L. Tan

The management of postpartum hypertension

Hypertensive disorders of pregnancy are responsible for significant maternal and perinatal morbidity and mortality. Medical literature covering this area is mainly focussed on antenatal and intrapartum management. Hypertension in the postpartum period is a common phenomenon and is often a cause for concern. However, it is difficult to know to what extent this concern is justified and there are few guidelines available concerning management. Hypertension in the puerperium is usually seen in the following situations: 1. Persistence of hypertension in women with antenatal gestational hypertension or pre-eclampsia. 2. Women who had hypertension before pregnancy and continue to be hypertensive after delivery. Some of these women may have developed superimposed pre-eclampsia. 3. Hypertension arising de novo in the postpartum period in women who did not have hypertension in the antepartum period. This could be a non-specific phenomenon in women with no underlying disease. However, it could also be lateonset pre-eclampsia or the unmasking of underlying essential hypertension or secondary hypertension (e.g. renal disease, phaeochromocytoma). Essential hypertension can be missed during pregnancy if the first blood pressures are not taken until the end of the first trimester, when a spontaneous fall in blood pressure may have occurred. Secondary causes of hypertension are less likely to be missed (i.e. the blood pressure is likely to fall in early pregnancy except possibly in cases of primary hyperaldosteronism, where the excess progesterone antagonises the mineralocorticoid effects of aldosterone). The underlying pathophysiology is therefore heterogeneous ranging from the benign to the potentially lifethreatening, although clinical experience suggests that benign causes are far more common.

Massive postpartum haemorrhage after uterus-conserving surgery in placenta percreta: the danger of the partial placenta percreta.

Placenta percreta is a rare but potentially life‐threatening condition associated with high maternal mortality and morbidity rates, usually arising from severe obstetric haemorrhage. Due to rising caesarean section rates, an increase in the incidence of morbidly adherent placentas (accreta, increta and percreta) has been observed. Various treatment strategies have been employed in different centres, ranging from performing a caesarean hysterectomy at the time of delivery to leaving the placenta in situ, with or without adjuvant internal iliac and uterine arterial embolisation and/or methotrexate therapy. In the case of placenta percreta, irrespective of the treatment method employed, women are still at high risk of life‐threatening haemorrhage and morbidity secondary to placental invasion beyond the confines of the uterine serosa into surrounding organs, most commonly the bladder. We describe an unusual case of a partially adherent placenta percreta in which partial separation of the normally implanted placenta led to torrential haemorrhage on the third postoperative day after the placenta was left in situ at the time of delivery. We therefore advise caution in following a conservative approach in the treatment of cases of placenta percreta in which the percreta feature is only partial and will discuss the merits and disadvantages of alternative options.

Spontaneous uterine perforation from uterine infarction: a rare case of acute abdomen

Summary: A case of spontaneous uterine perforation from uterine infarction is presented. The authors believe that this is the first reported case.

Two dosing regimens for preinduction cervical priming with intravaginal dinoprostone pessary: a randomised clinical trial

Objective To compare the efficacy within 24 hours of a three‐times‐a‐day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming.

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.

Starting a uterus transplantation service: notes from a small island

from a small island H-K Tan, B-K Tan, L-K Tan, JI Olofsson, P Dahm-K€ ahler, M Br€ annstr€ om a Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore, Singapore b Department of Plastic, Reconstructive & Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore c Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden d Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden e Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, G€ oteborg, Sweden Correspondence: L-K Tan, Department of Obstetrics and Gynaecology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore. Emails aetlk@yahoo.com; tan.lay.kok@singhealth.com.sg

EP15.20: Ultrasound evaluation of complex endometrial disorders: case report: Electronic Poster Abstracts

Results: We analysed 160 patients with suspicion of endometrial polyp. We diagnosed 107 polyps in our study group. We also analysed the diagnostic parameters for ultrasonography in diagnosing endometrial polyps: sensitivity, specificity, negative predictive value, positive predictive value and accuracy were as follows: 48.6, 80.2, 65.6, 66.7, 66, p-value was<0.001. Conclusions: Transvaginal probes give very good images which have good specificity in diagnosing endometrial polyps.

EP10.21: Fetal aortic and pulmonary artery diameters in normal pregnancy: Electronic Poster Abstracts

Introduction Abnormal diameters of the great vessels are known to be markers of congenital heart diseases, e.g. tetralogy of Fallot, truncus arteriosus and coarctation of aorta. In order to improve prenatal detection of these forms of congenital heart defects, we include the great vessels diameter in the routine fetal ultrasound examination. Objective To construct centile nomograms for aortic and pulmonary artery diameters in the second and third trimesters. Method The patients recruited all fulfilled the following criteria : (1) known last menstrual period with regular cycles, (2) no fetal anomalies, (3) no pregnancy complications, (4) live birth at term, (5) birth weight above the 5th and below the 95th centile for gestation. Pulmonary and aortic diameters were measured by transabdominal ultrasound on long-axis views of the great vessels. Measurements of the great vessels were taken at the level just above the aortic and pulmonary valves during ventricular systole. The relationship between the mean of each measurement and gestational age was modelled by a fractional polynomial regression. Results 150 cases were recruited. Diameters range from 2.1mm (aortic) and 2.5mm (pulmonary artery) at 18 weeks of gestation to 6.5mm ( aortic) and 9.7mm ( pulmonary artery ) at 39 weeks of gestation. Conclusion We conclude that the diameter of the great vessels grows linearly with gestational age in normal fetuses. The procedure for selecting the best fitting model was based on minimising the deviance as in the appendix of Royston and Wright (1998). Similarly a standard deviation (SD) curve for each measurement was estimated by regressing the ‘scale absolute residuals’ on gestational age, again using fractional polynomial. The 5th and 95th percentile of the measurement at each gestational age is given by means ± 1.645 SD. All analyses and graphics were made using software STATA version 13. 0 1 2 3 4 5 6 7 8

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.

Authors’ reply re: Starting a Uterus transplantation service: Notes from a small island

tive of the International Society of Uterus Transplantation (ISUTx), and international controls of UTx should be established to prevent rapid clinical application in countries that are not fully prepared. Research into UTx should be performed to confirm efficacy and safety in an appropriate manner, in order that UTx can be established as a novel technology to enable patients with UFI to have a child. The commentary by Tan et al. described the current situation in Singapore, a nation that is carefully preparing for the clinical application of UTx. We strongly agree with their opinion that ‘Setting up a UTx programme requires careful planning, integration, and coordination of multiple clinical specialties, and institutional support and continuous international collaboration and proctorship from expert teams that have an established track record of successful UTx’, and we believe that this approach provides a good lesson for teams aiming for the clinical application of UTx, including our team in Japan. International collaboration similar to that between Japan and Singapore is required among many countries to ensure the future development of this new technology.&