Uterine rupture is still a common problem in developing countries although even here the incidence varies from urban to rural settings. This article is a review of uterine rupture in an urban referral hospital in Malaysia. It examines aetiology, clinical presentation, complications and management of the problem. Meticulous screening of patients together with optimal antenatal and intrapartum care will markedly reduce the incidence of uterine rupture. Early diagnosis and prompt treatment will further help reduce morbidity and mortality to both mother and fetus.
Sudden maternal death from amniotic fluid embolism is a rare but serious complication which usually occurs during late pregnancy, often during labour or shortly after, with more than 80% mortality. Such a death causes immense stress to both the relatives and the attending doctors as it is sudden and unexpected. Three such deaths are discussed here. Traditionally, it was believed that this complication usually occurred in prolonged and difficult labour, but there is evidence contrary to this, and it is not possible to predict when and where this fatal complication will occur. Current views and various pathophysiologic mechanisms leading to the fatal outcome are also discussed.
OBJECTIVES: The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects.
METHODS: This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging.
RESULTS: Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small.
CONCLUSIONS: Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.
We report on a retrospective study of maternal deaths in Malaysia that occurred within 24 hours of delivery, abortion or operative termination of the pregnancy (defined as sudden deaths) in the years 1995-1996. There were 131 sudden maternal deaths (20.6% of all maternal deaths); postpartum hemorrhage, obstetric embolisms, trauma and hypertensive disorders of pregnancy were the main causes. There was a disproportionately increased risk of sudden maternal deaths in the Chinese and the 'other bumiputra' racial groups. The proportion of mothers who had no obstetric risk factors in the pregnancy that led to death was 16.8%. Fourteen mothers died in transit Twenty mothers died after a cesarean section. The findings of this review emphasize the fact that caregivers in obstetrics need to be forever vigilant. All maternity staff need to be well trained in emergency care and there needs to be quick referral to centers that can provide expertise in handling these emergencies.
Placenta praevia is a known obstetric condition that causes complications to mother and fetus. This study was done to evaluate the knowledge of placenta praevia amongst the obstetric patients. A cross sectional study was carried out in Hospital Ipoh, Perak among 323 antenatal and postnatal patients. Socio-demographic parameters (ie age, race, parity, occupation, educational level) and history of placenta praevia were studied in relation to level of knowledge and attitude towards placenta praevia. Twenty (6.2%) from 323 women had current or past history of placenta praevia. Three had history of placenta praevia while 17 had current placenta praevia with prevalence of 5.3%. The mean score of knowledge achieved by patients was 11.8 which indicated overall poor knowledge. Occupation, level of education and history of placenta praevia were found to have a relationship with level of knowledge regarding placenta praevia in all obstetric patients. There was a significant relationship between attitude of patients with current and history of placenta praevia to level of knowledge regarding placenta praevia. (p=0.037,
Near-miss cases in life-threatening obstetric patients occurring over a one year period are analysed retrospectively with regards to morbidity measured in terms of hospital stay, utilisation of high dependency ward and intensive care beds and adequacy of clinical management. One-hundred and twenty two cases occurred among 9932 deliveries. Massive obstetric haemorrhage (54.2%) and hypertensive disorders of pregnancy (36.9%) were the two main diagnostic groups. Seventy one (58.2%) cases were referred from peripheral centres for obstetric management and 77 (63.1%) were not booked at this hospital for antenatal care. A majority were not ill-looking (92 cases) at the time of admission but turned for the worse in the course of labour. Interventional measures taken in clinical management were considered appropriate in all cases. Delay in instituting treatment was present in 6 cases. Remediable measures were recognised in 15 (12.3%). This study, apart from supplementing mortality audits, demonstrates that high risk obstetric patients can be triaged at the time of admission to labour wards by trained midwives and junior doctors in busy obstetric units without compromising standards of care.
Study site: Obstetric and Gynaecologic Unit in Ipoh Hospital.
A rare case of spontaneous rupture of a branch of the uterine vein in a primigravida is discussed. The patient with an uncomplicated pregnancy presented with signs and symptoms suggestive of abruptio placenta with foetal distress. Lower segment Caesarean section was performed. The cause of acute pain was identified to be intra-abdominal bleeding secondary to the rupture of a branch of the uterine vein. The pathophysiology of the problem is discussed.
Prostaglandin E2 administered orally and combined with amniotomy was used for induction of labour at or near term in 1533 patients. The study was carried out as a collaborative project between the University Departments of Obstetrics and Gynaecology in Singapore, Medan (Indonesia) and Kuala Lumpur (Malaysia). The overall success rates for Medan, Kuala Lumpur and Singapore were 95.6%, 88.1% and 84.7% respectively.
Eleven maternal deaths were recorded in Hulu Terengganu between 1981-1985. This represents a high average maternal mortality rate of 1.4 per thousand deliveries annually over the five years. Nine of the 11 women were high priority pregnancies, but only three had hospital deliveries. The most common cause of death was post-partum haemorrhage (PPH), and PPH with a retained placenta. Hospital deliveries constitute only a low proportion of total deliveries in the district. In a survey of women with high priority pregnancies attending antenatal clinics in Hulu Terengganu, it was found that 79 (69%) out of 115 respondents were resistant to advice for hospital delivery. Grandmultiparae were a significant proportion of this group.
Study site: Maternal Child Health Centre (Klinik Kesihatan), Hulu Terengganu, Malaysia
Hypnosis has been shown to help pregnant women experience improved labor and postpartum periods. The present study compares the differences between experimental (n = 23) and control groups (n = 22) on specific variables measured both during labor and 24 hr postpartum. The participants in the experimental group received the hypnosis intervention at weeks 16, 20, 28, and 36 of pregnancy, while those in the control group received only routine antenatal care. The data collected at the labor stage describe the length of the labor stage, pain relief used during labor, the method of delivery, and the type of assisted vaginal delivery. Within 24 hr of delivery, data on neonatal birth weight, neonatal Apgar scores, and self-reported pain were obtained. The labor stage results showed no significant differences in the length of the second and third stages of labor. Although the participants in the experimental group reported higher pain levels immediately prior to, during, and immediately after delivery, their use of pethidine during labor was significantly lower than the control group participants. None of the experimental group participants opted for an epidural, and they had a greater number of assisted vaginal deliveries than the control group participants. The 24 hr postpartum results showed that the neonates of the experimental group participants had nonsignificantly higher Apgar scores than those of the women in the control group. Group differences in neonatal weight were not significant. The results of the present study indicate that hypnosis is useful for assisting pregnant women during labor and the postpartum period.
There was limited knowledge on the sexual function in women who have survived severe obstetric complications. The aim of this study was to compare the level of sexual functioning among women with and without severe morbidity at six months postpartum and to identify the factors associated with sexual function scores of women. A prospective double-cohort study design was applied at two tertiary hospitals over a six-month period. Postpartum women with and without severe maternal morbidity were selected as the exposed and the non-exposed group, respectively. The study included 145 exposed and 187 non-exposed women. Those with severe maternal morbidity were significantly ( P
A 21-year-old primigravida with previous history of pulmonary tuberculosis had a normal but assisted vaginal delivery after a prolonged second stage. Within 12 hours, she complained of dyspnoea and was found to have abnormal neck and anterior chest wall swelling. A diagnosis of subcutaneous emphysema was made and this was confirmed with the chest radiograph, which also revealed pneumomediastinum. She recovered well within four days with conservative treatment.
Cardiomyopathy developed in the peripartum period in two healthy primigravida at 41 and 42 weeks of gestation are presented. In the first case, the patient presented with pulmonary oedema and had cardiac arrest immediately after admission. After resuscitation, a live baby was delivered by Caesarean section. Second cardiac arrest occurred after 12 hours of operation and the patient was resuscitated again. On the 8th post operative day, patient died of D.I.V.C. and renal failure. The second case was a twin pregnancy associated with pregnancy induced hypertension. Caesarean section was performed for foetal distress. She developed pulmonary oedema with left ventricular failure on the second post operative day, was resuscitated and discharged on the 15th day. These are the first two cases to be reported from Hospital University Sains Malaysia. Reference is made to three other cases in which a similar pathological process might have occurred.
To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma.
Although maternal mortality is a significant global health issue, achievements in mortality decline to date have been inadequate. A review of the interventions targeted at maternal mortality reduction demonstrates that most developing countries face tremendous challenges in the implementation of these interventions, including the availability of unreliable data and the shortage in human and financial resources, as well as limited political commitment. Examples from developing countries, such as Sri Lanka, Malaysia and Honduras, demonstrate that maternal mortality will decline when appropriate strategies are in place. Such achievable strategies need to include redoubled commitments on the part of local, national and global political bodies, concrete investments in high-yield and cost-effective interventions and the delegation of some clinical tasks from higher-level healthcare providers to mid- or lower-level healthcare providers, as well as improved health-management information systems.
OBJECTIVE:
To evaluate the 50-g glucose challenge test (GCT) on pregnancy outcome in a multiethnic Asian population at high risk for gestational diabetes (GDM).
METHODS:
GCT was positive if the 1-hour plasma glucose level was >or=7.2 mmol/L. GDM was diagnosed by a 75-g glucose tolerance test using WHO (1999) criteria. Of the 1368 women enrolled in the study, 892 were GCT negative, 308 were GCT false-positive, and 168 had GDM. Pregnancy outcomes were extracted from hospital records. Multivariable logistic regression analysis was performed with GCT negative women as the reference group.
RESULTS:
GCT false-positive status was associated with preterm birth (adjusted odds ratio [AOR] 2.1; 95% CI, 1.2-3.7) and postpartum hemorrhage (AOR 1.7; 95% CI, 1.0-2.7). GDM was associated with labor induction (AOR 5.0; 95% CI, 3.3-7.5), cesarean delivery (AOR 2.2; 95% CI, 1.6-3.2), postpartum hemorrhage (AOR 2.1; 95% CI, 1.2-3.7), and neonatal macrosomia (AOR 2.5; 95% CI, 1.0-6.0).
CONCLUSION:
GCT false-positive women had an increased likelihood of an adverse pregnancy outcome. The role and threshold of the GCT needs re-evaluation.