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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 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 Symphysis-pubis fundal height charts to assess fetal size in women with a normal body mass index(Sri Lanka Medical Association, 2016) Dias, T.; Abeykoon, S.; Kumarasiri, S.; Gunawardena, C.; Pragasan, G.; Padeniya, T.; Pathmeswaran, A.OBJECTIVES: To construct symphysis-pubis fundal height (SFH) charts to estimate fetal size in pregnant women with a normal body mass index (BMI) and to describe the variation of SFH measurements according to BMI. METHODS: cross sectional study was carried out at Ampara and Gampaha Districts in Sri Lanka. Women with normal nutritional and health status, normal BMI and minimal environmental constraints on fetal growth, with ultra sound confirmation of dates by fetal crown-rump length measurements between 11 weeks and 13 weeks + six days,had their SFH measured, using non-elastic tape and standard techniques, between 24 and 41 weeks gestation. Only one measurement of SFH was obtained from each pregnant woman. Linear and polynomial regression models were fitted separately to the means and standard deviations (SD) as functions of gestational age to identify the model with the best fit. Centiles were derived from the mean and SD at each gestational age. RESULTS: Pregnant women from the districts of Ampara (n=387) and Gampaha (n=200) were recruited. Other than a difference of -1.5 cm (95% CI -2.27 to -0.23) at 38 weeks of gestation, there were no significant differences between the SFH measurements obtained from women with normal BMI in Ampara and Gampaha Districts. Using the SFH measurements from the Ampara sample, charts were created for 10th, 50th and 90th centile values of SFH. At 40 weeks of gestation these were 34 cm, 37 cm and 41 cm respectively. At 40 weeks gestation, the variation in SFH measurements between BMI sub groups within the normal range was approximately 1.4 cm to 1.6 cm. CONCLUSIONS: These SFH charts could be used to estimate fetal size in pregnant women with normal BMI.Item The Ability of ICU admission to detect maternal near misses as defined by the who near-miss criteria(Sri Lanka College of Obstetricians & Gynaecologists, 2015) Bower, G.; Dias, T.; Shanmugaraja, V.; Lee, M.; Cooper, D.; Crofton, H.; Kumarasiri, S.; Padeniya, T.OBJECTIVE: to assess the ability of intensive care unit (ICU) admission in pregnancy, or the postpartum period, to detect cases of obstetric near-miss. METHODS: All obstetric admissions to the ICU were included retrospectively and data collected as specified by 2011 World Health Organization (WHO) guidelines on evaluating obstetrics near-misses between 2010 and 2013 in a Sri Lankan Hospital. Proportion of ICU admissions which fulfilled the WHO criteria for Severe Acute Maternal Morbidity (SAMM), maternal mortality ratio (MMR), maternal near-miss mortality ratio (MNM: MM)), and maternal near-miss ratio (MNMR) were analysed. RESULTS: A total of 9,608 live births were reported. 118 ICU admissions and four maternal deaths were analysed. MMR was 42 per 100,000. MNMR was 9.7 per 1000, and MNM: MM was 23:1. From all ICU admissions 99 cases (79.8%) met additional WHO near-miss criteria and were classified as true SAMM. Pregnancy-induced hypertensive disorders accounted for majority of ICU admissions (37.7%). Out of eight published studies from our region none of them had a MNM: MM higher than ours. CONCLUSIONS: Obstetric near-misses may be over-diagnosed if ICU admission is considered an independent inclusion criterion for SAMM. Reporting the proportion of patients admitted to ICU which are true near-miss may illustrate differing admission thresholds for a given institution.Item Determinants of timely pregnancy dating scan in a Sri Lankan antenatal clinic setup(Sri Lanka College of Obstetricians and Gynaecologists, 2015) Dias, T.; Fernando, A.; Kumarasiri, S.; Padeniya, T.Background: Early accurate estimation of gestational age is the most important intervention in pregnancy. Ultrasound between 11 and 13 weeks is most reliable in dating. There is no uniform policy in timing of dating scan in Sri Lanka. Objective: Aim of this study was to find out factors that determine the timely dating scan before 14 weeks in a district general hospital in Sri Lanka. Methods: This was a prospective observational study carried out at District General Hospital in Sri Lanka. A detail history was taken in order to ascertain age, parity, menstrual history, time taken to reach the hospital, distance to the hospital, level of education and gestation at the first booking visit with public health midwife (PMH). We offered dating scans for every pregnant mother before 14 weeks. Logistic regression analyses were performed to evaluate the association of socio-demographic factors and receiving timely dating scan before 14 Weeks. Results:A total 199 women were included for the analysis with a mean age of 26.98 years (SD 5.58). A 190 out of total recruitments (95.5%) were booked with PHM before 14 weeks. A total of 171 (86%) pregnant women received their first scan before 14 weeks. Logistic regression analysis demonstrated that only booking before 14 weeks with PMH (Odds ratio 12.272 (95% CI, 4.563-33.000) p<0.000) contributed significantly to receive dating scan before 14 weeks, while maternal age, parity, time taken to reach the hospital, distance to the hospital and mother’s level of education did not. Conclusion: Our study showed it is entirely possible to offer dating scan before 14 weeks even in a peripheral District General Hospital. Moreover, we demonstrated that none other than booking before 14 weeks was determined the dating scan prior to 14 weeks.Item Use of ultrasound in predicting the success of intrauterine contraceptive device (Copper T) insertion immediately after delivery(John Wiley and Sons, 2015) Dias, T.; Abeykoon, S.; Kumarasiri, S.; Gunawardena, C.; Padeniya, T.; D'Antonio, F.OBJECTIVES: To assess by ultrasound examination the success of insertion of an intrauterine contraceptive device (IUD) immediately after delivery and to determine the optimal distance between the lower end of the IUD and the internal os in predicting successful retention of an IUD. METHODS: This was a prospective study carried out between December 2012 and April 2013. Two ultrasound examinations, transabdominal and transvaginal, were performed prior to hospital discharge following delivery and again at 6 weeks following delivery in women who received a postpartum IUD. Distance from the internal os to the lower end of the IUD was measured at each examination and compared in unsuccessful and successful cases of postvaginal delivery (PVD) and post-Cesarean section (PCS) IUD insertion. Logistic regression and receiver-operating characteristics (ROC) curve analysis were used to determine the difference in success between the two modes of delivery and to determine the optimal cut-off of the internal os-to-IUD distance for successful retention, respectively. RESULTS: Ninety-one women were included in the study, comprising 60 PVD and 31 PCS IUD insertions. Thirteen PVD (22.4%) and eight PCS (25.8%) IUDs were either expelled spontaneously or removed at the 6-week scan because of improper placement. Mean distance from the internal os to the lower end of the IUD on ultrasound examination immediately after insertion was significantly greater in successful cases than in those in which IUDs were subsequently expelled/displaced (mean difference after PVD insertion, 20.1 mm (P = 0.006); mean difference after PCS insertion, 10.3 mm (P = 0.05)). Logistic regression analysis demonstrated that mode of delivery was not independently associated with successful retention of the IUD (P = 0.72; OR, 0.831 (95% CI, 0.301-2.189)). The distance from the lower end of the IUD to the internal os measured at ultrasound examination prior to hospital discharge provided reasonable predictive accuracy for determining retention of the IUD, with an area under the ROC curve of 0.74 (95% CI, 0.60-0.88) and an optimal cut-off of ≥ 30 mm (sensitivity, 64.71% (95% CI, 52.17-75.92%) and specificity, 80.95% (95% CI, 58.09-94.55%)). CONCLUSIONS: IUD insertion immediately postpartum is feasible but carries a substantial risk of unsuccessful IUD retention. Ultrasound examination after insertion of an IUD could be considered for predicting the success of IUD retention. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.Item Birthweight standards - Ability of birthweight percentiles in predicting abnormal fetal growth and outcome(Sri Lanka College of Obstetricians and Gynaecologists, 2014) Dias, T.; Shanmugaraja, V.; Ganeshamoorthy, P.; Kumarasiri, S.; Abeykoon, S.; Padeniya, T.Introduction: Birthweight references for different populations are varied and most of abnormal growth deviations of given populations could be detected by creating local birthweight charts. The aim of this study was to compare the accuracy of commonly used birthweight centile charts in birthweight percentiles in predicting abnormal growth trajectories. Methods: This was a retrospective analytical study conducted between April 2010 and October 2013. Patient data and mortality data were traced from respective units and cross checked with the hospital monthly perinatal statistics. Centile values of >90th (large for gestational age -LGA),10th - 90th (appropriate for gestational age -AGA) and <10th (small for gestational age - SGA) of previously validated Sri Lankan fetal/ birthweight charts were compared with birthweight charts adopted by child health development record (CHDR) and for commonly used Hadlock charts. Proportions of adverse outcomes (perinatal deaths and late neonatal deaths) among preterm (<37 weeks) and term deliveries were also compared for SGA, AGA and LGA in three different birthweight centile charts. Results: Among 12501 singleton births, preterm and term neonates were classified differently for SGA, AGA, and LGA by Sri Lankan, CHDR and Hadlock birthweight references. More than 20% of babies were SGA by CHDR charts. SGA derived from Sri Lankan charts have detected significantly higher proportion of adverse outcomes among preterm babies than Hadlock (OR 2.08 95% CI, 1.21 to 3.56) charts. Furthermore, there is a positive trend in detecting more adverse outcomes among SGA babies from Sri Lankan charts than CHRD and Hadlock charts at term (OR 1.44, 95% CI, 0.66 to 3.12 and OR 1.93, 95% CI, 0.98 to 3.82 respectively). Conclusions: The newly created Sri Lankan birthweight chart detects most true SGA infants. It also improves the classification of abnormalities in birthweight and predicts substantially higher adverse outcomes. These new reference charts are clinically effective and can be used in the Sri Lankan population. DOI: http://dx.doi.org/10.4038/sljog.v36i4.7729 Sri Lanka Journal of Obstetrics and Gynaecology Vol.36(4) 2014: 85-88 Keywords: Birth weight standards, Fetal growth abnormalities, Prediction, Adverse perinatal outcome, Patient care, Preventive medicineItem Sexual violence against women: a challenge(Sri Lanka Medical Association, 2014) Dias, T.; Kociejowski, A.; Rathnayake, S.; Kumarasiri, S.; Abeykoon, S.; Padeniya, T.Item Accuracy of ultrasound estimated fetal weight formulae to predict actual birthweight after 34 weeks: prospective validation study(Sri Lanka Medical Association, 2013) Kumarasiri, S.; Wanigasekara, R.; Wahalawatta, L.; Jayasinghe, L.; Padeniya, T.; Dias, T.OBJECTIVES: Late onset fetal growth restriction is often missed and is responsible for most intrauterine deaths. Ultrasound fetal biometry is routinely used to calculate estimated fetal weight (EFW). The aim of this study was to determine the accuracy of established ultrasound EFW formulae to identify small and large for gestational age fetuses when used after 35 weeks gestation. METHODS: This was a prospective validation study done between January 2012 and July 2012 at General Hospital Ampara. An ultrasound examination was performed and fetal biometry was documented within one week before the delivery in well dated pregnancies. The mean of the differences between ultrasound EFW derived from 9 formulae and true birthweight and their standard error of mean (SE) were calculated for each formula. Systematic measurement error was assumed to exist if zero lay outside the mean difference ± 2SE. To show the EFW frequency distribution, z-scores were calculated as the number of standard deviations an observed EFW measurement deviated from the mean for gestation. RESULTS: A total of 393 pregnancies at gestational age between 35 and 41 weeks were recruited. Mean gestational age at the ultra sound scan was 39.36 weeks SD (1.05). All EFW formulae either under or over estimated the birthweight in singleton pregnancies. Almost all the formulae over estimated the fetal weight in low birthweight babies whilst underestimating the fetal weight in birthweight >3500g. Campbell formula remained the only EFW formula without systematic error when measuring babies between 2500g and 3500g. None of the EFW z-scores were normally distributed. CONCLUSIONS: This study found that all routinely used EFW formulae would either over or under estimate the fetal weight. Until an optimum EFW formula that suits the Sri Lankan population is determined, interpretation of ultrasound EFW should be done cautiously, especially in small for gestational age babiesItem Pregnancy outcome in extremes of reproductive age at a tertiary care hospital(Sri Lanka College of Obstetricians and Gynaecologists, 2013) Dias, T.; Wijesinghe, E.; Abeykoon, S.; Ganeshamoorthy, P.; Kumarasiri, S.; Kodithuwakku, M.; Gunewardena, C.; Padeniya, T.INTRODUCTION: Pregnancy outcomes in teenagers and in elderly are independently associated with adverse outcomes. The aim of this study was to find out pregnancy outcome at extremes of reproductive age. METHODS: This was a retrospective cohort study conducted between April 2010 and October 2013 at a tertiary care hospital. Individual pregnancy records, delivery suite register and neonatal care unit records were traced in order to gather information. Mortality data were traced from respective units and cross checked with hospital monthly perinatal statistics. Outcome data were compared between teenage pregnancies and pregnancies at normal age (20-34). Same comparison was done for mothers with advanced maternal age. RESULTS: A total of 12477 pregnancies were included (teenage-1009, normal-10192, advanced maternal age-1276). Intra-uterine death (IUD) rate and early neonatal death rates were not significantly higher among teenagers compared to age group 20-34 (OR 0.57, 95% CI 0.17 to 1.83 and OR 2.53, 95% CI 0.71 to 8.97 respectively). Preterm birth rate was significantly high among teenagers (OR 1.33, 95%, CI 1.12 to 1.56). In mothers with advanced age, early neonatal death rate and caesarean section rate were significantly higher than the age group of 20-34 (OR 3.33 95% CI 1.17 to 9.49 and OR 2.17 95% CI 1.92 to 2.44 respectively). In contrast, caesarean section rate was low in teens (OR 0.44 95% CI 0.36 to 0.52). Stillbirth and preterm birth rates were not significantly different (OR 1.36 95% CI 0.66 to 2.76 and OR 0.98 95% CI 0.83 to 1.15) in mothers with advanced maternal age. CONCLUSIONS: Risks of pregnancy complications are different from teens and in advanced maternal age. More studies are needed to establish the exact causes of these risks and evaluate management options in these women.