnancies (11-22 weeks). METHODS: A prospective cross-sectional descriptive study was conducted in which low-risk pregnant women whose pregnancies were singleton with accurate gestational age were recruited into the study. All neonates were subsequently proven to be healthy at birth. The sonographic measurements of MCA PSV were performed by the same examiner with a high-resolution machine. RESULTS: The total number of measurements was 410, and the number of measurements for each gestational week ranged from 30 to 40. The best regression model between gestational week and placental thickness was observed to be a linear function, and reference curves were constructed. The results showed a continuous increase in MCA PSV over the period from 11 to 22 weeks. During the period of study, 3 fetuses with hemoglobin Bart disease in the first half of pregnancy were encountered, and all of them had PSV of greater than the 95th percentile as well as 1.5 multiples of the median for each gestational week. CONCLUSIONS: A nomogram of MCA PSV for each gestational age from 11 to 22 weeks was constructed. These reference ranges may be useful noninvasive tools in risk assessment for fetal anemia in early pregnancy, especially due to hemoglobin Bart disease

147 Tongsong T, Wanapirak C, Sukpan K, Khunamornpong S, Pathumbal A. Subjective sonographic assessment for differentiation between malignant and benign adnexal masses. Asian Pac J Cancer Prev 2007 Jan;8(1):124-6.

Abstract: OBJECTIVE: To determine the accuracy of subjective sonographic assessment in distinguishing between benign and malignant adnexal masses. STUDY DESIGN: Cross-sectional descriptive study. METHODS: The patients scheduled for elective surgery due to adnexal masses were recruited into the study. All patients were sonographically examined within 72 hours of surgery were subjectively evaluated by the experienced sonographer, who had no any information of the patients, to differentiate between benign and malignant adnexal masses based on sonographic morphology. The final diagnoses, used as gold standard, were based on either pathological or operative findings. RESULTS: One hundred and fifty-eight patients with 174 adnexal masses, (benign; 108 and malignant; 66) were recruited into the study. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were of 89.7%, 84.9 % and 92.6 %, 87.5% and 90.9%, respectively. CONCLUSIONS: Subjective evaluation of sonographic morphology has high accuracy in differentiating between benign and malignant adnexal masses

148 Tsang JC, Charoenkwan P, Chow KC, Jin Y, Wanapirak C, Sanguansermsri T, et al. Mass spectrometry-based detection of hemoglobin E mutation by allele-specific base extension reaction. Clin Chem 2007 Dec;53(12):2205-9.

Abstract: BACKGROUND: The specific detection of a minor population of mutant DNA molecules requires methods of high specificity and sensitivity. While the single-allele base extension reaction (SABER) was shown to be useful for the detection of certain beta-thalassemia mutations, we encountered problems with false positivity during development of SABER for the noninvasive prenatal diagnosis of the hemoglobin E (HbE) disease. Systematic optimization resulted in an alternative protocol, the allele-specific base extension reaction (ASBER). METHODS: An artificial model was established by mixing genomic DNA of HbE carriers and normal individuals. Effects of terminator concentration and annealing temperature on the nonspecificity of SABER were then studied. The use of a single relevant terminator and the other 3 types of dideoxynucleotide as competing terminators were also compared in the development of the ASBER protocol. Thirteen cases of HbE-susceptible pregnancies were tested to compare the SABER and the ASBER protocols. RESULTS: Decreasing the single relevant terminator concentration and increasing the annealing temperature in SABER were found to improve specificity. The use of the other 3 types of dideoxynucleotide as competing terminators was shown to offer better detection sensitivity than a single terminator in ASBER. Genotyping results were all correctly determined by ASBER, except one false-negative detection (sensitivity: 80%, specificity: 100%). CONCLUSIONS: An alternative mass spectrometry-based protocol for noninvasive prenatal diagnosis, ASBER, has been successfully developed to allow the detection of a minor DNA population with a point mutation

149 Luewan S, Bunmaprasert T, Chiengthong K, Tongsong T. Spinal tuberculosis in pregnancy. Int J Gynaecol Obstet 2008 Sep;102(3):298-300.

No abstract is available

150 Lun FM, Tsui NB, Chan KC, Leung TY, Lau TK, Charoenkwan P, et al. Noninvasive prenatal diagnosis of monogenic diseases by digital size selection and relative mutation dosage on DNA in maternal plasma. Proc Natl Acad Sci U S A 2008 Dec 16;105(50):19920-5.

Abstract: Prenatal diagnosis of monogenic diseases, such as cystic fibrosis and beta-thalassemia, is currently offered as part of public health programs. However, current methods based on chorionic villus sampling and amniocentesis for obtaining fetal genetic material pose a risk to the fetus. Since the discovery of cell-free fetal DNA in maternal plasma, the noninvasive prenatal assessment of paternally inherited traits or mutations has been achieved. Due to the presence of background maternal DNA, which interferes with the analysis of fetal DNA in maternal plasma, noninvasive prenatal diagnosis of maternally inherited mutations has not been possible. Here we describe a digital relative mutation dosage (RMD) approach that determines if the dosages of the mutant and wild-type alleles of a disease-causing gene are balanced or unbalanced in maternal plasma. When applied to the testing of women heterozygous for the CD41/42 (-CTTT) and hemoglobin E mutations on HBB, digital RMD allows the fetal genotype to be deduced. The diagnostic performance of digital RMD is dependent on interplay between the fractional fetal DNA concentration and number of DNA molecules in maternal plasma. To achieve fetal genotype diagnosis at lower volumes of maternal plasma, fetal DNA enrichment is desired. We thus developed a digital nucleic acid size selection (NASS) strategy that effectively enriches the fetal DNA without additional plasma sampling or experimental time. We show that digital NASS can work in concert with digital RMD to increase the proportion of cases with classifiable fetal genotypes and to bring noninvasive prenatal diagnosis of monogenic diseases closer to reality

151 Pongsatha S, Tongsong T. Randomized comparison of dry tablet insertion versus gel form of vaginal misoprostol for second trimester pregnancy termination. J Obstet Gynaecol Res 2008 Apr;34(2):199-203.

Abstract: AIM: To compare the effectiveness of vaginal misoprostol between dry tablet insertion and gel form for second trimester pregnancy termination. METHODS: A non-blinded block randomized controlled trial was conducted on 148 pregnant women with live fetuses in the second trimester undergoing pregnancy termination. They were randomly allocated to receive vaginal misoprostol (400 microg) either dry tablet insertion (n=72) or gel form (n=76). The same dose was then repeated every 3 h if adequate uterine contraction was not achieved until 48 h after the initiation of misoprostol. If abortion did not occur within this period, the treatment was considered a failure and other technique of termination was then given based on the decision of the attending physicians and the cervical status. RESULTS: The mean induction-abortion interval in group 1 (20.9+/-12.3 h) was not significantly different from that in group 2 (17.7+/-10.2 h). The mean total dose of misoprostol was also not significantly different between the two groups (group 1, 1556.9 microg; group 2, 1350.9 microg), but the adverse effects of misoprostol (chill and diarrhoea) were more common in the gel group. CONCLUSION: Tablet insertion or gel form of vaginal misoprostol have similar effectiveness but the gel form was associated with more common adverse effects

152 Rujiwetpongstorn J, Tongsong T. Amniotic band syndrome following septostomy in management of twin-twin transfusion syndrome: a case report. J Perinatol 2008 May;28(5):377-9.

Abstract: Septostomy, a rupture of the diamniotic membrane separating monozygotic twins essentially creating a monoamniotic gestation, is a potential therapeutic modality for twin-twin transfusion syndrome (TTTS). This may be associated with complications including cord entanglement or complete rupture of the membranes. We report a case of severe amniotic band syndrome with cord amputation after septostomy. A 33-year-old woman with a Mo-Di twin pregnancy was diagnosed with TTTS at 18 weeks of gestation. Septostomy as well as amnioreduction were performed at 24 weeks of gestation. A repeat cesarean delivery was performed at 31 weeks resulting in a live recipient baby of 1340 g and a dead donor with amniotic band syndrome. The donor showed pieces of membrane tightening both legs. The right thigh became entangled in the bands connecting to the umbilical cord of the live fetus. The umbilical cord of the dead twin was completely amputated, whereas the umbilical cord of the live infant was also entrapped within the amniotic band resulting in small diameter and some degree of stricture. This is the first report of a rare but serious complication following septostomy

153 Sirichotiyakul S, Piyamongkol W, Tongprasert F, Srisupandit K, Luewan S. Transabdominal chorionic villus sampling: experience at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai 2008 Jun;91(6):813-7.

Abstract: OBJECTIVE: To describe the experience of transabdominal chorionic villus sampling (CVS) at Maharaj Nakorn Chiang Mai Hospital. MATERIAL AND METHOD: Between January 2004 and July 2006, 185 pregnant women chose to have CVS for prenatal diagnosis after counseling. Transabdominal CVS under ultrasound guidance was performed in all cases under local anesthesia using spinal needle 20-gauge with back and forth movement technique. The sample was immediately examined under a microscope to determine if the villi were obtained and to remove the decidua (maternal cells) from the villi. RESULTS: The mean gestational age was 12.25 +/- 1.05 weeks (range 10-20 weeks). The procedure was successful in all cases, 168 cases (90.9%) with one attempt. The indications for prenatal diagnosis included fetal risk for chromosomal abnormalities (110 cases; 59.46%), severe thalassemia syndrome (57 cases; 30.81%), both of them (17 cases; 9.19%) and for HLA typing in one case. The results could not be obtained in 11 cases (5.95%) due to laboratory failure. In the present study, abnormal chromosomes were detected in chorionic villi from 12 fetuses, including 45,X (3), trisomy 18 (3), trisomy 21 (2), trisomy 7 (1) and mosaicism (3). Additionally, 18 fetuses with severe thalassemia syndrome were identified; five homozygous beta-thalassemia, 11 beta-thalassemia/Hb E disease, and two homozygous alpha-thalassemia (Hb Bart’s). The complications found in the present study included one case (0.54%) of fetal loss following the procedure and one case (0.54%) of vaginal bleeding. No case with limb reduction defect, infection, or rupture of membranes following the procedure was seen. CONCLUSIONS: Transabdominal CVS is a rather safe and reliable prenatal diagnostic technique. The fetal loss rate following the procedure in the present study was 0.54%. However operator’ experience and skill in ultrasound-directed needle guidance procedure are essential

154 Srisupundit K, Piyamongkol W, Tongsong T. Comparison of red blood cell hematology among normal, alpha-thalassemia-1 trait, and hemoglobin Bart’s fetuses at mid-pregnancy. Am J Hematol 2008 Dec;83(12):908-10.

Abstract: The objective of this study was to compare red blood cell indices among normal, alpha-thalassemia-1 trait, and hemoglobin (Hb) Bart’s fetuses at mid-pregnancy. A total of 87 pregnancies (88 fetuses) at risk of homozygous alpha-thalassemia-1, who underwent cordocentesis including the measurement of Hb level and red blood cell indices of fetuses at 18-22 weeks of gestation at Maharaj Nakorn Chiang Mai Hospital, were recruited into this study. The final outcome was based on the fetal DNA analysis using PCR technique for SEA type alpha-thalassemia-1. Fetuses were divided into three groups: normal, alpha-thalassemia-1 trait, and homozygous alpha-thalassemia-1 (Hb Bart’s disease). The mean gestational age of the 87 pregnant women recruited into the study was 18.7 +/- 0.8 weeks. According to the DNA analysis, the incidence of Hb Bart’s disease, alpha-thalassemia-1 trait, and normal fetuses were 29.5%, 45.5%, and 25%, respectively. The mean Hb level, mean corpuscular volume, mean corpuscular Hb, and mean cell Hb concentration were significantly different in all three groups of fetuses. Moreover, these differences were also found among fetuses with the alpha-thalassemia-1 trait and those that were normal. Ninety-two percent of fetuses with Hb Bart’s disease had some degree of anemia at mid-pregnancy. However, two Hb Bart’s fetuses did not have anemia. Furthermore, two fetuses in the alpha-thalassemia-1 trait group were mildly anemic, but most (95%) were not. There is a highly significant difference in red blood cell indices among normal, alpha-thalassemia-1 trait, and Hb Bart’s fetuses, and most fetuses with Hb Bart’s disease have some degree of anemia from mid-pregnancy

155 Srisupundit K, Sirichotiyakul S, Tongprasert F, Luewan S, Tongsong T. Fetal therapy in fetal thyrotoxicosis: a case report. Fetal Diagn Ther 2008;23(2):114-6.

Abstract: INTRODUCTION: Fetal thyrotoxicosis, often caused by maternal Grave’s disease, can have adverse effects on fetal outcomes, such as growth impairment or fetal hydrops. Therefore, intrauterine treatment is recommended. Objective: To describe the experience of intrauterine medical treatment of fetal thyrotoxicosis. CASE: A 19-year-old woman with a history of Grave’s disease in a euthyroid clinical status after subtotal thyroidectomy became pregnant 2 months after thyroidectomy. At gestational age 28 weeks, persistent fetal tachycardia was identified and the diagnosis of fetal thyrotoxicosis was established by fetal thyroid function test on umbilical cord blood obtained by cordocentesis. Intrauterine treatment for hyperthyroidism was initiated with antithyroid drugs (150 mg/day of propylthiouracil) via maternal oral administration. Fetal heart rate, size of fetal thyroid gland and umbilical cord blood sampling for thyroid function test were monitored. Fetal heart rate became normal and fetal thyroid function tested on fetal cord blood at 1 month after antithyroid fetal therapy was also normal. Fetal thyrotoxicosis improved but the mother had some degree of hypothyroidism from fetal therapy and needed thyroid hormone replacement. The remaining course of gestation was uneventful. The patient had spontaneous labor and delivery at 38 weeks of gestation resulting in normal female baby, 2,900 g, and had no clinical of neonatal thyrotoxicosis. Maternal thyroid medications were stopped immediately after birth. CONCLUSION: Intrauterine treatment of fetal thyrotoxicosis with medication via the maternal circulation can possibly improve fetal outcome

156 Supadilokluck S, Tongprasert F, Tongsong T, Wanapirak C, Piyamongkol W, Sirichotiyakul S, et al. Amniocentesis in twin pregnancies. Arch Gynecol Obstet 2008 Dec 27.

Abstract: OBJECTIVE: To describe the experiences in diagnostic amniocentesis in twin pregnancies. METHODS: The computerized database and medical records of pregnant women attending Maternal Fetal Medicine Unit of the hospital for diagnostic amniocentesis at 16-20 weeks gestation between January 1992 and December 2006 were retrospectively reviewed. RESULTS: During 15 years of experience, 7,890 amniocenteses at 16-20 weeks gestation were performed for prenatal diagnosis, including 174 procedures in 87 twin pregnancies. The mean gestational age at the time of amniocentesis was 17.13 +/- 3.35 weeks. Preterm birth rate defined as the delivery before 36 gestational weeks was 36.24%. The total fetal loss rate was 5.17%, however, the procedure related fetal loss within 2 weeks after the procedure was 1.15%. CONCLUSION: Based on our limited data and previous studies, we can counsel patients undergoing twin amniocentesis at mid-trimester that the fetal loss rate may be slightly higher than that of singleton amniocentesis

157 Tongsong T, Luewan S, Phadungkiatwattana P, Neeyalavira V, Wanapirak C, Khunamornpong S, et al. Pattern recognition using transabdominal ultrasound to diagnose ovarian mature cystic teratoma. Int J Gynaecol Obstet 2008 Nov;103(2):99-104.

Abstract: OBJECTIVE: To determine the validity of sonographic pattern recognition in the diagnosis of mature cystic teratoma. METHODS: Consecutive patients scheduled for elective surgery for adnexal masses were included in the study. All patients underwent transabdominal ultrasound with color extended-flow mapping within 24 hours prior to surgery. Examinations were performed by the same sonographer to identify benign cystic teratoma. The final diagnoses were based on histopathologic findings. RESULTS: A total of 329 consecutive patients were recruited; 23 were excluded because the masses were not adnexal masses. Of the remaining 306 patients, 36 masses were found to be mature cystic teratomas and 270 were nonteratomas. Sonographic pattern recognition showed a sensitivity of 94.4% and a specificity of 98.2%. CONCLUSION: Sonographic pattern recognition using transabdominal ultrasound with color extended-flow mapping can accurately diagnose mature cystic teratoma

158 Tongsong T, Sukpan K, Wanapirak C, Phadungkiatwattna P. Fetal cytomegalovirus infection associated with cerebral hemorrhage, hydrops fetalis, and echogenic bowel: case report. Fetal Diagn Ther 2008;23(3):169-72.

Abstract: We describe some fetal ultrasound findings associated with intrauterine cytomegalovirus (CMV) infection. We report a 38-year-old gravida 3, para 2 at 16 weeks of gestation who underwent ultrasound examination for anomaly screening. The scan revealed an extensive irregular echogenic area in the fetal brain, especially at the level of lateral ventricles, suggestive of intraventricular and cerebral hemorrhage. Cardiomegaly, hepatomegaly, and mild ascites as well as an echogenic bowel were demonstrated. Abnormal chromosomes and hemoglobin Bart disease were excluded by analysis of fetal blood. Follow-up ultrasound at 20 weeks of gestation showed frank hydrops fetalis, and termination of the pregnancy was performed based on the couple’s decision, giving stillbirth to a male fetus weighing 450 g. Autopsy findings showed intracerebral hemorrhage (right cerebral hemisphere) and hydrops fetalis with hepatosplenomegaly. Microscopic investigation showed typical changes of CMV infection in several organs, including brain, thyroid gland, lung, liver, kidney, heart, pancreas, and placenta. Sonographically, the combination of hydrops fetalis, cerebral hemorrhage, and hyperechoic bowel should raise the possibility of a CMV infection, particularly in cases with no obvious cause of hydrops fetalis

159 Luewan S, Srisupundit K, Tongsong T. Outcomes of pregnancies complicated by beta-thalassemia/hemoglobin E disease. Int J Gynaecol Obstet 2009 Mar;104(3):203-5.

Abstract: OBJECTIVE: To assess the outcomes of pregnancies affected by beta-thalassemia/hemoglobin E (beta-thal/HbE) disease. METHODS: A retrospective cohort study was conducted with 54 women with singleton pregnancies complicated by beta-thal/HbE disease only. The controls-to-cases ratio was 2:1. RESULTS: Although maternal outcomes were similar in both groups, gestational age at birth and birth weight were significantly lower in the study group and the cesarean delivery rate was significantly higher in that group (relative risk [RR], 2.1). The incidences of fetal growth restriction, preterm birth, and low birth weight were also significantly higher in the study group, with RRs of 2.8, 2.7, and 5.6, respectively. CONCLUSION: Pregnancies affected by beta-thal/HbE disease were significantly associated with an increased risk of fetal growth restriction, preterm birth, and low birth weight

160 Lumbiganon P, Villar J, Laopaiboon M, Widmer M, Thinkhamrop J, Carroli G, et al. One-day compared with 7-day nitrofurantoin for asymptomatic bacteriuria in pregnancy: a randomized controlled trial. Obstet Gynecol 2009 Feb;113(2 Pt 1):339-45.

Abstract: OBJECTIVE: To evaluate whether a 1-day nitrofurantoin regimen is as effective as a 7-day regimen in eradicating asymptomatic bacteriuria during pregnancy. METHODS: A multicenter, double-blind, randomized, placebo controlled noninferiority trial was conducted in antenatal clinics in Thailand, the Philippines, Vietnam, and Argentina. Pregnant women seeking antenatal care between March 2004 and March 2007 who met the inclusion and exclusion criteria were invited to participate in the study. Those who consented were randomly allocated to receive either a 1-day or a 7-day course of 100 mg capsules of nitrofurantoin, which was taken twice daily. The primary outcome was bacteriologic cure on day 14 of treatment. RESULTS:: A total of 1,248 of 24,430 eligible women had asymptomatic bacteriuria, making the overall prevalence of 5.1%. Of these 1,248 women, 778 women were successfully recruited, and 386 and 392 women were randomly allocated to 1-day and 7-day regimens, respectively. Escherichia coli was the most common potentially pathogenic bacteria detected, its prevalence approaching 50%. Bacteriologic cure rates at treatment day 14 were 75.7% and 86.2% for 1-day and 7-day regimens, respectively. The cure rate difference was -10.5% (95% confidence interval -16.1% to -4.9%). Mean birth weight and mean gestational age at delivery were significantly lower in the 1-day regimen group. There were fewer adverse effects in the 1-day regimen group, but the differences were not statistically significant. CONCLUSION: A 1-day regimen of nitrofurantoin is significantly less effective than a 7-day regimen. Women with asymptomatic bacteriuria in pregnancy should receive the standard 7-day regimen. CLINICAL TRIAL REGISTRATION: ISRCTN, isrctn.org, ISRCTN11966080 LEVEL OF EVIDENCE: I

161 Pornprasert S, Mary JY, Faye A, Leechanachai P, Limtrakul A, Rugpao S, et al. Higher placental anti-inflammatory IL-10 cytokine expression in HIV-1 infected women receiving longer zidovudine prophylaxis associated with nevirapine. Curr HIV Res 2009 Mar;7(2):211-7.

Abstract: Placental cytokine balance may be critical for the control of mother-to-child transmission (MTCT) of HIV. We assessed whether the type and duration of antiretrovirals used for prevention of HIV-1-MTCT modified the inflammatory cytokine profile. We investigated the levels of cytokine expression in the placentas of 61 HIV-1-infected women who received zidovudine (ZDV) plus single dose nevirapine (SD-NVP) or ZDV only for prevention of MTCT. Placentas of 38 HIV-1-uninfected women were included as controls. All placentas were obtained after vaginal delivery. Levels of mRNA and cytokine expression were quantified using real-time PCR and ELISA, respectively, in placental explants and 24-hour culture supernatants and analyzed in relation to the women’s characteristics and the type and duration of antiretroviral prophylaxis. HIV-1-infected and uninfected women did not show any differences in the expression of placental cytokine secretion except for a trend toward lower TNF-alpha mRNA levels in HIV-1-infected women. Within the HIV-1-infected group, women who were exposed to a long duration of ZDV (>72 days) or received SD-NVP less than 5h prior to delivery, more frequently expressed detectable levels of IL-10 in their placentas (32% versus 7% (p = 0.01) and 32% versus 5% (p = 0.02), respectively). No infant was found to be HIV-1-infected. Our results showed a normalization of the placental cytokine balance in HIV-1-infected women receiving antiretroviral prophylaxis. Furthermore, the type and duration of antiretroviral prophylaxis have an impact on the placental anti-inflammatory IL-10 expression level, which may contribute to controlling HIV replication at the placental level, thus reducing MTCT of HIV-1

162 Pranpanus S, Sirichotiyakul S, Srisupundit K, Tongsong T. Sensitivity and specificity of mean corpuscular hemoglobin (MCH): for screening alpha-thalassemia-1 trait and beta-thalassemia trait. J Med Assoc Thai 2009 Jun;92(6):739-43.

Abstract: OBJECTIVE: To evaluate sensitivity, specificity, and positive and negative predictive value of mean corpuscular hemoglobin (MCH) for screening alpha-thalassemia-1 trait and beta-thalassemia trait. MATERIAL AND METHOD: Descriptive analysis, diagnostic test, was conducted on 396 pregnant women attending the antenatal clinic between September 2007 and June 2008. Blood samples were collected from pregnant women after counseling and getting informed consent. MCH was measured in all samples by automated hematology analyzer Determination of HbA2 level for diagnosis of beta-thalassmia trait and PCR for alpha-thalassemia-1 gene (SEA type) were performed in all cases as a gold standard The data were collected and analyzed for sensitivity, specificity, and positive and negative predictive value of MCH for screening alpha-thalassemia-1 trait and beta-thalassemia trait. RESULTS: Based on the ROC curve, the best cut-off level of MCH in predicting the thalassemia carriers was 26.5 picrograms. Positive MCH (< 26.5 picrograms) gave the sensitivity of 95.2% and specificity of 82.3% in screening alpha-thalassemia-1 trait and beta-thalassemia trait. The positive predictive value and negative predictive value were 40.4% and 99.3% respectively. CONCLUSION: MCH is a good tool for screening alpha-thalassemia-1 trait and beta-thalassemia trait during pregnancy because of its simplicity, low cost, (when determined as a part of complete blood count), and high sensitivity

163 Sirichotiyakul S, Saetung R, Sanguansermsri T. Prenatal diagnosis of beta-thalassemia/Hb E by hemoglobin typing compared to DNA analysis. Hemoglobin 2009;33(1):17-23.

Abstract: To determine the accuracy of prenatal diagnosis of beta-thalassemia (beta-thal)/Hb E disease using fetal hemoglobin (Hb) typing compared to DNA analysis, automated DNA sequencing was performed on 98 blood samples from fetuses diagnosed as beta-thal/Hb E by Hb typing. Thirteen samples from homozygous Hb E fetuses were also collected. The Hb patterns obtained by high performance liquid chromatography (HPLC) from both groups were analyzed. The codon 26 (G>A) mutation was identified in all 98 samples. The beta-globin gene mutation was identified in 97 cases by DNA sequencing and the 3.4 kb deletion by polymerase chain reaction (PCR) in one case. The result from DNA analysis was in agreement with the HPLC result in all samples. In beta-thal/Hb E fetuses, the Hb A level was 0-0.3% and mean Hb A(2)(E) level was 1.3 +/- 0.3%. In homozygous Hb E fetuses, the Hb A level was 0% and mean Hb A(2)(E) level was 2.48 +/- 0.6%. The Hb pattern obtained by HPLC on fetal blood is a reliable and accurate method for prenatal diagnosis of this disease

164 Srisupundit K, Piyamongkol W, Tongsong T. Identification of fetuses with hemoglobin Bart’s disease using middle cerebral artery peak systolic velocity. Ultrasound Obstet Gynecol 2009 Jun;33(6):694-7.

Abstract: OBJECTIVES: To determine the sensitivity and specificity of middle cerebral artery peak systolic velocity (MCA-PSV) in mid-pregnancy for the identification of homozygous alpha-thalassemia-1 (hemoglobin (Hb) Bart’s disease) in fetuses at risk of the disease. METHODS: A total of 88 pregnancies (91 fetuses) at risk of Hb Bart’s disease and undergoing MCA-PSV measurement before cordocentesis at 18-22 weeks of gestation were recruited into the study. Definitive diagnosis was made using the gold standard technique of Hb typing by high-performance liquid chromatography. RESULTS: The mean +/- SD age of the 88 pregnant women recruited into the study was 28.3 +/- 5.7 years, the gestational age was 18.8 +/- 1.1 weeks and the incidence of Hb Bart’s disease was 22% (20 fetuses). Using MCA-PSV above 1.5 multiples of the median as a cut-off point, the sensitivity of MCA-PSV for detecting affected fetuses was 85% (17/20 cases), with a specificity of 100%, and positive and negative predictive values of 100% and 95.9% respectively. Three of 20 fetuses with Hb Bart’s disease had normal MCA-PSV. CONCLUSIONS: MCA-PSV assessment in mid-pregnancy is a useful method for identifying Hb Bart’s disease with high sensitivity and specificity among fetuses at risk, and may allow avoidance of unnecessary cordocentesis in some cases

165 Tongsong T, Wanapirak C, Neeyalavira V, Khunamornpong S, Sukpan K. E-flow doppler indices for prediction of benign and malignant ovarian tumors. Asian Pac J Cancer Prev 2009 Jan;10(1):139-42.

Abstract: OBJECTIVE: To determine the validity of pulsatility and resistance index of transabdominal Doppler ultrasound (e-flow) in distinguishing between benign and malignant adnexal masses. METHODS: A cross-sectional descriptive study was conducted on patients scheduled for elective surgery due to adnexal masses at Maharaj Nakorn Chiang Mai Hospital, Thailand, between April 2006 and March 2008. All patients were sonographically evaluated for pulsatility and resistance indices aided with color e-flow within 24 hours of surgery. The examinations were performed by the same experienced sonographer, who had no information on the patients, to differentiate between benign and malignant adnexal masses based on Doppler indices. The final diagnoses were based on either pathological or operative findings, used as gold standards. RESULTS: Three hundred and twenty-nine patients were recruited and 23 were excluded, since the masses were finally not proven to be adnexal, for example with intrauterine myomas. Of the remaining 306 cases available for analysis, 191 were benign and 115 were malignant. The sensitivity and specificity of the pulsatility index for distinction were 93.0% and 92.7%, respectively and the values for the resistance index were 94.8 % and 93.2%. CONCLUSIONS: Pulsatility and resistance indices with transabdominal Doppler ultrasound (e-flow) have high accuracy for differentiating between benign and malignant adnexal masses

166 Tongsong T, Srisupundit K, Luewan S. Outcomes of pregnancies affected by hemoglobin H disease. Int J Gynaecol Obstet 2009 Mar;104(3):206-8.

Abstract: OBJECTIVE: To determine the outcomes of pregnancies affected by hemoglobin H (HbH) disease. METHODS: A retrospective cohort study was conducted with 120 women with singleton pregnancies complicated by HbH disease only. The controls-to-cases ratio was 2:1. RESULTS: Maternal outcomes were similar in the 2 groups. The incidences of fetal growth restriction (relative risk [RR], 2.4; 95% confidence interval [CI], 1.60-3.50), preterm birth (RR, 1.4; 95% CI, 1.03-1.96), and low birth weight (RR, 1.9; 95% CI, 1.46-2.56) were significantly higher in the study than in the control group. The perinatal mortality rate was slightly higher in the study group. CONCLUSION: In spite of attempts to keep hemoglobin levels sufficiently high (>7.0 g/dL), pregnancies with HbH disease were significantly associated with increased risks of fetal growth restriction, preterm birth, and low birth weight

167 Tongsong T, Tongprasert F, Srisupundit K, Luewan S. High fetal splenic artery peak velocity in fetuses with hemoglobin Bart disease: a preliminary study. J Ultrasound Med 2009 Jan;28(1):13-8.

Abstract: OBJECTIVE: The purpose of this study was to evaluate the role of the splenic artery (SPA) peak systolic velocity (PSV) in identifying fetuses with hemoglobin (Hb) Bart disease among pregnancies at risk for the disease. METHODS: Pregnancies at risk for fetal Hb Bart disease scheduled for cordocentesis at 18 to 25 weeks’ gestation at Maharaj Nakorn Chiang Mai Hospital were recruited into the study. The SPA PSV was measured before cordocentesis, and the final fetal diagnosis of Hb Bart disease was based on fetal Hb typing using high-performance liquid chromatography. RESULTS: Seventy-six singleton pregnancies at risk for fetal Hb Bart disease were sonographically evaluated for the SPA PSV and underwent cordocentesis for fetal blood analysis. Among the 76 recruited pregnancies, 17 fetuses with Hb Bart disease were finally diagnosed by fetal blood analysis with high-performance liquid chromatography, and the remainder had no abnormalities or had the alpha-thalassemia 1 trait and were defined as unaffected fetuses. The mean SPA PSVs +/- SD for the unaffected and affected fetuses were significantly different: 21.17 +/- 3.7 cm/s (range, 13.8-29.9 cm/s) and 26.12 +/- 3.6 cm/s (range, 20.4-31.5 cm/s) respectively. The SPA PSV of the affected fetuses was higher than that of the unaffected ones (Wilcoxon signed rank test, P < .001). CONCLUSIONS: Splenic artery PSV assessment at mid pregnancy may have a potential role in identifying fetuses with Hb Bart disease. Further studies to evaluate the effectiveness of the SPA PSV in differentiating affected from unaffected fetuses among pregnancies at risk are desirable

168 Traisrisilp K, Luewan S, Tongsong T. Pregnancy outcomes in women complicated by thalassemia syndrome at Maharaj Nakorn Chiang Mai Hospital. Arch Gynecol Obstet 2009 May;279(5):685-9.

Abstract: OBJECTIVE: To determine the maternal and fetal outcomes of women complicated with thalassemia syndrome. STUDY DESIGN: Retrospective descriptive study. MATERIALS AND METHODS: The database of Maternal-Fetal Medicine unit and medical records, between January 2001 and April 2008, were reviewed to search for pregnant women complicated with thalassemia syndrome and medical records were reviewed for patient’s baseline characteristics and pregnancy outcomes. The inclusion criteria consisted of (1) pregnant women diagnosed for thalassemia syndrome by hematologist either during or before pregnancy based on hemoglobin typing, (2) attending the antenatal care clinic and delivery at Maharaj Nakorn Chiang Mai hospital, and (3) available data of pregnancy outcomes. RESULTS: During the study period, 80 pregnant women with thalassemia syndrome were recruited, including 52 (65%) cases of HbH disease, 23 (28.8%) cases of beta-thalassemia/HbE disease, 2 cases of AE Bart’s disease, 2 cases of EF Bart’s disease and 1 case of beta-thalassemia major. Excluding 2 twin pregnancies and 1 case with beta-thalassemia major, 77 were available for analysis of the outcomes. The mean gestational age (+/-SD) at delivery was 37.40 (+/-2.6) weeks, range 27-42 weeks. Twenty-five (32.5%) had delivery by cesarean section and the remainder had successful vaginal delivery. Fetal growth restriction was found in 21 cases (27.3%), 16 (20.8%) had preterm births and the rate of low birth weight (<2,500 g) was 44.1%. Regard to the type of thalassemia, baseline hemoglobin levels and mean birth weight of women with beta-thal/Hb E was significantly lower than the levels of those with Hb H disease. CONCLUSION: This series indicates that, in spite of an attempt to keep hemoglobin levels above 7.0 g/dl, pregnancy with thalassemia is likely to be associated with an increased rate of fetal growth restriction, preterm birth and low birth weight

169 Wanapirak C, Sirichotiyakul S, Luewan S, Srisupundit K, Tongsong T. Comparison of the accuracy of dichlorophenolindophenol (DCIP), modified DCIP, and hemoglobin E tests to screen for the HbE trait in pregnant women. Int J Gynaecol Obstet 2009 May 26.

No abstract is available