Gut Microbiota Composition in the First and Third Trimester of Pregnancy among Malay Women is Associated with Body Mass Index: A Pilot Study.

Background: This study has analysed the pattern of gut microbiota during the first and third trimesters among pregnant Malay women. Methods: This was a pilot prospective observational study involving 12 pregnant Malay women without any endocrine disorders and on neither antibiotics nor probiotics. Demographic details and anthropometric measurements were obtained, and the faecal 16S ribosomal ribonucleic acid (rRNA) metagenome microbiota of the first and third trimesters (T1 and T3) were analysed. Univariate and multivariate statistics, partial least squares discriminant analysis (PLSDA) and Kendall rank correlation testing were used to identify key genera and associations with pregnancy trimester and body mass index (BMI). Results: The most abundant phyla were Bacteroidetes, Firmicutes, Proteobacteria and Actinobacteria, with significant differences in composition at the genus level demonstrated between T1 and T3. Sequencing showed a statistically significant difference in beta diversity between normal and abnormal BMI at all taxonomic ranks (R 2 = 0.60; Q 2 = 0.23) and genus levels (R 2 = 0.57; Q 2 = 0.37). The relative abundances of Akkermansia (P < 0.05; false discovery rate [FDR] < 0.05), Olsenella (P < 0.05; FDR < 0.05) and Oscillospira (P < 0.05; FDR < 0.05) were found to be significantly higher in normal BMI cases by 2.4, 3.4 and 3.1 times, respectively. Conclusion: Three genera (Akkermansia, Olsenella and Oscillospira) were correlated with normal BMI during pregnancy. All three could be promising biotherapeutic targets in body weight regulation during pregnancy, subsequently reducing complications associated with higher BMI.

Maternal COVID-19 vaccine acceptance among Malaysian pregnant women: A multicenter cross-sectional study.

Introduction: The coronavirus disease 2019 (COVID-19) caused a global pandemic that resulted in devastating health, economic and social disruption. Pregnant mothers are susceptible to COVID-19 complications due to physiological and immunity changes in pregnancy. We aimed to assess the maternal vaccine acceptance of the COVID-19 vaccine. Methods: A multi-center study across four teaching hospitals in the Klang Valley, Malaysia was conducted between September 2021 and May 2022. A survey was conducted using a self-administered electronic questionnaire. The survey instruments included; (1) maternal perception and attitude toward COVID-19 vaccination, (2) COVID-19 pregnancy-related anxiety, and 3) generalized anxiety disorder. Results: The response rate was 96.6%, with a final number for analysis of 1,272. The majority of our women were Malays (89.5%), with a mean age (standard deviation, SD) of 32.2 (4.6). The maternal vaccine acceptance in our study was 77.1%. Household income (p < 0.001), employment status (p = 0.011), and health sector worker (p = 0.001) were independent predictors of maternal willingness to be vaccinated. COVID-19 infection to self or among social contact and greater COVID-19 pregnancy-related anxiety were associated with increased odds of accepting the SARS-CoV-2 vaccine. Women who rely on the internet and social media as a source of vaccine information were more likely to be receptive to vaccination (adjusted odd ratio, AOR 1.63; 95% CI 1.14-2.33). Strong correlations were observed between maternal vaccine acceptance and the positive perception of (1) vaccine information (p < 0.001), (2) protective effects of vaccine (p < 0.001), and (3) getting vaccinated as a societal responsibility (p < 0.001). Discussion: The high maternal vaccine acceptance rate among urban pregnant women in Malaysia is most likely related to their high socio-economic status. Responsible use of the internet and social media, alongside appropriate counseling by health professionals, is essential in reducing vaccine hesitancy among pregnant women.

Delayed presentation of a huge abdominopelvic mass during the COVID-19 pandemic.

Background: Giant ovarian cysts are rare in developed countries due to advanced achievements in medical diagnostics. However, in the midst of the coronavirus disease 2019 (COVID-19) pandemic, patients with non-COVID-19-related illnesses tend to delay their health-seeking attention; thus, they had presented late. Case presentation: A 25-year-old single lady complained of a 3-month worsening abdominal pain and distention. She was initially well but neglected the symptoms due to the COVID-19 situation, yet came to our attention after she developed obstructive symptoms. A computed tomography (CT) scan of the abdomen revealed a huge cystic lesion from the pelvic area, which later was found to be from the right ovary upon urgent laparotomy exploration. The histopathological examination was consistent with mucinous cystadenoma of the ovary. Discussion: Acute non-COVID-19-related emergencies have decreased, as evidenced by reduced visits to the Emergency Department, and the number of abdominal CT scans. An emergency case like a huge abdominopelvic mass deserves an extensive radiologic examination as clinical assessment alone may not be adequate. Preoperative CT is superior to ultrasonography in getting the extent of the lesion, local infiltration, staging purpose, and surgical intervention. Pathology with a variety of spectrums such as mucinous neoplasm deserves to be investigated, evaluated, and resected even during the COVID-19 pandemic. Conclusion: A giant abdominopelvic cystic mass can present emergency havoc during the COVID-19 pandemic. Urgent surgical intervention is mandatory by using full protection and exercising extreme precaution, regardless of the preoperative screening to avoid unnecessary viral transmissions.

Gut microbiota in pregnant Malaysian women: a comparison between trimesters, body mass index and gestational diabetes status.

BACKGROUND: The primary purpose of the study is to determine the variation of gut microbiota composition between first (T1) and third trimester (T3); gestational diabetes mellitus (GDM) and non-gestational diabetes mellitus (NGDM); and also within a different category of Body Mass Index (BMI) of selected pregnant Malaysian women. METHODS: A prospective observational study on selected 38 pregnant Malaysian women attending a tertiary medical centre was carried out. Those with preexisting diabetes, metabolic syndrome or any other endocrine disorders were excluded. GDM was determined using oral glucose tolerance test (OGTT) while BMI was stratified as underweight, normal, pre-obese and obese. Fecal samples were then collected during the first trimester (T1) and the third trimester (T3). The V3-V4 region of 16S rRNA gene amplicon libraries were sequenced and analyzed using QIIME (version 1.9.1) and METAGENassist. RESULTS: Twelve women (31.6%) were diagnosed as GDM. A trend of lower α-diversity indices in GDM, pre-obese and obese pregnant women were observed. Partial Least Squares Discriminant Analysis (PLS-DA) shows a clustering of gut microbiota according to GDM status and BMI, but not by trimester. Genera Acidaminococcus, Clostridium, Megasphaera and Allisonella were higher, and Barnesiella and Blautia were lower in GDM group (P < 0.005). Obese patients had gut microbiota that was enriched with bacteria of Negativicutes and Proteobacteria class such as Megamonas, Succinatimonas and Dialister (P < 0.005). The normal and mild underweight profiles on the other hand had a higher bacteria from the class of Clostridia (Papillibacter, Oscillibacter, Oscillospira, Blautia, Dorea) and Bacteroidia (Alistipes, Prevotella, Paraprevotella) (P < 0.005). CONCLUSION: The prevalence and variation of several key bacteria from classes of Negativicutes, Clostridia and Proteobacteria has potential metabolic links with GDM and body weight during pregnancy which require further functional validation.

Endometrioma Presented as Acute Abdomen in a Peritoneal Dialysis Patient: A Case Report and Literature Review.

Laparoscopic management in patients on peritoneal dialysis offers good postoperative outcome and early resumption to peritoneal dialysis. This is a report of a 43-year-old woman with end-stage kidney disease on peritoneal dialysis presented with left iliac fossa pain due to a large endometrioma. Emergency diagnostic laparoscopy was performed with careful laparoscopic entry, Tenckhoff catheter care and anti-adhesive application. The patient underwent temporary hemodialysis for two weeks before full resumption to peritoneal dialysis. She was planned for GnRH analogue for three months post-operatively. In conclusion, laparoscopy is a safe and advantageous route of surgery for ovarian endometrioma in patients on peritoneal dialysis. However, mindful surgical strategies are needed to ensure the Tenckhoff catheter's longevity and early resumption to peritoneal dialysis post-operatively.

Spontaneous Rupture in a Non-Laboring Uterus at 20 Weeks: A Case Report.

BACKGROUND Uterine rupture is uncommon but when it happens, it can cause significant morbidity and mortality to both mother and fetus. Incidence reportedly is higher in scarred than in unscarred uteri. Most cases occur in laboring women in their third trimester with a previous history of uterine surgery, such as caesarean delivery or myomectomy. We present a case of spontaneous uterine rupture in a non-laboring uterus in the mid-trimester of pregnancy. CASE REPORT The patient presented with threatened miscarriage at 17 weeks' gestation and ultrasound findings were that raised suspicion of a morbidly adherent placenta. Her history was significant for two previous cesarean deliveries more than 5 years ago followed by two spontaneous complete miscarriages in the first trimester. The patient was managed conservatively until 20 weeks' gestation, when she presented with acute abdomen with hypotensive shock. Her hemoglobin dropped to a level such that she required blood transfusion. An emergency exploratory laparotomy was performed, which revealed a 5-cm rupture in the lower part of the anterior wall of the uterus, out of which there was extrusion of part of the placenta. Given the patient's massive bleeding, the decision was made to proceed with subtotal hysterectomy. Histopathology of the specimen confirmed the diagnosis of placenta percreta. CONCLUSIONS Identification of uterine scarring with morbidly adherent placenta is crucial because even in early pregnancy, it can lead to uterine rupture. Furthermore, failure to recognize and promptly manage uterine rupture may prove fatal.

Prevalence of sexual dysfunction in pregnancy.

PURPOSE: This study aims to determine the prevalence of sexual dysfunction during pregnancy and to determine its associated factors. METHODS: This 6-month cross-sectional study adopted convenience sampling; inclusion criteria were healthy pregnant women, sexually active and living together with their partner for 3 months prior to recruitment into this study. Women who received advice to avoid sexual intercourse, with any medical illness and/or those conceived via assisted reproductive technology were excluded. Participants filled in a questionnaire consisting of demographic details and Malay Version Female Sexual Function Index Questionnaire. Data were analysed using SPSS 24.0; categorical data were analyzed by Chi-square and Fisher exact test. RESULTS: One hundred pregnant women with a mean age of 31 + 4.31 years old participated. By using the cut-off FSFI score of 26.55, 81 (81%) participants were diagnosed to have sexual dysfunction. The mean FSFI score was 20.41 ± 8.45 (range 2.6-33.5; median 23.6). All the mean FSFI scores of first, second and third trimesters were low with 22.80 ± 10.67, 23.81 ± 7.18 and 18.74 ± 8.43, respectively. The mean score for desire, arousal, satisfaction and pain were significantly lower in the third trimester than earlier gestation. There was a significant difference in the incidence of difficulties in desire, arousal, lubrication, satisfaction and pain between first and second trimester combined, as compared to the third trimester of pregnancy. Trimester of pregnancy was found to have a significant association with the incidence of sexual dysfunction. CONCLUSION: Sexual dysfunction among pregnant women is a significant burden. Despite being a common health problem, it is often neglected.

Clinical and urodynamic assessment in patients with pelvic organ prolapse before and after laparoscopic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: We hypothesized that patient-reported urinary symptoms and urodynamic evaluation improve after laparoscopic sacrocolpopexy (LSC) despite deeper vesicovaginal space dissection. METHODS: This was a retrospective study of women with pelvic organ prolapse who underwent LSC from January 2013 to January 2016 in a tertiary center. Urinary function was clinically evaluated using the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), the Overactive Bladder Symptom Score (OABSS) and the Pelvic Floor Distress Inventory Questionnaire- - Short Form 20 (PFDI-20). Urodynamic assessment was performed before and 6 months after surgery. The Wilcoxon signed-ranks test and the McNemar test were applied with p < 0.05 considered significant. RESULTS: A total of 155 patients were included in the study. Of these, 46 had urodynamic assessment before and after LSC. There were significant improvements after LSC in urodynamic storage phase parameters (higher volume at first desire, higher volume at strong desire, and larger bladder capacity) and voiding phase parameters (higher Q max, higher Q ave, lower P det Q max, increased voided volume and reduced postvoid residual urine volume). Clinically, there was a significant increase after LSC in stress urinary incontinence and a significant reduction in urgency urinary incontinence, overactive bladder and voiding dysfunction. CONCLUSIONS: Apart from increased stress urinary incontinence, there was an improvement in overall urinary function in terms of patient-reported symptoms and urodynamics, despite deep vesicovaginal space dissection. Hence, LSC is a viable surgical option for pelvic organ prolapse, restoring both level 1 and level 2 support without detrimental effects on urinary function.

[CLINICAL OUTCOMES OF LAPAROSCOPIC SACROCOLPOPEXY FOR PELVIC ORGAN PROLAPSE: A RETROSPECTIVE ANALYSIS OF 500 CASES FROM A SINGLE INSTITUTION].

(Objectives) Laparoscopic sacrocolpopexy (LSC) is becoming a more popular alternative for pelvic organ prolapse (POP) repair in Japan in the recent years. This study aimed to evaluate the safety and efficacy of LSC. (Patients and methods) This is a retrospective study on all the LSC cases that were performed in Urogynecology center, Kameda Medical Center, Japan from January 2013 to March 2016. Medical records of all the patients were retrieved and details on operating time, estimated blood loss, perioperative complications, anatomical recurrence (postoperative POP-Q stage≥II) rate and reoperation rate were assessed.Our procedure of LSC used two pieces of polypropylene mesh placed on the vesico-vaginal and recto-vaginal space in which the dissection was extended to the level of the bladder neck and levator ani muscle. Subtotal hysterectomy was performed in almost all patients with uterus except in 39 women who chose to preserve their uterus. Additionally, multivariate analysis of risk factors for recurrence-free survival was performed using the Cox regression method. (Results) Five hundred and five patients who were diagnosed as POP (cystocele, rectocele, enterocele, uterine prolapse, vaginal vault prolapse) were included. The mean operating time and estimated blood loss were 236 min and 27.2 ml. There were 2.6% perioperative complication rate and 1.0% severe complication rate (Clavien grade≥IIIa). With a median follow-up of 12 months, anatomical recurrence rate was 8.0%, significant anatomical recurrence (stage≥III) rate was 1.2% and reoperation rate was 1.0%. Preoperative POP-Q stage IV was found as independent risk factors for anatomical recurrence. (Conclusions) The present study demonstrated a relatively low complication rate, low significant anatomical recurrence rate and low reoperation rate. Therefore, LSC is a safe and effective surgical treatment for various types of POP.

Oestrogen-soaked vaginal packing for decubitus ulcer in advanced pelvic organ prolapse: a case series.

INTRODUCTION: Cervicovaginal decubitus ulceration is a well-known complication of advanced pelvic organ prolapse (POP). There is no consensus for its management. This case series describes the outcome of using repeated vaginal packs soaked with oestrogen cream to reduce POP and promote decubitus ulcer healing. We aimed to investigate the speed of ulcer healing and endometrial safety with this regimen. METHODS: This was a retrospective study of patients with stage 3 or 4 POP and intact uterus with decubitus ulcer who were planned for surgery that included hysterectomy after ulcer healing. Vaginal packs are replaced at least biweekly-or more frequently if extruded-until ulcer resolution. RESULTS: Thirteen patients were studied. Mean age was 69 ± 6 years and mean duration of menopause was 19 ± 6 years. Nine patients had a single ulcer and four had multiple ulcers. Mean ulcer diameter was 2.8 ± 1.5 cm and mean duration for ulcer healing was 26 ± 14 days. Hysterectomy and pelvic floor reconstruction was performed a median of 5 (range 0-153) days after ulcer healing was first noted. Histopathological examination of the endometrium following hysterectomy showed three specimens with endocervical hyperplasia; one had concurrent proliferative endometrium, two had simple endometrial hyperplasia and another two had proliferative endometrium. CONCLUSION: Oestrogen-soaked vaginal packing is a viable option for managing a decubitus ulcer in advanced POP. We document a measurable impact on the endometrium with this short-term preoperative regimen. Further research is needed to evaluate its efficacy in promoting ulcer healing and endometrial safety.

Gender bias in training of medical students in obstetrics and gynaecology: a myth or reality?

OBJECTIVE: To investigate the experience of medical students during a clinical attachment in obstetrics and gynaecology (O&G). STUDY DESIGN: A questionnaire was distributed to medical students who completed their O&G posting between August 2012 and August 2013. The first part included basic demographic details (age, gender, and ethnicity) and frequency of actual clinical experience; the second part explored students' perception of their training and their relationship with other staff, in particular feeling of discrimination by specified groups of medical personnel. The responses were recorded using a Likert scale and were recategorised during analysis. RESULTS: A total of 370 questionnaires were distributed, and 262 completed questionnaires were returned, giving a response rate of 71%. Female students had a significantly higher median (IqR) number of vaginal examinations performed 0.25(0.69) (p=0.002) compared to male students. Male students experienced a higher proportion of patient rejections during medical consultation, 87% vs. 32% of female students (p<0.001), a higher rate of refusal for clerking (71.4% vs. 57.5% of females, p=0.035) and a higher rate of patients declining consent for internal examination (93.3% vs. 67.6% of females, p<0.001). The majority of male students felt that their gender negatively affected their learning experience (87% vs. 27.4% of the female students, p<0.001). Male students reported a significantly higher proportion of discrimination against their gender by medical officers (p=0.018) and specialists/consultants (p<0.001) compared to females but there was no discrimination between genders by staff nurses or house officers. A majority (58%) of female students stated an interest in pursuing O&G as a future career compared to 31.2% of male students. CONCLUSIONS: Our study confirmed that gender bias exists in our clinical setting as male students gain significantly less experience than female students in pelvic examination skills. We also demonstrated that compared to female students, male students experience higher levels of discrimination against their gender by trainers who are medical officers and specialists/consultants. Trainers must improve their attitudes towards male students, to encourage them and make them feel welcome in the clinical area. We must minimize gender discrimination and educational inequities experienced by male students, in order to improve their learning experience.

Severe acute pancreatitis in pregnancy.

This is a case of a pregnant lady at 8 weeks of gestation, who presented with acute abdomen. She was initially diagnosed with ruptured ectopic pregnancy and ruptured corpus luteal cyst as the differential diagnosis. However she then, was finally diagnosed as acute hemorrhagic pancreatitis with spontaneous complete miscarriage. This is followed by review of literature on this topic. Acute pancreatitis in pregnancy is not uncommon. The emphasis on high index of suspicion of acute pancreatitis in women who presented with acute abdomen in pregnancy is highlighted. Early diagnosis and good supportive care by multidisciplinary team are crucial to ensure good maternal and fetal outcomes.