George Gregory Buttigieg

Predictors of post-caesarean section pain and analgesic consumption

Background: Ideally, the intensity of postoperative pain should be predicted so as to customize analgesia. The objective of this study was to investigate whether preoperative electrical and pressure pain assessment can predict post-caesarean section pain and analgesic requirement. Materials and Methods: A total of 65 subjects scheduled for elective caesarean section, who gave written informed consent, were studied. Preoperatively, PainMatcher® was used to evaluate electrical pain threshold, while manual PainTest™ FPN 100 Algometer and digital PainTest™ FPX 25 Algometer determined pressure pain threshold and tolerance. Postoperatively, numerical rating scales were used to assess pain at regular time intervals. Patients received intramuscular pethidine (100mg, 6 hourly), rectal diclofenac (100mg, 12 hourly), and oral paracetamol (1g, p.r.n.) for pain relief. Statistical analysis was conducted using PASW Statistics 18 software. Results: Preoperative electrical pain threshold correlated significantly with post-caesarean pain scores at 6 and 24 hours (r = –0.26, P < 0.02; r = –0.23, P < 0.04, respectively), and with the quantity of paracetamol consumed by the patient within 48 hours of surgery (r = –0.33, P < 0.005). Preoperative pressure pain tolerance measured by PainTest™ FPX 25 Algometer was significantly correlated with pain scores 6 hours postsurgery (r = –0.21, P < 0.05). Pain scores 6 hours post-caesarean section correlated significantly with anesthesia—general or spinal (F = 4.22, v1 = 1, v2 = 63, P < 0.05). Conclusions: The predictive methods proposed may aid in identifying patients at greater risk for postoperative pain. Electrical pain threshold could be useful in personalizing the postoperative analgesic protocol.

Pre-operative pain sensitivity: A prediction of post-operative outcome in the obstetric population.

CONTEXT Experimental assessments can determine pain threshold and tolerance, which mirror sensitivity to pain. This, in turn, influences the post-operative experience. AIMS The study intended to evaluate whether the pre-operative pressure and electrical pain tests can predict pain and opioid requirement following cesarean delivery. SETTINGS AND DESIGN Research was conducted on females scheduled for cesarean section at a tertiary care hospital of the state. Twenty women were enrolled, after obtaining written informed consent. MATERIALS AND METHODS PAIN ASSESSMENT WAS PERFORMED ON THE EVE OF CESAREAN SECTIONS USING THREE DEVICES: PainMatcher(;) determined electrical pain threshold while the algometers PainTest(™) FPN100 (manual) and PainTest(™) FPX 25 (digital) evaluated pressure pain threshold and tolerance. Post-operative pain relief included intravenous morphine administered by patient-controlled analgesia, diclofenac (100 mg, every 12 h, rectally, enforced) and paracetamol (1000 mg, every 4-6 h, orally, on patient request). Pain scores were reported on numerical rating scales at specified time intervals. STATISTICAL ANALYSIS USED Correlational and regression statistics were computed using IBM SPSS Statistics 21 software (IBM Corporation, USA). RESULTS A SIGNIFICANT CORRELATION WAS OBSERVED BETWEEN MORPHINE REQUIREMENT AND: (1) electrical pain threshold (r = -0.45, P = 0.025), (2) pressure pain threshold (r = -0.41 P = 0.036) and (3) pressure pain tolerance (r = -0.44, P = 0.026) measured by the digital algometer. The parsimonious regression model for morphine requirement consisted of electrical pain threshold (r(2)= 0.20, P = 0.049). The dose of morphine consumed within 48 h of surgery decreases by 0.9 mg for every unit increment in electrical pain threshold. CONCLUSIONS The predictive power of pain sensitivity assessments, particularly electrical pain threshold, may portend post-cesarean outcomes, including opioid requirements.

Obstetric outcomes in immigrants of African nationality

African women delivering in the Maltese Islands are either regular or irregular migrants. The latter group presents significant socio-economic problems. Objective: This study sets out to compare the obstetric outcomes of African-nationals delivering in Malta to the general population. Study design: The obstetric data of three subgroups of women - those from the Maghreb region; the sub-Saharan and Horn of Africa; and the overall population registered for the Maltese Islands were obtained using the computerised National Obstetrics Information System. Results: Women from the sub-Saharan regions were statistically younger than those from the Maghreb region or the general population. African women from both regions were more likely to be multiparous; and were more likely to have experienced a previous perinatal loss. The multiple pregnancy rates were significantly higher in both African groups. Women from the sub-Saharan region were more likely to suffer from sexual and blood-borne infections. African women had lower obstetric intervention rates but higher operative deliveries. Infants born to African women were more likely to be premature and of low birth weight. Conclusion: Women originating from the African continent particularly from the sub-Saharan regions present socio- biological and cultural differences which can contribute towards adverse obstetric and perinatal outcomes.

The shifting sands of medico-legal intra-partum Ctg (I-P Ctg) monitoring.

Intra-partum (IP) surveillance of the unborn child by cardiotacography (CTG) monitoring is the commonest obstetric procedure in the developed world. 1 It is also the most medico-legally contested obstetric procedure in labour. In 2011, ‘birth asphyxia’ comprised 50% of the UK National Health Service (NHS) litigation costs, 2 and in the 2000–2010 decade, the same NHS paid out £3.1 billion for maternity medico-legal claims (the highest of any speciality), mostly involving cerebral palsy and CTG misinterpretation. 3 This article looks at a number of characteristics of IP CTG monitoring which argue for its questionable solidity of base in court proceedings.

Reproductive health in Malta

Objectives The Maltese population traditionally harbours Roman Catholic beliefs that have been gradually secularised. The present study sets out to quantify the consequences of more liberal sexual attitudes in this community. Methods We reviewed the reproductive and sexual health indicators reported from Malta and from other selected European countries. We then analysed the findings of a questionnaire study which was carried out among 200 Maltese and 2200 other European individuals to investigate various aspects of their sexual history. Results A greater proportion of Maltese births occur in teenagers but the out-of-wedlock maternity rate in Malta appears to be the third lowest in Europe. However, the rate appears to have nearly trebled over seven years. Sexually transmitted infections rates in Maltese are either similar to or lower than those reported from the other European countries. The Maltese reported a higher mean age at first intercourse and a lower mean number of sexual partners mainly in women aged over 35 years. They received an earlier sexual education but they still predominantly resorted to unreliable contraception methods at their first sexual encounter. Conclusions The study confirms that sexual behaviour has changed. The educational support to deal with these altered practices is in place but still needs to be reinforced.

Outcomes of hypertensive obstetric patients in the Maltese Islands

a Chinese population with the highest rate of MTHFR C677T mutation. The number of cases is rather low in the NTD group, as in the control group, and larger population studies are needed to confirm this association. These results suggest that the presence of MTHFR C677T in mothers with normal folate levels may be a risk factor for NTD development in our population and that consideration should perhaps be given to folate supplementation.

Cervical carcinoma in the Maltese population

Background: The incidence rates of cervical carcinoma are closely associated with the degree of promiscuous sexu- ality experienced by a population. Methods: The study reviews the registered incidence and mortality data of this malignancy in the Maltese population and relates the observed trends to the increasing sexual promiscuity and HPV infections experienced by the population. Results: The observed recent fall in malignancy rates have been offset by an apparent rise in premalignant conditions identi- fied by the cervical screening program in force on the Islands. Much of the observed rise in premalignant conditions appears to be related to the influence of HPV cervical infection. Conclusions: Strict vigilance to identify potentially malignant conditions and institute timely treatment remains the corner- stone for maintaining control of this disease. The introduction of protective vaccines against HPV should serve to reduce the size of the problem further.

Metabolic carcinogenesis in the Maltese population.

Endometrial adenocarcinoma has been associated with prolonged oestrogen exposure causing endometrial hyperplasia and adenocarcinoma. Metabolic disorders and nutritional factors may contribute towards obesity and the increased adipose production of oestrogen. The study confirms the association between endometrial carcinoma risk and diabetes mellitus and increased total fat intake. It further relates the malignancy to a prolonged natural oestrogen exposure period and confirms the protective role of past pregnancies.

Submitting medico-legal intra-partum CTG (I-P CTG) monitoring to the Bolam and Bolitho principles

The article analyses some of the seeming weaknesses of the Bolam and Bolitho tests as applied to electronic foetal monitoring in labour, in the form of intra-partum CTG monitoring. Homing on to such aspects as confirmation of foetal hypoxia/acidosis, it evaluates the Bolam and Bolitho tests in the context of evidence-based medicine versus traditionally held views, which still hold their own in medical jurisprudence. Case law examples are quoted to illustrate various points. The discussion is of practical relevance both to the individual obstetrician as well as to national budgetary implications, bearing in mind, that, for example, in 2011, ‘birth asphyxia’ comprised 50% of the UK NHS litigation costs, and in the 2000–2010 decade, the same NHS forked out £3.1 billion for maternity medico-legal claims (the highest of any speciality), mostly involving cerebral palsy and CTG misinterpretation. The article concludes with suggestions to help level the potential extant equivocity between legal principle and medical practice. It also looks at the ruling in Montgomery v Lanarkshire Health Board, UK Supreme Court, and its challenge to Bolam. The implications pose a serious and overdue challenge to a test, born in 1957 and lacking the necessary qualities to serve many 21st century medical quandaries, including the ones raised here.

Hb Valletta [β87(F3)Thr→Pro] and Hb Marseille/Long Island [β2(NA2)His→Pro; (–1)Met-(+1)Val-(+2)Pro-Leu], in a Unique Compound Heterozygote with a Normal Hemoglobin Phenotype

This study refers to the quantitative hemoglobin (Hb) phenotype of a 19-year-old female with Hb Valletta [β87(F3)Thr→Pro] in association with Hb Marseille/Long Island [β2(NA2)His→Pro; (–1)Met-(+1)Val-(+2)Pro-Leu] and a normal Hb electrophoretogram. The data serve to alert investigators to the possibility that relatives with apparently normal Hb phenotypes may be transmitting mutant alleles and suggest methods for identification.