Current management of pregnancy-associated breast cancer.

Pregnancy-associated breast cancer is the most common malignancy during pregnancy with an expected rise in incidence. The belief in the need for termination of pregnancy and that chemotherapy is contra-indicated during pregnancy is challenged by recent evidence. Patients can consider breast-conserving surgery and sentinel lymph node biopsy with acceptably low fetal risk from radiation exposure. A range of chemotherapeutics is possible in the second trimester in terms of drug class and frequency. Hormonal therapy and monoclonal antibody therapy are contra-indicated during pregnancy and lactation. Fetal outcome after in-utero exposure to chemotherapy appears similar to that in a non-pregnant population. Future pregnancy, in most situations, does not appear to be contra-indicated but a multidisciplinary and patient-centred approach is recommended. Fertility preservation techniques are also being developed with reported success and consequent pregnancies.

Dairy and nondairy beverage consumption for childhood atopic eczema: what health advice to give?

BACKGROUND: Many parents of children with atopic eczema (AE) practise empirical dietary avoidance and supplementation, and seek healthcare advice on whether consumption of dairy and nondairy beverages may be beneficial or detrimental for this condition. AIM: We investigated if frequency of consumption of beverages was associated with disease severity and quality of life (QoL). METHODS: Parent-reported frequency of drinks and beverages were recorded in consecutive children with AE, and disease severity (Nottingham Eczema Severity Score; NESS), QoL (Children's Dermatology Life Quality Index; CDLQI), skin hydration (SH), transepidermal water loss (TEWL), blood pressure (BP), resting heart rate (RHR) and body mass index (BMI) were evaluated. RESULTS: AE was associated with worse QoL than miscellaneous non-AE skin diseases (P < 0.001). Compared with children without AE, there was a trend for children with AE to drink less milk (P = 0.06) and more miscellaneous beverages (such as Chinese herbal tea and soymilk; P = 0.03). In children with AE, NESS correlated with CDLQI (ρ = 0.66, P < 0.001) and reduced SH (ρ = -0.32, P < 0.001), whereas CDLQI correlated with a higher RHR (ρ = 0.25, P < 0.01). Multiple logistic regression showed that male sex (OR = 0.44, 95% CI 0.20-0.97; P = 0.04) and drinking fresh milk (OR = 0.42, 95% CI 0.20-0.93; P = 0.03) were independent factors associated with less severe disease. Moderate to severe impairment of CDLQI was associated with NESS (OR = 1.48, 95% CI 1.28-1.71; P < 0.001) and RHR (OR = 1.05, 95% CI 1.02-1.08; P < 0.01) but not with reported habits of beverage consumption. Concerning cardiovascular health in AE, frequency of formula milk consumption was associated with RHR (ρ = 0.17, P = 0.04), and soft drink consumption was associated with higher systolic blood pressure (SBP) (ρ = 0.18, P = 0.04). CONCLUSION: This study provides evidence for parental/patient guidance. Children with AE who reported more fresh milk consumption had less severe disease. There was no correlation between consumption of nondairy beverages with disease severity or QoL, but frequency of soft drink consumption correlated with SBP. With these results being supported by a literature review, it is reasonable to advise parents that fresh milk can be consumed by unsensitized children with AE. Soft drinks and other beverages should not be consumed in excess for optimal cardiovascular health and for other health reasons.

Change in prevalence of group B Streptococcus maternal colonisation in Hong Kong.

OBJECTIVES: To re-examine the prevalence of group B Streptococcus colonisation in our antenatal population, and identify demographic factors associated with carriage. DESIGN: Prospective observational study. SETTING: A tertiary obstetrics unit in Hong Kong. PARTICIPANTS: A total of 1002 pregnant women were recruited at the booking clinic in a tertiary obstetrics unit in Hong Kong. High and low vaginal swabs and rectal swabs were taken for group B Streptococcus culture. Demographic data and delivery outcomes of the recruits were analysed. RESULTS: The prevalence of group B Streptococcus colonisation in our antenatal population was 10.4%. The majority of carriers were identified by low vaginal swabs (78%), while high vaginal swabs and rectal swabs only identified 31% and 30% of the carriers, respectively. Professional women yielded a higher carrier rate than housewives (21% vs 10%, P=0.03). There was no increase in preterm delivery rate in group B Streptococcus carriers. CONCLUSIONS: We noted a dramatic increase in the prevalence of group B Streptococcus colonisation in the Hong Kong pregnant population at their booking visit. Professional women had a higher colonisation rate compared to other groups.

Fetal crown-rump length and estimation of gestational age in an ethnic Chinese population.

OBJECTIVES: To develop a sonographic dating formula based on fetal crown-rump length (CRL) in a Hong Kong Chinese population, quantify its systematic prediction error and compare its performance with established dating formulae. METHODS: This was a prospective observational study of women with a spontaneously conceived singleton pregnancy and a regular menstrual cycle in the preceding 12-month period. Ultrasound examinations were performed at gestational ages ranging from 6 to 15 + 6 weeks according to menstrual dates. The CRL of each fetus was measured three times, the mean of which was used to derive the best-fit fractional polynomial regression model for estimation of gestational age in relation to CRL. For each fetus, the menstrual age was compared to the gestational age calculated using three established dating formulae based on CRL measurement. The mean of the differences between estimated and menstrual age was calculated for each formula. RESULTS: Of the 394 subjects recruited one was excluded as the pregnancy resulted in intrauterine demise. The best-fit equation for the sonographic estimate of gestational age (GA, in days) from CRL (in mm) was GA = 26.643 + 7.822 x CRL(1/2)(R(2) = 0.96). The mean difference between menstrual age and the predicted gestational age was 0.22 days (95% CI, - 0.14 to 0.56), which was lower than that of the three established CRL dating formulae. CONCLUSION: We have derived a formula suitable for the dating of naturally conceived pregnancies between 6 and 15 weeks of gestation that has no systematic prediction error (the 95% CI of mean difference between predicted and menstrual age included zero), comparing favorably with established CRL dating formulae.

Trends in maternal obesity and associated risks of adverse pregnancy outcomes in a population of Chinese women.

OBJECTIVE: To assess the effect of increasing body mass index (BMI) on pregnancy outcome in a population of Chinese women. DESIGN: A retrospective study. SETTING: A university teaching hospital. POPULATION: Women delivering singleton babies between 1995 and 2005 who sought antenatal care before 20 weeks of gestation. METHODS: A total of 29,303 women were categorised into six BMI groups according to WHO's classification. Univariate, multivariate and logistic regression analysis were performed to compare obstetric and perinatal outcomes between BMI groups. MAIN OUTCOME MEASURES: Incidences of caesarean delivery, pre-eclampsia, gestational diabetes, preterm delivery, small for gestational age (SGA) and large for gestational age (LGA), perinatal death, and the respective odd ratios in reference to the normal group with BMI > or = 18.5 kg/m(2) and <23 kg/m(2). RESULTS: The median BMI increased with increasing maternal age, parity, gestation at the first visit, but decreased with year of delivery (P < 0.001). Concerning the obstetric outcomes, increasing BMI was associated with increasing incidence of caesarean section, pre-eclampsia, gestational diabetes, preterm delivery, LGA, as well as SGA according to customised growth standards (P < 0.001). The odds ratios for most of these adverse outcomes are higher than those reported in Caucasian population. Increasing BMI was not associated with the rate of stillbirth, neonatal death or shoulder dystocia. CONCLUSION: Increasing BMI is associated with increased risks of adverse obstetric outcomes. The impacts of high BMI on pre-eclampsia, gestational diabetes and preterm delivery in Chinese women might be stronger than that in Caucasian. Hence, it may be appropriate to use a lower BMI cutoff for defining overweight in Chinese.

Side-effect and vital sign profile of nifedipine as a tocolytic for preterm labour.

OBJECTIVE: To examine the side-effect and vital sign profile of nifedipine used as a tocolytic. DESIGN: Retrospective audit. SETTING: Tertiary care university hospital, Hong Kong. PATIENTS: Women presenting with preterm labour (before 34 weeks of gestation) between March 2001 and September 2004. MAIN OUTCOME MEASURES: Maternal heart rate, blood pressure, and foetal heart rate were monitored regularly. A four-point Likert scale multiple-choice questionnaire was used to assess the perceived degree of flushing, headache, nausea, dizziness, and shortness of breath. All assessments were performed at predefined intervals from the onset of treatment. Repeated measures analysis of variance was performed to identify any time-dependent association with nifedipine treatment. RESULTS: In all, 212 episodes of preterm labour were treated with nifedipine in 203 women. In 120 episodes, preterm labour was suppressed for more than 48 hours. Treatment was discontinued in three women because of profound hypotension (<90/60 mm Hg), and in one because of severe flushing. Only one patient developed maternal tachycardia (>or=140 beats per minute), and in two foetal tachycardia (>or=180 beats per minute) was encountered. Moderate headache was experienced in nine women, flushing in nine, dizziness in four, nausea in three, and shortness of breath in one. Repeated measures analysis of variance with time of measurement revealed a significant reduction in maternal blood pressure and increase in maternal heart rate that plateaued after 1 hour of therapy. The foetal heart rate returned to baseline values 3 hours after commencing therapy. CONCLUSION: In general, use of nifedipine as the first-line tocolytic was safe. However, severe maternal hypotension can occur and close monitoring of vital signs is warranted.

Umbilical cord ulceration causing foetal haemorrhage and stillbirth.

We report a case of umbilical cord ulceration associated with obstruction of the duodeno-jejunal junction by a peritoneal band. Umbilical cord ulceration is a rare condition; a literature review identified a total of 17 cases only. In all cases, the ulceration was associated with congenital intestinal obstruction. Cord ulceration usually presents as sudden foetal deterioration due to foetal haemorrhage. This condition is associated with high perinatal mortality and morbidity. The causes of this condition are still unknown, and prenatal diagnosis is difficult. Awareness of the possible association between umbilical cord ulceration and intestinal obstruction, and of the need to deliver such pregnancies immediately when an abnormal foetal heart rate pattern develops might be the only means of preventing intrauterine death and improving neonatal outcomes.

Fetal biometry in ethnic Chinese: biparietal diameter, head circumference, abdominal circumference and femur length.

OBJECTIVES: To construct new reference charts and equations for fetal biometry in the Hong Kong ethnic Chinese population, and to compare them with existing references from different populations. METHODS: This was a prospective observational study involving 709 women with singleton pregnancies and confirmed gestational age. For the purposes of this study, each woman was scanned once only, between 12 and 40 completed weeks of gestation, and the following fetal biometric measurements were recorded: biparietal diameter, head circumference, abdominal circumference and femur length. For each measurement, regression models were fitted to estimate the mean and SD at each gestational age. For comparison, the fetal biometric measurements of other populations at each gestation were expressed as Z-scores calculated with our reference equations. Results were presented graphically across the different gestational ages to allow visual comparison. RESULTS: New charts and reference equations are reported in this Hong Kong Chinese population for fetal outer-inner and outer-outer biparietal diameter, head circumference, abdominal circumference and femur length. Equations for dating of pregnancy are presented. Our charts were very similar to those of the Singaporean population for most parameters. The main difference in our fetal biometric measurements compared with those of the UK and French populations was in FL. CONCLUSIONS: Our new set of reference centiles for fetal biometric measurements and equations for dating of pregnancy in a Hong Kong Chinese population are ready for clinical use and research in appropriate ethnic Chinese groups.

Prediction of birth weight by fetal crown-rump length and maternal serum levels of pregnancy-associated plasma protein-A in the first trimester.

OBJECTIVE: To determine whether the first trimester crown-rump length (CRL), maternal serum levels of pregnancy-associated plasma protein A (PAPP-A) and free beta-human chorionic gonadotropin (fbeta-hCG) are independent predictors of birth weight. METHODS: This was an observational study over 1.5 years in Chinese patients who underwent first-trimester combined screening for Down syndrome in a University fetal medicine unit. After excluding cases with multiple pregnancies, congenital malformations and in-utero deaths, the relationship between fetal CRL (expressed as standardized Z-score (Z-CRL)), maternal PAPP-A and fbeta-hCG levels (expressed as log(10) of multiples of the median) and birth weight (Z-BW) were analyzed by Pearson's correlation test followed by multiple regression to check for their independency. The predictive power of the independent predictors for small-for-gestational age (SGA, defined as birth weight < 10(th) centile) was then assessed using receiver-operating characteristics (ROC) curves, and the likelihood ratios were derived. RESULTS: A total of 2760 cases were included. Z-CRL, log(10) PAPP-A(MoM), and log(10) fbeta-hCG were positively correlated with Z-BW (P < 0.0001), but only Z-CRL and log(10) PAPP-A(MoM) were independent predictors (P < 0.0001). The areas under the ROC curves of PAPP-A(MoM) and Z-CRL were 0.608 and 0.593, respectively (P < 0.0001). Likelihood ratios increased with decreasing PAPP-A(MoM) and Z-CRL, but were around 1 when the markers were at or above the mean. CONCLUSION: First-trimester CRL and PAPP-A are independent factors that influence final birth weight. The lower the PAPP-A and the smaller the CRL, the higher the risk of a fetus becoming SGA. However, their predictive powers are not sufficiently good for them to be used alone for SGA screening.

Foetal intracranial teratoma: choosing the best time and mode of delivery.

We present a case of foetal intracranial teratoma diagnosed at 28 weeks of gestation after prior normal sonographic examinations. A multidisciplinary team, involving obstetricians, neonatologists, and neurosurgeons, suggested management. The foetus was delivered by lower segment caesarean section at 30 weeks of gestation but the neonate succumbed 3 days after delivery, 1 hour after the withdrawal of active treatment. Issues governing the timing and mode of delivery, together with the role of cephalocentesis in the management of this condition, are discussed.

A longitudinal observational study of preference for elective caesarean section among nulliparous Hong Kong Chinese women.

OBJECTIVE: To establish whether women's preference for elective caesarean section (ELCS) changes as gestation advances. DESIGN: A prospective longitudinal observational study. SETTING: Two units providing obstetric care in Hong Kong, one public and one private. SAMPLE: Five hundred and one nulliparous Chinese pregnant women attending their routine fetal anomaly scan in either unit. METHODS: Consented subjects had two interviews using a structured questionnaire at 18-22 weeks and 35-37 weeks of gestation, respectively. Multivariate analysis was performed to identify determinants for preferring ELCS at the two gestational ages. MAIN OUTCOME MEASURE: The preferences for the mode of delivery at the two gestational ages. RESULTS: The prevalence of maternal preference for ELCS in the study cohort was 17.2% (95% CI 13.9-20.5) and 12.7% (95% CI 9.6-15.8) at mid-trimester and at term, respectively. Significantly more women who preferred ELCS at mid-trimester changed to a trial of vaginal delivery (VD) at term than vice versa (42.0 versus 3.8%). The partner's preference for ELCS was a significant determinant for women preferring ELCS throughout the antenatal period. Among the women booked in the public sector, more women who preferred ELCS at term changed to deliver in private hospitals than those who preferred VD (46.2 versus 9.7%). CONCLUSIONS: Many women changed from preferring ELCS to preferring VD as their pregnancy approached term. The partner's preference was a significant determinant for the women's choice. If a decrease in the proportion of women preferring ELCS is desired, the intervention programme should target the women and their partners who hold such a preference at 20 weeks.

First-trimester combined screening for trisomy 21 in a predominantly Chinese population.

OBJECTIVE: To examine the effectiveness of first-trimester fetal trisomy 21 screening using a combination of maternal age, nuchal translucency thickness (NT) and maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) levels in a predominantly Chinese population in Hong Kong. METHODS: This was a prospective study over a 1.5-year period of 2990 women who underwent combined screening for trisomy 21 between 11+0 and 13+6 weeks of gestation in a university fetal medicine unit. NT was measured according to the criteria set by The Fetal Medicine Foundation (FMF), maternal serum free beta-hCG and PAPP-A levels were measured, and the risk of trisomy 21 was calculated using The FMF's algorithm. Fetal karyotyping was advised when the risk was 1 : 300 or above. All subjects were followed up for pregnancy and fetal outcome. RESULTS: Of the 2990 women who underwent the screening program, 99% were Chinese. There were 57 twin pregnancies, giving a total of 3047 fetuses. Thirty-one percent of the women were 35 years old or above. One hundred and eighty-five (6.1%) fetuses were screen-positive; this included 14 cases of trisomy 21 and 17 cases of other chromosomal abnormalities. The positive predictive value was 16.7%. Among the 2862 screen-negative fetuses, only 18 (0.6%) cases had an unknown fetal outcome. There were no cases in which trisomy 21 was missed and the infant was liveborn. CONCLUSION: First-trimester combined screening for fetal trisomy 21 is highly effective among Chinese subjects.

Identification of a Streptococcus agalactiae serotype III subtype 4 clone in association with adult invasive disease in Hong Kong.

Characterization of Streptococcus agalactiae serotype III isolates revealed a subtype 4 clone that has an indistinguishable pulsed-field gel electrophoresis pattern and possesses a C-alpha protein, IS1381, and a novel sequence type (ST), ST 283, by multilocus sequence tagging. This clone was significantly associated with diseases caused by invasive strains from nonpregnant adults (P

First-trimester maternal serum levels of placental hormones are independent predictors of second-trimester fetal growth parameters.

OBJECTIVE: To determine whether first-trimester maternal serum levels of pregnancy-associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotropin (fbeta-hCG) are independent predictors of second-trimester fetal growth parameters. METHODS: This was a cohort study over a 1-year period involving 594 Chinese women who underwent both first-trimester combined screening for Down syndrome and a routine second-trimester ultrasound examination. Maternal PAPP-A and fbeta-hCG levels (expressed in log(10) of multiples of median (MoM)), crown-rump length (CRL) (expressed in standardized Z-score (Z-CRL)), and maternal height and weight, were correlated with the Z-score of biparietal diameter (Z-BPD), femur length (Z-FL) and abdominal circumference (Z-AC) measured in the second trimester, using the Pearson test, followed by multiple regression analysis. RESULTS: Z-BPD, Z-FL and Z-AC were positively correlated with log(10) PAPP-A MoM, CRL and maternal height (all P < 0.05), while log(10) fbeta-hCG MoM was negatively correlated with Z-AC (P < 0.05). After controlling for the effects of CRL, maternal height and weight, log(10) PAPP-A MoM was found to be an independent positive predictor of Z-FL (r = 0.797, P < 0.001) and Z-AC (r = 0.305, P = 0.049), and log(10) fbeta-hCG MoM was an independent negative predictor of Z-FL (r = -0.381, P = 0.023) and Z-AC (r = -0.418, P = 0.002). Neither hormonal level was related to Z-BPD. CONCLUSIONS: First-trimester PAPP-A and fbeta-hCG are independent factors that influence subsequent fetal growth. PAPP-A level is positively correlated with FL and AC in the second trimester, while fbeta-hCG level is negatively correlated with them. However, BPD is not affected by either of the hormones.

First-trimester maternal serum level of pregnancy-associated plasma protein-A is an independent predictor of fetal maxillary bone length.

OBJECTIVE: To derive a nomogram of fetal maxillary bone length (MAX) for a Chinese population and to study whether first-trimester maternal serum levels of pregnancy-associated plasma protein-A (PAPP-A) is an independent predictor of fetal MAX. METHODS: This was a prospective observational study over 10 months examining Chinese women with a singleton pregnancy who attended the first-trimester screening program for Down syndrome. The subjects had the fetal crown-rump length (CRL), nuchal translucency, MAX, maternal serum PAPP-A and free beta-human chorionic gonadotropin (fbeta-hCG) levels measured. A nomogram of MAX was derived using normal pregnancies with reliable dates. The correlations between MAX, CRL, PAPP-A and fbeta-hCG levels were studied, after correction for gestational dependency using Z-score transformation for the ultrasound markers (Z-MAX and Z-CRL), and logarithmic transformation of multiple of gestation-specific medians for the biochemical markers (log10PAPP-A multiples of the median (MoM) and log10fbeta-hCG MoM), using the Pearson test and multiple regression analysis. RESULTS: During the study period, 607 Chinese women met the inclusion criteria. The mean gestational age at the first-trimester screening was 12 + 4 weeks (SD, 4 days). Curve estimation analysis showed that a linear relationship fit best between MAX and CRL (MAX (mm) = -0.01 + 0.101 * CRL (mm); r = 0.826; P < 0.0001), and between MAX and gestational age (MAX (mm) = -8.465 + 0.170 * gestational age (day); r = 0.754; SD = 0.71; P < 0.0001). There were significant positive correlations between Z-MAX and Z-CRL (r = 0.627; P = < 0.0001), Z-MAX and log10PAPP-A MoM (r = 0.239; P = < 0.0001). Multiple regression analysis showed that both Z-CRL (P = < 0.0001) and log10 PAPP-A MoM (P = 0.048) were independent predictors for Z-MAX. CONCLUSION: Both CRL and maternal levels of PAPP-A are independent predictors of the fetal MAX measured during the first trimester. The positive correlation between PAPP-A levels and fetal MAX is consistent with the known biological function of PAPP-A on bone growth. This association must be adjusted for when both PAPP-A and MAX are combined for screening of Down syndrome.

Cervical length at 18-22 weeks of gestation for prediction of spontaneous preterm delivery in Hong Kong Chinese women.

OBJECTIVE: To assess the value of a single cervical length measurement by transvaginal sonography (TVS) at the time of mid-trimester anomaly scan for predicting spontaneous preterm delivery (SPD) among Chinese women. METHODS: A prospective observational study was carried out involving 2880 subjects with singleton pregnancies and confirmed gestational age. Cervical length was measured at 18-22 weeks of gestation. RESULTS: The incidence of SPD < 34 weeks and < 37 weeks were 0.7% and 3.7%, respectively. Women with SPD < 34 weeks and SPD < 37 weeks had shorter median cervical lengths (32.6 mm and 36.2 mm, respectively) than those with term deliveries (37.6 mm) (P = 0.006 and 0.025, respectively). The predictive performance of cervical length was better for SPD < 34 weeks compared with < 37 weeks. A cervical length < or = 27 mm, which corresponded to the 4th centile, occurred in 36.8%, 62.5% and 100% of those with SPD < 34, < 30 and < 26 weeks, respectively. The positive likelihood ratio (LR) of a cervical length < or = 27 mm in predicting SPD < 34 weeks was 9.8. Using logistic regression, both short cervix and funneling were independent predictors for SPD < 34 weeks of gestation. The coexistence of funneling and a cervical length < or = 27 mm gave a positive predictive value (PPV) and LR of SPD < 34 weeks of 14.7% and 26.0, respectively. CONCLUSIONS: Mid-trimester cervical length is predictive of SPD in Chinese women. However, given the low PPV of a short cervical length, its clinical utility is still limited in low-risk populations.