Peng Chiong Tan

Dengue infection in pregnancy: prevalence, vertical transmission, and pregnancy outcome.

OBJECTIVE: To estimate prevalence rate of recent dengue infection in parturients, as well as the vertical transmission rate, and to compare pregnancy outcomes among infected women. METHOD: A prospective cohort study was performed. Maternal and paired umbilical cord bloods were taken at delivery. A brief questionnaire on febrile illness and dengue in pregnancy was completed by participants. The samples were sent to a World Health Organization Collaborating Center for Arbovirus Reference and Research. Maternal sera were tested with a dengue-specific immunoglobulin M (IgM) capture test. The paired umbilical cord serum was tested to determine when the maternal sample was positive. Dengue reverse transcriptase polymerase chain reaction (PCR) was performed on all dengue IgM–positive sera. Pregnancy outcome was extracted from delivery records. RESULTS: A total of 2,958 parturients were enrolled, and 2,531 paired maternal-umbilical cord blood samples were available for testing. Dengue-specific IgM was positive in 63 of 2,531 (2.5%, 95% confidence interval [CI] 1.9–3.2%) maternal samples. Only 1 of 64 (1.6%, 95% CI 0.0–9.5%) of the paired umbilical cord sera was IgM-positive. All reverse transcriptase PCR tests were negative. Fifty-six of 63 (88.9%) of dengue IgM–positive women did not report a febrile illness in pregnancy. Apart from a higher mean age in dengue IgM–positive women of 30.6±5.2 compared with 29.2±4.9 years (P=.025) compared with dengue IgM–negative women, all other characteristics were similar. Rates of preterm birth, mode of delivery, postpartum hemorrhage, low birth weight, and neonatal outcomes were not different. CONCLUSION: Recent dengue infection was demonstrated in 2.5% of parturients, with a vertical transmission rate of 1.6%. Pregnancy outcome of recently infected women was not different. LEVEL OF EVIDENCE: II

Anxiety and depression in hyperemesis gravidarum: prevalence, risk factors and correlation with clinical severity

OBJECTIVE To evaluate prevalence, risk factors and clinical severity correlates of anxiety and depression caseness in hyperemesis gravidarum (HG). STUDY DESIGN A prospective study of self-assessment using the Hospital Anxiety and Depression Scale (HADS) was performed. Women at their first hospitalization for HG were recruited as soon as possible after hospital admission. Cut-off at the score of 7/8 was used for both the anxiety and depression subscales of HADS to denote anxiety and depression caseness respectively. Risk factors for anxiety and depression caseness were identified using Chi-square test, Fishers exact test, Mann-Whitneys U-test or the Students t-test. Multivariable logistic regression analysis incorporating all co-variables with crude P<0.1 was performed to identify independent risk factors. Bivariate analyses were performed to identify associations between clinical markers of severity and anxiety and depression caseness. Prolonged hospitalization and a number of biochemical and hematological abnormalities were used as clinical markers of HG severity. RESULTS Criteria for anxiety and depression caseness were fulfilled in 98/209 (46.9%) and 100/209 (47.8%) women respectively. 78 (37.3%) participants fulfilled the criteria for both anxiety and depression caseness, 89 (42.6%) neither, 20 (9.6%) anxiety caseness only and 22 (10.5%) depression caseness only. Gestational age at commencement of vomiting, duration of vomiting leading up to hospitalization and paid employment status had crude P<0.1 in association with anxiety caseness. After adjustment, only paid employment was independently associated with anxiety caseness (AOR 2.9 95% CI 1.3-6.5; P=0.009). Previous miscarriage, gestational age at commencement of vomiting and duration of vomiting leading up to hospitalization all had P<0.1 in association with depression caseness. After adjustment, only previous miscarriage was negatively associated with depression caseness (AOR 0.4 95% CI 0.2-0.9; P=0.022). There was no marker of HG severity associated with anxiety caseness on bivariate analysis. High hematocrit was associated with depression caseness (OR 2.1 95% CI 1.1-3.9; P=0.027). CONCLUSION Anxiety and depression caseness is common in HG and risk factors can be identified. There is no convincing association between anxiety and depression and more severe illness. Psychological symptoms may be a response to physical illness but further studies are needed.

Promethazine Compared With Metoclopramide for Hyperemesis Gravidarum: A Randomized Controlled Trial

OBJECTIVE: To compare the effects of promethazine with those of metoclopramide for hyperemesis gravidarum. METHODS: Women at their first hospitalization for hyperemesis gravidarum were approached when intravenous antiemetic therapy was needed. They were randomly assigned to receive 25 mg promethazine or 10 mg metoclopramide every 8 hours for 24 hours in a double-blind study. Primary outcomes were vomiting episodes by diary and well-being visual numerical rating scale score (10-point scale) in the 24-hour main study period. Participants also filled out an adverse-effects questionnaire at 24 hours and a nausea visual numerical rating scale score at recruitment and at 8, 16, and 24 hours. RESULTS: A total of 73 and 76 women, randomized to metoclopramide and promethazine, respectively, were analyzed. Median vomiting episodes were one (range 0–26) compared with two (range 0–26) (P=.81), and well-being visual numerical rating scale scores were 8 (range 1–10) compared with 7 (range 2–10) (P=.24) for metoclopramide and promethazine, respectively. Repeat-measures analysis of variance of the nausea visual numerical rating scale scores showed no significant difference between study drugs (F score=0.842, P=.47). Reported drowsiness (58.6% compared with 83.6%, P=.001, number needed to treat to benefit [NNTb] 5), dizziness (34.3% compared with 71.2%, P<.001, NNTb 3), dystonia (5.7% compared with 19.2%, P=.02, NNTb 8), and therapy curtailment owing to adverse events (0 of 73 [0%] compared with 7 of 76 [9.2%], P=.014) were encountered less frequently with metoclopramide. CONCLUSION: Promethazine and metoclopramide have similar therapeutic effects in patients who are hospitalized for hyperemesis gravidarum. The adverse effects profile was better with metoclopramide. CLINICAL TRIAL REGISTRATION. ISRCTN, www.isrctn.org, ISRCTN34918844. LEVEL OF EVIDENCE: I

Transvaginal sonographic measurement of cervical length vs. Bishop score in labor induction at term: tolerability and prediction of Cesarean delivery

To compare transvaginal sonography for cervical length measurement and digital examination for Bishop score assessment in women undergoing labor induction at term, to assess their tolerability (in terms of pain) and ability to predict need for Cesarean delivery.

Pregnancy outcome in hyperemesis gravidarum and the effect of laboratory clinical indicators of hyperemesis severity

Objective:  To determine pregnancy outcome in hyperemesis gravidarum and the effect of metabolic, biochemical, hematological and clinical indicators of disease severity on outcome.

Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial

Please cite this paper as: Raheem I, Saaid R, Omar S, Tan P. Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial. BJOG 2012;119:78–85.

The fetal sex ratio and metabolic, biochemical, haematological and clinical indicators of severity of hyperemesis gravidarum

The association between female fetal sex and hyperemesis gravidarum is well established in European and North American populations. The association between female fetuses and severity of hyperemesis remains uncertain. A retrospective study based on case notes review of 166 Asian women hospitalised for hyperemesis was performed. Female fetuses were significantly associated with hyperemesis in our population (P= 0.004, OR 1.6, 95% CI 1.2–2.2) as well as associated with severe ketonuria and high urea. When both severe ketonuria and high urea were present at initial hospital admission for hyperemesis, 83% (95% CI 66–93) of the fetuses were female.

Contemporary approaches to hyperemesis during pregnancy.

Purpose of review Nausea and vomiting of pregnancy (NVP) affects 90% of pregnant women and its impact is often underappreciated. Hyperemesis gravidarum, the most severe end of the spectrum, affects 0.5–2% of pregnancies. The pathogenesis of this condition remains obscure and its management has largely been empirical. This review aims to provide an update on advances in pregnancy hyperemesis focusing on papers published within the past 2 years. Recent findings The cause of hyperemesis is continuing to be elaborated. Recent data attest to the effectiveness of the oral doxylamine–pyridoxine in NVP. Follow-up data of children exposed in early pregnancy to doxylamine–pyridoxine for NVP are reassuring. Evidence is increasing for ginger as an effective herbal remedy for NVP. Metoclopramide is effective in NVP and hyperemesis gravidarum, with a good balance of efficacy and tolerability. A recent large-scale study on first trimester exposure to metoclopramide is reassuring of its safety. Evidence is emerging for the treatment of acid reflux to ameliorate NVP. The role of corticosteroids for hyperemesis gravidarum remains controversial. Transpyloric feeding may be warranted for persistent weight loss, despite optimal antiemetic therapy. Summary Women with significant NVP should be identified so that they can be safely and effectively treated.

Ondansetron Compared With Metoclopramide for Hyperemesis Gravidarum A Randomized Controlled Trial

OBJECTIVE: To compare ondansetron with metoclopramide in the treatment of hyperemesis gravidarum. METHODS: We enrolled 160 women with hyperemesis gravidarum in a double-blind randomized trial. Participants were randomized to intravenous 4 mg ondansetron or 10 mg metoclopramide every 8 hours for 24 hours. Participants kept an emesis diary for 24 hours; at 24 hours, they expressed their well-being using a 10-point visual numeric rating scale and answered an adverse effects questionnaire. Nausea intensity was evaluated using a 10-point visual numeric rating scale at enrollment and at 8, 16, and 24 hours. Primary analysis was on an intention-to-treat basis. RESULTS: Eighty women each were randomized to ondansetron or metoclopramide. Median well-being visual numeric rating scale scores were 9 (range, 5–10) compared with 9 (range, 4–10) (P=.33) and vomiting episodes in the first 24 hours were 1 (range, 0–9) compared with 2 (range, 0–23) (P=.38) for ondansetron compared with metoclopramide, respectively. Repeat-measures analysis of variance of nausea visual numeric rating scale showed no difference between study drugs (P=.22). Reported rates of drowsiness (12.5% compared with 30%; P=.01; number needed to treat to benefit, 6), xerostomia (10.0% compared with 23.8%; P<.01; number needed to treat to benefit, 8), and persistent ketonuria at 24 hours (12.5% compared with 30%; P=.01; number needed to treat to benefit, 6) were less frequent with ondansetron. Length of hospital stay was similar. CONCLUSION: Ondansetron and metoclopramide demonstrated similar antiemetic and antinauseant effects in hyperemesis gravidarum. However, the overall profile, particularly regarding adverse effects, was better with ondansetron. In our setting, metoclopramide was significantly less expensive than ondansetron and remained a reasonable antiemetic choice. CLINICAL TRIAL REGISTRATION: ISRCN Register, www.isrctn.org, ISRCTN00592566. LEVEL OF EVIDENCE: I

Effect of coitus at term on length of gestation, induction of labor, and mode of delivery.

OBJECTIVE: To determine coital incidence at term and to estimate its effect on labor onset and mode of delivery. METHODS: Healthy women with uncomplicated pregnancies and established gestational age were recruited to keep a diary of coital activity from 36 weeks of gestation until birth and to answer a short questionnaire. Two hundred women with complete coital diaries were available for analysis. Outcome measures include coitus, postdate pregnancy (defined as pregnancy beyond the estimated date of confinement), gestational length of at least 41 weeks, labor induction at 41 weeks of gestation, and mode of delivery RESULTS: Reported sexual intercourse at term was influenced by a womans perception of coital safety, her ethnicity, and her partners age. After multivariable logistic regression analysis controlling for the womens ethnicity, education, occupation, perception of coital safety, and partners age, coitus at term remained independently associated with reductions in postdate pregnancy (adjusted odds ratio [AOR] 0.28, 95% confidence interval [CI] 0.13–0.58, P = .001), gestational length of at least 41 weeks (AOR 0.10, 95% CI 0.04–0.28, P < .001), and requirement for labor induction at 41 weeks of gestation (AOR 0.08, 95% CI 0.03–0.26, P < .001). At 39 weeks of gestation, 5 (95% CI 3.3–10.3) couples needed to have intercourse to avoid one woman having to undergo labor induction at 41 weeks of gestation. Coitus at term had no significant effect on operative delivery (adjusted P = .15). CONCLUSION: Reported sexual intercourse at term was associated with earlier onset of labor and reduced requirement for labor induction at 41 weeks. LEVEL OF EVIDENCE: II-2