Detection of foetal anomaly in advanced maternal age.

OBJECTIVE: The aim of this study was to assess the prevalence of foetal anomaly diagnosed during a detailed ultrasonography amongst patients of advanced maternal age (AMA) and to identify the related anomalies in these age groups. METHOD: A retrospective observational study amongst AMA mothers was done in Universiti Kebangsaan Malaysia Medical Centre, a Malaysian teaching hospital. The data over a period of three years (January 2013 - December 2016) obtained from the Maternal Foetal Medicine clinic registry was analysed. AMA mothers with singleton pregnancy presenting for foetal structural anomaly scan was included. They were later subdivided into 2 groups (35-39 years and ≥ 40 years). The logistic regression analysis was used to analyse the association of the chromosomal anomalies and the age groups. RESULTS: In all 486 patients were recruited and 84 patients were identified with foetal anomaly (17.3%). There was no significant difference in the prevalence of foetal anomalies or significant association with a specific structural foetal anomaly identified (p>0.05). However, the number of followups for these patients are significantly higher (p<0.001). CONCLUSION: The prevalence of structural foetal anomalies identified in detailed ultrasonography was low in AMA mothers. Hence, referral criteria for detailed anomaly ultrasonography need to be re-looked.

Sonographically abnormal placenta: an association with an increased risk poor pregnancy outcomes.

BACKGROUND: The placenta is a most interesting but unfortunately often ignored and misunderstood organ. Placental abnormalities, therefore, can be an "early warning system" for fetal problems. A complete prenatal sonographic examination of the placenta is an essential component as its abnormalities can have a direct effect on fetal or maternal outcomes, obstetrical management and future fertility. OBJECTIVE: To determine whether any association exists between the finding of an increased thickness of placenta, abnormal placenta shape, placental calcification, placental lake and abnormal cord insertion site at 20-22 and 30-32 weeks gestation with an increased risk of uteroplacental complications or a poor pregnancy outcome. METHODOLOGY: A real-time ultrasound was used at the time of detail scan (at 20-22 weeks gestation) and at 30-32 weeks gestation to look for placenta appearance, fetal growth and anomaly. The main outcome measures were risk of hypertension disease in pregnancy, fetal growth restriction and poor fetal outcomes such as low Apgar score and low cord pH. RESULT: The majority of the participants were Malay (77.9%). Abnormal placenta found at both gestations were placental lakes and thickness, and only one case had marginal cord insertion. Approximately 6% of the cases were confirmed placenta previa. No abnormal shape or abnormal calcification found at both gestations. About 10% patient developed hypertensive disease in pregnancy, 15% of the fetus was found to have growth restriction and another 16% have low umbilical cord pH. Majority of them delivered at term (90%) and via vaginal delivery (81%). There was no significance between presence of abnormal placental lake and thickness at both gestations with the maternal and fetal outcome. CONCLUSION: Presence of abnormal placental thickness and lakes at 30-32 weeks scan associated with maternal hypertensive disease, fetal growth restriction and low umbilical cord pH, however these were not statistically significant.

Case Control Study of Anxiety and Depression Among Patients with Miscarriage Compared to Those with Successful Pregnancy

Miscarriage is one of the most common complications in pregnancy. There is emerging evidence that psychological impact following miscarriage is not unusual. Understanding the magnitude of psychological morbidity is important in the management of miscarriage. The main objective of this study was to compare the mean Hospital Anxiety and Depression Scale (HADS) score between women with miscarriage and women with successful pregnancy and to determine the socio-demographic factor and clinical characteristic that are associated with anxiety and depression. A descriptive case control study was conducted in a teaching hospital, over a period of 12-months (from October 2014 till September 2015). A total of 65 women were recruited with 32 women as the study group (miscarriage) and another 33 women as the control group (women with successful pregnancy). Mean HADS-anxiety score was higher in the study group compared to control group although it was not statistically significant (6.53 ± 3.427 vs 5.73 ± 2.875, p=0.309). Mean HADS-depression score was higher in the control group (4.34 ±2.695 vs 4.45 ± 3.073, p=0.878). Women with maternal age more than 35 years and history of previous miscarriage had a higher tendency of anxiety and depression with higher mean HADS score. There was no association between other socio-demographic data and clinical characteristic with risk of anxiety and depression. As conclusion, there was no significant difference in women with miscarriage as compared to those with successful pregnancies, although older women with history of miscarriage had a preponderance to both disord

Multiple Faces of the Same Pathology

Ectopic pregnancy is defined as an extrauterine pregnancy. We report three cases where the ectopic pregnancies were implanted in different sites. The first case was a 28-year-old in her second pregnancy at 9 weeks gestation. She presented with painless vaginal bleeding. Ultrasound showed unruptured cornual pregnancy with hCG level of 7456mIU/ml. A single dose of 75mg IM methorexate was given and she responded well with significant reduction of hCG level. The second case, a 26-year-old gravida 5 para 2+2, with 2 previous ectopic pregnancies and bilateral salpingectomy, conceived via in-vitro fertilization (IVF). She presented with acute abdomen and one episode of syncope at 8 weeks 4 days gestation. Laparotomy showed ruptured ectopic pregnancy at the left tubal stump requiring a left salpingectomy. The third case was a 26-year-old, gravida 5 para 2+2, with two previous vaginal deliveries and two previous first trimester miscarriages. Her menses was irregular since she took injectable progestin. She presented to the emergency department with sudden onset of lower abdomen pain. Urine pregnancy test was positive. Ultrasound showed empty uterus, no adnexal mass but there was significant free fluid in the cul-de-sac. During laparoscopy, a ruptured ovarian pregnancy was diagnosed and salpingo-oophorectomy performed. There was no significant risk factor contributing to ectopic pregnancy identified in the first and third case. In the second case, despite previous bilateral salpingectomy, the patient still had ectopic pregnancy in the left fallopian tube remnant.

Renal Angiomyolipoma During Pregnancy: What Can We Offer?

Renal angiomyolipoma is a rare disease seen during pregnancy. Rupture of renal angiomyolipoma could be catastrophic and might result in maternal and even perinatal mortality. Management includes conservative vs surgical approach. A 29-year-old woman Para 2 with history of bleeding renal angiomyolipoma in her first pregnancy at 11 weeks treated with selective arterial embolisation. The pregnancy was terminated. Even though having small residual tumour, her subsequent pregnancy progressed well with conservative management. Intervention is advisable in the presence of large or symptomatic renal angiomyolipoma prior to pregnancy in order to minimise potential lifethreatening haemorrhage during pregnancy. For those with small tumour of less than 4cm, perhaps conservative approaches i.e. frequent follow-up and close monitoring would assist in early identification of any rupture or bleeding.

Prenatal diagnosis of aneuploidies in amniotic fluid by multiple ligation-dependent probe amplification (MLPA) analysis.

Prenatal diagnosis is essential in the new era of diagnosis and management of genetic diseases in obstetrics. Multiple ligation-dependent probe amplification (MLPA) is a recent technique for prenatal diagnosis for the relative quantification of 40 different nucleic acid sequences in one single reaction. We had utilized the MLPA technique in detecting aneuploidies in amniotic fluid samples from 25 pregnant women from the Obstetrics and Gynaecology Department UKMMC, versus the quantitative fluorescent polymerase chain reaction (QF-PCR) method. Conclusive results were obtained in 18 cases and all were concordant with that of the QF-PCR. All four cases of trisomies were correctly identified including one case with maternal cell contamination.

Sexual dysfunction among postmenopausal women.

INTRODUCTION AND OBJECTIVE: Female sexual dysfunction (FSD) has a major impact on interpersonal relationships and quality of life. For many women it has been emotionally distressing, physically disconcerting, and socially disruptive. To determine the prevalence and factors that contribute to female sexual dysfunction (FSD) and to evaluate the different sexual domains that influence sexual function amongst post menopausal women. MATERIALS AND METHODS: This was a cross-sectional study among postmenopausal women attended the Menopause Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). It was conducted over a period of one year. A validated English and Malay Version of the Female Sexual Function Index (FSFI) were used to assess female sexual function. RESULTS: The median age of menopause in this study population was 50 years and majority of these patients was on hormonal therapy (58.2%). The prevalence for sexual dysfunction was high (85.2%). The most affected sexual domains were: dissatisfaction (89.0%), arousal (67.0%) and desire (62.4%). Factors associated with sexual dysfunction among post menopausal women that were statistically significant were age more than 60 (p=0.033), lower educational level (p<0.001), and type of menopause (p=0.029). Women with naturally occurring menopause were found to be 2.5 times more likely to have sexual dysfunction. CONCLUSIONS: The prevalence of sexual dysfunction among post menopausal women was high. The most affected domains were satisfaction, desire and arousal. The associated factors were older age, lower education level, and type of menopause.

Early Versus Late ECV In Primigravidae With Breech Presentation: A Pilot Study

This was a pilot study comparing the success between early versus late external cephalic version (ECV) involving primigravidae with singleton breech pregnancy. They were randomised into early (34–36 weeks) and late (37-40 weeks) ECV groups. A total of 44 women were initially randomised into 22 women for each group. The overall ECV success rate was acceptable in both groups although insignificantly higher in the late ECV group (55.6% versus 46.7%, p= 0.732.) Caesarean section in the early ECV group was higher (80% versus 72.2%). Early ECV group had women with higher BMI (29.5 versus 26.8 kg/m2, p=0.107), anterior placentation (60% versus 38.9%) and extended breech presentation (55.6% versus 44.4%; p= 0.296). In conclusion, early ECV in primigravidae showed no better success rate than late ECV. Maternal obesity, anterior placentation and extended breech presentation should alert to failure risk.

Usage Of Home-Based Maternal Health Record In Antenatal Monitoring Among Malaysian Women Attended University Kebangsaan Malaysia Medical Centre

Maternal Home-based Record (MHR) is a concise medical record that can be kept by the pregnant women for regular documentation throughout pregnancy stages. This study was done to assess the usage of the MHR among the pregnant women and its associated factors. A good MHR usage was assigned using mean value as cut-off point that has been agreed by an expert group from scoring system which incorporates usage elements in term of follow-up, information documentation, knowledge seeking, continuity of care and self-monitoring of pregnancy. A cross-sectional survey was conducted in University Kebangsaan Malaysia Medical Centre (UKMMC) and a total of 79 pregnant women who attended the antenatal clinic were recruited. A validated self-administered questionnaire was used. The questionnaire was newly developed in Bahasa Malaysia. Content validity and reliability test for internal consistency for the knowledge, satisfaction and usage scale was performed. The Cronbach’s Alpha value for each domain was 0.764, 0.716 and 0.877 respectively. The results showed that the prevalence of good MHR usage was 51.3%. There were significant association found between level of education (Adj OR=0.32, 95% CI 0.12, 0.85, p=0.023) and doctor as birth attendant in previous pregnancies (Adj OR= 2.54, 95% CI 1.97, 6.59, p=0.045) with good usage of MHR. There was a positive significant relationship between satisfaction level among the respondent and the level of the usage (p=0.01, r=0.377), whereby with every increase in 1 score in satisfaction level will increase the usage score by 0.4 (95% CI 0.2 to 0.7) units, p<0.01. Therefore, MHR is still relevant as antenatal care monitoring instruments and it is important to make an effort to improve patient satisfaction in using MHR. Health care providers can use this validated self-administered questionnaire to assess function of MHR to remain relevant to the pregnant women population in their locality.

Sexual Dysfunction among Post Menopausal Women

The prevalence of sexual dysfunction among post menopausal women was high. The most affected domains were satisfaction, desire and arousal. The associated factors were older age, lower education level, and type of menopause.

Cervical Ectopic Pregnancy: A Management Dilemma

A 28-year-old G3P1+1 at 6 weeks period of amenorrhea with a previous Caesarean section presented with per vaginal bleeding. A cervical ectopic pregnancy was confirmed by a transvaginal scan. An intramuscular methotrexate was given followed by intracervical route due to poor decline of the serum βHCG. However, due to persistent increment of serum βHCG, an additional four doses of intramuscular methotrexate with folinic acid rescue were administered and she responded well to the regime. Unfortunately, following the last dose, she developed an episode of excessive per vaginal bleeding which required suction and curettage of the cervical canal. A Foley‘s catheter balloon was placed intracervically as a tamponade and the bleeding was successfully arrested.

Maternal melanoma with placental metastasis.

A 40-year-old woman, a grand multipara with uncertain gestation, presented with severe, prolonged diarrhoea. She was previously diagnosed to have melanoma. Examination revealed gross ascites with hepatosplenomegaly and uterus corresponding to 29 weeks gestation. An emergency caesarean section confirmed widespread metastases to the ovaries, mesentery and placenta. A viable male foetus was delivered with features of intrauterine growth restriction. The baby survived, but the mother died a week later. This case highlights the importance of thoroughly assessing placentas and babies of patients with melanoma for metastases.

Postpartum pneumomediastinum.

A 21-year-old primigravida with previous history of pulmonary tuberculosis had a normal but assisted vaginal delivery after a prolonged second stage. Within 12 hours, she complained of dyspnoea and was found to have abnormal neck and anterior chest wall swelling. A diagnosis of subcutaneous emphysema was made and this was confirmed with the chest radiograph, which also revealed pneumomediastinum. She recovered well within four days with conservative treatment.