Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Fetal echocardiographic assessment: impact of gestational age and maternal obesity.(Jaypee Brothers Medical Publishers, 2023) Patabendige, M.; Kodithuwakku, S.U.; Perera, M.N.I.; Dias, T.AIM: To identify the ability to acquire various fetal cardiac views using two-dimensional ultrasound at different gestational age and body mass index (BMI) categories. MATERIALS AND METHODS: We performed a prospective observational study among low-risk women with singleton pregnancies attending the University Obstetrics Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka. The ability to obtain satisfactory views of the situs, four chambers, right and left outflow tracts, three vessels, aortic arch, ductal arch, and superior and inferior vena cava of fetal heart was studied. RESULTS: A total of 314 eligible pregnant women underwent fetal echocardiography and 288 had complete data. All eight cardiac views were obtained with 100% success at the gestational age of 18 – 21 + 6 weeks and days. All eight cardiac views were satisfactory in more than 97% at the gestational age of 22 – 25 + 6 weeks and days. Body mass index was not significantly associated with acquisition of cardiac views at all gestations (p = 0.62). All eight cardiac views were obtained with 50% success at 14 – 17 + 6 weeks and 5.4% success at 11 – 13 + 6 weeks and days. CONCLUSIONS: Acquisition of all fetal cardiac views was best at 18 – 21 + 6 weeks and days of gestation, but reasonably successful till 26 weeks. Acquisition was sub-optimal in first trimester, below 18 weeks and for some cardiac views after 26 weeks. BMI does not hamper the ability to obtain cardiac views during fetal echocardiography. CLINICAL SIGNIFICANCE: This could be used as a guide for the timing of echocardiography when a particular cardiac defect is suspected in the fetus, where specific cardiac view(s) are used to confirm the particular diagnosis as well as the most appropriate gestational age period.Item Non-reassuring fetal status(Taylor and Francis Group, 2021) Dias, T.; Bhide, A.; Ugwumadu, A.No abstract availableItem Does emigration by itself improve birth weight? Study in European newborns of Indo-Pakistan origin(Elsevier Ltd, 2023) Morales-Roselló, J.; Buongiorno, S.; Loscalzo, G.; Scarinci, E.; Dias, T.; Rosati, P.; Lanzone, A.; Marín, A.P.OBJECTIVE: Our aim was to evaluate the effect of emigration on fetal birth weight (BW) in a group of pregnant women coming from the Indian subcontinent. METHODS: This was a retrospective study in a mixed population of pregnant women from the Indian subcontinent that either moved to Europe or stayed in their original countries. The influence of emigration along with several pregnancy characteristics: GA at delivery, fetal gender, maternal age, height, weight, body mass index (BMI) and parity on BW was evaluated by means of multivariable linear regression analysis. RESULTS: According to European standards, babies born to Indo-Pakistan emigrants and babies born to women staying in the Indian subcontinent were similarly small (BW centile 30± 29 and 30.1 ± 28, p<0.68). Multivariable regression demonstrated that emigration by itself did not exert a direct influence on BW (p = 0.27), being BMI and gestational age at delivery the true determinants of BW (p<0.0001). Conclusions: Maternal BMI is the most relevant parameter affecting fetal growth regardless of the place of residence. © 2023Item Development of size charts of symphysis pubis height measurement for Sri Lankan Population(Wiley-Blackwell, 2015) Dias, T.; Pathmeswaran, A.; Abeykoon, S.; Gunawardena, C.; Pragasan, G.; Padeniya, T.INTRODUCTION Fetal growth restriction is responsible for majority of explained and unexplained intrauterine deaths. Screening and diagnosis of fetal growth restriction is one of the main objectives of the antenatal care. Symphysis pubis height measurement (SFH) is routinely measured to assess the fetal growth during antenatal period. Use of SFH charts made elsewhere may either under or overestimate the fetal size in our population. The aim of this study was to construct new size charts for SFH for Sri Lankan population. METHODS This was a prospective, cross-sectional study carried out at the District General Hospital Ampara. In order to increase generalisability 1220 women with normal nutritional and health status and minimal environmental constraints on fetal growth were enrolled during first trimester. Fetal crown–rump length measurement between 11+0 and 13+6 was considered for gestational age assessment in all patients. Each mother considered only once for measurement of SFH for the purpose of this study at gestations between 24 and 41 weeks. SFH was measured using non-elastic, blinded tape using standard technique. For SFH measurement separate regression model was fitted to estimate the mean and standard deviation at each gestational age. Centiles were derived from this mean and standard deviation, assuming that the measurements have a normal distribution at each gestational age. RESULTS A total of 387 mothers had their SFH measured directly. New charts were created for SFH. 10th, 50th and 90th centile values for SFH at 40 weeks are 34, 37 and 41 cm. CONCLUSIONS We have constructed new size chart for SFH. This chart can now be used to assess the fetal size of Sri Lankan population.Item A retrospective analysis of the prevalence of heart disease in pregnancy – a Sri Lankan experience(Wiley-Blackwell, 2015) Motha, C.; Palihawadana, T.; Dias, T.; Thulya, S.D.; Godage, T.INTRODUCTION: With improvement in obstetric care, the burden due to direct causes of maternal mortality has declined bringing medical conditions to the forefront. Heart disease in pregnancy remains a major cause of maternal morbidity and mortality in Sri Lanka. In the absence of a robust pre-conception care programme, many women with pre-existing heart disease embark on pregnancy unaware of the underlying abnormalities. This study was aimed at describing the proportion of women with heart disease, the type of heart disease and the time of detection in this population. METHODS: The North Colombo Obstetric database (NORCOD) records data for all women who deliver at the university obstetric unit of the North Colombo Teaching hospital, Ragama, Sri Lanka. Details of women delivered between March and August 2014 were used in a retrospective analysis. Data on booking screening, and pregnancy care with regard to heart disease were analysed. RESULTS: A total of 1830 pregnancies were included. Fifty (2.7%) were complicated with heart disease. 15 (0.8%) patients were known to have pre-existing heart disease at the time of booking. They included 10 with congenital heart disease (treated ASD in 3, untreated ASD in 1, untreated VSD in 1, ligated PDA in 1 and mitral valve disease in 4) and 5 acquired heart disease due to rheumatic heart disease. A cardiac murmur on auscultation was detected in 61 women (3.3%) at their booking screening. 26 (42.6%) of them were found to have an underlying cardiac lesion. The commonest lesion was isolated mitral valve prolapse (n = 11), followed by mitral regurgitation associated with mitral valve prolapse (MVP) in 10, tricuspid regurgitation (TR) in 3, and one each of ASD and VSD. Nine others were found to have underlying cardiac lesion at assessment during pregnancy, in the absence of any abnormality at booking. These included 6 with MVP, 2 with mitral regurgitation (MR) with MVP, and one with MR. CONCLUSION A significant proportion of women with cardiac abnormalities (70%) were detected during pregnancy. This highlights the importance of pre-conception care with screening in this population. While booking screen was able to identify a majority of patients, some were detected only during subsequent assessment. Clinical vigilance throughout pregnancy facilitates such detection.Item Diabetes mellitus in pregnancy – a Sri Lankan experience(Wiley-Blackwell, 2015) Dias, T.; Palihawadana, T.; Motha, C.; Thulya, S.D.INTRODUCTION Diabetes mellitus in pregnancy carries high perinatal morbidity/mortality and maternal morbidity. Only a proportion of women would have pre-existing diabetes mellitus with the majority developing gestational diabetes (GDM). The burden of diabetes in pregnancy is expected to increase in Sri Lanka as obesity is high among pregnant population. Aims of this study were to look at the prevalence, risk factors and complications of diabetes in pregnancy. METHODS The North Colombo Obstetric database (NORCOD), which records pregnancy data of all women delivering at the university obstetric unit of the North Colombo Teaching hospital, Ragama, Sri Lanka, was used for retrospectively analysis. 1830 deliveries between March and August 2014 were included. Those with incomplete data were excluded. Details regard to prevalence, associated risk factors and complications were identified. RESULTS: Diabetes mellitus complicated 130 (7.1%) pregnancies. This consisted of 26 with pre-existing disease and 104 with GDM. A positive family history in first degree relative (OR 7.87, 95% CI 5.08–12.1), and a BMI of >23 kg/m2 (OR 2.68 95% CI 1.75–4.11) were associated with development of GDM. The mean (SD) age was significantly higher among women who developed GDM compared to those did not (32.1 (4.76) versus 28.7 years (4.7), P = 0.03 respectively). The mean (SD) postprandial blood sugar (PPBS) estimate done in the first half of the pregnancy was significantly higher among women who developed GDM later in pregnancy compared to those who did not (120 (39.2) versus 95 mg/dL (14.6), P < 0.0001 respectively). Hypertensive disorders of pregnancy was significantly associated with diabetes in pregnancy (OR 2.39 95% CI 1.49–3.83) and a birthweight of >3 kg at term (OR 1.63 95% CI 1.11–2.40). CONCLUSION: Diabetes mellitus complicates a significant number of pregnancies. Pre-existing diabetes constitutes one fifth of thesepregnancies, highlighting the importance of provision of preconception care to women contemplating pregnancy. A positive family history increases the risk of GDM by nearly 8 fold. Abnormal PPBS results in early part of pregnancy, in women who later develop GDM suggest the presence of abnormal glucose homeostasis in this group even at early stages of pregnancy. This has the potential for developing in to a test of early detection of GDM in pregnancy.Item Management of anaemia in pregnancy: experience from a Sri Lankan tertiary hospital unit(Wiley-Blackwell, 2015) Palihawadana, T.; Dias, T.; Motha, C.; Thulya, S.D.; Herath, R.; Wijesinghe, P.S.INTRODUCTION: Higher rates of pregnancy complications have been reported among anaemic pregnant women. Universal iron supplementation during pregnancy is recommended in countries where iron deficiency anaemia (IDA) prevalence rates are high. Sri Lanka also carries out a policy of such supplementation. The effectiveness of such programmes in different settings is variable. A retrospective analysis of the effectiveness of our current policy on prevention and treatment of anaemia was done for programme evaluation. METHODS: The North Colombo Obstetric Database (NORCOD) was used retrospectively to analyse the data between March and August 2014, at the university obstetric unit of the North Colombo Teaching Hospital, Sri Lanka. All singleton pregnancies without medical comorbidities were included in the analysis. Those who did not have haemoglobin (Hb) recording in the first trimester or in the third trimester were excluded at the data cleaning stage. An Hb level of <11 g/dL and a level of <10.5 g/dL were considered as anaemia in first and third trimesters respectively. The prevalence of anaemia at booking, and the Hb status in the third trimester were assessed. RESULTS: A total of 1340 singleton pregnancies were included in the analysis and 74 were excluded from the analysis due to incomplete data. 28.9% (n = 366) were found to be anaemic at booking while 63.9% (n = 809) were with a normal Hb and 7.1% (n = 91) were with an Hb of >13 g/dL. In the third trimester the prevalence of anaemia was 11.5% (n = 146) while 64.7% (n = 820) were with normal Hb and 23.6% (n = 300) were with an Hb of >13 g/dL. Among the anaemic women at booking, 22% (n = 81) persisted to be anaemic in the third trimester while 65% (n = 238) became normal and 12.8% (n = 47) developed a higher Hb level. Among those with a high Hb at booking only 1% became anaemic by third trimester while 40.6% persisted to have a high Hb level. CONCLUSION The prevalence of anaemia in this population was of moderate severity (>20% but <40%) as defined by the WHO. Major shortcoming in our practice is that we were unable to successfully treat nearly quarter of women who present with anaemia at booking, thus highlighting sub-optimal treatment. Furthermore, a policy of universal supplementation seems to over treat women with a high Hb at booking. Therefore, a more individualised supplementation and treatment policy should be encouraged in routine clinical practice.Item Fetal Doppler reference values in women with a normal body mass index(Sri Lanka Medical Association, 2019) Dias, T.; Abeykoon, S.; Mendis, P.; Gunawardena, C.; Pragasan, G.; Padeniya, T.; Pathmeswaran, A.; Kumarasiri, S.OBJECTIVES:To construct gestation specific reference limits for fetal umbilical (UA), middle cerebral artery (MCA) pulsatility indices (PI) and the cerebroplacental ratio (CPR) in singleton pregnancies with normal BMI between 16 and 40 weeks of gestation.METHODS:We ultrasonographically examined 596 fetuses from women with normal nutritional and health status and minimal environmental constraints on fetal growth. Each mother was considered only once for measurement of fetal Doppler indices, at gestations between 16 and 40 weeks in a prospective cross-sectional study. Gestational age was confirmed by fetal crown-rump length measurement between 11 and 14 weeks. Pulsatility indices of umbilical and middle cerebral arteries were measured by real time and Doppler ultrasonography. CPR ratio was calculated by dividing MCA PI by UA PI. The fetal Doppler measurements obtained from the current study were compared with commonly used reference charts. For each parameter separate polynomial regression models were fitted to estimate the gestation specific means and standard deviations, assuming that the measurements have a normal distribution at each gestational age.RESULTS:A significant difference of fetal Doppler indices was observed between our study and previously published reference charts for most gestational weeks. The fitted 10th, 50th and 90th centiles at 40 weeks of gestation were 0.65, 0.87 and 1.08 for UA PI; 0.93, 1.32 and 1.71 MCA PI; 1.02, 1.58 and 2.13 for CPR.CONCLUSIONS: These charts can be used for better defining the normal range of fetal arterial Doppler indices. This will be useful in the diagnosis and management of fetuses with abnormal fetal growthItem Prediction of fetal distress at labour at term(Sri Lanka College of Obstetricians & Gynaecologists, 2016) Dias, T.“Fetal distress”, commonly described by fetal hypoxia or compromise of the fetus during antepartum or intrapartum period, adversely affects the fetal outcome during pregnancy. Ability of early detection of fetal distress therefor improves fetal outcomes. Recent studies have proven that cerebroplacental ratio (CPR) can be used to predict / detect fetal distress. Moreover various biophysical and bio chemical markers (soluble fms-like tyrosine kinase-1 and estimated foetal weight) have also been effective in the detection of fetal distress in labourItem A comparison between ultrasonically assessed cervical volumes with modified bishop score to predict the favourability of the uterine cervix prior to induction of labour(Sri Lanka College of Obstetricians & Gynaecologists, 2018) Athulathmudali, S.R.; de Silva, P.H.P.; Dias, T.; Palihawadana, T.; Chandrasinghe, S.K.; Solangaarachchi, D I.K .INTRODUCTION AND OBJECTIVES: Induction of labour (IOL) is one of the most frequently performed obstetric interventions. In current obstetric practice approximately 15-20% of women undergo induction of labour. Sri Lanka has the highest prevalence of IOL in the region (35%) according to WHO. Conventionally Bishop score system have been used to assess pre induction cervical favourability for vaginal delivery. Several recent studies have proposed that transvaginal sonographic assessment of cervical length is more sensitive in prediction of obstetric outcome in induction of labour. The purpose of this study was to comparatively assess the predictive value of ultrasonically assessed cervical volume, in compared to Modified Bishop’s score, prior to IOL. The primary objectives of the study were To compare the cervical volume with Modified Bishop Score for assessing the favorability of cervix prior to induction of labour. To evaluate the women’s perception on degree of discomfort caused by a transvaginal ultrasound scan at term. METHODS: Study was carried out as a cross sectional study. Pre induction digital cervical assessment and transvaginal two dimensional sonographic cervical volume assessment was done in 120 consecutive women admitted for IOL at term, by two different clinicians who were unaware of each other's findings. IOL was done according to a standard protocol, uniformly in all women. All the obstetric outcomes including induction delivery interval were documented.RESULTS: Out of 125 study participants 83(66.4%) were nulliparous and 42 (33.6%) were multiparous. The mean gestational age at induction of labour was 40 weeks. Vaginal delivery succeeded in 97 (77.6%) women and 28 (22.4%) of women needed caesarean section. In vaginal delivery group, in 65 (52%) women, delivery occurred within first twenty-four hours of primary modality of induction. In 56% of nulliparous women vaginal delivery occurred in first 24 hours compared to 85% of multiparous women. The median induction to delivery interval in multiparous women was 9 hours and in nulliparous women it is 19 hours. Induction success and likelihood of vaginal delivery within first 24 hours, increased with Bishop Score and decreased with cervical volume in a linear correlation. There was a significant association between induction to delivery interval (IDI) with the Bishop score and the cervical volume. Out of 125 study participants, 110 (88%) experienced minimal or no pain during procedure. 15 (12%) experienced moderate discomfort and no study participant report severe pain or discomfort.CONCLUSIONS: Transvaginal cervical volume assessment is comparable to Modified Bishop’s core, in predicting the likelihood of vaginal delivery within 24 h following IOL. It doesn’t cause significant discomfort to the pregnant women, when performed at term.