Eng Loy Tan

Alterations in physiology and anatomy during pregnancy

Pregnant women undergo profound anatomical and physiological changes so that they can cope with the increased physical and metabolic demands of their pregnancies. The cardiovascular, respiratory, haematological, renal, gastrointestinal and endocrine systems all undergo important physiological alterations and adaptations needed to allow development of the fetus and to allow the mother and fetus to survive the demands of childbirth. Such alterations in anatomy and physiology may cause difficulties in interpreting signs, symptoms, and biochemical investigations, making the clinical assessment of a pregnant woman inevitably confusing but challenging. Understanding these changes is important for every practicing obstetrician, as the pathological deviations from the normal physiological alterations may not be clear-cut until an adverse outcome has resulted. Only with a sound knowledge of the physiology and anatomy changes can the care of an obstetric parturient be safely optimized for a better maternal and fetal outcome.

Rational dissection of a high institutional cesarean section rate: An analysis using the Robson Ten Group Classification System

Cesarean section (CS) rates have risen far in excess of the optimal 15% recommended by the World Health Organization. The Robson Ten Group Classification System (TGCS) allows meaningful analysis of a CS rate. The aim of this study is to identify the leading patient categories contributing to our institutions CS rate.

Repeated failed non-invasive prenatal testing in a woman with immune thrombocytopenia and antiphospholipid syndrome: lessons learnt.

We present a case of a 37-year-old Chinese woman (gravida 4 para 0) with a history of immune thrombocytopenia and type IIb antiphospholipid syndrome. She was started on 100 mg of aspirin, 20 mg of prednisolone and 20 mg of subcutaneous low-molecular-weight heparin daily for her fourth pregnancy. She opted for non-invasive prenatal testing for aneuploidy screening but had failed results three times consecutively from insufficient fetal cfDNA initially or high variance in cfDNA counts on redraws. She declined invasive karyotyping. Her pregnancy was complicated by severe pre-eclampsia and fetal growth restriction at 19+6 weeks of gestation and was terminated. Subsequent fetal karyotyping revealed a normal karyotype of 46XY with no apparent abnormalities.

Decision-to-delivery intervals and total duration of surgery for Caesarean sections in a tertiary general hospital.

INTRODUCTION This study aimed to determine the decision-to-delivery intervals (DDIs), total duration of surgery and factors influencing these for Caesarean sections (CSs). METHODS A retrospective study was conducted of all CSs performed from August 2013 to June 2014 at a single tertiary general hospital. Data collected included maternal demographics, indications for CS, category of urgency, DDI, total duration of surgery, grade of first surgeon and number of previous CSs. RESULTS In total, 488 CSs (Category 1: n = 28; Category 2: n = 137; Category 3: n = 184; Category 4: n = 139) were studied. Overall mean duration of surgery was 41.7 minutes. Mean DDI was 23.9 minutes and 64.5 minutes for Category 1 and Category 2 CSs, respectively. For Category 1 CSs, deliveries during office hours had a significantly shorter DDI than deliveries out of office hours (p < 0.05). For Category 2 CSs, deliveries during office hours had a significantly longer DDI (p < 0.05). Total duration of surgery for senior surgeons was significantly shorter than for trainee surgeons (p < 0.05). Women with no previous CSs had a significantly shorter duration of surgery than those who had one or more (p < 0.05). CONCLUSION The majority of the deliveries were within the recommended DDI corresponding to the degree of urgency of CS. The influence of time of day on DDI might be due to challenges of time taken to transfer patients to operating theatres. Total duration of surgery was influenced by surgical experience, history of previous CS and individual surgical styles and preferences.

A review of caesarean section techniques and postoperative thromboprophylaxis at a tertiary hospital.

INTRODUCTION Although Caesarean sections (CSs) are among the most commonly undertaken procedures in the world, there are wide variations in the surgical techniques used. This study aimed to: (a) review the surgical techniques used for CS by obstetricians working in a tertiary hospital in Singapore; (b) compare the techniques with those recommended in evidence-based guidelines; and (c) examine the relationship between the technique used and the level of seniority of the surgeons. METHODS Data on 490 CSs performed in Singapore General Hospital (SGH) between 1 August 2013 and 30 June 2014 was collected from the Delivery Suite database and reviewed. The surgical techniques studied were closure of the pelvic and parietal peritoneum, closure of the uterine layer, use of surgical drains and use of postoperative thromboprophylaxis. RESULTS A total of 486 CSs were analysed after four cases were excluded due to missing data. Most fetal head deliveries were manual. The majority of surgeons did not close the peritoneum; most of those who did were senior surgeons. Double-layer uterine closures were done for all cases and drain usage was rare. 2.0% of the patients received grossly inadequate thromboprophylaxis. CONCLUSION The surgical techniques currently practised in SGH are closely aligned with those of the evidence-based guidelines. Peritoneal closure appears to be associated with the surgeons early training, with a greater number of senior surgeons being less willing to abandon this step. Greater vigilance in implementing appropriate thromboprophylaxis is recommended.

Multiple pregnancy is the leading contributor to cesarean sections in in vitro fertilization pregnancies: An analysis using the Robson 10‐group classification system

In vitro fertilization (IVF) pregnancy is an important contributor to rising cesarean section (CS) rates. The profile of CS in this group is not well documented. This study sought to identify leading patient categories of the Robson 10‐Group Classification System (TGCS) contributing to the high IVF CS rate.

357. Pregnancy in Cardiac disease – An audit on outcomes in the Joint Cardiac Pregnancy Clinic, Singapore General Hospital.

Introduction Cardiac disease is an increasingly important cause of maternal morbidity and mortality. Joint multidisciplinary care of these pregnancies is strongly advocated. Aim Pregnancy outcomes in cardiac patients seen at the cardiac joint clinic. Method and results All pregnant mothers with acquired or congenital heart diseases are referred to CJC, which is jointly run by consultant obstetricians and cardiologists., with easy access to anaesthesia and neonatal referrals. Delivery was in a tertiary level teaching hospital. 60 new cases were seen from 2009 to 2013. Median maternal age was 29 (19–40). Most had WHO class 1 disease (66.6%) with NYHA status 1 (90%). 10% of the population had WHO class 4 disease but none had a NYHA score worse than 2. Two thirds had congenital heart disease, which 55% were valvular. Acquired heart conditions made up the remaining third of which only 15 % were valvular. The most common cardiac diagnoses include MVP (21.7%), AS/VSD (16.7%) and cardiomyopathy (16.7%). Caesarian sections rate was 59.3% (40% emergency sections) with a median hospital stay of 3 days. Vaginal delivery rates were 40.7% with 16% being assisted. There were no neonatal or maternal mortalities. Patients who developed cardiomyopathy postpartum or have a history of previous or existing cardiomyopathy had longer hospitalisation stays. Median gestational age was 38 + 2 days (32–41 weeks) and median birth weight was 3072.5 g. Median APGAR scores were 8, 9 at 1 and 5 min respectively. Median length of stay for the baby was 4 days with average length of stay being 5.58 days. Conclusion Congenital heart disease remains an important contributing aetiology to cardiac disease in pregnancy. The majority of our patients achieved good maternal and neonatal outcomes, underpinning the importance of providing a seamless joint service providing multi-disciplinary pre-pregnancy, antepartum, intrapartum and postpartum care.