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Fulltext Effectiveness of selective risk based screening for gestational diabetes (GDM) in Malaysia: A retrospective cohort study based on the National Obstetric Registry (NOR) of Malaysia

Muniswaran G, Soelar SA, Karalasingam SD, Bujang MA, Jeganathan R, Suharjono H

Med J Malaysia, 2017 02;72(1):46-49.
PMID: 28255139 MyJurnal

INTRODUCTION: Gestational diabetes (GDM) has significant maternal and foetal implications. screening allows active interventions which significantly improves pregnancy outcomes. Despite World Health Organization (WHO), FIGO and National Institute of clinical Excellence (NIcE) recommendations for universal screening especially among high risk population; Malaysia currently adopts a selective risk based screening for GDM.
OBJECTIVE: the objective is to audit the effectiveness of the current practice of selective risk based screening in detection of GDM in Malaysia.
METHODOLOGY: this is a retrospective cohort study based on the National Obstetric Registry (NOR) which comprises of 14 major tertiary hospitals in Malaysia. the study period was from 1st January 2011 till 31st December 2012 and a total of 22,044 patients with GDM were analysed. Logistic regression analysis was used to calculate the crude odd ratio.
RESULTS: the incidence of GDM in Malaysia is 8.4%. Maternal age of ≥25, booking bMI ≥27kg/m2, booking weight ≥80kg and previous hypertension are non-significant risk of developing GDM in Malaysia. Parity 5 and more was only associated with an odds-ratio of 1.02 (95% confidence Interval: 0.90-1.17) as compared to parity below 5. the association of women with previous stillbirth with GDM was not significant.
CONCLUSION: current risk based screening for GDM based on maternal age, booking bMI, weight and hypertension is inappropriate. An ideal screening tool should precede disease complications, which is the novel objective of screening. Universal screening for GDM in Malaysia may be a more accurate measure, especially with regards to reducing maternal and foetal complications.
Fulltext Caesarean section rates from Malaysian tertiary hospitals using Robson's 10-group classification

Karalasingam SD, Jeganathan R, Jegasothy R, Reidpath DD

BMC Pregnancy Childbirth, 2020 Jan 31;20(1):64.
PMID: 32005188 DOI: 10.1186/s12884-020-2760-2

BACKGROUND: Rising caesarean section rates is a concern worldwide. This study aimed to use Robson's ten group classification to identify which groups of women were contributing most to the rising caesarean section rates in Malaysian tertiary hospitals and to compare between hospitals, using a common standard set of variables.
METHODS: A 5-year (2011-2015) cross-sectional study was conducted using data from the Malaysian National Obstetrics Registry (NOR). A total of 608,747 deliveries were recorded from 11 tertiary state hospitals and 1 tertiary hospital from the Federal territory.
RESULTS: During the study period, there were 141,257 Caesarean sections (23.2%). Caesarean sections in Group 1 (nulliparous term pregnancy in spontaneous labour) and Group 3 (multiparous term pregnancy in spontaneous labour) had an increasing trend from 2011 to 2015. The group that contributed most to the overall caesarean section rates was Group 5 (multiparous, singleton, cephalic≥37 weeks with previous caesarean section) and the rates remained high during the 5-year study period. Groups 6, 7 and 9 had the highest caesarean section rates but they made the smallest contribution to the overall rates.
CONCLUSIONS: Like many countries, the rate of caesarean section has risen over time, and the rise is driven by caesarean section in low-risk groups. There was an important hospital to hospital variation. The rise in caesarean section rates reflects a globally disturbing trend, and changes in policy and training that creates a uniform standard across hospitals should be considered.
Fulltext Factors associated with recovery from 1 minute Apgar score <4 in live, singleton, term births: an analysis of Malaysian National Obstetrics Registry data 2010-2012

Jeganathan R, Karalasingam SD, Hussein J, Allotey P, Reidpath DD

BMC Pregnancy Childbirth, 2017 Apr 08;17(1):110.
PMID: 28390414 DOI: 10.1186/s12884-017-1293-9

BACKGROUND: The neonatal Apgar score at 5 min has been found to be a better predictor of outcomes than the Apgar score at 1 min. A baby, however, must pass through the first minute of life to reach the fifth. There has been no research looking at predictors of recovery (Apgar scores ≥7) by 5 min in neonates with 1 min Apgar scores <4.
METHODS: An analysis of observational data was conducted using live, singleton, term births recorded in the Malaysian National Obstetrics Registry between 2010 and 2012. A total of 272,472 live, singleton, term births without congential anomalies were recorded, of which 1,580 (0.59%) had 1 min Apgar scores <4. Descriptive methods and bi- and multi-variable logistic regression were used to identify risk factors associated with recovery (5 min Apgar score ≥7) from 1 min Apgar scores <4.
RESULTS: Less than 1% of births have a 1 min Apgar scores <4. Only 29.4% of neonates with 1 min Apgar scores <4 recover to a 5 min Apgar score ≥7. Among uncomplicated vaginal deliveries, after controlling for other factors, deliveries by a doctor of neonates with a 1 min Apgar score <4 had odds of recovery 2.4 times greater than deliveries of neonates with a 1 min Apgar score <4 by a nurse-midwife. Among deliveries of neonates with a 1 min Apgar score <4 by doctors, after controlling for other factors, planned and unplanned CS was associated with better odds of recovery than uncomplicated vaginal deliveries. Recovery was also associated with maternal obesity, and there was some ethnic variation - in the adjusted analysis indigenous (Orang Asal) Malaysians had lower odds of recovery.
CONCLUSIONS: A 1 min Apgar score <4 is relatively rare, and less than a third recover by five minutes. In those newborns the qualification of the person performing the delivery and the type of delivery are independent predictors of recovery as is maternal BMI and ethnicity. These are associations only, not necessarily causes, and they point to potential areas of research into health systems factors in the labour room, as well as possible biological and cultural factors.
Importance of Adopting BMI Classifications Using Public Health Action Points to Delineate Obstetric Risk Factors Resulting in Worsening Obstetric Outcomes Among Asian Population

Ganeshan M, Bujang MA, Soelar SA, Karalasingam SD, Suharjono H, Jeganathan R

J Obstet Gynaecol India, 2018 Jun;68(3):173-178.
PMID: 29895995 DOI: 10.1007/s13224-017-1000-9

Aims: The aim of this study is to compare obstetric outcomes between overweight and class 1 obesity among pregnant women in their first pregnancy based on WHO's BMI cut-offs and the potential public health action points identified by WHO expert consultations specific for high-risk population such as Asians.
Methods: This is a retrospective cohort review of data obtained from the Malaysian National Obstetrics and Gynaecology Registry between the year 2010 and year 2012. All women in their first pregnancy with a booking BMI in their first trimester were included in this study. The association between BMI classifications as defined by the WHO cut-offs and the potential public health action points identified by WHO expert consultations towards adverse obstetric outcomes was compared.
Results: A total of 88,837 pregnant women were included in this study. We noted that the risk of adverse obstetric outcomes was significantly higher using the public health action points identified by WHO expert consultations even among the overweight group as the risk of stillbirths was (OR 1.2; 95% CI 1.0,1.4), shoulder dystocia (OR 1.9; 95% CI 1.2,2.9), foetal macrosomia (OR 1.8; 95% CI 1.6,2.0), caesarean section (OR 1.9; 95% CI 1.8,2.0) and assisted conception (OR 1.9; 95% CI 1.6,2.1).
Conclusion: A specifically lower BMI references based on the potential public health action points for BMI classifications were a more sensitive predictor of adverse obstetric outcomes, and we recommend the use of these references in pregnancy especially among Asian population.
Fulltext Spontaneous Preterm Births in Malaysia: Are There Modifiable Antenatal Risk Factors?

Damanhuri NH, Hairi NN, Ismail M, Jeganathan R, Karalasingam SD, Nasir MJM, et al.

Cureus, 2024 Apr;16(4):e59152.
PMID: 38680821 DOI: 10.7759/cureus.59152

Background Spontaneous preterm birth (SPB) is a global public health concern with devastating health effects on SPB survivors. This study aimed to determine modifiable antenatal risk factors associated with SPB among women attending government healthcare facilities in Malaysia. Methodology A retrospective record review of 49,416 national obstetrics registry data from 2015 was conducted and analyzed using binary logistic regression based on six antenatal factor divisions. Results Mothers with pre-existing diabetes had higher odds (adjusted odds ratio (aOR) = 3.09) of delivering prematurely than mothers without diabetes. Mothers with chronic hypertension with superimposed pre-eclampsia (aOR = 2.51) and gestational hypertension (aOR = 1.44) had higher odds of experiencing preterm birth than mothers with no hypertension. Underweight mothers had higher odds (aOR = 1.27) of delivering prematurely than mothers with an ideal body mass index (18.5 to <25.0 kg/m2). Mothers with moderate anemia (hemoglobin level: 7 to <9 g/dL) had higher odds (aOR = 1.18) of preterm birth than mothers with normal hemoglobin levels (≥11 g/dL). Conclusions Maternal biomarkers, such as glucose level, blood pressure, BMI, and hemoglobin level, play an important role in reducing the rate of SPB in Malaysia. This study recommends strengthening pre-pregnancy, antenatal, and postpartum care through multidisciplinary and multi-agency team collaboration, addressing both modifiable and non-modifiable risk factors and adopting a dual approach that combines preventive and curative care.
Stillbirths: Contribution of preterm birth and size-for-gestational age for 125.4 million total births from nationwide records in 13 countries, 2000-2020

Okwaraji YB, Suárez-Idueta L, Ohuma EO, Bradley E, Yargawa J, Pingray V, et al.

BJOG, 2023 Nov 29.
PMID: 38018284 DOI: 10.1111/1471-0528.17653

OBJECTIVE: To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'.
DESIGN: Population-based multi-country analyses.
SETTING: Births collected through routine data systems in 13 countries.
SAMPLE: 125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020.
METHODS: We included 635 107 stillbirths from 22+0 weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0 weeks versus term, T, ≥37+0 weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards.
MAIN OUTCOME MEASURES: Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types.
RESULTS: 635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0 weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age.
CONCLUSIONS: In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.