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					                       Abstracts : Speakers
                                                                      26 August , Wednesday
                                                                          Opening Ceremony
                       The Importance of Having an Evidence-Based Adhesion Prevention Strategy
                       Gregory T. FOSSUM

                       Adhesion formation is recognised as a consequence of abdominopelvic surgery. Certain procedures have a high chance of
                       adhesion formation while others are associated with a relatively low risk. Adhesions form in 60 to 90% of patients
                       undergoing major gynecological procedures, but adhesion formation after procedures such as tubal ligation is low. Small
                       bowel obstruction secondary to adhesions can occur after hysterectomy. Three to 5% of patients have small bowel
                       obstruction after hysterectomy (median time 5.3 years). The costs of these adhesions are known to be high. It was
                       estimated that the cost of adhesions was $3 to $10 for each person living in the U.S. or $1.33 billion dollars. A successful
                       adhesion prevention strategy utilises a multiple faceted approach. Of primary importance is good surgical technique:
                       minimizing injury to tissue, preventing infection, and limiting the use of foreign bodies. Next in order is the selection and
                       use of an adhesion prevention adjuvant that has been considered from an evidence-based perspective. In the US, the FDA
                       only approves medical devices with evidence. Pharmacologic and fluid based adhesion prevention adjuvants that have not
                       been shown to be of benefit are heparin, corticosteroids, phenergan, and Hyskon. Adept is a new fluid based adhesion
                       adjuvant that is FDA approved for laparoscopy. Adept has been evaluated in one RCT which demonstrated limited clinical
                       effectiveness in gynecological patients and was equivalent to Ringer‟s lactate solution. Physical barriers appear to be the
                       most effective means of reducing adhesions. Effective barriers need to be present during the critical time of adhesion
                       formation (approximately 3-7 days) and are then removed or gradually resorbed after the peritoneal surface is healed.
                       Permanent barriers such as Gore-tex and omental grafts are not FDA approved for adhesion prevention and may need to
                       be removed at subsequent surgical procedures. The FDA has approved temporary barriers: Seprafilm and Interceed which
                       are present during early peritoneal healing and then absorbed. Seprafilm has been extensively evaluated in men and
                       women in clinical studies involving over 6000 patients in a wide variety of surgical indications, and has repeatedly been
                       demonstrated to be safe and effective. Seprafilm has been shown to reduce adhesion formation where placed, and in the
                       case of myomectomy by 70%. Interceed has only been evaluated in gynecologic procedures and may reduce the incidence
                       of adhesion formation by 24% but must be used only when complete hemostasis is achieved. Sepraspray (Seprafilm in a
                       powder spray formulation) has recently completed a laparoscopic myomectomy pilot study and was found to be efficacious
                       in this limited setting. Pivotal trials will begin in the near future. The routine use of adhesion adjuvants during low risk
                       procedures may not be cost effective, whereas use during high risk procedures may reduce the risk of adhesion formation,
                       pain, infertility, the number, time and difficulty of subsequent procedures, and small bowel obstruction. High risk
                       procedures that I would recommend the use of adhesion barriers include hysterectomy, tubal anastomosis, fimbrioplasty,
                       ovarian cystectomy, moderate/severe lyses of adhesions, moderate/severe resection of endometriosis, hysterotomy,
                       myomectomy, and c-section.
Abstracts : Speakers




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                                                  27 August, Thursday
                                              Symposium 1 : Fetal Screening
S1.1
First Trimester Screening - What’s the Latest?
Tony TAN

First Trimester Screening (FTS) involves the integration of maternal age, ultrasound findings of crown-rump length (CRL)
and nuchal translucency (NT), and maternal serum levels of free bhCG and PAPP-A to assess each individual's risk of
having a fetus with Trisomies 21, 18 and 13. It is already a well-established test and is routinely offered in many centres,
and recent guidelines from the Singapore College of Obstetricians and Gynaecologists support the routine offering of this
test to all pregnant women.

There are many recent improvements to the FTS test. Latest strategies designed to improve detection rate and reduce
false positive rate of common chromosomal abnormalities in FTS include the use of:

a)   Other sonographic markers like nasal bone, ductus venosus, tricuspid regurgitation and facial angle
b)   Major abnormalities (e.g. exomphalos, megacystis)
c)   Minor markers (e.g. Choroid plexus cyst, echogenic bowel) and fetal heart rate

Other strategies include using optimal timing of blood tests at 8-11 weeks and ultrasound scan at 12 weeks where feasible
to improve detection rate of chromosomal abnormalities.

At the FTS, patients can now be screened for early structural abnormalities and also the risk of early severe pre-eclampsia.
Early severe pre-eclampsia that requires delivery before 34 weeks may be predicted by the integration of:
a) Historical findings such as past history of pre-eclampsia, chronic hypertension and parity
b) Ultrasound findings of mean uterine artery PI at 11-13 weeks
c) Maternal serum PAPP-A levels

Calcium supplementation of at least 1 g/day reduces the risk of pre-eclampsia, and the early use of aspirin in those at high
risk of severe pre-eclampsia may also reduce the risk of it happening.


S1.2
The New 20-Week Scan
Fon Min LAI

Traditionally, the 20 week obstetric ultrasound scan was performed to screen and diagnose structural fetal anomalies and
to screen for chromosomal abnormalities using soft markers. With the widespread adoption of first trimester combined
screening using nuchal translucency and serum biochemistry for Trisomy 21, the emphasis of the 20 week scan has shifted
towards screening for congenital malformations and for pre-term delivery, which are the two most common causes of
perinatal morbidity. Screening for pre-eclampsia is still being investigated while we await an effective intervention strategy
for preventing its onset.
                                                                                                                                   Abstracts : Speakers

Structural anomaly screening
The Routine Antenatal Diagnostic Imaging with Ultrasound (RADIUS) Study did not show a decrease in perinatal outcome
with routine ultrasound in low-risk pregnancy because the standard of ultrasound and hence the detection rate of fetal
anomalies was low. The results of a systematic review of 17 studies by National Collaborating Centre for Women‟s and
Children‟s Health reported a sensitivity and specificity of detecting fetal structural anomalies before 24 weeks of gestation of
24.1% (range 13.5% to 85.7%) and 99.92% (range 99.40% to 100.00%), respectively, while overall sensitivity and
specificity were 35.4% (range 15.0% to 92.9%) and 99.86% (range 99.40% to 100.00%), respectively.

A meta-analysis by Bucher and Schmidt showed that perinatal mortality was decreased by 49% and Tegnander has shown
that operator experience improves detection of cardiac anomalies. Current literature shows that although early pregnancy
ultrasound (<16 weeks gestation) is promising, it should still be used as an adjunct to the 18- to 20-week scan. As yet, the
early pregnancy ultrasound scan has not replaced the mid-trimester fetal anatomical survey.

An example of the components of a fetal anatomy survey at 18-22 weeks is that by the American Institute of Ultrasound in
Medicine. The International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG) in 2006 came up with a set of

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                       guidelines for performing the „basic‟ and „extended basic‟ cardiac scan. This was followed by the basic examination of the
                       fetal central nervous system guidelines in 2007. The latest ACOG, NICE and SCOG guidelines indicate that the routine
                       anomaly scan (genetic sonogram) should not be used for Down Syndrome screening using soft markers. With the
                       exception of hypoplastic nasal bone and increased nuchal fold, the finding of an isolated soft marker on the routine anomaly
                       scan should not be used to adjust the a priori risk for Down Syndrome.

                       Preterm delivery
                       Preterm delivery results in significant neonatal morbidity and mortality and economic costs. A considerable body of
                       evidence indicates that the risk of preterm birth increases as the cervical length decreases. Endovaginal sonography has
                       been shown to be a reproducible and safe method to assess cervical length objectively when compared to transabdominal
                       ultrasound.

                       Transvaginal cervical length measurement recognises an early asymptomatic phase that is predictive and precedes
                       preterm delivery by many weeks in all populations studies so far; and perhaps most importantly, it has been shown that
                       „early‟ treatment is effective in prevention. The 2 interventions effective only in specific populations are ultrasound-indicated
                       cerclage and vaginal progesterone.


                       S1.3
                       Screening for Genetic Syndromes
                       Angeline LAI

                       Advances in genetic technology have resulted in increased availability of genetic testing. Over 10,000 human diseases are
                       caused by single gene defects. In the prenatal setting, deciding which conditions to screen for is challenging. Taking a
                       family history remains important in identifying the pregnancies at risk of being affected with a genetic disorder. These
                       couples can then be offered genetic counselling and testing. In couples with no family history of a genetic disorder, carrier
                       testing for single-gene disorders can be considered. The approach to this has historically been ethnicity-based, e.g.
                       thalassaemia or Tay Sachs disease. Universal population screening is being considered for conditions such as Fragile X
                       syndrome and spinal muscular atrophy. Screening for Down syndrome and chromosomal aneuploidies is usually offered in
                       the first trimester. This combines maternal age, ultrasound findings and maternal serum tests. When fetal structural
                       anomalies are detected on ultrasound, there is a possibility of an underlying genetic syndrome and genetic testing may be
                       considered. Analysis of cell-free fetal nucleic acids in maternal blood is currently used for non-invasive prenatal fetal sex or
                       Rhesus D status determination. The application of this technology for non-invasive prenatal diagnosis of Down syndrome,
                       thalassaemia and other single-gene disorders may soon be a clinical reality. While scientific advances provide many
                       benefits, it also presents challenges to healthcare providers and patients. Patients need education about their prenatal
                       screening and testing options, as well as adequate counselling regarding the significance of test results. Thus, genetic
                       counselling must be an integral part of any prenatal screening programme.


                       S1.4
                       Fetal Screening in 2020
                       George YEO

                       Abstract not available at time of print
Abstracts : Speakers




                                                                         Symposium 2 : Oncology
                       S2.1
                       Getting it Right (And Wrong) in Gynaecologic Oncology
                       Ian HAMMOND

                       This session will concentrate on the interface between general gynaecology and gynaecologic oncology. The majority of
                       women with genital tract cancer and precancerous conditions are initially seen by a General Practitioner and then referred
                       to a specialist Obstetrician and Gynaecologist for evaluation, diagnosis and initial management. The importance of an
                       appropriate diagnostic evaluation cannot be overemphasized. Short cuts to diagnosis/treatment often lead to inappropriate
                       treatment with potential compromise of the patient in regard to treatment related morbidity and long term cure.

                       If a diagnosis of invasive cancer is made, then it is usually in the patient‟s best interest to have her care managed by a
                       gynaecologic oncologist. Even if the specific technical treatment is within the domain of the gynaecologist, the
                       comprehensive and holistic care of the woman with gynaecologic cancer is best managed by a cancer specialist. There are

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certain situations when the continuing care will be appropriately managed by the specialist gynaecologist, but it is often
reassuring to both patient and gynaecologist to have an assessment by a gynaecologic oncologist, particularly for those
women who have very early invasive disease in whom no further treatment may be necessary.

Clinical cases will be presented to highlight some of the areas of difficulty in diagnosis and management, and the necessity
for good communication and working relationship between the gynaecologist and the gynaecologic oncologist. The
following scenarios will be used to demonstrate the importance of appropriate diagnosis, referral and treatment.
 Post menopausal bleeding, thickened endometrium and histology showing severe atypical endometrial hyperplasia
 Post menopausal bleeding, D&C showing Grade 1 endometrioid adenocarcinoma of the endometrium
 47 yr old woman with a Pap showing HSIL and glandular change, with menorrhagia and irregular bleeding
 28 yr old with LLETZ showing CIN3 and early invasion
 Unexpected ovarian malignancy discovered at operation
 Itchy vulva with leukoplakia

These cases will be discussed in an interactive manner highlighting the fact that the best outcomes for patients are
achieved by appropriate communication and referral.


S2.2
Routine Laparoscopic Radical Hysterectomy: Pune Technique
Shailesh PUNTAMEKAR

Study objective: To describe our experience and technique of total laparoscopic radical hysterectomy with pelvic
lymphadenectomy, which is the largest single institution study.

Setting: Private Hospital

Patients: Two hundred forty eight patients with International Federation of Gynecology and Obstetrics stage 1A2 {n= 32}
and 1b 1{n=216} of cancer of the cervix.

Intervention : Total laparoscopic type 3 radical hysterectomy with bilateral pelvic lymphadenectomy was done. Simple
repetitive steps were used to perform this surgery develop an easily replicable technique. Harmonic shears, bipolar
coagulation, and vascular clips were used resection of the cardinal and uterosacral ligaments was performed with Ligasure
{Ligasure vessel sealing system }Valley lab, Tyco Healthcare Boulder CO} or the Harmonic Shears {Ethicon Endosurgery
Inc Cincinnati .OH}. Pelvic lymph node dissection was done.

Measurement and main results : Histopathologically, there were 183 {73% cases of squamous cell carcinoma}, 52{20
% } adenocarcinomas, and 13 {5% }adenosquamous carcinoma. The operation was performed entirely by laparoscopy in
all patients and by the same surgical team. The patient median age was 61 yrs.The median operative time was 92 min
{range 65-120 min}, The median number of pelvic nodes was 18. The median blood loss was 165 ml. The median length of
stay is 3 days. All 15 intraoperative complications were tackled laparoscopically. No patient were converted to the open
technique. There were no deaths. Seventeen patients had complications within 2 months of surgery. Seven patient had
recurrence after a median follow up of 36 months.
                                                                                                                               Abstracts : Speakers

Conclusion : Our technique of total laparoscopic radical hysterectomy, developed over 248 cases can be performed
safely. It is an easily replicable technique. This procedure reduces the morbidity associated with abdominal radical
hysterectomy. All of the complications can also be tackled laparoscopically which does not further add to the morbidity.


                                             Keynote Lecture 1 : Obstetrics
KL1
How the Pharmaceutical Industry Has Failed Obstetrics – Past, Present and Future
Nicholas FISK

Abstract not available at time of print.




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                                                                          Lunch Symposium 1
                       LS1.1
                       YAZ in Clinical Practice: the 3 Year US Experience
                       Anita NELSON

                       Abstract not available at time of print


                       LS1.2
                       Added Benefits Beyond Contraception : the Evidence
                       Lorraine DENNERSTEIN

                       Abstract not available at time of print


                                                                   Symposium 3 : Prenatal Diagnosis
                       S3.1
                       Same-Day Prenatal Diagnosis
                       Mahesh CHOOLANI

                       Chromosomal abnormalities are the most frequent genetic disorders seen in live born babies. Trisomies, the most frequent
                       chromosomal disorder, account for more than half of all chromosomal abnormalities in early fetal deaths. Amniocentesis is
                       usually performed in the second trimester to obtain sufficient amounts of amniotic fluid for karyotyping. Chorion villus
                       sampling is performed earlier, but is associated with a slightly higher risk of fetal miscarriage. After invasive testing, the
                       standard method for chromosomal assessment is by karyotyping, which can take over a week for the results to be ready.
                       This results in a long delay before the mother could be reassured of the health of her baby, or informed of any abnormality,
                       and this can be emotionally traumatic.

                       Molecular diagnostic technologies, such as polymerase chain reaction (PCR) and fluorescence in situ hybridization (FISH)
                       allow a more rapid turn around time. We present our data on these molecular diagnostic technologies that allow rapid
                       prenatal diagnosis, and ask the question if karyotyping is still relevant and necessary. We discuss how Same Day Prenatal
                       Diagnosis is now a clinical reality.


                       S3.2
                       Non-Invasive Prenatal Diagnosis – Are We Getting Closer?
                       Sinuhue HAHN

                       The application of recent technical developments such as digital PCR or shot-gun sequencing have for the analysis of cell-
                       free fetal DNA have indicated that the long sought goal of the non-invasive detection of Down syndrome may finally be
                       attained.

                       Although these methods are still cumbersome, and not high-throughput, they provide a paradigm shift in prenatal diagnosis,
Abstracts : Speakers




                       as they could effectively pronounce the end of invasive procedures such as amniocentesis or chorionic villous sampling for
                       the detection of such fetal anomalies. It, however, remains to be determined how suitable these approaches are for the
                       detection of more subtle fetal genetic alterations, such as those involved in hereditary Mendelian disorders (thalassemia,
                       cystic fibrosis).

                       New technical developments such as micro-fluidics and reliable automated scanning microscopes have indicated that it
                       may be possible to efficiently retrieve and examine circulating fetal cells. As these contain the entire genomic complement
                       of the fetus, future developments may include the non-invasive determination of the fetal karyotype.


                       S3.3
                       Intrauterine Therapy for Genetic Disease – The Last Frontier
                       Nicholas FISK

                       Abstract not available at time of print.



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                                        Symposium 4 : Genetics in Reproduction
S4.1
Pre-Conception Genetic Screening of Oocytes and Embryos – Results and Implications
E P BALAJI

Pre-natal genetic diagnosis detects genetic abnormality of a fetus in utero leading to medical termination of pregnancy if
fetus is abnormal. In vitro fertilization (IVF) offers unique access to diagnose genetic normalcy at oocyte or embryo level
through pre-implantation genetic diagnosis (PGD) or screening (PGS). PGD/PGS is advantageous in terms of preventing
conception of genetically unhealthy baby thereby avoiding medical termination of pregnancy and unwanted consequences.
PGD/PGS can be performed at oocyte level or embryonic level. Genetic analysis is performed either by florescence in situ
hybridization (FISH) or polymerase chain reaction (PCR).

Polar body, the meiotic by product during oogenesis, has the complimentary set of chromosomes. Analysis of
chromosomes from polar body discloses abnormality of maternal chromosomes. PGD/PGS of polar body gives information
on X-linked genetic disorders and other genetic diseases specific to the female patient. However, genetic defects derived
from paternal side, at fertilization or during embryonic development are not diagnosed by analysis of polar body.

Complete information on genetic normalcy of the embryo can be obtained by analyzing the blastomeres of the embryo.
PGD/PGS of embryos is available in many IVF centres worldwide with varying results. Although PGD-IVF cycles have
acceptable success rate, PGS-IVF cycles appear to have lower pregnancy rate compared to non PGS-IVF cycles.

Misdiagnosis occurs in approximately 0.15% of the cases. Misdiagnosis rate is lesser in FISH than PCR. Cause of
misdiagnosis varies from confusion in cell number to allele dropout. Biopsy and testing of two cells is recommended to
minimize errors or misdiagnosis in PGD/PGS. Both polar body and blastomere testing of the oocyte and the embryos
derived out of it is performed to increase availability of genetic material for PGD/PGS.


S4.2
Pre-implantation Genetic Diagnosis – Studying All Chromosomes – Is More Better?
Samuel CHONG

Preimplantation genetic diagnosis (PGD) and screening (PGS) are procedures in which early embryos created by in vitro
fertilization (IVF) techniques are tested for the presence of a known heritable disease due to a known family history, or
screened to detect de novo chromosomal abnormalities, respectively. Embryos determined to be unaffected are selected
for implantation into the uterus. At-risk couples undergoing PGD embark on a pregnancy knowing that their child will be
born unaffected, while patients undergo PGS in an effort to improve chances of pregnancy or minimize risk of miscarriage
or abnormal offspring. In Singapore, PGD for a number of specific Mendelian disorders has been available for a number of
years since 2003, funded by the Biomedical Research Council (BMRC) of the Agency for Science, Technology and
Research (A*STAR), and the Health Services Development Programme (HSDP) of the Ministry of Health. Single cell
molecular diagnostic tests have been developed for various monogenic disorders, the majority of these being targeted
towards alpha- and beta-thalassemia. A human leucocyte antigen (HLA) marker panel has also been developed to enable
preimplantation tissue typing (PTT). Other diseases for which PGD have been performed include Werdnig-Hoffman
infantile spinal muscular atropy and Herlitz junctional epidermolysis bullosa. Recently, we have also developed
                                                                                                                                 Abstracts : Speakers

microsatellite-based assays and performed PGD testing to avoid unbalanced karyotypes arising from translocation carrier
parents. In 2006, PGS for aneuploidy detection was made available on a limited basis under an IRB-approved research
protocol, for patients with difficulty conceiving or maintaining a pregnancy after undergoing at least two rounds of IVF. This
study involves the use of a commercial 5-chromosome fluorescent in situ hybridization (FISH) probe panel, which has
obvious significant limitations in coverage and aneuploidy detection sensitivity. Although protocols to detect additional
chromosomes are available, these invariably require sequential hybridization processes, which present their own technical
challenges. To overcome this severe limitation, recent reports have surfaced on the use of metaphase comparative
genomic hybridization (CGH) and arrayed-CGH strategies, involving a prior step of whole genome amplification of the
single cell genome. If reproducible, this technology promises true aneuploidy screening of all 24 human chromosomes in a
single assay. We will discuss our experience with several different whole genome amplification strategies, as well as
results obtained using several microarray platforms. The advantages and limitations of the different strategies for
downstream microsatellite analysis and aneuploidy detection from single cells will also be discussed.




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                       S4.3
                       ICSI Babies – Fetal Anomalies and Neurodevelopmental Issues
                       Pratibha AGARWAL

                       Over the course of the last three decades, ART technology has progressed from in vitro fertilization (IVF) in the seventies to
                       micro assisted ICSI in the 1990s and most recently the development of pre-implantation genetic diagnosis (PGD).

                       Due to various medical and lifestyle practice changes, ART is becoming increasingly necessary and frequent. More than a
                       million babies have been conceived world wide using ART.

                       ICSI represented a major breakthrough in ART with a superior fertilization rate and success in all forms of infertility.
                       However valid concerns persisted regarding adverse neurodevelopmental outcome and higher incidence of congenital
                       malformations in children conceived using this technique. Since ICSI bypasses the natural sperm selection barrier, the
                       sperms used in ICSI may carry genetic abnormalities in the child. Other factors predisposing to this higher risk include
                       advanced parental age, use of ovulation inducing medications and factors associated with the ART procedure itself. In a
                       meta-analysis of international data it has been shown that ICSI conceived children had a higher incidence of birth defects
                       especially genitourinary abnormalities.

                       Regarding general health, growth, mental and psychomotor development ICSI children do not differ from spontaneously
                       conceived peers. In a local prospective cohort study conducted at KKH, Singapore, neurodevelopmental and functional
                       outcomes were comparable in 76 ICSI and 261 control children at the age of 2 years. Cognitive outcomes were affected by
                       socio-economic and maternal educational status.

                       ICSI pregnancies are associated with higher pregnancy related and subsequent perinatal complications due to prematurity,
                       multiple pregnancies, with higher usage of hospital resources. Single embryo transfer (SET) is an important intervention to
                       consider in fine-tuning future ART programmes as SET enables adequate success rate while decreasing the neonatal and
                       neurodevelopmental complications associated with multiple gestations.

                       Further research on the safety and outcomes of ICSI pregnancies is vital, to enable appropriate counseling of infertile
                       couples, assist in informed parental decision and to ensure long term follow-up of this cohort of babies.


                       S4.4
                       Stem Cell Research and Preserving Ovarian Function
                       Bing LIM

                       Abstract not available at time of print.


                                                                  Symposium 5 : Multiple Pregnancies
                       S5.1
                       Multiple Pregnancies – Understanding Clinical Presentations from Placental Studies
                       Tony TAN
Abstracts : Speakers




                       Multiple pregnancies account for 1-2% of all pregnancies. Chorionicity refers to the placentation while zygosity refers to
                       whether the multiples are identical or non-identical. With rare exceptions, the simple rule to note is that all monochorionic
                       twins are monozygotic while all dizygotic twins are dichorionic.

                       Monochorionic placentas are characterised by the ubiquitous sharing of vascular anastomoses while dichorionic placentas
                       do not have vascular anastomoses.

                       The anatomy of monochorionic (MC) placentas affects the wide spectrum of clinical presentations in monochrionic
                       pregnancies.

                       Having more moderate to large artery-vein anastomoses (AVA) from one twin to the other without the presence of any
                       artery-artery anastomoses (AAA) is typical of monochorionic twins presenting with chronic twin transfusion syndrome
                       (TTTS) resulting in twin oligohydramnios polyhydramnios sequence (TOPS). On the other hand, having multiple small AVA
                       without AAA is characteristic of pregnancies presenting with chronic TTTS resulting in twin anaemia polycythaemia
                       sequence (TAPS). TAPS is not a common clinical presentation among untreated MC pregnancies, but has been
                       increasingly recognised in some MC pregnancies treated by laser photocoagulation.
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Grossly unequal placental sharing with or without marginal or velamentous cord insertions is characteristic of MC twins with
intrauterine growth restriction (IUGR). MC twins with IUGR with AAA tend to present as Gratacos' type III IUGR, whereas
types I and II tend not to have AAA.

MC Monoamniotic (MA) pregnancies typically have cord insertions very close to one another, and hence predispose to cord
entanglement in at least 70% of such pregnancies.

The presence of AVA and/or AAA in MC placenta causes hypotensive / ischaemic episodes to the co-twin when there is
severe hypotension in one twin. This often results in death or ischaemic damage to the brain or kidneys of the co-twin.

Dichorionic twins do not suffer from transfusional complications such as TTTS (either TOPS or TAPS), death or ischaemic
damage when 1 twin dies, or twin reversed arterial perfusion (TRAP) sequence seen in acardiac twins.


S5.2
Surveillance of Multiple Pregnancies
T P BASKARAN

Fetal development and growth is a constant yet rapid sequence of events. Changes which do not conform to acceptable
trends may be a sign of poor prognosis for the fetus. Fetal growth charts vary especially beyond 28 weeks. Fetal
surveillance in expected to identify theses changes. Determining these changes as early as possible may initiate actions
that may save the baby. Growth pattern disorders and fetal anomalies are increased in a multiple pregnancy. The
ultrasound scan has given us the ability to monitor the fetuses directly. Serial fetal biometry assessment forms the basis of
monitoring the growth pattern and surveillance of fetal wellbeing. Twins, just as in singletons are subject to growth patterns
problems. In addition twins need to be monitored for discrepancy between the fetuses. These may occurs as early as the
first trimester which may indicated chromosomal abnormality. If it occurs later, it may be related to the monochorionicity
which is best determined between 10 and 14 weeks of gestation. Growth restriction is associated in up to 20 % of twins
irrespective of chorionicity. Sharing of a placenta give raises various haemodynamic issues which may result in conditions
such as twin to twin transfusion syndrome resulting in fetal compromise. As the pregnancy progresses, fetal wellbeing
maybe assessed by Doppler monitoring of the umbilical artery. The risk of a structural abnormality is three time higher than
singletons. Concordant abnormalities are rare but discordant abnormalities are not uncommon. As such, a targeted scan
should be considered at 20 weeks to rule out fetal abnormality. In the third trimester, the cardiotocograph will provide
addition information regarding fetal wellbeing. This becomes more apparent while patient is in labour. Close surveillance
will enable early identification of fetal compromise.


S5.3
Management of Higher Order Multiple Pregnancies
Arijit BISWAS

Higher order multiple (HOM) pregnancies (triplets and higher) are usually the result of aggressive fertility treatment and
present a serious challenge to the obstetric team. Most important management of HOM pregnancies is its prevention. The
major problem with HOM pregnancies is the marked increase in the rate of preterm birth and its consequences. Of
particular concern is the significantly increased risk of cerebral palsy in HOM births. Higher the order of multiple, lower the
                                                                                                                                  Abstracts : Speakers

average gestation at delivery. Unfortunately, therapeutic intervention for preventing preterm births in HOM has largely been
unsuccessful. Prenatal diagnosis and fetal monitoring of ongoing pregnancies present special challenges to the
obstetrician. Birth is almost universally through elective abdominal delivery. To reduce the complications of HOM, one of
the options presented to the parents is fetal reduction to twins or singleton. Although it has been shown to improve overall
outcome and reduce neonatal morbidity, ethical issues are still disturbing to many.


S5.4
Complications from Multiple Pregnancies – A Thing of the Past?
Nicholas FISK

Abstract not available at time of print.




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                                                              Symposium 6 : Minimally Invasive Surgery 1
                       S6.1
                       Fertiloscopy in Gynaecological Practice
                       Antoine WATRELOT

                       Since our first description of fertiloscopy, a little more of 10 years are spent. It is probably a good opportunity to review this
                       technique and its place in the infertile work-up. Many papers have shown the reproducibility of fertiloscopy as well as the
                       safety of the procedure.

                       The FLY study (comparing fertiloscopy and laparoscopy) published in 2003 has demonstrated the accuracy of fertiloscopy.

                       Moreover the technique allows the routine practise of salpingoscopy and microsalpingoscopy, which is not the case with
                       laparoscopy.

                       Today, the place of fertiloscopy may be considered as central allowing determining the best therapeutic option according to
                       the findings: Intra utérine insémination when everything is normal including, tubal mucosa, surgery when either
                       endometriosis or peri tubal adhésions are found but with normal tubal mucosa and in vitro fertilization (IVF) in case of
                       abnormal mucosa.

                       Therefore fertiloscopy appears to be a complimentary tool to artificial reproductive technologies such as IIU or IVF.

                       So if practiced early in the infertile work-up then pregnancy may be obtained avoiding unnecessary delay which is always
                       stressful for infertile women.


                       S6.2
                       Robotic Surgery is Better for the Surgeon and the Patient
                       Arnold ADVINCULA

                       Technical advancements such as improved hand instrumentation and electrosurgical devices have clearly brought about
                       improvements to modern day laparoscopy. This technology has continued to grow by leaps and bounds in the area of
                       minimally invasive gynecologic surgery. Studies have clearly shown that laparoscopic surgery allows faster recovery with
                       shorter hospitalization, improved cosmesis, decreased blood loss and less postoperative pain. Despite these technological
                       advancements and proven benefits, more complex procedures such as the management of advanced endometriosis, and
                       procedures that require extensive suturing such as myomectomy and sacrocolpopexy are typically still managed by
                       laparotomy.

                       One major obstacle to the more widespread acceptance and application of minimally invasive surgical techniques to
                       advanced gynecologic surgery has been the steep learning curve for surgeons. Other limitations encountered with
                       conventional laparoscopy include counter-intuitive hand movement, two-dimensional visualization, and limited degrees of
                       instrument motion within the body as well as ergonomic difficulty and tremor amplification. In an attempt to overcome these
                       obstacles, robotics has been incorporated into the gynecologic armamentarium. The advantages obtained with robot-
                       assisted laparoscopy may be the way forward in terms of improving surgical outcomes for the patient and facilitating
Abstracts : Speakers




                       assimilation of minimally invasive surgical techniques by surgeons as evidenced by the growing number of gynecologic
                       applications and data to support its use.


                       S6.3
                       Single Port Laparoscopic Hysterectomy
                       Shailesh PUNTAMBEKAR

                       Background: LESS – World over Laparo Endoscopic Single Site Surgery or scar less laparoscopy is now a term that has
                       been adopted as a multidisciplinary consensus statement, white paper term for single insicion laparoscopic surgery.

                       Method: Here, we describe the series of six patients operated by single incision total laparoscopic hysterectomy for
                       various benign conditions of the uterus. Three routinely used ports were introduced through a single incision taken at the
                       umbilicus. Uterus was manipulated per vaginally by a vaginal manipulator. The steps of hysterectomy proceeded according
                       to the „our technique‟ of total laparoscopic hysterectomy.

                       Results: All the steps of the surgery could be successfully completed including successful intracorporeal vaginal vault
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closure. The average time taken for the procedure was 85 minutes. The average blood loss was 100 ml. There were no
intra-operative or post-operative complications. All the patients were discharged on the next day after the surgery.

Discussion: Laparo endoscopic single site total laparoscopic hysterectomy is technically challenging procedure with the
conventional laparoscopic instruments. Better instrumentation and use of advanced energy sources in experienced hands
can definitely make it a popular procedure. Intracorporeal vaginal vault closure is the most difficult part of the whole
procedure. Whether it has any additional benefits besides cosmesis is a question we need to ask our self.

Conclusion: LESS for total laparoscopic hysterectomy is feasible. It has all the benefits of conventional laparoscopy and
an additional benefit of cosmesis. Technical difficulties like chopstic effect of instruments, learning curve and the other
problems faced during the procedure can be resolved with better instrumentation.


S6.4
Fertility Sparing Surgery in Endometriosis and Malignancy
Charles KOH

Abstract not available at time of print.




                                                                                                                              Abstracts : Speakers




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                                                                        27 August, Thursday
                                                                       Symposium 7 : Miscarriage
                       S7.1
                       Genetics in Miscarriages
                       Sinuhue HAHN

                       Abstract not available at time of print.


                       S7.2
                       New Thoughts on the Management of Recurrent Miscarriages
                       Mahesh CHOOLANI

                       Care of patients with recurrent pregnancy losses is challenging at best and controversial at worst. This is because the
                       underlying pathology of the condition is as yet poorly understood. Thrombophilic conditions have been implicated in the
                       pathogenesis of this condition, and empirical treatment focuses on coagulation strategies. New ideas are now evolving in
                       the pathogenesis of this condition, and placental microparticles and immune dysregulation are among these. These new
                       concepts in the etiology of recurrent pregnancy loss will be discussed and possible directions for future research into the
                       management.


                       S7.3
                       Placental and Trophoblast Damage in Recurrent Miscarriages
                       Kenneth CHANG

                       Histopathological examination of products of conception from miscarriages including recurrent miscarriages is part of
                       routine clinical practice. Such examination may identify hydatidiform moles and villous dysmorphism suggestive of fetal
                       aneuploidy. Other important pathologies include chronic histiocytic intervillositis, massive perivillous fibrinoid deposition,
                       extensive chronic villitis, lymphoplasmacytic deciduitis, and impaired trophoblast invasion. The identification of the latter
                       group of conditions is important as they have recurrence potential. Antiphospholipid syndrome is the most important
                       treatable cause of recurrent miscarriage. Antiphospholipid antibodies interfere with signal transduction mechanisms
                       controlling trophoblast function.


                       S7.4
                       What if a Woman Starts Bleeding in Early Pregnancy?
                       Peter VAN DER WEIJER

                       Vaginal bleeding in early pregnancy (first trimester of pregnancy) is the commonest complication in pregnancy, occurring in
                       one in five pregnancies. Failure to make an accurate diagnosis may cause unnecessary pain and distress or compromise a
                       woman‟s reproductive future.

                       The differential diagnosis of vaginal bleeding in early pregnancy should include:
Abstracts : Speakers




                        Ectopic pregnancy: Abdominal pain and vaginal bleeding are the classic symptoms of an ectopic pregnancy.
                           Evaluation is by transvaginal ultrasound and quantitative hCG levels.

                           Vaginal bleeding in early pregnancy has been related with higher risk for miscarriage (threatened cq recurrent
                            miscarriage) and with later complications in pregnancy.

                            There is still considerable debate about cause and associations as the exact pathophysiological mechanisms of most
                            known etiologies have not been precisely elucidated. Current research is directed at theories related to implantation,
                            trophoblast invasion and placentation, as well as pharmacological interventions. The potential value of progesterone
                            supplementation to improve outcome of pregnancy needs consideration. Since the pioneering days of IVF, it has been
                            evident that administering luteal phase hormonal support to maintain adequate progesterone levels during the period
                            of implantation following ovarian hyperstimulation and IVF improves outcomes. In recent years, an increased
                            understanding of the importance of progesterone in modulating the immune response to early pregnancy has been
                            demonstrated.

                           Hydatidiform mole: Complete and partial moles occur after aberrant fertilization with proliferation of trophoblastic

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     tissue. Ultrasound findings will show a characteristic sonographic appearance also molar pregnancies are also
     misdiagnosed as incomplete or missed abortion. About 40% of complete moles are associated with hCG levels >
     100,000 mIU/mL.

    Vanishing twin: Among pregnancies with twin sacs early in pregnancy approximately 30% will ultimately result in a
     singleton pregnancy.

    Heterotopic pregnancy: The simultaneous occurrence of 2 or more implantation sites. It is commonly manifested as
     concomitant intrauterine pregnancy and ectopic pregnancy.

    Implantation bleed, which is presumed to be related to implantation of the blastocyst in the decidua. It is characterized
     by a small amount of bleeding approximately 10 -14 days after fertilization (at the time of the missed menstrual
     period). Implantation bleeding is a diagnosis of exclusion.

    Ectropion of the cervix: The exposed columnar epithelium is prone to light bleeding when touched (i.e. during
     intercourse).

    Cervical neoplasm for which expert treatment is warranted during pregnancy.

    Cervicitis for which Chlamydia is the most common cause and should be treated with antibiotics.

    Cervical polyps which should be removed when symptomatic (bleeding, excessive discharge) or appearing atypical.
     This can usually be accomplished by grasping the base of the polyp with forceps and twisting it off.

    Condylomata acuminate are a rare cause for vaginal bleeding in early pregnancy.

    Vaginal/ vulvar lacerations

    Blood loss from urethra or rectum

Vaginal bleeding in early pregnancy occurs in about a quarter of all pregnancies and has a profound psychological impact
on a significant proportion of women, their partners and families. Clinical expertise and reasoning underpin proper
assessment and management.


                                     Symposium 8 : A New Look at Ovarian Stimulation
S8.1
Principles of Infertility Treatment of Obese Women
Anne CLARK

Abstract not available at time of print.
                                                                                                                                 Abstracts : Speakers

S8.2
GnRH Antagonists: Role in Superovulation and Intrauterine Insemination
Sheila LOH

The rationale of superovulation and intrauterine insemination (SOIUI) includes overcoming subtle defects in ovulation,
enhancing the number of oocytes available and optimizing the likelihood for sperm-egg interaction by timing the IUI
accurately. Most SOIUI programmes achieve between 10 to 13% clinical pregnancy rate (J. Balasch, 2007). In addition, a
proportion of IUI procedures may be cancelled if ovulation falls on a weekend or public holiday and when there may not be
a gynaecologist available to perform the procedure. Depending on the stimulation protocol, an average of 5-10% of cycles
may also be cancelled due to inappropriate response – asynchronous response or over-response.

Introduction of 3rd generation GnRH Antagonists has lead to much knowledge and familiarity with its use in IVF cycles – in
fact, the GnRH Antagonist protocol is the preferred protocol for IVF in many centres. Extending the role of GnRH
antagonist to SOIUI cycles may lead to improvement in the efficacy of SOIUI cycles – reduced premature LH surge,
reduced premature luteinization, achievement of multi-follicular (2 to 3 follicles) recruitment and improved timing of IUI
procedures, especially on weekends or public holidays. Meta-analysis of 6 RCT has shown an Odds Ratio for pregnancy of
1.56, in favour of cycles utilizing GnRH antagonists. There was, however, a parallel but not significant increase in multiple
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                       pregnancy rate (Komas, 2008).

                       Using GnRH antagonists to avoid weekend procedures has not led to a reduction in clinical pregnancy rate. For over-
                       responders, addition of GnRH antagonists may allow some cycles to be “salvaged” and converted to IVF, particularly if they
                       fulfill certain criteria. Otherwise, a strict cancellation policy should prevail to avoid the occurrence of High-Order Multiple
                       Pregnancies.

                       GnRH antagonists are not a panache for improving pregnancy rates for all SOIUI cycles. They may however improve
                       certain situations if unexpected ovarian responses occur, albeit at the expense of prolonged stimulation, more injections
                       and the need for mandatory luteal support.


                       S8.3
                       Critical Evaluation of Role of LH Supplementation in Ovarian Stimulation
                       Nick MACKLON

                       A central role has also been demonstrated for LH in monofollicular selection and dominance in the normal ovulatory cycle.
                       Although granulosa cells from early antral follicles respond only to FSH, those from mature follicles also contain LH
                       receptors and therefore become responsive to both FSH and LH. The maturing dominant follicle may become less
                       dependent on FSH because of the ability to respond to LH. It is suggested that the leading follicle continues its development
                       owing to LH responsiveness, whereas smaller follicles enter atresia because of insufficient support by decreasing FSH
                       concentrations during the late follicle phase.

                       However, it has been reported that high levels of LH during the follicular phase of the IVF cycle could have a detrimental
                       affect on the outcome of IVF. On the other hand, a minimum threshold serum concentration appears to be required for
                       optimum folliculogenesis. The effect of LH on growing follicles appears to exert a ceiling effect, whereby exceeding a
                       certain threshold may compromise follicular development. The recent availability of both recombinant LH and FSH
                       preparations has allowed the effects of each component to be distinguished in clinical studies. A recent Cochrane review
                       was unable to confirm any benefit of the addition of recombinant LH to recombinant FSH in GnRH agonist down regulated
                       cycles (OR 1.51, 95% CI 0.79 to 2.87). Moreover meta-analyses of RCTS where GnRH antagonists were used to prevent
                       premature luteinization also failed to demonstrate any significant differences in clinical pregnancy rates.

                       Studies of the addition or LH to rec FSH stimulation regimens have shown no effect on miscarriage rate. However there
                       was a suggestion that live birth arte might be improved by the addition of LH in poor responders. Finally, a systematic
                       review of trials in which both GnRH agonists and antagonists were used showed no effect of the addition of rec LH to rec
                       FSH on live birth rates. At present therefore, there is no evidence that the addition of LH had a beneficial effect in IVF.

                       Recently other novel protocols have come under investigation which includes the replacement of FSH by LH, an approach
                       based on the acquired LH responsiveness of granulosa cells of dominant follicles. Besides the expected reduction of
                       gonadotropin usage, this ovarian stimulation approach might also reduce the number of small, less mature follicles,
                       possibly reducing the chance of OHSS, because smaller ovarian follicles are unlikely to be responsive to LH. A number of
                       controlled trials have shown that this approach can result in a significant reduction in FSH needed and in the number of
                       small follicles at final oocyte maturation. Pregnancy rates do not appear to be compromised. More extensive studies are
                       required to determine the critical threshold for FSH replacement by LH stimulation and the most appropriate dosage of LH
Abstracts : Speakers




                       or hCG.


                       S8.4
                       Ovarian Stimulation for the Poor- Responders
                       Anne CLARK

                       Abstract not available at time of print.


                                                                  Symposium 9 : Infections in Pregnancy
                       S9.1
                       Congenital CMV Infections – Experience in Singapore
                       Natalie Ann EPTON

                       Congenital CMV infects 0.2-2% of all live births across the world, as well as being responsible for unknown numbers of

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stillbirths and second trimester abortions. Sequelae in the neonate can range from asymptomatic infection to microcephaly,
hydrocephalus, petechiae, hepatosplenomegaly, CNS abnormalities, intrauterine growth retardation, and hydrops. Late
onset sequelae can present as sensorineural hearing loss, chorioretinitis, and mental retardation.

CMV is the leading viral cause of late onset sensorineural hearing loss, and a major cause of non-syndromic mental
retardation. Recent studies also show a significant risk of damage to the foetus even in the presence of maternal antibodies
to CMV (that is, secondary infection). Although our local seroprevalence is in the region of 89%, the potential for severe
sequelae from secondary infection is a real concern.

The US has recently highlighted CMV as a priority for vaccine development and prevention of congenital infection. Various
treatment and vaccination options are on the horizon. The challenges lying ahead are defining a practical screening
programme that seeks not only to treat already infected neonates, but also to intervene prior to the infection reaching the
foetus.

The presentation will include some local case studies and an overview of the potential for neonatal intervention, both
current and future.


S9.2
New Developments in the Diagnosis and Experimental Treatment of CMV Infection in Pregnant Women
Gregory MAINE

One of the challenges obstetricians face in the management of their patients is to ensure a good clinical outcome for the
pregnancy, i.e. the birth of a healthy baby.

Human cytomegalovirus (CMV) is a herpesvirus that commonly infects the human population. CMV is the most common
congenital infection, occurring in approximately 1% of all live births. In order to accurately assess the risk of a pregnancy
potentially complicated by CMV, it is important to determine whether or not the patient is experiencing a primary or non-
primary CMV infection. Intrauterine transmission of a primary CMV infection, especially during the first trimester, has the
potential to cause significant fetal morbidity and mortality. The monitoring and diagnosis of maternal infection and
evaluation of the possible risks to the fetus and newborn infant remain a significant challenge to the diagnostic laboratory.

However, the development of the fully automated CMV immunoassays, including a reflex CMV IgG avidity test, on the
ARCHITECT high throughput analyser, coupled with improved diagnostic algorithms, will permit modern laboratories to
better assist clinicians in the diagnosis of disease. A clinical trial testing the indication of Cytotect for treatment of
pregnant women with primary CMV infection in collaboration with BioTest has begun. This trial will hopefully prove the
efficacy of Cytotect in preventing intrauterine transmission of CMV and be used to mitigate the harmful effects of
congenital CMV disease in the foetus and newborn infant.


S9.3
HIV Infection in Pregnancy
Asok KURUP
                                                                                                                                Abstracts : Speakers

According to UNAIDS estimates in 2007, there are 2 million children less than 15 years old who are living with HIV and in
the same year, an estimated 270 000 HIV-infected children died because of AIDS. These statistics serve to remind us that
most of these children acquired the virus from their mothers during pregnancy, birth or breastfeeding; forms of HIV
transmission that can be prevented.

Managing HIV in pregnancy is a science that has evolved considerably over the last quarter of a century and continues to
advance to improve the outcome for the mother while preventing mother-to-child transmission of HIV. To achieve this end,
it is imperative that every effort should be undertaken to screen for antenatal HIV. The provider must however be aware of
certain nuances of HIV screening which include the concept of false positive screening results which should be
distinguished from acute seroconversion. Highly active antiretroviral therapy (HAART) use throughout pregnancy is now
standard of care in many resource rich settings. In these areas, the implementation of universal prenatal HIV counseling
and testing, antiretroviral prophylaxis, scheduled cesarean delivery, and avoidance of breastfeeding has resulted in
perinatal HIV infection transmission of less than 2%.




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                                                               Keynote Lecture 2 : Reproductive Medicine
                       KL2
                       From Gamete to Heartbeat: ART in 2020
                       Nick MACKLON

                       IVF is changing. Over the past 30 years we have witnessed an evolution in technologies, indications for treatment, and
                       more recently, in the very population we are being asked to help using this approach. These changes are now beginning to
                       impact on our daily work, and in the coming years, we can expect to see our role as clinicians treating women with IVF
                       radically change.

                       If we consider the indications for treatment, we will see a growing number of non-fertility related reasons for employing IVF
                       techniques develop. As more and more genetic defects amenable to detection are identified, the role of preimplantation
                       diagnosis in the prevention of serious illness is likely to grow. Moreover it can be expected that many more of our patients
                       will request this technique to reduce risk of their offspring developing cancer or other chronic diseases.

                       At the same time, many women with chronic illness, such as cystic fibrosis, are now surviving well into adulthood, and
                       requesting help with having children. Improving prognosis from childhood and certain adulthood cancers now make
                       parenthood feasible, and there is a rapidly growing demand for gamete preservation for later use. And the demographics of
                       those seeking fertility treatments are changing. In the West, female infertility patients are getting older and fatter.

                       All these changes in the patients we are seeing demand that our role develop from being primarily fertility specialists, to
                       specialists in a new area which is developing at the interfaces between obstetrics, gynaecology and reproductive medicine.
                       In 2020 we will not be Infertility Specialists, but experts in Periconceptional Medicine.

                       In 2020 only a small proportion of our patients will be seeking IVF to treat present infertility. The majority of our patients will
                       be consulting us for other reasons related to other health risks. It is therefore crucial that we prepare for the new role
                       expected for us, particularly in the training of the reproductive endocrinologists of the future. They will require a greater
                       knowledge of Obstetric Medicine, Genetics, and Oncology to fulfill this role.

                       In addition to changing the doctors role, that of the patient will also change. They will become more engaged as partners in
                       care rather than consumers. As more information becomes available regarding the impact of periconceptional maternal and
                       paternal health on the long term wellbeing of the offspring, patients will need to take more responsibility for ensuring that
                       the embryo has a good future. This will mean more attention to lifestyle and medical issues before embarking on therapy.
                       But what about the technologies of ART in 2020? Will we be moving to intrauterine- or intrafallopian in-vivo culture
                       systems? Will gamete manufacturing from stem cells be available? And will we have solved the greatest challenge still
                       facing us in the area of infertility: preventing the effects of ovarian ageing?

                       These challenges stand before us now. 30 years after the development of IVF, the field is as exciting, demanding,
                       innovative and important as it ever was.


                                                                            Lunch Symposium 2
Abstracts : Speakers




                       LS2
                       Are All Prebiotics The Same? Clinically Proven Effects of Immunofortis on Immune System Development
                       Leon KNIPPELS

                       After birth, the development of a healthy gut microflora is important in the maturation of the infant‟s immune system.
                       Prebiotics (non-digestible oligosaccharides) in breast milk may influence the development of the immune system by
                       stimulating growth of beneficial bacteria but can also directly interact with immune cells.

                       We showed that addition of short-chain GOS plus long-chain FOS (scGOS/lcFOS, ratio 9:1) to infant formula induces a gut
                       microflora comparable to the flora of breastfed infants. Furthermore, lower fecal pH, inhibition of pathogen growth,
                       protection of gut mucosa barrier integrity and formation of fermentation products (SCFA) that can improve in vitro mucin
                       production by gut epithelial cells were observed.

                       Besides indirect effects via microflora changes, prebiotic oligosaccharides can directly affect immune cells. TLR9 induced
                       Th1 stimulation of human blood cells co-cultured with gut epithelial cells significantly increased after addition of
                       scGOS/lcFOS, indicative for down-regulation of allergy induction and improvement of immune resistance to pathogens. Co-
                       culture of cord blood derived dendritic cells (DC) with “healthy” peripheral blood lymphocytes in the presence of
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scGOS/lcFOS showed down-regulation of Th2 development. We also demonstrated that addition of lcFOS stimulated a
dose dependent NO2 production by lipopolysaccharide (LPS) activated macrophages implying stimulation of the classical
macrophage pathway, in turn indirectly predictive for Th1 stimulation and pathogen killing. These human and murine in vitro
data lead to the conclusion that scGOS/lcFOS affects DC/T cell interactions, macrophages, and TLR9 stimulation directly,
without any bacteria or bacterial products available.

In healthy children, standard formula plus scGOS/lcFOS reduced the mean gastroenteritis episodes, showed a trend for
reduced recurrence of upper respiratory tract infections and less antibiotics use. Another study on preterm infants receiving
standard formula with a new prebiotic mixture showed a reduced number of serious infectious morbidity compared to
control children. ScGOS/lcFOS also improved the vaccination response in a murine influenza vaccination model, thereby
supporting the idea that oligosaccharides can prevent infections and increase the vaccination capacity in healthy
individuals. Administration of hypoallergenic (HA-) formula plus scGOS/lcFOS to high risk children resulted in unaltered
IgG1 responses induced by vaccination compared to control children. However, the upper respiratory tract infections
declined when high risk infants consumed HA-formula plus scGOS/lcFOS.

Besides effects on infection/vaccination, oligosaccharides have shown a capacity to modulate allergic responses. Recent,
not yet published, data showed that a formula with a new prebiotic mixture in healthy children resulted in a significant
reduced cumulative incidence of atopic dermatitis. Also in high risk children studies were conducted with HA-formula
containing scGOS/lcFOS for 6 months showing that HA plus scGOS/lcFOS significantly reduced both the cumulative
incidence of atopic dermatitis and the allergy related total IgE levels at 6 months and significantly lower numbers of atopic
dermatitis, recurrent wheezing and allergic urticaria at 2 years of age. Very recent work with a cow‟s milk allergy mouse
model also showed that pre-exposure of these animals to a HA formula with a new prebiotic mixture resulted in a reduced
incidence of cow‟s milk allergy in these animals which is suggestive for tolerance induction.


                                          Symposium 10 : Obstetrics Medicine 1
S10.1
Pregnancy in Women with Congenital Heart Disease
Ju Le TAN

The incidence of heart disease is 0.5–1% in all pregnant patients in developed countries with no decline over the last
decades. In the 7th report of the Confidential Enquiries into Maternal death in UK (2007), cardiac related death was the
commonest cause of death in pregnant women. The cardiac causes include underlying ischemic heart disease, heart
failure, peripartum cardiomyopathy, sudden cardiac death, aortic dissection, congenital heart disease, infective
endocarditis, pulmonary hypertension and rheumatic heart disease.

Knowing the physiological adaptation during pregnancy including the increase in cardiac output, redistribution of blood flow,
specific changes during exercise and at delivery is essential in understanding and explaining the various cardiac
presentations which may be encountered in patients with underlying heart disease.

Elective pre-pregnancy counseling should also be considered in all women of child-bearing age who has cardiac disease to
discuss potential risks of pregnancy to the mother and foetus, complications which may occur, the risk of recurrence of
certain congenital heart defects, the level of monitoring and hospitalization required during pregnancy. In addition, should
                                                                                                                                  Abstracts : Speakers

pregnancy be absolutely contraindicated, advice regarding the types and availability of different contraception methods
should also be discussed with the women and her partner.

There are specific predictors of adverse events in women with heart disease (CARPREG; Circulation 2001; 104:515-521)
which include the following:
1. Poor functional class status (NYHA Class > II) or cyanosis
2. Systemic ventricular systolic dysfunction (EF < 40%)
3. Left heart obstruction (mitral valve area <2.0 cm2, aortic valve area <1.5 cm 2 or peak LVOT gradient >30 mmHg)
4. Cardiac events (arrhythmia, stroke, TIA, pulmonary oedema) prior to pregnancy

Patients with congenital heart disease comprise of a heterogeneous group with varying degree of cardiac risks during
pregnancy. The risk is often specific to the underlying cardiac defects. Lesions with low maternal risk include small atrial or
ventricular septal defects with no significant pulmonary hypertension, repaired cardiac defects such as aortic coarctation,
Tetralogy of Fallot (no sign RVOT obstruction or severe PR or RV dysfunction), etc. Lesions with medium maternal risk
include mild mitral or aortic stenosis, patients with systemic right ventricle and patients with single ventricle post Fontan
operation (no ventricular dysfunction, NYHA Class > II). Patients with the highest risk belong to those with either Marfan or

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                       Eisenmenger Syndrome with reported 30-40% maternal risk of death.

                       In this lecture, we will discuss the outcome and management of women with cardiac conditions such as ischemic heart
                       disease, peripartum cardiomyopathy and specific cardiac defects during pregnancy, at delivery and post delivery. A
                       multidisciplinary team approach with open dialogue between the obstetrician, cardiologists, anesthetists, midwives and
                       nurses is important to establish effective communication between the patient and her medical team. This is important for
                       risk modification, in helping to anticipate problems and in planning the best management strategy for each individual
                       patient.


                       S10.2
                       Thromboprophylaxis in pregnancy
                       Heng Joo NG

                       Pregnancy and the puerperium are well-established risk factors for developing acute venous thromboembolism (VTE).
                       Expectant mothers should therefore routinely be screened for other clinical risk factors, which may further compound their
                       thrombotic potential and be risk-stratified for VTE prevention, using the appropriate strategies. VTE prevention strategies
                       and anticoagulant regimes are usually based on limited data from pregnant subject and often extrapolated from non-
                       pregnant subjects. Generally, there is lower threshold for pharmacological thromboprophylaxis in the postpartum period,
                       which carries the highest risk for VTE as there are no more concerns about fetal complications.

                       Although there is very little evidence on the efficacy of mechanical thromboprophylaxis (e.g., frequent left-lateral decubitus
                       positioning during late pregnancy, graduated elastic compression stockings, and pneumatic compression devices), such
                       measures have very few side effects other than the sheer physical discomfort to the users. Hence women with a history of
                       VTE or risk factors for VTE are encouraged to wear graduated compression stockings.

                       Antepartum pharmacological prophylaxis is indicated for women with recurrent VTE and those with a single episode of VTE
                       and the presence of high risk thrombophilias which include antithrombin deficiency, persistent antiphospholipid antibodies,
                       compound heterozygosity for the prothrombin and factor V Leiden mutations, homozygosity for the prothrombin mutation,
                       and homozygosity for the factor V Leiden mutation. VTE Prophylaxis should also be discussed with women who have a
                       single prior episode of VTE that was related to pregnancy or estrogen use or single prior episode of idiopathic VTE.

                       Postpartum pharmacological thromboprophylaxis is indicated for women who have had one or more episodes of VTE and
                       those with any type of thrombophilia. For women who underwent cesarean section, prolonged pharmacological
                       thromboprophylaxis is not recommended without additional risk factors for VTE. For those who have other risk factors for
                       VTE, pharmacologic thromboprophylaxis of up to 6 weeks postpartum should be considered.

                       Pharmacologic agents used during pregnancy are unfractionated heparin (UFH) and low molecular weight heparins
                       (LMWHs). Warfarin can be used post partum but generally not recommended during antepartum periods because of its
                       associated teratogenic properties and fetal bleeding complications. UFH does not cross the placenta, is not usually
                       associated with fetal bleeding complications but it has several side effects, including maternal bleeding, thrombocytopenia,
                       skin necrosis, and osteoporosis. LMWH-based regimens are generally preferred for antepartum thromboprophylaxis as
                       they are also more convenient, more efficacious, safer, and produced more reliable anti-Xa levels at therapeutic doses than
                       standard heparins. However, in the presence of severe renal failure, (creatinine clearance <30 mL/min). UFH is preferred
Abstracts : Speakers




                       over LMWH, as elimination of UFH is both hepatic and renal, whereas LMWH is nearly entirely renally excreted. Hence
                       accumulation and bleeding complications are less likely with UFH in the setting of severe renal failure. When indicated,
                       antepartum pharmacologic thromboprophylaxis should be continued until labour when anticoagulation should be stopped to
                       allow for safe delivery. Postpartum pharmacologic thromboprophylaxis be continued for four to six weeks after delivery.


                       S10.3
                       Should We Screen For Thyroid Disease in Pregnancy?
                       Walfrido W. SUMPAICO

                       Background: Undiagnosed thyroid disease carries significant clinical implications during pregnancy, when the health of the
                       mother and child can be adversely affected by abnormal thyroid function. Currently, there is ambivalence in screening for
                       thyroid function during pregnancy. The measurement of thyroid stimulating hormone (TSH), thyroxine (T4) and antibodies
                       to thyroid peroxidase (TPO-Ab) are important assays to assess maternal thyroid status.

                       Objective: The purpose of this report is to determine the prevalence of abnormal thyroid function tests in a population of

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pregnant women at four (4) Obstetric Out-Patient Clinics (3 government, 1 Private) in urban Manila, Philippines. This is a
sub-analysis of a previously-reported six-nation study on the prevalence of thyroid disease in pregnancy in the Southeast
Asian population.1

Method: We assayed serum samples (n = 933) of pregnant women during each trimester of pregnancy and postpartum on
the Abbott AxSYM platform using a 3rd generation TSH and TPO-Ab assay. Results outside the manufacturer's reference
range (TSH= 0.47-4.64 µIU/mL; TPO Ab < 12 IU/mL) were considered to be abnormal.
COUNTRY            Trimester 1         Trimester 2    Trimester 3       All Pregnancy     Post-partum       Total
Philippines        156                 211            292               659               274               933

Results:
1) Overall prevalence for an abnormal test result was 5.3%. Across the different age groups, the average prevalence for
    an abnormal result was TSH=7.1% and TPO-Ab=19. 5%.
2) TSH: The Frequency Distribution Curves for TSH showed:
• 1st Trimester with a sharp peak at the 0.5 mIU/L range and a 2nd peak at the 2 mIU/L region.
• 2nd Trimester shows an overlap of 3 peaks at 1.5, 2.5 and 4.5 mIU/L. This may be due to a heterogeneous mix of
    thyrotoxic and subclinical hypothyroid populations.
• 3rd Trimester has a right skewed unimodal distribution
• Postpartum shows a mixture of 2 populations with a large number of subjects in the subclinical and hypothyroid ranges
3) TPO-Ab assay:
• The positive antibodies prevalence is 19.5% and they are concentrated in the 1st Trimester and postpartum, producing
    a large number of thyrotoxic subjects in 1st trimester (23.1%) and an equally large number of subclinical and
    hypothyroids in post partum (23.0%).
• Thyrotoxic subjects form 2.4% with the highest in 1st Trimester (7.1%) and hypothyroid subjects form 3.6% with the
    highest concentration in the post partum (7.3%).
                   Pregnancy                                            Post-Partum
COUNTRY            TPO-Ab +ve          Borderline     Abnormal TSH      TPO-Ab +ve        Borderline        Abnormal TSH
                                       TSH                                                TSH
Philippines        18.1                10.0           4.9               23.0              36.1              4.4

Conclusion: Our data show a high prevalence of abnormal thyroid function tests in this population. Further longitudinal
studies are necessary before suggesting that screening for thyroid dysfunction may be appropriate during routine prenatal
care in the Philippine setting.

S10.4
Use of Oral Hypoglycaemics in Gestational Diabetes
Su Chi LIM

Abstract not available at time of print.

                                     Symposium 12 : Presidents’ Round Table Session 1
                                                                                                                               Abstracts : Speakers

S12.1
Perimortem Caesarean Section
Siu Keung LAM

Although most of the patients in obstetrics are young and healthy, serious obstetric complications can sometimes occur. The
incidence of cardiac arrest in pregnancy is around one in 30,000 deliveries. The main reasons being hypertension, embolism
(pulmonary or amniotic fluid), bleeding, infection, cardiac cause, aortic dissection, anaesthesia, trauma, suicide,
anaphylaxis, drug overdose, etc. Some of the Labour Ward or Accident Emergency Room staffs may not be aware of this
rare possibility and are not well prepared to manage this critical condition involving two human beings.

Beside the basic cardiopulmonary resuscitation, one of the major decisions to be made swiftly and boldly in the Accident and
Emergency Department (AED) or in the Labour Ward/Antenatal Ward is the need for Perimortem Caesarean Section
(PMCS). Perimortem CS should be seriously considered when the patient has cardiac arrest for four minutes (the Four
Minutes Rule, the time interval should best be witnessed). The rationale of PMCS includes: save the fetus from terminal
asphyxia, relieve the compression on the maternal IVC enhancing cardiac output, less splinting of the diaphragm, easier for
ventilation.


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                       The pre-requisite for PCMS includes skilled personnel (A&E doctor or obstetrician or both), no spontaneous maternal
                       circulation for at least four minutes, potential fetal viability (at least 23 week) and facilities for intensive care for fetus +/-
                       mother.

                       The technique of PMCS is similar to usual classical CS with omission of some non-essential steps (aiming for the speediest
                       delivery). Debriefing of staffs and relative is also important when the acute event is over.

                       Conclusion: PMCS though rare should be put in the regular drill list of every A&E Department and Obstetric Unit.


                       S12.2
                       Violence against Women in Pakistan from Murder, Maternal Death to Vesico Vaginal Fistulae
                       Shershah SYED

                       Women in Pakistan are victims of tradition, culture, religion and of a state that is gender-insensitive. Every year thousands
                       of women consult doctors or quacks for termination of pregnancy after diagnosis of female fetus. Hundreds of women are
                       murdered in the name of “honour”. More than forty thousand pregnant women die every year because of pregnancy, and
                       about four hundred thousand women suffer from pregnancy related complications. VVF and RVF are the major
                       complications which make life miserable for its victims. The irony is that it all happens in a country which has atomic
                       bombs, a very strong army and extremely rich politicians.

                       Pakistan is a country with 170 million people, of which about fifty million live below the poverty line with a very high rate of
                       illiteracy. Pakistani obstetricians and gynaecologists are working in an environment where they have to fight – and,
                       sometimes, compromise with – societal norms, corruption and inefficient state. UN and international agencies, and local
                       NGOs are working hard to help Pakistan achieve MDGs, but because of insensitivity of government and lack of
                       coordination between key stakeholders it seems unlikely that the MDG goals will be achieved by 2015.

                       This presentation focuses on the problems faced by Pakistani obstetricians and gynaecologists, and the role of medical
                       profession in dealing with healthcare issues of women in Pakistan.


                       S12.3
                       Teenage Pregnancy and Preventing Unsafe Abortion in Thailand
                       Suwachai INTARAPRASERT

                       Thailand has a successful family planning record with a total population of 63 millions, a total fertility rate of 1.5 and a
                       contraceptive prevalence rate of 74 percent in 2009. Most Thai adolescent reported that their first sexual experience,
                       whether within or outside of marriage, was without contraception, unmarried adolescent girls still have difficulties access to
                       family planning services. The teenage birth rate in Thailand is relatively high, resulted in teenage fertility rate at 60 per
                       1000. If all pregnancies, including those which end in abortion, are taken into account, then the total teenage pregnancy will
                       be higher than that. Surveys found that 25% of women admitted to hospitals for complication of induced abortion are
                       students. Unsafe abortion and its resulting complications are still a major public health concern.

                       In Thailand induced abortion is illegal, with 2 exceptions, if the pregnancy either jeopardized a woman‟s health or is a result
Abstracts : Speakers




                       of rape and / or incest. However, despite restrictive laws, the estimated induced abortion in Thailand is 300,000 – 400,000
                       cases a year. While a small proportion of these are induced by trained medical practitioners, access remains problematic
                       for many women and potentially unsafe techniques are also employed. Complications reported include injury, infection,
                       infertility and even maternal death. The risk of death following complication of unsafe abortion procedures in Thailand is 300
                       per 100,000 procedures. While in nations where abortion is permitted, the death rate from safe abortion is less than 1 per
                       100,000 procedures.

                       Current efforts by the Thai Medical Council to allow abortion for maternal mental health (previously defined health as
                       physical health only) and a limited number of fetal conditions (e.g. genetic disorders, anomalies etc.) grant more women
                       access to legal and safe abortion.

                       The Department of Health, Ministry of Public Health and The Royal Thai College of Obstetricians and Gynaecologists set
                       up a training course called “Safe Abortion”. The course contents are: diagnosis of pregnancy, provision Of an appropriate
                       abortion method: MVA (Manual Vacuum Aspiration) and medical abortion, pre- and post-procedure counselling, post
                       abortion care and counselling for appropriate contraception. So far we have trained 254 doctors, 266 nurses from 217
                       hospitals. Much, much more have to be done.

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S12.4
Hysterectomy: Why Vaginal?
C N PURANDARE

Hysterectomy is one of the most commonly performed operations in the world. A review by the Centers for Disease Control
and Prevention (CDC) have reported that from 1988-1990, 1.7 million U.S. women had hysterectomies, an overall rate of
56.8 hysterectomies per 10,000 women. Lepine EA et al reported approximately 600,000 hysterectomies are performed
every year in U.S. In the past, abdominal approach was popularized and taught in U.S. when gynecological departments
were under surgical departments. After World War II, many teaching institutions incorporated gynecological surgeries into
the departments of Obstetrics and gynecology, since then technique of vaginal hysterectomy has been developed. In early
days vaginal hysterectomy was restricted to genital prolapse but today superiority of hysterectomy by vaginal route is
widely accepted because of its lower morbidity, fewer complications, shorter hospital stay and convalescence compared to
abdominal hysterectomy. Hence, the indications for vaginal hysterectomy are no longer restricted to genital prolapse.
Factors favoring abdominal route for hysterectomy are uterine size more than 12 wks, previous C. Section or other surgery,
need to perform oopherectomy, endometriosis, pelvic inflammatory disease, adenexal pathology, restricted mobility and
contracted bony pelvis with narrow vagina can be done successfully vaginally by experienced surgeons. With the
introduction of laparoscopy assisted hysterectomy there has been a further resurgence in vaginal hysterectomy.
Laparoscopic assistance helps in resolving the traditional contraindications to vaginal hysterectomy and provides the
patients the benefit of vaginal hysterectomy. Therefore, in today‟s scenario, vaginal hysterectomy is preferred method and
abdominal hysterectomy is almost exclusively the operation of choice in the presence of malignancy, uterine size more than
20 wks and presence of dense adhesions.


                                         Symposium 13: Obstetrics Medicine 2
S13.1
Thrombophilia and the Adverse Pregnancy outcomes
Lay Kok TAN

Adverse pregnancy outcomes are not uncommon, and the role played by thrombophilia will be discussed. Thrombophilia
can be broadly divided into acquired and congenital or heritable forms, of which the acquired variety in the form of
antiphospholipid antibodies provides the strongest link with pregnancy complications, with evidence of improved outcomes
subsequent to clinical intervention with low dose aspirin and heparin.

The relationship of adverse pregnancy outcomes with heritable thrombophilias is more tenuous, and the uncertainty
associated with the magnitude of risk, and also that of benefits of thromboprophylaxis, as well as the issue of screening for
thrombophilias, will be discussed.


S13.2
SLE and Other Rheumatologic Conditions
Sheila VASOO

Pregnancy is a time of great physiologic change, in particular for women with rheumatic diseases and may pose a risk to
                                                                                                                                Abstracts : Speakers

both mother and fetus. Studies have shown that women with rheumatic diseases are more likely to have adverse obstetric
and neonatal outcomes compared to controls. Various immunoregulatory and hormonal mechanisms are employed to
protect the fetus from rejection and these, in turn have been shown to influence the activity of certain rheumatic diseases.
In the past, advice to such women, especially those with systemic lupus erythematosus (SLE), systemic sclerosis and
systemic vasculitis was to avoid pregnancy for fear of maternal and fetal complications. However, over the years, better
understanding and a multidisciplinary approach to the management of these conditions have led to successful pregnancy
outcomes; particularly in women with recurrent pregnancy losses due to the antiphospholipid syndrome. The effects of
pregnancy on mother and fetus, the effects of autoimmune disease on the fetus, the management of these conditions shall
be discussed.


S13.3
Intensive Care Obstetrics
Sebastian CHUA

The criteria for admission to the intensive care unit for obstetric patients are not much different from those of the general
population. However, certain physiological and metabolic alterations unique in pregnancy deserve special attention.

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                       Pregnant patients need intensive care secondary to either obstetric related disorders or concomitant critical illness or
                       trauma. The importance of early recognition, intensive monitoring and management proves crucial for the survival for the
                       mother as well as foetus.


                       S13.4
                       The Natural Caesarean Section
                       Nicholas FISK

                       Abstract was not available at time of print


                                                                  Symposium 14 : General Gynaecology 1
                       S14.1
                       NUH Botanical Drug Discovery Programme: Standardization, Preclinical and Clinical Studies of an Herb for
                       Menopause
                       Eu Leong YONG

                       Herbal plants contain small molecules that may activate members of the steroid/nuclear receptor family of transcription
                       factors and other molecular targets. Extracts of Epimedium were strongly estrogenic due to the presence of potent
                       phytoestrogens of the prenyl-flavones group. Epimedium extracts, and to a lesser degree the bioactive flavonoid
                       Breviflavone B, dose-dependently inhibited the proliferation of estrogen-responsive MCF-7 breast cancer cells. This was
                       due to the dose-dependent suppression of estrogen receptor protein, possibly due to increased proteasome degradation of
                       the ER liganded to Breviflavone B. The estrogenic properties of Epimedium coupled with these anti-proliferative effects on
                       breast cancer cells suggest its possible use for estrogen replacement therapy.

                       Phylogenetic profiles of 37 specimens from 19 Epimedium species indicated that they have widely differing degrees of
                       relatedness, with differing compositions of major flavonoid glycosides and bioactive aglycones. Estrogenicity of the different
                       extracts correlated with concentrations of known phytoestrogens only when the same (or closely related) sub-species were
                       compared, indicating the possible presence of unknown bioactive compounds which confound such predictions in distantly
                       related sub-species. Our study indicates the importance of using genetically identical cultivars, the measurement bioactive
                       compounds concentrations, and bioresponse profiling in the definition of a standardized product.

                       Clinical evaluation of botanical extracts is complicated by the absence of basic pharmacokinetic/pharmacodynamic
                       (PK/PD) that is necessary to formulate medicines with appropriate absorption, distribution, metabolism and excretion
                       characteristics. We evaluated a panel of estrogen-responsive cell-based bioassays compared to mass spectrometric
                       measurement of bioactive compounds in PK/PD studies. Animals and human subjects administered a standard estrogenic
                       pro-drug and standardized Epimedium extracts resulted in bioactive compounds in serum which induced proportionate
                       estrogenic responses in estrogen-responsive bioassays. The NUH Botanical Drug Discovery programme has for the first
                       time measured global effects of the myriad bioactive compounds in botanical extracts and performed rigorous animal and
                       clinical studies for the use of a standardized botanical extract for the menopause.


                       S14.2
Abstracts : Speakers




                       Traditional Chinese Medicine and Gynaecology
                       Yong Peng SWEE

                       Abstract not available at time of print.


                       S14.3
                       Fiborids – We are Not Short of Modalities, so why is it Still a Problem?
                       Arnold ADVINCULA

                       The most common tumours in reproductive-aged women are uterine myomas. Although they are most often benign, they
                       are associated with debilitating symptoms. Uterine myomas are the major cause for hysterectomy in the United States.
                       Economically, the impact to health care cost in the United States has been quoted to be over $2,000,000,000. Multiple
                       treatments exist for uterine myomas. These include pharmacologic therapies, uterine fibroid embolization; MRI-guided
                       focused ultrasound, and surgical techniques. Unfortunately, many of these options are maximally invasive and/or are
                       contraindicated in the patient seeking future fertility or strongly desiring uterine preservation. Critical to the success of any
                       treatment modality will be its ease of use, accessibility & costs, minimal invasiveness, reproducibility, and ability to achieve
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the desired outcome (whether it be fertility preservation, symptom relief, or prevention of myoma recurrence over the long
term).


S14.4
Mirena in the Treatment of Menorrhagia
Wee KANG

The levonorgestrel-releasing intrauterine system (LNG-IUS or Mirena) was developed in 1980s in Finland for contraception.
It was subsequently found to be effective in reducing menstrual blood loss in women who have menorrhagia. Many clinical
studies showed that LNG-IUS can reduce menstrual blood loss by over 90%1. There is also substantial evidence that LNG-
IUS is effective in treating women who have menorrhagia due to fibroids or adenomyosis. In United Kingdom, under NICE
guideline 2007, it is recommended to be the first-line of pharmaceutical treatment for women with idiopathic menorrhagia
and women who has menorrhagia with small uterine fibroid of less than 3 cm in diameter.

A retrospective study on the effectiveness of LNG-IUS in the treatment of menorrhagia was carried out in KK Women‟s &
Children‟s Hospital on patients who had LNG-IUS insertion for treatment of menorrhagia from 1 January 2000 to 31
December 2007. These patients were followed up till 31 March 2009 (unpublished data). Our study showed that LNG-IUS is
effective in reducing menstrual blood loss in women who have idiopathic menorrhagia, menrrhagia with fibroids and/or
adenomyosis. The success rate was between 75% and 90%. There was high degree of patients‟ satisfaction (60% to 85%)
and most of them reported improvement in their quality of life.

As LNG-IUS contains only progestogen, irregular menses is common among the users. Detailed counseling before
insertion is therefore, very important to ensure continuous usage of the device.

LNG-IUS is an effective treatment for menorrhagia. It reduces menstrual blood loss more than other medical treatments
such as tranexamic acid and non-steroidal anti-inflammatory drugs2. The cost of treatment for menorrhagia is also
significantly lower than that of hysterectomy and endometrial ablation3-4. It is also reversible and does not involve the
removal of uterus. Furthermore, its action is long acting and effective for up to 5 years.


                                           Symposium 15 : AOFOG Symposium
S15.1
Medical Abortions
Pak Chung HO

The standard method of medical abortion in the first trimester is the administration of mifepristone followed by a
prostaglandin analogue 48 hours later. Misoprostol is now the prostaglandin of choice because it is cheap, highly effective,
active by various routes and stable at room temperature. Vaginal misoprostol is more effective and better tolerated than
oral misoprostol. Sublingual misoprostol is as effective as vaginal misoprostol but it is associated with a higher incidence of
side effects. The efficacy of buccal misoprostol is probably comparable to that of vaginal misoprostol. With vaginal
misoprostol, the interval between mifepristone and misoprostol can be shortened to 24 hours and the dose of mifepristone
can also be reduced to 100 mg without loss of efficacy. Administration of misoprostol at home was also found to be safe
                                                                                                                                  Abstracts : Speakers

and acceptable in some countries. As mifepristone is not available in many countries, misoprostol alone has also been tried
to induce abortions. Usually repeated doses are required; the incidence of side effects is higher and the complete abortion
rate is lower than the combined mifepristone-misoprostol regimen. Most women who choose medical abortion found it
acceptable but the acceptability decreases with increase in gestational age and failure of the method. Both medical and
surgical abortions are safe and effective. When compared to surgical abortion, medical abortion is less effective at more
advanced gestation, and there is also more blood loss. Recent data also showed that the outcome of subsequent
pregnancies in women with history of medical abortion is comparable to that of women with history of surgical abortion.


S15.2
Updates on the 2008 Electronic Fetal Monitoring Guidelines
Yuji MURATA

Cardiotocogram (CTG) has globally spread since 1960‟s. Its diagnostic accuracy and clinical values, however, have been
repeatedly challenged. Many obstetric societies published practice standards in an attempt to attain more objective
interpretations of CTG patterns.


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                       AOFOG members met in Miyazaki, Japan to propose a consensus on CTG interpretation, hoping it will be adoptable
                       among different types of obstetrical practice within the societies to provide more objective view in interpreting CTG patterns.


                       S15.3
                       Angiogenic Markers in Pre-eclampsia
                       Walfrido W. SUMPAICO

                       Preeclampsia is currently perceived as a 2-stage process:
                       a) The first is an asymptomatic placental stage marked by abnormal placentation with its elaboration of certain soluble
                           factors that enter the maternal circulation and cause subsequent widespread endothelial dysfunction.
                       b) The second maternal stage is characterized primarily by hypertension and proteinuria, the clinical picture known as
                           the preeclampsia syndrome.

                       This lecture shall focus on the recent advances in the first or asymptomatic placental stage (pseudo-vasculogenesis)
                       especially on the role of Placental growth factor (PlGF) and its antagonist, sFlt-1. New angiogenic markers like endoglin
                       and PP 13 and screening procedures before the onset of the second or maternal stage of the disease using these markers
                       will be discussed.
Abstracts : Speakers




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                                                  29 August, Saturday
                                           Symposium 16 : Labour Management
S16.1
Crash Caesarean Section in Private Practice
Yew-Ghee TAN

A Crash Caesarean Section (CCS) is an extreme obstetric emergency in which there is immediate threat to the life of the
foetus or mother. Timing is crucial, with rapid access to operation facilities and a disciplined, multi-disciplinary team
approach being key factors.

The ideal Decision-To-Delivery Interval (DDI) is internationally recognised as 30 minutes by the American College of
Obstetricians and Gynaecologists and the Royal Australian and New Zealand College as well.

In Raffles Hospital, which is a group-based private hospital, there is a Women‟s Centre with eleven obstetricians. The unit
has instituted a protocol named “Code Brown” specifying well-defined, co-ordinated actions in managing a CCS, with the
targeted DDI of 20 minutes.

Personnel involved include obstetricians, midwives, nurses, operation room personnel, anaesthetists, paediatricians and
support staff. Regular 2-monthly drills are conducted so that all concerned are prepared, along with formal debrief and
audit.

In the private practice setting, where an important problem is the fact that the anaesthetist is not full-time residential, the
Ketamine Local Anaesthesia (KLA) option is a viable stop-gap to allow surgery to proceed until proper standard
anaesthesia is available.

The success of a Crash Caesarean Section in a private practice setting is dependant on a disciplined protocol, multi-
disciplinary teamwork, regular drills and proper audit. If not properly conducted, a CCS may cause more harm than good.


S16.2
Classical Caesarean Section in Modern Obstetrics
Devendra KANAGALINGAM

This initial description of a caesarean section involves a longitudinal midline incision into the body of the uterus. Though
long super ceded by the lower segment incision, 2 developments in modern obstetrics have resulted in a resurgence of the
classical operation. The first is the increasing incidence of placenta accrete, increta and percreta (collectively referred to as
morbidly-adherent placentae) and, secondly, the ability to sustain life in severely premature babies. A series of 22 classical
operations performed at the Singapore General Hospital (SGH) is presented. Morbidity and length of hospitalization in
these women appear to be related to their underlying medical condition and associated surgical procedures rather than the
classical caesarean section alone. A step-by-step description of the operation as performed at SGH is described with
photographs taken at an actual surgical procedure. Training in performing a classical caesarean section should be
considered, perhaps using simulation and mannequins, as many obstetricians will not acquire these skills from routine
                                                                                                                                    Abstracts : Speakers

practice. In many circumstances, the need for the procedure may arise without prior warning.


S16.3
Management of Placenta Accreta
Jing Jye CHEE

Placenta percreta is a condition where the placenta has invaded through the uterine myometrium and serosa into
surrounding organs like the bladder. Detailed examination of the placenta, either through 2D ultrasound scan with Doppler
or with Magnetic Resonance Imaging, can reveal both the depth and location of placental invasion. Knowing the exact
location of the placenta allows a strategic uterine incision which avoids cutting into the placenta. Not only will this reduce
the blood loss, it allows the option of conserving and leaving the placenta in situ.

If placenta percreta is suspected antenatally, delivery should be planned in an appropriate setting with adequate resources.
Good support from Anaesthesiology colleagues and availability of crossed match blood and blood products are essential
prerequisite. Depending on the patient‟s condition and the availability of such services, other auxiliary support includes pre-
operative insertion of internal iliac arterial catheters and ureteric stents.

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                       After the baby is delivered, three surgical options may be considered. The first is total hysterectomy. The second option
                       leaves the placenta in-situ and wait for its spontaneous reabsorption. The third is a one-step surgery that involves resection
                       of the invaded uterine tissue followed by primary uterine repair.

                       Every case of placenta percreta is unique in the site and degree of the placental invasion; much akin to the local
                       metastastatic invasion into surrounding tissues by malignant growths. Surgery should be individualised for each patient
                       depending on the surgical expertise of the operator, the set-up of the hospital and the patient‟s own clinical condition.


                                                          Symposium 17 : Fetal Programming and Stem Cell
                       S17.1
                       The Future of Cellular Therapies Using Umbillical Cord Blood
                       Mark KIRKLAND

                       Umbilical cord blood (UCB) is a rich source of hematopoietic stem cells (HSC‟s), and it has been used for clinical
                       transplantation since 1989. Public banks have been established in many countries to provide a ready source of HLA-
                       matched unrelated donor cells and, to date, more than 8000 UCB transplants have been performed worldwide. A small
                       number of these transplants have been autologous or from related donors (including the first ever transplant, performed in
                       France for a child with Fanconi‟s anemia using cord blood from a sibling). There is a mistaken belief that autologous UCB
                       should not be used for malignant diseases such as Acute Myeloid Leukemia because of potential contamination of the UCB
                       by small numbers of malignant cells present at birth, but in fact the data underlying this belief has been refuted, and a
                       number of such transplants have been performed.

                       Nevertheless, autologous UCB may not be the best source of cells for treating some malignant diseases, because of the
                       lack of a “graft-versus-leukemia” effect. In addition, the probability of developing childhood leukemia is small, so the cost-
                       benefit of storing UCB for this purpose alone may not be high.

                       The rationale for storing autologous UCB, in fact, lies elsewhere. UCB is a rich source of many different cells with
                       significant therapeutic potential in addition to HSC‟s:
                       • UCB is a potential source of mesenchymal stem cells, which are entering the clinic for many applications, such as
                             repair of non-healing fractures and immune modulation.
                       • Endothelial progenitor cells can also be found in cord blood, and have shown potential in the treatment of a range of
                             diseases including stroke and myocardial infarction. Trials are currently being undertaken in the US to test the efficacy
                             of UCB in the treatment of Cerebral Palsy and hypoxic brain injury
                       • A population of primitive stem cells, called “Unrestricted Stem Cells”, has been isolated from UCB, and these have the
                             potential to differentiate into a wide variety of tissues, including neurons and muscle.
                       • In addition, stem cells, of any kind, isolated from UCB have characteristics and proliferative potential not seen in cells
                             collected later in life.
                       • Perhaps of most interest, UCB is a rich source of “regulatory T-cells” (Tregs). These cells are important in the
                             maintenance of “self tolerance”, and abnormalities or deficiencies of these cells are associated with autoimmune
                             diseases. In animal studies, the reinfusion of neonatal Tregs (collected prior to any damage or insult) into pre-diabetic
                             mice can prevent the development of diabetes. A human trial currently underway in Florida is showing evidence that
                             reinfusion of autologous UCB can stop the progression of diabetes in its early stages, and further trials, including true
Abstracts : Speakers




                             prevention trials in high risk children, are under development. If these trials demonstrate efficacy, other autoimmune
                             diseases may also be therapeutic targets in the future.

                       UCB, then, is something of a “cell therapies toolkit”, rich in many types of cells that may have a number of clinical uses in
                       the near and medium future. Although many of these are still under development, it is a realistic expectation that these
                       therapies will become available during the child‟s lifetime, and there is only one opportunity to collect UCB.


                       S17.2
                       Development Pathways to Metabolic Disease
                       Yap-Seng CHONG

                       Singapore has a particularly high incidence of metabolic disease. Metabolic disease in Asia has features that distinguish it
                       from that seen in most western countries and shows ethnic differences not yet understood or explainable in genomic terms
                       alone. Research in the post geneomic era to understand the particularities of its pathogenesis, prevention, and therapy offer
                       unparalleled opportunities for translational research. This session will outline some of the current thinking and evidence


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regarding mechanisms during fetal and early childhood development that may influence an individual‟s risk for future
metabolic disease.


S17.3
Fetal Stem Cells and Opportunities for Fetal and Postnatal Therapy
Jerry CHAN

Regenerative medicine, through harnessing the self-renewal and multi-lineage differentiation capacity of various stem /
progenitor cells, have tremendous potential for clinical applications in a variety of tissue injury paradigms in a wide range of
tissue / organ systems.

The identification of pluripotent human embryonic stem cells (ESC), and more recently, the inducible pluripotent stem cells
(iPSC) have enlarged the field of cellular therapy considerably. However, achieving efficient directed differentiation and
avoidance of teratoma formation in both ESC and iPSC remain formidable hurdles to their clinical application at present.
Adult stem cells on the other hand, are safer and less muddled in ethical mire, but have limited capacity in generating
clinically relevant cell numbers. Moreover, some cell types such as neural stem cells are generally inaccessible, and are
found in low numbers in specific areas of the central nervous system.

Fetal stem cells represent a rich source of stem cells with more primitive features, self-renewal capacity, multi-lineage
differentiation, lower immunogenicity and propensity for transmission of infections. Fetal mesenchymal stem cells (MSC)
are currently being investigated for bone tissue engineering and cellular replacement therapy for skeletal dysplasia, while
fetal neural stem cells and hepatoblasts are being developed for neural and hepatic regeneration applications. Other rich
sources of stem cells can be isolated from extra-fetal sources such as the amnion, chorion, umbilical cord and amniotic
fluid, further expanding the source of cell types of use in the various fields of regenerative medicine.


                                   Symposium 18 : Presidents’ Round-Table Session 2
S18.1
Role of Nutrition in Prevention of Preeclampsia
Noroyono WIBOWO

Objective: To investigate maternal and neonatal outcomes after antioxidant supplementation relatively early in pregnancy
(8 to 12 weeks) for pregnant women with low FRAP status.

Methods: A randomized, double-blind, placebo-controlled trial of daily milk enriched with antioxidant supplementation was
performed on pregnant women screening positive for low FRAP status at 8 to 12 weeks of gestation. Low FRAP status was
defined as a level below 900 UM. The supplementation group received the following milk enriched with antioxidants daily: b
caroten (10000 IU), B6 (2.2 mg), B12 (2.2 μg), C (200 mg), and E (400 IU), folic acid (400 μg), cysteine from whey protein
(200 mg), Cu (2 mg), Zn (15 mg), Mn (0.5 mg), Fe (30 mg), calcium (800 mg), and selenium (100 μg). The control group
received prenagen emesis: Vitamin A (1000 IU), Vitamin C (48 mg), Vitamin D3 (100 IU), Vitamin E (2.5 mg), Vitamin B1
(0.45 mg), Vitamin B2 (0.45 mg), Niasin (5 mg), Vitamin B6 (0.65 mg), Vitamin B12 (1 μg), Asam folat (300 μg), Asam
pantotenat (2.1 mg), Kalsium (400 mg), Besi (10 mg), Fosfor (300 mg), Magnesium (100 mg), Seng (2.5 mg), Yodium (50
                                                                                                                                   Abstracts : Speakers

μg), Selenium (7.5 μg), DHA (20 mg), Biotin (18 μg), Kolin (70 mg). Maternal (preeclampsia, abortion, and hypertension)
and perinatal outcomes were assessed. Results: In the supplementation group (54 subjects); we observed 1 case of
preeclampsia (1.85%). In the control group (54 subjects), 8 cases of preeclampsia (14.8%) with perinatal outcome: 3
preterm delivery cases and 1 IUGR (birth weight 2030 g at 39 weeks). Preeclampsia was significantly less frequent in the
supplementation group when compared to the control group (1 vs. 8 cases, p = 0.0001, OR = 0.18 [95% CI: 0.03, 0.92]).

Conclusion: Antioxidant supplementation was associated with better maternal and perinatal outcome in pregnant women
with low antioxidant status than control supplementation with maternity milk.


S18.2
Fistula Programme in Bangladesh
Sayeba AKHTER

Objective: The aim of this presentation is to share the existing fistula programme in Bangladesh.

Introduction: Bangladesh is a densely populated country. MMR is 320 per 100000 live-birth and about 80% women have

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                       their deliveries at home at the hand of unskilled birth attendants. Obstetrics fistula is one of the devastating maternal
                       morbidity and Government of Bangladesh (GOB) has taken holistic programmes to address the issue of fistula.

                       Methods: GOB has taken preventive programmes such as, EmOC programme, Skilled Birth Attendant (SBA) and
                       Advocacy programme. For treatment of fistula, the National Fistula Centre was established at Dhaka Medical College
                       Hospital in 2003; doctors and nurses from home and abroad was trained here. Rehabilitation centers have also been
                       established for waiting patients. Fistula survivors are trained as Community Fistula Advocate to work in community for
                       prevention of fistula and referral of patient for treatment in fistula centres.

                       Results: Rapid assessment estimates that more than 70,000 women are living with fistula. Since 2003, The National
                       Fistula Center is training doctors and nurses using structured training curriculum. So far, a total of 238 Bangladeshi doctors
                       and nurses have been trained under this curriculum.

                       From 2005 till now, 12 fistula camps have been organized, 260 doctors and 125 nurses received on-site short orientation
                       training and 1977 stakeholders have attended the orientation meeting where preventive strategies and treatment facilities
                       for fistula were discussed. Ten fistula corners were established where 150 patients received treatment. In the rehabilitation
                       center, 140 patients were rehabilitated. 105 fistula survivors were trained as fistula advocates. The advocacy, training and
                       monitoring of their work is performed through Government and NGO collaboration.

                       Conclusion: Obstetric fistula is a burning health problem for women in Bangladesh. Further research is needed to identify
                       the additional physical and reproductive health problems, and management plan should include those issues.


                       S18.3
                       Training the Next Generation of Obstetricians and Gynaecologists – What are the Pitfalls?
                       Edward WEAVER

                       The selection of junior doctors for a specialist training programme, and the subsequent design and execution of that training
                       programme to produce competent specialist practitioners is a difficult process.
                       This presentation will focus on some of the difficulties encountered in trainee selection, and in designing an effective
                       training programme for future specialists and sub-specialists in Obstetrics and Gynaecology.
                       Areas to be discussed include: trainee selection processes, length of training, assessment dilemmas, streaming,
                       subspecialisation and its assessment.


                       S18.4
                       Management of Gestational Trophoblastic Neoplasia in the Philippines
                       Lourdes BLANCO-CAPITO

                       The term Gestational Trophoblastic Neoplasia (GTN) encompasses the spectrum of trophoblastic diseases that are locally
                       proliferative with the ability to invade normal tissue and the potential to spread outside of the uterus. It includes
                       choriocarcinoma, invasive mole, placental site trophoblastic tumour and epithelioid trophoblastic tumour. Gestational
                       trophoblastic neoplasias are unique in the sense that one can diagnose the presence of malignancy and institute
                       chemotherapy even without the benefit of a histopathologic diagnosis. Although these tumours can rapidly progress to a
Abstracts : Speakers




                       fatal outcome if left untreated, trophoblastic neoplasias are curable even in cases of disseminated disease.

                       Broad variations in the distribution of GTN exist worldwide with higher frequencies noted in some parts of Asia. The
                       Philippines has one of the high incidences of GTN, occurring in 10.6 per thousand pregnancies. The Philippine General
                       Hospital (PGH), which provides the only known subspecialty training programme for the diagnosis and treatment of
                       gestational trophoblastic disease, is the national referral center for the management of GTN. An average of 40 new cases
                       of GTN are seen and treated in the hospital every year.

                       Once the diagnosis of GTN is made, laboratory examinations, which include a complete blood count, blood typing,
                       urinalysis, and renal and liver function tests, are requested prior to institution of any therapy. A metastatic work-up is
                       likewise performed to determine the extent of the disease. Following this, patients are staged and scored using the FIGO
                       2000 staging and risk factor scoring system.

                       Chemotherapy is the cornerstone in the management of patients with GTN. For patients with nonmetastatic (NMGTN) and
                       low-risk metastatic gestational trophoblastic neoplasia (LRMGTN), single agent chemotherapy is the treatment of choice. At
                       the Philippine General Hospital, a total of 203 patients with NMGTN and LRMGTN received complete treatment between

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the years 1988 and 2004. These patients were initially treated with methotrexate given at a dose of 0.3-0.4 mg/kg/day
intramuscularly (IM) for 5 days. Treatment courses were repeated every 7-10 days. 178 (88%) achieved complete
remission after 4-5 cycles. 25 patients (12.31%) were shifted to actinomycin due to toxicity and resistance with complete
remission in 18 patients. Sustained remission rate was 98.5%. Patients who did not have complete response to single
agent chemotherapy were given multiple agent therapy and subsequently attained remission. Patients with high-risk
metastatic disease (HRMGTN) are initially treated with combination chemotherapy composed of Etoposide, Methotrexate,
Actinomycin, Cyclophosphamide and Vincristine (EMACO). In PGH, remission rate with this regimen is 82% for previously
untreated patients and 89% for those previously given chemotherapy.

Surgery is an adjuvant form of treatment performed to remove chemotherapy-resistant foci. A total of 420 patients were
treated for GTN at the PGH, from 1996 to 2006. Of these, 129 underwent hysterectomy, 3 had pulmonary resection and
two had excision of a liver metastasis. Surgery not only decreased the number of chemotherapeutic cycles needed to
achieve remission, but most importantly, improved survival rate of patients.


S18.5
Management of Breech Presentation at Term
Malik GOONEWARDENE

The best method of management of a breech presentation at term has been a topic of debate for several decades.

External Cephalic Version (ECV) described by Aristotle (circa 330 BC) was practised extensively up to the mid 20th century
and thereafter abandoned as being of no value. During the later part of the 20th century there was renewed interest in this
procedure and today ECV is recommended at term as it safely reduces the risk of vaginal breach delivery and Caesarean
section (CS).

Spontaneous breech delivery is not recommended but may occur unexpectedly. Breech extraction is indicated only after
internal podalic version for a second of twins lying transversely. Therefore the options available are Assisted Vaginal
Breech Delivery (AVBD), Elective CS or Emergency CS after a Trial of Breech.

Two randomised controlled trials in 1980 and 1983 demonstrated no difference in perinatal outcome of babies with breech
presentations, irrespective of whether they were delivered abdominally or vaginally. A retrospective study in 1985 and a
follow up study in 1996 showed that AVBD was safe and did not increase perinatal morbidity or mortality in properly
selected cases. The Term Breech Trial (TBT) in 2000 suggested that planned CS reduced perinatal and neonatal morbidity
and mortality, but did not reduce the risk of death or neurodevelopmental delay in these children at two years of age.

The TBT has caused great concern because it has had a very significant impact on the management of breech presentation
at term. Critics of the TBT have shown that most cases of neonatal death and morbidity in the TBT could not be attributed
to the mode of delivery. The clinical conduct of the TBT too has been questioned and it has been suggested that its results
and conclusions should not be generalised internationally. There is a suggestion that the recommendation of the TBT
should be withdrawn. In the TBT, 44 % of women were from non industrialised countries and in these women; the benefits
of planned CS were much less when compared with the benefits in industrialised countries. This could be due to
obstetricians in non industrialised countries being more experienced and skilled in AVBD. The critical factors which will
influence the success of an AVBD are clinical experience, foetal size and pelvic adequacy. The attitude of the foetus
                                                                                                                              Abstracts : Speakers

and the type of breech presentation also affect the outcome.

Observational studies in 2003 and 2008 have shown that AVBD in carefully selected cases did not have any adverse
outcomes. A study in 2007 showed that although the CS rates for breech presentation markedly increased after the TBT,
there was no improvement in outcomes for the child although the risks for the mother were increased in comparison to a
vaginal delivery.

Therefore in a breech presentation at term, an experienced, skilled obstetrician should attempt ECV, and if it fails an
assisted vaginal delivery should be a valid option in properly selected women.




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                                                                    Keynote Lecture 3 : Gynaecology
                       KL3
                       New Discoveries in Pelvic Prolapse – Imaging, Modelling, Insight and Change
                       John DELANCEY

                       Injury to the pelvic floor has been observed for over a century and presumed to be associated with pelvic organ prolapse
                       and perhaps other pelvic floor disorders. Although there have been many competing hypotheses concerning the relative
                       importance of the muscle or facial damage in the causation for pelvic floor defects.

                       Modern cross sectional imaging (MRI and 3D Ultrasound) has allowed injuries of the levator and muscles and abnormalities
                       seen in the pelvic facial tissues to be studied in both symptomatic and asymptomatic women allowing hypotheses to be
                       tested about its association with PFD. This allows us to answer the many questions that have lingered in the literature for
                       many years.

                       Among women with pelvic organ prolapse 55% have major injuries (>50% of muscle involved) while the injury rate in
                       normal volunteers matched for age and race is 16%. There is no difference in the occurrence of levator ani injury in typical
                       middle aged women with stress urinary incontinence although the injuries are seen more often in women with de novo
                       stress incontinence seen during the first year after first vaginal birth. Less is known about the association between levator
                       ani injury and fecal incontinence but emerging data suggest it is seen more commonly in older women with fecal
                       incontinence than healthy age and parity matched controls. Although facial defects have not yet received as much attention
                       as the obviously visible muscle defects we are now beginning to identify them as well.

                       Perhaps the biggest advances in our concepts have come from computer based biomechanical modeling. These models
                       have shown the important interactions between the fascias and the muscles. If the muscle is damaged, this subjects the
                       facial tissues to excessive force increasing the chance that failure occurs.

                       There are several ways in which these injuries have clinical importance. First, it is likely that women who have levator
                       injury are more likely to have operative failure as several studies have suggested. In the future if this is corroborated, then
                       more aggressive strategies may be justified in this population. Second, because they cause pelvic floor dysfunction, steps
                       should be taken to develop techniques to reduce their injury during vaginal birth. Finally, as we begin to identify specific
                       connective tissue injuries, we can see which specific injuries are associated with high operative failure rates. Just as
                       surgery for ruptured intervertebral disks and complex knee and shoulder injuries have benefitted from accurate,
                       anatomically specific, preoperative MRI so too will prolapse advance as we begin to know specifically which muscle and
                       facial defects are present.


                                                                           Lunch Symposium 3
                       LS3.1
                       Strategising the Role of Anti-Human Papillomavirus Vaccines for Reducing the Burden of Cervical Cancer
                       Sun Kuie TAY

                       Cervical cancer is the second most common cancer in women globally, accounting for 10% of all cancers in women in
Abstracts : Speakers




                       developed world and 15% in developing world. Of the 534,000 new cases diagnosed each year, half of them die from the
                       cancer. Managing the burden of cervical cancer is a major global challenge.

                       The unique natural history of squamous cell carcinoma of the cervix with a long pre-malignant phase or intra-epithelial
                       neoplasia (CIN) provides a strategic opportunity for prevention of invasive cancer. For almost a century, application of
                       cytology screening, coupled with colposcopic evaluation of women with abnormal cytology, allows detection and eradication
                       of CIN through a variety of surgery. National cancer registries from countries with well-organised screening mechanism and
                       healthcare infra-structure have demonstrated marked reduction of the incidence and mortality rate of cervical cancer.
                       Recent data from these registries, however, demonstrated that the benefit of cytology screening has either reached a
                       plateau or began to show a rise in the incidence of this cancer, in particular, among young women.

                       Technical and human and financial demands of comprehensive cytology screening programmes are prohibitive for
                       universal introduction worldwide. Not surprisingly, cervical cancer is most prevalent in poor resource countries where the
                       burden of the disease is rising. Naked eye examination of the cervix after staining with diluted acetic acid, a technique
                       known as VIA, has recently been introduced in these countries as an alternative to cytology for detection of CIN in
                       asymptomatic women. The low specificity which may lead to over-treatment of many women is major public concern.


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Research in the last 3 decades has identified a group of human papillomavirus (HPV) as a necessary aetiological agent for
development of cervical cancer. Among the dozen of oncogenic HPV subtypes, HPV 16 and 18 account for 70% of all
cervical cancer. HPV 45, 31 and 33 accounts for another 10% of the cases. Vaccines against HPV 16 and 18 have recently
been introduced in clinical practice. Large phase III trials have demonstrated almost 100% sero-conversion in vaccinated
women. Using high-grade CIN (CIN 2 or more severe) as a disease end point, these vaccines confer more than 98%
protection against HPV16/18 related disease. Among HPV DNA and serology negative women, clinical trial on CervarixTM
recently reported a protection rate of 100%. Taking the entire cohort of women entered into the trial, some of them were
either having an ongoing HPV infection or had been infected, and the vaccinated arm demonstrated a significant overall
reduction of CIN by 31%.


L3.2
HPV Vaccination Controversies: Separating the Trees from the Woods
Choo Beng GOH

Phase II and III clinical trial data suggest that currently available prophylactic HPV vaccines are both safe and efficacious.
The AS04-adjuvanted vaccine (CervarixTM GlaxoSmithKline) conferred 100% protection against HPV-16/18 associated
cervical intraepithelial neoplasia (CIN) grade 1, 2 or worse for 6.4 years in an efficacy study in women 15-25 years old.
Furthermore, substantial cross-protection has been observed against incident infection caused by individual types HPV-45
and HPV-31 up to 6.4 years. Interim results of the PATRICIA trial (n=18,644 women 15-25 years old) showed 100%
vaccine efficacy against HPV-16/18-associated CIN2+, based on an additional causality analysis. Cross-protection against
six-month persistent infection caused by HPV-45, -31, and -52 was also demonstrated.

The role of immune memory after HPV infection in vaccinated subjects remains unclear. For long-term prophylactic
efficacy, a cervical cancer vaccine should induce both a strong antibody response and high frequency of B memory cells.

In an efficacy study in women 15-25 years of age, >98% remained seropositive and maintained high and sustained
antibody levels (total IgG and neutralising) against HPV-16 and -18 for 6.4 years. Furthermore, additional trials have shown
that CervarixTM is highly immunogenic across the age range 10-55 years. After CervarixTM vaccination, good correlation
has been shown between anti-HPV-16 and -18 antibody levels in serum and cervicovaginal secretions, suggesting
transudation of antibodies to the cervical epithelium - the primary site of infection.

In addition, based on mathematical modeling, vaccination with the AS04-adjuvanted vaccine is predicted to provide
sustained antibody levels for both HPV-16 and -18 for at least 20 years. High and sustained levels of neutralising antibodies
may be predictive of the vaccine's preventive potential in the future.


                                            Symposium 19 : Pre-Term Delivery
S19.1
Placental Pathology and Pre-Term Labour
Kenneth CHANG

Up to 60 to 70% of neonatal death, morbidity and cost are linked to preterm birth. Preterm delivery, whether spontaneous or
                                                                                                                                    Abstracts : Speakers

indicated, is an indication for the submission of the placenta for formal pathological (i.e. gross and histological) examination.
Pathological findings that may be identified by the pathologist include acute chorioamnionitis, chronic infectious villitis, and
villitis of unknown aetiology, placental haemorrhages, massive perivillous fibrinoid deposition, maternal floor „infarction‟, and
fetal thrombotic vasculopathy. Pathological examination of a preterm placenta by a placental pathologist can provide
important information on placental abnormalities and pre-existing adverse intrauterine conditions resulting in fetal distress,
intrauterine growth restriction or preterm labour. Risks of neurological injury in the infant have been linked to specific
placental pathologies. The placental pathology report may serve as a means of formal documentation of placental
abnormalities and adverse intrauterine conditions in situations of adverse obstetrical outcome when litigation is initiated on
the basis of alleged suboptimal intrapartum care.


S19.2
Timing the Use of Corticosteroids in Threatened Pre-Term Delivery
Lay Kok TAN

There is now good evidence that the administration of antenatal corticosteroids in preterm labour is associated with
significant reductions in the risk of respiratory distress syndrome (RDS), intraventricular haemorrhage (IVH) and necrotizing

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                       enterocolitis (NEC). Yet in practice, not all mothers who deliver preterm receive antenatal steroids. Conversely, some are
                       given corticosteroids before the earlier limit of 24 weeks. Safety concerns of steroids, the role of repeated courses of
                       corticosteroids, and the choice of corticosteroid will also be discussed.


                       S19.3
                       Role of Cervical Cerclage in Preventing Pre-Term Delivery
                       Devendra KANAGALINGAM

                       Cervical incompetence is a difficult diagnosis to make. The aetiology and treatment of this condition is subject to much
                       debate. Although cervical cerclage has been practiced for more than 50 years, there is a lack of supporting evidence. It is
                       useful to classify the procedure according to its indication. A history-indicated cerclage, also known as an elective cerclage,
                       is performed in a woman with prior history of recurrent mid-trimester losses suggestive of cervical incompetence. An
                       ultrasound-indicated cerclage is performed on the basis of a shortened cervix on ultrasound scan. A physical-examination
                       indicated cerclage, also known as an emergency cerclage, is performed following physical findings of a painlessly dilated
                       cervix with intact membranes. A review of the current evidence is discussed. The procedure, as performed at the Singapore
                       General Hospital (SGH), as well as 3 illustrative SGH cases demonstrated the challenges in treating these women, are
                       presented.


                                                                    Symposium 20 : Urogynacology
                       S20.1
                       What Causes SUI and Why Do Our Operations Sometimes Fail
                       John DELANCEY

                       It has been accepted for a long time that stress urinary incontinence (SUI) is caused by loss of urethral support. Many
                       hypotheses concerning damage to the urethral supportive tissues have been put forth. Treatment strategies for stress
                       incontinence are based on the concept that urethral mobility is the predominant causal factor with sphincter function a
                       secondary contributor. Although plausible, there were studies that assessed the relative contribution of these two factors in
                       properly controlled studies with truly asymptomatic women for controls (most studies used non-stress incontinent women
                       who needed urodynamics).

                       We therefore conducted the Research on Stress incontinence Etiology (ROSE) project which was a case-control study that
                       compared 103 women with stress incontinence and 108 asymptomatic controls in groups matched for age, race, parity and
                       hysterectomy. Urethral closure pressure, urethral and pelvic organ support, levator ani muscle function and intravesical
                       pressure were measured and analysed. Mean maximal urethral closure pressure was 42% lower in cases (40.8 vs. 70.2 cm
                       H2O). This was an effect size of 1.47. Lesser effect sizes were seen for support parameters, including resting urethral axis
                       and urethrovaginal support (effect sizes of 0.41 and 0.50, respectively). Other pelvic floor parameters, including genital
                       hiatus size and urethral axis during muscle contraction (effect sizes of 0.60 and 0.58, respectively), differed but levator
                       strength and levator defect status did not. Maximum cough pressure, which is an assessment of stress on the continence
                       mechanism, was also different (effect size 0.43). After adjusting for body mass index the maximal urethral closure pressure
                       alone correctly classified 50% of cases. Adding the best predictors for urethrovaginal support and cough strength to the
                       model added 11% of predictive ability. In addition, recent studies have shown that women with urge incontinence also have
Abstracts : Speakers




                       poor urethral function. The difference between those with urge and stress comes from differences in urethral support. This
                       explains why there is such an overlap between the two conditions (mixed incontinence). It is our hypothesis that poor
                       urethral function is associated with incontinence and those who have excellent urethral support tend to have urge
                       incontinence and those with poor support, SUI.

                       Operations for stress incontinence have a high success rate. However, there is a persistent failure rate of 10 to 15%.
                       When they fail, we often do not have an explanation for why. In some instances, it is obvious such as the instances in
                       which the original operation is not performed properly. In other situations, however the operation accomplished its goal.
                       The mid-urethral tape operations depend on the urethra being forced against the tape to occlude the lumen. Normal
                       women and most women with stress incontinence have enough urethral mobility to activate the tape. However, the fact that
                       urethral function is the primary factor responsible SUI means that some women may have stress incontinence despite a
                       well-supported urethra. Strategies need to be developed that objectively assess urethral support so that data can be
                       collected to determine how much mobility is required for sling activation.

                       In addition, it becomes obvious that understanding why some women have poor urethral function while others do not. Age,
                       even in the absence of parity is associated with a 15% decline in urethral function each decade yet, even at that, two
                       women at the same age may have vastly different urethral function. The urethra, therefore, is an important therapeutic
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target that is relatively unexplored. Muscle derived stem cell injections and novel pharmacologic strategies become
important when one understands that urethral function is the primary factor causing this common problem.


S20.2
Anatomy of the Pelvis and how it influences Current Approaches to Urogynaecology and Pelvic Reconstructive
Surgery
John DELANCEY

The pelvic organs are supported in their positions by the levator ani muscles and various connective tissue attachments.
The levator ani muscles have a constant activity that closes the pelvis. This constant “resting” activity is increased during
events such as coughing or jumping. The pubic portion of the levator ani muscles are frequently injured during vaginal
birth, especially when forceps are used. Fifty-six percent of women who have pelvic organ prolapse are found to have this
type of injury involving more than half of the muscle while only 16% of women with normal support of similar age and parity
have this type of injury. This results in 40% reduction in muscle force exerted on an instrumented vaginal speculum during
a maximal voluntary contraction.

The vaginal is a fibro-muscular tube that is attached to the pelvic walls on either side. Although it is traditional to refer to
these connections as fascias and ligaments they resemble mesenteries more than skeletal ligaments. In the upper portion
of the genital tract, the cervix and upper vagina are attached to the pelvic walls by the cardinal and uterosacral ligaments.
The cardinal ligaments are primarily vascular in composition and are relatively vertical in the standing position. Separate
from the vertical cardinal ligaments, there is a complex of connective tissue that is more horizontal passing between the
upper genital tract and the sacrum.

The superficial portion of this complex is visible from above and is typically called the uterosacral ligament. MR imaging
(and anatomical cross section) reveal an extensive network of connective tissue below the peritoneum that has variously
been called the rectal pillars, pararectal fascia and other names. In contrast to the vertical cardinal ligaments, these
structures are more horizontal in orientation and pull the upper vaginal dorsally into the hollow of the sacrum. The middle of
the vagina is attached laterally to the arcus tendineus fascia pelvis ventrally, and to the posterior arcus dorsally. Distally,
the vagina is fused with the levator ani muscles laterally and the perineal body dorsally.

Pelvic organ support is provided by the interactions between the connective tissues and muscles. When normal muscle
function is present, the muscles hold the genital hiatus closed. In this situation increases in abdominal pressure are
balanced so that rises in bladder and rectal pressure are equal, cancelling one-another out. However, if the muscles are
not strong enough to maintain closure during pressure increases, the some portions of the vagina descend to become
exposed at the introitus. In this configuration, there is not a balance of pressures. The high pressures in the bladder, for
example are on one side of the vaginal wall while the other side of the wall is exposed to atmospheric pressure. The force
that results from this pressure differential forces the pelvic organs downward; placing tension on the supportive tissues. If
the tissues are very strong they can resist this force, but if they are marginal, then they may fail. This can happen either
acutely as described by some women who experience a sudden occurrence of prolapsed while lifting something heavy or
slowly over time.

Clinical Implications: The fact the muscle injury plays an important role in pelvic organ support, but is not correctable by
our current surgical procedures implies that some of our operative failures are probably due to muscular damage. It is
                                                                                                                                   Abstracts : Speakers

likely that women with normal muscle have higher success rates. This suggests that mesh augmented repairs and the
potential complications they pose may be most relevant to women with muscle damage and clinical trials of this idea seem
warranted. In addition, our recent investigations have revealed that the normal position of the vagina lies above the upper
suspension points used in anterior and posterior mesh operations. We have seen a number of women with apical prolapse
after anterior and posterior mesh placement and feel that the issue of apical support deserves serious attention.


S20.3
Overactive Bladder Syndrome – the Need for a Holistic Approach to Management
Arthur TSENG

The Overactive Bladder Syndrome (OAB) is a problem affecting approximately 16 to 17% of women, and the prevalence
appears to increase with age, parity, menopausal status, profession and a whole host of other factors. The restrictive and
possibly crippling nature of OAB is due to the significant morbidity it causes, the psychological and emotional trauma it
generates, and the knock-on effect in terms of loss of man-hours in all aspects of life, including the patient‟s profession.

Medical therapy is the mainstay of management of OAB, in a bid to control the bothersome symptoms of urinary urgency,
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                       frequency, incontinence and nocturia. There is currently a wide range of drugs on the market, emphasizing the fact that
                       there is no ideal treatment for this poorly understood condition at present. The significant adverse side effects of present
                       medications also limit their usage and adversely affect patient compliance with therapy.

                       At present, the available drugs in Singapore are limited (Oxybutynin IR, Tolterodine IR and Tolterodine ER), with
                       Propiverine and Trospium Chloride recently made available on the market. Unfortunately, all available drugs are of an
                       efficacy level of 60% only; hence the need to combine different therapies to improve the overall efficacy of OAB treatment.

                       Surgery is usually a last resort measure with limited efficacy, the risk of significant morbidity, and possible physical
                       disfigurement; making such an option distasteful to women.

                       It is hoped that with a holistic approach towards management, with improved patient education and awareness of their
                       disease pattern of progression and regression; combined therapies will translate into improvement of quality of life and
                       ultimately patient satisfaction.


                       S20.4
                       Ins and Outs of Hands-On Training of Porcine Anal Sphincter Repair in the Netherlands
                       Julien DONY

                       During their 6 years lasting training Dutch Ob/Gyn residents have on average 5 times an opportunity to perform a post
                       partum anal sphincter injury repair (ASIR). This number is critical low. Moreover training in the acute situation isn‟t done by
                       the most experienced tutor and doesn‟t offer the opportunity to become familiar with normal anal sphincter anatomy. For
                       this reason, inspired by Abdul Sultan, a hands-on training course on ASIR for residents was started in 2005. The course
                       starts with a lecture about anal sphincter anatomy, histology, and function and consequences of anal sphincter injury. The
                       hands-on training starts with repair on an anal sphincter injury simulator and thereafter on a porcine bottom of sow or boar.
                       Logistics of pig bottom harvesting, preparation of suitable specimens, MRSA-contamination prevention measures and
                       leasing of suitable instruments are explained and discussed.


                                                                          Nursing Symposium 1
                       NS1.1
                       Perinatal Mental Health – When Mind and Body Interact at the Beginning of Life
                       Helen CHEN

                       Mental health problems are common during pregnancy, a time of emotional vulnerability as women navigate the
                       challenging transition to motherhood. Local statistics have shown that depression illnesses affects 12% of pregnant women,
                       and about 20% have significant depressive symptomatology, which though not amounting to clinical depression, can affect
                       the woman‟s functioning capacity.

                       The negative effects of antenatal depression have been well documented, and in the April 2008 Practice Bulletin of the
                       American College of Obstetricians and Gynecologists has definitively highlighted that untreated or inadequately treated
                       maternal mental illness “may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional
Abstracts : Speakers




                       medications or herbal medicines, increased alcohol and tobacco use, deficits in mother-infant bonding and disruptions
                       within the family environment”. Women who suffer from antenatal depression are also at risk of postnatal depression if let
                       untreated.

                       We now know that what profoundly affects women when they experience emotional turmoil during childbearing period is not
                       just the distressing symptoms of mental illness, but also the idea that perhaps they themselves are defective individuals,
                       and not good enough as mothers, not good enough as women.

                       Here then is the interface of science and humanity – wherein medically recognised disorders and scientifically
                       demonstratable conditions result in a beaten human spirit.

                       Understanding how this can impact on an afflicted woman is crucial, in helping her regain a healthy sense of self, a sense
                       of wholeness, as she transitions into her role as mother.

                       The KKH Mental Wellness Service, which was established three years ago, provides comprehensive evaluation and
                       ongoing care to women who suffer from a spectrum of psychiatric disorders in relation to pregnancy and childbirth, with an
                       aim to improve the lives of patients and families. Holistic care by a multidisciplinary team approach is provided, as is
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appropriate to the needs of each individual patient. The professionals that may be involved comprise the psychiatrist, social
worker, psychologist and occupational therapist. Case management is central to the service, with the case managers,
providing integrated and individualized care for our patients together with the psychiatrist, thus ensuring continuity of care
through the different phases of the illness. Support group intervention is also available, as this has been shown to be
beneficial for selected women. The service works in close liaison with the obstetric and gynaecological specialists, and
pediatricians.

The main goal of intervention is to enable the depressed mother to recover functioning, and as she prepares to become a
mother, and to achieve a good bond with her infant. In essence, to become a mother.


NS1.2
The Efficacy of Vaginal Dilator with Versus Dilator Alone In Preventing Radiation-Induced Vaginal Adhesion and
Stenosis for Patients Undergoing Pelvic and Vaginal Radiation
Fang HUANG

Introduction: Following radiation therapy (RT) for gynaecological malignancies, patients may experience radiation-induced
toxicities such as vaginal adhesion and stenosis. This may cause considerable physical and psychological effect on
patients‟ sexual function as well as causing difficulties in future vaginal examination. Various preventive methods such as
vaginal dilator and douching are available to minimize these side effects, however, studies were limited. The purpose of this
study is to evaluate the efficacy of using a dilator with vaginal douching vs. dilator alone in preventing radiation-induced
vaginal adhesion and stenosis in patients undergoing radiotherapy.

Method: This is a randomized controlled trial of patients with newly diagnosed Stage I-III cervical or uterine cancer
recruited from a single institution. Patients are assigned to either dilator group or dilator with douching group by using
sealed envelopes randomization. They are taught to perform the procedure three times a week during radiation therapy and
for a period of three months post-radiation and once a week subsequently. Vaginal adhesion is assessed through vaginal
examination. Impact of sexual intercourse through direct asking based on the set questions is also recorded.

Statistical consideration
Statistical analysis was carried out using SPSS 15.0. Difference of adhesion rate and vaginal stenosis rate between dilator
group and dilator with douching group is assessed using Chi-Square test with odds ratios presented where applicable.
McNemar‟s test is used to analyse the impact of treatment on changes of sexual intercourse from baseline.

Results: From September 2007 till end February 2009, a total of 47 patients were recruited, 2 out of 47 patients had died at
time of analysis. Twenty-three patients were randomised to the dilator group and 22 to the dilator with douching group.
Median age was 51.83 (minimum 42.94 to maximum 78.96), majority of patients received either surgery and RT or surgery
and chemo-radiation. Three (6.7%) patients developed vaginal adhesion three months after radiation therapy, of which one
(4.3%) was from the dilator group and two (9%) from the dilator with douching group. There was however no significant
difference in terms of adhesion rate between the two groups (p = 0.586) using the Chi-square test. Three patient developed
vaginal stenosis 6 months after radiation therapy and they were all from douching and dilator group. Of which, two of them
had stopped using douching and dilator 3 month after radiation due to discomfort and inconvenient. Another one had
adhesion prior to stenosis. Impact of treatment induced vaginal toxicity on sexual intercourse was significant (P= 0.031)
using McNemar‟s test. There where no major side effects noted in either group.
                                                                                                                                 Abstracts : Speakers


Conclusion: The finding of this study supports the use of a dilator as a proactive measurement in the prevention of
radiation-induced vaginal adhesion and stenosis. Finding also suggests that discomfort and inconvenient of the douching
with dilator may have discouraged continuation of procedure thus resulting in adhesion and stenosis. However, the
effectiveness of douching in preventing radiation-induced vaginal adhesion still require further evaluation as the research
continues. In addition, impaired sexual health reported above seems to be another area of concern to be addressed further.


NS1.3
Risk Assessment: an Imperfect Science
Lydia SEOW

Background: Risk assessment is a step in risk management process. In the context of midwifery practice, risk assessment
relates to the formal process of quantifying the probability of a harmful effect to pregnant women and their foetus. It is an
integral part of midwifery care and is intended to direct attention and provide specialized care to women at risk of poor
perinatal outcome (Saxell, cited in Page & Percival, 2000).

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                       In recent years, a number of factors such as the ubiquitous use of screening tools, rising litigation and medicalisation of
                       childbirth; have led to the amplification of perceived risks and increasing reliance on medical interventions during childbirth.

                       Objectives: This dialogue centres on the emerging discourses in the understanding and application of risk assessment by
                       midwives in the Intrapartum settings. It focuses on two central themes germane to the science behind risk assessment
                       tools and the art of performing risk assessment.


                                                                  Symposium 21 : Minimally Invasive Surgery 2
                       S21.1
                       Endometriosis – The Challenge in Surgical Treatment, Recurrence and Avoidance of Surgical Castrations
                       Anthony SIOW

                       Abstract not available at time of print.


                       S21.2
                       Minimal-Invasive Surgery and Adhesions – A European Consensus
                       Rudy Leon de WILDE

                       Adhesions are the most frequent complication of gynecological surgery, yet many surgeons are still not aware of the extent
                       of the problem and its serious consequences. While adhesions may cause few or no detrimental effects to patients, in a
                       considerable proportion of cases there are major short- and long-term consequences, including small bowel obstruction,
                       infertility and chronic pelvic pain. Adhesions complicate future surgery with important associated morbidity and expense –
                       and a considerable risk of mortality. Despite advances in surgical techniques in recent years, the burden of adhesion-
                       related complications has not changed. Adhesiolysis remains the main treatment, despite the fact that adhesions reform in
                       most patients. Developments in adhesion-reduction strategies and new agents now offer a realistic possibility of reducing
                       the risk of adhesions forming and can improve the outcomes for patients and the associated onward burden. A European
                       consensus statement reviews the published literature on the extent of the problem of adhesions and opportunities to reduce
                       their incidence. It provides recommendations on the actions that European gynaecologists should take to avoid causing
                       adhesions. Importantly it also advises that it is now time to inform patients of the risks associated with adhesion-related
                       complications during the consent process. With evidence increasing to support the efficacy of adhesion-reduction agents to
                       complement good surgical practice, all surgeons should act now to reduce adhesions and fulfil their duty of care to patients.


                       S21.3
                       A Medical-Legal Odyssey – A Survivor Speaks
                       Jiwan SINGH

                       Upon receiving a legal letter regarding a medicolegal lawsuit, the GYN undergoes a journey that is often quite harrowing.
                       The journey is long, lonely and the end unknown, quite the opposite of medical practice where one is in control and has the
                       support of colleagues and friends. It is often difficult to maintain the status quo and practice without self doubt and
                       recriminations of one‟s actions. The temptation to practice defensive medicine overcomes oneself and no amount of
                       reassurances from colleagues will restore the self confidence that comes with a successful resolution of a medicolegal
Abstracts : Speakers




                       case.

                       This presentation will give you an insight into a journey that we all dread to embark upon and I hope you will be better
                       prepared than I was, should you be called upon to do it one day.


                                                                    Symposium 22 : General Gynaecology 2
                       S22.1
                       Women’s Mental Health and the Impact on the Patient-Gynaecologist Relationship
                       Gail Erlick ROBINSON

                       Many women experience psychiatric disorders or psychological issues that may have an impact on their relationship with
                       their gynaecologist. Some of these may be obvious whereas others have a more subtle impact. Up to 25% of women will
                       experience depression in their lifetime, most frequently occurring during pregnancy, postpartum, premenstrually or during
                       the perimenopause. Women also react more strongly to miscarriage than most obstetricians realize. Women who are or
                       want to be pregnant may also have mental health problems that complicate their management.

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Patients may also present with more subtle psychological problems. It is easy to work with the pleasant, cooperative patient
who complies with your advice and does not bother you between appointments. All clinicians, however, have to deal with
“problem” patients. Problems arise when patients. These are the women who don‟t cooperate with treatment, become very
upset during examinations, come frequently with seemingly frivolous complaints, call repeatedly between appointments or
appear to be more interested in you than their medical problem. It is important to understand what underlies this potentially
annoying behaviour and learn how to deal with it. Various underlying factors may contribute to difficult patient behaviour.

Women who are the victims of domestic violence may not be allowed by their abusive partners to comply with treatment. It
has been reported that a woman may come to a physician up to 11 times with seemingly minor complaints or evidence of
her clumsiness before the clinician realizes she is the victim of violence. Women with a history of childhood sexual abuse,
sexual assault or sexual misconduct on the part of a previous physician may have difficult trusting and/or become very
anxious during a physical examination. Patients who appear seductive may be lonely, needy or angry. The clinician should
not be fooled into thinking the patient is really attracted to him as opposed to using the clinician to work out the patient‟s
personal issues. This talk will explore how the gynaecologist can identify and manage mental health issues in their patients.


S22.2
Hormone Replacement Therapy – Interpreting the WHI and Getting Back on Track
Su Ling YU

The results of the two randomized trials of Women‟s Health Study (WHI) on hormone replacement treatment (HRT)
published in 2002 and 2003 appeared to have dealt a fatal blow to the use of HRT in the treatment of menopausal women.
The repercussions had left indelible doubts in the minds of menopausal women regarding the possible complications of
HRT. More often than not they no longer trust the advice of their doctors. Indeed the results of WHI had polarized the
doctor‟s opinions leading to conflicting opinions which left the patients even more confused.

The aftermath of WHI led to several changes in consensus guidelines. Great caution was placed in the duration and
indications of HRT.

Is there still a place for HRT in 2009 and beyond? The answer is still yes in a small segment of menopausal women.
Moderately and severely symptomatic menopausal women still require HRT. There is no better substitute. Several post
WHI studies indeed have showed that HRT is safe for younger menopausal women.

Other studies are conducted looking at ultra low dosages of hormones and different progestogens. Latest studies on
tibolone are also discussed.


S22.3
The Effectiveness and Risk of Liposuction: A Gynaecologist’s Experience
Alex OOI

Introduction: Tumescent liposuction (TLS) and autologous fat transfer (AFT) services were added to a regular obstetrics
and gynaecology (ObGyn) practice after due training which included a hands-on course with Dr Jeffrey Klein, inventor of the
tumescent technique.
                                                                                                                                 Abstracts : Speakers

Materials and Methods: The first 200 cases are presented as to site, aspirate and outcome. Relevant counselling
materials, informed consent and weight & hormone management protocols are used. Treatment protocol, device used and
safety measures will be presented.

Conclusion: With appropriate training, TLS and AFT can be incorporated into a regular ObGyn practice. This is in view of
our surgical training, “key-hole” approaches and safety awareness. We are in a position to provide such services as we
manage hormonal issues, including lifestyle and weight management. Medical indemnity and operating facility cost is
marginally higher.


S22.4
New Innovations in Stratification of Pelvic Mass Patient in a Gynaecology Setting
Hamid ERFANIAN

Ovarian cancer is considered to be one of the most serious forms of gynaecological malignancies. Worldwide there are
more than 204,000 new cases of ovarian cancer each year, accounting for around 4% of all cancers diagnosed in women.
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                       The poor survival rate in ovarian cancer is due in part to the lack of effective screening coupled with a lack of symptoms in
                       early stage disease. The serum marker CA125 is the most widely used biomarker to detect and monitor ovarian cancer;
                       however it is elevated above 35 U/mL in only 50 – 60% of patients.

                       Recently, several groups have shown that using a combination of biomarkers, including CA125, improves the sensitivity
                       and specificity for detection of ovarian cancer. Moore et al showed that the sensitivity of CA125 at 95% specificity was
                       43.3%, the sensitivity of HE4 was 72.9%, and the sensitivity of both CA125 and HE4 was 76.4%. Both Havrileky et al and
                       Moore et al. have shown that the serum marker HE4 demonstrated the highest sensitivity for detecting early stage ovarian
                       cancer, and that using a combination of CA125 and HE4 provides a more accurate predictor of ovarian cancer than using
                       either marker alone.

                       Furthermore, using an algorithm that includes both HE4 and CA125, patients with a pelvic mass can be correctly classified
                       as either low or high risk for ovarian cancer with up to 93.8% accuracy. By combining ARCHITECT HE4 and ARCHITECT
                       CA125 one can significantly improve the ability to differentiate between malignant and benign pelvic mass.


                                                                           Nursing Symposium 2
                       NS2.1
                       Holistic Care in Labouring Women
                       Julie TAY

                       Childbirth itself has not changed at all! Babies are still born today in the same way that that they have been born for
                       generations. But many things associated with childbirth have changed, including:
                        Women's expectations of childbirth
                        Pain management options
                        The technology used during pregnancy and birth

                       These factors have greatly changed women‟s childbirth experiences. Today, many women plan their pregnancies and tend
                       to have fewer children than a century ago. This has created a culture where each pregnancy and baby generates intense
                       attention.

                       KK Women‟s & Children‟s Hospital believe that excellent health care is best fostered in an atmosphere of relationship and
                       trust, where women are empowered to work collaboratively with their caregivers. To provide a holistic care for pregnant and
                       labouring women, we are constantly reviewing and introducing new services and care such as:

                           Midwife-led care during intrapartum for low risk women
                           Doula Services – We have developed a programme to train our own pool of retired midwives to be doulas
                           KK Birth Plan
                           Environment – aromatherapy and music
                           Telemetry CTG monitor
                           Birthballs to cope with labour pain
                           Initiation of breastfeeding within 1st hour of birth to promote bonding
Abstracts : Speakers




                       Moving towards the future to promote a highly personalized care we are working towards setting up the midwife-led clinic
                       and also reviewing the possibilities of challenging the traditional model of delivering antenatal care by providing group
                       antenatal care where women gather together for their antenatal follow-up.


                       NS2.2
                       Water Birth, a Choice for Labouring Women?
                       Germac SHEN

                       Introduction: “It isn't often that a genuine breakthrough occurs, with major significance for all humanity, unless, of course,
                       it's in the realm of technology. Yet this subject, although completely un-technological, has the potential for widespread use
                       and benefits to millions of people and society at large. It is exciting the imaginations of forward looking thinkers, parents and
                       expectant parents, humanist psychologists, nurses, midwives and progressive doctors worldwide. I‟m referring to the
                       newest form of gentle delivery, which honors the spiritual and emotional, as well as the physical aspects of birth, and
                       incorporates the use of water into obstetrics – water birth.”
                       Daniels 2007, Water Birth Information


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There has been a long history of water birth and proponents argue strongly about the documented benefits of this birthing
method, yet water birth is still at its rudimentary stage in Singapore. To date, little literature has looked at women‟s
perceptions and experiences of water birth. Research on the factors that influence women‟s choice of water birth, and the
impact of such factors upon mothers‟ decision concerning whether or not she will have a water birth are also deficient. The
paucity in existing qualitative research specifically exploring such areas thus supports the aim of this study, which was to
conduct a qualitative research to investigate the factors that influence women‟s choice of water birth.

Material & Methods: This study will utilise a descriptive explanatory research design by conducting semi-structured
interviews to six Australian participants who had received a water birth. Using the grounded theory approach, it provides a
detailed and systematic process for analyzing the comprehensive data. The philosophical underpinnings of grounded theory
also allow the researcher to examine social forces that shape human behavior, so that phenomena can be explained.

Results: Women had a sense of what water birth is about from their knowledge of it, and this understanding was supported
by what they perceived is good for themselves and their baby. It is also accepted that women‟s views and beliefs about
water birth can be principally fashioned by significant others and this successively influences their decision of having a
water birth. The degree to which these other people influenced their decision to choose this birthing method was reliant on
the individual‟s decision-making processes and by how much they depended on other people‟s opinions, as well as trusting
their personal beliefs.

Conclusions: It is imperative for healthcare professionals to recognise the significant impact of educating women on the
safety and benefits of water birth as well as acknowledge the influence their significant others have on them. Only through
this can nurses and midwives find out what could be done to help women overcome any problems or doubts that they face
in their decision to have a water birth. This information will positively contribute to the current body of healthcare
professionals‟ knowledge regarding the choices women make for a significant event in their lives.


NS2.3
Translating Evidence into the Art of O&G Nursing
Serena KOH

The ultimate goal of evidence based practice (EBP) is to reduce practice variability and improve patient outcomes.
Evidence-based practice, an approach to solving clinical problems emphasizes the integration of the best research
evidence with other sources of knowledge to aid decision making. These sources include clinical experience, reasoning,
authority, quality improvement data and the patient situation, experiences and values. EBP therefore suggests that
decisions about care not only flow from the literature and the empirical evidence but also include patient preferences and
values as well as patient judgements about alternatives for care. Thus, good nurses use both individual clinical expertise
and the best available external evidence and neither alone is enough. Clinical expertise informs decision making about the
applicability of external scientific evidence to a patient care situation.

This presentation will share KKH‟s journey of translating evidence into the art of O&G nursing. To promote and support
EBP, workgroups comprising a panel of experts from the various departments were tasked to conduct systematic reviews
on O&G nursing practices such as cord care, pre-operative shaving and neonatal suctioning. Through a scientific review,
evidence is critiqued systematically and rigorously to minimize bias. A list of evidence based recommendations that was
practical within the context of the local environment was subsequently drawn up and implemented to change practice. In
                                                                                                                               Abstracts : Speakers

addition to systematic reviews, research findings from randomized controlled trials conducted at KKH and
recommendations from local nursing clinical practice guidelines are translated to policies and put into everyday practice.

As we move towards EBP, let us take time to think through the obstacles of making EBP a reality in your institutions. A
multi-faceted approach comprising of various implementation strategies will be highlighted today, together with your
leadership and role-modeling of EBP will enable us to meet this challenge of making EBP a reality, enabling health practice
changes across the nation and beyond.




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