Factors associated with deep infiltrating endometriosis, adenomyosis and ovarian endometrioma

INTRODUCTION@#To compare epidemiological features and clinical presentations of deep infiltrating endometriosis with endometrioma and adenomyosis, as well as to identify risk factors for the respective histologically confirmed conditions.@*METHOD@#Patients undergoing index surgery at the National University Hospital, Singapore for endometriosis or adenomyosis over a 7-year period-from 2015 to 2021-were identified from hospital databases using the Table of Surgical Procedures coding. Social and epidemiological features of cases with histologically confirmed diagnoses of endometrioma only, adenomyosis only, and deep infiltrating endometriosis were compared. Significant variables from univariate analysis were entered into 3 binary multivariate logistic regression models to obtain independent risk factors for: deep infiltrating endometriosis versus endometrioma only, deep infiltrating endometriosis versus adenomyosis only, and adenomyosis only versus endometrioma only.@*RESULTS@#A total of 258 patients were included with 59 ovarian endometrioma only, 47 adenomyosis only, and 152 deep infiltrating endometrioses. Compared to endometrioma only, deep infiltrating endometriosis was associated with higher rates of severe dysmenorrhoea (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.02-7.70) and out-of-pocket private surgical care (OR 4.72, 95% CI 1.85-12.04). Compared to adenomyosis only, deep infiltrating endometriosis was associated with a higher fertility desire (OR 13.47, 95% CI 1.01-180.59) and a lower body mass index (OR 0.89, 95% CI 0.79-0.99). In contrast, heavy menstrual bleeding was the hallmark of adenomyosis, being less common in patients with endometriosis.@*CONCLUSION@#Deep infiltrating endometriosis is associated with severe dysmenorrhoea, pain related to urinary and gastrointestinal tracts, higher fertility desire and infertility rate. Patients with pain symptomatology and subfertility should be referred early to a tertiary centre with the capability to diagnose and manage deep infiltrating endometriosis.

Diagnosis and management of polycystic ovary syndrome: Perspectives of clinicians in Singapore

INTRODUCTION@#To harmonise the diagnostic processes of polycystic ovary syndrome (PCOS) and enable clinicians to provide better patient care, it is critical to understand the knowledge gaps in PCOS diagnosis. We evaluated how clinicians in endocrinology, family medicine, general practice and gynaecology diagnose PCOS.@*METHODS@#This cross-sectional survey involved 208 clinicians from specific subspecialties across various healthcare settings in Singapore.@*RESULTS@#A total of 160 responses were included in the final analysis. Among all the diagnostic criteria, the Rotterdam 2003 criteria was most frequently used (66.3%). More than half of the gynaecologists reported having a standardised workplace protocol while the majority from other specialties reported otherwise. A large percentage of respondents (60.5%) were unable to identify the correct PCOS clinical features, which is concerning. Only 8.8% of respondents used clinical and biochemical hyperandrogenism, menstrual disturbances and pelvic ultrasound to diagnose PCOS without performing unnecessary and incorrect investigations. Most clinicians recognised insulin resistance/type 2 diabetes mellitus and fertility problems as complications while only a few recognised psychological complications. Many clinicians (37.3%) sought standardisation of PCOS diagnosis and management guidelines for improvement in PCOS care and 81.9% of respondents would appreciate standardised educational materials.@*CONCLUSION@#This is the first study to the best of our knowledge that gives an insight into the diagnostic and management processes of PCOS among various healthcare institutions in Singapore. This study calls for greater harmonisation of diagnostic processes and holistic evidence-based management of patients with PCOS through standardised workplace protocols and patient education resources.

Menopausal osteoporosis: screening, prevention and treatment

Screening for osteoporosis in women can be based on age and weight, using the Osteoporosis Screening Tool for Asians and assessment for other risk factors such as early menopause, Chinese ethnicity and other secondary factors. Based on the resulting risk profile, women can be triaged to dual-energy X-ray absorptiometry (DEXA) scanning for definite diagnosis of osteoporosis. Treatment should be considered in women with previous fragility fractures, DEXA-diagnosed osteoporosis and high risk of fracture. Exercise improves muscle function, can help prevent falls and has moderate effects on improvements in bone mass. Women should ensure adequate calcium intake and vitamin D. Menopausal hormone therapy (MHT) effectively prevents osteoporosis and fractures, and should be encouraged in those aged < 50 years. For women aged < 60 years, MHT or tibolone can be considered, especially if they have vasomotor or genitourinary symptoms. Risedronate or bisphosphonates may then be reserved for those aged over 60 years.

Preventing early-onset group B streptococcal sepsis: clinical risk factor-based screening or culture-based screening?

INTRODUCTION@#Two strategies are available for prevention of early-onset group B streptococcal (GBS) sepsis - clinical risk factor-based screening and routine culture-based screening of pregnant women for GBS colonisation. In our hospital, we switched from the former to the latter approach in 2014.@*METHODS@#We compared the incidence of early-onset GBS sepsis during 2001-2015 between infants born to pregnant women who were screened for GBS colonisation and those born to women who were not screened.@*RESULTS@#Among 41,143 live births, there were nine cases of early-onset GBS sepsis. All infants with GBS sepsis were born to pregnant women who were not screened for GBS colonisation. The incidence of early-onset GBS sepsis among infants of women who were not screened was 0.41 per 1,000 live births (95% confidence interval [CI] 0.19-0.77) when compared to infants of women who were screened, for whom the sepsis incidence was zero per 1,000 live births (95% CI 0-0.19; p = 0.005).@*CONCLUSION@#Our data suggests that routine culture-based screening of pregnant women for GBS colonisation is a better preventive strategy for early-onset GBS sepsis in neonates when compared to clinical risk factor-based screening.

A review of Zika virus infections in pregnancy and implications for antenatal care in Singapore

Given the consensus that there is a causal relationship between Zika virus (ZIKV) infection in pregnancy and congenital Zika syndrome (CZS), clinicians must be prepared to manage affected patients despite the numerous gaps in current knowledge. The clinical course in pregnancy appears similar to that in non-pregnant women, although viraemia may be prolonged. ZIKV infection can be diagnosed by serum and urine reverse transcription-polymerase chain reaction, but commercially available serological tests are currently unreliable in dengue-endemic regions. Although vertical transmission can occur at any time during gestation, first- and second-trimester infections have the highest risk of developing central nervous system anomalies. Aberrant fetal growth and pregnancy loss may also occur. Serial ultrasonography should be conducted for infected cases. Without a vaccine, pregnant women should be advised to minimise mosquito bites and reduce sexual transmission risk. Overall, the absolute risk of CZS arising amid a ZIKV outbreak appears relatively low.

Gynaecologic robot-assisted cancer and endoscopic surgery (GRACES) in a tertiary referral centre

<p><b>INTRODUCTION</b>Robotic-assisted gynaecologic surgery is gaining popularity and it offers the advantages of laparoscopic surgery whilst overcoming the limitations of operative dexterity. We describe our experience with the fi rst 40 cases operated under the GRACES (Gynaecologic Robot- Assisted Cancer and Endoscopic Surgery) programme at the Department of Obstetrics & Gynecology, National University Hospital, Singapore.</p><p><b>MATERIALS AND METHODS</b>A review was performed for the fi rst 40 women who had undergone robotic surgery, analysing patient characteristics, surgical timings and surgery-related complications. All cases were performed utilising the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) with 3 arms and 4 ports. Standardised instrumentation and similar cuff closure techniques were used.</p><p><b>RESULTS</b>Seventeen (56%) were for endometrial cancer and the rest, for benign gynaecological disease. The mean age of the patients was 52.3 years. The average docking time was 11 minutes (SD 0.08). The docking and operative times were analysed in tertiles. Data for patients with endometrial cancer and benign cases were analysed separately. There were 3 cases of complications- cuff dehiscence, bleeding from vaginal cuff and tumour recurrence at vaginal vault.</p><p><b>CONCLUSION</b>Our caseload has enabled us to replicate the learning curve reported by other centres. We advocate the use of a standard instrument set for the fi rst 20 cases. We propose the following sequence for successful introduction of robot-assisted gynaecologic surgery - basic systems training, followed shortly with a clinical case, and progressive development of clinical competence through a proctoring programme.</p>

Differential risk for early breastfeeding jaundice in a multi-ethnic Asian cohort

<p><b>INTRODUCTION</b>To explore the relationship between ethnic origin and mode of feeding with early neonatal jaundice, we examined maternal and neonatal risk factors for hyperbilirubinaemia in a multi-ethnic Asian cohort of healthy term newborns.</p><p><b>MATERIALS AND METHODS</b>This is an observational cohort study in a maternity ward serving a multi-ethnic cosmopolitan community. The relationship between hyperbilirubinaemia (bilirubin >or=150 mmol/L before 48 hours to 72 hours after birth), ethnic origin, weight loss after birth, need for phototherapy, and other factors were examined. Bivariate comparisons and binary logistic regression were used to investigate the relationship between hyperbilirubinaemia/phototherapy with maternal and neonatal risk factors.</p><p><b>RESULTS</b>A consecutive group of 1034 neonates (56% Chinese, 24% Indian subcontinent, 9% Malay) with birth weights >or=2500 g was investigated. Overall factors that contributed significantly to hyperbilirubinaemia/phototherapy were gestational age, Chinese ethnic origin, weight loss of >or=7%, vaginal delivery, glucose-6-phosphate-dehydrogenase (G6PD) deficiency, breastfeeding and ABO incompatibility. Chinese neonates who were totally breastfed had a higher risk for jaundice [adjusted odds ratio (OR) = 1.64; 95% confidence intervals (CI), 1.11- 2.44; P <0.014], and phototherapy (adjusted OR = 2.75; 95% CI 1.77-4.27; P <0.001) compared to those supplemented with, or totally formula fed. In contrast, the risk of jaundice for non- Chinese infants did not differ according to the mode of feed. Although weight loss as a whole increased the risk for jaundice (adjusted OR = 1.43; 95%CI, 1.03-1.99; P = 0.031), jaundice in Chinese neonates was not due to ineffective breastfeeding because both Chinese and non-Chinese breastfed infants lost similar weights.</p><p><b>CONCLUSIONS</b>Chinese ethnic origin was an independent risk factor for hyperbilirubinaemia and phototherapy. Breastfeeding was not a risk factor for hyperbilirubinaemia/phototherapy in non-Chinese Asian infants.</p>