Nirmala Kampan

Evaluation of BV(®) Blue Test Kit for the diagnosis of bacterial vaginosis.

The aim of this study is to determine the sensitivity, specificity and the predictive value of the BV(®) Blue Test Kit in the diagnosis of bacterial vaginosis and to observe the risk factors associated with bacterial vaginosis (BV) in the study population. A prospective, cross-sectional study on 151 non-pregnant women who presented or referred to HUKM with presence of vaginal discharge, abnormal vaginal odour, pruritus vulvae of lower genital tract or incidental finding of abnormal PV discharge on pelvic examination. Samples of vaginal discharge were tested for bacterial vaginosis infection using Amsels criteria, BV(®) Blue test and Gram stain (Nugents score). Gram stain interpretation was made blinded without knowledge of other test result. Using Gram stains criteria as a gold standard, the sensitivity, specificity, positive and negative predictive value of BV(®) Blue test and each of Amsels criteria were estimated. The use of vaginal douches increased the risk of BV. The risk of BV with vaginal douching was 2.8 (95% CI 1.0-7.8) compared to never users. BV(®) Blue test showed a sensitivity of 100.0%, specificity of 98.3%, positive predictive value (PPV) of 94.4% and negative predictive value (NPV) of 100.0% compared to Gram stain (Nugents method). BV(®) Blue test had excellent agreement with Gram stain which was 98.7%. BV(®) Blue test is a simple, rapid and reliable test allowing immediate diagnosis and prompt treatment of BV in the absence of microscopy which would greatly benefit majority of women at the greatest risk of sequel of bacterial vaginosis.

Spontaneous rupture of uterine varicose veins: A rare cause for obstetric shock

Spontaneous rupture of uterine surface varicose veins is rare but may result in serious complication of pregnancy, as it is associated with high perinatal and maternal mortality. We report a 24‐year‐old primigravida who presented with this rare condition mimicking placenta abruption, which was successfully managed. A review of reported cases was performed.

Factors Associated with Placenta Praevia in Primigravidas and Its Pregnancy Outcome

Aim. To examine the factors associated with placenta praevia in primigravidas and also compare the pregnancy outcomes between primigravidas and nonprimigravidas. Method. A retrospective cohort study was conducted in women who underwent caesarean section for major placenta praevia in a tertiary university hospital from January 2007 till December 2013. Medical records were reviewed. Result. Among 243 with major placenta praevia, 56 (23.0%) were primigravidas and 187 (77.0%) were nonprimigravidas. Factors associated with placenta praevia in the primigravidas were history of assisted conception (P = 0.02) and history of endometriosis (P = 0.01). For maternal outcomes, the nonprimigravidas required earlier delivery than primigravidas (35.76 ± 2.54 weeks versus 36.52 ± 1.95 weeks, P = 0.03) and had greater blood loss (P = 0.04). A vast majority of the primigravidas had either posterior type II or type III placenta praevia. As for neonatal outcomes, the Apgar score at 1 minute was significantly lower for the nonprimigravidas (7.89 ± 1.72 versus 8.39 ± 1.288.39 ± 1.28, P = 0.02). Conclusion. This study highlighted that endometriosis and assisted conception were highly associated with placenta praevia in primigravida. Understanding the pregnancy outcomes of women with placenta praevia can assist clinicians in identifying patients who are at higher risk of mortality and morbidity. Identifying potential risk factors in primigravida may assist in counseling and management of such patients.

Growing Teratoma Syndrome: A Rare Case Report and Review of the Literature

Growing teratoma syndrome is rare and usually it occurs in the younger aged group. The use of chemotherapy following initial surgical resection will yield the diagnosis following tumour enlargement. Complete resection is usually curative and renders better prognosis.

Cesarean scar pregnancy: What can we offer?

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy where implantation of the gestational sac occurs at the previous scar with the surrounding myometrium [1]. The incidence reported by Seow et al [2] was extremely low (approximately 1 in 2000), which is consistent with the prevalence of 1:1800 reported by Jurkovic et al [3]. The precise mechanism is still not clear and poorly understood. Implantation of the conceptus into the myometrium through a microscopic tract or scar defect had been suggested [4]. Catastrophic and life-threatening complications such as uterine rupture and massive hemorrhage could occur in case of misdiagnosis. Therefore, prompt and early diagnosis is essential to facilitate early intervention. This is a case of CSP successfully treated with local injection of methotrexate (MTX) and hypertonic dextrose solution. Subsequent vaginal bleeding after the termination of CSP was effectively controlled by tranexamic acid followed by gonadotropin releasing hormone analog (GnRHa). This approach resulted in avoidance of surgical intervention. A 30-year-old gravida 3 para 2 woman in the 9th week of amenorrhea who had two previous cesarean sections (CSs), was referred for an incidental finding of CSP during her first antenatal visit. She was asymptomatic, and the result of her physical examination was unremarkable. An ultrasound scan noted a gestational sac embedded at the previous CS scar. The pregnancy was considered viable with a crown rump length of 25.8 mm. The uterine cavity was empty with no free fluid seen in the pouch of Douglas (Figs. 1e3). Her serum beta human chorionic globulin

Antenatal scoring system in predicting the success of planned vaginal birth following one previous caesarean section

Abstract This was a prospective observational study to determine the predictive factors for a successful vaginal birth after caesarean section (VBAC) and to develop a relevant antenatal scoring system. Patients with one previous caesarean section were included in this study. All data including maternal demographics, obstetric history, pregnancy progress and outcomes were collected and analysed. A total of 142 out of the 186 women (76.3%) had successful VBAC. History of previous vaginal delivery and non-recurrent indications for previous caesarean section were the significant predictive factors for a successful VBAC. Five variables for our scoring tool were selected. By using a proposed mean score of 4 out of 7, the scoring system had a sensitivity of 81.0%, specificity of 52.3% and a positive predictive value of 84.6%. VBAC antenatal scoring system was potentially a useful predictive tool in antenatal counselling. Impact statement What is already known on this subject: Planned vaginal birth after caesarean section (VBAC) is an important strategy to limit the overall caesarean section rate, which is related to maternal morbidities. However, trial of vaginal delivery does involve potential complications including scar dehiscence, postpartum haemorrhage and emergency hysterectomy. What the results of this study add: Clinical predictors of a successful VBAC include non-recurrent indications for the previous caesarean section, previous vaginal delivery, spontaneous onset of labour and birthweight less than 4kg. There were multiple screening tools developed to predict the likelihood of successful VBAC. These scoring systems involved various variables such as age, ethnicity, Bishop’s score and previous caesarean indication. We had prospectively developed an antenatal scoring system based on five variables. Our result showed that patient with a score of four and above will have around 85% chance of successful VBAC. What the implications are of these findings for clinical practice and/or further research: We have also found that, estimated foetal weight based on ultrasound scan is a potential predictor for successful VBAC. This simple scoring method will be useful in-patient counselling regarding mode of delivery after one previous caesarean section. A multicentre study involving large cohort of patients is ideal to validate our scoring system.

Screening for gestational diabetes in low-risk women: Effect of maternal age

Abstract Background Gestational diabetes mellitus (GDM) is on the rise globally and there are various screening guidelines with regard to patients’ criteria. Materials and methods We conducted a prospective cross-sectional study to determine the prevalence of GDM amongst low-risk pregnant women above the age of 25 years. A modified glucose tolerance test (MGTT) was performed between 24 and 36 weeks of gestation. Women with GDM were divided into two groups for analysis: age between 25 and 34 years (group A) and above 35 years (group B). They were managed as per hospital protocol and followed-up until delivery. The women’s demographic data, treatment and subsequent pregnancy outcomes were analysed. Results The overall prevalence of GDM in our low-risk women was 14%. GDM was less common in the younger age group (25–34 years) in comparison to those aged above 35 years (9.7% vs. 26.3%, p = 0.001). There was a non-significant increase in the induction of labour (IOL) rate amongst those aged below 35 years compared to the older group (46.7 % vs. 38.5%). The insulin requirement in the age group 25–34 years and above 35 years, were 6.7% and 23.1%, respectively. There was no significant difference between both age groups with regard to caesarean delivery, birth weight above the 95th centile and neonatal hypoglycaemia. Conclusion In low-risk women, the prevalence of GDM is significantly lower in those aged less than 35 years. Diagnosing GDM had resulted in the increment of IOL in this group, although with no significant increase in maternal and neonatal morbidity.

Uterine Atony: Management Strategies

It is estimated about 529,000 mothers die every year (World Health Organisation [WHO] 2005). Postpartum haemorrhage (PPH), a life-threatening condition, remains the major cause of maternal mortality worldwide (Pahlavan et al., 2001). Majority of these mortalities are from Asia (48%) and Africa (47.5%) with only the minority (less than 1%) from developed countries.(Ramanathan & Arulkumaran, 2006) In Malaysia, the Confidential Enquiry into Maternal Deaths (CEMD) from 1991 to 2005 revealed that PPH attributed 13-27% of all reported deaths(Division of Family Health Development, Ministry of Health, 1994; Division of Family Health Development, Ministry of Health, 1996; Division of Family Health Development, Ministry of Health, 2000; Division of Family Health Development, Ministry of Health, 2005).

A case report: Metastatic choriocarcinoma to the gum

Choriocarcinoma is a rare neoplasia with a tendency of distant metastasis although highly sensitive to chemotherapy renders a good prognosis and outcome. Lungs, liver and cerebral metastasis are commonly implicated with maxillofacial region rarely involved. We illustrate a case of overwhelming metastatic choriocarcinoma to lungs, liver, brain and to the extreme of gum metastasis. Decompressive craniectomy for intracranial bleeding, multiple transfusions to correct anaemia and coagulopathy were done before high-risk-regime chemotherapy. Despite this, due to fulminant multi-organs involvement she finally succumbed to death. In conclusion, gum bleeding in choriocarcinoma may suggest metastasis and poor prognosis.