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Abstracts Delegates


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									                        Abstracts : Delegates
                        Abstract: 12
                        Biomarker Discovery for Ovarian Cancer and Trisomy
                        1Kothandaraman N, 1Su LL, 1Koh S, 2Low J, 2Ng J, 2Arunachalam I, 2Biswas A, 2Choolani M
                        1National University of Singapore, 2National University Hospital, Singapore


                        Introduction: Clinical diagnostic approaches for various disease conditions are undergoing radical changes in the last
                        couple of years. Emerging technologies based on mass spectrometry (MS) based platform has made significant
                        contributions towards accelerating the pace of biomarker discovery. We have developed and successfully demonstrated the
                        use of a MS coupled with a proteomics platform to detect different gynaecological associated pathological conditions (1) to
                        detect epithelial ovarian cancer (EOC) during its early stage and (2) to detect trisomy conditions in mothers carrying
                        abnormal fetuses. In both cases using peripheral blood obtained from the patient. Our study interrogates the feasibility to
                        translate MS based platform techniques towards non-invasive detection and diagnosis for cancer and as well as carry out
                        prenatal diagnosis.

                        Material & Methods: For EOC project we used a total of 123 plasma (13 early EOC, 34 late EOC, 41 BOC, 35 healthy
                        controls) and 101 serum samples (7 early EOC, 18 late EOC, 41 BOC, 35 healthy controls). For the trisomy project we
                        used maternal serum samples (total: 108); normal (85); T13 (6), T18 (8) and T21 (9), with positive triple test. Protein
                        profiles/fingerprints were generated using Surface Enhanced Laser Desorption and Ionization/Time of Flight Mass
                        Spectrometry (SELDI-TOF-MS) technique. Using an in-house algorithm, peak features (biomarkers) were selected. Patient
                        serum proteins unique to disease conditions (EOC and trisomy conditions) were identified using gel electrophoresis
                        followed by Tandem MALDI-TOF-MS/MS approach and validated using immunoblotting studies.

                        Results: In both cases we were able to achieve near 100% sensitivity and specificity to diagnose early EOC as well as
                        patients carrying fetuses with different chromosomal abnormalities (Trisomy conditions 21, 18 and 13). Discriminatory
                        proteins/peptides identified were in the range between 2-20 kDa. Using a minimal set of 21 markers for EOC all the cancer
                        test samples (for both plasma and serum) could be diagnosed accurately. Protein spectral features unique to each trisomy
                        conditions, T13 (5), T18 (12) and T21 (8) were identified, along with hCG and AFP, which could discriminate normal
                        samples from the three trisomy conditions with near 100% sensitivity and specificity. Unique proteins in blood from patients
                        carrying foetuses with trisomies were identified. Proteins identified belong to specific groups associated with (a)
                        amyloidosis, (b) immune tolerance, (c) cell division, (d) proteinase inhibitors, (e) proteases, (f) amniotic fluid proteins, (g)
                        acute phase reactant proteins and (h) proteins for neuromuscular development. The above proteins, when used as a panel
                        of markers, were found to successfully distinguish normal from trisomy cases without misdiagnosis.

                        Conclusion: Mass spectrometry based platform could be used successfully to diagnose pathological conditions such as
                        gynaecological malignancies as well as used for non-invasive prenatal diagnosis for fetal trisomy conditions. This approach
                        is highly accurate and non-invasive and will have significant impact in the near future to replace conventional screening
                        tools for EOC such as CA125, and triple test and ultrasound for trisomy screening.

                        Abstract: 26
                        Management of a Caesarean Section Scar Ectopic Pregnancy
                        Teo W, Chua SYI
Abstracts : Delegates

                        KK Women’s & Children’s Hospital, Singapore

                        Pregnancy within a caesarean scar is rare. Diagnosis is often made by Ultrasound and colour flow Doppler coupled with
                        raised beta human chorionic gonadotrophin (β HCG) levels. Both medical and surgical methods have been used in the
                        treatment of a scar ectopic pregnancy. There is however no reliable scientific data to support the use of one method over
                        the other. The management of such patients should be tailored individually.

                        Here, we report a case of a patient with scar ectopic pregnancy. The patient was a thirty two year old lady diagnosed with a
                        scar ectopic pregnancy on ultrasound at six weeks amenorrhea. Patient was offered an option of intramuscular
                        methotrexate versus laparoscopic excision of scar ectopic pregnancy. She decided on the latter.

                        Hysteroscopy was first done to assess the intra-uterine involvement. Decision to proceed on to laparoscopy was made.
                        Intraoperatively, the anterior wall of the uterus was totally covered with omental and bladder adhesions. She had a
                        successful laparoscopic excision of the scar ectopic.

                        Six months later, she presented to the emergency department again complaining of abdominal discomfort. She was 5

weeks amenorrhoea and urine pregnancy test positive. The diagnosis of a caesarean scar ectopic pregnancy was
suspected on ultrasound scan. Patient was keen for a diagnostic laparoscopy with the view for an excision of scar
pregnancy if diagnosed intra operatively. She was not keen to keep the pregnancy and wanted an evacuation of uterus if an
intrauterine pregnancy was noted.

Laparoscopy did not reveal an obvious ectopic pregnancy. Hysteroscopy done revealed products of conception in the
posterior uterine cavity. An evacuation of uterus was done.

Caesarean scar ectopic pregnancy can be a diagnostic challenge in early pregnancy. As the rates of caesarean section
rises worldwide, an increase in the incidence of caesarean scar ectopic pregnancies may rise. It is therefore important for
obstetric and gynaecology centres to establish early pregnancy units with more widespread use of transvagina ultrasound
to allow for early diagnosis.

Abstract: 27 – Free Paper S11.1
The Prevalence and Clinical Characteristics of PMS
1Choi DS, 1Lee DY, 2Jung H, 3Park Y, 4Lee T, 5Ahn E
1Samsung Medical Center, 2Baylor Ehwa OBGY, 3RIZ OBGY, 4Kyungbuk University, 5RIZ OBGY, South Korea

Introduction: To estimate the prevalence of Premenstrual syndrome (PMS) and Premenstrual dysphonic disorder (PMDD)
and to evaluate their impacts on daily life and the management patterns in Korean women.

Material & Methods: A cross-sectional nation-wide online survey in conjunction with Asia pacific national cross-sectional
studies on PMS/PMDD was conducted in 1000 Korean women of reproductive age (15-49 years). The statistical analysis
was performed using SAS statistical package, version 9.2 and R statistical package ( according to each

Results: The estimated prevalence of PMS/PMDD by ICD-10, ACOG and DSM-Ⅳ was 98.6%, 32.1% and 2.8%
respectively. The PMS prevalence could not be accurately predicted from the socio-demographic or socio-cultural
variables, only OC use and to a lesser extent smoking habits might provide some prediction. And PMS (ACOG) prevalence
seemed to increase with age for OC non users.

Among 23 documented symptoms, the most severe symptoms were abdominal bloating, irritability and muscle pain, and
irritability and lethargy were the most bothersome symptoms in overall perception of all symptoms. There was high
correlation between frequency and severity of symptoms. Physical symptoms seemed more important than mental

The effects of PMS severity on activity of daily life were significant. The proportion of impaired women increased with PMS
level. The proportion of women consulting a physician increased with severity of PMS from 2%, 2.3% and 10.7% for ICD-
10, ACOG PMS and PMDD women, respectively.
 On the 986 ICD-10 PMS women, 77% did not take any drug and 22.5% used analgesics or antispasmodics. More than
half of the women were satisfied with the use of these drugs. Most of the women (91.5%) did not have the knowledge
                                                                                                                               Abstracts : Delegates

regarding terminology of PMS/;PMDD.

Conclusion: Our study provides an insight on the current status of PMS/PMDD and will be useful for establishing
management plan for PMS/PMDD in Korean women.

Abstract: 28 – Free Paper S11.7
Azurocidin & CLC6: Novel Prenatal Diagnosis Markers
1Kadam P, 1Sukumar P, 2Zhang H, 1Choolani M
1National University of Singapore, 2Nanyang Technological University, Singapore

Azurocidin and CLC6: two novel potential markers for enrichment of fetal nucleated erythrocytes from maternal blood for
non-invasive prenatal diagnosis.

Introduction: Current prenatal diagnosis using fetal cells involves invasive procedures such as amniocentesis, chorionic
villus sampling and fetal blood sampling which are associated with 1-4% risk of fetal miscarriage. Fetal nucleated red blood

                        cells (FNRBCs) are considered ideal cells for noninvasive prenatal diagnosis due to their short half-life in maternal blood
                        and whole fetal genome present in them. However these cells are rare in maternal blood and lack a specific marker for
                        enrichment from overwhelming majority of maternal red blood cells (RBCs). To discover such unique markers, we
                        compared membrane protein profiles of fetal primitive NRBCs and adult RBCs by mass spectrometry methods. Eight
                        unique markers identified on primitive NRBCs were chosen for validation of their expression to determine the best marker
                        for separation of FNRBCs from maternal blood for non-invasive prenatal diagnosis.

                        Material and Methods: FNRBCs were extracted from placental tissues samples collected at termination of pregnancies
                        with informed consents. RBC samples were obtained from healthy volunteers. Membrane proteins were extracted from a
                        pooled samples of FNRBCs and RBCs. Tryptic digests of membrane proteins were analysed by two-dimensional liquid
                        chromatography coupled with matrix assisted laser desorption/ionization-time of flight/time of flight tandem mass
                        spectrometry (2DLC-MALDI-TOF/TOF-MS) method. Unique FNRBC membrane proteins were identified by comparing the
                        membrane protein profiles of FNRBCs and RBCs. Eight unique proteins were evaluated for their expression by alkaline
                        phosphatase immunocytochemistry using either monoclonal or polyclonal antibodies. The results obtained were analysed

                        Results: A total of 315 proteins were identified from FNRBC membrane preparation, of which 54 had transmembrane
                        domains. The comparison with adult RBC membrane proteome revealed 22 surface proteins unique to FNRBCs. Of the
                        eight proteins markers investigated by immunocytochemistry, relatively equal distribution on FNRBCs and RBCs was found
                        with six markers: Armadillo repeat containing X-linked protein 3 (ALEX3), Solute carrier family 1 member 5 (SLC1A5),
                        Cathelicidin anti-microbial peptide (CAMP), Isoform A of solute carrier family 3, member 2 (SLC3A2), Cleft lip and palate
                        transmembrane protein 1 (CLPTM1) and Olfactory receptor 11H4 (OR11H4). Expression of Azurocidin and Splice isoform
                        B of Chloride channel protein 6 (CLC6) were opposite in these two cell types, 92% of FNRBCs were immunoreactive with
                        anti-azurocidin while only 49% immunoreactivity was seen in adult RBCs. Conversely, in the case of the protein CLC6, only
                        19% of FNRBCs showed positive immunostaining with its antibody while it was as high as 87% in adult RBCs.

                        Conclusion: Identification of unique protein markers using proteomic strategy (2DLCMS/MS) and their validation have
                        revealed two novel potential markers, Azurocidin and CLC6. Azurocidin and CLC6 will be useful for the enrichment of fetal
                        primitive FNRBCs from maternal blood by positive selection of FNRBCs and negative depletion of adult RBCs respectively.
                        These potential markers are now being tested.

                        Abstract: 29
                        Enrichment of Fetal Primitive Erythroblasts from Adult Erythrocytes Using a Microdevice
                        1Ponnusamy S, 2Lee D, 2Xu GL, 3Choolani M, 2Ying J
                        1National University of Singapore, 2Institute of Bioengineering & Nanotechnology, 3National University Hospital, Singapore


                        Introduction: Current prenatal diagnosis requires invasive testing by amniocentesis, chorionic villus sampling and fetal
                        blood sampling which are associated with 1-4% of fetal miscarriage. Primitive FNRBCs circulating in first trimester maternal
                        blood which contain epsilon globin are the appropriate cells for first trimester noninvasive prenatal diagnosis. Enrichment of
                        FNRBCs from maternal blood remains challenge because of their rarity while techniques for their post-enrichment genetic
                        analyses are readily available. Protocols available are not efficient enough to enrich sufficient numbers of FNRBCs from
Abstracts : Delegates

                        maternal blood for noninvasive prenatal diagnosis as most of the FNRBCs are lost among red blood cell pellet in the first
                        step of density gradient centrifugation generally done during the conventional enrichment procedure. Our objective was to
                        design, fabricate and test a microfilter for the separation of primitive FNRBCs from adult erythrocytes. Characteristics of
                        red blood cells such as size, morphology and deformability were exploited to design the devices. Principles of microfluidics
                        were employed in the separation of FNRBCs from adult erythrocytes using these devices.

                        Material & Methods: Micro-filter devices fabricated in our laboratory were tested for their efficiency to recover primitive
                        FNRBCs from mixtures containing adult erythrocytes (1 : 100 = 104 : 106). Three micro-devices were successively
                        developed with modifications in designs to improve their efficiency. Modifications included filter array angle, reduction in
                        filter gap, and increase in parallel filter gap distance. Three flow rates (0.1ml/mim, 0.3ml/min and 0.45ml/min) were tested
                        with devices 2 and 3. Five replicates were run using all three devices and for different flow rates. Statistical analyses were
                        done to calculate the recovery of FNRBCs and depletion of adult erythrocytes from model mixtures. FNRBCs were
                        identified using epsilon globin immunocytochemistry following enrichment.

                        Results: A trend in increase in the recovery of FNRBCs with different flow rates was seen with device 2. We obtained a
                        significant and the highest recovery of spiked FNRBCs from model mixtures (74.0 ± 6.3%, p = 0.05) at a flow rate of 0.3
                        ml/min with device 3. The depletion of adult erythrocytes ranged 45.6%-50.9% with this device. Immunocytochemical

localization of epsilon globin indicated that the morphology of enriched FNRBCs were not affected by the procedure.

Conclusion: Our data demonstrate that it is possible to enrich FNRBCs using microdevices based on cell size and
hydrodynamic pressure at the device. The device will be tested using first trimester maternal blood to enrich FNRBCs. We
hope that the enrichment of these target cells from maternal blood using this device would enable to enhance the recovery
FNRBCs for noninvasive prenatal diagnosis.

Abstract: 30 – Free Paper S11.2
Treatment of Large Defect Using TE Bone Graft
Zhang Z, Teoh SH, Chong SKM, Mattar C, Lee SME, Tan LG, Choolani M, Chan KYJ
National University of Singapore, Singapore

Introduction: The generation of large voluminous tissue engineered grafts which can be modeled into different shapes and
sizes are useful for healing of critical sized bone defects. However, the lack of osteogenicity and difficulties in maintaining
mass transfer of nutrients results in high cellular death in the necrotic interior, and hence graft failure. We have recently
reported that the use of highly osteogenic human fetal bone marrow derived MSC (hfMSC) seeded unto high porosity
scaffolds and matured in a novel biaxial rotating bioreactor demonstrated enhanced osteogenic differentiation and cellular
viability over a standard static culture system. We now test this bioreactor-enhanced hfMSC-scaffold‟s ability to heal a
critical size bony defect in an orthotopic rat femoral defect.

Material & Methods: hfMSC were seeded to polycaprolactone -tricalcium phosphate (PCL-TCP) high-porosity bioactive
scaffolds, and cultured in our bi-axial bioreactor, and predifferentiated for 2 weeks before transplantation into a 7mm rat
femoral segmental defect. Vascularisation was studied through microfil vascular contrast on microCT, and bone healing
monitored through serial microCT, histological analysis and mechanical testing.

Results: Compared with empty defect, bioreactor enhanced hfMSC/PCL-TCP scaffolds can induce the larger vasculature
network forming in the defect area after 1 month‟s implantation and regenerate greater new bone in the defect area after 3
months demonstrated by microCT analysis and histological study, resulting in repair femur with significantly higher
mechanical strength.

Conclusion: This proof-of-principle experiment demonstrate the superior bone forming capacity of a bioreactor-enhanced
cellular-scaffold, with improved vascularisation and osteogenic capacity of value to all large voluminous defects.

Abstract: 34
Maternal Serum Level of Bcl-2 and Caspase-3: a Comparison between Normal Pregnancies and Spontaneous
1Noerjasin H, 1Handono B, 1Mose JC, 1Effendi JS, 2Faried LS, 2Faried A, 1Wirakusumah FF, 2Kuwano H
1Padjadjaran University/Hasan Sadikin General Hospital, 2Gunma University, Indonesia
                                                                                                                                  Abstracts : Delegates
Introduction: Spontaneous abortions represent a common form of embryonic death caused by early pregnancy failure.
However, the exact mechanisms underlying pregnancy loss are not fully understood and animal models are used for the
investigation of pathways leading to pregnancy termination. Studies show that increasing apoptosis activities in
uteroplacenta and reproductive organs are associated with abnormal pregnancies. The Bcl-2 is family of proteins, mainly
through regulation of the formation of apoptotic protein-conducting pores in the outer mitochondrial membrane, although the
precise molecular mechanisms are still not completely understood. Caspase-3 is the final phase of caspase-cascade and
the executor of both extrinsic and intrinsic pathways.

Material & Methods: This study was conducted in the Department of Obstetrics and Gynecology, Padjadjaran University,
Bandung Indonesia in collaboration with the Department of General Surgical Science (Surgery I), Gunma University, Japan.
A cross-sectional study among 38 patients with spontaneous abortion and 38 patients with normal pregnancies with
matched gestational age was performed. Serum concentration of Bcl-2 and caspase-3 were examined using ELISA. Chi-
square test was used to analyse the result and p<0.05 was considered as statistically significant.

Results: In normal pregnancies and spontaneous abortion, Bcl-2 concentration rates ranged from 5.67-29.44 and 2.60-
11.15 ng/ml with a median of 6.44 and 7.11 ng/ml, caspase-3 concentration rates ranged from 0.0-76.0 and 6.50-707.75
mg/ml with a median of 0.7 and 76.5 mg/ml, respectively. Patients with spontaneous abortion showed a significantly lower
Bcl-2 and higher caspase-3 concentration than those with normal pregnancies (p<0.05). There were two abortion patients
                        with the highest caspase-3 concentration (690.75 and 707.75 mg/ml), which is too high from the average. However, even if
                        they are excluded from the analysis, their results are still considered significant.

                        Conclusion: There is a significantly lower Bcl-2 and higher caspase-3 concentration in serum of patients with spontaneous
                        abortion compared to those with normal pregnancies. Our results strengthen as one of the apoptosis‟s role in the
                        pathogenesis of spontaneous abortion.

                        Abstract: 35
                        Effectiveness of Katuk Leave Extract in Successful Breast Feeding
                        1Aloysius Suryawan A, 2Mose J, 2Handono B, 3Rimonta G, 3Sastrawinata US
                        1obsgyn, 2Padjajaran University, 3 Maranatha University, Indonesia


                        Introduction: Breast feeding in Indonesia becomes lower every year. Inadequate milk production is the most popular
                        reasons told by mother especially in the first week of post partum and influenced 50-80% pregnant woman. Katuk leaf
                        (Saoropus androgynus) has known in traditional medicine in South Asia and South East Asia as enhancer milk production.

                        Objectives: To examine katuk leave extract effectiveness in exclusive breast feeding during research period.

                        Material & Methods: Randomized double blinded control trial, included 80 pregnant women with gestational age ≥37
                        weeks which delivered the baby at Immanuel Hospital and Hasan Sadikin Hospital Bandung. Research group has been
                        treated with katuk leave extract and control group with placebo. Katuk leaf extract was taken once a day everyday for 4
                        weeks. All the participants had been monitored for 4 weeks by phone.

                        Results: Katuk leaf extract shows no significant differences in successful breast feeding. (ρ=0,530).

                        Conclusion: Use of Katuk leaf extract shows no significant differences in successful breast feeding.

                        Abstract: 36
                        Evaluation of Cervical Cancer Screening in Low Resource Setting
                        Ali SR
                        Khulna Medical College, Bangladesh

                        Introduction: Cervical cancer is the second most common cancer among women worldwide. Approximately 80% of these
                        deaths occurred in developing countries. Though cervical cancer is preventable, most women in poorer countries do not
                        have access to effective screening programmes. Cervical cancer is the most common reproductive cancer in women in
                        Bangladesh. To support early detection of pre-cancerous conditions and prevent cervical cancer, Bangladesh undertook a
                        screening programme using visual inspection of the cervix with acetic acid (VIA) and through a public sector programme
                        sponsored by UNFPA. The programme was launched in 2004−05 in a phased manner, starting with a pilot programme in
                        16 of the 64 districts in the country and scaled up to 44 districts at the end of 2007.
Abstracts : Delegates

                        Material & Methods: As an outpatient procedure of Gynaecology and Obstetrics department of a teaching hospital placed
                        in the remote and southern part of Bangladesh.- women underwent a detailed pelvic examination, visual inspection of cervix
                        after 5% acetic acid application, cytology (pap's smear),detailed colposcopic examination in the VIA positive cases.

                        Results: Evaluation of the pilot programme's performance showed that VIA carried out by trained doctors, nurses, and
                        paramedics with a poor resource. Women their partners and families are often not aware of the disease and its
                        consequences. The present study evaluated the performance of (3-5%)VIA, magnified visual inspection after application of
                        acetic acid (VIAM), and cytology in the detection of cervical cancer in rural Bangladesh. Screened women of age between
                        25-60 were 6452, with VIA, VIAM, and conventional cervical cytology from January 2007 to mid 2008. Detection of well-
                        defined, opaque acetowhite lesions close to the squamocolumnar junction; well-defined, circumorificial acetowhite lesions;
                        or dense acetowhitening of ulceroproliferative growth on the cervix constituted a positive VIA or VIAM. Cytology was
                        considered positive if reported as mild dysplasia or worse lesions. All screened women (N = 6452) were evaluated –
                        colposcopy, and biopsies done in VIA positive cases. VIA positive were-155, colposcopic abnormalities (N = 166/344). The
                        final diagnosis was based on histology-punch biopsy, loop electrical excisional procedure (LEEP) on colposcopic findings.
                        Among them CIN-I(19),CIN-II(32),CIN-III(13), none(54), cervicitis(34), carcinoma(09).

Conclusion: Screening for cervical precancerous and cancerous lesions using visual inspection aided by acetic acid may
be a suitable low-cost and a feasible alternative modality for control of cervical cancer in a resource poor setting.

Abstract: 37
Effect of Isoflavone Genistein Daidzeing (IGD) to the Expression of Estrogen Receptor α, Estrogen Receptor β ,
VEGF, eNOS and Adoptosis of Endothelial Cells
Sutrisno S, Rahmat J, Ananingati A, Ahmad S, Hermawan W, Ahmad H
Saiful Anwar General Hospital, Indonesia

Introduction: to determine the effects of doses of Isoflavone Genistein Daidzein (IGD) to the level of apoptosis and
expression estrogen receptor α (ER α ), estrogen receptor β (ER β), VEGF and eNOS of hypoestrogenic rattus novergicus
aorta‟s endothelium.

Setting: Biomedical and Pharmacology Department of Brawijaya University Faculty of Medicine

Design: Animal experimental study

Material & Methods: 30 rats (Rattus novergicus) wistar strain with criteria: female, healthy, aged 8-10 weeks, weighted
100-200 grams, were divided to 5 groups. 1 group is positive control (intact) (group I), 4 groups had been ovariectomized,
waited for 2 weeks to be hypoestrogenic status. From the latter groups, 1 group without extract of bithok (Pueraria Lobata)
diet which contains IGD (group II), the other 3 groups each had been given IGD diet 15 mg (group III), 30 mg (group IV),
and 60 mg (group V) per kg body weight/day. After 21 days, the rats were terminated and their aorta were taken out to
determine the quantity of apoptotic endothelial cells and estrogen receptor α, estrogen receptor β, VEGF and eNOS
expression per 100 endothelial cells using immunohistochemistry technique.

Results: the means of endothelial cells which expressed ER α are group I: 100,89, group II: 42,12, group III: 6,832,99,
group IV: 11,501,64 group V: 13,674,14 with p<0,05, means of endothelial which expressed ER β are group I: 6,0 
1,673, group II : 2,4  0,548, group III : 2,67  1,211, group IV : 5,17  1,835, and group V : 9,17  1,602 with p< 0,005,
the mean of eNOS expression are group I: 9,332,055, group II: 3,62,074, group III: 3,831,472, group IV: 9,03,286 and
group V: 9,671,751 with p<0,05, the expression of VEGF are group I: 3,671,506, group II: 1,801,643, group III:
6,672,944, group IV: 9,832,714 and group V: 12,04,296 with p<0,05, means of apoptotic cells from 100 aorta‟s
endothelial are group I: 1,33  1,2, group II: 10,20  1,9, group III : 9  2,4, group IV : 6,33  1,7 and group V: 2,33  1,5
with p<0,05,

Conclusion: The dose of IGD had significantly correlate with expression of ER α, ER β, eNOS, VEGF and number of
apoptotic endothelial cells.

Abstract: 38
Systemic Ovarian Cancer Biomarkers in Indonesian Women with Ovarian Tumours
1Koh CLS, 2Sahil F, 2Lutan D, 2Siddik D, 3Suwiyoga K, 3Budiana G, 4Pradjatmo H, 5Saleh AZ, 6Aziz MF, 6Winarto H,
                                                                                                                                 Abstracts : Delegates
7Narasimhan K, 7Ilancheran A, 8Razvi K, 7Choolani M
1National University of Singapore, 2Adam Malik Hospital, Medan, 3Sanglah Denpasar Hospital, Denpasar, 4Sardjito

Hospital, Yogyakarta, 5Dr Mohammad Hoesin General Hospital, Palembang, 6Dr Cipto Manguksumo Hospital, Jakarta, 7
Yong Loo Lin School of Medicine, NUS, 8 Southend University Hospital, NHS Foundation Trust, UK, Ovarian Cancer
Research Consortium (Indonesia, Malaysia, Vietnam)

Introduction: Ovarian cancer is one of the most lethal gynaecologic malignancies known with 5-year overall survival rate
of less than 30% in advanced stage and about 80% to 90% in early stage disease. Early detection remains the most
important approach to improve long-term survival but until reliable screening or diagnosis strategies become available,
identification of markers for prognostication of disease may contribute to the optimal management of ovarian cancer
patients. Recently microarray and proteomic-based expression profiling on tumour-associated prognostic markers with
biological relevance to tumour progression have been discovered and proteolytic enzyme have emerged as important
prognosticators in ovarian cancer. Human tissue kallikreins (KLK) have been included. Emerging diagnostic biomarkers
notably KLK6, KLK10 and KLK11 are highly expressed in the majority of ovarian cancer and cancer progression.

No single biomarker can provide the necessary information for cancer diagnosis and treatment. We determined the known

                        cancer biomarkers, CA-125, KLK6, KLK10 together with selected haemostatic markers of fibrinolysis/inhibitors, D-dimer
                        and von Willebrand Factor (vWF) in Indonesian cohorts diagnosed with benign cysts and epithelial ovarian cancer.

                        Material & Methods: The participating centres for this study were from the Ovarian Cancer Research Collaboration
                        Consortium university departments of Obstetrics and Gynaecology (Indonesia); University of Sumatera Utara, Medan;
                        Universities Udayana, Denpasar; University Gadjah Mada, Yogyakarta; University of Sriwijaya, Palembang and University
                        of Indonesia, Jakarta. Data from 74 women benign 41, epithelial ovarian cancer 33 (Stage I/II n= 13, Stage III/IV n=20) were
                        analysed. The following assays were determined at pre-operative state: serum CA-125, KLK6 and KLK10 (Ibex, Canada),
                        citrated-plasma D-dimer (Stago, France), tissue plasminogen activator (tPA), urokinase PA (uPA), plasminogen activator
                        inhibitor-1 (PAI-1) (Zymutest, France), antithrombin (AT) activity (chromogenic substrate assay), von Willebrand Factor
                        (vWF) antigen (Elisa). The study was made possible through the support from Lee Foundation.

                        Results: No significant differences in age between benign cyst and ovarian cancer cohorts were seen (median 43.0 years
                        and 45.5 years) respectively. Ovarian cancers had significantly elevated levels of CA-125, KLK6, KLK10 together with D-
                        dimer, vWF, uPA and uPAR levels. No significant differences were seen for tPA, PAI-1 and AT levels between benign cysts
                        and ovarian cancer. Advanced stage cancer showed significant elevated CA-125, KLK6, KLK10 D-dimer, vWF, uPA and
                        uPAR levels whilst early stage cancer showed significant KLK6, KLK10, D-dimer and uPAR levels. No significant
                        differences in the parameters studied including age between early and advanced cancer.

                        The study suggested that ovarian cancer at diagnosis were from younger age group as opposed to those reported for
                        Scandinavia (median 61 years) and the United States (median 62 years). KLK6, KLK10 appears to be promising markers
                        for ovarian cancer together with uPA antigen levels which have been associated with malignancy and D-dimer an indicator
                        of indirect enhanced fibrinolysis in this study. Elevated CA-125 levels are associated with advanced stage disease.

                        Conclusion: Human tissue kallikreins KLK6 and KLK10 showed promising markers for ovarian cancer. Cancer patients
                        have associated subclinical abnormalities of haemostasis and that D-dimer upregulation suggested an indirect enhanced
                        state of fibrinolysis. Prognostication with these markers may contribute to the optimal management of ovarian cancer

                        Abstract: 39
                        Haemostatic Markers, Human Tissue Kallikreins KLK6, KLK10 and the Association With Age for Five-Year Survival
                        and Adverse Outcome From Advanced Epithelial Ovarian Cancer
                        1Koh CLS, 2Razvi K, 3Narasimhan K, 3Low JJ, 3Ilancheran A, 3Chan YH, 3Choolani M
                        1National University of Singapore, 2 Southend University Hospital, NHS Foundation Trust, UK, 3Yong Loo Lin School of

                        Medicine, NUS, Ovarian Cancer Research Consortium (Indonesia, Malaysia, Vietnam)

                        Introduction: The precise cause of epithelial ovarian cancer is still unknown. Most women present late stage disease at
                        diagnosis has contributed to the high mortality rate. Early detection remains the most important approach to improve long-
                        term survival and until reliable screening or diagnostic strategies become available, identification of markers for
                        prognostication of disease may contribute to the optimal management of ovarian cancer patients.
Abstracts : Delegates

                        Recently microarray and proteomic-based expression technologies on tumour-associated prognostics were discovered and
                        proteolytic enzymes emerged as prognosticators in ovarian cancer. Human tissue kallikreins (KLKs) are serine proteases,
                        their expression and proteolytic activity are dysregulated in tumours especially adenocarcinomas. KLK6, KLK10 and KLK11
                        emerged as diagnostic biomarkers of ovarian cancer and cancer progression. Ovarian cancer is associated with a state of
                        hypercoagulation, increased platelets, enhanced fibrinolysis and thrombin generation especially in the advanced stage.

                        The study was to assess retrospectively the value of known cancer biomarkers especially CA-125, KLK6, KLK10 and
                        haemostatic markers and age association with survival and adverse outcome from advanced stage epithelial ovarian

                        Material & Methods: Forty-one patients had benign cysts and 84 diagnosed to have ovarian cancer were analysed.
                        Follow-up visits by cancer patients were noted for more than 60 months. The following assays were performed: plasma-
                        fibrinogen, von Willebrand Factor (vWF) antigen, D-dimer, antithrombin (AT) activity, tissue plasminogen activator (tPA),
                        uPAR, PA inhibitor-1 (PAI-1), serum KLK6, KLK10 and CA-125. Associations with adverse outcome within 36 months were
                        compared to those who survived past 60 months from disease.

                        Results: Excluded from analysis were germ cell tumours (n=18), borderline cancer (n=14) lost to follow-up (n=6). Only 24

patients with epithelial cancer lived past 60 months and 31 patients with cancer died (Stage I/II n=4, Stage III/IV n=27).
Benign cyst cohorts were significantly younger (median 42.0 years) than cancer cohorts (median 52.2 years). Significantly
elevated levels in the parameters studied with reduced AT levels was seen in advanced cancer. Elevated CA-125, KLK10,
D-dimer and older age was seen in patients living past 60 months compared to benign cyst cohorts. Advanced stage cancer
mortality within 12 months (n=11) showed significantly elevated KLK6, D-dimer, fibrinogen, vWF, tPA antigen with reduced
AT levels compared to those living past 60 months. Mortality within 13 months and 24 months (n=6) showed no significant
differences but mortality within 25 months and 36 months (n=8) showed elevated CA-125, KLK6, KLK10, vWF and D-dimer
levels. The overall 5-year survival rate outcome from advanced epithelial cancer was 22.9% and early stage cancer 80%.

Conclusion: This small cohort study showed that good prognostic outcome as seen in those living past 60 months are
younger and associated with pre-operative parameters similarly seen in benign cysts cohorts despite upregulation of D-
dimer, CA-125, and KLK10. Adverse outcome in advanced stage cancer was associated with older age, upregulated KLK6,
fibrinogen vWF, D-dimer, tPA antigen and reduced AT levels. They together may be suggested to be novel biomarkers for
outcome from advanced epithelial ovarian cancer and an enlarged study need to confirm these findings.

Abstract: 40
Significance of Measuring Serum and Cervical Markers in the Diagnosis of the Perinatal Infection in Premature
Preterm Rupture of Fetal Membranes
Savic S
Obstetrics and Gynaecology Clinic, Bosnia and Herzegovina

The aim of the study is to determine significance of serum and cervical markers as possible etiological factors in perinatal
infection in PPROM. The study was conducted with 80 patients that were diagnosed with PPROM (Premature Preterm
Rupture of Membrane) and possibility of premature birth in gestation time of 24 to 37 weeks hospitalised in the
Gynaecology and Obstetrics Clinic. Women(n 80) were divided in two groups (experimental, n30) made patients with
PPROM and control (n 50) with threat of premature birth. Respondents were of similar age, parity, gestation period and
social and economic status. C-reactive protein, WBC and cervical smear culture results were analysed. CRP was
significantly higher in the group of women with PPROM (56,6%) when compared to the control group/18%/.Analysis of
leucocytosis has not shown significant difference between experimental group (36,6%) and control group (38%)as well as in
comparison of rates of positive results of cervical smear cultures (70% in experimental) and (58,8%) in control group.

Conclusion: CRP is more sensitive marker for diagnosis of infection in PPROM compared to leucocitosis and positive
culture of cervical smear. Still, CRP is not sufficiently specific as single marker in the evaluation of infection as possible
factor in PPROM. Research of new serum biomarkers in the amniotic fluid and in mother serum by serum utilization of
modern technologies like ionisation time flight mass spectrometry shall, according to the preliminary studies, in future help
in discovering whether the infection actually causes PPROM.

Abstract: 41
An Audit of Fetal and Neonatal Dysrhythmias at Singapore General Hospital
Tan WC
                                                                                                                                 Abstracts : Delegates
Department of Obstetrics and Gynaecology, Singapore

Introduction: Fetal dysrhythmias manifest as irregular, fast, or slow heart rates. About 90% are self-limiting. Sustained or
recurrent dysrhythmias are associated with morbidity and mortality from cardiac failure, hydrops fetalis and stillbirths.

Material & Methods: An audit was conducted of stillbirths and livebirths delivered at Singapore General Hospital
diagnosed with fetal or neonatal dysrhythmias.

Results: Of 18043 livebirths and 70 stillbirths over the period Feb 1999 to Jan 2009, 7 fetuses were antenatally detected
with dysrhythmia at a median gestational age of 30 (range 20 – 38) weeks. One fetus diagnosed of an irregular rhythm
underwent termination at 23 weeks when Trisomy 13 was confirmed. The remaining 6 babies were delivered at a median
gestation of 33 (range 31-39) weeks. Of these 6, 2 were antenatally diagnosed with atrial ectopics, 1 with atrial extrasystole
and the last with 2:1 A:V block but postnatal ECGs documented sinus rhythm at birth. The remaining 2 babies diagnosed
with atrial tachycardia were confirmed postnatally to have supra-ventricular tachycardia (SVT). Both fetuses did not
respond to antenatal digoxin, but cardioverted following postnatal antiarrhythmic medication.

Conclusion: Our 10-year SGH audit revealed the incidence of fetal dysrhythmias to be 1 in 2586 births which is likely to be
                        underestimated as intermittent extra-systoles go undetected. Of 7 fetuses with dysrhythmia, one (14%) was associated
                        with trisomy. The majority (4/6, 67%) of fetal dysrhythmias was self-limiting with 2 cases (33%) requiring postnatal
                        administration of anti-arrhythmic medications. Prognosis remains generally good.

                        Abstract: 42
                        The Relationship of the Level of Circulating Antiangiogenic Factors to the Clinical Manifestations of Preeclampsia
                        Kim YN
                        Inje University, Pusan Paik Hospital, South Korea

                        Introduction: This study investigated whether the antiangiogenic factors concentrations differ according to the clinical
                        manifestations of preeclampsia.

                        Material & Methods: This study included 62 preeclampsia and compared the soluble fms-like tyrosine kinase-1 (sFlt-1),
                        soluble endoglin (sEng), and placental growth factor (PlGF) concentrations among patients with different clinical
                        manifestations of preeclampsia. We also compared the patients with preeclampsia to 62 controls matched by age,
                        gestational age, and parity after 20 weeks of gestation.

                        Results: The sEng concentrations were significantly elevated in early-onset than in late-onset preeclampsia (105.4 ± 37.9
                        vs. 66.3 ± 36.0 ng/mL, p=0.0008). Moreover, the sEng levels were also higher in severe preeclampsia compared to mild
                        (42.5 ± 31.0 vs. 79.2 ± 38.6 ng/mL, p=0.0013) and in the small for gestational age (SGA) group compared to the group
                        without SGA (68.3 ± 39.3 vs. 85.7 ± 38.2 ng/mL, p=0.0273). The sFlt-1 levels, however, did not reveal significant difference
                        according to the onset-time, severity, and presence of SGA. The antiangiogenic factors concentrations were not related
                        with the degree of hypertension or proteinuria.

                        Conclusion: Altered antiangiogenic factors might be involved in the pathogenesis of preeclampsia with synergistic, but
                        different roles. Especially, sEng may be more related with early and severe preeclampsia.

                        Abstract: 43
                        Lyssencephaly Caused by Cytomegalo Virus Infection
                        1Mufida L, 2Irianti S
                        1Obstetric and Gynaecology, 2Maternal Fetal Medicine, Indonesia


                        Introduction: Lyssencephaly is a rare congenital brain malformation manifested by a smooth cerebral surface due to
                        incomplete neuronal migration. Incidence of classical lyssencephaly has been estimated to 1.2 in 100.000 births. There are
                        several types of Lyssencephaly, based on associated malformation and etiologic. This case is a classic lyssencephaly x
                        linked with agenesis of corpus callosum and caused by cytomegaloviral infection. Etiology of lyssencephaly are intrauterine
                        viral infection, insufficient blood supply to the baby‟s brain and genetic disorder. Diagnosis with CT or MRI scans of the
                        brain, and ultrasound can be suspected. Prognosis depends on the degree of brain malformation. Many children will die
                        before age 2, some may survive, but will not develop beyond a 3-5 month old level and very few will have normal
Abstracts : Delegates

                        development and intelligence, and many die from aspiration of food or fluids and also from respiratory disease. Treatment
                        is limited, because many children have severe mental retardation.

                        Case: Woman 29 years old who is married 1 year ago. She came to obstetric policlinic Hasan Sadikin Hospital to check her
                        pregnancy. We diagnosed with 32-33 of pregnancy with agenesis of corpus callosum, absent of nasal bone, agenesis of
                        cerebellum, hypertelorism, hydramnion and absent of end diastolic flow. Before this, she always checks her pregnancy to
                        midwife 5 times and Ob/Gyn doctor 3 times. In blood count we found; Hemoglobin count is: 11,9 g/dl, hematocrit 34%,
                        lekocyt: 8800mm3, trombocyt: 279000 mm3. And serologic count are: toxoplasma IgG: 601,7 IU/ml, anti toxoplasma IgM:
                        1,46, anti CMV IgG: >250, anti CMV IGM: negatif. We terminated this patient with misoprostol induction and the baby was
                        born: female baby, body weight body: 1600 gram and body length: 39 cm with absent of nasal bone, hipertelorism> we did
                        cordosintesis to check caryotyping in Eijkman clinic of genetica Jakarta. And the result was trisomi 21 and appropriate with
                        Down syndrome. We check the chromosomal of the mother, and the result was 46,xx.

Abstract: 44
Single-Port Laparoscopic Salpingectomy in Ectopic Pregnancy
Seong SJ, Park H, Bo SY, Park CT
College of Medicine CHA University, South Korea

Introduction: A new and still evolving method for extremely minimally invasive surgery has been introduced to reduce
incisional morbidity and improve cosmesis. Single-port laparoscopic surgery is carried out through the umbilicus, the body‟s
natural embryonic orifice, allowing virtually scarless surgery. We evaluated the feasibility of a single-port laparoscopic
salpingectomy in the surgical treatment of tubal pregnancy.

Material & Methods: A total of 20 patients with tubal pregnancy have undergone single-port laparoscopic salpingectomy
from November 2008. Entry through a single port was established using a wound retractor, as fascial retractor, and a
surgical glove, which served as the working channels for the laparoscopic equipment. A 30° laparoscope and a rigid or
flexible grasper were used during the procedure.

Results: Single-port laparoscopic salpingectomy was successfully performed in all 20 patients with ectopic pregnancy. The
median operative time was 55 min (range, 25-85 min) and blood loss in all patients was minimal. The median difference in
pre- and postoperative hemoglobin was 1.8 g/dL (range, 0–3.2 g/dL). The median postoperative hospital stay was 2 days
(range, 2–4 days). No complication was encountered, nor was there any need for conversion to conventional laparoscopy.

Conclusion: Single-port laparoscopic salpingectomy is feasible. Additional investigations are needed to compare this
approach with conventional laparoscopy.

Abstract: 46
Physiological Skin Changes in Pregnancy
Rajasekaran T
KK Women’s & Children’s Hospital, Singapore

Introduction: The aim of this study was to evaluate the type, frequency and pattern of physiologic skin changes in
Singapore women during pregnancy.

Material and Methods: This study was conducted on 102 randomly selected postpartum women seen between September
2008 to January 2009 in the obstetrics and gynecological unit of a women‟s hospital in Singapore. A complete cutaneous
examination was done in all cases to document the presence of physiologic skin changes. Descriptive and chi-square
statistics were used to analyse the data.

Results: Of the sample, 30 (29.4%) pregnant women were primigravida. Their age ranged from 17 to 45 years (mean=29
years). Striae were seen in 71 (69.6%) cases, of which the abdomen (n=64, 62.7%) was the most common site involved.
The other common physiological change was linea nigra (n=91, 89.2%). Pigmentary demarcation lines on the thigh were
only seen in 3 cases (2.9%). Despite the high percentage of women with physiological changes, less than half of them were
                                                                                                                               Abstracts : Delegates

concerned about it (n=48, 47.1%), while a third self-intervened (n=39, 38.2%). Gravida and race were not found to be
associated with the presence of skin changes.

Conclusion: This study brings into focus various skin changes during pregnancy in Singapore. The findings also highlight
the perception of women to their skin changes and the lack of interventional options available for women who are
concerned about these skin changes. A follow up study on available interventions and their effect on skin changes is

Abstract: 47
Treatment of Idiopathic Menorrhagia with Mirena Intra-uterine System
Kang W
KK Women's & Children's Hospital, Singapore

Introduction: This study evaluates the effectiveness and acceptability of Mirena IUS in treatment of women with Idiopathic
menorrhagia. Mirena is a long acting levonorgestrel releasing intra-uterine system that can last up to of 5 years.

                        Material & Methods: A retrospective study was carried out on 66 patients who had Mirena insertion for Idiopathic
                        menorrhagia in KK Women‟s & Children‟s Hospital from 1 January 2000 to 31 December 2005. They were followed up till
                        30 June 2006. The information was obtained from the medical records and through telephone interview with the patients.

                        Results: The mean age of the patients was 41.5 ± 5.7 years. The median parity was 2.2. Sixty-three (95.5%) of them were
                        multiparous. The commonest age group was between 40 to 44 years old. After Mirena insertion, 92.2% of them
                        experienced significant reduction in menstrual blood loss. It took an average of 2.4 months to achieve this successful
                        outcome. A total of 87.0% of the patients were very satisfied with Mirena treatment, and 88.7% reported improvement in
                        quality of life. Irregular menstrual pattern was common. It occurred in 55.7% of the patients during the first 3 months of
                        usage, and 40.5% of the subjects after one year of usage. Other common problems were Mirena expulsion (9%) and
                        menstrual cramp (6.1%). The cumulative continuation rate was 84.8% after one year, 81.8% after two years, 74.9% after
                        three years, 70.2 % after four and five years of usage. The reasons for early termination of Mirena usage include side
                        effects (15.2%), completed usage (3.0%) and desire for future pregnancy (1.5%).

                        Conclusion: In conclusion, Mirena is very effective in treating patients with idiopathic menorrhagia with a success rate of
                        92.2%. It significantly improved their quality of life.

                        Abstract: 48
                        Acceptability of Mirena Intrauterine System as a Form of Contraception in Singaporean Women
                        1Kang W, 2Hong SC, 1Kew CYC
                        1KK Women's & Children's Hospital, Singapore, 2Department of General Obstetrics and Gynaecology, Singapore


                        Introduction: This study evaluates the long-term acceptability and effectiveness of Mirena IUS as a form of contraception
                        in Singapore women. It is a long acting levonorgestrel-releasing intra-uterine contraceptive device that can use for 5 years.

                        Material & Methods: A retrospective study was carried out on 240 women who had Mirena insertion for contraception in
                        KK Women‟s & Children‟s Hospital from 1 January 2000 to 31 December 2005. They were followed up till 30 June 2006.
                        The information was obtained from medical records and through telephone interview with the patients.

                        Results: The mean age of the subjects was 35 ± 5.8 years. The median parity was 2.0. Mirena IUS was the first
                        contraception in 86.3 % of the subjects. Irregular menstrual pattern was common. It was present in 62.0 % of the subjects
                        during the first 3 months of usage, and 48.5 % of the subjects after 1 year of usage. The other common side effects were
                        menstrual cramp (5.4%), vaginal discharge (4.8%) and weight gain ≥ 5 kg (3.75 %). There was no contraceptive failure in
                        this study (Pearl index = 0). A total of 86.6% of them expressed satisfaction with Mirena contraception and 59.6% of them
                        found that it improved their quality of life. The cumulative continuation rate was 89.2% after one year, 83.2% after two
                        years, 77.0% after three and four years, and 69.5% after five years of usage. The reasons for early removal of Mirena IUS
                        include side effects (14.6%), completed usage (3.3%) and desire for future pregnancy (1.3%).

                        Conclusion: Mirena is a well-accepted long-acting intrauterine contraceptive device. It has a very high degree of
                        effectiveness (Pearl index = 0) and relatively high user satisfaction and continuation rate.
Abstracts : Delegates

                        Abstract: 49
                        Treatment of Adenomyosis With Mirena Intra-Uterine System
                        Kang W, Agarwal IM
                        KK Women's & Children's Hospital, Singapore

                        Introduction: The objective of this study is to evaluate the effectiveness and acceptability of Mirena IUS in treating women
                        with adenomyosis problem. Mirena is a long acting levonorgestrel-releasing intrauterine system that can last up to 5 years.

                        Material & Methods: A retrospective study was carried out on twenty one patients who were diagnosed to have
                        adenomyosis on pelvic ultrasound scan and had Mirena insertion during the period from 1st January 2000 to 31st
                        December 2005. They were followed up till 30 June 2006. The information was obtained from the medical records and
                        through telephone interview with the patients.

                        Results: The age of the patients ranged from 33 to 51 years old. The mean age was 42.3 ± 5.2 years. The median parity
                        was 2.3. Twenty (95.3%) of them were multi-parous. Seventeen patients were Chinese and four were Malay. More than half

of them (85.7%) had tried other medical treatments but these were not effective. After Mirena insertion, sixteen (76.2%)
patients experienced significant relief in symptoms. The mean period taken to achieve this successful outcome was 3.1
months. More than half (68.4%) of them were very satisfied with Mirena treatment and 52.6% reported improvement in their
quality of life.

Irregular menstrual pattern was common. It occurred in 55.0% of the patients during the first 3 months of usage, and 54.5%
of the patients after one year of usage. The other common side effects were vaginal discharge (19.0%) and menstrual
cramp (9.5%).

Conclusion: Mirena IUS is an effective alternative for medical treatment of adenomyosis with a success rate of 76.2%.
There was good patient satisfaction and it improved their quality of life.

Abstract: 50
How Effective is the Use of More Than 6mgs of PGE2 in Achieving Spontaneous Vaginal Delivery in Term Labour
Rasool F, Wijeshriwardhana A, Matar M
North Cumberland NHS Trust, United Kingdom

Introduction: To analyse the efficacy of use of more than 6 mg of PGE2 vaginal tablets in term labour induction.

Design: A non-blinded, controlled trial.

Setting: A district general Hospital in United Kingdom.

Population: One thousand and thirty nine women at term with indications for labour induction and modified Bishop's
cervical score of less than 6.

Material & Methods: Retrospective case notes analysis of 90 women out of 1039, who underwent induction of labour with
vaginal prostaglandin E2 (PGE2) in the form of tablets of 3mgms each from July 2005-Dec 2008 at Cumberland Infirmary
Carlisle. The study population had dose of PGE2 more than 2 vaginal pessaries (repeated in 6 hours, according to routine
departmental protocol), that is, more than 6 milligrams.

Results: Among 1039 women induced with prostin, 90 women had 3 prostins (>6 mgms). The spontaneous vaginal
deliveries were achieved in 32 women (36%) who followed the protocol. The assisted vaginal deliveries were seen in 11
women (12%). Of those 11 women 6 (55%) had ventouse deliveries and non-rotational low cavity forceps were used in 5
(45%) women. Out of total 90 women, 47 (52%) women had caesarean section for safe delivery of the baby. Of those 47
women, failed induction of labour was noted in 27 women (58%) in which no change was seen in cervical bishop scoring
after using 3 prostins (>6mgms) as according to hospital guideline. 8 women (17%) didn‟t progress in 1st stage of labour,
while 4 women (6%) failed to progress in 2nd stage of labour. Emergency caesarean section was performed in 8 women
(17%) during the course of labour because of pathological CTG (cardio-tocograph).
                                                                                                                             Abstracts : Delegates

Conclusion: More women had failed induction of labour when more than 2 prostins were used due to poor bishop score
(bishop score of <6). There was a higher caesarean section rate, which was mainly because of failed induction while the
second most common reason was failure to progress in 1st stage of labour. Large randomised controlled trials are needed
to confirm or refute these findings.

Abstract: 51
A Ray of Hope for Monitored HIV Positive Women in Preventing Cancer Cervix in Chennai, India.
1Christe DM, 2Mohanambal M, 2Sundaram A, 3Karthickeyan DSA, 4Manjula
1ICMR, RSRM Hospital, Stanley Medical College, India, 2Stanley Medical College, India, 3GHTM, Stanley Medical College,

India, 4RSRM, Stanley Medical College, India

Introduction: The causative agent for cancer cervix is Human Papilloma Virus. Commonly occurring infections of cervix
and vagina are major predisposing risk factors for development of cancer cervix Treatment of infective and, ASCUS pap
smears will reduce the incidence of cancer cervix.

To find out the incidence of abnormal Pap smears in HIV+ women with low CD4 counts as compared to pap smears of
women attending routine Gynec. Out Patient Department (OPD).
                        Material & Methods: In this comparative (Prospective) Analytical study 30 HIV positive women with CD4 counts below 350
                        admitted in Government Hospital of Thoracic Medicine for initiation of Anti Retroviral Therapy, and had received continuous
                        prophylactic Cotrimoxazole therapy of six months or more and had been treated for opportunistic infections were selected.
                        Routine cancer screening tests of down staging, visual inspection of cervix after application of acetic acid /Lugol‟s iodine
                        and pap smears were done. We compared the pap smear reports of the HIV positive women with the Pap smears reports of
                        30 women in the same age group (general group G) attending general Gynec. OPD, on the same days.

                        Results: The women in both groups were aged between 24 and 53 years. The Mean age of women was 35.5 years.
                        Normal smears were found in 46.7% of HIV positive women as compared to 26.7 % in general group G. In the age group of
                        < 35 years HIV+ women (27.3%) had significant [p=0.038] lower levels of infective Pap smears than G group (66.7 %).
                        ASCUS smears were found in 6.7% of HIV positive group and in 10 % of G group. The incidence of LSIL smears was 3.3%
                        l in both groups. High-grade squamous intraepithelial lesion (HSIL) was seen in 3.3 % of HIV+ women only.

                        Conclusion: HIV+ women had higher rates of Normal Pap smears and lower rates of infective and ASCUS smears,
                        probably because of antibiotic prophylaxis and effective control of opportunistic infections. This therapy appears to be a ray
                        of hope in life of HIV+ woman, crossing the hurdle of cervical and vaginal infections which is a major predisposing risk
                        factor in development of Cancer Cervix.

                        Abstract: 52
                        Quality of Life and Related Factors in Menopausal Women in Kashan City
                        1Abedzadeh M, 2Taebi M, 1Saberi F, 1Sadat Z
                        1Kashan University of Medical Sciences, Iran, 2Azad University of Iran, Iran


                        Introduction: Menopause is a physiological event that occurs in women's life and result in physical, emotional and social
                        changes which affects their quality of life. Considering to controversial finding in previous researches and lack of such study
                        in Kashan City, this study investigated the quality of life in menopausal women and its related factors.

                        Material and Methods: A cross - sectional study was performed on 700 menopausal women aged 40-60 in Kashan city
                        with cluster sampling. Menopausal Specific Quality of life questionnaire (MENQOL) was used for estimation of QOL and
                        related factor such as age, job, educational level, marriage age, menopause age, menarche age, duration of menopause,
                        child, child at home, dysmenorrhea, income satisfaction, marital satisfaction, exercise, smoking and family smoking were
                        examined with statistical tests.

                        Results: The quality of life was high in 17.9%, medium in 68.9% and low in 13.3% of women. Most of women had medium
                        quality of life at vasomotor domain (67.3 %), psychosomatic domain (67.4%), physical domain(46.3%) and sexual domain
                        (51.6%).Also there was a significant difference between quality of life and educational level (P=0.004), income satisfaction
                        (P=0.01) and exercise (P=0.0001). There was a significant difference between duration of menopause and quality of life in
                        vasomotor domain (P=0.004) and psychosomatic domain (P=0.04).

                        Conclusion: Considering our findings, we emphasis on teaching about menopause, its symptom and adverse effects. Also
                        emphasizes the necessity use of non pharmacological methods such as exercise and change in life style and diet to
Abstracts : Delegates

                        improve quality of life in menopausal women.

                        Abstract: 53
                        Comparison of In-Vitro Maturation Medium of Mouse Immature Oocytes
                        Kim M, Hong SJ, Lee JH, Park SH, Hwang KJ
                        Ajou University Hospital, South Korea

                        Introduction: In vitro maturation (ivm) of immature oocytes obtained from small antral follicles is a promising technique for
                        infertility treatment or fertility preservation. The crucial part of this technique is the maturation process itself, and the choice
                        of the base medium for ivm considered particularly difficult. Considering that the most commonly used culture medium for
                        ivm is conventional ivm medium and that tissue culture medium-199 (tcm-199). This study was performed to compare
                        developmental competency of immature oocytes after in vitro culture in blastocyst culture medium, conventional ivm
                        medium, or tcm-199 medium.

                        Material and Methods: The AJOU institutional review board approved the research protocol. Cumulus-enclosed germinal

vesicle stage oocytes retrieved and matured according to the protocol (group A; conventional ivm medium, group B;
blastocyst culture medium, and group C; tcm-199 medium). We analysed oocyte maturation rate, fertilization rate, and
developmental rate to the blastocyst stage.

Results: A total 163 immature oocytes were cultured in vitro and then analysed. The ivm rate (31/59; 52.5%, 31/56; 55.4%,
17/48; 35.4%), fertilization rate (12/31; 38.7%, 15/31; 48.4%, 6/17; 35.3%), and developmental rate to the blastocyst stage
(1/12; 8.3%, 2/15; 13.3%, 0/6; 0%) were significantly high in groups A and B than in group C. There is no difference
between group A and B.

Conclusion: Developmental competency of immature oocytes did not differ between convetional ivm medium and
blastocyst culture medium. However, tcm-199 medium did not appropriate. Our results suggest that blastocyst culture
medium can replace conventional ivm medium for in vitro maturation of immature oocytes.

Support: This work was supported by the Korea Research Foundation Grant funded by the Korean Government
(MOEHRD) (KRF-2007-611-E00011).

Abstract: 54 – Free Paper S11.8
TP53 Gene Expression in Premature Rupture of the Membranes
Suhaimi D
Arifin Achmad Hospital Pekanba, Indonesia

Introduction: Premature rupture of membranes (PROM) is defined as spontaneous rupture of the chorioamniotic
membranes prior to the onset of labor. PROM occurs in about 10-15% of all pregnancies and is usually followed by the
onset of labor. The cause of PROM is usually multifactorial and often unknown. The factors that assumed as the cause are
infection, apoptosis, hormonal, stress, over distension of uterus like in multiple pregnancy and polyhidroamnion. TP53 play
role in apoptosis that described as the guardian of the genome. We hypothesized that apoptosis-related genes, both the
extrinsic and intrinsic pathways, would be expressed differentially between normal labor and PROM. Apoptosis membrane
would provide a mechanism for the reduced membranes strength that presumably precedes spontaneous rupture of the

Material & Methods: This study was an observational analytical study using cross sectional design on 43 patients
consisting of 22 normal labors and 21 labors with PROM. After delivery, samples of fetal membranes were obtained from
placenta approximately 5x5cm in diameter. Samples were stored in -80°C for mRNA isolation. This study was performed at
the maternity ward, Dr. Hasan Sadikin Hospital-Bandung, Indonesia and Gunma University, Japan. cDNA synthesis and
PCR amplification for TP53 gene expression was examined using TaKaRa kit. All samples were normalized against β-actin.
Bands scanning densitometry was performed using Photoshop software and analysed by the Quantity One (Bio-Rad).

Results: In normal labour and PROM, TP53 gene expression ranged from 2.7-46.8 and 33.8-81.9 % with a mean of 18.28
and 56.6%, respectively. Patients with PROM showed a significantly higher TP53 expression than those with normal labour
                                                                                                                              Abstracts : Delegates

Conclusion: There is a significantly higher TP53 gene expression in placenta of patients with PROM compared to normal
pregnancy. Our results provide evidence for possible role of TP53-induced apoptosis membrane in the pathogenesis of
premature rupture of the membranes.

Abstract: 55
Effect of Equol on Differentiation of Human Mesenchymal Stem Cells into Osteoblasts In-Vitro
Kim T
Korea University Anam Hospital, South Korea

Soy isoflavones inhibit bone loss in animal studies. Positive association between dietary soy isoflavones and BMD in
epidemiologic studies of Asian women. However, contradictory findings on bone metabolism have been reported among
clinical studies of postmenopausal women. Inter-individual differences in the metabolism of isoflavones to produce “equol”,
the most effective metabolite of isoflavone, might be the cause of these inconsistent findings. The exact mechanism of
isoflavone on bone metabolism is still unclear.

                        Objectives : To investigate the effect of equol on gene expression in differentiation of human mesenchymal-stem-cells into
                        osteoblasts in vitro.

                        Material and Methods: Human mesenchymal stem cells (h-MSC) were cultured for 0~7 days in DMEM (Gibco, UK)
                        supplemented with osteogenic assays. Add equol, genistein, and equol+genistein to the wells at final concentration of 10-5
                        M. Total RNA was isolated. Total RNA was reverse transcribed using reverse transcriptase and oligo-dT primers in a
                        standard reaction. The resultant cDNA was then used as template for PCR amplification of BMP-2, and ALPL mRNA-
                        derived cDNA. Real-time PCR was carried out using the LightCycler System and the LightCycler Instrument using high-
                        hydrolyses Taq Man probes. The initial normalized value in each sample was represented by the ΔCT (target CT _ GAPDH
                        CT). They were expressed as the fold increase, at each time point, over the respective GAPDH controls.

                        Results: BMP-2 expression and ALPL expression are Over-expressed in equol+genistein group compared with control

                        Conclusion: Equol may act as an strong agonist on genistein to induce early osteoblast differentiation. We suggest that
                        equol is a important co-factor of genistein for inducing h-MSC into osteoblast with further enhancement on bone formation.

                        Abstract: 56
                        Retinopathy of Prematurity Screening Among Patients at Neonatal Intensive Care Unit Delivered in a Tertiary
                        Government Hospital
                        Sabtula C
                        Philippine Pediatric Society, Philippines

                        Introduction: Retinopathy of Prematurity (ROP) is a blinding eye disease affecting premature infants weighing less than
                        equal to 1,500- 2,000grams with gestational age of less than equal 32 weeks. Premature infants beyond 32 weeks are
                        included attributed to their critical course requiring oxygen supplementation. The aim of this study is to determine
                        prevalence and stages of retinopathy of prematurity among patients delivered at Neonatal Intensive Care Unit in a tertiary
                        government hospital and the risks factors associated with its occurrence. Prospective cross sectional study, East Avenue
                        Medical Center Neonatal Intensive Care Unit.

                        Material & Methods: This is a 13½ month study period from July 2005 to September 2006 of premature patients for
                        possible discharge delivered in our institution that required oxygen supplementation, intensive management and stable.
                        They are referred to Retina Service for Retinopathy of Prematurity Screening conducted by Retina Specialist.

                        Results: In the study period a total 139 subjects were identified, 93 premature infants are included in this analysis
                        while 46 premature infants are drop-outs. The total number of documented retinopathy of prematurity cases was 22
                        (23.65%). The mean birth weight was 1,395.00 ± 337.23 grams; the mean gestational age was 31.55 ± 2.26 weeks;
                        11(50%) male gender. The disease occurred in twins was 6 (27.3%). There are three probable risk factors identified the
                        oxygen saturation, APGAR score and Ballard score. Only the oxygen saturation (0R=1.3; CI: 0.48, 3.69; p=0.579) is the
                        main variable independently associated affecting the development of retinopathy of prematurity at a lower APGAR score
                        and lower Ballard Score. Pre-theshold ROP Stage 3 ROP with plus disease is seen in majority of our cases and threshold
Abstracts : Delegates

                        cases ROP Zone I and II. Thirteen (59.1%) subjects with retinopathy of prematurity out of 22 cases underwent endolaser

                        Conclusion: There is high incidence of retinopathy of prematurity given the duration of our study period. Prematurity with
                        the associated factors only the oxygen saturation is the documented risk factor for the development of retinopathy of
                        prematurity followed by Appearance Pulse Grimace Activity Respiration score (APGAR) less than 5 in 1 minute and Ballard
                        Score of less than 32 weeks. Through the retinopathy of prematurity screening stages were seen among the study groups
                        and early management and advised for follow up.

Abstract: 57 – Free Paper S11.4
Comparison of Active Versus Active Management Modified of the Third Stage of Labor: a Randomized Controlled
1Tran Thi L, 2Pham Ha TN
1University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam, 2Tu Du Hospital, Ho Chi Minh City, Vietnam

Introduction: Postpartum hemorrhage (PPH) is a major cause of maternal mortality in developing countries. Tu Du
Hospital is a largest maternity hospital in Vietnam with about 40.000 deliveries per year, and the incidence of PPH is 0.6%.
Since 2006 we have employed active management (AM) of the third stage of labor including: (1) a prophylactic uterotonic
drug oxytocin: 10UI, IM, (2) early clamping and division of umbilical cord, and (3) controlled cord traction. Although AM
reduces the incidence of PPH, it still has complications such as disruption of umbilical cord and increased need for manual
removal of the placenta. Further, cord clamping before cord pulsation has ceased limits infant iron stores. We have thus
modified our AM protocol: (1) a prophylactic uterotonic drug oxytocin: 10UI, IM, (2) clamping and division of umbilical cord
after cord pulsation ceased, and (3) expression of placenta immediately after its separation. We aim to compare the
estimated blood loss and the incidence of complications between the more traditional method of AM and our modified
protocol. Our research hypothesis is that the estimated blood lost between the two methods is equal, but that the modified
active management (MAM) protocol will have a lower rate of complications.

Material & Methods: In a randomized controlled trial between April 2008 to November 2009, 300 healthy pregnant women
in Tu Du Hospital were randomized according to administrative number to 2 groups: AM (150) and MAM (150). One doctor
and 4 midwives were responsible for the deliveries, measuring blood lost, and managing complications. The primary
outcome was comparison of the estimated blood loss within 2 hours of delivery as well as complications such as disruption
of the umbilical cord and need for manual removal of the placenta. Analysis was by EPI DATA 3.1 and STATA 8.0

Results: The estimated blood loss within 2 hours of delivery of AM group was 174.45±106.34ml, while the MAM group had
an estimated blood loss of 208.33±192.62ml (P=0.06). The duration of the third stage for the AM group was
3,20±2.69minutes, and 4.47±2.47 minutes for the MAM group (P<0.001). Of complications, there was one umbilical cord
disruption in AM group, and none in MAM group. The AM group also had five cases of manual removal of the placenta,
compared with 3 cases in the MAM group.

Interpretation: MAM of the third stage of labor merits study with a larger sample to examine its potential benefits for infants
and women, particularly in developing countries.

Abstract: 58
Preterm Prelabour Rupture of Membrances – a Prospective Study
Anayath I, Shetty V, Thein NN
Ministry of Health, Brunei Darussalam

Introduction: Preterm prelabour rupture of membranes is associated with 30-40% of preterm deliveries and is the leading
identifiable cause of preterm delivery. PPROM complicates 3% of all pregnancies
                                                                                                                                  Abstracts : Delegates

PPROM also appears to be linked to underlying pathologic processes, most likely due to inflammation and/or infection of
the membranes. Clinical factors associated with preterm PROM include low socioeconomic status, low body mass index,
tobacco use, preterm labor history, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and

Objective: To find out the incidence of PPROM in RIPAS Hospital, a tertiary care Hospital in Brunei Darussalam, assess
the risk factors and find out the maternal and perinatal outcomes.

Design & Setting: A prospective study over a period of 6 months (September 2006 to February 2007). Conducted in the
Department of Obstetrics & Gynaecology, RIPAS Hospital, Brunei Darussalam.

Material & Methods: All pregnant patients between the gestational age group of 24 – 37 weeks who were admitted with a
definitive history of PPROM were included. Demographic characteristics were studied, risk factors assessed and obstetric
and neonatal outcomes evaluated.

Results: 73 cases of PPROM were evaluated over a time period of 6 months. Incidence was noted to be 2.8%.

                        78% of the patients were between 20-35 (mean 28.24) age group. 53.4% were Primigravidas. 15.1% had a previous history
                        of miscarriage. Mean gestational age at presentation was 237 days.64% presented between 35-36 weeks and 30% were in
                        the group of 29-34 weeks. Only 7% had a history of preterm delivery in the past. 13.6% had a previous history of either
                        Candidiasis, GBS or BV infection. 8.2%had UTI in pregnancy. Only 4 cases (5.5%) were multiple pregnancies.17 cases
                        (23%) gave a history of either DM or GDM in pregnancy. 4.1%had a history of antepartum haemorrhage in the index

                        30% received 2 doses of antenatal corticosteroids and 21% had only 1 dose. 16% mothers were diagnosed to have either
                        candidiasis or GBS at the time of admission. >50% had a raised WBC count.
                        60.3% progressed spontaneously and 72.6%% delivered normally. Admission delivery interval was less than 24 hrs for
                        43.8% cases. Only 1 case had a conservative management for more than 7 weeks which had a good outcome.

                        Most babies (61.1%) were males. 39% babies were >2.5kg. 53.4% needed SCBU admission. Of them 1/3 were discharged
                        within 1 week itself. The mean days of stay in SCBU were 13.

                        Commonest neonatal complications were Neonatal jaundice (23.3%) & Hyaline membrane disease (16.8%).

                        Conclusion: Incidence of PPROM in our hospital was 2.8%. It complicated 21% of preterm deliveries. Previous history of
                        preterm birth, genital tract infections and maternal diabetes were found to have associations with it. About 60% of them
                        delivered spontaneously and 43% within 24 hours. The commonest neonatal complications were neonatal jaundice and
                        hyaline membrane disease.

                        Abstract: 59
                        A 10 Year Review of Ureteric Injuries from Hysterectomies
                        Ye D, Wong L
                        Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore

                        Introduction: To evaluate the incidence and clinical presentation of ureteric injuries from abdominal and vaginal
                        hysterectomies and to determine the risk factors, management and outcome from our institution.

                        Material and Methods: Clinical records of all ureteric injuries from July 1998 to June 2008 were retrospectively reviewed.
                        Patient demographics, previous pelvic surgery or irradiation, clinical presentation, subsequent management and outcomes
                        were studied.

                        Results: A total of 18 ureteric injuries were identified in 3960 hysterectomies, of which majority were simple abdominal
                        hysterectomy (TAH), others include subtotal hysterectomy (SH), pelvic extenteration, Werthiem‟s hysterectomy, extended
                        hysterectomy and vaginal hysterectomy (VH) .The incidence of ureteric injury for TAH is 0.27% (7/2638), Wertheim‟s
                        hysterectomy is 3.73% (5/134), extended hysterectomy is 0.69%( 2/289) and VH is 0.24% (2/822). Only 33 %( 6/18) of the
                        injuries were identified intraoperatively. All injuries that were discovered intraoperatively underwent primary repair with DJ
                        stenting and did not have adverse urological outcome. Injuries diagnosed postoperatively presented most commonly with
                        leaking PV discharge (7/18) or loin pain (6/18). 1 had coexisting PV leakage with anuria, while the other had anuria with loin
Abstracts : Delegates

                        pain. Time to presentation ranged from 3-5 weeks postoperatively with a median of 3 weeks. The ureteric injuries
                        diagnosed postoperatively were managed with reimplantation of ureter (5), Boari Flap (6) /psoas hitch (1) with ureteric
                        reimplantation. 33 %( 4/12) of these patients had long term complications such as persistent hydronephrosis, urogenic
                        bladder or bacteraemia secondary to UTI. 72% of ureteric injuries were related to strictures causing ureteric obstruction.
                        22% were due to lacerations, while 6 % were crush injuries. The median post operative follow up was 2 yrs. Risk factors
                        identified were adhesions from previous pelvic surgery or pelvic irradiation, endometriosis, large uterine volume and pelvic
                        inflammatory disease.

                        Conclusion: Early intraoperative recognition of ureteric injury is vital to minimising adverse urological outcomes.
                        Meticulous surgical techniques are important particularly in patients with pelvic adhesions.

Abstract: 60
Does Delaying the Insemination Time for IVF Compromise Results?
Kan A
IVF Australia, Australia

Introduction: We noticed that especially on busy days, the time between the hCG trigger injection and the insemination of
the oocyte can be delayed beyond 43 hours. Ideally in our laboratory, we try to inseminate the oocytes 39-41 hours after the
hCG trigger injection. However, as we get busier, we are increasingly seeing that this interval is extended.

It is thus our intention to see if the extending the timing interval between hCG trigger injection and the insemination of the
oocyte affects our fertilization and pregnancy rates.

Material and Methods: Between 1 January 2004 and 31 December 2007, all autologous, fresh, non ICSI, IVF cycles of
woman less than 38 years old were included in the studies. Only a patient‟s first cycle was included during that time so as
not to include multiple cycles of the same patient.

For each patient, we collected data about her age, the interval between hCG trigger and insemination of oocytes, the
number of oocytes collected, number of embryos created, number of embryos transferred and the pregnancy outcome.

We then created 4 groups based on the trigger intervals: Group A (trigger interval less than 40h); Group B (trigger interval
between 40h and less than 41h); Group C (trigger interval between 41h and 43h); and Group D (trigger interval >43h).

To compare the 4 groups for homogeneity, we used Chi square and student t tests as appropriate.

We then looked to see if there was a difference in the primary outcome i.e. fertilization rates between Group A and Group
D. We also looked at; as a secondary outcome, the pregnancy rate between Group A and Group D.

Results: As shown in Table 1, there is no difference in the 4 groups with regards to the age of the patient, the average
number of eggs collected and the average number of embryos transferred.

The fertilisation rate dropped from 62.7% when the trigger interval was less than 40h to 59.4% when it was more than 43h.
This was statistically significant at the 0.05 level and there was a trend in this drop as shown in Graph 1.

The pregnancy rate also decreased from 47.4%in Group A to 37.2% in Group D although this was just above the statistical
significance level. The trend of this decrease is clearly shown in Graph 1.

Discussion: As shown in Table 1, insemination of oocytes in an IVF cycle is best done between 38 and 40 hours. If left
beyond this time, the oocyte matures and there is disaggregation of the meiotic spindle leading to the compromise of both
fertilisation and implantation capacity. This has been shown by our colleague Dr Kilani (1) using polarizing light microscopy

Conclusion: Insemination of oocytes up to 40 hours after hCG trigger injection gives the best fertilization and pregnancy
                                                                                                                                 Abstracts : Delegates

rate. In busy laboratories when they may be more than 20 oocytes retrievals a day, effort must be made to increase
resources to deal with the cases within the 40 hours limit.

Abstract: 61 – Free Paper S11.5
Maternal Body Mass Index and its Effect on Delivery Mode
Tan EL, Kanagalingam D
Singapore General Hospital, Singapore

Introduction: To assess the effect of increasing body mass index (BMI) on mode of obstetric delivery in the Department of
Obstetrics & Gynaecology, Singapore General Hospital (SGH).

Material & Methods: A retrospective records-review was carried out on mothers delivering in SGH between 2005-2008
with the following criteria: 1) first booking visit at less than 12 weeks gestation, and 2) singleton pregnancy. Data for the

                        mother‟s age, weight and height at booking, and mode of delivery were extracted and analysed statistically.

                        Results: Out of 6804 deliveries from 2005-2008, 3117 women were identified with the requisite criteria. 288 (9.2%) women
                        were obese (BMI ≥ 30 kg/m2) while 579 (18.6%) women were overweight (BMI ≥ 25 and < 30 kg/m2). 1886 (60.5%)
                        women were of normal BMI (≥ 18.5 and < 25 kg/m2) with the remaining 364 (11.7%) being underweight (BMI < 18.5
                        kg/m2). Obese women were more likely to require caesarean delivery (38.5% vs. 23.5%, RR 1.64, p < 0.05) compared to
                        women with normal BMI. A similar trend was observed for overweight women with 30.6% of them requiring caesarean
                        delivery (RR 1.3, p < 0.05). Obese and overweight women were less likely to undergo vacuum-assisted vaginal deliveries
                        compared to women with normal BMI (RR 0.42 and RR 0.54 respectively, p < 0.05). There were no observed differences in
                        the modes of delivery between women with normal BMI versus underweight women.

                        Conclusion: Women who are obese or overweight are at increased risk for caesarean delivery but are less likely to
                        undergo vacuum-assisted vaginal delivery. No difference in mode of delivery exists between underweight women and those
                        with normal BMI.

                        Abstract: 62
                        Biology of Human Endothelial Progenitor Cells from Mid-Gestation Fetal Blood
                        Chong M, Chan J, Choolani M
                        National University of Singapore, Singapore

                        Introduction: Endothelial progenitor cells (EPC) can be found in the peripheral circulation and suggested to contribute to
                        angiogenesis and vasculogenesis, particularly at sites of tissue injury. Similar populations of EPC are found in cord blood at
                        higher frequency with greater proliferative capacity. We hypothesise that EPC can be found and isolated from the fetal
                        circulation, and may play a crucial role in vasculogenesis during development. Here, we present data on the
                        characterisation of fetal blood-derived EPC, as compared against their umbilical cord blood (UCB) derived counterparts.

                        Material & Methods: EPC were isolated from umbilical cord blood and mid-gestation fetal blood by adhesion selection in
                        endothelial growth media. Following expansion, the cells were assessed by immunocytochemistry (ICC) for expression of
                        endothelial markers. Matrigel differentiation assay was carried out to compare the vasculogenic potential of the cell
                        sources. Colony forming capability was assessed. Finally, a genome-wide microarray analysis was carried out to compare
                        the expression profiles of both cell populations.

                        Results: Fetal EPC (fEPC) and UCB-EPC were found to be capable of generating endothelial-like progeny as assessed by
                        ICC. However, marked differences could be found in the expression patterns and fEPC is found to be morphologically
                        diverse. When plated on Matrigel, fEPC demonstrated more extensive network formation. Colony forming assays
                        demonstrate that 29.3% of fEPC was capable of generating colonies. In spite of 92.3% of these colonies being capable of
                        taking up acetylated LDL (suggesting endothelial nature) the cells appear to transdifferentiate following extended culture,
                        adopting a fibroblastic morphology. This was not observed in UCB EPC.

                        Conclusion: This study demonstrates that EPC can be isolated from the fetal circulation. fEPC is phenotypically and
                        functionally different from UCB-EPC, suggesting a unique role for circulating EPC during the fetal stage.
Abstracts : Delegates

                        Abstract: 63
                        Women's Attitudes, Knowledge and Practices with Regards to Epidural Analgesia for Pain Relief in Labour
                        Kanagalingam D, Sim XYJ, Chen J
                        Singapore General Hospital, Singapore

                        Introduction: The use of analgesia in labour is an important aspect of the management of a pregnant woman during
                        childbirth. In particular, epidural analgesia is known to be the most effective method of pain relief during childbirth and is
                        offered to all expectant mothers in this hospital.

                        Aim: To identify women‟s attitudes towards the use of epidural analgesia in labour and their knowledge regarding its
                        availability and associated complications, and comparing the differences in antenatal, postnatal, primigravid and multigravid
                        groups of patients.

                        Material & Methods: A cross sectional study carried out at the Singapore General Hospital surveying both antenatal and
                        postnatal patients.
Recruitment criteria for antenatal patients were patients who were at least 24 weeks of gestation eligible for a vaginal
delivery. They were mainly recruited from the antenatal clinics at the Obstetrics & Gynaecology Centre and wards.
Excluded from the study were patients who have had 2 lower segment caesarean sections or patients scheduled for an
elective caesarean section regardless of indication.

The survey was carried out via an interviewer-administered questionnaire, conducted in English or Chinese. All
questionnaires required women‟s epidemiological data for later analysis.

Results: A total of 129 valid completed surveys were analysed. Of these, 70 were antenatal and 59 were postnatal women.
Antenatal primigravidas consisted of 26 patients whilst there were only 44 antenatal multigravidas present.

86% of respondents were exposed to the concept of epidural. In this group, 37% learnt about the service from family or
friends. (antenatal 36% postnatal 51%) A large majority (88%) also knew that an epidural service was available at the
Singapore General Hospital. Only 46% of respondents considered epidural to be the most effective form of pain relief in
child birth. Amongst antenatal respondents, 39% did not want to have epidural analgesia for their delivery (25% of
primigravida, 48% of multigravida). These patients cited wanting a “natural” labour (31%) and the fear of complications
(36%) as the main reasons for not wanting epidural analgesia. In the primigravid group of women who would consider
epidural analgesia, 79% would prefer to have a formal introduction and explanation of the procedure, only 21% understood
the procedure well and did not require this. Amongst postnatal respondents, 41% requested epidural analgesia and 96% of
this group were at least satisfied with the pain relief provided by the procedure. When asked about their understanding of
the complications of epidural analgesia, 74% were aware of post partum back pain as a possible complication. 36% thought
that the insertion of epidural catheter could damage vital structures in the back.

Conclusion: Our women are not well educated regarding their options for analgesia during labour, most having heard of an
epidural from friends and relatives, although wishing for the issue to be formally addressed by an obstetrician or
anaesthetist. Our recommendation is for hospitals to allocate resources to address the women‟s concerns and worries and
to explain both the procedure and complications of epidural analgesia. Antenatal classes or anaesthesia clinics are one
such avenue.

Abstract: 67 – Free Paper S11.9
Fetal Gene Transfer with Self-Complimentary Recombinant Adeno-Associated Vectors Achieves Long-Term
Factor IX Expression in Non-Human Primates
1Mattar C, 1Dighe N, 2Waddington S, 2McIntosh J, 1Biswas A, 3Fisk N, 2Nathwani A, 1Choolani M, 1Chan J
1National University of Singapore, Singapore, 2University College London, United Kingdom, 3University of Queensland,


Introduction: Boys affected by haemophilia experience repeated bleeding episodes, often with minimal trauma. Recurrent
bleeds may affect physical development, complicate simple surgical procedures and can be fatal. Available treatment
focuses on post-hoc replacement of absent clotting factors and carries risks of immune toxicity and infectious sequelae, in
addition to considerable expense. Despite the rarity of the disease the socioeconomic and medical burden is great.
Intrauterine gene transfer (IUGT) offers the possibility of a permanent correction of this genetic defect while exploiting the
                                                                                                                                 Abstracts : Delegates

stoichiometric advantage and immunological naïveté of the developing fetus while exploiting its. We have previously
demonstrated long-term transgene expression in adult non-human primates (NHP) after scAAV8-FIX delivery. We now
investigate the use of this vector for IUGT in an NHP model.

Material & Methods: Cynomolgus macaques were time-mated, and at 0.9 gestation, 4x1012 vg of scAAV2/5- or scAAV
2/8-LP1-hFIXco were injected into the fetal intrahepatic vein under ultrasound guidance. Maternal blood was sampled
serially for viraemia studies. Offspring were delivered by caesarean section and maternal tissue biopsies performed for
vector biodistribution and transgene expression. Maternal and infant blood was sampled serially to quantitate transgene

Results: Eight fetuses received AAV-hFIX (1.0-1.6x1013 vg/kg). Maternal viraemia (2-32vg/��������l) was detected up to 24 hours
post-injection, with higher vector copy numbers following AAV5 delivery. Widespread maternal tissue transduction was
detected at low levels and maternal anti-AAV antibody response was transient. hFIX was not detected in maternal plasma.

Post IUGT, plasma hFIX was expressed between 10-633% of normal, with expression being ten-fold higher after AAV8
administration. Expression persisted at 5 ug/ml for at least 11 months despite progressive increase in infant weight. There
was widespread tissue transduction, with AAV8 demonstrating liver tropism. Despite this, transgene expression was

                        specific to the liver. Anti-AAV antibody production was initially robust, although this did not prevent long-term transgene

                        Conclusion: This is the first demonstration of IUGT in a macaque model using a disease-relevant transgene. Long-term
                        hFIX plasma concentrations that would be therapeutic in a disease context were achieved postnatally with liver-directed
                        IUGT. Protein production was liver-specific despite extensive tissue transduction and was not negated by the resultant
                        antibody response. Transplacental trafficking and maternal response to transient viraemia was demonstrated. The utility of
                        AAV-mediated IUGT at an earlier gestation is under investigation.

                        Abstract: 73
                        Obstetricians' Knowledge of the Management of Pregnant Women with Rhesus Negative Blood Groups – A
                        Questionnaire Survey
                        Kanagalingam D, Wee WW,
                        Singapore General Hospital, Singapore

                        Introduction: The population in Singapore is predominantly Asian with Chinese, Malay and Indians forming the main ethnic
                        groups. Rhesus (Rh) negative groups are uncommon (2%) and hence Rh disease is rare here. Knowledge of appropriate
                        management of Rh negative women may be deficient in this setting. The development of anti-D antibodies results from feto-
                        maternal sensitization occurring in Rh negative women who carry an Rh positive fetus. RhD iso-immunization is largely
                        „silent‟ with no overt sensitizing event. Inadequate Rh immunoprophylaxis is responsible for many cases.

                        Aim: To assess knowledge of Anti-D prophylaxis amongst obstetricians and obstetric trainees in Singapore. To ascertain
                        routine local practice in the care of an Rh negative mother; and hence to audit this practice against evidence-based

                        Material & Methods: Questionnaire survey (18 questions) based on recommendations from evidence-based guidelines,
                        auditing the obstetricians‟ knowledge of guidelines on Anti-D prophylaxis and their usual practice in the clinical setting. The
                        participants were each individually approached and asked to complete the short questionnaire on the spot.

                        Results: There were 55 respondents. The mean score was 75.9%. The participants were divided into 2 groups: specialist
                        (34) vs non-specialist (21). Specialists have 6 years of specialty training and MRCOG. The mean score for the specialist
                        and non-specialist groups were 75.92% and 75.89% respectively. The individual scores were divided into 3 categories
                        arbitrarily: score ≥ 80% (adequate knowledge), 60 – 79% (inadequate knowledge) and <60% (poor knowledge). Most
                        doctors knew the brand of the most commonly used anti-D Ig in Singapore (90.9%). Only 54.6% of them could identify the
                        cost of a vial of anti-D Ig. All would offer anti-D Ig prophylaxis to Rh negative women both antenatally and postnatally. Only
                        12.7% of them would routinely perform a Kleihauer test in Rh negative women postnatally.

                        Conclusion: Knowledge of anti-D prophylaxis amongst obstetricians can be improved. Rhesus negative groups are
                        uncommon; hence correct practice is not reinforced by frequent patient contact. Therefore, a continual system of education
                        to raise awareness of evidence-based practices, departmental protocols as well as clinical audit has been implemented to
                        address this.
Abstracts : Delegates

                        Abstract: 74 – Free Paper S11.6
                        Carbetocin Versus Syntometrine for the Third Stage of Labour Following Vaginal Delivery – a Double-Blind
                        Randomised Controlled Trial
                        1Su LL, 2Rauff M, 2Chan YH, 1Nurhidayati b/ MS, 1Lau TP, 2Biswas A, 2Chong YS
                        1National University Hospital, Singapore, 2Yong Loo Lin School of Medicine, National University of Singapore, Singapore


                        Introduction: Prevention of postpartum haemorrhage is essential in the pursuit of improved healthcare for women.
                        However, limited literature is available comparing the use of oxytocin agonist carbetocin with syntometrine in women
                        undergoing vaginal deliveries. We aimed to compare intramuscular carbetocin with intramuscular syntometrine for the
                        routine prevention of postpartum haemorrhage in women who deliver vaginally.

                        Material & Methods: This is a prospective double-blind randomised controlled trial conducted in a tertiary referral centre.
                        Pregnant women with no contraindication for vaginal delivery were recruited from January 2005 to April 2008. Participants
                        were randomised to receive either syntometrine or carbetocin during the third stage of labour. Primary outcome measure

was postpartum haemorrhage requiring additional uterotonics. Secondary outcome measures were the incidence of
postpartum haemorrhage (≥500ml), severe postpartum haemorrhage (≥1000ml), and adverse effects profile.

Results: 13.5% of women in the carbetocin group and 16.8% women in the syntometrine group had postpartum
haemorrhage requiring additional uterotonics (p=0.384). 1.6% of women in each group had postpartum haemorrhage
(p=1.0) and the estimated blood loss during the third stage of labour was similar between the two groups (p=0.294). Women
who had syntometrine were four times more likely to experience nausea (RR=4.2; 95%CI 2.2-7.8) and vomiting (RR=4.3;
95%CI 1.9-9.5) compared to women who had carbetocin. Tremor, sweating, retching and uterine pain were also more
likely in the syntometrine group compared to the carbetocin group (p<0.05).

Conclusion: Carbetocin has an efficacy similar to syntometrine for prevention of postpartum haemorrhage but is
associated with less adverse effects.

Abstract: 75
D&C for Abnormal Per Vaginal Bleeding: A Correlation of Ultrasound Findings with Histological Diagnosis
Tan WK, Tan WC
Singapore General Hospital, Department of Obstetrics & Gynaecology, Singapore

Introduction: Abnormal menstrual bleeding is a very common gynaecological problem and endometrial biopsy has been
the primary intervention for definite diagnosis. Ultrasound plays an important role as an initial evaluation tool for patients
with abnormal per vaginal bleeding. This retrospective survey is to audit the indications for dilatation and curettage (D & C)
and correlate ultrasound findings with histological diagnosis for cases at the Department of Obstetrics & Gynaecology at the
Singapore General Hospital.

Material & Methods: D & C was chosen as the procedure to be audited as it was the most commonly performed surgery
based on the department‟s statistics in 2008. This is a retrospective audit of patients who underwent D & C from January till
March 2008 in day surgery and the major operating theatres. Ultrasound and histology results were traced from the hospital
online database and patients‟ casenotes. Indications for D&C performed were identified and summarized based on
presentation i.e. irregular menstruation, post-menopausal bleed, and endometrial thickness from pelvic ultrasound.

Results: Of the 125 patients included in the audit, the majority were Chinese (76%) and about half (44.8%) were aged
between 45 to 55 years. Overall, 11 (8.8%) patients from the study population had non-benign histology regardless of their
presentation. Of the 42 patients who presented with an endometrial thickness (ET) of more than 10mm, 2 (4.8%) showed
non-benign histological findings. Four of the 68 (6%) patients who presented with abnormal menstruation, intermenstrual
bleed, or post-menopausal bleed are at risk of non-benign endometrial findings.

Conclusion: Women with menstrual irregularities should at least undergo endometrial biopsy, whether by outpatient
endometrial biopsy or D & C. Majority (92%) of patients with increased ET of greater than 10mm are not associated with
                                                                                                                                 Abstracts : Delegates
Abstract: 76
Isolation and Characterization of Neural Stem Cells from Various Anatomical Regions of the Second Trimester
Central Nervous System
1Chong M, 2Fan Y, 2Mattar C, 2Choolani M, 2Chan J
1National University of Singapore, Singapore, 2National University Health System, Singapore

Introduction: Most recently, neural stem cells (NSC) transplantation have been the basis for the development of
therapeutic strategies for neurological disorders, which are both common and debilitating. To date, NSC have been isolated
from only the human fetal subventricular zone and spinal cord which greatly limits the supply of cell sources for both
therapeutic purposes and scientific research, which is still lacking. We hypothesized that fetal NSC are present in the
various anatomical locations in the second-trimester CNS with potentially different neurogenic potential and roles during
development and aimed to isolate and characterize them.

Material & Methods: Fetal brain tissues were collected from medically indicated pregnancy terminations between 12-24
weeks gestation, with informed consent (n=3). The subventricular region, hippocampus, anterior and posterior cerebra,
thalamus, cerebellum and brain stem were minced and dissociated enzymatically. The cells were then cultured as clonal

                        neurospheres (NS) with their initiating frequencies enumerated. NS formed were then dissociated enzymatically for
                        passaging and differentiation to interrogate their self-renewal and multi-lineage differentiation capacities.
                        Immunocytochemistry for nestin, BIII-tubulin and glial fibrillary acidic protein (GFAP) was performed on the differentiated
                        cells to establish their identities.

                        Results: We isolated NS from cells derived from the seven different regions of the human fetal brain. Based on a plating
                        density of 3X104 cells per ml of medium, we observed a NS-initiating frequency of 0.026±0.01%, 0.062±0.01%,
                        0.098±0.08%, 0.066±0.06%, 0.072±0.06%, 0.032±0.015% and 0.11±0.04% with the cells derived from the hippocampus,
                        subventricular zone, posterior cerebrum, anterior cerebrum, thalamus, cerebellum and brain stem respectively at passage
                        0. NS demonstrated a self-renewal capability through the generation of secondary NS following dissociations beyond five
                        passages. We also observed a non-linear increase in the efficiency of NS generation between 3 and 30 x 104 cells/ ml of
                        NS culture medium, suggesting the importance of paracrine factors for NS self-renewal.

                        We found a marked distinction in the differentiation potential of NS derived from the various anatomical sites (p<0.001). The
                        proportion of nestin+ cells ranged from 2.0±1.3% in the anterior cerebrum to 70.4±15.8% in the hippocampus, while the
                        proportion of BIII-tubulin – expressing cells ranged from 7.0±3.9% in the anterior cerebrum to 39.5±13.9% in the
                        hippocampus. GFAP-expressing cells constituted 27.9±3.9% of hippocampal cells and up to 75.9±5.9% of cerebral cells.

                        Conclusion: We have shown that NSC can be isolated from several anatomical locations in the second trimester fetal
                        brain at varying frequencies. The differentiation potential of predominatedly neurons in the thalamus, and glial in the
                        cerebra suggests potentially distinct functional roles of the NSC in the various regions. In addition to identifying new
                        sources of NSC for development of effective cellular replacement therapies, further characterization of NSC from different
                        regions of the brain can function as an in-vitro model of developmental neurogenesis, contributing to the identification of key
                        regulators of NSC self-renewal and lineage-specific differentiation.

                        Abstract: 77 – Free Paper S11.3
                        Evaluation of Haptoglobin in Ovarian Cyst Fluid as an Independent Biomarker for Epithelial Ovarian Cancer
                        1Liu L, 2Zhao C, 1Annamalai L, 1Kothandaraman N, 1Choolani M
                        1National University of Singapore, Singapore, 2Singapore Immunology Network (SIgN), Singapore


                        Introduction: Epithelial ovarian cancer (EOC) is the most lethal of female genital tract cancers. Owing to a paucity of
                        symptoms and their insidious onset, most patients presented with advanced stages of disease, with the 5-year survival rate
                        less than 30%. Intra-operative diagnosis malignancy in an ovarian cyst is important in determining the choice and extent of
                        surgical procedures, especially for younger patients wanting to preserve fertility and patients undergoing laparoscopic
                        surgery for ovarian pathology. Currently, frozen section is the mainstay of intra-operative diagnosis but it has limited
                        sensitivity and availability. In our preliminary study, haptoglobin, a protein differentially expressed in benign and malignant
                        ovarian cystic tumour patients has been identified and validated in serum as a biomarker for EOC. This study was
                        conducted to evaluate the diagnostic performance of haptoglobin level in ovarian cyst fluid as a potential biomarker for

                        Material & Methods: Women aged 12-74 with malignant (n=46) and benign (n=82) epithelial ovarian tumours were
Abstracts : Delegates

                        recruited for open surgical or laparoscopic treatment at the Department of Obstetrics and Gynecology, National University
                        Hospital (Singapore), from 2004-2009. Fluid within ovarian cyst was carefully collected during surgery without spillage. An
                        in-house sandwich enzyme-linked immunosorbent assay was employed to determine the concentration of haptoglobin in
                        ovarian cyst fluid samples obtained from 82 benign tumours, 21 early stage and 25 late stage cancers. Western blot
                        analysis as an alternative validation method was performed on 9 randomly selected cyst fluid samples (3 benign tumours, 3
                        early stage and 3 late stage cancers).

                        Results: Our data indicated that cyst fluid haptoglobin levels in patients with early and late stage EOCs (6.51±2.2 and
                        6.00±1.9 mg/ml, respectively) were both significantly elevated than those with benign tumours (0.83±0.9 mg/ml, p <0.001),
                        but there is no significant difference in haptoglobin level comparing early and late stage cancers (p=0.453).There was
                        absence of linear correlation between cyst fluid haptoglobin and serum CA125 levels in early stage (r=-0.109, p=0.735), late
                        stage EOCs (r=0.216, p=0.299) and cancer of all stages (r=-0.039, p=0.796), suggesting it was an independent marker to
                        systemic CA125. The Receiver Operating Characteristic (ROC) curve was plotted to assess and compare the diagnostic
                        accuracy of cyst fluid haptoglobin and serum CA125 in discriminating between benign and malignant tumours. Haptoglobin
                        (AUC 0.998, 95% CI 0.995-1.002) showed superior diagnostic power over gold standard CA125 (AUC 0.925, 95% CI 0.874-
                        0.977) and RMI (AUC 0.914, 95% CI 0.859-0.969) in 76 benign ovarian tumours and 46 ovarian cancers (p<0.05). Using
                        2.85 mg/ml as the cut-off level, cyst fluid haptoglobin achieved sensitivity of 100% (90.4%-100%), specificity of 96.3%

(88.9%-99.1%), positive predictive value (PPV) of 93.9% (82.1%-98.4%) and negative predictive value (NPV) of 100%
(94.1%-100%). Western blot analysis were compatible with ELISA result in which a higher intensity of staining was
observed in both early and late stage EOCs than in benign tumours.

Conclusion: This study provided evidence that intra-operative haptoglobin in ovarian cyst fluid could serve as an
independent biomarker for EOC. Overall, our data suggest that haptoglobin is a better marker than CA125 and RMI in intra-
operative diagnosis of malignancy.

Abstract: 79
Green Bean Gargle in Preventing Chemotherapy-Induced Nausea, Vomiting
Na D, Wang L, Ang YL
KK Women's and Children's Hospital, Singapore

Introduction: Nausea and vomiting is one of the common side effects of chemotherapy despite the advanced development
of antiemetic. Among the common chemotherapy drugs, cisplatin probably has the most emetic effect. Green bean is a
type of very traditional Chinese food and Chinese believe that it has cooling and detoxication effects. Hence this study is to
determine if it helps prevent or minimize nausea and vomiting.

Material & Methods: 20 patients admitted for cisplatin-based chemotherapy were enrolled and randomized into this
double-blinded placebo-controlled study. The experimental group received water soaked with green bean and the control
group received water with food coloring similar to color of green bean water as gargle before and after each meal. At the
end of the day, survey form was given to record episodes of nausea and vomiting and how distress they were from the

Results: Majority of patients did not experience nausea and vomiting. However between the two groups, 30% of patient
who received the placebo experience more vomiting and nausea and non from the experimental group experience vomiting
and 20% experience nausea. They also rated moderate to severe distress from the nausea and vomiting vs mild to
moderate distress from the experimental group.

Discussion: The result from this study did show that patient in the experimental group have lesser nausea and vomiting
and less distress with the symptoms but data did not show any significant differences between two groups. However
majority patients in the experimental group found it refreshing and pleasant.

Abstract: 80
Ultrasound Evaluation of Ectopic Pregnancy : A Pictorial Review
Lee SL, Tan LK, Kanagalingam D, Tan WC, Tan HK
Singapore General Hospital, Singapore

Introduction: The advances in ultrasound technology, in particular transvaginal sonography together with the application of
                                                                                                                                 Abstracts : Delegates
colour and power Doppler as well as three-dimensional imaging, has contributed to the high accuracy in ultrasound
diagnosis of ectopic pregnancy. A woman of reproductive age group who presents with abdominal pain and bleeding is at
high risk of harbouring an ectopic pregnancy, a life-threatening condition. Ultrasound has remained as the primary imaging
modality for the diagnostic workup of these patients and many ectopic pregnancies were accurately diagnosed before
management had commenced.

Case reports: The commonest site for an ectopic pregnancy is in the ampullary or isthmic portions of the fallopian tube, but
with the increase in cesarean sections, an increase in cesarean scar pregnancies was noted recently. We would like to
present an ultrasound pictorial review from several cases in our collection which exemplified different sonographic
presentations of ectopic pregnancy. They included tubal pregnancy, interstitial pregnancy, cesarean scar pregnancy,
angular pregnancy, heterotopic pregnancy and cervical pregnancy.

The techniques which were utilised included transabdominal and transvaginal ultrasonography, colour Doppler, Power
Doppler and three-dimensional ultrasound. The addition of blood flow studies often increased the diagnostic confidence by
demonstrating supplying flow to these ectopic masses. The application of 3- dimensional ultrasound added a third plane of
view, namely the coronal plane. It was especially useful in the demonstration of angular pregnancy. The collection of a
volume had the added advantage of a shorter examination time for the patient. The volume may be reviewed later to obtain
more images of diagnostic value.
                        Abstract: 81
                        Male Factor Infertility – Evaluating the Role of Pytochemical Derived from Tribulus Terretus L. (Tribestan)
                        Azahariah K R, Natassha M, Krishnan K, Joyce L L L, Eeson S, Kannappan P, Iswaran K K, Ravindren J
                        Reproductive Unit, Hospital Kuala Lumpur, Malaysia

                        This is an ongoing prospective study involving all male patients with oligozoospermia who had been treated with tribestan.
                        Tribestan is a completely non-hormonal herbal (phytochemical) biostimulator derived from the plant Tribulus terrestris L.
                        The objective of this study was to evaluate the semen parameters after completing treatment.

                        Material & Methods: This study was conducted at the infertility centre Hospital Kuala Lumpur between 1st January 2009 till
                        to date. All male patients with oligozoospermia (< 20mill/ml) and agreed to comply with treatment using tribestan on
                        therapeutic dose were recruited. The duration of treatment was 90 days with total daily dose of 3 film tablets of 0.250gm
                        tribestan. The pre-treatment semen analysis and subsequent analysis 90 days later were verified by a senior science officer
                        to minimise operator dependent biasness. The semen parameters were standardised for this study based on WHO 3rd
                        edition criteria.

                        Results: The study till to date involved 30 patients. The bio data of the patients are as follows. Majority (83.3%) of the
                        patients were from the Malay and Indian ethnic group. Age of the patients ranged in between 25 till 44 where 42% were
                        above 40. All were non-smokers. The post treatment semen analysis revealed significant improvement of the motility of the
                        sperm mainly grade A (66.7%) followed by grade B (58.3%). However the concentration and morphology did not show any
                        significant difference.

                        Discussion: These findings correlated with other clinical studies that had shown similar improvement in sperm motility.
                        However the insignificant effect on the sperm concentration was in contrast with findings in the same studies, which had
                        shown marked improvement.

                        Conclusion: Male infertility treatment continuous to be an enigma. Tribestan seems to have limited benefit. More research
                        is needed in the future.

                        Abstract: 82
                        Refractory Large Uterine Leomyoma – Transitioning from Conventional Hysterectomy to VALH with Confidence:
                        Tips, Tools and Tricks
                        Rabindra NB, Vijaendreh S
                        Melaka General Hospital, Melaka, Malaysia

                        Aim: To analyse the feasibility and safety of a different approach in managing the large refractory uterine leomyoma even
                        up to the size of about 26weeks by utilizing the minimum invasive surgical technique without utilizing any suture, clips or
                        staples for the pedicles.

                        VALH (vaginal assisted laparoscopic hysterectomy) is a surgical procedure of initial vaginal hydro dissection with securing
Abstracts : Delegates

                        the lower uterine pedicles and ligaments by Erbe open programmed biclamp forceps followed by laparoscopic operation of
                        upper uterine appendages and removal of large uterus by morcellation.

                        Material & Methods: A prospective study of sixty cases was conducted at Melaka General Hospital, Malaysia from
                        January 2007 to May 2009. Relatively large refractory benign leomyomas up to the size of twenty-six weeks were operated
                        successfully by vaginal assisted laparoscopic hysterectomy procedure without any peri-operative complications.

                        Results: Patient‟s weight varied between 60-114killogram (less than 60kg-4cases (7.5%), 60-80kg-38cases (62.5%), 80-
                        100kg-12cases (20%) more than 100kg-6cases (10%) The mean operating time was about 92 minutes (65-158 minutes)
                        with average blood loss about 110cc (60-350cc) Three (5%) cases required one unit and 4cases (6.6%) needed two units
                        (more than 24weeks size) of blood transfusion. Uterine weight ranges from 2.4 kilogram (one case, 1.66%), 1-2.4 kilogram
                        (50cases, 83.33%) and 500gram –1 kilogram (9cases, 15%). Postoperative analgesia was minimal with one dose of
                        Dynastat followed by Tramal injection.95% (57cases) were discharged within 30 hours postoperative while 5 % (3 cases)
                        stayed up to 48 hours. Postoperative period was uneventful. 90% (54cases) resumed work within three weeks and rest six
                        (10%) patients after four weeks of postoperative period with excellent patient‟s satisfaction. Histopathology revealed 85%
                        (51cases) leomyoma, 10% (6patients) degenerated leomyoma and 5% (3patients) with adenomyosis and leomyoma
                        without any features of malignancy.

Conclusion: A different MIS approach, VALH- may be an alternative feasible, safe and consumer friendly qualitative option
for large benign refractory uterine leomyoma even up to the size of 26 weeks.

Abstract: 83
Case Management in Perinatal Mental Health – Transforming Women’s Life from Within
Ch’ng YC, Roshayati M, Chen YH
Mental Wellness Service, KK Women’s and Children’s Hospital, Singapore

The Case Management model used by the Mental Wellness Service, aims to promote and maintain the mental well being of

Case Managers seek to enhance a patient‟s access to care by being a liaison person between patients and doctors. They
work with patients and families to help understand patient‟s condition, provide supportive counseling, and run support
programmes, such as workshops and patient support groups.

This care model is especially helpful with patients who develop psychological difficulties during the perinatal period as
women benefit from optimal support and care at this emotionally vulnerable period. This paper aims to highlight the
effectiveness of Case Management using 2 case studies.

Case 1: Ms X presented at 16 weeks pregnancy with low mood, negative thoughts, poor sleep and appetite, feeling irritable
and having suicidal thoughts. She had marital problems and a volatile relationship with her mother. She had 4 prior
abortions and had guilt and bad dreams about them. Her Case Manager helped Ms X cope through her pregnancy by
coordinating community resources and providing.

Case 2: Ms A presented with symptoms of depression and hearing voices criticizing her, two weeks after delivering her
fourth child. She also had delusional guilt, believing that she was being punished for her past misdeeds. Other than
psychiatric treatment and follow-up, Ms A was followed through closely by a Case Manager, who monitored her medical
compliance, and helped with the care arrangement of her 4 children.

Abstract: 84
One-Year Results of Singapore’s First Postnatal Depression Intervention Programme
Chua TE, Ch’ng YC, Wang J, Mingoo R, Ong J, Chen H
Mental Wellness Service, KK Women’s & Children’s Hospital, Singapore

Introduction: To assess the prevalence of depressive symptoms in postnatal women and outcomes in those who
underwent psychiatric intervention, under the first local intervention programme for postnatal depression.

Material & Methods: From April 2008 till March 2009, women attending 2 – 8 week postnatal obstetric follow-up at
KKWCH Clinics A and B were offered screening for depressive symptoms, using the Edinburgh Postnatal Depression
                                                                                                                            Abstracts : Delegates
Scale (EPDS). Women with borderline and high scores were offered psychiatric intervention. Post-intervention outcomes
were then measured.

Results: Of the 990 mothers who were screened, 91 (9.2%) had high EPDS scores indicating probable major depressive
disorder. They were offered consultation with a psychiatric specialist. 63 women (6.4%) had borderline scores, and were
offered further assessment and counseling by a psychiatric case manager. Only 33 of the 91 high scorers (36%) accepted
psychiatric intervention, but 24 of these (73%) showed ≥20% improvement in their post-treatment EPDS scores. Telephone
contact was provided to the high scorers who declined specialist consultation.

Conclusion: A significant proportion of mothers had symptoms of postnatal depression. Most of the high scorers declined
psychiatric consultation, but the majority of those who accepted treatment clearly showed improvement. These results
highlight the importance of promoting awareness and reducing stigma about postnatal depression.


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