Investigating stillbirths using a simplified obstetric events-based protocol.

INTRODUCTION: A stillbirth remains a distressing enigma to parents and clinicians alike as the cause often remains elusive. Few papers describe a protocol for the investigation of stillbirths. We evaluate the first obstetric events-based protocol designed for local use with an aim to adequately investigate stillbirths in a cost-effective manner. METHODS: A prospective cohort study was performed on 61 stillbirths at KK Women's and Children's Hospital. There were a total of 16,980 births in the year 2000. RESULTS: 37.7 percent of cases remained unexplained. There was protocol compliance in 51 cases (83.6 percent) with deviation in 10 cases (16.4 percent). The protocol helped to minimise costs in 18 cases (29.5 percent) as selected investigations were performed in view of obvious causes. The overall postmortem rate was 27.9 percent with the lowest rates in the Malay population. CONCLUSION: An obstetric events-based protocol allows clinicians to tailor their investigations easily and appropriately. It helps to provide optimal investigations and minimise unnecessary costs. It could be further fine-tuned by initiating detailed serum investigations only after delivery so as to exclude an obvious cause, like cord accidents, where full investigations are unnecessary.

Acardiac anomaly.

Two cases of acardius, one in a twin and the other in a triplet pregnancy are presented. The obstetrical significance and current management options are discussed.

Confidential enquiry of stillbirths in current obstetric practice.

OBJECTIVE: Confidential panel enquiry into sub-optimal factors relating to stillbirths. METHOD: All 121 stillbirths in KK Women's and Children's Hospital in the years 1995 and 1996 were studied. Three assessors reviewed the case records of each death, and panel consensus was reached regarding sub-optimal antenatal care and factors leading to stillbirths. RESULT: The incidence rate of stillbirth was 4.04 per 1000 deliveries. A total of 76 cases (62.8%) were found to have grade II and III sub-optimal factors in their management. Patients themselves were involved in the sub-optimal management of their own pregnancy in 52.9% of the stillbirths. Primary healthcare givers were involved in 8.3% of all stillbirths, specialist caregivers 12.4% and antenatal care system 4.1%. CONCLUSION: The study has identified sub-optimal antenatal management in over 60% of cases. As patients' factors form the major contribution towards sub-optimal care, management strategy aimed towards improving patients' education and compliance to antenatal care should be a priority.

A case report: cephalic replacement and emergency caesarean section for the resolution of shoulder dystocia.

Shoulder dystocia is a serious complication of delivery. Various manoeuvres had been described, all aim at achieving shoulder descent and vaginal delivery. We report a case whereby shoulder dystocia was managed by a rather unique technique--the foetal head was replaced in the vagina and baby delivered by emergency Caesarean Section.

Nausea and vomiting after termination of pregnancy as day surgery cases: comparison of 3 different doses of droperidol and metoclopramide as anti-emetic prophylaxis.

Frequency of nausea and vomiting following day case termination of pregnancy was found to be rather high (42%) without anti-emetic prophylaxis. Droperidol in doses of 2.5 mg, 1.25 mg and 0.25 mg were found to be equally effective as prophylactic anti-emetic, but not metoclopramide 10 mg. This study confirms that low dose droperidol 0.25 mg is effective as a prophylactic anti-emetic, without any delay in immediate recovery and hence suitable for day surgery cases.

PIP: 325 outpatients at Alexandra Hospital in Singapore received intravenously either 2.5 mg droperidol, 1.25 mg droperidol, 0.25 mg droperidol, 10 mg metoclopramide, or a placebo before undergoing surgical abortion. Nursing staff assessed their condition 4-6 hours postoperatively. 42.3% of the women in the untreated group experienced nausea and vomiting after the operation compared to 25.6% for women who received 0.25 mg droperidol (p.05), 23.7% for those who received 1.25 mg droperidol (p.05), and 15.6% for those who received 2.5 mg (p.01). Yet women who received 2.5 mg droperidol were more likely to require sedation 2 hours postoperatively than the other groups and the untreated group (p.05). Even though the percentage of women who experienced nausea and vomiting and received 10 mg metoclopramide was less (37.9%) than those who received the placebo, the difference was not significant. In another study, 1 mg of droperidol slowed perceptual speed and ambulatory recovery. Since 0.25 mg of droperidol resulted in faster recovery in this study and other studies, it was the most effective prophylactic antiemetic.

Seroprevalence of cytomegalovirus, toxoplasma and parvovirus in pregnancy.

AIM OF STUDY: The aim of our study was to determine the seroprevalence of cytomegalovirus (CMV), toxoplasma and parvovirus infection in our local antenatal population, and to see the effects, if any, of age, race, parity and nationality on its seroprevalence. METHODOLOGY: The sera of 120 consecutive antenatal women seen in KK Women's and Children's Hospital between the period of October 1997 and March 1998 were screened for cytomegalovirus (CMV) IgG, toxoplasma IgG and parvovirus B19 IgG and IgM. An antibody titer greater than 1:32 was regarded as positive. RESULTS: A total of 87.0% of patients were tested seropositive for CMV IgG, 17.2% seropositive for toxoplasma IgG and 30.0% seropositive for parvovirus IgG. There seemed to be a trend of increasing seropositivity with age in all three groups, however only parovirus B19 reached statistical significance. The incidence of all three infections were higher among the Malays, Indians and other races compared to the Chinese. CONCLUSION: CMV is endemic in our population and hence the most common infection. Toxoplasmosis and parvovirus is relatively low in our population but this implies that a large proportion of our antenatal women are still susceptible to these infections. Prevention of congenital CMV, toxoplasmosis and parvovirus infection is mainly by educating the antenatal population.

Optimising management of stillbirths in modern Singapore.

OBJECTIVE: To conduct a critical analysis of stillbirths in Kandang Kerbau Hospital with emphasis on epidemiological factors, related causes and investigation strategies. DESIGN: A prospective study. SETTING: Kandang Kerbau Hospital. PATIENTS: Case records containing antenatal and post-partum details of all 136 stillbirths were obtained from the medical records office and reviewed by 3 obstetricians. Epidemiological data, antenatal history, intrapartum progress, post-partum investigation, post-mortem findings (where applicable) were reviewed and recorded. RESULTS: The incidence of stillbirths was 4.48/ 1,000 in 1994. 73.1% of the stillbirths were macerated. Significantly higher stillbirth rates were noted in the Malays and unbooked or late booking cases. The causes of stillbirths were unexplained in 29.4%. Fetal anomalies constituted 18.4%, followed by asphyxia, abruptio, and cord accidents. Maternal obstetrical problems contributed to the rest. CONCLUSION: A comprehensive management strategy to reduce stillbirths include community and patient education, early or shared antenatal care, careful prenatal surveillance, optimum investigations as well as a careful audit with adequate bereavement and counselling.

Management and outcome of gestational diabetes in Alexandra Hospital, Singapore.

We analysed 216 patients with gestational diabetes over a 3 year period. These patients were managed by a diabetic team under a standardised protocol. Forty percent of these patients required insulin therapy. The incidence of pregnancy hypertension was 14.4%, macrosomia 8.8% and major congenital malformation 3.7%. The Caesarean Section rate was 34% and the overall Perinatal Mortality Rate was 1.9%. However, neonatal morbidity rate remained high--44% of infants have had one neonatal complication and 17.6% had 2 or more complications. Pregnancy outcome was further analysed among patients with different degrees of glucose intolerance at diagnosis. We noted that both macrosomic rate, neonatal morbidity rate, as well as proportion of patients requiring insulin were higher in the group with a higher degree of glucose intolerance. There was, however, no difference in incidence of hypertension or hydramnios in the different subgroups.

Evaluation of different promoters driving the GFP reporter gene and selected target tissues for particle bombardment of Dendrobium Sonia 17.

Three different morphological callus types, identified as type A, B and C, and tips of in vitro inflorescences were used as target tissues for genetic transformation. Five different DNA plasmids carrying a synthetic green fluorescent protein (gfp) gene driven by different promoters, CaMV 35S, HBT, and Ubi1 were tested for the genetic transformation of Dendrobium Sonia 17. 35S-sgfp-TYG-nos (p35S) with the CaMV 35S promoter showed the highest GFP transient expression rate, while the HBT and Ubi1 promoters showed a relatively lower expression rate in all of the target tissues tested. The highest number of GFP-expressing cells was observed on day 2 post-bombardment, and the number declined gradually over the course of the next 2 weeks. Type A and B callus were found to be the best potential target tissues for genetic transformation.