Challenges in the management of hypercalcemia in pregnancy - Case report of two cases.

Hypercalcemia in pregnancy is rare and can pose a great diagnostic challenge due to its asymptomatic presentation. It is associated with maternal complications such as urolithiasis, pancreatitis, renal insufficiency and preeclampsia, fetal complications such as growth restriction and intrauterine fetal demise, and neonatal complications such as neonatal hypocalcemia, tetany and hypoparathyroidism. Prompt diagnosis and treatment of the underlying cause of hypercalcemia is important. Two cases of hypercalcemia in pregnancy were encountered over 12 months. Both presented asymptomatically in the first trimester and were associated with hyperparathyroidism and hypertensive disease in current and previous gestations. Genetic testing ruled out familial hypocalciuric hypercalcemia, and both women required surgical management in the second trimester for control of hypercalcemia. The literature on the diagnosis and management of hypercalcemia in pregnancy is reviewed, and the challenges and pitfalls are discussed. Hypercalcemia in pregnancy requires a high index of suspicion for early diagnosis, and young women with unexplained hypertension in early pregnancy should be investigated for secondary causes, including hypercalcemia and primary hyperparathyroidism. Management of hypercalcemia secondary to primary hyperparathyroidism requires multidisciplinary team management, and surgery should be considered if the patient has not responded to conservative measures, ideally in the second trimester.

Continuous Glucose Monitoring Feedback in the Subsequent Development of Gestational Diabetes: A Pilot, Randomized, Controlled Trial in Pregnant Women.

OBJECTIVE: This study evaluated the effects of receiving glucose feedback from continuous glucose monitoring (CGM) by intermittent scanning (unblinded group), and CGM with masked feedback (blinded group) in the subsequent development of gestational diabetes mellitus (GDM). STUDY DESIGN: This was a prospective, single-center, pilot, randomized controlled trial including n = 206 pregnant women in the first trimester of pregnancy with no prior diagnosis of type 1 or type 2 diabetes. The participants were randomized into the unblinded group or blinded group and wore the CGM in the first trimester of pregnancy (9-13 weeks), the second trimester of pregnancy (18-23 weeks), and late-second to early-third trimester (24-31 weeks). The primary outcome was GDM rate as diagnosed by the 75-g oral glucose tolerance test (OGTT) at 24 to 28 weeks. RESULTS: Over 47 months, 206 pregnant women were enrolled at 9 to 13 weeks. The unblinded group had a higher prevalence of women who developed GDM (21.5 vs. 14.9%; p > 0.05), compared to the blinded group. In the unblinded group compared to the blinded group, plasma glucose values were higher at 1 hour (median 7.7 [interquartile range {IQR}: 6.3-9.2] vs. 7.5 [6.3-8.7]) and 2 hours (6.3 [5.8-7.7] vs. 6.2 [5.3-7.2]), but lower at 0 hour (4.2 [4.0-4.5] vs. 4.3 [4.1-4.6]; p > 0.05). All these differences were not statistically significant. CONCLUSION: Glucose feedback from CGM wear in the first to the third trimester of pregnancy without personalized patient education failed to alter GDM rate. KEY POINTS: · Continuous glucose monitoring (CGM) is feasible for use in pregnant women.. · No significant difference in gestational diabetes rates with or without CGM feedback.. · Future clinical trials should incorporate CGM education and personalized guidance to enhance study outcomes..

ChatGPT outscored human candidates in a virtual objective structured clinical examination in obstetrics and gynecology.

BACKGROUND: Natural language processing is a form of artificial intelligence that allows human users to interface with a machine without using complex codes. The ability of natural language processing systems, such as ChatGPT, to successfully engage with healthcare systems requiring fluid reasoning, specialist data interpretation, and empathetic communication in an unfamiliar and evolving environment is poorly studied. This study investigated whether the ChatGPT interface could engage with and complete a mock objective structured clinical examination simulating assessment for membership of the Royal College of Obstetricians and Gynaecologists. OBJECTIVE: This study aimed to determine whether ChatGPT, without additional training, would achieve a score at least equivalent to that achieved by human candidates who sat for virtual objective structured clinical examinations in Singapore. STUDY DESIGN: This study was conducted in 2 phases. In the first phase, a total of 7 structured discussion questions were selected from 2 historical cohorts (cohorts A and B) of objective structured clinical examination questions. ChatGPT was examined using these questions and responses recorded in a script. Of note, 2 human candidates (acting as anonymizers) were examined on the same questions using videoconferencing, and their responses were transcribed verbatim into written scripts. The 3 sets of response scripts were mixed, and each set was allocated to 1 of 3 human actors. In the second phase, actors were used to presenting these scripts to examiners in response to the same examination questions. These responses were blind scored by 14 qualified examiners. ChatGPT scores were unblinded and compared with historical human candidate performance scores. RESULTS: The average score given to ChatGPT by 14 examiners was 77.2%. The average historical human score (n=26 candidates) was 73.7 %. ChatGPT demonstrated sizable performance improvements over the average human candidate in several subject domains. The median time taken for ChatGPT to complete each station was 2.54 minutes, well before the 10 minutes allowed. CONCLUSION: ChatGPT generated factually accurate and contextually relevant structured discussion answers to complex and evolving clinical questions based on unfamiliar settings within a very short period. ChatGPT outperformed human candidates in several knowledge areas. Not all examiners were able to discern between human and ChatGPT responses. Our data highlight the emergent ability of natural language processing models to demonstrate fluid reasoning in unfamiliar environments and successfully compete with human candidates that have undergone extensive specialist training.

Challenges in management of gastrointestinal cancers in pregnancies: A report of three cases.

Gastrointestinal cancer occurs in approximately 1 in 13,000 pregnancies, making up 4% of malignancies detected in pregnancy. It is a complex and challenging condition to diagnose and manage and is often only detected in its more advanced stages. This is partly due to symptoms of gastrointestinal cancer being incorrectly attributed to physiological symptoms of pregnancy, as well as concerns about the safety of diagnostic investigations in pregnancy, both of which may delay diagnosis and lead to disease progression. Challenges in management also arise from under-treatment in pregnancy due to concerns about the impact of surgery or chemotherapy on the pregnancy. We present here three cases of gastrointestinal cancer diagnosed in pregnancy in our centre and discuss the challenges and pitfalls one may encounter in the diagnosis and management of gastrointestinal malignancies in pregnancy.

Glycemic Variability in Early Pregnancy May Predict a Subsequent Diagnosis of Gestational Diabetes.

Purpose: This study examined the prospective association between CGM-derived glycemic variability (GV) and glycemic control (GC) parameters in the first and second trimester, with subsequent diagnosis of GDM in the early third trimester. Methods: In a longitudinal observational study, 60 study participants in the first trimester (9-13 weeks' gestation), and 53 participants (18-23 weeks' gestation) in the second trimester of pregnancy had CGM data extracted after a minimum of 8 days' wear time (up to 14 days). At 24-31 weeks' gestation, participants underwent a 75 g, 2-hour oral glucose-tolerance test as per IADPSG criteria to diagnose GDM. GV parameters examined in both first and second trimesters were mean amplitude of glycemic excursion (MAGE), standard deviation (SD), mean glucose, and coefficient of variation (CV). GC parameters measured were J-Index and percentage of time spent in glucose target ranges. Results: The first trimester SD and MAGE were significantly higher in participants subsequently diagnosed with GDM (SD adjusted median 1.31 [interquartile range 1.2-1.3] mmol/L; MAGE 3.26 [3.2-3.3] mmol/L) than those who were not (SD 1.01 [0.9-1.0] mmol/L, MAGE 2.59 [2.4-2.6] mmol/L; p<0.05). Similarly, second trimester SD and MAGE were also significantly higher in participants subsequently diagnosed with GDM (SD 1.35 [1.3-1.4] mmol/L; MAGE 3.32 (3.31-3.41) mmol/L) than those who were not (SD 0.99 [0.98-1.01] mmol/L, MAGE 2.42 [2.42-2.55] mmol/L; p<0.05). Associations between SD and MAGE with GDM outcomes were adjusted for prepregnancy BMI and ethnicity. There were nonsignificant trends of higher J-Index scores in the first and second trimester, higher CV in the first trimester only, and higher mean in the second trimester only in participants diagnosed with GDM. Other study parameters measured were not significantly different between groups (p>0.003). Conclusion: Our study suggests the potential value of CGM-derived SD and MAGE in early pregnancy as potential predictors of subsequent GDM diagnosis.

Asia-Pacific consensus on physical activity and exercise in pregnancy and the postpartum period.

Physical activity and exercise in pregnancy are generally beneficial and enhance the physical and mental health of women. These benefits also prevent excessive weight gain and reduce risks of obesity in pregnancy, such as gestational diabetes, hypertensive disorders, higher rates of caesarean delivery, macrosomia and stillbirth. Thus, there is a need to optimise perinatal exercise and physical activity globally. There is currently no consensus recommendation on the role of physical activity and exercise in pregnancy and the postpartum period in the Asia-Pacific region. In this paper, we present seven key consensus recommendations on physical activity and exercise in pregnancy and the postpartum period by 18 key members representing 10 countries in Asia-Pacific regions during an international workshop of the Asia Diabetes in Pregnancy Conference in Singapore on 11-12 January 2020. Through these consensus recommendations, we hope to improve the metabolic health of pregnant women living in Asia-Pacific regions by educating the public and guiding healthcare professionals on the safety and importance of physical exercise and activity to benefit pregnant women and after childbirth.

Pregnancy Outcomes in COVID-19: A Prospective Cohort Study in Singapore.

INTRODUCTION: Pregnant women are reported to be at increased risk of severe coronavirus disease 2019 (COVID-19) due to underlying immunosuppression during pregnancy. However, the clinical course of COVID-19 in pregnancy and risk of vertical and horizontal transmission remain relatively unknown. We aim to describe and evaluate outcomes in pregnant women with COVID-19 in Singapore. METHODS: Prospective observational study of 16 pregnant patients admitted for COVID-19 to 4 tertiary hospitals in Singapore. Outcomes included severe disease, pregnancy loss, and vertical and horizontal transmission. RESULTS: Of the 16 patients, 37.5%, 43.8% and 18.7% were infected in the first, second and third trimesters, respectively. Two gravidas aged ≥35 years (12.5%) developed severe pneumonia; one patient (body mass index 32.9kg/m2) required transfer to intensive care. The median duration of acute infection was 19 days; one patient remained reverse transcription polymerase chain reaction (RT-PCR) positive >11 weeks from diagnosis. There were no maternal mortalities. Five pregnancies produced term live-births while 2 spontaneous miscarriages occurred at 11 and 23 weeks. RT-PCR of breast milk and maternal and neonatal samples taken at birth were negative; placenta and cord histology showed non-specific inflammation; and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific immunoglobulins were elevated in paired maternal and umbilical cord blood (n=5). CONCLUSION: The majority of COVID-19 infected pregnant women had mild disease and only 2 women with risk factors (obesity, older age) had severe infection; this represents a slightly higher incidence than observed in age-matched non-pregnant women. Among the women who delivered, there was no definitive evidence of mother-to-child transmission via breast milk or placenta.

Spontaneous preterm birth and cervical length in a pregnant Asian population.

OBJECTIVE: Preterm birth (birth before 37 weeks of completed gestation) is the leading cause of neonatal death, and has an incidence of 5-13% which is believed to be on the rise. The objective of this study was to determine the rate of spontaneous preterm birth and investigate the relationship between preterm birth and cervical length in a pregnant Asian population. MATERIALS AND METHODS: A prospective observational study between September 2010 and November 2013 was performed at KK Women's and Children's Hospital, Singapore. 1013 women with single viable pregnancies were recruited at less than 14 weeks of gestation between September 2010 and November 2013, excluding those with multiple gestation, pre-existing autoimmune or renal disease or those with current pregnancies complicated by aneuploidy or fetal anomalies. Participant characteristics were obtained from an interviewer-administered questionnaire at the first recruitment visit. Cervical length was measured using ultrasound at each of the 4 antenatal visits (Visit 1: < 14 weeks, Visit 2: 18-22 weeks, Visit 3: 28-32 weeks and Visit 4: > 34 weeks) using the Fetal Medicine Foundation protocol. Data on pregnancy outcomes were obtained from obstetric case notes and records. The main outcome measure examined in this study was that of spontaneous preterm birth and its relationship to cervical length. RESULTS: There was a significantly shorter cervical length both in the 2nd trimester (18 to 22 weeks) and the 3rd trimester (28 to 32 weeks) in the preterm birth group compared to the term birth group (p = 0.028 and p < 0.001 respectively). In the first trimester (11 to 14 weeks), there was no statistically significant difference in cervical length between the two groups (p = 0.425). ROC curve analysis for cervical length in the preterm birth group for 18 to 22 weeks and 28 to 32 weeks showed an AUC of 0.605 and 0.725 respectively. At 28 to 32 weeks of gestation, a cut-off level at 2.49 cm has a sensitivity of 54.8%, specificity of 82.5%, negative predictive value of 97.9% and positive predictive value of 11.1%. CONCLUSION: There is a significantly shorter cervical length in the 2nd and 3rd trimester in the preterm birth group. Cervical length is a moderate predictor of preterm birth with good negative predictive value and a relatively good specificity. Ultrasound cervical length screening for pregnant Asian women between 18 and 22 weeks of gestation with a cutoff of ≥ 2.48cm can help to identify a group of women who are at risk for preterm birth.

A rare case of spontaneous rupture of uterine surface vessels in pregnancy mimicking acute appendicitis.

Spontaneous hemoperitoneum in pregnancy (SHiP), an unprovoked, non-traumatic intraperitoneal bleed in pregnancy and up to 42 days postpartum, is a rare but potentially life-threatening clinical condition. Here, we report a rare case of spontaneous rupture of uterine surface variceal vessels in the second trimester of pregnancy mimicking acute appendicitis that posed diagnostic difficulties and challenges in management.

Fetoscopic laser photocoagulation in twin-to-twin transfusion syndrome: experience from a single institution.

INTRODUCTION: Twin-to-twin transfusion syndrome (TTTS) is the most common serious complication of monochorionic (MC) twin pregnancies, with perinatal mortality rates of up to 90% if untreated. This study aimed to review the perinatal and perioperative outcomes of MC twin pregnancies treated for TTTS by fetoscopic laser photocoagulation (FLP) since its introduction at KK Women's and Children's Hospital (KKH), Singapore, in 2011. METHODS: This was a retrospective review of five consecutive patients who underwent FLP of placental anastomoses for TTTS at KKH from June 2011 to March 2014. FLP was offered to patients who were diagnosed with TTTS of at least Quintero Stage II before 26 weeks of gestation. The main outcome measures were perioperative complications and perinatal survival rates. RESULTS: Five sets of MC twin pregnancies underwent FLP during the study period - three pregnancies were diagnosed with Stage III TTTS and two pregnancies with Stage II TTTS. Median gestational ages at initial presentation, laser photocoagulation and delivery were 19 (range 17-20) weeks, 20 (range 19-23) weeks and 29 (range 28-34) weeks, respectively. One patient had bleeding into the amniotic cavity intraprocedurally. Overall, the perinatal survival rate, double-infant survival rate and survival rate for at least one twin were 60% (6/10 fetuses), 40% (2/5 twins) and 80% (4/5 twins), respectively. CONCLUSION: FLP is a feasible treatment for TTTS, with minimal maternal complications. Perinatal survival rates of this patient group that was managed at our centre were comparable to those of international centres.

Are pregnant women adequately equipped for autonomy in pregnancy screening?

INTRODUCTION: Aneuploidy screening is widely practised in the field of obstetrics in current times. This study thus aims to gain an insight on pregnant women's knowledge and risk perception of Down syndrome and first trimester screening (FTS), as well as their views on various potential pregnancy outcomes and how these may affect their decision-making processes. MATERIALS AND METHODS: A cross-sectional questionnaire-based qualitative study of consecutive 50 women choosing to undergo FTS at KK Women's and Children's Hospital (KKH), Singapore was conducted. The women completed a questionnaire after their FTS pretest counselling session. Basic knowledge of Down syndrome and FTS as well as participants' risk perception with regards to various cut-off values used in FTS were examined. Patients' views of various potential pregnancy outcomes were also studied. RESULTS: Most patients had good retention and comprehension of what FTS entailed after a FTS counselling session at the KKH Antenatal Monitoring Clinic. However, knowledge of the risks of invasive diagnostic testing was poor. Patients also did not possess an adequate understanding of FTS risk values. With regards to risk perception, patients had very different views on acceptable pregnancy outcomes and what constituted a high-risk FTS value to them personally. A significant number of women were concerned even at medically low-risk values of 1:500 and 1:1000 in FTS. The majority of patients viewed highest detection rate followed by a lowest false positive rate as the more important factors impacting their choice of a Down syndrome screening test. CONCLUSION: This study demonstrates the diversity of pregnant women's risk perception, risk aversion and participation in decision processes when there are 2 different values in competition. The study also highlights our patients' gaps in knowledge and lack of understanding of risk values used in FTS.