Cervical length screening among low-risk women; relationship of body mass index on cervical length and risk of preterm birth.

BACKGROUND: Preterm birth (PTB) contributes to nearly 11% of all deliveries in the world. The majority of spontaneous preterm birth (sPTB) remains unexplained. Risk factors include abnormal body mass index (BMI), short cervical length, comorbidities and many more. However, there is limited study on the association between body mass index, cervical length and preterm birth in Malaysia among low-risk women. Hence, we aim to examine the relationship between body mass index, cervical length and the risk of spontaneous preterm birth. METHOD: In this prospective cohort study, pregnant women between 16 and 24 weeks who fulfilled the criteria were recruited. Women with history of preterm birth were excluded. Demographic and clinical data (age, BMI, ethnicity, education level and parity) were obtained. Cervical length was measured using transvaginal scan. Patients were then followed up till delivery to determine their delivery gestation and outcome of delivery. RESULTS: Out of 153 women who participated in this study, 146 women had cervical length of more than 30 mm, six had cervical length between 25 mm and 30 mm and one had cervical length of 24 mm. There were nine (9) cases of sPTB, with all of them being late preterm with normal midtrimester cervical length. Almost half of them (44%) were overweight/obese. A significant association was found between age, cervical length, and parity compared to BMI. Nevertheless, no significant association was seen between the BMI and risk of sPTB. CONCLUSION: This study demonstrates a higher BMI is associated with longer cervical length, but it is not necessarily protective against sPTB. Hence, we concluded there is a limited role in cervical length screening among low-risk women regardless of their BMI in predicting sPTB.

Correction: Vitamin D Deficiency and Its Association With Vitamin D Receptor Gene Variants Among Malaysian Women With Hypertensive Disorders in Pregnancy: Protocol for a Nutrigenomics Study.

[This corrects the article DOI: 10.2196/53722.].

Listeriosis in pregnancy: a challenge in diagnosis.

Listeriosis is a rare foodborne infection caused by Listeria monocytogenes It has been reported to be commonly found among the obstetric population, immunocompromised group and elderly, presumably due to the lower immunity status in these populations. Presentation in pregnancy is usually non-specific like fever, diarrhoea, respiratory tract symptoms and preterm rupture of membrane. These make the diagnosis challenging and may delay the correct management. We present a case of a female in her early 40s, gravida 4 para 0+3 at 27 weeks who presented with fever. She later developed preterm rupture of membrane 24 hours after admission. The leaking of liquor later changed from clear to meconium stained raising the suspicion of listeria chorioamnionitis, necessitating an emergency preterm delivery via caesarean section. The newborn acquired listeria infection and required ventilation support. He subsequently was discharged from neonatal unit after nearly 3 months of life.

Vitamin D Deficiency and Its Association With Vitamin D Receptor Gene Variants Among Malaysian Women With Hypertensive Disorders in Pregnancy: Protocol for a Nutrigenomics Study.

BACKGROUND: Vitamin D deficiency has been associated with hypertensive disorders in pregnancy (HDP). The risk of developing HDP was reported to be further augmented among individuals with a vitamin D receptor (VDR) genetic variant. However, the reported roles of VDR variants in hypertensive disorders are inconsistent among different populations. Given the relatively higher incidence of vitamin D deficiency among Malaysian pregnant women and the high incidence of HDP in this population, we hypothesize that there may be associations between the risk of vitamin D deficiency and HDP with VDR genetic variants. OBJECTIVE: This paper outlines the protocol for a study to determine the association of vitamin D status and VDR sequence variants among Malaysian pregnant women with HDP. METHODS: This prospective study consists of two phases. The first phase is a cross-sectional study that will entail gathering medical records, a questionnaire survey, and laboratory testing for vitamin D status, with a planned recruitment of 414 pregnant women. The questionnaire will be utilized to assess the risk factors for vitamin D deficiency. The vitamin D status will be obtained from measurement of the vitamin D (25-hydroxyvitamin D3) level in the blood. The second phase is a case-control study involving a Malay ethnic cohort with vitamin D deficiency. Participants will be divided into two groups with and without HDP (n=150 per group). Genomic DNA will be extracted from the peripheral blood monocytes of participants using the Qiagen DNA blood kit, and VDR sequence variants will be determined using polymerase chain reaction-high-resolution melting (PCR-HRM) analysis. Sanger sequencing will then be used to sequence randomly selected samples corresponding to each identified variant to validate our PCR-HRM results. The VDR genotype and mutation frequencies of BsmI, ApaI, TaqI, and FokI will be statistically analyzed to evaluate their relationships with developing HDP. RESULTS: As of December 2023, 340 subjects have been recruited for the phase 1 study, 63% of whom were determined to have vitamin D deficiency. In the phase 2 study, 50 and 22 subjects have been recruited from the control and case groups, respectively. Recruitment is expected to be completed by March 2024 and all analyses should be completed by August 2024. CONCLUSIONS: The outcome of the study will identify the nonmodifiable genetic components contributing to developing vitamin D deficiency leading to HDP. This will in turn enable gaining a better understanding of the contribution of genetic variability to the development of HDP, thus providing more evidence for a need of customized vitamin D supplementation during pregnancy according to the individual variability in the response to vitamin D intake. TRIAL REGISTRATION: ClinicalTrials.gov NCT05659173; https://clinicaltrials.gov/study/NCT05659173. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53722.

A Mobile Phone App for the Prevention of Type 2 Diabetes in Malaysian Women With Gestational Diabetes Mellitus: Protocol for a Feasibility Randomized Controlled Trial.

BACKGROUND: Over 50% of women with a history of gestational diabetes mellitus (GDM) will develop type 2 diabetes (T2D) in later life. Asian women experience a disproportionate risk of both GDM and T2D compared to women from other ethnic backgrounds. Lifestyle interventions and behavior change can delay or even prevent the onset of T2D. We have developed a digitalized diabetes prevention intervention for the prevention of T2D in Malaysian women with GDM. OBJECTIVE: The protocol describes a randomized controlled trial (RCT) to test the feasibility of undertaking a definitive trial of a diabetes prevention intervention, including a smartphone app and group support. Secondary aims are to summarize anthropometric, biomedical, psychological, and lifestyle outcomes overall and by allocation group, and to undertake a process evaluation. METHODS: This is a two-arm parallel feasibility RCT. A total of 60 Malaysian women with GDM will be randomized in the antenatal period to receive the intervention or standard care until 12 months post partum. The intervention is a diabetes prevention intervention delivered via a smartphone app developed based on the Information-Motivation-Behavioral Skills model of behavior change and group support using motivational interviewing. The intervention provides women with tailored information and support to encourage weight loss through adapted dietary intake and physical activity. Women in the control arm will receive standard care. The Malaysian Ministry of Health's Medical Research and Ethics Committee has approved the trial (NMRR-21-1667-60212). RESULTS: Recruitment and enrollment began in February 2022. Future outcomes will be published in peer-reviewed health-related research journals and presented at national, regional, or state professional meetings and conferences. This publication is based on protocol version 2, January 19, 2022. CONCLUSIONS: To our knowledge, this will be the first study in Malaysia that aims to determine the feasibility of a digital intervention in T2D prevention among women with GDM. Findings from this feasibility study will inform the design of a full-scale RCT in the future. TRIAL REGISTRATION: ClinicalTrials.gov NCT05204706; https://clinicaltrials.gov/ct2/show/NCT05204706. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37288.

Study protocol on risk factors for the diagnosis of gestational diabetes mellitus in different trimesters and their relation to maternal and neonatal outcomes (GDM-RIDMAN).

INTRODUCTION: Gestational diabetes mellitus (GDM) is often associated with adverse pregnancy outcomes. However, the association of risk factors with GDM diagnosis, maternal and neonatal health outcomes is less established when compared with women without GDM. We aim to examine the diagnostic accuracy of the conventional and novel risk factors for a GDM diagnosis and their impact on maternal and neonatal health outcomes. METHODS AND ANALYSIS: This retrospective cohort and nested case-control study at six public health clinics is based on medical records and questionnaire survey of women between 2 and 12 months postpartum. The estimated required sample size is 876 complete records (292 cases, 584 control, at a ratio of 1:2). Oral glucose tolerance test results will be used to identify glucose dysregulation, and maternal and neonatal outcomes include maternal weight gain, pre-eclampsia, polyhydramnios, mode of delivery, preterm or postdate birth, complications in labour, birth weight, gestational age at birth, Apgar score, congenital anomaly, congenital hypothyroidism, neonatal death or stillbirth, hypoglycaemia and hyperbilirubinaemia. Psychosocial measures include the WHO Quality of Life: brief, mother-infant bonding (14-item Postpartum Bonding Questionnaire and 19-item Maternal Postnatal Attachment Scale), anxiety (7-item Generalised Anxiety Disorder), depression (9-item Patient Health Questionnaire) and stress (Perceived Stress Scale symptoms) questionnaires. The comparative incidences of maternal and neonatal health outcomes, the comparative prevalence of the psychosocial outcomes between women with GDM and without GDM, specificity, sensitivity, positive and negative predictive values of the risk factors, separately and combined, will be reported. All GDM risk factors and outcomes will be modelled using multivariable regression analysis and the receiver operating characteristics curve will be reported. ETHICS AND DISSEMINATION: This study was approved by the Malaysia Research and Ethics Committee, Ministry of Health Malaysia. Informed consent will be obtained from all participants. Findings will be submitted for publications in scientific journals.

Improving knowledge, attitudes and beliefs: a cross-sectional study of postpartum depression awareness among social support networks during COVID-19 pandemic in Malaysia.

BACKGROUND: Postpartum depression (PPD) is the most prevalent mental health disorder after childbirth, notably during the COVID-19 pandemic. In addition, PPD is known to have a long-term influence on the mother and the newborn, and the role of social support network is crucial in early illness recognition. This study aims to evaluate the social support networks' level of knowledge, attitudes and beliefs regarding PPD and examine their sociodemographic variables and exposure to the public information relating to PPD during the COVID-19 pandemic in Malaysia. METHODS: A cross-sectional study was conducted via an online Google Form disseminated to people in Klang Valley through WhatsApp, Email, Facebook, Instagram and other available social media among postpartum women's social support networks aged 18 years and living in the Klang Valley area (N = 394). Data were collected from 1 March to 5 July 2021 and analysed using the Mann-Whitney U-test and generalised linear mixed models. RESULTS: During the COVID-19 epidemic in Klang Valley, most participants had good knowledge, negative attitudes and awareness of PPD. Marital status, gender and parity all had significant correlations with the amount of awareness regarding PPD. Ethnicity, gender, parity and educational level showed significant association with attitude towards PPD. No significant relationship was noted between sociodemographic variables and PPD beliefs. Public awareness of PPD was also associated with knowledge and attitude towards it. CONCLUSIONS: A significant positive knowledge, negative attitude and negative awareness level of PPD exist among social support networks for postnatal women. However, no significant effect of belief on PPD awareness level was noted. IMPLICATIONS: Insight campaigns and public education about PPD should be conducted to enhance postnatal mothers' awareness and knowledge. Postnatal care, mental check-ups and counselling sessions for the new mothers are recommended. In future studies, a closer assessment of postpartum social support, variances and similarities across women from diverse racial/ethnic origins is critical. STRENGTHS AND LIMITATIONS: This cross-sectional study is one of the early studies on the area of PPD in the Malaysian region during COVID-19. Numerous data have been collected using low-cost approaches using self-administered surveys through Google Forms in this research.

Protocol for a qualitative study exploring the perception of need, importance and acceptability of a digital diabetes prevention intervention for women with gestational diabetes mellitus during and after pregnancy in Malaysia (Explore-MYGODDESS).

INTRODUCTION: Women who develop gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes, and to reduce this risk the women have to adopt healthy behaviour changes. Although previous studies have explored the challenges and facilitators to initiate behaviour change among women with GDM, there is limited data from Malaysian women. Thus, this study will explore the factors affecting the uptake of healthy behaviour changes and the use of digital technology among women and their healthcare providers (HCPs) to support healthy behaviour changes in women with GDM. METHODS AND ANALYSIS: The study will be modelled according to the Capability, Opportunity, Motivation and Behaviour and Behaviour Change Wheel techniques, and use the DoTTI framework to identify needs, solutions and testing of a preliminary mobile app, respectively. In phase 1 (design and development), a focus group discussion (FGDs) of 5-8 individuals will be conducted with an estimated 60 women with GDM and 40 HCPs (doctors, dietitians and nurses). Synthesised data from the FGDs will then be combined with content from an expert committee to inform the development of the mobile app. In phase 2 (testing of early iterations), a preview of the mobile app will undergo alpha testing among the team members and the app developers, and beta testing among 30 women with GDM or with a history of GDM, and 15 HCPs using semi-structured interviews. The outcome will enable us to optimise an intervention using the mobile app as a diabetes prevention intervention which will then be evaluated in a randomised controlled trial. ETHICS AND DISSEMINATION: The project has been approved by the Malaysia Research Ethics Committee. Informed consent will be obtained from all participants. Outcomes will be presented at both local and international conferences and submitted for publications in peer-reviewed journals.

Prophylactic gonadectomy in 46 XY females; why, where and when?

OBJECTIVES: We compared cases of phenotypic female patients who presented with male karyotype and underwent prophylactic gonadectomy. CASE PRESENTATION: Five patients with female phenotypes presented in early adulthood with primary amenorrhoea with varying degrees of puberty. One was tall with breast development. Another was very short with clitoromegaly and multiple co-morbidities. The other three had no secondary sexual characteristics. They were examined, after which hormonal profile, karyotyping, ultrasound examination and magnetic resonance imaging were done to assess the site of gonads. Gonadectomy was performed once their 46 XY karyotype was confirmed. Results of histopathological examination of their gonads ranged from dysgenetic gonads to having testicular tissues and malignancy. CONCLUSION: Female patients with 46 XY karyotypes require prophylactic gonadectomy performed at different timings depending on diagnosis due to the malignancy risk. Pre-operative assessment is essential to locate the gonads prior to surgery.

Celecoxib versus mefenamic acid in the treatment of primary dysmenorrhea.

Background The objective was to compare the effectiveness and tolerability of mefenamic acid and celecoxib in women with primary dysmenorrhea (PD) and to compare the quality of life of study participants pre- and post-treatment. Materials and methods This was a randomized crossover clinical trial conducted among sexually inactive female adults aged 18-25 years with PD. Participants were asked to rate their pain score and answer a validated quality of life questionnaire (EQ-5D-3L) before and after consumption of each medication in two menstrual cycles. The effectiveness of celecoxib and mefenamic acid in treating PD was compared with regard to reduction in pain score and the need for medical leave and rescue therapy. Drug tolerability was determined by comparing the occurrence of side effects of both drugs. Quality of life scores pre- and post-intervention were measured and compared. Results Mefenamic acid had a comparable effect to celecoxib in relieving symptoms of PD. Both drugs were equally tolerable and showed similar impacts on quality of life. Conclusions This study demonstrated that mefenamic acid and celecoxib had similar effectiveness in improving pain score and quality of life in women with PD.

Management Options and Outcome of Cerebral Arteriovenous Malformation in Pregnancy: Case Series.

Cerebral arteriovenous malformation (AVM) is a rare entity with an estimated prevalence of 0.01-0.05% in the general population. We reviewed hospital obstetric records during 2010-2017 and reported a case series of six patients with cerebral AVM in pregnancy, of which five patients had successful pregnancy, and one maternal mortality.

Congenital complete heart block in pregnancy.

Complete heart block (CHB) is infrequently encountered during pregnancy. Its management requires a multidisciplinary approach involving the obstetrician, cardiologist, anesthetist and neonatologist. It varies from conservative, temporary or permanent pacemaker (PPM) insertion (either during the antenatal, intrapartum or postpartum period). We present the case of a 30-year-old, gravida 2 para 1 at the 36-week period of amenorrhea (POA) with congenital CHB. She was asymptomatic throughout her pregnancy despite having a pulse rate between 40 and 50 beats per minute. She delivered a healthy boy via cesarean section due to breech presentation after a failed external cephalic version. A temporary pacemaker was inserted prior to delivery. However, she required permanent insertion of pacemaker during the postpartum period.

The World Health Organization (WHO) versus The International Association of Diabetes and Pregnancy Study Group (IADPSG) diagnostic criteria of gestational diabetes mellitus (GDM) and their associated maternal and neonatal outcomes.

Background Gestational diabetes mellitus (GDM) is a common medical complication in pregnancy. The aim of this study was to compare the prevalence of GDM using the World Health Organization (WHO) criteria and the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria in our population. We further compared the incidence of adverse maternal and neonatal outcomes in women diagnosed with GDM using these criteria and determined whether the IADPSG criteria is suitable in our population. Methods This randomized controlled trial was conducted at our antenatal clinic involving 520 patients from 1st February 2015 until 30th September 2017. They were randomized into the WHO and the IADPSG groups. All eligible women underwent a standard oral glucose tolerance test with 75 g glucose, their fasting and 2 h post prandial glucose levels were taken. The primary outcome was the prevalence of GDM. The secondary outcomes were the incidence of primary cesarean section, gestational hypertension or preeclampsia, preterm delivery <37 weeks, fetal macrosomia, neonatal hypoglycemia and shoulder dystocia or birth injury. Results The prevalence of GDM in both groups were similar (37.9% vs. 38.6%). GDM women in the WHO group had a significantly higher incidence of gestational hypertension or preeclampsia (p = 0.004) and neonatal hypoglycemia (p = 0.042). In contrast, GDM women in the IADPSG group had a significantly higher incidence of fetal macrosomia (p = 0.027) and cesarean section (p = 0.012). Conclusion The IADPSG diagnostic criteria for GDM may not be suitable for use in our population as it resulted in women being diagnosed later and being undertreated, thus leading to adverse maternal and neonatal outcomes.