Are the WHO (1980) criteria for the 75 g oral glucose tolerance test appropriate for pregnant women?

OBJECTIVE: To determine the normal response to a 75 g glucose challenge in the context of an oral glucose tolerance test in the third trimester of pregnancy. DESIGN: Prospective observational study. SETTING: Antenatal clinic, Kandang Kerbau Hospital, Singapore. SUBJECTS: Sixty-four normal pregnant women with a low risk for diabetes. INTERVENTIONS: Glucose (75 g) challenge following an overnight fast after 28 weeks of gestation. MAIN OUTCOME MEASURE: Venous plasma glucose levels taken before and 2 h after the glucose challenge. RESULTS: Upper limits of normality were found to be fasting glucose 4.9 mmol/l and 2 h glucose 9.2 mmol/l. CONCLUSION: The WHO (1980) criteria should not be used in pregnancy.

PIP: To assess the normal response to the 75 gm oral glucose tolerance test (OGTT) in normal pregnant women, healthy Chinese and Malay women who had been referred to the antenatal clinic of the Department of Reproductive Medicine, Kandang Kerbau Hospital, Singapore, were evaluated. The women were selected on the basis of having none of the generally accepted risk factors for diabetes mellitus: their age was 35 years, they weighed 80 kg, they did not have a personal history of diabetes or a family history of diabetes or a family history of diabetes in first degree relatives, nor did they have a history of babies weighing 4000 gm at birth, still-births, neonatal deaths, congenital malformations, or recurrent miscarriages. All OGTTs were performed after 28 weeks of gestation. The fasting blood sample was taken from the antecubital vein. Further samples were taken 1 and 2 hours after the glucose drink. A glucose analyzer using 5 mcl of plasma was employed. The analytical method was based on the glucose oxidase/peroxidase/aminophenazone process. There was no significant difference in mean glucose levels at corresponding points of the OGTT in Chinese and Malay women. correlation calculations confirmed the absence of any influence of gestational age after 28 weeks on glucose tolerance. Of the 64 women, 47 were Chinese and 17 Malays; 20 wee nulliparous, and 44 were parous. Their mean age was 27.2 years (range 18-35). The mean birthweight of the infants was 3140 gm (range 2094-4240 gm). There were 33 female and 31 male infants. The mean apgar scores at 1 and 5 min were 8.8 (range 7-9) and 9.0 (range 6-10). The mean values and the proposed upper limits of normality for the 75 gm OGTT were 3.9 and 4.9 mmol/1, respectively. 6 women had abnormal OGTT results according to the WHO criteria (fasting glucose 6 mmol/1; 2 hour glucose 8 mmol/1).

A double-blind, randomised, cross-over study comparing the 50g OGTT and the 75g OGTT for pregnant women in the third trimester.

There is little consensus in the conduct and interpretation of the oral glucose tolerance test (OGTT) in pregnancy. In Singapore much data has been accumulated about the 50g OGTT while the converse is true of the 75g OGTT. A double-blind, randomised, crossover study of 56 subjects in the third trimester was conducted to compare both glucose challenges to determine if there was a difference in glucose handling in the context of a two hour OGTT. A significant difference (p < 0.001, t = 5.76) was found at two hours where the mean glucose concentrations were 5.2 +/- 0.8 mmol/L and 6.2 +/- 1.4 mmol/L for the 50g and 75g OGTT respectively. These findings suggest that the 75g OGTT is potentially more effective in unmasking pregnant subjects with impaired glucose tolerance.

A case-control study of cervix cancer in Singapore.

Cervix cancer is about twice as common in Asia as in the Western world and its incidence varies among different Asian ethnic groups. A study based in Singapore, the population of which comprises Chinese, Indians and Malaysians, offers the opportunity to evaluate whether the same risk factors are important in this part of the world as in the West. A total of 135 cases and an equal number of controls were interviewed and details concerning reproductive and sexual history, smoking, hygiene, socio-economic status and education were collected. Seventy-three cases had invasive cancer while 62 had micro-invasive disease or CIN III. The most important risk factors were parity and number of sexual partners. Smoking was rare in cases and controls and did not appear to be an important determinant of risk. Of the socio-economic factors, education appeared most predictive and lowered the risk. Age at first intercourse was strongly correlated with education (positively) and parity (negatively), but not with number of sexual partners. Biopsies were available for HPV DNA analysis in 38 cases and 37% were positive, mostly for HPV type 16. All these factors gave similar risks in invasive and preinvasive disease.

Epitheloid sarcoma of the vulva.

A rare case of epitheloid sarcoma of the vulva is described. This is a soft-tissue malignancy arising from tenosynovial tissue. The patient presented with a painless lump of the vulva of a month's duration. An excision biopsy was performed followed by a wide local excision after the actual diagnosis was confirmed. Post-operatively, her recovery was uneventful and she was seen in the Cancer clinic at regular intervals. Three years following surgery, she was well with no evidence of any recurrence. The suggested mode of treatment ranged from a wide local excision to radical vulvectomy with groin node dissection.

Gynaecological screening--the benefits and pitfalls.

Gynaecological screening, as with all screening, must have clear indications, objectives and modus operandi. The types of screening addressed are osteoporotic screening, gynaecological oncological screening involving the various hormonal target organs and breast cancer screening. Apropos osteoporotic screening, a suggestion is made that assessment of bone mineral content be used as a research tool in following the progress of therapy in osteoporosis rather than a screening modality. Cervical cytological screening remains the mainstay of screening for pre-invasive cancer of the cervix, and has contributed significantly to reduction of the incidence and mortality in cervical cancer over the past decade in many countries worldwide. Data should be standardised. Causes of false negative smears are outlined. Colposcopy, with colposcopically directed biopsies where necessary, is advocated in selected cases, namely all CIN, atypical and persistently inflammatory cytological smears. In the near future, DNA hybridisation tests could become desirable for the detection of HPV in targetted cases. Oncology screening for vagina and vulva follow a similar pattern for the cervix. Ultrasound screening of the uterine body and endometrium as well as the ovaries has had favourable reports. Mammographic screening is recommended in patients at higher risk for breast cancer. The benefits and pitfalls of screening are outlined both for individual screening modalities and generally.

A prospective randomised controlled trial of external cephalic version comparing two methods of uterine tocolysis with a non-tocolysis group.

The use of tocolvtic agents to enhance uterine relaxation and facilitate external cephalic version (ECV) has come under recent debate. We studied 90 breech presentations in late pregnancy who did not have contra-indications to ECV. The patients were randomised into 3 groups of 30 patients each: one was administered oral salbutamol 4 mg t.d.s.; another had intravenous salbutamol infused until the maternal heart rate rose above 100 bpm for 30 mins; and the last served as a control group. All patients in each group were matched for parity and gestation, and each had an intravenous line, thereby masking the treatment group from the 2 doctors who performed half the number of ECVs each. There was no significant difference in the success of ECV between the treatment and control groups (46.6% vs 50.0% vs 46.6%). The gestational age, the placental site, the attitude of the breech, the abdominal girth, and the maternal weight and fetal birth weights did not seem to influence results. On the other hand, there was a significant difference in successful ECV between nullipara (26%) and multipara (75%) (p less than 0.001). There were no cases of abruptio placenta or foetal distress, and one patient entered labour one day after the ECV at 39 weeks gestation. There were 2 cases of spontaneous version after failed ECV, and one case of spontaneous reversion to breech after successful ECV. We conclude that the use of salbutamol does not increase the incidence of successful ECV, but multiparity predicts for a successful outcome.

The treatment of breast engorgement with Serrapeptase (Danzen): a randomised double-blind controlled trial.

We evaluated an anti-inflammatory enzyme drug Danzen (Serrapeptase: Takeda Chemical Industries, Ltd.) on 70 patients complaining of breast engorgement. These patients were randomly divided into 2 groups, a treatment group and a placebo group. A single observer, unaware of the group the patients were in, assessed the severity of each of the symptoms and signs of breast engorgement before treatment was commenced, and daily for 3 days, during which therapy was administered. Danzen was noted to be superior to placebo for improvement of breast pain, breast swelling and induration and while 85.7% of the patients receiving Danzen had "Moderate to Marked" improvement, only 60.0% of the patients receiving placebo had a similar degree of improvement. "Marked" improvement was found in 22.9% of the treatment group and 2.9% of the placebo group. These differences were statistically significant (P less than 0.05). No adverse reactions were reported with the use of Danzen. Danzen is a safe and effective method for the treatment of breast engorgement.

The relationship of serum vitamin A, cholesterol, and triglycerides to the incidence of ovarian cancer.

Prospective and retrospective studies have suggested that serum vitamin A and total cholesterol levels may be associated with cancer. Our study showed that the mean (+/- SEM) concentrations of serum vitamin A 489 +/- 33.28 (mean +/- SEM micrograms/liter and serum total cholesterol 174.7 +/- 8.96 (mean +/- SEM) mg/dl from ovarian cancer patients in Singapore were significantly lower than the respective values of 668 +/- 25.10 (mean +/- SEM) microgram/liter and 210.7 4.48 (mean +/- SEM) mg/dl from noncancerous control subjects (P less than 0.0001 for both compounds). In addition, ovarian cancer patients did not show significantly lower serum triglyceride levels than the control subjects. Age did not significantly correlate the serum vitamin A and total cholesterol concentrations, but there was correlation with respect to the serum triglyceride levels. There were moderate correlations between vitamin A and cholesterol levels (r = 0.36, P less than 0.0027) and between cholesterol and triglyceride levels (r = 0.37, P less than 0.0024) in the control subjects but not in the cancer patients. Vitamin A levels correlated moderately with triglyceride levels in both the cancer patients (r = 0.42, P less than 0.0258) and the control subjects (r = 0.33, P less than 0.0069). The inverse relationship between the incidence of ovarian cancer and serum vitamin A and serum total cholesterol concentrations may have distinct implications for preventive medicine and public health.

Cervical ripening by breast stimulation.

The effect of breast stimulation on cervical ripening was studied. One hundred patients who had completed 38 weeks' gestation and had uncomplicated antenatal courses were recruited and divided into two groups: treatment and control. In the treatment group, gentle breast stimulation of alternate breasts was performed first for 1.5 hours under monitoring in the hospital and then for three hours daily for three days at home. No uterine hypertonus was detected. It was found that there was a significant change in the Bishop score of 3.96 +/- 1.34 points in the stimulated group as compared with the control group 1.04 +/- 1.03 points. After three days, a cross-over trial was performed with the extreatment group becoming the control and the excontrol group undergoing breast stimulation for the same period of time and under the same conditions. Again, the excontrol group was found to have a better mean cervical score (3.11 +/- 1.42 points) than the extreatment group (0.76 +/- 0.97 points) during breast stimulation. It is stressed that no uterine hypertonus was detected with gentle, unilateral breast stimulation, and there were no maternal or fetal complications as a result of this modality of cervical ripening.

Serum selenium concentrations in ovarian cancer patients using a simplified fluorimetric procedure.

The serum selenium (Se) concentrations were determined to be 105.6±15.6 µg/L ([Formula: see text]) and 116.7±18.4 µg/L ([Formula: see text]) for the ovarian cancer patients and the control subjects in Singapore, respectively (p<0.0065). When we separated the patients into three age groups, namely <30, 30-50, and >50 yr, the ovarian cancer patients showed significantly lower mean serum Se levels than the control subjects for the 30-50-yr age group only. However, when the analysis of variance was used to evaluate the data, the values indicated that the age of the subject did not significantly affect the serum Se level. Our findings suggest that there is an inverse relationship between serum Se concentration and the incidence of human ovarian cancer.A modified simple fluorimetric method for the determination of serum Se concentration is described. The procedure, with a sensitivity limit of 5 µg/L and percentage recoveries of 96.2-100.7%, requires only 0.2 mL of serum sample.

Neonatal serum bilirubin levels in spontaneous and induced labour.

An investigation was made into the onset and severity of neonatal jaundice in 114 patients following spontaneous labour and labour induced by (a) amniotomy, (b) amniotomy and simultaenous infusion of oxytocin, (c) amniotomy and simultaneous administration of oral prostaglandin E2 (PGE2). No significant difference in serum bilirubin levels in the first five days of life was found in the four groups.