Original Article

Vaiyapuri GR, Han HC, Lee LC, Tseng LA, Wong HF
Correspondence: Dr Ganesh Raj Vaiyapuri,  rajfeelsgood@yahoo.com

ABSTRACT
Introduction This retrospective study assessed the surgical outcomes of patients for whom the transobturator polypropylene mesh kit was used for the management of pelvic organ prolapse (Gynecare Prolift®) in a tertiary urogynaecological centre in Singapore from January 1, 2006 to December 31, 2007.
Methods 169 patients (2006 n = 95; 2007 n = 74) with total (n = 76), anterior (n = 82) and posterior (n = 11) Prolifts were followed up for two years post-surgery.
Results Intraoperatively, the incidence of haematoma, blood loss > 1,000 mL and blood transfusion was lower in 2007 than in 2006, although the difference was not statistically significant. One (1.4%) patient had rectal perforation in 2007. The mesh erosion rates were similar for all Prolift types (total 17.2%; posterior 14.5%; anterior 18.2%). Two patients, who had total Prolift in 2006, required mesh excision under anaesthesia for mesh extrusion. 138 (81.7%) patients were available for review at two years – nine (6.5%) patients had recurrent cystourethrocoeles and two (1.4%) had recurrent vault prolapse. Of the nine patients who had total Prolift with uterine conservation, two (1.4%) had recurrent uterine descent. The subjective cure rates two years after Prolift surgery were 98.7% for patients from 2006 and 100% for patients from 2007. The objective cure rates were 89.6% for patients from 2006 and 91.8% for patients from 2007.
Conclusion Prolift mesh surgery appears to have a very high success rate for pelvic reconstructive surgery. The learning curve of the surgeon may, however, be a factor determining surgical outcome in these patients.

Keywords: pelvic organ prolapse, prolift mesh, surgery, treatment outcome
Singapore Med J 2012; 53(10): 664–670

Tan WK, Lim SK, Tan LK, Bauptista D
Correspondence: Dr Tan Wei Keat, andy_twk@yahoo.com

ABSTRACT
Introduction Pregnancies in women with thrombophilia are associated with a higher risk of obstetric complications. We systematically reviewed the findings of relevant randomised controlled trials (RCTs) with the aim of investigating the effectiveness of low-molecular-weight heparins (LMWHs) in pregnant women with inherited thrombophilic disorders and its effect on the incidence of live births in these patients.
Methods The MEDLINE-PubMed and Cochrane CENTRAL databases from 2000 to 2010 were searched using a combination of keywords, including low-molecular-weight heparin, enoxaparin, pregnancy, live birth and thrombophilia. Studies were included if they were RCTs assessing the effect of anticoagulant treatment on live birth rates in women with a history of miscarriage without apparent causes other than thrombophilic disorder. Interventions included LMWH, with or without aspirin, aspirin alone or placebo controlled for the prevention of adverse pregnancy outcome.
Results 43 articles with seven RCTs were retrieved following the initial search, of which four studies had to be excluded as they assessed thromboembolic events as the final outcome (n = 1), focused on idiopathic recurrent miscarriages (n = 1), compared efficacy and safety of two doses of enoxaparin (n = 1), and examined patients with or without thrombophilic disorder (n = 1). Pooled data from the remaining three RCTs showed no significant difference in the improvement of live birth rates following LMWH interventions (p = 0.15).
Conclusion At present, the use of LMWH in women with inherited thrombophilia with recurrent pregnancy loss is not indicated. Large randomised placebo-controlled trials are further needed to prove the effectiveness of LMWH in these patients.

Keywords: enoxaparin, live birth, low-molecular-weight heparin, pregnancy, thrombophilia
Singapore Med J 2012; 53(10): 659–663

Radha P, Shephali T, Muhammad Fairuz AR, Tee CS
Correspondence: Dr Pandian Radha, radhahk@gmail.com

ABSTRACT
Introduction This study aimed to assess maternal and perinatal outcomes following second stage Caesarean sections.
Methods A retrospective study was conducted in a Singapore-based tertiary referral centre from January 1, 2009 to December 31, 2009. The medical records of all the women who underwent emergency Caesarean sections in the second stage of labour were reviewed.
Results Out of 2,501 emergency Caesarean sections performed, 116 were Caesarean sections in the second stage of labour. Women with non-vertex, twins and preterm deliveries were excluded, and 110 (4.4%, 110/2,501) Caesarean sections were recruited. The majority of the Caesarean sections were determined and performed by registrars or consultants. With regard to maternal outcome, 2.7% (3/110) of patients had primary postpartum haemorrhage and 4.5% (5/110) of patients had vertical or lateral lower uterine segment tears. As for neonatal outcome, although the Apgar scores of newborns were low at birth for 8.2% (9/110) of patients, the Apgar score was > 4 at 5 minutes for all patients.
Conclusion Overall, there was no statistically significant adverse maternal or perinatal outcome.

Keywords:  Caesarean section, maternal morbidity, perinatal morbidity
Singapore Med J 2012; 53(10): 655–658

Loh SF, Wong PC, Jiang B, Yeo GH, Tan AS, Prasath EB, Mathew J, Chan ML, Tan WC, Choolani M, Yap C, Chong SS
Correspondence: Dr Samuel S Chong, paecs@nus.edu.sg

ABSTRACT
Introduction We aimed to develop and implement a short tandem repeat (STR) polymerase chain reaction alternative to fluorescence in situ hybridisation (FISH) for the preimplantation genetic diagnosis (PGD) of chromosomal translocations.
Methods Selected informative STRs located on translocated arms of relevant chromosomes were used to discriminate between normal and unbalanced chromosome states in each embryo.
Results PGD cycles were performed on five couples where one spouse carried a balanced translocation. 27 embryos were analysed, of which 12 were normal/balanced, 12 were abnormal/ unbalanced and three were indeterminate. Four PGD cycles proceeded to embryo transfer, of which two led to pregnancy. The first pregnancy showed a normal male karyotype, and a healthy baby was delivered at term. A second pregnancy unexpectedly miscarried in the second trimester from unknown causes.
Conclusion STR analysis is a simple and suitable alternative to FISH for detecting unbalanced chromosomal states in preimplantation embryos.

Keywords: capillary electrophoresis, chromosome translocation, polymerase chain reaction, preimplantation genetic diagnosis, short tandem repeat
Singapore Med J 2012; 53(10): 648–654

Dhanardhono T, Thia EW, Wei X, Saktini F, Dewi PK, Yeo GS
Correspondence: Dr George SH Yeo, dr.george.sh.yeo@gmail.com

ABSTRACT
Introduction Congenital heart defect (CHD) is a significant cause of neonatal and infant mortality. We aimed to evaluate the incidence and pregnancy outcome of foetuses diagnosed with chromosomally normal CHD in KK Women’s and Children’s Hospital (KKH), Singapore, in 2008–2009.
Methods We reviewed the medical records of pregnant women who underwent first trimester screening and were diagnosed with foetal CHD at KKH. Additional information was obtained from the Birth Defect Registry for the period 2008–2009. Foetuses with abnormal karyotype or minor lesions not expected to be detected by ultrasonography were excluded.
Results 38 out of 9,834 euploid foetuses were diagnosed with CHD. Major defects were found in 26 (68%) foetuses, while 12 (32%) had minor CHDs. Tetralogy of Fallot, atrioventricular septal defect, hypoplastic left heart syndrome, transposition of the great arteries and ventricular septal defect constituted the five most common major CHDs observed. In 14 (54%) foetuses with prenatally diagnosed major CHD, the outcome was termination of pregnancy, while 12 (46%) pregnancies continued to birth. Among the live-born babies with major CHD, eight (67%) underwent surgery.
Conclusion The incidence of non-chromosomal major CHD in Singapore was about 2.6 per 1,000 foetuses. A detection rate of 88.5% was achieved for major CHD during the study period. Advances in CHD management have thrown up new challenges for clinicians in the area of diagnosis, treatment and ethics. Therefore, it may be beneficial to constitute a regulatory entity as a fundamental guide to improve the future management of foetuses diagnosed with CHD.

Keywords: congenital heart defects, incidence, outcome, prenatal diagnosis, ultrasonography
Singapore Med J 2012; 53(10): 643–647

Malekshahi Moghadam A, Saedisomeolia A, Djalali M, Djazayery A, Pooya S, Sojoudi F
Correspondence: Dr Ahmad Saedisomeolia, a _saedi@tums.ac.ir

ABSTRACT
Introduction Consumption of omega-3 fatty acids can alter the inflammatory response in diabetic patients. This study aimed to determine the effects of omega-3 fatty acid supplementation on the serum levels of C-reactive protein (CRP), interleukin (IL)-2 and tumour necrosis factor-alpha (TNF-α) in type 2 diabetes mellitus patients.
Methods A randomised, double-blind, placebo-controlled clinical trial was conducted on 84 subjects aged 45–85 years with at least a two-year history of type 2 diabetes mellitus. Participants were randomly assigned to the treatment or control group. Each subject in the treatment group received three omega-3 capsules per day (eicosapentaenoic acid 1,548 mg; docosahexaenoic acid 828 mg; other omega-3 fatty acids 338 mg), while each subject in the control group received three placebo capsules (sunflower oil 2,100 mg) for a period of eight weeks. At the beginning of the study and post intervention, fasting blood samples were taken and serum concentrations of IL-2, TNF-αand CRP were assessed and compared.
Results Serum IL-2 and TNF-αlevels were significantly reduced in the treatment group compared to the controls (p < 0.01). There was no significant change in serum CRP levels.
Conclusion Short-term omega-3 fatty acid supplementation (3 g/day for eight weeks) can decrease the serum levels of TNF-αand IL-2 in diabetic patients, with no change in CRP levels. Consumption of omega-3 fatty acid supplements is highly recommended to alleviate inflammation caused by type 2 diabetes mellitus.

Keywords: CRP, diabetes mellitus type 2, IL-2, omega-3 fatty acid, TNF-α
Singapore Med J 2012; 53(9): 615–619

El-Bassyouni HT, Abdel Maksoud SA, Salem FA, Badr El-Deen R, Abdel Aziz H, Thomas MM
Correspondence: Dr Hala Tabie El-Bassyouni, halabassyouni@yahoo.com

ABSTRACT
Introduction Peroxisomal disorders are subdivided into peroxisome biogenesis disorders (PBDs) and single peroxisomal enzyme deficiency. Many peroxisomal diseases exhibit excessive oxidative stress, leading to neurological alterations and dysfunction. Peroxisomes use oxygen in oxidative reactions that generate hydrogen peroxide. This study aimed to investigate various oxidative stress parameters in patients suffering from peroxisomal disorders.
Methods A total of 20 patients with peroxisomal disorders, aged six months to 13 years (mean age 5.9 ± 3.2 years), were compared to 14 healthy controls. All individuals were subjected to full history-taking, including a three-generation pedigree analysis concerning parental consanguinity and similarly affected members in the family, with meticulous clinical examination to detect any malformation or anomaly. Estimation of very-long-chain fatty acids and phytanic acid was done to verify the diagnosis. Brain magnetic resonance imaging, electroencephalogram, visual evoked potential, auditory potential and plain radiography were conducted to assess the pathological condition of the patients. Oxidative stress parameters, including nitric oxide (NO), malondialdehyde (MDA) and superoxide dismutase (SOD), were estimated in both the patients and controls.
Results Significant increases in both MDA and NO were found in patients with PBDs. It was also demonstrated that SOD was significantly lower in patients with PDB than the controls.
Conclusion This study sheds more light on the link between oxidative stress and peroxisomal disorders, as oxidative stress may be a hallmark of peroxisomal disorders. Consequently, one of the useful neuronal rescue strategies could be treatment with antioxidant agents in addition to other lines of treatments.

Keywords: oxidative stress, peroxisomal disorders, reactive oxygen species
Singapore Med J 2012; 53(9): 608–614

Lee MY, Telisinghe PU, Ramasamy R
Correspondence: Prof Ranjan Ramasamy, ranjan.ramasamy@ubd.edu.bn

ABSTRACT
Introduction Cervical cancer caused by the human papilloma virus (HPV) is a common cancer in women. There is no published data on the recent incidence of cervical dysplasia, cervical cancer and genital warts caused by the different types of HPVs in Brunei Darussalam.
Methods A cross-sectional, retrospective study was conducted utilising data from patients diagnosed with cervical cancer during the period 2005–2009 in Brunei Darussalam. The varying incidences of different types of cervical lesions among various ethnic and age groups, and in the overall population, were determined.
Results The mean age-standardised incidence of invasive cervical cancer during the five-year period was 24.9 per 100,000 women per year (95% confidence interval [CI] 21.7, 28.1). Age-specific invasive cervical cancer incidence peaked in the age group 45–59 years. Chinese females tended to have a higher incidence of invasive cervical cancer (28.2 per 100,000 women per year; 95% CI 17.8, 38.7) than Malay females (20.6 per 100,000 women per year; 95% CI 17.1, 24.2), while other ethnic groups in Brunei Darussalam had a significantly lower incidence (6.5 per 100,000 women per year; 95% CI 3.0, 10.0).
Conclusion The results suggest that Brunei Darussalam has a relatively higher incidence of cervical cancer compared to its neighbouring countries. The findings support the need for more comprehensive screening, public education programmes and vaccination against HPV in the country.

Keywords:  Brunei Darussalam, cancer epidemiology, cervical cancer, human papilloma virus 
Singapore Med J 2012; 53(9): 604–607

Dashti-Khavidaki S, Khalili H, Shahverdi S, Abbasi MR, Lessan-Pezeshki M
Correspondence: Dr Simin Dashti-Khavidaki, dashtis@sina.tums.ac.ir

ABSTRACT
Introduction The number of patients suffering from chronic kidney disease (CKD) is increasing worldwide. Hyperphosphataemia and high serum calcium (Ca) and phosphorus (P) product contribute to the substantial increase in cardiovascular events in CKD patients. Although reports of CKD complications in Iranian haemodialysis (HD) patients are comparable to data from other developed countries, management of these complications has failed to meet generally accepted targets. This study evaluated the impact of clinical pharmacy services in the management of complications in HD patients.
Methods During a six-month prospective study, clinical pharmacists conducted medical visits in the HD ward and adjusted the patients’ medications according to their laboratory findings.
Results Serum Ca concentration was increased in hypocalcaemia patients and decreased in hypercalcaemia patients until it reached the optimal range in both groups. A decline in serum P level was noted in hyperphosphataemia patients, although it did not reach the target range. The Ca × P product decreased in patients with Ca × P > 55 mg²/dL². Although it did not reach the goal, there was an increase and decrease in serum intact parathyroid hormone (iPTH) concentration in suboptimal and supraoptimal range patients, respectively. Serum Ca, P and iPTH levels did not change in patients with optimal values at the initiation of the study. Haemoglobin concentration increased in anaemic patients and serum ferritin reached target values in all patients. Total cholesterol, low-density lipoprotein cholesterol and triglycerides decreased to near-optimal values in dyslipidaemia patients.
Conclusion This study showed that clinical pharmacy services at the HD centre can improve the management of complications in CKD patients.

Keywords: anaemia, dyslipidaemia, haemodialysis, hyperparathyroidism, NKF-K/DOQI guidelines
Singapore Med J 2012; 53(9): 599–603

H’ng M, Loh SS, Earnest A, Wansaicheong G
Correspondence: Dr Martin H’ng Weng Chin, martin_hng@ttsh.com.sg

ABSTRACT
Introduction Patients with suspected deep vein thrombosis (DVT) pose a diagnostic dilemma to the Emergency Department (ED) clinician. This study aimed to implement a known algorithm incorporating the modified Wells criteria and D-dimer testing to guide the ED clinician, thus reducing unnecessary ultrasound scans (USS).
Methods Patients who presented to the ED between August 2008 and April 2009 with suspected DVT underwent Wells scoring. Those with scores < 2 were deemed unlikely to have DVT and underwent D-dimer testing first. Patients with scores ≥ 2 were regarded as likely to have DVT and underwent urgent USS. USS findings were tabulated as positive or negative/indeterminate for DVT. The latter group was followed up for one year to check whether DVT was missed during the initial USS.
Results 75 patients presented with suspected DVT and underwent USS. Of these, 14 results were positive and 61 were negative. 37 patients had Wells scores < 2, with three (8.1%) having DVT. Another 38 patients had Wells scores ≥ 2, with 11 (28.9%) having DVT. D-dimer testing was performed on 27 of the 75 patients. Those with DVT had higher average values compared to those without DVT (1.305 vs. 0.595 µg/ml). The majority of patients with raised D-dimer values had cellulitis, although three also had DVT (with values ≥ 0.99 µg/ml).
Conclusion We managed to reduce the number of unnecessary USS and increase the pick-up rate of DVT. A cut-off score ≥ 2 in our algorithm is suitable for use in the ED setting.

Keywords: D-dimer, deep vein thrombosis, modified Wells score, ultrasound scan, venous thromboembolism
Singapore Med J 2012; 53(9): 595–598