Continuous Glucose Monitoring Feedback in the Subsequent Development of Gestational Diabetes: A Pilot, Randomized, Controlled Trial in Pregnant Women.

OBJECTIVE: This study evaluated the effects of receiving glucose feedback from continuous glucose monitoring (CGM) by intermittent scanning (unblinded group), and CGM with masked feedback (blinded group) in the subsequent development of gestational diabetes mellitus (GDM). STUDY DESIGN: This was a prospective, single-center, pilot, randomized controlled trial including n = 206 pregnant women in the first trimester of pregnancy with no prior diagnosis of type 1 or type 2 diabetes. The participants were randomized into the unblinded group or blinded group and wore the CGM in the first trimester of pregnancy (9-13 weeks), the second trimester of pregnancy (18-23 weeks), and late-second to early-third trimester (24-31 weeks). The primary outcome was GDM rate as diagnosed by the 75-g oral glucose tolerance test (OGTT) at 24 to 28 weeks. RESULTS: Over 47 months, 206 pregnant women were enrolled at 9 to 13 weeks. The unblinded group had a higher prevalence of women who developed GDM (21.5 vs. 14.9%; p > 0.05), compared to the blinded group. In the unblinded group compared to the blinded group, plasma glucose values were higher at 1 hour (median 7.7 [interquartile range {IQR}: 6.3-9.2] vs. 7.5 [6.3-8.7]) and 2 hours (6.3 [5.8-7.7] vs. 6.2 [5.3-7.2]), but lower at 0 hour (4.2 [4.0-4.5] vs. 4.3 [4.1-4.6]; p > 0.05). All these differences were not statistically significant. CONCLUSION: Glucose feedback from CGM wear in the first to the third trimester of pregnancy without personalized patient education failed to alter GDM rate. KEY POINTS: · Continuous glucose monitoring (CGM) is feasible for use in pregnant women.. · No significant difference in gestational diabetes rates with or without CGM feedback.. · Future clinical trials should incorporate CGM education and personalized guidance to enhance study outcomes..

Tranexamic acid, as an adjunct to oxytocin prophylaxis, in the prevention of postpartum haemorrhage in women undergoing elective caesarean section: A single-centre double-blind randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of tranexamic acid (TXA) in reducing blood loss during elective caesarean sections in women with and without risk factors for postpartum haemorrhage (PPH). DESIGN: A double-blind, randomised placebo-controlled trial. SETTING: An academic tertiary referral centre in Singapore. POPULATION: Multiethnic women aged 21 years or older undergoing elective caesarean section. METHODS: Randomisation to intravenous TXA or normal saline (placebo) 10 minutes before skin incision. MAIN OUTCOME MEASURES: Calculated estimated blood loss (cEBL), derived from blood volume and haematocrit levels. RESULTS: Between June 2020 and October 2021, 200 women were randomised to the placebo or TXA groups. Women who received prophylactic TXA had a significantly lower mean cEBL compared with those receiving placebo (adjusted mean difference -126.4 mL, 95% CI -243.7 to -9.1, p = 0.035). The effect was greatest in those at high risk for PPH, with a reduction in cEBL (mean difference -279.6 mL, 95% CI -454.8 to -104.3, p = 0.002) and a lower risk of cEBL ≥500 mL (risk ratio [RR] 0.54, 95% CI 0.36-0.83, p = 0.007) and cEBL ≥1000 mL (RR 0.44, 95% CI 0.20-0.98, p = 0.016). Subgroup analysis showed benefit for women with preoperative haemoglobin <10.5 g/dL (mean difference -281.9 mL, 95% CI -515.0 to -48.8, p = 0.019). There was no significant difference in need for additional medical or surgical interventions. There were no maternal or neonatal adverse outcomes. CONCLUSION: Prophylactic TXA should be considered in women with risk factors for PPH, and those most likely to benefit are those with preoperative haemoglobin <10.5 g/dL.

Sleep quality and BMI in pregnancy- a prospective cohort study.

BACKGROUND: Pregnancy associated sleep disturbances is a common pregnancy-related complication which can lead to significant maternal distress and adverse pregnancy outcomes. Sleep quality can be affected by multiple factors and obesity has been recognized as one of them. Various previous studies have demonstrated poorer sleep quality during pregnancy. However, most studies included assessment at only one point of pregnancy. This prospective cohort study aimed to better evaluate the effect of pregnancy on the quality of sleep throughout the antenatal period and how BMI affects antenatal sleep. METHODS: A total of 926 women were recruited before 14 weeks of gestation and followed throughout pregnancy. The Pittsburgh Sleep Quality Index questionnaire (PSQI) was employed to assess sleep quality in 4 antenatal visits throughout pregnancy. Their weight was also recorded at each visit. RESULTS: The PSQI global score was higher towards the later part of pregnancy (6.4 to 8.0, p < 0.001) and highest at the 4th visit. Sleep latency was longer as pregnancy progressed (18.5 mins to 23.2 mins, p = 0.001). Sleep duration became shorter over time and was the shortest at the 4th visit (7.1 h to 6.5 h, p < 0.001). Sleep efficiency was the lowest at the 4th visit (85.2 to 81.6%, p < 0.001). The same trend was observed for subjects in different BMI groups throughput pregnancy. PSQI score increased and sleep duration decreased as BMI increased. The effect of increasing BMI on PSQI and sleep duration was only observed in the higher BMI groups (> 25 kg/m2). CONCLUSIONS: Our study showed that sleep quality gradually declined throughout pregnancy for all BMI groups. Higher BMI was associated with poorer sleep as represented by PSQI score and sleep duration, particularly in the overweight and obese subgroups.

Multicentre randomised controlled trial comparing the safety in the first 12 h, efficacy and maternal satisfaction of a double balloon catheter and prostaglandin pessary for induction of labour.

OBJECTIVE: To evaluate the safety in the first 12 h, efficacy and maternal satisfaction of a double balloon catheter (DBC) with vaginal prostaglandin (PGE) for induction of labour (IOL). METHODS: We conducted a multicentre randomised controlled study of 420 patients from 1st January 2016 to 31st December 2017 to evaluate the use of DBC in IOL in an Asian population looking at the adverse effects in the first 12 h after insertion. Women were assigned randomly to cervical ripening with either a DBC or a prostaglandin pessary. The adverse events in the 12 h after DBC or first prostaglandin inserted, the efficacy of a DBC to a prostaglandin in labour induction and maternal satisfaction were evaluated. RESULTS: There were significantly less women with uterine hyperstimulation in the DBC (2 vs 24, p ≤ 0.0001) compared to the prostaglandin group. There were no women with uterine hyperstimulation and non-reassuring foetal status in the DBC while there were 5 women with uterine hyperstimulation and foetal distress in the prostaglandin group. Use of entonox was significantly less in the DBC group (p = 0.009). There were no significant differences in both groups in caesarean section, vaginal deliveries and time to delivery, although significant less time was needed to achieve cervical os dilation more than 4 cm in the DBC group (p ≤ 0.0001). Neonatal birth outcomes were similar. Women's pain scores were similar for both methods. 80.1% of women allocated the DBC and 76.8% of women allocated the PGE were keen to recommend their method of induction. CONCLUSION: Double balloon catheter remains a good alternative method for inducing women in view of a good safety profile with low risk of hyperstimulation and high maternal satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02620215.

Dinoprostone vaginal insert (DVI) versus adjunctive sweeping of membranes and DVI for term induction of labor.

AIM: To compare the efficacy and safety of dinoprostone vaginal insert (DVI) alone versus DVI with adjunctive sweeping of membranes (ASM) for induction of labor (IOL). METHODS: Single-center, prospective, randomized controlled trial; women with singleton term pregnancies, cervical dilation ≥1 and <3 cm, intact membranes allocated to either DVI or DVI with ASM. The primary outcome was vaginal delivery within 24 h of insertion. Secondary outcomes included mean time from insertion to delivery, tachysystole, operative delivery for non-reassuring fetal status (NRFS), tocolytics, fetal outcomes, pain information, and subject satisfaction. RESULTS: One hundred and four received DVI (Group 1) alone and 104 DVI with ASM (Group 2). The rate of vaginal delivery within 24 h was 53% versus 56%, cesarean rate 8.7% versus 10.6% in Groups 1 and 2 respectively. Although the duration of labor was similar in both groups, about 6% of women required additional ripening with dinoprostone vaginal tablets in Group 2 compared to 11.5% in Group 1 (p-value = 0.2). The frequency of hyperstimulation syndrome, failed induction, analgesic requirements, and fetal outcomes were comparable. The majority (83%-86%) in either cohort were satisfied with their labor experience. Multivariate logistic regression demonstrated a slightly better chance for vaginal delivery within 24 h (odds ratio [OR] 1.22 [95% confidence interval, CI 0.65-2.29]; p-value 0.53] for DVI with ASM, although statistically insignificant. Younger maternal age and multiparity (OR 10.36 [95% CI 4.88-23.67]; p-value <0.0001) contributed to successful IOL. CONCLUSION: DVI with ASM is at least as efficacious as DVI for cervical ripening with no increase in morbidity. Although DVI with ASM group less often needed additional dinoprostone tablets to complete the process of IOL (p-value = 0.2), adjunctive sweeping has not been shown to have a significant impact on the duration of labor or mode of delivery.

Antenatal corticosteroids administration: are we giving them at the right time?

OBJECTIVE: Antenatal corticosteroids before preterm births are considered to be most effective 48 h after and up to 1 week after the first dose. We aim to evaluate: (1) our practice of administration of antenatal corticosteroids in Singapore; (2) admission characteristics of women for discriminatory factors of spontaneous preterm delivery within 1 week. METHODS: This is a retrospective study in a tertiary obstetrics unit in Singapore. 3044 women who delivered live births (at term or preterm) from 1st November 2014 to 31st January 2015, who were at risk of spontaneous or induced preterm delivery, were included. Data related to the time of and indications for antenatal corticosteroids administration, characteristics assessed at the time of presentation, and time of delivery were collected and analysed. RESULTS: 85.9% of women who delivered at gestational age ≤ 34+6 received at least one dose. 22.1% had delivered within the window of efficacy. Gestational age > 32 weeks at presentation, uterine activity on tocography and cervical dilation with effacement were associated with preterm delivery within 1 week of presentation. CONCLUSION: Overall, our antenatal corticosteroids administration rate is comparable to that attained by centres in other developed countries. It is difficult but important to discriminate women who will benefit from this timely intervention.

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.

Timing of antenatal steroids exposure and its effects on neonates.

OBJECTIVE: Antenatal corticosteroid (ACS) has long been regarded as the standard of care for women at risk of preterm labour. There are, however, varying practices and regimes in ACS administration. It is unclear if "a window of efficacy" truly exists and if the benefits of ACS would diminish after 7 days from the first dose. The objective of this study is to determine if the time interval between antenatal corticosteroids and delivery influences the neonatal outcomes in preterm deliveries from 23+5 to 36+6 weeks' gestation. METHODS: This is a retrospective analysis of 302 women and 352 infants who delivered from 23+5 to 36+6 weeks' gestation in KK Women's and Children's Hospital from 1st November 2014 to 31st January 2015. The timings of the first two doses of corticosteroids and the delivery were retrieved. Neonatal outcomes were compared between those delivering within 7 days and those delivering beyond 7 days of first dose of ACS. RESULTS: 61.2% of preterm infants received at least one dose of antenatal corticosteroids, of which 23.6% received it within the window of efficacy. Overall incidence of respiratory distress asyndrome in our study is 17.6%. Significantly, neonates with ACS exposure beyond 7 days were seven times more likely to have RDS as compared to those exposed to ACS within the window of efficacy (RR 0.535, 95% CI 0.166-1.72), after adjusting for potential confounders. CONCLUSION: The results of this study support the current practice among obstetricians to aim to administer ACS within 7 days of delivery.

Retrospective Study Comparing Treatment Outcomes in Obstetric Patients With Iron Deficiency Anemia Treated With and Without Intravenous Ferric Carboxymaltose.

Introduction Iron deficiency anemia is associated with an increased risk of adverse maternal and perinatal outcomes. Intravenous iron preparation containing ferric carboxymaltose has been shown to be a safe and effective way of increasing hemoglobin (Hb) and mean corpuscular volume (MCV) levels and reducing the need for blood transfusion. In our center, it used to be given as an inpatient procedure because of the risks of potential drug reactions. In 2021, we initiated the administration of intravenous ferric carboxymaltose as an outpatient procedure. We compared the outcomes of patients between 2021 and 2023 after the initiation of outpatient administration of intravenous ferric carboxymaltose in 127 obstetric patients with iron deficiency anemia in the second and third trimesters. Methods In this study conducted in a large maternity unit in Singapore between 2021 to 2023, we compared the changes in maternal hematological parameters among obstetric patients with iron deficiency anemia presenting to the day care unit in the second or third trimester with a Hb level of <8 g/dl treated with a single dose of ferric carboxymaltose injection (Ferinject) against a control group who were referred for treatment but defaulted on and declined treatment. Results Ferric carboxymaltose significantly increased the Hb and MCV levels at delivery in obstetric patients with iron deficiency. The mean Hb at delivery was 10.8 g/dL in the case group compared to 8.8 g/dL in the control group. The percentage of patients with Hb ≥10.0 g/dL was 73.4% in the case group compared to 27.8% in the control group. The incidence of adverse side effects was low and mild (2/127; 1.6%). None of the patients received were hospitalized because of ferric carboxymaltose. Conclusion A single injection dose of ferric carboxymaltose as an outpatient antenatal procedure was easily administered and well tolerated. Obstetric patients with iron deficiency anemia who received intravenous ferric carboxymaltose had a significantly higher level of Hb than those who did not.

Multidisciplinary Obstetric Simulation Training: Experience at KK Women's and Children's Hospital (KKH), Singapore, a Tertiary Referral Centre.

Background Multidisciplinary simulation training in the management of acute obstetric emergencies has the potential to reduce both maternal and perinatal morbidity. It is a valuable tool that can be adapted for targeted audiences of different specialities at all experience levels from medical students to senior consultants. Methods In this study, pre- and post-course questionnaires of learners with varying levels of clinical experience from Obstetrics and Gynaecology (O&G), Anaesthesia, Neonatology, Emergency Medicine, midwifery, and nursing who undertook two simulation courses (namely the Combined Obstetrics Resuscitation Training course, CORE, and the CORE Lite), which comprised lectures and simulation drills with manikins and standardized patients, between 2015 and 2023 were compared. This also included a period when training was affected by the coronavirus disease 2019 (COVID-19) pandemic.  Results The results showed that both simulation courses increased confidence levels among all learners in the management of obstetric emergencies.  Pre-course, participants were most confident in the management of neonatal resuscitation and severe pre-eclampsia, followed by postpartum haemorrhage. They were least confident in the management of vaginal breech delivery, uterine inversion, and twin delivery. Post-course, participants were most confident in the management of neonatal resuscitation and shoulder dystocia, followed by postpartum haemorrhage. They were least confident in the management of uterine inversion and maternal sepsis, followed by vaginal breech delivery and twin delivery. Whilst we saw a huge improvement in confidence levels for all obstetric emergencies, the greatest improvement in confidence levels was noted in vaginal breech delivery, twin delivery, and uterine inversion. Conclusion The simulation courses were effective in improving the confidence in the management of obstetric emergencies. While it may be difficult to measure the improvement in clinical outcomes as a result of simulation courses alone, the increase in confidence levels of clinicians can be used as a surrogate in measuring their preparedness in facing these emergency scenarios.

Obstetric red cell transfusion in a high-volume tertiary hospital: a retrospective cohort study.

Introduction: Red cell transfusion is expensive and not without risks. Despite the availability of transfusion guidelines, studies report a wide interhospital variation in transfusion rates. This retrospective cohort study was conducted to define the incidence of red cell transfusion in a multi-ethnic obstetric population and to evaluate current transfusion practice with regard to indications and appropriateness. Methods: All parturients who delivered a live or stillbirth in the period 2014-2015 and who received allogeneic blood transfusion during pregnancy and up to six weeks postnatally were identified. Their medical records were reviewed to extract the relevant demographic, obstetric and transfusion data. Descriptive analysis of data was performed using IBM SPSS Statistics software. Results: Out of 23,456 parturients who delivered in the study period, 760 were administered red cell transfusion, resulting in a transfusion rate of 3.2% or 32 in 1,000 maternities. A total of 1,675 red cell units were utilised in 863 transfusion episodes. Major indications for transfusion were anaemia in pregnancy (49.2%) and postpartum haemorrhage secondary to an atonic uterus. Transfusion was more frequently associated with caesarean than vaginal births (4.9% vs. 2.4%). About 14% of transfusions were initiated with pre-transfusion haemoglobin (Hb) ≥ 8.0 g/dL, whereas 37% of transfusions resulted in post-transfusion Hb > 9.0 g/dL. Conclusion: The incidence of red cell transfusion was 3.2% in a multiethnic obstetric population. Patient blood management strategies should focus on optimising antenatal anaemia, reducing blood loss during delivery and eliminating inappropriate transfusion.

Perinatal Palliative Care Service: Developing a Comprehensive Care Package for Vulnerable Babies with Life Limiting Fetal Conditions.

Background: Perinatal Palliative Care provides comprehensive and holistic care for expectant and new parents, who receive a diagnosis of life-limiting fetal condition and opt to continue pregnancy and care for their newborn infant. Aim: To develop a service providing individually tailored holistic care during pregnancy, birth, postnatal and bereavement period. Methods: Following a baseline survey of neonatologists and discussions with key stakeholders we launched the Perinatal Palliative service at the KK Women's and Children's hospital, Singapore in January 2017. The multidisciplinary team, led by a Palliative care specialist comprised of Obstetricians, Neonatologists, nurses and medical social workers. The Birth defect clinic referred parents with antenatally diagnosed 'Lethal' fetal conditions. The team checked the understanding and the decision making process of parents and initiated and finalized advance care plans. The service also embraced deserving postnatal referrals upon request. Results: A total of 41 cases were seen from January 2017 to December 2019. Of these, 26/41(63%) were referred antenatally and had completed advance care plans. 18/41 (44%) died during or shortly after birth and 10/41(24%) continue to survive and are supported by the community palliative team. During this time a workflow was formulated and modified based on parent and team feedback. Conclusion: Awareness of the service has increased over the years and a clear workflow has been formulated. Advance care plans are prepared and documented before birth so as to enable service teams on board to provide well timed pertinent care. Feedbacks from parents about this service were positive.

Comparative analysis of insulin-like growth factor binding protein-1 (IGFBP-1), placental alpha-microglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membranes in pregnancy.

PURPOSE: to compare insulin-like growth factor binding protein-1 (IGFBP-1) (non-phosphorylated), placental alpha-microglobulin-1 (PAMG-1) and nitrazine test to diagnose premature rupture of membrane to allow gestation-specific management. METHODS: we recruited 100 women with signs or symptoms of premature rupture of membranes (PROM), between 17 and 37 weeks at a tertiary referral center. RESULTS: in 100 women in whom PAMG-1 was performed, sensitivity was 92.7%, specificity was 100%, positive predictive value (PPV) was 100% and negative predictive value (NPV) was 95.2%. IGFBP-1 was performed in 94 women, the sensitivity was 87.5%, specificity was 94.4%, PPV was 92.1% and NPV was 91.1%. In 98 women in whom nitrazine test was performed, the sensitivity was 85%, specificity was 39.7%, PPV was 49.3% and NPV was 79.3%. CONCLUSION: PAMG-1 was the most accurate test in diagnosing rupture of membranes and had the highest sensitivity, specificity, PPVs and NPVs.

A retrospective review of uterine scar pregnancies: single centre experience.

PURPOSE: Our aim was to present our experience with the management of six women with uterine scar pregnancies in KK Women's and Children's Hospital, Singapore. METHODS: The medical records of women with a pregnancy in previous uterine scar that had been diagnosed in our department during 2004-2008 were reviewed. RESULTS: Out of six women, one woman presented in mid-trimester, at 16 weeks with severe abdominal pain and persistent vomiting. She underwent a hysterectomy complicated with massive haemorrhage. The other five women presented in first trimester. Two women had excision of the scar with the sac, two had ultrasound-guided injection of methotrexate in the sac and one had systemic methotrexate. In all cases, maternal recovery was complete. Uterine scar pregnancy was diagnosed by ultrasonography. CONCLUSION: Women at a risk appear to be those with multiple Caesarean sections, termination of pregnancy and myomectomy. Operative as well as medical treatments have been reported for scar pregnancy. Surgical treatment includes excision of trophoblastic tissues by laparotomy or laparoscopy whilst medical treatment includes local and/or systemically administered methotrexate. Although many interventions have been described, optimal treatment is still not known and they remain a challenge.

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.

DORSCON Orange: An Approach to Challenges in a Busy Antenatal Diagnostic Centre in the Midst of a Global Pandemic.

The WHO declared the coronavirus disease 2019 (COVID-19) a global pandemic on 11 March 2020. Lessons from SARS epidemic led Singapore to develop stringent infection control protocols in preparation for future pandemics. However, unlike SARS, COVID-19 appears to be more transmissible and is predicted to continue for longer. As of 14 June 2020, there have been 40,197 positive cases with 26 deaths in Singapore, and KK Women's and Children's Hospital (KKH) has managed a total of 73 cases. Obstetrics ultrasound is an indispensable medical service and must continue to operate during a pandemic. A key balance must be struck between keeping patients and healthcare workers safe while being able to provide quality and prompt obstetric care. Our Antenatal Diagnostic Centre (ADC) in KKH developed new strategies to adapt to the pandemic when the national Disease Outbreak Response System Condition (DORSCON) was raised from yellow to orange on 7 February 2020. In this paper, we discuss our clinical workflow to reduce the risk of transmission amongst patients and staff while minimising disruption to our services.

Pregnancy Outcomes in COVID-19: A Prospective Cohort Study in Singapore.

INTRODUCTION: Pregnant women are reported to be at increased risk of severe coronavirus disease 2019 (COVID-19) due to underlying immunosuppression during pregnancy. However, the clinical course of COVID-19 in pregnancy and risk of vertical and horizontal transmission remain relatively unknown. We aim to describe and evaluate outcomes in pregnant women with COVID-19 in Singapore. METHODS: Prospective observational study of 16 pregnant patients admitted for COVID-19 to 4 tertiary hospitals in Singapore. Outcomes included severe disease, pregnancy loss, and vertical and horizontal transmission. RESULTS: Of the 16 patients, 37.5%, 43.8% and 18.7% were infected in the first, second and third trimesters, respectively. Two gravidas aged ≥35 years (12.5%) developed severe pneumonia; one patient (body mass index 32.9kg/m2) required transfer to intensive care. The median duration of acute infection was 19 days; one patient remained reverse transcription polymerase chain reaction (RT-PCR) positive >11 weeks from diagnosis. There were no maternal mortalities. Five pregnancies produced term live-births while 2 spontaneous miscarriages occurred at 11 and 23 weeks. RT-PCR of breast milk and maternal and neonatal samples taken at birth were negative; placenta and cord histology showed non-specific inflammation; and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific immunoglobulins were elevated in paired maternal and umbilical cord blood (n=5). CONCLUSION: The majority of COVID-19 infected pregnant women had mild disease and only 2 women with risk factors (obesity, older age) had severe infection; this represents a slightly higher incidence than observed in age-matched non-pregnant women. Among the women who delivered, there was no definitive evidence of mother-to-child transmission via breast milk or placenta.

A sustainable model to improve maternal health and promote early obstetric care in resource-poor regions.

OBJECTIVE: To design and examine the feasibility of a sustainable training program to build local capacity and improve obstetric outcomes in Kampong Chhnang, Cambodia. METHODS: A "train-the-trainers" model was used to conduct an obstetrics course between 2012 and 2015, its aim to reduce maternal mortality and morbidity. All Cambodian healthcare providers trained by the program were included in the study. The obstetric outcomes of all patients under the care of the trained healthcare providers were analyzed retrospectively to assess the feasibility of the program. Data from all three hospitals and 42 health centers in the province that the trainees worked at were collected from case logs. RESULTS: There was a significant increased trend in recognition of cases of postpartum hemorrhage and pre-eclampsia, and occurrence of difficult deliveries and cesarean deliveries (P<0.001). The maternal mortality ratio decreased from 64.7 per 100 000 deliveries in 2012 to 40.8 per 100 000 deliveries in 2016. CONCLUSION: This sustainable model has the potential to positively impact obstetric education and maternal outcomes and could be adopted in other resource-poor countries, particularly in Southeast Asia.

Patient satisfaction with the cervical ripening balloon as a method for induction of labour: a randomised controlled trial.

INTRODUCTION: Evidence has shown that balloon catheters are as effective as prostaglandins (PGE) in achieving vaginal delivery within 24 hours of the start of induction of labour (IOL), with lower rates of uterine hyperstimulation, and similar Caesarean section and infection rates. International guidelines recommend mechanical methods as a method of IOL. We designed a prospective randomised controlled study to evaluate patient acceptance of the cervical ripening balloon (CRB) for IOL. METHODS: Suitable women with a singleton term pregnancy without major fetal anomaly suitable for vaginal delivery were recruited and randomised to receive the CRB or PGE on the day of IOL. Characteristics of the women, labour and birth outcomes were obtained from case notes. Pain and satisfaction scores were obtained by interviewing the women at IOL and after delivery. The main outcome measures were participant characteristics, labour and birth outcomes, pain score, satisfaction scores, and whether the participant would recommend the mode of IOL. RESULTS: There was no difference in the pain score between the two groups at the start of IOL, but thereafter, pain scores were lower in the CRB group compared to the PGE group (4.5 ± 2.3 vs. 5.6 ± 2.4, p = 0.044). Women were equally satisfied with both methods and equally likely to recommend their method for IOL. CONCLUSION: Patient experience of IOL with CRB or PGE was equally satisfactory, although pain during induction was lower in the CRB group. We found that both methods of IOL are acceptable to women and should be made available to provide more options.