Multidisciplinary Obstetric Simulation Training: Experience at KK Women's and Children's Hospital (KKH), Singapore, a Tertiary Referral Centre

Background Multidisciplinary simulation training in the management of acute obstetric emergencies has the potential to reduce both maternal and perinatal morbidity. It is a valuable tool that can be adapted for targeted audiences of different specialities at all experience levels from medical students to senior consultants. Methods In this study, pre- and post-course questionnaires of learners with varying levels of clinical experience from Obstetrics and Gynaecology (O&G), Anaesthesia, Neonatology, Emergency Medicine, midwifery, and nursing who undertook two simulation courses (namely the Combined Obstetrics Resuscitation Training course, CORE, and the CORE Lite), which comprised lectures and simulation drills with manikins and standardized patients, between 2015 and 2023 were compared. This also included a period when training was affected by the coronavirus disease 2019 (COVID-19) pandemic.  Results The results showed that both simulation courses increased confidence levels among all learners in the management of obstetric emergencies.  Pre-course, participants were most confident in the management of neonatal resuscitation and severe pre-eclampsia, followed by postpartum haemorrhage. They were least confident in the management of vaginal breech delivery, uterine inversion, and twin delivery. Post-course, participants were most confident in the management of neonatal resuscitation and shoulder dystocia, followed by postpartum haemorrhage. They were least confident in the management of uterine inversion and maternal sepsis, followed by vaginal breech delivery and twin delivery. Whilst we saw a huge improvement in confidence levels for all obstetric emergencies, the greatest improvement in confidence levels was noted in vaginal breech delivery, twin delivery, and uterine inversion. Conclusion The simulation courses were effective in improving the confidence in the management of obstetric emergencies. While it may be difficult to measure the improvement in clinical outcomes as a result of simulation courses alone, the increase in confidence levels of clinicians can be used as a surrogate in measuring their preparedness in facing these emergency scenarios.

Continuous Glucose Monitoring Feedback in the Subsequent Development of Gestational Diabetes: A Pilot, Randomized, Controlled Trial in Pregnant Women

OBJECTIVE

 This study evaluated the effects of receiving glucose feedback from continuous glucose monitoring (CGM) by intermittent scanning (unblinded group), and CGM with masked feedback (blinded group) in the subsequent development of gestational diabetes mellitus (GDM).

STUDY DESIGN

 This was a prospective, single-center, pilot, randomized controlled trial including n = 206 pregnant women in the first trimester of pregnancy with no prior diagnosis of type 1 or type 2 diabetes. The participants were randomized into the unblinded group or blinded group and wore the CGM in the first trimester of pregnancy (9-13 weeks), the second trimester of pregnancy (18-23 weeks), and late-second to early-third trimester (24-31 weeks). The primary outcome was GDM rate as diagnosed by the 75-g oral glucose tolerance test (OGTT) at 24 to 28 weeks.

RESULTS

 Over 47 months, 206 pregnant women were enrolled at 9 to 13 weeks. The unblinded group had a higher prevalence of women who developed GDM (21.5 vs. 14.9%; p > 0.05), compared to the blinded group. In the unblinded group compared to the blinded group, plasma glucose values were higher at 1 hour (median 7.7 [interquartile range {IQR}: 6.3-9.2] vs. 7.5 [6.3-8.7]) and 2 hours (6.3 [5.8-7.7] vs. 6.2 [5.3-7.2]), but lower at 0 hour (4.2 [4.0-4.5] vs. 4.3 [4.1-4.6]; p > 0.05). All these differences were not statistically significant.

CONCLUSION

 Glucose feedback from CGM wear in the first to the third trimester of pregnancy without personalized patient education failed to alter GDM rate.

KEY POINTS

· Continuous glucose monitoring (CGM) is feasible for use in pregnant women.. · No significant difference in gestational diabetes rates with or without CGM feedback.. · Future clinical trials should incorporate CGM education and personalized guidance to enhance study outcomes..

Knowledge, Attitude and Perceptions Around Perinatal Mental Health Among Doctors in an Obstetrics and Gynaecology Academic Department in Singapore

Background Frontline healthcare professionals who provide regular care to women in the antenatal and postnatal period play a critical role in the early detection and management of maternal perinatal mental health (PMH). This study aimed to assess the knowledge, attitudes, and perceptions of doctors around perinatal mental health in an obstetrics and gynaecology (O&G) department in Singapore. Methods Using an online survey, data was collected from 55 doctors who participated in the Doctor's Knowledge, Attitudes and Perceptions of Perinatal Mental Health (I-DOC) study. The survey questions assessed the knowledge, attitudes, perceptions and practices in relation to PMH among doctors in the O&G specialty. Descriptive data was presented as means and standard deviations (SDs), or frequency and percentages. Results Out of the 55 doctors, more than half (60.0%) were not aware of the adverse impacts of poor PMH; 83.7% of doctors were not confident in providing PMH advice and 65.5% did not routinely screen patients for PMH disorders. There was a lower percentage of doctors (10.9% vs. 34.5%, p<0.001) who discussed PMH issues in the antenatal period compared to the postnatal period and this was statistically significant. Majority of doctors (98.2%) agreed that having standardised PMH guidelines will be useful. All doctors agreed on the benefits of having PMH guidelines, education and routine screening for patients. Conclusion There is inadequate PMH literacy among O&G doctors and lack of emphasis on antenatal PMH disorder. The findings highlighted the need for increased education and development of perinatal mental health guidelines.

Attitudes and practices of exercise among pregnant mothers in Singapore

Introduction

There is increasing evidence demonstrating the safety and benefits of physical activity (PA) in uncomplicated pregnancies. Literature has shown that pregnant women around the world do not engage in adequate exercise. This study aims to assess the current practices of exercise among pregnant women in Singapore, determine the proportion of women meeting different PA targets and evaluate the factors influencing the practice of exercise.

Methods

In this cross-sectional study, pregnant women in different trimesters of pregnancy from KK Women's and Children's Hospital and Singapore General Hospital were surveyed. Information regarding patient demographics, attitudes and perceptions of exercise, and practice of exercise was collected. The International Physical Activity Questionnaire (IPAQ) was used to determine the amount of PA.

Results

A total of 201 pregnant women aged 20-44 years were surveyed. Almost all (99.0%) participants thought that exercise was beneficial in pregnancy. Only 31.6% of them engaged in any moderate or vigorous leisure-time PA (LTPA) and they were active for a median of 120 min/week. Only 12.6% of the pregnant women met the national recommendations of at least 150 min of moderate exercise per week. The amount of total PA performed was lower among women in later trimesters of pregnancy and higher among working mothers.

Conclusion

Although most Singaporean pregnant women perceived exercise as beneficial, the majority did not engage in PA. Most of the participants did not meet the international PA targets and recently published national guidelines. More can be done to promote the uptake of exercise in pregnancy and optimise metabolic management of pregnant women in Singapore.

Unexpected case of postnatal pancreatitis: first presentation of autoimmune diabetes

Gestational diabetes mellitus (GDM) is defined as the first onset of glucose intolerance in pregnancy without prior known diabetes. While it is commonly associated with metabolic risk factors such as obesity and hypertension, a small percentage of women with GDM have underlying autoimmune causes, with presence of islet-cell antibodies resulting in autoimmune-mediated destruction of the pancreas. We present a case of idiopathic postpartum pancreatitis precipitating fulminant diabetic ketoacidosis in a patient with otherwise well-controlled GDM during pregnancy, and subsequent findings of positive anti-glutamic acid decarboxylase antibody. This is the first presentation of autoimmune diabetes diagnosed postnatally in a woman who has no previous medical or family history.

Glycemic Variability in Early Pregnancy May Predict a Subsequent Diagnosis of Gestational Diabetes

PURPOSE

This study examined the prospective association between CGM-derived glycemic variability (GV) and glycemic control (GC) parameters in the first and second trimester, with subsequent diagnosis of GDM in the early third trimester.

METHODS

In a longitudinal observational study, 60 study participants in the first trimester (9-13 weeks' gestation), and 53 participants (18-23 weeks' gestation) in the second trimester of pregnancy had CGM data extracted after a minimum of 8 days' wear time (up to 14 days). At 24-31 weeks' gestation, participants underwent a 75 g, 2-hour oral glucose-tolerance test as per IADPSG criteria to diagnose GDM. GV parameters examined in both first and second trimesters were mean amplitude of glycemic excursion (MAGE), standard deviation (SD), mean glucose, and coefficient of variation (CV). GC parameters measured were J-Index and percentage of time spent in glucose target ranges.

RESULTS

The first trimester SD and MAGE were significantly higher in participants subsequently diagnosed with GDM (SD adjusted median 1.31 [interquartile range 1.2-1.3] mmol/L; MAGE 3.26 [3.2-3.3] mmol/L) than those who were not (SD 1.01 [0.9-1.0] mmol/L, MAGE 2.59 [2.4-2.6] mmol/L; p<0.05). Similarly, second trimester SD and MAGE were also significantly higher in participants subsequently diagnosed with GDM (SD 1.35 [1.3-1.4] mmol/L; MAGE 3.32 (3.31-3.41) mmol/L) than those who were not (SD 0.99 [0.98-1.01] mmol/L, MAGE 2.42 [2.42-2.55] mmol/L; p<0.05). Associations between SD and MAGE with GDM outcomes were adjusted for prepregnancy BMI and ethnicity. There were nonsignificant trends of higher J-Index scores in the first and second trimester, higher CV in the first trimester only, and higher mean in the second trimester only in participants diagnosed with GDM. Other study parameters measured were not significantly different between groups (p>0.003).

CONCLUSION

Our study suggests the potential value of CGM-derived SD and MAGE in early pregnancy as potential predictors of subsequent GDM diagnosis.

Asia-Pacific consensus on physical activity and exercise in pregnancy and the postpartum period

Physical activity and exercise in pregnancy are generally beneficial and enhance the physical and mental health of women. These benefits also prevent excessive weight gain and reduce risks of obesity in pregnancy, such as gestational diabetes, hypertensive disorders, higher rates of caesarean delivery, macrosomia and stillbirth. Thus, there is a need to optimise perinatal exercise and physical activity globally. There is currently no consensus recommendation on the role of physical activity and exercise in pregnancy and the postpartum period in the Asia-Pacific region. In this paper, we present seven key consensus recommendations on physical activity and exercise in pregnancy and the postpartum period by 18 key members representing 10 countries in Asia-Pacific regions during an international workshop of the Asia

Diabetes in Pregnancy Conference in Singapore on 11–12 January 2020. Through these consensus recommendations, we hope to improve the metabolic health of pregnant women living in Asia-Pacific regions by educating the public and guiding healthcare professionals on the safety and importance of physical exercise and activity to benefit pregnant women and after childbirth.

Risk factors for pregnancy-associated venous thromboembolism in Singapore

OBJECTIVES

Pregnancy-associated venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with increased risk of maternal mortality and morbidity. This study aimed to assess potential risk factors for pregnancy-associated VTE.

METHODS

In this case-control study, women with pregnancy-associated VTE were identified via International Classification of Diseases codes and included if they had been objectively diagnosed with VTE during pregnancy or within six weeks postpartum, from 2004 to 2016, at KK Women's and Children's Hospital or Singapore General Hospital in Singapore. Controls, i.e. pregnant women without VTE, were selected from a prospective longitudinal study. The odds ratio (OR) for VTE was computed for a range of maternal and obstetric factors.

RESULTS AND CONCLUSIONS

From 2004 to 2016, 89 cases of pregnancy-associated VTE and 926 controls were identifed and analysed using logistic regression. The most significant risk factors for pregnancy-associated VTE were smoking (OR 5.44, p=0.0002) and preterm delivery (OR 5.06, p=0.023). Malay race, multiparity, non-O blood group and caesarean section, were also identified to be of higher risk. These risk factors should be useful in the development of thromboprophylaxis strategies for pregnancy and the postpartum period, especially in Singapore.

Pregnancy Outcomes in COVID-19: A Prospective Cohort Study in Singapore

INTRODUCTION

Pregnant women are reported to be at increased risk of severe coronavirus disease 2019 (COVID-19) due to underlying immunosuppression during pregnancy. However, the clinical course of COVID-19 in pregnancy and risk of vertical and horizontal transmission remain relatively unknown. We aim to describe and evaluate outcomes in pregnant women with COVID-19 in Singapore.

METHODS

Prospective observational study of 16 pregnant patients admitted for COVID-19 to 4 tertiary hospitals in Singapore. Outcomes included severe disease, pregnancy loss, and vertical and horizontal transmission.

RESULTS

Of the 16 patients, 37.5%, 43.8% and 18.7% were infected in the first, second and third trimesters, respectively. Two gravidas aged ≥35 years (12.5%) developed severe pneumonia; one patient (body mass index 32.9kg/m2) required transfer to intensive care. The median duration of acute infection was 19 days; one patient remained reverse transcription polymerase chain reaction (RT-PCR) positive >11 weeks from diagnosis. There were no maternal mortalities. Five pregnancies produced term live-births while 2 spontaneous miscarriages occurred at 11 and 23 weeks. RT-PCR of breast milk and maternal and neonatal samples taken at birth were negative; placenta and cord histology showed non-specific inflammation; and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific immunoglobulins were elevated in paired maternal and umbilical cord blood (n=5).

CONCLUSION

The majority of COVID-19 infected pregnant women had mild disease and only 2 women with risk factors (obesity, older age) had severe infection; this represents a slightly higher incidence than observed in age-matched non-pregnant women. Among the women who delivered, there was no definitive evidence of mother-to-child transmission via breast milk or placenta.

Maternal and Fetal Outcomes in Systemic Lupus Erythematosus Pregnancies

Abstract Introduction: To describe the maternal and fetal outcomes in systemic lupus erythematosus (SLE) pregnancies followed-up in a single tertiary referral centre. Methods: We performed a retrospective cohort study of 75 SLE pregnancies who were followed up in Singapore General Hospital over a 16-year period from 2000 to 2016. Adverse fetal and maternal outcomes including preterm delivery, miscarriages, fetal growth restriction, congenital heart block, neonatal lupus, pre-eclampsia and SLE flares were obtained from the medical records. Results: The mean age at conception was 32 years old (SD 3.8). The mean SLE disease duration was 5.9 years (SD 5.2). The majority (88%) had quiescent SLE disease activity at baseline. Most pregnancies resulted in a live birth (74.7%). The mean gestational age at birth was 37.4 weeks (SD 3.4). Adverse fetal outcomes occurred in 53.3%. Preterm delivery (33.9%), miscarriages (20%) and fetal growth restriction (17.3%) were the most frequent adverse fetal outcomes. There was 1 neonatal death and SLE flares occurred in a third (33%). In the subgroup of SLE pregnancies with antiphospholipid syndrome, there were higher SLE flare rates (40%) and adverse fetal outcomes occurred in 8 pregnancies (80%). There were no predictive factors identified for all adverse fetal and maternal outcomes. In the subgroup analysis of preterm delivery, anti-Ro (SS-A) antibody positivity and hydroxychloroquine treatment were associated with a lower risk of preterm delivery. Conclusion: Although the majority had quiescent SLE disease activity at baseline, SLE pregnancies were associated with high rates of adverse fetal and maternal outcomes. Keywords: Antiphospholipid syndrome, anti-La (SS-B) antibody, anti-Ro (SS-A) antibody, lupus nephritis

Attitudes and precaution practices towards COVID-19 among pregnant women in Singapore: a cross-sectional survey

Background

COVID-19 may predispose pregnant women to higher risks of severe disease and poorer neonatal outcome. Psychological sequalae of this pandemic may pose a greater conundrum than its clinical aspects. It is currently unknown that how pregnant women cope with this global pandemic and its ramifications. The aims of the study are to understand the attitudes and precaution practices of non-infected pregnant women towards the COVID-19 outbreak in Singapore.

Methods

An online cross-sectional survey of COVID-19 awareness among pregnant women attending antenatal clinics in Singapore was conducted. An internet link was provided to complete an online electronic survey on Google platform using a quick response (QR) code on mobile devices. The online survey consists of 34 questions that were categorized into 4 main sections, namely 1) social demographics 2) attitude on safe distancing measures 3) precaution practices and 4) perceptions of COVID-19. Multiple linear regression analysis was performed to examine women’s precaution practices among six independent socio-demographic variables, including age, ethnicity, education, front-line jobs, history of miscarriage and type of antenatal clinic (general, high risk).

Results

A total of 167 survey responses were obtained over 8 weeks from April to June 2020. The majority of women were aged ≤35 years (76%, n = 127), were of Chinese ethnicity (55%, n = 91), attained tertiary education (62%, n = 104) and were not working as frontline staff (70%). Using multiple linear regression models, Malay ethnicity (vs. Chinese, β 0.24; 95% CI 0.04, 0.44) was associated with higher frequency of practicing social distancing. Malay women (β 0.48; 95% CI 0.16, 0.80) and those who worked as frontline staff (β 0.28; 95% CI 0.01, 0.56) sanitized their hands at higher frequencies. Age of ≥36 years (vs. ≤30 years, β 0.24; 95% CI 0.01, 0.46), Malay (vs. Chinese, β 0.27; 95% CI 0.06, 0.48) and Indian ethnicity (vs. Chinese, β 0.41; 95% CI 0.02, 0.80), and attendance at high-risk clinic (vs. general clinic, β 0.20; 95% CI 0.01, 0.39) were associated with higher frequency of staying-at-home.

Conclusion

Social demographical factors including age > 36 years old, Malay ethnicity, employment in front line jobs and attendance at high-risk clinics are likely to influence the attitudes and precaution practices among pregnant women towards COVID-19 in Singapore. Knowledge gained from our cross-sectional online survey can better guide clinicians to communicate better with pregnant women. Hence, it is important for clinicians to render appropriate counselling and focused clarification on the effect of COVID-19 among pregnant women for psychological support and mental well being.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03378-w.

Epidemiology of pregnancy-associated pulmonary embolism in South Asian multi-ethnic country: Mortality trends over the last four decades

OBJECTIVE

To determine the cumulative incidence, time of occurrence and risk factors of pregnancy-associated pulmonary embolism (PE) in Singapore, and to review the maternal mortality ratio of PE over the last four decades.

STUDY DESIGN AND SETTING

In this retrospective epidemiology review, women with pregnancy-associated PE were identified via International Classification of Diseases codes and included if they had been objectively diagnosed on imaging with PE during pregnancy or within 6 weeks postpartum from 2004 to 2016 at KK Women's and Children's Hospital (KKH) and Singapore General Hospital (SGH) in Singapore. The medical records were reviewed and the time of occurrence of confirmed PE cases and risk factors for PE were noted.

RESULTS

There were 18 PE cases out of 174 708 deliveries, of which two were fatal, giving a cumulative incidence of PE at 1.03 per 10 000 deliveries and a mortality rate of 11.1%. The maternal mortality ratio is 1.14 per 100 000 deliveries, the lowest compared to that of the previous three decades (2.5-4.9 per 100 000 deliveries). Majority of PE (66.7%) occurred during the first 2 weeks postpartum. Cumulative incidence of postpartum PE was four times more in caesarean section compared to vaginal delivery at 1.58 per 10 000 deliveries and 0.40 per 10 000 deliveries, respectively.

CONCLUSION

Although the cumulative incidence of pregnancy-associated PE in Singapore is low, it is comparable to the United Kingdom (UK) and United States (US). Risk assessment and thromboprophylaxis have decreased PE mortality significantly during this period.

P884 Rare case of primary cardiac lymphoma in immunocompetent patient

Primary cardiac lymphoma is a rare tumour especially in immunocompetent person. It is invariably fatal unless diagnosed and treated early. Our patient was a 76 year old Chinese gentlemen, known case diabetes mellitus and hypertension, who presented with 3 months history of failure symptoms. He also had loss of appetite.

His vital signs were stable. There was bibasal crepitation, raised JVP with normal heart sounds and bilateral pedal edema. Chest X-ray showed bilateral pleural effusion.He was admitted for stabilization of heart failure and started on diuretics.

Echocardiography showed the LV ejection fraction was 50% with grade 1 diastolic dysfunction. There was a global pericardial effusion with effusion size 2.52cm maximum at posterior to LV. There was partial RA collapse .Patient was otherwise hemodynamically stable. Patient was observed closely and diuretics continued. Echocardiography on the third day of admission showed a suspicious looking mass in the right atrial (RA) and right ventricular (RV) wall near the AV groove. It become apparent after pericardial effusion became less. Patient was counselled and agreed for pericardial tapping but procedure had to be abandoned as effusion has reduced compared to before (&lt;20mm).

MRI cardiac showed an infiltrating mass around the right atrio-ventricular groove extending to the right ventricular free wall and around the pericardial lining around the ascending aorta and pulmonary trunks. There is inhomogenous signal in STIR with iso-intensity on T1 weighted images. First pass metabolism revealed some vascularity. There was a patchy myocardial enhancement on late gadolinium enhancement. pericardium was thickened with global pericardial effusion- 16mm. Large right pleural effusion seen and minimal left pleural effusion. Mediastinal lymphadenopathy was seen. The finding were suggestive of cardiac lymphoma with differential sarcoma.

Subsequent day, patient develop acute ischemic stroke which was complicated by aspiration pneumonia and septic shock. Fortunately he recovered after 1 week of antibiotics and non-invasive ventilatory support.

FDG PET- CT scan showed FDG-avid primary cardiac lymphoma with pericardial involvement and conglomerate of multiple group of mediastinal and supra clavicular lymph nodes . Bilateral hypermetabolic adrenal nodule were seen but unable to determine its relevance to the primary pathology(lymphoma). No marrow or other organ involvement. Stage is likely IIE.

We were unable to harvest the lymph node because they were too deep. Patient"s family was counselled for cardiac biopsy but family did not want to take the risk as patient was bedridden and fragile. They were also not keen for any chemotherapy or invasive procedure. Once patient was out of infection, they requested to bring back patient to home. He was sent to nursing home for full time care but succumbed to another bout of aspiration pneumonia one week after discharge.

Abstract P884 Figure. Echo, MRI, Pet CT scan

P1342 Secondary cardiac tumour -a metastasis from renal cell carcinoma via transvenous extension

Secondary cardiac tumour is 20-40 times more common than primary cardiac tumour. Most common tumour that metastasize to the heart are lung cancer, breast cancer and hematologic malignancy. Melanoma and pleural mesothelioma has high inclination to metastasize. Other cancer with high rate of cardiac metastasis include gastric, ovarian, renal and pancreatic cancer. The presentation of cardiac metastasis is usually non-specific and sometimes mimic other cardiac condition. We would like to present one such case where we used multimodality approach for proper evaluation.

A 57 year old lady presented with intermittent chest discomfort for one month which worsen on day of admission. Otherwise she had good effort tolerance. Electrocardiogram had no acute ischemic changes and Troponin T was not elevated. Bedside echocardiography revealed a large cardiac mass in right atrium around 66mm x 29mm, protruding to right ventricle. Apart from that noted aneurysm of interatrial septum towards LA.

MRI cardiac showed an inhomogenous mass extending from the right renal vein and inferior vena cava(IVC) into the right atrium(RA). The tumour mass in the right atrium a highly mobile and flops across the tricuspid valve into the right ventricle during ventricular diastole causing right ventricular outflow tract obstruction. The mass was hyperintense on T2- and isointense on T1-weighted images. There was vascularity within the mass with inhomogenous gadolinium enhancement. There was also 2 masses in right kidney , a larger inhomogenous encapsulated mass at the right lower pole and smaller at lower pole. The findings were suggestive of a primary renal cell carcinoma with tumour mass extension into right renal vein, inferior vena cava and into the right atrium.

A staging CT scan thorax , abdomen and pelvis did not show any other possible primary source of cancer and reconfirm the extracardiac finding of the MRI. No evidence of tumour extension into hepatic veins and left renal vein. There was however small nodular opacities in both right and left lung suggesting lung metastasis.

A combined operation was done with our cardiothoracic surgeon and urologist from nearby tertiery hospital. Nephrectomy and removal of tumour thrombus from IVC and RA was done with 18 degree Celcius circulatory arrest with cardiopulmonary bypass.

Section of renal mass showed a poorly circumscribed lobulated tumour with areas of hemorrhage and necrosis. The tumour was close to capsule but has not breached it. The tumour was mainly clear cell carcinoma variant, nuclear grade III. Section from IVC that extend to RA appeared elongated sausage-like measuring 150mm in length and 30mm in diameter had tumour embolus. Pulmonary artery and perirenal blood vessel also had tumour emboli. The hilar nodes however were free from tumour.

Patient recovered well and was discharged home day 9 post operation. Follow-up echocardiogram 3weeks post-op showed no recurrence of the mass and good LV function.

Abstract P1342 Figure. Echo, CTscan, MRI and Pathology images

Coverage and determinants of influenza vaccine among pregnant women: a cross-sectional study

Background

Pregnant women are at increased risk of influenza-related complications. The World Health Organisation recommends influenza vaccination to this high-risk population as highest priority. However, achieving high influenza vaccine coverage among pregnant women remains challenging. We conducted a cross-sectional survey to estimate the coverage and determinants of influenza vaccination among pregnant women in Singapore.

Methods

Between September and November 2017, pregnant women aged ≥21 years were recruited at two public hospitals in Singapore. Participants completed an anonymous, self-administered online questionnaire assessing participants’ influenza vaccination uptake, knowledge of and attitudes towards influenza and the influenza vaccine, vaccination history, willingness to pay for the influenza vaccine, and external cues to vaccination. We estimated vaccine coverage and used multivariable Poisson models to identify factors associated with vaccine uptake.

Results

Response rate was 61% (500/814). Only 49 women (9.8, 95% Confidence Interval (CI): 7.3–12.7%) reported receiving the vaccine during their current pregnancy. A few misconceptions were identified among participants, such as the belief that influenza can be treated with antibiotics. The most frequent reason for not being vaccinated was lack of recommendation. Women who were personally advised to get vaccinated against influenza during pregnancy were 7 times more likely to be vaccinated (prevalence ratio (PR) = 7.11; 95% CI: 3.92–12.90). However, only 12% of women were personally advised to get vaccinated. Other factors associated with vaccine uptake were vaccination during a previous pregnancy (PR = 2.51; 95% CI: 1.54–4.11), having insurance to cover the cost of the vaccine (PR = 2.32; 95% CI: 1.43–3.76), and higher vaccine confidence (PR = 1.62; 95% CI: 1.30–2.01).

Conclusions

Influenza vaccination uptake among pregnant women in Singapore is low. There is considerable scope for improving vaccination coverage in this high-risk population through vaccination recommendations from healthcare professionals, and public communication targeting common misconceptions about influenza and influenza vaccines.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7172-8) contains supplementary material, which is available to authorized users.

Echocardiographic and electrocardiographic presentations of patients with endomyocardial biopsy-proven cardiac amyloidosis

OBJECTIVE

Cardiac amyloidosis is under diagnosed and its prevalence is unknown. This is a retrospective, nonrandomised, single centre study of patients with endomyocardial biopsy-proven cardiac amyloidosis focusing on their echocardiographic and electrocardiogram (ECG) presentations. This is the first case series in Malaysia on this subject.

METHODS

We identified all of our endomyocardial biopsyproven cardiac amyloidosis patients from January 2010 to January 2018 and reviewed their medical records. All patients echocardiographic and ECG findings reviewed and analysed comparing to basic mean population value.

RESULTS

In total there are 13 biopsy-proven cardiac amyloidosis patients. All of the biopsies shows light chain (AL) amyloid. Majority of the patients (8, 61.5%) is male, and most of our patients (8, 61.5%) is Chinese. All seven patients on whom we performed deformation imaging have apical sparing pattern on longitudinal strain echocardiogram. Mean ejection fraction is 49.3%, (SD=7.9). All patients have concentric left ventricular hypertrophy and right ventricular hypertrophy. Diastolic dysfunction was present in all of our patients with nine out of 13 patients (69.2%) having restrictive filling patterns (E/A ≥2.0 E/e' ≥15). On electrocardiogram, 12 (92%) patients have prolonged PR interval (median 200ms, IQR 76.50ms) and 9 (69.2%) patients have pseudoinfarct pattern.

CONCLUSION

Echocardiography plays an important role in diagnosing cardiac amyloidosis. The findings of concentric left ventricular hypertrophy with preserved ejection fraction without increased in loading condition should alert the clinician towards its possibility. This is further supported by right ventricular hypertrophy and particularly longitudinal strain imaging showing apical sparing pattern.

Altered Placental Chorionic Arterial Biomechanical Properties During Intrauterine Growth Restriction

Intrauterine growth restriction (IUGR) is a pregnancy complication due to placental dysfunction that prevents the fetus from obtaining enough oxygen and nutrients, leading to serious mortality and morbidity risks. There is no treatment for IUGR despite having a prevalence of 3% in developed countries, giving rise to an urgency to improve our understanding of the disease. Applying biomechanics investigation on IUGR placental tissues can give important new insights. We performed pressure-diameter mechanical testing of placental chorionic arteries and found that in severe IUGR cases (RI > 90th centile) but not in IUGR cases (RI < 90th centile), vascular distensibility was significantly increased from normal. Constitutive modeling demonstrated that a simplified Fung-type hyperelastic model was able to describe the mechanical properties well, and histology showed that severe IUGR had the lowest collagen to elastin ratio. To demonstrate that the increased distensibility in the severe IUGR group was related to their elevated umbilical resistance and pulsatility indices, we modelled the placental circulation using a Windkessel model, and demonstrated that vascular compliance (and not just vascular resistance) directly affected blood flow pulsatility, suggesting that it is an important parameter for the disease. Our study showed that biomechanics study on placenta could extend our understanding on placenta physiology.

Comparison of Caesarean sections and instrumental deliveries at full cervical dilatation: a retrospective review

INTRODUCTION

This study aimed to compare instrumental vaginal deliveries (IDs) and Caesarean sections (CSs) performed at full cervical dilatation, including factors influencing delivery and differences in maternal and neonatal outcomes.

METHODS

A retrospective review was conducted of patients who experienced a prolonged second stage of labour at Singapore General Hospital from 2010 to 2012. A comparison between CS and ID was made through analysis of maternal/neonatal characteristics and peripartum outcomes.

RESULTS

Of 253 patients who required intervention for a prolonged second stage of labour, 71 (28.1%) underwent CS and 182 (71.9%) underwent ID. 5 (2.0%) of the patients who underwent CS had failed ID. Of the maternal characteristics considered, ethnicity was significantly different. Induction of labour and intrapartum epidural did not influence delivery type. 70.4% of CSs occurred outside office hours, compared with 52.7% of IDs (p = 0.011). CS patients experienced a longer second stage of labour (p < 0.001). Babies born via CS were heavier (p < 0.001), while the ID group had a higher proportion of occipitoanterior presentations (p < 0.001). Estimated maternal blood loss was higher with CSs (p < 0.001), but neonatal outcomes were similar.

CONCLUSION

More than one in four parturients requiring intervention for a prolonged second stage of labour underwent emergency CS. Low failed instrumentation rates and larger babies in the CS group suggest accurate diagnoses of cephalopelvic disproportion. The higher incidence of CS after hours suggests trainee reluctance to attempt ID. There were no clinically significant differences in maternal and neonatal morbidity.

A case of successfully managed pregnancy in a patient with complex cyanotic congenital heart disease

Medical advances have increased survival of patients with congenital heart disease. However, cardiac disease in pregnancy carries significant maternal and fetal risks, posing enormous challenges to obstetricians. Cyanotic congenital heart disease is associated with maternal complications such as arrhythmias, thromboembolic events and death. Fetal complications include small for gestational age, miscarriage and prematurity. Cyanotic congenital heart disease patients who continue their pregnancies require holistic multidisciplinary team care with early and coordinated planning for delivery. Management of such patients include early counseling regarding pregnancy-associated risks, close monitoring of their cardiac function and regular scanning for fetal assessment. Choice of anesthesia for these patients requires meticulous planning to achieve a favorable balance between systemic and pulmonary vascular resistance, ensuring minimal change in right-to-left shunting. We report a case of a successfully managed pregnancy in a patient with complex congenital heart disease and a single ventricle of left ventricle morphology.

Multiple pregnancy in a primigravida with uncorrected Pentalogy of Fallot

Pentalogy of Fallot is a cyanotic congenital heart disease that has guarded prognosis without surgical intervention in infancy. Women with uncorrected defects rarely survive into childbearing age and pregnancy in this group is associated with a high rate of perinatal loss. Physiological cardiovascular changes in pregnancy can lead to maternal haemodynamic instability with subsequent adverse cardiac sequelae with or without fetal decompensation. Optimum management and pregnancy outcomes in mother with uncorrected Pentalogy of Fallot and twin pregnancy have not been described in the literature. We describe a successful case of monochorionic diamniotic twin pregnancy in an affected woman who has not undergone surgical repair. Her pregnancy progressed without any adverse cardiopulmonary complications. Her caesarean delivery and postpartum recovery were favourable, with successful birth of two healthy babies at 35.7 weeks. This case emphasises the importance of a multidisciplinary team, especially of obstetricians with expertise in high-risk pregnancies, adult congenital heart disease cardiologists and anaesthesiologist.

Primary omental pregnancy

We present a case of primary omental ectopic pregnancy in a 31-year-old woman which was discovered intraoperatively during a diagnostic laparoscopy and subsequently removed via mini-laparotomy. We emphasise the rarity of this diagnosis, and the importance of careful inspection of the abdominal cavity including the omentum should an ectopic pregnancy be suspected when bilateral fallopian tubes and ovaries appear normal during surgical exploration.

Repeated failed non-invasive prenatal testing in a woman with immune thrombocytopenia and antiphospholipid syndrome: lessons learnt

We present a case of a 37-year-old Chinese woman (gravida 4 para 0) with a history of immune thrombocytopenia and type IIb antiphospholipid syndrome. She was started on 100 mg of aspirin, 20 mg of prednisolone and 20 mg of subcutaneous low-molecular-weight heparin daily for her fourth pregnancy. She opted for non-invasive prenatal testing for aneuploidy screening but had failed results three times consecutively from insufficient fetal cfDNA initially or high variance in cfDNA counts on redraws. She declined invasive karyotyping. Her pregnancy was complicated by severe pre-eclampsia and fetal growth restriction at 19+6 weeks of gestation and was terminated. Subsequent fetal karyotyping revealed a normal karyotype of 46XY with no apparent abnormalities.

Multiple pregnancy is the leading contributor to cesarean sections in in vitro fertilization pregnancies: An analysis using the Robson 10-group classification system

AIM

In vitro fertilization (IVF) pregnancy is an important contributor to rising cesarean section (CS) rates. The profile of CS in this group is not well documented. This study sought to identify leading patient categories of the Robson 10-Group Classification System (TGCS) contributing to the high IVF CS rate.

METHODS

We carried out a prospective study of IVF patients who delivered in the Singapore General Hospital from January 2010 to July 2012. Parity, singleton/multiple pregnancy, previous CS, mode of labor onset and gestational age at delivery were collected based on the TGCS. All other deliveries during the study period served as control.

RESULTS

There were a total of 215 IVF deliveries, of which 114 (54.4%) were CS. Group 8 (all multiple pregnancies) was the greatest contributor to the overall CS rate (43.0%). Group 2 (term nulliparous singleton cephalic pregnancies with induction of labor or planned CS) was the second largest contributor to overall CS rate (12.3%). The third and fourth leading contributors were Group 10 (preterm singleton pregnancies) and Group 5 (pregnancies with previous CS), respectively. In contrast, these two groups were top contributors to the overall CS rate for the control group.

CONCLUSION

Multiple pregnancy is the principal contributor to CS in our IVF population, and reducing its incidence may reduce its CS rate. Among singleton pregnancies, planned CS and failed induction for cephalic term pregnancies and preterm singleton pregnancies were the next largest contributors, suggesting a higher prevalence of maternal request and high-risk obstetric indications requiring interventions at preterm gestations.

Antithrombin deficiency in pregnancy

We present a case of a 39-year-old, gravida 3 para 2, Chinese female with a history of inherited type 1 Antithrombin deficiency and multiple prior episodes of venous thromboembolism. She presented at 29+4 weeks' gestation with severe pre-eclampsia complicated by haemolysis, elevated liver enzymes and low platelet (HELLP) syndrome. She subsequently underwent an emergency caesarean section for non-reassuring fetal status, which was complicated by postpartum haemorrhage secondary to uterine atony, requiring a B-Lynch suture intraoperatively.

A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals

BACKGROUND

A common national MTP was jointly implemented in 2011 by the national blood service (Blood Services Group) and seven participating acute hospitals to provide rapid access to transfusion support for massively haemorrhaging patients treated in all acute care hospitals.

METHODS

Through a systematic clinical workflow, blood components are transfused in a ratio of 1:1:1 (pRBC: whole blood-derived platelets: FFP), together with cryoprecipitate for fibrinogen replacement. The composition of components for the MTP is fixed, although operational aspects of the MTP can be adapted by individual hospitals to suit local hospital workflow. The MTP could be activated in support of any patient with critical bleeding and at risk of massive transfusion, including trauma and non-trauma general medical, surgical and obstetric patients.

RESULTS

There were 434 activations of the MTP from October 2011 to October 2013. Thirty-nine per cent were for trauma patients, and 30% were for surgical patients with heavy intra-operative bleeding, with 25% and 6% for patients with gastrointestinal bleeding and peri-partum haemorrhage, respectively. Several hospitals reported reduction in mean time between request and arrival of blood. Mean transfusion ratio achieved was one red cell unit: 0·8 FFP units: 0·8 whole blood-derived platelet units: 0·4 units of cryoprecipitate. Although cryoprecipitate usage more than doubled after introduction of MTP, there was no significant rise in overall red cells, platelet and FFP usage following implementation.

CONCLUSION

This successful collaboration shows that shared transfusion protocols are feasible and potentially advantageous for hospitals sharing a central blood provider.

Glaucoma severity affects diffusion tensor imaging (DTI) parameters of the optic nerve and optic radiation

OBJECTIVES

To evaluate whether MR diffusion tensor imaging (DTI) of the optic nerve and optic radiation in glaucoma patients provides parameters to discriminate between mild and severe glaucoma and to determine whether DTI derived indices correlate with retinal nerve fibre layer (RNFL) thickness.

METHODS

3-Tesla DTI was performed on 90 subjects (30 normal, 30 mild glaucoma and 30 severe glaucoma subjects) and the FA and MD of the optic nerve and optic radiation were measured. The categorisation into mild and severe glaucoma was done using the Hodapp-Parrish-Anderson (HPA) classification. RNFL thickness was also assessed on all subjects using OCT. Receiver operating characteristic (ROC) analysis and Spearman's correlation coefficient was carried out.

RESULTS

FA and MD values in the optic nerve and optic radiation decreased and increased respectively as the disease progressed. FA at the optic nerve had the highest sensitivity (87%) and specificity (80%). FA values displayed the strongest correlation with RNFL thickness in the optic nerve (r=0.684, p ≤ 0.001) while MD at the optic radiation showed the weakest correlation with RNFL thickness (r=-0.360, p ≤ 0.001).

CONCLUSIONS

The high sensitivity and specificity of DTI-derived FA values in the optic nerve and the strong correlation between DTI-FA and RNFL thickness suggest that these parameters could serve as indicators of disease severity.

Abstract P1-02-09: Positive predictive value (PPV) of the diagnosis of atypia in breast core biopsies: An audit of MSKCC breast pathology service

Percutaneous needle core biopsy is the standard of care in the assessment of suspicious breast lesions. The diagnostic term “Atypia” is used in breast biopsy reporting when histologic appearances are suspicious but not diagnostic of malignancy. Multiple histopathological appearances are encompassed by the umbrella term “atypia”, including atypical ductal hyperplasia (ADH), columnar cell change with atypia (CCCWA), which is also known as flat epithelial atypia (FEA), and a miscellaneous group of diagnoses, known as atypia NOS.

A pathologic diagnosis of “atypia” in breast core biopsies usually leads to a recommendation to surgically excise the lesion. Many studies have correlated the diagnosis of “atypia” in core biopsies with the subsequent finding of carcinoma in the surgical excisions, and the percentage of carcinoma found represents the positive predictive value (PPV) of the diagnosis. To date, there is no agreed target PPV for the diagnosis of breast atypia on biopsy, but the most studies have demonstrated a PPV of 20- 40%. Individual “atypia” diagnoses such as CCCWA have an even lower PPV of 10-15%.

One method of performance review is an audit of the average breast-atypia PPV within individual pathology departments, which then can be monitored and studied over time, to detect trends and “diagnostic drift” at an early stage. In addition, assessment of the individual PPV of each breast pathologist allows for analysis of the consistency of the diagnostic practice of each individual with their colleagues. Surprisingly, there have been no major studies assessing the intradepartmental range of PPVs for breast atypia diagnoses to date. In contrast, the American College of Radiology has designed the BIRADS classification system in order to audit and monitor the PPV of breast imaging in diagnosing malignancy.

We undertook to measure the departmental PPV for malignancy following a biopsy diagnosis of breast atypia, and performed an anonymized subanalysis in order to establish the range of PPVs of atypia diagnoses between the sub-specialized breast pathologists within the department.

This study established that the baseline PPV in our department is comparable to previously reported studies at 24%, while the range of PPV for an atypia diagnosis between pathologists is between 22.8 and 25% for 5 of 6 pathologists, with one pathologist demonstrating a higher PPV of 36.8%. ADH was the most common diagnosis of the atypia subtypes, and the PPV for ADH alone was 29.9%. 15% of ADH diagnoses were described as “ADH bordering on low grade DCIS”; within this subgroup the PPV was 48.5%. The PPV for a diagnosis of CCCWA alone was 10%.

This study demonstrates that the PPV for breast atypia in a major tertiary cancer center is approximately 24%. We have demonstrated very reproducible use of this diagnostic term within the department. We plan to use the findings of this study to identify subgroups of patients with a sufficiently low PPV to justify a decision not to proceed to surgical intervention. We aim to develop an algorithm for use in the clinical setting in order to direct further patient management. The ultimate aim of this research is to reduce the number of patients undergoing unnecessary surgical interventions.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-02-09.

Does low-molecular-weight heparin improve live birth rates in pregnant women with thrombophilic disorders? A systematic review

INTRODUCTION

Pregnancies in women with thrombophilia are associated with a higher risk of obstetric complications. We systematically reviewed the findings of relevant randomised controlled trials (RCTs) with the aim of investigating the effectiveness of low-molecular-weight heparins (LMWHs) in pregnant women with inherited thrombophilic disorders and its effect on the incidence of live births in these patients.

METHODS

The MEDLINE-PubMed and Cochrane CENTRAL databases from 2000 to 2010 were searched using a combination of keywords, including low-molecular-weight heparin, enoxaparin, pregnancy, live birth and thrombophilia. Studies were included if they were RCTs assessing the effect of anticoagulant treatment on live birth rates in women with a history of miscarriage without apparent causes other than thrombophilic disorder. Interventions included LMWH, with or without aspirin, aspirin alone or placebo controlled for the prevention of adverse pregnancy outcome.

RESULTS

43 articles with seven RCTs were retrieved following the initial search, of which four studies had to be excluded as they assessed thromboembolic events as the final outcome (n = 1), focused on idiopathic recurrent miscarriages (n = 1), compared efficacy and safety of two doses of enoxaparin (n = 1), and examined patients with or without thrombophilic disorder (n = 1). Pooled data from the remaining three RCTs showed no significant difference in the improvement of live birth rates following LMWH interventions (p = 0.15).

CONCLUSION

At present, the use of LMWH in women with inherited thrombophilia with recurrent pregnancy loss is not indicated. Large randomised placebo-controlled trials are further needed to prove the effectiveness of LMWH in these patients.

Specialist training in obstetrics and gynecology in singapore: transition to structured residency program

BACKGROUND

The article describes the experience of planning and implementing the transition of the residency program in obstetrics and gynecology at Singhealth, Singapore, from a model largely based on British training principles to a new model in accordance with the ACGME-International (ACGME-I) standards.

INTERVENTION

Initial steps in transitioning to the new model entailed (1) identifying faculty with an interest in education to lead the various initiatives and programs and to ensure appropriate educational role models, (2) securing adequate funding, (3) holding focus groups with physicians to identify opportunities for improvement in the new system, and (4) developing a schedule for the phased implementation of key features of the structured system.

RESULTS

The program started in July 2011, with 14 residents for a 4-year course of training. The curriculum consisted of 5 modules: (1) general obstetrics and gynecology and ambulatory care, (2) maternal fetal medicine, (3) urogynecology and minimally invasive surgery, (4) reproductive medicine, and (5) gynecology oncology. Faculty was assigned responsibility for teaching and assessing the 6 competencies, and appropriate training was provided through specially designed, professional-development programs.

CONCLUSIONS

Challenges in the implementation of the new training program included the need to replace clinical service previously provided by trainees, a lack of fit between the traditional qualifying exam and the new model for training, and the need to adapt teaching strategies to new competencies not explicitly taught in the prior program, particularly practice-based learning and improvement and systems-based practice. The strength of the new obstetrics and gynecology residency lies in having a structured, competency-based, closely supervised approach to training with standardized evaluations, timely feedback, and a committed faculty.

Quantification of diffusion tensor imaging in normal white matter maturation of early childhood using an automated processing pipeline

OBJECTIVES

The degree and status of white matter myelination can be sensitively monitored using diffusion tensor imaging (DTI). This study looks at the measurement of fractional anistropy (FA) and mean diffusivity (MD) using an automated ROI with an existing DTI atlas.

METHODS

Anatomical MRI and structural DTI were performed cross-sectionally on 26 normal children (newborn to 48 months old), using 1.5-T MRI. The automated processing pipeline was implemented to convert diffusion-weighted images into the NIfTI format. DTI-TK software was used to register the processed images to the ICBM DTI-81 atlas, while AFNI software was used for automated atlas-based volumes of interest (VOIs) and statistical value extraction.

RESULTS

DTI exhibited consistent grey-white matter contrast. Triphasic temporal variation of the FA and MD values was noted, with FA increasing and MD decreasing rapidly early in the first 12 months. The second phase lasted 12-24 months during which the rate of FA and MD changes was reduced. After 24 months, the FA and MD values plateaued.

CONCLUSION

DTI is a superior technique to conventional MR imaging in depicting WM maturation. The use of the automated processing pipeline provides a reliable environment for quantitative analysis of high-throughput DTI data.

KEY POINTS

Diffusion tensor imaging outperforms conventional MRI in depicting white matter maturation. • DTI will become an important clinical tool for diagnosing paediatric neurological diseases. • DTI appears especially helpful for developmental abnormalities, tumours and white matter disease. • An automated processing pipeline assists quantitative analysis of high throughput DTI data.

Ministry of health clinical practice guidelines: clinical blood transfusion

The Health Sciences Authority (HSA) and the Ministry of Health (MOH) publish clinical practice guidelines on Clinical Blood Transfusion to provide doctors and patients in Singapore with evidence-based guidance for blood transfusion. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HSA-MOH clinical practice guidelines on Clinical Blood Transfusion, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=25700). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Obstetric outcomes in women with end-stage renal disease on chronic dialysis: a review

Pregnancies in women on chronic dialysis for end-stage renal disease are high risk, but outcomes appear to have improved with increasing experience and advances in dialysis care. This paper reviews the existing data on outcomes in such pregnancies to enable evidence-based preconception counselling and anticipation of antenatal complications.

Molar pregnancy with false negative urine hCG: the hook effect

Urine pregnancy tests are widely used in emergency departments as the first screening test for patients of reproductive age presenting with gynaecological problems in order to rule out pregnancy. Conditions such as complete molar pregnancy, which produces large amounts of beta human chorionic gonadotropin (beta-hCG), may cause a false negative result due to an oversaturation of the assay system, known as the "hook effect". We report a case where the exclusion of pregnancy by urine testing led to the initial misdiagnosis of a molar pregnancy as a degenerative fibroid. Physicians need to be reminded of the possibility of false negative results with this commonly used test. Negative or inconclusive results in patients with a high suspicion of pregnancy should be further evaluated by serum quantification of beta-hCG and appropriate sample dilution.

B-Lynch suture for the treatment of uterine atony

INTRODUCTION

Over 125,000 women die of postpartum haemorrhage (PPH) each year, with the commonest cause being uterine atony (75-90 percent). Failing conservative management, hysterectomy is usually the final resort. In 1997, Christopher B-Lynch devised an innovative technique to treat uterine atony, and it has been widely used around the world since its original report. However, there are hardly any reports of this technique being utilised in East Asian countries, including Singapore. Our study reviews the cases in which the B-Lynch suture was used to treat uterine atony, and the clinical outcomes of these cases.

METHODS

A retrospective study of data of all women who delivered between May 2004 and June 2007 was collected from the department's database, to identify patients who had undergone the B-Lynch procedure. Primary PPH is defined as a blood loss of more than 500 ml at or within 24 hours of delivery.

RESULTS

There were a total of 5,470 deliveries during this period, with primary PPH occurring in 100 cases. The B-Lynch procedure was performed in seven women, avoiding the need for a hysterectomy in five cases.

CONCLUSION

Our series of cases treated with the B-Lynch procedure showed that it is an effective method of containing PPH. It has the advantage of being applied easily and rapidly, and should be taught to all trainees and registrars in obstetrics. It should be attempted when conservative management of PPH fails and before any radical surgery is considered.

Foetal peak systolic velocity in the middle cerebral artery: an Asian reference range

INTRODUCTION

The aim of this study was to establish reference values of peak systolic blood flow velocity measurement in the foetal middle cerebral artery (MCA-PSV) in the local Asian obstetric population and to compare our reference ranges with those of previously-published studies.

METHODS

329 normal pregnant women attending the outpatient antenatal clinics of the Department of Obstetrics and Gynaecology in the Singapore General Hospital underwent Doppler ultrasonography at least once between 16 and 40 weeks' gestation. The blood flow velocity recordings from the foetal middle cerebral artery were obtained. New reference ranges were constructed by regressing each parameter on gestational age.

RESULTS

New reference ranges for foetal middle cerebral artery with gestation were constructed for an Asian population. Our reference curves were compared with that of a previously-constructed one.

CONCLUSION

MCA-PSV increases with advancing gestational age. There appear to be differences between Asian and non-Asian reference ranges for MCA-PSV.

The association between maternal depression and frequent non-routine visits to the infant's doctor--a cohort study

BACKGROUND

Perinatal depression is common, but women typically do not seek help for it. We studied its association with frequent non-routine physician visits, which may be a form of help-seeking behaviour.

METHODS

A prospective cohort study of women in their 34th to 38th week of pregnancy at the outpatient obstetrics clinic at a Singapore tertiary hospital was done. Screening was done using the Edinburgh Postnatal Depression Scale and diagnosis of major or minor depressive disorder was made using the SCID-IV. At 6 to 12 months' post-partum, women were screened and interviewed again for depression and asked to report the frequencies with which they had brought their infants to the doctor on non-routine visits in the preceding 6 weeks. Four hundred and seventy-one of the 559 patients recruited before delivery were re-interviewed.

RESULTS

After adjusting for confounders, women who had brought their infants for three or more non-routine visits to the infant's doctor had a significantly higher prevalence of depression (32.6%) than those with fewer visits (13.6%) (OR 2.87, 95% CI 1.41 to 5.85, p=0.004). The relative risk reduction for women who did not bring their infants for frequent non-routine visits was 0.583 (95% CI 0.44 to 0.73, p=0.002). They were also more likely to have poorer perceived emotional support from their families.

LIMITATIONS

These included use of self-reported doctor visits, and relatively high educational levels of the participants.

CONCLUSIONS

Doctors should have a high index of suspicion for enquiring about depression and emotional support in mothers who bring their infants for frequent non-routine visits.

Delayed bleeding after liver biopsy: a dreaded complication

We present an unusual case of percutaneous liver biopsy complicated by delayed haemothorax in a 55-year-old Chinese man with hepatitis C cirrhosis and severe haemophilia A. The patient presented ten days after the initial liver biopsy, and was managed with prompt investigations for confirming the diagnosis, infusion of factor VIII and fresh frozen plasma, and early referral to the surgeon for consideration of surgical repair. The importance of early detection and aggressive therapy is emphasised.

Ultrasonographical features of morbidly-adherent placentas

Morbidly-adherent placentas manifest as placenta accreta, increta or percreta, depending on the depth of placental invasion. These conditions present high risks of severe obstetrical haemorrhage at delivery. The underlying pathology is due to defects in the decidua basalis caused by a variety of insults, such as previous surgery, excessive curettage or infection. The incidence of morbidly-adherent placentas is rising as the frequency of caesarean sections increase. Imaging plays an important role in the antenatal detection of this condition. Based on the case series seen at our local institution, we describe the imaging characteristics of this condition as seen on grayscale ultrasonography, colour/power Doppler ultrasonography, three-dimensional ultrasonography and magnetic resonance imaging.

Intrapartum maternal sinus bradycardia with spontaneous resolution following delivery

Pregnancy is a normal physiological state that is characterised by significant adaptive changes, many of which take place in the cardiovascular system. These adaptations are believed to be the cause for the increased incidence in cardiac arrhythmias in pregnancy and particularly, in labour. We report an unusual case of a healthy 32-year-old primigravida who developed profound intrapartum bradycardia which persisted throughout labour. Spontaneous recovery to pre-labour baseline heart rate occurred following spontaneous vaginal delivery. Maternal and foetal statuses remained satisfactory during labour. This case report underscores the importance of recognising that arrhythmias in various forms are common in labour. In the absence of detectable underlying cardiac disease or maternal and foetal compromise, continuation of the labour with a view to vaginal delivery should be the goal.

Tocolytic treatment for the management of preterm labour: a systematic review

Spontaneous preterm labour and delivery accounts for approximately one-third of preterm births, which is the predominant cause of perinatal mortality and morbidity. This review aims to evaluate the evidence on the benefits and harms of five classes of tocolytic therapy, namely: betamimetics, calcium channel blockers, magnesium, non-steroidal anti-inflammatory agents, and atosiban. We performed a systematic review of the effectiveness of tocolytics to stop uterine contractions (first-line therapy). Reports of randomised controlled trials from searches of MEDLINE, bibliographies of review articles, Cochrane Collaboration and its Pregnancy and Childbirth Review Group between 1966 and 2003 were identified, using the search terms "randomised controlled trial" (RCT), "preterm labor", "tocolysis", "betamimetics", "ritodrine", "prostaglandin synthetase inhibitors", "indomethacin", "calcium channel blockers", "nifedipine", "oxytocin receptor blockers", "atosiban", and "magnesium sulphate". Studies on women with preterm labour comparing the effects of a tocolytic with a placebo or no treatment that met our inclusion criteria, were included. To our knowledge, the trials were conducted mainly before 1999 and there were no placebo-controlled trials after that. Of the 86 articles identified and evaluated, 14 first-line studies met more stringent requirements for meta-analyses. Tocolytics were associated with significant decreases in the odds of delivery within 24 hours (odds-ratio [OR] 0.54, 95 percent confidence interval [CI] 0.32-0.91) and 48 hours (OR 0.47, 95 percent CI 0.30-0.75). These effects were significant for beta-agonists, atosiban and indomethacin, but not magnesium sulphate. Maternal side-effects significantly associated with betamimetics were pulmonary oedema, cardiac arrhthymias and hypokalaemia. Although calcium antagonists have not been evaluated against placebo, comparative trials with beta-agonists have shown more favourable neonatal outcomes and better prolongation of gestation. In conclusion, the management of threatened preterm labour with first-line tocolytic therapy can prolong gestation. However, the time gained in-utero need to be optimised. There is no clear first-line tocolytic agent. The use of tocolytic agents should be individualised and based on maternal condition, potential side-effects and gestational age.