Use of Bakri balloon tamponade (BBT) for conservative management of postpartum haemorrhage: a tertiary referral centre case series.

The aim of this study was to investigate the efficacy of the Bakri balloon in the management of PPH. This was a retrospective review of 49 patients, who had Bakri balloon inserted for PPH in KK Hospital between April 2013 and December 2015. The main outcome measure was achievement of haemostasis by Bakri balloon tamponade (BBT). Our success rate was 81.6%. Out of the nine failures (18.0%), five (55.6%) had subtotal hysterectomies and four (44.4%) had total hysterectomies. The causes of PPH in these nine women were unsuspected or foci of placenta accreta (55.6%), uterine atony (33.3%) and retained products of conception (11.1%). Our study suggests that BBT is more likely to fail when bleeding is secondary to undiagnosed focal placenta accreta (p = .011) and when the estimated blood loss is more than 1.5 litres (p < .001). Our study adds to the growing body of evidence that BBT is not only effective for management of PPH in haemodynamically stable patients and in cases secondary to uterine atony and placenta praevia, but also in a small number of undiagnosed focal placenta accreta. Impact statement There is limited evidence regarding efficacy of BBT for PPH. Our study supports the use of BBT for PPH due to uterine atony and placenta praevia and in a small number of undiagnosed placenta accreta.

Single versus combination tocolytic regimen in the prevention of preterm births in women: a prospective cohort study.

OBJECTIVE: Our objective is to compare the efficacy of combination regimen (salbutamol and nifedipine) against single regimen (nifedipine alone) in preventing preterm births among women with preterm labor. RESULTS: A total of 76 women with gestational age (GA) ranging from 24+0 to 35+6 weeks, who sought treatment for preterm labor with or without cervical dilatation, were recruited for the prospective cohort study. Of these, 38 (50%) had single tocolytic regimen and 38 (50%) had combination tocolytic regimen. The mean GAs at admission were similar for both groups at 31 weeks (±2.93) for Group 1 and 30.9 weeks (±2.88) for Group 2 (P=0.873). The mean GAs at delivery were 37.8 weeks (±1.98) for the single regimen and 36.2 weeks (±3.26) for the combined regimen (P=0.011). The mean tocolytic to delivery interval for the single regimen was longer at 6.74 weeks (±3.13) as compared with 5.21 weeks (±3.61) for the combination regimen (P<0.05). Those on the combination regimen complained of more adverse effects (P<0.001). CONCLUSION: Our study results suggested that the use of nifedipine as a single tocolytic regimen is as effective as the combination regimen in the delay of preterm births and has much less side effects. Hence, we recommend the sole use of nifedipine for the management of preterm labor.

Perception and Feelings of Antenatal Women during COVID-19 Pandemic: A Cross-Sectional Survey.

INTRODUCTION: To assess the level of anxiety and knowledge regarding COVID-19 amongst antenatal women. MATERIALS AND METHODS: This cross-sectional survey was conducted in the antenatal clinics of KK Women's and Children's Hospital, Singapore, from 31 March to 25 April 2020 to assess pregnant women's knowledge of COVID-19, their perceptions of its impact upon pregnancy and psychological impact using the validated Depression, Anxiety, and Stress Scales (DASS-21). RESULTS: Of the 324 women who participated in the study, the mean age was 31.8 years (range, 20-45). The majority (53.7%) were multiparous with mean gestational age of 23.4 weeks (SD 10). The commonest sources of information were Internet-based social media platforms. A significant proportion were unaware, or associated COVID-19 infection during pregnancy with fetal distress (82.1%), intrauterine death (71.3%), fetal anomalies (69.8%), miscarriages (64.8%), preterm labour (67.9%) and rupture of membranes (61.4%). A total of 116 (35.8%) women screened positive for anxiety, 59 (18.2%) for depression, and 36 (11.1%) for stress. There was a significant association between household size and stress scores [B = 0.0454 (95% CI, 0.0035-0.0873)]. Women who associated COVID-19 infection with fetal anomalies and intrauterine fetal death had significantly higher anxiety scores [B = -0.395 (95% CI, -0.660 to -0.130) and B = -0.291 (95% CI, -0.562 to -0.021) respectively]. CONCLUSION: Our study highlights that a lack of timely and reliable information on the impact of COVID-19 on pregnancy and its outcomes results in increased levels of depression, anxiety and stress. The healthcare provider must address these issues urgently by providing evidence-based information using Internet-based resources and psychological support.

Longitudinal circulating placental growth factor (PlGF) and soluble FMS-like tyrosine kinase-1 (sFlt-1) concentrations during pregnancy in Asian women: a prospective cohort study.

OBJECTIVES: To analyse the placental growth factor (PlGF) and soluble FMS-like tyrosine kinase-1 (sFlt-1) trends in the normal pregnant Asian population in Singapore. DESIGN: A prospective study was conducted. SETTING: The largest tertiary hospital in Singapore. METHODS: Women with single viable pregnancies, less than 14 weeks of gestation, were recruited between September 2010 and November 2013 in KK Women's and Children's Hospital. They were followed up from recruitment till their postnatal discharge from the hospital. There were four antenatal visits: gestational age (GA) less than 14+0 weeks of gestation (V1), GA 18+0 to 22+0 weeks (V2), GA 28+0 to 32+0 weeks (V3) and GA 34+0 and above (V4). Serum biochemical markers (sFlt-1, PlGF) were measured at each visit. RESULTS: There were 934 participants in the study, of which 674 had normal pregnancy outcomes. The sFlt-1 remained relatively constant till GA 28-32 weeks before it increased (p<0.001). The sFlt-1 levels increased earlier before 30 weeks' of gestation among the Malay participants and the other ethnicities. For PlGF, the levels increased from the first to the third trimester, peaking at 30-32 weeks before decreasing (p<0.001). Its serum levels significantly differed among the Indian participants and other ethnicities as compared with the Malay and Chinese participants at V3 and V4, (p=0.04 and p<0.001, respectively). CONCLUSION: There are significant differences in the PlGF and sFlt-1 concentrations during pregnancy between different ethnicities, which should be taken into consideration when using these references values for further research.

Vaginal metastasis presenting as postmenopausal bleeding.

Vaginal cancer is rare worldwide and represents 2% of all gynaecological cancers in Singapore. Primary vaginal malignancies are rare and vaginal metastases constitute the majority of vaginal malignancies. Most of these metastases arise from the cervix, endometrium or ovary, although they can also metastasise from distant sites such as the colon, breast and pancreas. We report a rare case of vaginal metastasis in a patient with previous gastric and rectal adenocarcinomas. An 89-year-old woman with a history of gastric and rectal malignancy presented with postmenopausal bleeding. A 2-cm vaginal tumour at the introitus was discovered upon examination. This case demonstrates the importance of performing a gynaecological examination during follow-up for patients with a history of malignancy. The prognosis for vaginal metastasis is poor, as it is often associated with disseminated disease. Depending on the extent of the lesions, radiotherapy or surgery can be considered.