Y.F. Fong

Medical treatment of a grossly enlarged adenomyotic uterus with the levonorgestrel-releasing intrauterine system

Adenomyosis is an important cause of menorrhagia. Besides hysterectomy, the treatment options for adenomyosis have been limited. Presented here is the successful treatment of adenomyosis in a woman presenting with menorrhagia, dysmenorrhea, and an enlarging uterus, for whom conservative therapy initiated with mefenamic acid was unsatisfactory. The patient had insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS). A marked decrease in uterine size occurred within 12 months of insertion accompanied by resolution of the menorrhagia and dysmenorrhea. Thus, the LNG-IUS is a viable option and represents a real advance in the treatment of adenomyosis.

Randomized trial to determine optimal dose of Vaginal misoprostol for preabortion cervical priming

Objective To determine the optimal dosage of vaginal misoprostol for cervical priming before vacuum aspiration abortion. Methods One hundred twenty women were assigned randomly to receive 200, 400, 600, or 800 μg of misoprostol given vaginally. Vacuum aspiration was performed 3–4 hours after the insertion of misoprostol tablets. The degree of cervical dilation before operation was measured with a Hegar dilator. Preoperative and intraoperative blood loss and associated side effects also were assessed. Results Twenty-nine (96.7%) women in the 400-μg group and all in the 600-μg and 800-μg groups achieved cervical dilation of at least 8 mm. The success rate for the 200-μg group was only 23.3%, significantly less efficacious than the 400-μg dose (odds ratio 95.3; 95% confidence interval 10.9, 830.9; P < .001). There was no significant difference among the 400-, 600-, and 800-μg groups (P = .364) with respect to achieving cervical dilation at least 8 mm. However, 800 μg was associated with significantly more side effects than 600 μg (preoperative and intraoperative blood loss, P < .001; abdominal pain, P = .005; products of conception at os, P < .001; fever higher than 38.0C, P = .002). When 400 μg and 600 μg were compared, we found that the higher dose also was associated with significantly more side effects. The 600-μg group was used twice in the comparison, but all P values remained significant even after the Bonferroni adjustment for multiple comparisons. Conclusion Vaginal application of 400 μg of misoprostol is the optimal dose for vacuum aspiration preabortion cervical dilation in first-trimester nulliparas.

A comparative study using two dose regimens (200 μg or 400 μg) of vaginal misoprostol for pre‐operative cervical dilatation in first trimester nulliparae

Objective To determine the optimal dosage and dosing interval for the use of misoprostol administered vaginally for pre‐operative cervical dilatation.

Effect of the levonorgestrel-releasing intrauterine system on uterine myomas in a renal transplant patient.

The levonorgestrel-releasing intrauterine system (LNG-IUS) has been used in the treatment of both idiopathic menorrhagia and adenomyosis. An electronic search of the on-line medical literature revealed no reports of its use for menorrhagia secondary to uterine myomas. Presented here is the successful treatment of uterine myomas with menorrhagia in a woman with a renal transplant. There was a significant reduction in menorrhagia, dysmenorrhea, and uterine and myoma size with the use of the LNG-IUS. We believe that this system provides an alternative to conventional hysterectomy and gonadotrophin-releasing hormonal analog medical treatment for uterine myomas, with a possibly inhibitory effect on myoma growth.

Vaginal misoprostol for pre‐abortion cervical priming: is there an optimal evacuation time interval?

Objective To determine the optimal evacuation time interval in the use of vaginal misoprostol for cervical priming before first trimester termination of pregnancy.

A comparison between intravenous iron polymaltose complex (Ferrum Hausmann) and oral ferrous fumarate in the treatment of iron deficiency anaemia in pregnancy.

Abstract: Anaemia is the most common medical disorder in pregnancy with iron deficiency anaemia accounting for the majority of cases. Over 90% of the iron deficiency anaemia is due to red cell iron deficiency associated with depleted iron stores and deficient intake. The two main modalities of treating iron deficiency anaemia are oral or parenteral iron. Ferrous Hausmann® (iron dextrin) is the latest iron preparation which can be used for intravenous parenteral administration as a total dose infusion. This study compares the efficacy of Ferrum Hausmann® with oral ferrous fumarate therapy in the treatment of iron deficiency anaemia in pregnancy. Our study shows that treatment with intravenous Ferrum Hausmann® (iron dextrin) resulted in a significantly better level and rate of increase of haemoglobin (p<0.001). Serum ferritin, which is the best indicator of iron stores, was significantly higher (p<0.001) in the intravenous group. Other indices of iron status such as serum iron, serum transferrin and zinc protoporphyrin also showed a significant improvement in the intravenous group compared to those given oral iron. The results suggest that intravenous iron as a total dose infusion is able to replenish iron stores more efficiently, completely and at a faster rate than oral iron therapy, thus providing the fuel for stimulation of full erythopoiesis compared to oral iron. There were also no reports of any adverse reactions with intravenous iron dextrin, whereas there were a considerable proportion of women on oral iron therapy who reported side effects. In conclusion, intravenous iron therapy with Ferrous Hausmann® (iron dextrin) is a suitable, effective and safe alternative to oral iron therapy in the treatment of iron deficiency anaemia in pregnancy.

Acceptability of norplantR implants for fertility regulation in Singapore

The continuation rate at the end of this five-year clinical study was 60% with no accidental pregnancy occurring throughout the five years. The post-removal conception rate in women desiring pregnancy was 92% at the end of two years. The majority of acceptors described the overall experience with the implants as favourable. In fact, 75% of the women planning to use contraception after removal of the implants were going to use implants again.

A viable alternative to surgical vacuum aspiration: repeated doses of intravaginal misoprostol over 9 hours for medical termination of pregnancies up to eight weeks

Objective To study the efficacy of repeated doses of vaginal misoprostol over 9 hours in a day care setting for terminating pregnancies up to eight weeks of gestation.

The role of prophylactic iron supplementation in pregnancy

The prevalence, causes and role of iron prophylaxis in pregnant women was studied. All women delivered at the National University Hospital, Singapore in 1993 had their haemoglobin estimated. If it was less than 11 g/dl, blood was taken for serum iron, ferritin, transferrin, red cell zinc protoporphyrin, serum folate, vitamin B12 and thalassemia screen to establish cause of anaemia. Data was also collected with regards to their antenatal progress and iron prophylaxis. Logistic regression, Chi-square test, Fischers exact test and Mantel-Haenszel tests were also used to assess the relationships between categorical variables. The prevalence of anaemia at first antenatal visit was 20.6% while the prevalence of anaemia at delivery was 15.3%. The commonest cause of the anaemia in pregnancy was due to iron deficiency (81.3%). In the non-anaemic group, 90.7% were on prophylactic iron supplements compared to 50.6% in the anaemic group (P < 0.001). Of the 752 women found to be anaemic at booking, 591 received prophylactic iron supplements while 161 women did not. A total of 166 (28.1%) of those with iron supplements were anaemic at delivery, whereas 140 (87.0%) of those who did not receive prophylactic iron remained anaemic at delivery (P < 0.001). Of the 2516 non-anaemic women who received prophylactic iron, 118 (4.7%) developed anaemia at delivery while 133 (34.1%) out of the 390 women who did not receive prophylactic iron were anaemic at delivery (P < 0.001). Multivariate logistic regression analysis revealed the odds of anaemia for a woman not on iron therapy was about 11 times that of her counterpart on prophylactic iron therapy (95% CI 8.76 to 14.13). A 55% reduction in odds of anaemia was estimated per 1 gm% increase in haemoglobin at booking. Prophylactic antenatal iron supplements not only prevent a fall but also improved haemoglobin levels during pregnancy. Those who were not on any iron supplements were 11 times more likely to develop anaemia in the present pregnancy.

Profile of women presenting for abortions in Singapore at the National University Hospital

The study was conducted to profile women seeking abortions at the National University Hospital, with particular interest in the trend of teenage pregnancies with the aim of identifying risk factors for late presentation for abortions. All patients who underwent an abortion at our center from January 1, 1996 to December 31, 2000 were recruited. Data were entered into a prepared questionnaire during the mandatory pre-abortion counseling sessions and completed at the 6-week post-abortion follow-up. This was then keyed into a database (SPSS Version 10), and the results were analyzed. Multivariate analysis was used in identifying risk factors associated with late presentation for abortions. Chi-square analysis of variables was used where relevant. A total of 1370 women presented for induced abortions during the period of study. The mean age of women was 29.6 years. Most women were either homemakers (35.3%) or semi-skilled workers (28.5%) with at least a secondary school education (58.3%). The majority were married (75.5%). There was a significant trend in the proportion of single women seeking abortions, from 18.3% in 1996 to 27.8% in 2000 (p < 0.05). At the same time, the proportion of women presenting for repeat abortions also increased from 13.8% in 1996 to 33.2% in 2000 (p < 0.05). Teenage abortions made up 117 (8.5%) of the study group, of which 95% were single women. Significant proportions (52.1%) were students at the time of abortion. In contrast to women above 20 years of age, pregnant teenagers were more likely not to have used any contraception (67.1% vs. 37.3%) and more likely to present late for abortion (18.8% vs. 10.4%). Teenage pregnancies are a major risk factor for late presentation for abortions. This emphasizes the need for availability and easy access to early abortion counseling, and the need for sex education with use of contraception starting in schools, to reduce abortions among teenagers.