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Biomedical subjects

S Arulkumaran

Publications and source records attributed to S Arulkumaran.

At least 73 records · Page 4Linked to original sources

Influence of PvuII (intron 6) polymorphism of the lipoprotein lipase gene on cord plasma lipid and apolipoprotein levels in Indian and Chinese newborns of Singapore.

The influence of the PvuII polymorphism (intron 6) of the lipoprotein lipase (LPL) gene on cord plasma lipid traits was studied in 252 ethnic Chinese and 240 ethnic Indian newborns of Singapore. The allelic frequencies of P+ (presence of the restriction site) were 0.67 and 0.56 in the Chinese and Indian newborns, respectively, similar to their respective adult populations. The genotype distributions at the PvuII site were at Hardy Weinberg equilibrium in both ethnic Chinese (chi2 = 2.0) and ethnic Indians (chi2 = 3.6). Cord blood HDL-cholesterol (HDL-C) levels are higher in newborn Chinese than newborn Indians. In addition, cord blood LDL-cholesterol (LDL-C), apoB, and lipoprotein(a) levels are lower in newborn Chinese than newborn Indians. Both newborn Chinese and Indian male homozygotes for P- allele have higher cord blood LDL-C levels than newborns with the more common P+P+ or P-P+ genotypes. In Chinese male newborns, the LDL-C levels were 0.76 +/- 0.61 mmol/L, 0.53 +/- 0.29 mmol/L and 0.46 +/- 0.25 mmol/L, respectively (p = 0.01). In Indian male newborns, the LDL-C levels were 0.88 +/- 0.35 mmol/L for the P-P- genotype and 0.65 +/- 0.24 mmol/L for the P+P+ genotype (p = 0.003). In addition, the influence of the P- allele on LDL-C levels is remarkably similar in both ethnic groups, accounting for 8.48% of the population variance in the Chinese newborns and 8.09% in the Indian newborns. In contrast, no obvious effect of genotype is seen in this lipid parameter in the newborn females of either ethnic groups. There is presence of significant genotype specific influence on the LDL-C levels in cord plasma in male newborns, suggesting an early expression of the LPL gene locus.

Adult↗

Quality assessment of two lactate test strip methods suitable for obstetric use.

Accuracy of lactate determinations in cord blood was tested for one reflectometric (Accusport) and one amperometric (Lactate Pro) microvolume test strip lactate meter. Both meters, using a whole blood sample, measure lower levels of lactate than a reflectometric device considered as a reference method, which analyses lactate in plasma. Readings were unaffected irrespective of lactate concentrations for the Lactate Pro, whilst the Accusport overestimated low lactate concentrations and underestimated high values. Both lactate meters underestimated lactate concentrations at high hematocrits, as compared with the reference method. The Lactate Pro has a fixed sample volume of 5 microliters while the Accusport uses random blood drop as sample volume. However, in analyses with less than 20 microliters sample volume considerable underestimation was found with the Accusport. Coefficient of variation was 3.8-8.9% for the Accusport and 3.1-4.0% for the Lactate Pro within lactate concentrations between 2.1 and 5.3 mmol/l. The amperometric device, the Lactate Pro, performed best in these tests dealing with fetal blood lactate concentrations. The new technique can be a useful tool in perinatal research as well as in obstetric practice.

False Negative Reactions↗

The role of prophylactic iron supplementation in pregnancy.

The prevalence, causes and role of iron prophylaxis in pregnant women was studied. All women delivered at the National University Hospital, Singapore in 1993 had their haemoglobin estimated. If it was less than 11 g/dl, blood was taken for serum iron, ferritin, transferrin, red cell zinc protoporphyrin, serum folate, vitamin B12 and thalassemia screen to establish cause of anaemia. Data was also collected with regards to their antenatal progress and iron prophylaxis. Logistic regression, Chi-square test, Fischer's exact test and Mantel-Haenszel tests were also used to assess the relationships between categorical variables. The prevalence of anaemia at first antenatal visit was 20.6% while the prevalence of anaemia at delivery was 15.3%. The commonest cause of the anaemia in pregnancy was due to iron deficiency (81.3%). In the non-anaemic group, 90.7% were on prophylactic iron supplements compared to 50.6% in the anaemic group (P < 0.001). Of the 752 women found to be anaemic at booking, 591 received prophylactic iron supplements while 161 women did not. A total of 166 (28.1%) of those with iron supplements were anaemic at delivery, whereas 140 (87.0%) of those who did not receive prophylactic iron remained anaemic at delivery (P < 0.001). Of the 2516 non-anaemic women who received prophylactic iron, 118 (4.7%) developed anaemia at delivery while 133 (34.1%) out of the 390 women who did not receive prophylactic iron were anaemic at delivery (P < 0.001). Multivariate logistic regression analysis revealed the odds of anaemia for a woman not on iron therapy was about 11 times that of her counterpart on prophylactic iron therapy (95% CI 8.76 to 14.13). A 55% reduction in odds of anaemia was estimated per 1 gm% increase in haemoglobin at booking. Prophylactic antenatal iron supplements not only prevent a fall but also improved haemoglobin levels during pregnancy. Those who were not on any iron supplements were 11 times more likely to develop anaemia in the present pregnancy.

Anemia↗

A case of accelerated development of proliferative diabetic retinopathy in a woman with type 2 diabetes mellitus after pregnancy.

Whilst it is recognised that diabetic retinopathy is a consequence of prolonged elevation of blood glucose levels, recent studies suggest rapid normalisation of blood sugar as a causal factor in accelerating its development. In this case report, a non-insulin dependent diabetic with poor blood glucose control but no retinopathy in early pregnancy had normalisation of glucose control by the third trimester. However, glucose control deteriorated rapidly postnatally, and she had a sudden blurring of vision three months after delivery of her baby, at which time severe proliferative diabetic retinopathy was diagnosed. The reason for the unusually rapid development of proliferative retinopathy was uncertain, but appeared to have a temporal association with the deterioration of her glycaemic control postnatal after a period of strict diabetes control in the perinatal period.

Adult↗

Necrotising fasciitis originating from a vulval abscess--a case report.

This article reports a rare case of necrotising fasciitis starting out as a vulval abscess with rapid progression to a potentially lethal condition. Elderly people with medical conditions such as diabetes are especially prone to it. A high index of suspicion and an early surgical consult are essential in improving outcome in this condition. Once diagnosed, aggressive surgical debridement with antibiotic cover is crucial. This is followed up with meticulous nursing care of the large wound till it heals. The various diagnostic points and treatment modalities are also discussed.

Abdominal Muscles↗

External cephalic version at term with tocolysis and vibroacoustic stimulation.

OBJECTIVE: This study compared the obstetric outcome in women who had external cephalic version (ECV) for breech presentation after 36 weeks gestation with those who did not, to see whether ECV reduces breech deliveries and cesarean section rates with reduced complications. METHOD: External cephalic version was attempted in 200 women (study group) with the use of tocolysis and vibroacoustic stimulation. The control group (ECV not attempted) comprised of 278 women with breech presentation after 36 weeks. RESULT: The cesarean section rate was 14.0% in the successful version group compared with 55.2% in the unsuccessful version group. The overall cesarean section rate in the study group was 32.5%. In the control group of 278, the fetus remained in the breech presentation in labor in 269 women with a cesarean section rate of 51.4% which was not different from the unsuccessful version group (55.2%). CONCLUSION: This study supports the randomized trials conducted earlier in that ECV after 36 weeks gestation reduced the number of breech deliveries and cesarean sections (32.5% in the study group compared with 51.4% in the control group) (P > 0.00001).

Acoustic Stimulation↗

Amniotic fluid volume in spurious labour.

OBJECTIVE: A prospective study was undertaken to assess the amniotic fluid index (AFI) in women with spurious labour and its possible role in management. METHODS: Eight hundred and ninety-three women in early labour, who had uncomplicated pregnancy, were recruited for the study. Of these, 133 were later diagnosed to have had spurious labour, while 760 were in true labour. An admission cardiotocography and determination of AFI was done for all patients at the time of their admission to the labour ward. Labour was induced within 24 hours for those women in spurious labour who had severe oligohydramnios. RESULTS: The incidence of severe oligohydramnios (AFI < 5) was significantly higher in the patients later diagnosed to have had spurious labour (15.7%) compared with those in true labour (2.1%). With this management protocol, the obstetric and the neonatal outcome was similar in the spurious labour and the true labour groups. CONCLUSION: The assessment of AFI could be a simple and useful screening tool to avoid adverse perinatal outcome in women who experience spurious labour.

Adult↗

Preinduction cervical ripening: prostaglandin E2 gel vs hygroscopic mechanical dilator.

OBJECTIVES: To evaluate the efficacy and safety of hygroscopic mechanical dilators (Dilapan) for ripening the pregnant cervix prior to induction of labour at or near term and to compare it with an intracervical PGE2 gel (Prepidil). METHODS: One hundred and eighty-five women (69 nulliparae, 116 multiparae) at term with singleton pregnancies in cephalic presentation, who were scheduled for induction of labour in the labour ward at the National University Hospital, but had an unfavourable cervical score were randomized into 2 groups by random number table. In group 1 (Prepidil), 0.5 mg of PGE2 in 2.5 ml of triacetin gel was inserted into the endocervical canal. In women in group 2 (Dilapan) upto a maximum of 4 hygroscopic dilators were placed in the endocervical canal. If labour did not ensue at the end of 12 hours of ripening, the cervical score was assessed, amniotomy was performed and oxytocin commenced. Neonatal and obstetric outcome was compared, statistical analysis performed using Chi-square, and t-tests. RESULTS: Significantly more women in the group who received Dilapan for cervical ripening required amniotomy and oxytocin for induction of labour > 12 hours after priming compared with the group who received Prepidil (p < 0.001). Operative delivery for no progress and fetal distress respectively was similar in the 2 groups. The number of cases of hyperstimulation were higher in the Prepidil group but did not result in an increased incidence of operative deliveries for fetal distress. There was one neonatal death and one case of neonatal sepsis in the Dilapan group. Uterine rupture occurred in 1 woman who received Prepidil. CONCLUSION: Dilapan, a mechanical method of cervical ripening is as effective as the more widely accepted mode of ripening with an endocervical PGE2 gel in achieving vaginal delivery. Dilapan would be useful for cervical priming prior to induction of labour in places where prostaglandins are not available because of cost and the need for a cold chain.

Adult↗

Is there a need to treat hypokalaemia associated with intravenous salbutamol infusion?

OBJECTIVES: To investigate the evolution of metabolic effects associated with intravenous salbutamol infusion given together with 2 doses of intramuscular steroids in the treatment of preterm labour. METHODS: Preterm labour was inhibited with an intravenous infusion of salbutamol in 8 women between 26 and 32(+6) weeks with normal singleton pregnancies. Serum glucose concentration, serum potassium, sodium and insulin concentrations, and total white cell count both during the infusion as well as post-therapy, were plotted against time. RESULTS: Intravenous salbutamol infusion administered at a rate required to inhibit uterine contractions in preterm labour causes a rise in serum glucose and plasma insulin concentrations. The serum glucose and plasma insulin levels peaked soon after cessation of therapy and took 2-3 hours to come to pre-infusion levels. The decline in serum potassium concentration was gradual and plateaued after 2 hours. Once the salbutamol infusion was stopped the potassium levels were back to normal by 2 hours. There is an increase in total white cell count within an hour of the initiation of therapy. CONCLUSION: There is no need to administer insulin for hyperglycaemia and/or potassium for hypokalaemia unless the patient is a known diabetic or when a patient needs immediate surgery.

Adrenergic beta-Agonists↗

Fetal oxygen saturation during labour.

OBJECTIVE: To derive oxygen saturation by pulse oximetry (SpO2) values at each cervical dilation in labour in fetuses with normal neonatal outcome. PARTICIPANTS: One hundred and forty-five women at term in established labour with ruptured membranes and cervical dilation at least 2 cm who had normal delivery outcome. The infants had 5 minute Apgar scores > or = 7, birthweight > or = 2500 g, umbilical cord artery pH > or = 7.15 and did not require assisted ventilation or admission to neonatal intensive care. METHODS: Women were monitored continuously with cardiotocography and fetal pulse oximetry using the Nellcor N-400 fetal pulse oximeter and FS-14 fetal oxisensor till delivery. Labour was managed according to established protocol without recourse to SpO2 readings. RESULTS: There was a wide range of SpO2 values during labour in fetuses with normal outcome. Mean values averaged 50% +/- 10% throughout the first stage of labour, with lower ranges of SpO2 values above 30%. There was no significant difference in SpO2 readings at different cervical dilatations in the first stage of labour. Mean SpO2 values in the last 10 minutes before delivery were also not significantly different from those in the first stage of labour. CONCLUSION: The range of SpO2 in 115 healthy fetuses during normal labour was wide, but always above 30%. There was no trend of SpO2 values in this study of 115 fetuses with normal neonatal outcome.

Apgar Score↗

Trial of scar.

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Cesarean Section, Repeat↗

Intrapartum care.

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Anesthesia, Epidural↗

Pre and intraoperative diagnosis of ovarian tumours: how accurate are we?

In the assessment of malignant potential of ovarian tumours, frozen section has been found to be accurate in 97.1% (168 of 173) of cases. The positive predictive value of frozen section in the diagnosis of a malignant lesion was 100% (34 of 34). Errors were mainly made in the diagnosis of borderline tumours with a predictive value of 87.5% (7 of 8). The negative predictive value was 98.4% (127 of 129). Frozen section however, was less accurate in the diagnosis of specific histological type with an accuracy rate of 91.9% (159 of 173). Macroscopic features were found to be useful in the intraoperative prediction of malignant potential. Completely cystic tumours were benign in 96.4% (108 of 167) of cases. Solid/cystic tumors were malignant in 69% (27 of 38) of cases. Completely solid tumours were malignant in 56% (9 of 16) of cases. Frozen section in completely cystic tumours only marginally improved the clinical macroscopic diagnosis of malignancy. The sensitivity and specificity of ultrasound scan in the diagnosis of malignant/borderline tumours were 82% and 86% respectively. The false negative rate of 7% makes laparoscopic excision of unsuspected malignant ovarian cyst a significant possibility. The predictive value of ultrasound scan in the diagnosis of malignant ovarian tumour was 62% (26 of 42). In the preoperative assessment of malignant potential of ovarian tumours, this study shows that ultrasound scan has a high false positive and a significant false negative rate. Careful intraoperative assessment of gross features and the use of frozen section especially in those with solid/cystic and solid tumours will help achieve a high accuracy rate in the assessment of ovarian tumours.

Female↗

Ambulatory blood pressure monitoring in pregnancy induced hypertension.

OBJECTIVE: To determine the role of ambulatory blood pressure monitoring in the diagnosis of pregnancy-induced hypertension in women detected as hypertensive in the clinic by the conventional method. DESIGN: An observational study of ambulatory blood pressure monitoring. SETTING: A teaching hospital in Singapore. METHODS: One hundred and twenty-eight women between 28-37 weeks of pregnancy diagnosed to have non-proteinuric pregnancy-induced hypertension in the clinic had 24 hours ambulatory blood pressure monitoring. The mean systolic and diastolic BP, systolic and diastolic 'white coat effect' and the diastolic load were the main parameters noted. RESULTS: One hundred and twenty subjects had valid recordings. Only 46 (38.3%) were found to be truly hypertensive on ABP monitoring, using a mean diastolic pressure cut off of 85 mmHg. The 'white-coat effect' was seen in both groups of women--the hypertensives as well as the normotensives, although the magnitude of the white coat effect had poor correlation with the clinic diastolic BP. A cut-off value for diastolic load of 20 per cent was found to detect all hypertensives correctly (sensitivity 100%) with a modest false positive rate of 17.5 per cent. CONCLUSIONS: 'White-coat hypertension' is common in pregnancy and ambulatory blood pressure monitoring would be helpful in identifying the true hypertensive without requiring unnecessary hospitalization.

Adult↗

Fetal breathing recorded by actocardiogram and real--time ultrasonography. A comparison.

BACKGROUND: The aim of the study is to evaluate the ability of fetal actocardiogram to assess fetal breathing movements. METHODS: A descriptive study. Evaluation of the agreement between real-time ultrasound and actocardiographic assessment of fetal breathing movements. Eleven unselected pregnancies admitted because of various pregnancy complications. RESULTS: In six cases the breathing pattern recorded by the actocardiogram correlated to the findings with real-time ultrasonography. In five cases where fetal breathing was observed on the ultrasound screen, the actocardiogram did not either indicate breathing or was of an indecisive appearance. Two cases where no breathing was observed on real-time ultrasound yielded actocardiograms without patterns typical of breathing, but with activity difficult to distinguish from breathing. CONCLUSIONS: With the paper speed set at 3 cm/min it is possible to detect some types of fetal breathing or the absence of breathing with accuracy on the actocardiogram. However, in cases without deep and regular diaphragmatic excursions it is not possible to evaluate breathing with certainty by the actocardiogram.

Adult↗