This study was to assess the relationship between late pregnancy haemoglobin A (HbA) at 29-30 weeks of gestation and adverse pregnancy outcomes (APOs) in 272 pregnant women with pre-existing diabetes. HbA ≥6.1% was associated with significantly increased risk of preterm delivery, Caesarean section, large for gestational age (LGA), neonatal respiratory distress, neonatal hypoglycaemia, and composite adverse neonatal outcome (p < .05). The risk of pre-eclampsia increased significantly at the lower HbA cut-off of > 5.6% (p = .039). Reduction of HbA cut-off from 6.1% to 5.6% improved the sensitivity but reduced the specificity for prediction of APOs. Overall, the receiver operating characteristic (ROC) curves demonstrated the moderate predictive value of late pregnancy HbA for APOs. In conclusion, elevated late pregnancy HbA levels at 29-30 gestational weeks had a negative impact on APOs in pregnant women with pre-existing diabetes. However, HbA cut-off levels of neither ≥6.1% nor >5.6% were ideal for predicting APOs. Impact statement What is already known on this subject: Poorly controlled diabetes is associated with adverse pregnancy outcomes (APOs). Periconceptual haemoglobin A (HbA) correlates well with the risk of foetal anomaly but is not predictive of APOs at time of delivery. New evidence suggested that late pregnancy HbA is predictive of APOs but the definitions of a late pregnancy gestational week and target HbA cutpoint remain in doubt. What the results of this study add: This study investigated the relationship between late pregnancy HbA levels at 29-30 weeks of gestation and the APOs among pregnant women with pre-existing diabetes. Late pregnancy HbA ≥ 6.1% correlated with the risk of APOs but the increased risk of pre-eclampsia only became significant at the lower cut-off of >5.6%. Reducing HbA cut-off from 6.1% to 5.6% improved the sensitivity but reduced the specificity for prediction of APOs. Overall, late pregnancy HbA had a moderate predictive value for APOs. What the implications are of these findings for clinical practice and/or further research: HbA cut-off levels of neither ≥6.1% nor >5.6% were ideal in predicting APOs among pregnant women with pre-existing diabetes. As HbA levels tend to drop in pregnancy, caution should be taken when interpreting HbA in pregnancy. More multi-centred studies are required to explore the respective glycaemic target for each APO and to determine the ideal timing for late pregnancy HbA measurement.
Normal-sized ovarian carcinoma syndrome (NOCS) is a rare condition characterised by malignancy identified in ovaries of normal size with abdominal metastasis. We report two cases of advanced ovarian carcinoma with ovaries of normal size. The first case was a 13-year-old adolescent with malignant ascites and bilateral normal sized multicystic ovaries detected on ultrasound. Serum cancer antigen 125 (CA 125) and lactate dehydrogenase were markedly raised. A computed tomography (CT) scan showed the presence of thick omental cake but no ovarian tumour. An ultrasound-guided biopsy of the omental cake was undertaken. A histopathological examination and immunohistochemical studies of omentum caking confirmed a diagnosis of high-grade serous carcinoma of ovarian in origin. Despite neoadjuvant chemotherapy, she deteriorated rapidly with acute renal failure and respiratory distress. She succumbed to her disease 10 weeks after diagnosis. The second case, a 69-year-old postmenopausal female presented with malignant ascites and ultrasound evaluation showed hydrometra and bilateral atrophic ovaries. CA 125 was significantly raised. A laparoscopic biopsy of the left ovary and endometrial sampling were performed. A diagnosis of synchronous primary high grade papillary serous ovarian cystadenocarcinoma and endometrial adenocarcinoma were revealed. Relapse occurred despite ongoing adjuvant chemotherapy. We concluded that a preoperative definitive diagnosis of NOCS is difficult. Strong clinical suspicion is needed when all the important causes of malignant ascites are excluded. Radiological-guided biopsy and laparoscopic biopsy are useful to achieve the diagnosis of NOCS.
Hyperkalaemic periodic paralysis is a rare skeletal muscle disorder which is characterised by episodic muscle paralysis associated with hyperkalaemia. Although it is an autosomal-dominant disease, cases of de novo mutations have been reported. We report the case of a 30-year-old woman, gravida 5 para 3+1, who was planned for an elective repeated caesarean section at 38 weeks and 3 days of pregnancy. She developed recurrent episodes of hyperkalaemic periodic paralysis after receiving corticosteroids. Intravenous calcium gluconate was administered to normalise potassium levels (from 6.3 mmol/L to 4.1 mmol/L). Extra anaesthetic precautions were taken during the caesarean delivery. Postoperatively, she was well and discharged from the ward. She encountered similar symptoms in her third pregnancy, and there was no family history of muscle weakness which suggested a de novo mutation. Pregnancy seemed to result in vulnerability to hyperkalaemic attacks as she was never symptomatic outside pregnancy.
Chorioangioma or chorangioma is a benign placental tumour which occurs in 1% of the pregnancies. Large lesions of more than 4–5 cm in size, also known as giant chorangiomas, are rare with the incidence of 1:3500 and 1:9000 birth. Unlike small tumours, the giant chorangiomas are highly associated with pregnancy complications. We report a case of multiple large chorangiomas resulting in an extremely preterm delivery. A 24-year-old primigravida presented at 25 weeks of gestation for threatened preterm labour. Transabdominal ultrasound revealed an echogenic mass on the placenta measuring 8.7 × 4.4 cm. Following a successful tocolysis and administration of a course of antenatal corticosteroids, she was discharged home. At 27 weeks of gestation, she developed a second episode of preterm contractions. Besides, the foetus was found to be small for gestational age. In the second episode of preterm contractions, intravenous magnesium sulfate infusion was commenced for foetal neuroprotection. Tocolysis was commenced for severe prematurity. She went into spontaneous preterm labour. Placenta examination revealed multiple solid masses with fleshy and congested dark red surface. A histopathological examination of the placenta confirmed the diagnosis of chorangiomas. The baby was discharged in good condition at 5 months of age. Placental chorangiomas, notably when they are multiple and large in size, are associated with adverse pregnancy outcomes. Therefore, close antenatal surveillance is necessary to allow timely recognition and intervention of pregnancy complications. Our case portrays an unexpected favourable neonatal outcome associated with a giant chorangiomas.
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