Necrotising fasciitis originating from a vulval abscess--a case report.

This article reports a rare case of necrotising fasciitis starting out as a vulval abscess with rapid progression to a potentially lethal condition. Elderly people with medical conditions such as diabetes are especially prone to it. A high index of suspicion and an early surgical consult are essential in improving outcome in this condition. Once diagnosed, aggressive surgical debridement with antibiotic cover is crucial. This is followed up with meticulous nursing care of the large wound till it heals. The various diagnostic points and treatment modalities are also discussed.

Gestational diabetes: obstetric and neonatal outcome in 411 cases.

AIM: To study the obstetric and neonatal outcome of women with gestational diabetes mellitus. METHODS: Four hundred and eleven (411) women with gestational diabetes mellitus were studied retrospectively. The control group was 3,391 non-diabetic women delivered in the same period. RESULTS: Women with gestational diabetes mellitus had a significantly higher incidence of pregnancy-induced hypertension, and more were likely to present with malpresentation in labour. They had a higher incidence of surgical induction and an increased incidence of elective and emergency Caesarean section rate compared to controls. The neonatal outcome was excellent. The perinatal morbidity and mortality were similar to the non-diabetic controls. CONCLUSION: The excellent outcome of the women with gestational diabetes mellitus in this study is attributed to tight control of blood glucose level and close attention given to this group of patients.

Congenital abnormalities and pregestational diabetes mellitus in pregnancy.

Despite falling perinatal mortality rate, congenital malformation remains the major cause of mortality in infants of mothers with established diabetes. The perinatal mortality rate in this group of infants is 5 times the overall perinatal mortality rate in this hospital. It is well established that pre-pregnancy counselling and maintenance of euglycaemia during the periconception period are the keys to prevention of congenital malformation. We are able to offer pre-pregnancy counselling to 29% of our diabetic mothers who are diagnosed to have pregestational diabetes mellitus only after the 6 weeks postnatal oral glucose tolerance test. Even in the known established diabetes mellitus, 95% of the patients were first seen after the period of organogenesis (> 8 weeks). This could explain our high congenital malformation rate of 15.7%.

Maternal congenital heart disease and pregnancy outcome.

OBJECTIVE: To study the obstetrics and neonatal outcome of women with congenital heart disease. METHOD: This is a retrospective study of 85 women with congenital cardiac disease. Data collected include maternal characteristics, New York Heart Association Class, cardiac complications and obstetric and neonatal outcome. RESULTS: The maternal and neonatal outcomes were excellent with no maternal and perinatal mortality. The main cardiac lesions were mitral valve prolapse (60.8%), atrial septal defect (8.6%), ventricle septal defect (6.5%) and aortic regurgitation (4.3%) and 2.1% each of tricuspid regurgitation, pulmonary regurgitation, Ebstein's anomaly, coarctation of aorta, patent ductus arteriosus, and Eisenmenger's syndrome. Six deliveries were associated with New York Heart Association deterioration. Compared to the general obstetric population, more women in the study group were primigravida, had pregnancy induced hypertension, underwent instrumental vaginal deliveries and caesarean sections and had more babies with lower birth weights. CONCLUSION: Despite potential difficulties and complications associated with congenital heart disease, careful cardiac and obstetric management in a tertiary referal centre resulted in good maternal and fetal outcomes.

Obstetric outcome of pregestational diabetic pregnancies.

This retrospective study examined the obstetric and neonatal outcome in 23 pregestational diabetic pregnancies. The incidence of congenital malformations and mortality in infants of diabetic mothers was increased compared to the control population. Late booking for antenatal care and poor glycaemia control are probably the reasons for this high incidence. There was also a significantly higher preterm delivery and Caesarean section rate in the pregnancies complicated by pregestational diabetes. The neonatal morbidity was also higher than the controls in terms of jaundice, hypoglycaemia, respiratory distress syndrome and admissions to neonatal intensive care unit. Only with preconception counselling and tight glycaemia control in the periconception period and throughout pregnancy can we expect a drop in the complication rates in pregestational diabetic pregnancies.

Ethnicity and obstetric performance in Singapore.

The influence of ethnicity on obstetric performance in Singapore was assessed by retrospective analysis of all deliveries in the National University Hospital over a 7-year period. Malay mothers were younger, shorter, less educated, of higher parity, were more likely to have had no antenatal care, and had the highest incidence of premature labour. However, mothers of Indian origin had the smallest babies, the highest incidence of low birth weight and significantly higher perinatal mortality rates. Chinese mothers fared better than their Malay and Indian counterparts in all parameters assessed. The ethnic origin of the mother has an important bearing on perinatal performance. This emphasises the importance of designing appropriate strategies to improve perinatal health in the different ethnic groups.

Evaluation of new catheter systems for intrauterine pressure measurement.

To verify the reliability of intrauterine pressure recordings by a newly available intrauterine catheter. In five women in labor the tips of the two newly available catheters (Hewlett Packard HP 13975 A) were tied together and placed in the same amniotic fluid pocket. In three other women the tip of the new catheter (HP) and tip of an established catheter system (Intran II) were tied and placed in the uterine cavity above the fetal head. The difference in active pressure recorded by the two catheters for each contraction in all 8 women was calculated. The total active pressure recorded for each patient for the whole labor by the two catheter was calculated. The active pressure difference for individual contractions was less than 5 mm Hg in 95% of contractions (n = 222) with the two new catheters (HP versus HP) and 99% when the new catheter was compared with the established catheter system (HP versus Intran II) (n = 222). The total active pressure in each labor differed by 0.4% to 5.4% (n = 5) and 1.4% to 4.1% (n = 3) respectively when similar (new HP versus new HP) and different catheter systems (new HP versus established Intran II) were used. The new transducer tip catheter gives reliable pressure readings in-vivo. (n = 3) respectively when similar (new HP versus new HP) and different catheter systems (new HP versus established Intran II) were used. The new transducer tip catheter gives reliable pressure readings in-vivo.

Pregnancy outcome and mitral valve prolapse.

Mitral valve prolapse (MVP) comprises a large proportion of obstetric cardiac problems and has a general prevalence of 4%. We examined the obstetric outcome of patients with MVP delivered between 1988-1991 at the National University Hospital, Singapore. During this interval, deliveries totalled 16,755 of which 85 (0.51%) had maternal cardiac disease. Of these, 28 (32.9%) had echocardiographic evidence of non-myxomatous MVP. Ten patients (37.5%) had demonstrable mitral regurgitation and 4 (14.3%) had benign ventricular ectopics. All patients remained well throughout pregnancy. Gestation at delivery and use of analgesia did not differ significantly from non-cardiac patients. However, the labour induction rate was twice the department average at 17.9%. Twenty-four (85.7%) patients achieved vaginal delivery and 4 (14.3%) patients were delivered abdominally. All babies were liveborn. Eight patients (28.6%) did not receive antibiotic prophylaxis during labour and postpartum period and remained afebrile. The role of antibiotics in this category of patients is discussed. Patients with MVP without myxomatous valve changes may expect excellent pregnancy outcome.

Autologous blood transfusion in abdominal aortic aneurysm surgery.

We are reporting a case of autologous blood transfusion in a patient who underwent a repair of her aortic aneurysm. Even though the operation was major and carried a high mortality, no homologous blood was used at all.

Induction of labour: does internal tocography result in better obstetric outcome than external tocography.

A prospective randomized study was undertaken to evaluate the benefit of intrauterine catheters in induced labour. Two hundred and thirty nine women who had induced labour were studied. The patients in one group had intrauterine catheters inserted and oxytocin was titrated to achieve the 75th percentile of uterine activity observed in spontaneous normal labour according to parity. Contractions were assessed by external tocography in the other group and oxytocin was titrated to achieve 6 to 7 contractions per 15 minutes each lasting > 40 seconds. Mean maximum dose of oxytocin, mode of delivery, Apgar score < 7 at 5 minutes, cord arterial blood pH < 7.15 and admission to neonatal intensive care unit did not differ significantly in the 2 groups. In conclusion, women who had intrauterine catheters did not have a shorter duration of labour, lower dose of oxytocin, fewer operative deliveries or fewer babies in poor condition at birth compared with those who had external tocography in induced labour.

Do burn patients have a silver lining?

Silver-containing pharmacological preparations have been used for many years in the prophylaxis and management of burn wound sepsis and, more recently, 1 per cent silver sulphadiazine cream (SSD) has been the treatment of choice for such problems. A prospective clinical study has been undertaken to determine the absorption and effects of the silver ion from SSD, with particular reference to hepatic and renal function. Twenty-two patients were studied. The silver assay was done by atomic absorption spectrophotometry with an attached graphite furnace. The detection level was 0.5 micrograms/l. The precision at 3.5 micrograms/l was 4.8 per cent and at 8.5 micrograms/l was 2.8 per cent. Silver was rapidly absorbed through the burn wound and serum silver levels were elevated in 20 patients. Silver was found to be deposited biochemically and electronmicrographically in the liver and kidneys of the only patient who died in the study group. Early hepatic dysfunction was present in all burns greater than 10 per cent total body surface area. Liver and renal function tests did not correlate with serum silver levels. A urinary threshold to silver excretion was seen at a serum silver level of 100 micrograms/l. This study demonstrates that silver is rapidly absorbed through burn wounds, is deposited in large amounts throughout the body but appears safe when used in the treatment of moderate burns. Whether the very high levels recorded in the subject who died were inherently detrimental will remain a matter for speculation.

Effectiveness of transcutaneous electric nerve stimulator for pain relief in labour.

The effectiveness of transcutaneous electric nerve stimulation (TENS) for pain relief in labour was compared to inhalation analgesia consisting of 50% nitrous oxide and 50% oxygen (ENTONOX). In the first part of the study 101 patients in early labour were allocated to using TENS (Group A) or ENTONOX (Group B) for pain relief. Our results did not show any beneficial effect on pain relief in labour with the use of TENS over ENTONOX; 18.8% of patients in Group A went through labour without any further form of analgesia as opposed to 17.0% in Group B. In the second part of the study 20 nulliparous patients having induced labour were randomly allocated to use TENS (Group C) or ENTONOX (Group D) as the first modality of pain relief. A switchover was made when labour pains were no longer tolerable. The results showed that both TENS and ENTONOX could be used in early labour up to 5-6 cm cervical dilatation till the frequency of contractions was nearly 5 in 10 min or the first 3-4 hr from the time patients first requested pain relief in labour when frequency of contractions was nearly 4 in 10 min. TENS could be used in early labour for patients who wish to be ambulant and is as effective as ENTONOX. Either modality of pain relief was not adequate for pain relief throughout labour.