Twelve-hour fasting compared with expedited oral intake in the initial inpatient management of hyperemesis gravidarum: a randomised trial.

OBJECTIVE: To evaluate fasting for 12 hours compared with expedited oral feeding in hospitalised women with hyperemesis gravidarum (HG). DESIGN: Randomised trial. SETTING: University Hospital, Malaysia: April 2016-April 2017. POPULATION: One hundred and sixty women hospitalised for HG. METHOD: Women were randomised upon admission to fasting for 12 hours or expedited oral feeding. Standard HG care was instituted. MAIN OUTCOME MEASURE: Primary outcome was satisfaction score with overall treatment at 24 hours (0-10 Visual Numerical Rating Scale VNRS), vomiting episodes within 24 hours and nausea VNRS score at enrolment, and at 8, 16 and 24 hours. RESULTS: Satisfaction score, median (interquartile range) 8 (5-9) versus 8 (7-9) (P = 0.08) and 24-hour vomiting episodes were 1 (0-4) versus 1 (0-5) (P = 0.24) for 12-hour fasting versus expedited feeding, respectively. Repeated measures analysis of variance of nausea scores over 24 hours showed no difference (P = 0.11) between trial arms. Participants randomised to 12-hour fasting compared with expedited feeding were less likely to prefer their feeding regimen in future hospitalisation (41% versus 65%, P = 0.001), to recommend to a friend (65% versus 84%, P = 0.01; RR 0.8, 95% CI 0.6-0.9) and to adhere to protocol (85% versus 95%, P = 0.04; RR 0.9, 95% CI 0.8-1.0). Symptoms profile, ketonuria status at 24 hours and length of hospital stay were not different. CONCLUSION: Advisory of 12-hour fasting compared with immediate oral feeding resulted in a non-significant difference in satisfaction score but adherence to protocol and fidelity to and recommendation of immediate oral feeding to a friend were lower. The 24-hour nausea scores and vomiting episodes were similar. TWEETABLE ABSTRACT: Women hospitalised for hyperemesis gravidarum could feed as soon, as much and as often as can be tolerated compared with initial fasting.

A randomised trial of caesarean wound coverage: exposed versus dressed.

OBJECTIVE: To evaluate the superficial surgical site infection (SSI) rate to 28 days and patient satisfaction with wound coverage management when their transverse suprapubic caesarean wound is left exposed compared with dressed after skin closure. DESIGN: Randomised trial. SETTING: University Hospital, Malaysia: April 2016-October 2016. POPULATION: 331 women delivered by caesarean section. METHOD: Participants were randomised to leaving their wound entirely exposed (n = 165) or dressed (n = 166) with a low adhesive dressing (next day removal). MAIN OUTCOME MEASURES: Primary outcomes were superficial SSI rate (assessed by provider inspection up to hospital discharge and telephone questionnaires on days 14 and 28) and patient satisfaction with wound coverage management before hospital discharge. RESULTS: The superficial SSI rates were 2/153 (1.3%) versus 5/157 (3.2%) (relative risk [RR] 0.4, 95% CI 0.1-2.1; P = 0.45) and patient satisfaction with wound management was 7 [5-8] versus 7 [5-8] (P = 0.81) in exposed compared with dressed study groups, respectively. In the wound-exposed patients, stated preference for wound exposure significantly increased from 35.5 to 57.5%, whereas in the wound-dressed patients, the stated preference for a dressed wound fell from 48.5 to 34.4% when assessed at recruitment (pre-randomisation) to day 28. There were no significant differences in inpatient additional dressing or gauze use for wound care, post-hospital discharge self-reported wound issues of infection, antibiotics, redness and inflammation, swollen, painful, and fluid leakage to day 28 across trial groups. CONCLUSION: The trial is underpowered as SSI rates were lower than expected. Nevertheless, leaving caesarean wounds exposed does not appear to have detrimental effects, provided patient counselling to manage expectations is undertaken. TWEETABLE ABSTRACT: An exposed compared with a dressed caesarean wound has a similar superficial surgical site infection rate, patient satisfaction and appearance.

Maternal lipids are associated with newborn adiposity, independent of GDM status, obesity and insulin resistance: a prospective observational cohort study.

OBJECTIVE: To determine the association between maternal lipaemia and neonatal anthropometrics in Malaysian mother-offspring pairs. DESIGN: Prospective observational cohort study. SETTING: Single tertiary multidisciplinary antenatal clinic in Malaysia. POPULATION: A total of 507 mothers: 145 with gestational diabetes mellitus (GDM); 94 who were obese with normal glucose tolerance (NGT) (pre-gravid body mass index, BMI ≥ 27.5 kg/m2 ), and 268 who were not obese with NGT. METHODS: Maternal demographic, anthropometric, and clinical data were collected during an interview/examination using a structured questionnaire. Blood was drawn for insulin, C-peptide, triglyceride (Tg), and non-esterified fatty acid (NEFA) during the 75-g 2-hour oral glucose tolerance test (OGTT) screening, and again at 36 weeks of gestation. At birth, neonatal anthropometrics were assessed and data such as gestational weight gain (GWG) were extracted from the records. MAIN OUTCOME MEASURES: Macrosomia, large-for-gestational-age (LGA) status, cohort-specific birthweight (BW), neonatal fat mass (NFM), and sum of skinfold thickness (SSFT) > 90th centile. RESULTS: Fasting Tg > 95th centile (3.6 mmol/L) at screening for OGTT was independently associated with LGA (adjusted odds ratio, aOR 10.82, 95% CI 1.26-93.37) after adjustment for maternal glucose, pre-gravid BMI, and insulin sensitivity. Fasting glucose was independently associated with a birthweight ratio (BWR) of >90th centile (aOR 2.06, 95% CI 1.17-3.64), but not with LGA status, in this well-treated GDM cohort with pre-delivery HbA1c of 5.27%. In all, 45% of mothers had a pre-gravid BMI of <23 kg/m2 and 61% had a pre-gravid BMI of ≤ 25 kg/m2 , yet a GWG of >10 kg was associated with a 4.25-fold risk (95% CI 1.71-10.53) of BWR > 90th centile. CONCLUSION: Maternal lipaemia and GWG at a low threshold (>10 kg) adversely impact neonatal adiposity in Asian offspring, independent of glucose, insulin resistance and pre-gravid BMI. These may therefore be important modifiable metabolic targets in pregnancy. TWEETABLE ABSTRACT: Maternal lipids are associated with adiposity in Asian babies independently of pre-gravid BMI, GDM status, and insulin resistance.

Continuous glucose monitoring results in lower HbA1c in Malaysian women with insulin-treated gestational diabetes: a randomized controlled trial.

AIMS: To determine if therapeutic, retrospective continuous glucose monitoring (CGM) improves HbA1c with less hypoglycaemia in women with insulin-treated gestational diabetes mellitus (GDM). METHODS: This prospective, randomized controlled, open-label trial evaluated 50 women with insulin-treated GDM randomized to either retrospective CGM (6-day sensor) at 28, 32 and 36 weeks' gestation (Group 1, CGM, n = 25) or usual antenatal care without CGM (Group 2, control, n = 25). All women performed seven-point capillary blood glucose (CBG) profiles at least 3 days per week and recorded hypoglycaemic events (symptomatic and asymptomatic CBG < 3.5 mmol/l; non-fasting < 4.0 mmol/l). HbA1c was measured at 28, 33 and 37 weeks. In Group 1, both CGM and CBG data were used to manage diabetes, whereas mothers in Group 2 were managed based on CBG data alone. RESULTS: Baseline characteristics (age, pre-pregnancy BMI, HbA1c , total insulin dose) were similar between groups. There was a lower increase in HbA1c from 28 to 37 weeks' gestation in the CGM group [∆HbA1c : CGM + 1 mmol/mol (0.09%), control + 3mmol/mol (0.30%); P = 0.024]. Mean HbA1c remained unchanged throughout the trial in the CGM group, but increased significantly in controls as pregnancy advanced. Mean HbA1c in the CGM group was lower at 37 weeks compared with controls [33 ± 4 mmol/mol (5.2 ± 0.4%) vs. 38 ± 7 mmol/mol (5.6 ± 0.6%), P < 0.006]. Some 92% of the CGM group achieved an HbA1c ≤ 39 mmol/mol (≤ 5.8%) at 37 weeks compared with 68% of the control group (P = 0.012). Neither group experienced severe hypoglycaemia. CONCLUSION: CGM use may be beneficial in insulin-treated GDM because it improves HbA1c compared with usual antenatal care without increasing severe hypoglycaemia. (Clinical Trials Registry No.: NCT02204657).

Insulin-like growth factor binding protein 1, Bishop score, and sonographic cervical length: tolerability and prediction of vaginal birth and vaginal birth within 24 hours following labour induction in nulliparous women.

OBJECTIVE: To evaluate the tolerability of cervical insulin-like growth factor binding protein 1 (IGFBP-1) and its value as a predictor of successful labour induction, compared with Bishop score and transvaginal ultrasound (TVUS) cervical length. DESIGN: A prospective study. SETTING: A tertiary hospital in Malaysia. POPULATION: A cohort of 193 term nulliparous women with intact membranes. METHODS: Prior to labour induction, cervical fluid was obtained via a vaginal speculum and tested for IGFBP-1, followed by TVUS and finally Bishop score. After each assessment the procedure-related pain was scored from 0 to 10. Cut-off values for Bishop score and cervical length were obtained from the receiver operating characteristic (ROC) curve. Multivariable logistic regression analysis was performed. MAIN OUTCOMES MEASURES: Vaginal delivery and vaginal delivery within 24 hours of starting induction. RESULTS: Bedside IGFBP-1 testing is better tolerated than Bishop score, but is less well tolerated than TVUS [median (interquartile range) of pain scores: 5 (4-5) versus 6 (5-7) versus 3 (2-3), respectively; P < 0.001]. IGFBP-1 independently predicted vaginal delivery (adjusted odds ratio, AOR 5.5; 95% confidence interval, 95% CI 2.3-12.9) and vaginal delivery within 24 hours of induction (AOR 4.9; 95% CI 2.1-11.6) after controlling for Bishop score (≥4 or ≥5), cervical length (≤29 or ≤27 mm), and other significant characteristics for which the Bishop score and TVUS were not predictive of vaginal delivery after adjustment. IGFBP-1 has 81% sensitivity, 59% specificity, positive and negative predictive values of 82 and 58%, respectively, and positive and negative likelihood ratios of 2.0 and 0.3 for vaginal delivery, respectively. CONCLUSION: IGFBP-1 better predicted vaginal delivery than BS or TVUS, and may help guide decision making regarding labour induction in nulliparous women. TWEETABLE ABSTRACT: IGFBP-1: a stronger independent predictor of labour induction success than Bishop score or cervical sonography.

Immediate compared with on-demand maternal full feeding after planned caesarean delivery: a randomised trial.

OBJECTIVE: To evaluate immediate compared with on-demand full maternal oral feeding after caesarean delivery STUDY DESIGN: A randomised trial. SETTING: Obstetric unit of a university hospital in Kuala Lumpur, Malaysia. POPULATION: Women admitted for a planned caesarean under spinal anaesthesia. METHODS: Participants were randomised to a sandwich meal served immediately on return to the ward or on-demand. MAIN OUTCOME MEASURES: Primary outcomes were patient satisfaction VAS (visual analog scale of 100 mm) on the feeding regimen and vomiting at 24 hours. RESULTS: 453 women were initially enrolled, 395 were randomised and available for analysis. Median (full range) patient satisfaction VAS scores were 82 (15-100) versus 84 (0-100) mm, P = 0.88 and vomiting rates were 1/197 (0.5%) versus 2/198 (1.0%), P > 0.99 for immediate compared with on-demand feeding, respectively. The immediate versus on-demand arms first ate at a median of 105 (35-210) versus 165 (45-385) minutes, P < 0.001, had second meal at 5.3 (1.2-15.5) versus 5.8 (2.2-29.7), P < 0.001, flatus passage at 9.5 (3.1-29.0) versus 10.3 (2.8-24.6), P = 0.023 hours post-caesarean and opiate analgesia use was 10/197 (5.1%) versus 23/198 (11.6%), P = 0.028, RR 0.4 (95% CI 0.2-0.9), NNTb 16 (95% CI 8-89). The median visual numerical rating scale (0-10 scale) for nausea and bloating at 8, 16 and 24 hours was similarly scored at zero in both arms. Other outcomes were similar. CONCLUSION: Immediate full feeding has some advantage over on-demand feeding. Both regimens are tolerated well. Patients probably should be fed as soon as practicable after a caesarean. TWEETABLE ABSTRACT: Full maternal oral feeding should commence as soon as practicable after an uncomplicated caesarean section.

Genetic association of AKAP10 gene polymorphism with reduced risk of preterm birth.

OBJECTIVE: Preterm birth (PTB) is a multifactorial complication in which genetic and environmental factors contribute to the phenotype. The AKAP10 protein encoded by AKAP10 gene has a vital role in the maintenance of myometrial quiescence and pregnancy. This study aimed to investigate whether polymorphisms in the AKAP10 gene are associated with the risk of PTB. STUDY DESIGN: A total of 664 women (132 preterm and 532 term) with spontaneous singleton deliveries were genotyped for AKAP10 polymorphisms (rs119672, rs203462 and rs169412) using Sequenom MassARRAY platform. RESULT: A significant association was observed between the CC and AC genotypes of AKAP10 rs169412 with reduced risk of PTB (CC: adjusted odds ratio (OR) 2.95, 95% confidence interval (CI): 1.23-7.09, P=0.016. AC: adjusted OR 3.46, 95% CI: 1.38-8.68, P=0.008), respectively. Following stratification by ethnicity, a significant association was observed between the AC and CC genotypes of rs169412 and term birth in the Malay ethnic subgroup. (CC: OR 2.9, 95% CI: 1.01-8.59, P=0.041. AC: OR 3.14, 95% CI: 1.04-9.54, P=0.043). A significant association was also observed between the CT genotypes of AKAP10 rs119672 with reduced risk of PTB deliveries (CT: OR 3.2, 95% CI: 1.06-9.76 P=0.007, TT: OR 2.8, 0.98-8.34, P =.0.015) Alternatively, there was no association between AKAP10 rs169412 and rs119672 polymorphisms with PTB in the Indians and Chinese ethnic groups. CONCLUSION: This study indicates a significant association between the AKAP10 polymorphisms and reduced risk of PTB in the Malays. This demonstrates the potential role of AKAP10 polymorphisms in preterm complications.

Immunogenicity and Safety of the AS04-adjuvanted Human Papillomavirus-16/18 Cervical Cancer Vaccine in Malaysian Women Aged 18-35 years: A Randomized Controlled Trial.

INTRODUCTION: Cervical cancer is the third most common cancer in women worldwide. The HPV-16/18 AS04- adjuvanted vaccine (Cervarix©) has previously been shown to be highly immunogenic with a clinically acceptable safety profile. This phase IIIb, double-blind, randomized (1:1) and placebo controlled trial (NCT00345878) was designed to evaluate the vaccine immunogenicity against HPV-16 and HPV-18 as well as its safety and reactogenicity in Malaysian women. METHODS: Healthy women aged 18-35 years received intramuscularly three doses of either the vaccine (HPV group) or aluminium hydroxide (ALU group) at 0, 1, and 6 months. Antibody titers were measured by an enzyme-linked immunosorbent assay (ELISA). RESULTS: A total of 271 eligible subjects were enrolled and 266 subjects completed the study. Initially seronegative subjects in the HPV group showed 100% seroconversion one month post-dose-3 for anti HPV-16 and anti-HPV-18 antibodies with geometric mean titers of 11107.5 (95% CI: 9727.3-12683.4) EL.U/mL and 4273.5 (95% CI: 3771.8-4841.9) EL.U/mL, respectively. Over 96% of subjects in both groups received all three vaccine doses. Solicited local (pain) and general symptoms (myalgia, fatigue, arthralgia and headache) were commonly reported in both HPV and ALU groups. Eight serious adverse events were reported throughout the study (five in the HPV group; three in the ALU group), all considered by investigators to be unrelated to vaccination. CONCLUSION: The HPV-16/18 AS04-adjuvanted vaccine was immunogenic and generally well tolerated in Malaysian women aged 18-35 years.

Hormonal changes causing rhinitis in pregnancy among Malaysian women.

OBJECTIVES: To investigate the aetiology of rhinitis occurring in pregnancy, by (1) describing the relationship between pregnancy rhinitis and serum oestrogen, progesterone, placental growth hormone and insulin-like growth factor, and (2) assessing the prevalence of pregnancy rhinitis among Malaysian women. METHODS: Prospective study involving 30 pregnant women followed at an ante-natal clinic for 14 months. Hormone levels were analysed during pregnancy and the post-partum period. RESULTS: Levels of all four hormones were elevated in the third trimester, compared with first trimester and postpartum values. Rhinitis patients had higher levels of oestrogen and insulin-like growth factor 1 in the third trimester than non-rhinitis patients, although these differences were not statistically significant. The prevalence of rhinitis was 53.3 per cent, with most cases occurring in the third trimester. Patients with pregnancy rhinitis had a higher prevalence of female babies, compared with non-rhinitis patients (p = 0.003). CONCLUSIONS: Pregnancy rhinitis was significantly more common in women giving birth to female babies. Women with pregnancy rhinitis had a non-significant elevation in oestrogen and insulin-like growth factor 1 levels, compared with those without rhinitis.

Coitus to expedite the onset of labour: a randomised trial.

OBJECTIVE: To evaluate the effect of suggesting coitus as a safe and effective means to expedite labour on pregnancy duration and requirement for labour induction. DESIGN: A randomised trial. SETTING: Antenatal clinic in a university hospital in Malaysia. POPULATION: Women from 35 weeks of gestation with an uncomplicated singleton pregnancy. METHODS: The advise-coitus arm was counselled that coitus at term is a safe, natural and effective means to initiate labour and to avoid labour induction. The control arm was told coitus was safe. Both arms were asked to record coital activity. MAIN OUTCOME MEASURES: Pregnancy duration and labour induction. RESULTS: The intervention to delivery interval (mean ± SD) was 3.2 ± 1.4 versus 3.3 ± 1.3 weeks (P = 0.417), with a gestational age at delivery of 39.4 ± 1.2 versus 39.5 ± 1.2 weeks (P = 0.112), and with labour induction rates of 126/574 (22.0%) versus 120/576 (20.8%) (P = 0.666) for the advise-coitus and control arms, respectively, with no statistical difference between the groups. Coitus prior to delivery was more often reported in the advise-coitus arm compared with the control arm: 481/574 (85.3%) versus 458/576 (79.9%) (RR 1.5, 95% CI 1.1-2.0, P = 0.019). Also, the median (interquartile range) reported number of coital acts of 3 (2-5) versus 2 (1-4) (P = 0.006) was higher for the advise-coitus arm. Other pregnancy and neonatal outcomes did not differ between the groups. CONCLUSIONS: Labour onset and labour induction did not differ in the advise-coitus arm.

Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial.

OBJECTIVE: To compare oral nifedipine with intravenous labetalol in their rapidity to control hypertensive emergencies of pregnancy. DESIGN: A double-blind randomised trial. SETTING: A university hospital in Malaysia. POPULATION: Pregnant women with severe gestational hypertension≥160/110 mmHg who required immediate treatment. METHODS: Patients were randomised to receive nifedipine (10 mg tablet, orally, up to five doses) and intravenous placebo saline injection or intravenous labetalol injection (in an escalating dose regimen of 20, 40, 80, 80 and 80 mg) and a placebo tablet every 15 minutes until the target blood pressure of ≤150/100 mmHg was achieved. Crossover treatment was effected if the initial treatment regimen was unsuccessful. MAIN OUTCOME MEASURE The time taken to achieve a blood pressure of ≤150/100 mmHg. RESULTS: The median time taken to achieve target blood pressure was 30 minutes (interquartile range, IQR 22.5-67.5 minutes) versus 45 minutes (IQR 30-60 minutes) for nifedipine and labetalol, respectively (P=0.59). Repeated measures analysis of variance indicated that in the first hour both systolic (F=87.6, P<0.001) and diastolic (F=55.8, P<0.001) blood pressure significantly decreased, but there was no difference between the nifedipine and labetalol groups for both systolic (F=0.12, P=0.74) and diastolic (F=0.92, P=0.34) blood pressure trends over time. Crossover treatment was required in 20% of women from each group. CONCLUSIONS: Oral nifedipine and intravenous labetalol regimens are similarly effective in the acute control of severe hypertension in pregnancy.

Maternal hemoglobin level and red cell indices as predictors of gestational diabetes in a multi-ethnic Asian population.

OBJECTIVE: To evaluate maternal hemoglobin levels and red cell indices as predictive factors for gestational diabetes (GDM). METHOD: Data from 1,538 women were analyzed. At the first visit for prenatal care, the 50-gram glucose challenge test was followed by the 75-gram glucose tolerance test in those who screened positive. GDM was diagnosed based on the WHO (1999) criteria. Maternal complete blood count was obtained at the first visit, hospitalization for birth, and after birth. Receiver operator characteristic curves were generated to establish thresholds. Multivariable logistic regression analyses were performed to establish independent predictors of GDM. RESULTS: GDM was diagnosed in 182/1,538 (11.8%). GDM was associated with hemoglobin level, hematocrit and erythrocyte count at the first visit for prenatal care only. Hemoglobin threshold at the first visit was established at 11.5 g/dl. After adjustment, high hemoglobin [AOR 1.5 (95% CI 1.0-2.1); p = 0.027] remained predictive of GDM. CONCLUSIONS: High maternal hemoglobin level at the first prenatal visit is independently predictive of GDM.

Coitus and orgasm at term: effect on spontaneous labour and pregnancy outcome.

INTRODUCTION: Coitus and orgasm in late pregnancy are believed to facilitate the onset of labour. We aim to evaluate the relationship at term of reported coitus and orgasm with spontaneous labour. METHODS: Women at term scheduled for non-urgent labour induction were asked to keep a coitus and orgasm diary. These women were recruited for a randomised trial on the effect of coitus to promote spontaneous labour. For this analysis, the women were categorised into coitally-active and abstinent groups according to their coital diary. Spontaneous labour prior to the date of scheduled labour induction was the primary outcome. Labour, delivery and neonatal outcome were also evaluated. Multivariable logistic regression analysis was used to control for significant variables. RESULTS: On univariate analysis, the inverse association of coitus with spontaneous labour was borderline (odds ratio [OR] 0.6; 95 percent confidence interval [CI] 0.3-1.0; p-value is 0.052). Orgasm was not associated with spontaneous labour (p-value is 0.33). After adjustment, coitus (adjusted OR 0.4; 95 percent CI 0.2-0.8; p-value is 0.009) displayed a significant inverse association with spontaneous labour. Coitus and orgasm were not associated with any other adverse pregnancy outcome. CONCLUSION: Women who reported coitus were less likely to go into spontaneous labour prior to their scheduled labour induction. Reported coitus and orgasm were not associated with adverse pregnancy outcome.

Predictors for caesarean delivery and neonatal admission after trial of labour in women with one previous lower segment caesarean scar.

INTRODUCTION: Caesarean delivery rates are still increasing, and reliable predictors of adverse outcomes at a subsequent trial of scar are important as they guide decision-making on the best mode of delivery. We aimed to evaluate whether there are any predictors for caesarean delivery and neonatal admission, following trial of labour after one lower transverse caesarean section. METHODS: 768 women at term with singleton gestation and who had undergone a trial of labour between June 2002 and December 2005, were retrospectively identified using the labour ward register. 51 infants were admitted to a neonatal unit. Case notes for these cases were retrieved. Emergency repeat caesarean delivery and neonatal admission were the main outcome measures. RESULTS: Following multivariate logistic regression analysis, no previous vaginal birth (adjusted odds-ratio [AOR] 3.4), diabetes mellitus or hypertension in pregnancy (AOR 1.7), induction of labour (AOR 2.0), oxytocin use in labour (AOR 2.4), and meconium-stained liquor (AOR 4.9) were independent predictors of emergency caesarean delivery. Diabetes mellitus or hypertension in pregnancy (AOR 3.1), prelabour rupture of membranes (AOR 4.7) and caesarean delivery (AOR 6.0) were independent predictors of neonatal admission. CONCLUSION: Predictors for emergency caesarean delivery and neonatal admission following a trial of labour can be identified. This information should be incorporated into the counselling of women contemplating a trial of labour. The strongest predictor for neonatal admission was emergency caesarean delivery, further emphasising the need for careful case selection in a trial of labour to minimise the risk of failure.

Concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction of nulliparas with an unfavourable cervix: a randomised placebo-controlled trial.

OBJECTIVE: To compare concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction for nulliparas with an unfavourable cervix. DESIGN: A randomised double-blind study. SETTING: University Malaya Medical Centre, Malaysia. POPULATION: Nulliparas at term with intact membranes, Bishop score < or = 6 and admitted for labour induction. METHODS: All women received 3 mg dinoprostone pessary for labour induction. Those randomised to the oxytocin arm received oxytocin infusion started at 1 micro/minute and doubled every 30 minutes to a maximum 16 micro/minute. Women assigned to placebo received identical volume of saline infusion. After 6 hours, infusion was stopped and vaginal reassessment performed to guide further management. MAIN OUTCOME MEASURES: Primary outcome was vaginal delivery within 24 hours. RESULTS: Concurrent oxytocin infusion with dinoprostone pessary did not significantly increase vaginal delivery rate within 24 hours (48.6 versus 35.9%; P = 0.07, relative risk [RR] 1.4 [95% CI 1.0-1.9]). It reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P = 0.001, RR 0.61 [95% CI 0.45-0.81]) and improved maternal satisfaction with the birth process (median score of 3 versus 5 on a 10-point visual analogue scale, P = 0.007). Caesarean rates were not different (41.9 versus 44.7%, P = 0.52). CONCLUSIONS: Labour induction with concurrent oxytocin infusion and vaginal dinoprostone could be considered for nulliparas with an unfavourable cervix. Larger studies are needed.

The fetal sex ratio and metabolic, biochemical, haematological and clinical indicators of severity of hyperemesis gravidarum.

The association between female fetal sex and hyperemesis gravidarum is well established in European and North American populations. The association between female fetuses and severity of hyperemesis remains uncertain. A retrospective study based on case notes review of 166 Asian women hospitalised for hyperemesis was performed. Female fetuses were significantly associated with hyperemesis in our population (P= 0.004, OR 1.6, 95% CI 1.2-2.2) as well as associated with severe ketonuria and high urea. When both severe ketonuria and high urea were present at initial hospital admission for hyperemesis, 83% (95% CI 66-93) of the fetuses were female.

Profile of a menopause clinic in an urban population in Malaysia.

The object of this study is to determine the status of an urban Malaysian woman in her menopause age group with reference to her menopausal symptoms, lipid profile, breast, pelvis and bone. One hundred and sixty four women attending the Menopause Clinic of University Hospital, Kuala Lumpur who had not previously been on hormone replacement therapy were studied. Forty nine women were perimenopausal, 74 women were in early menopause (within 5 years of menopause) and 41 women were in late menopause (after 5 years of menopause). The most common symptoms were hot flushes (56%) and generalised tiredness (49%). Eighty four percent (84%) of women had high cholesterol levels. Serum triglycerides were highest in the late menopause group. There were 2 cases of intraductal carcinoma diagnosed on routine mammography, with 8 cases of fibrocystic breast disease and 7 cases of suspicious breast lumps. Routine ultrasound (pelvic and abdominal) revealed two women with ovarian cysts, 6 women with an endometrial thickness of more than 5 mm and 8 women with uterine fibroids. Eighty five women (51.8%) had mild osteoporosis while four women had moderate osteoporosis on dual photon measurements for bone mineral density. Menopause clinics should aim at investigating a woman in her menopause as a whole. Vasomotor symptoms were common in the urban Malaysian menopausal woman. There was a high incidence of lipid abnormalities. Routine mammography, pelvic ultrasound examinations and bone mineral density tests detected significant pathology and abnormalities.

Large lower segment myoma--myomectomy at lower segment caesarean section--a report of two cases.

Uterine leiomyoma is found in approximately 2% of pregnant women. One in ten women will have complications related to myoma in pregnancy. Myomectomy during pregnancy especially at Caesarean section is much discouraged in the literature. We present here 2 cases of large uterine myoma, situated in the anterior aspect of the lower segment, complicating pregnancy at term. Myomectomy in both instances allowed delivery of the fetus through the lower segment, making vaginal delivery in subsequent pregnancies possible.