REFERENCE MASSIVE PRIMARY POSTPARTUM HAEMORRHAGE SD Karalasingam¹, Ravindran J², R Jeganathan ³

National Obstetrics Registry rs and Parity≥ 6 had the highest rate of Massive Primary PPH. Rates T a b le 3 .1 M a s s iv e P ri m a ry P P H b y S D P 2 1 1 a n d 2 1 2 S D P T o ta l w o m e n w h o d e li v e re d P ri m a ry P P H T o ta l w o m e n w h o d e li v e re d P ri m a ry P P H 1 5 m ls ≥1 50 m ls N A 1 5 m ls ≥1 50 m ls N A n n n n n n H T J ,P e rl is 4 ,0 8 7 7 7 1 .8 8 1 6 .3 9 3 .0 7 3 ,9 2 5 9 1 .5 1 2 1 .5 4 1 .0 3 H SB , K e d a h 1 ,3 9 6 6 4 .6 2 4 2 .4 1 .0 1 1 ,3 7 4 .3 9 1 3 .1 3 .0 H PP 3 ,3 3 6 1 2 .3 6 .0 1 .0 3 3 ,0 1 4 .1 3 .0 .0 H R P B , P e ra k 6 ,2 1 7 8 .1 3 1 3 .2 1 .0 4 ,5 7 3 .0 7 2 .0 4 .0 H T A R , S e la n g o r 1 2 ,3 5 1 1 2 .1 8 .0 6 1 .0 1 1 2 ,0 5 6 4 2 .3 5 5 .0 4 1 .0 1 H KL 1 1 ,7 2 9 9 9 .8 4 1 5 .1 3 4 .0 3 1 1 ,8 4 3 7 9 .6 7 2 2 .1 9 .0 H T J, N e g e ri S e m b ila n 4 ,8 4 1 4 .0 8 2 .0 4 1 .0 2 6 ,1 9 2 7 .1 1 .0 1 .0 2 H o sp it a l Me la k a 1 ,8 3 3 2 4 .2 2 1 .0 9 .0 1 ,7 4 6 1 5 .1 4 6 .0 6 .0 H SA , Jo h o r 1 2 ,4 6 7 4 6 .3 7 1 5 .1 2 1 .0 1 1 2 ,2 9 5 6 5 .5 3 1 1 .0 9 2 .0 2 H T A A , P a h a n g 9 ,3 3 3 1 1 .1 2 6 .0 6 1 .0 1 8 ,7 2 8 2 .0 2 1 .0 1 .0 H SN Z , T e re n g g a n u 1 2 ,0 1 9 6 5 .5 4 2 7 .2 2 3 .0 2 1 2 ,8 3 8 5 .6 6 2 4 .1 9 8 .0 6 H R P Z 1 1 , K e la n ta n 1 3 ,0 6 6 3 9 .3 2 2 .1 7 1 .0 1 1 ,9 5 5 2 1 .1 9 1 1 .1 .0 H U ,S a ra w a k 9 ,8 5 4 8 6 .8 7 2 .2 5 .0 5 1 ,5 1 3 1 3 .8 6 .0 .0 H L , S a b a h 1 4 ,8 5 1 1 .0 1 .0 .0 1 3 ,7 5 9 8 .0 6 2 .0 1 .0 T o ta l 1 3 5 ,3 8 5 4 8 .4 1 9 6 .1 4 2 2 .0 2 1 2 2 ,6 3 4 4 4 3 .3 6 1 1 8 .1 1 3 .0 1 30 tio n a l O b st e tri cs R e g ist ry Table 3.2 Massive Primary PPH by ethnicity 2011 and 2012 Ethnicity 2011 2012 Total women who delivered Primary PPH Total women who delivered Primary PPH 1500 mls ≥1500 mls NA 1500 mls ≥1500 mls NA n n n n n n Malay 92,649 423 0.46 149 0.16 17 0.02 85,391 345 0.40 94 0.11 11 0.01 Chinese 8,428 28 0.33 18 0.21 1 0.01 7,417 36 0.49 3 0.04 1 0.01 Indian 6,400 10 0.16 3 0.05 0.00 6,128 11 0.18 2 0.03 1 0.02 KadazanDusun 4,003 2 0.05 0.00 0.00 3,685 2 0.05 1 0.03 0.00 Murut 345 1 0.29 0.00 0.00 262 1 0.38 0.00 0.00 Bajau 3,151 2 0.06 1 0.03 0.00 2,930 4 0.14 0.00 0.00 Melanau 123 0.00 0.00 0.00 38 0.00 0.00 0.00 Iban 2,149 15 0.70 5 0.23 0.00 760 2 0.26 0.00 0.00 Bidayuh 1,573 20 1.27 0.00 2 0.13 360 1 0.28 0.00 0.00 OA Peninsular Malaysia 909 2 0.22 1 0.11 0.00 748 1 0.13 0.00 0.00 Other indigenous group in Sabah Sarawak 2,695 2 0.07 1 0.04 0.00 2,338 0.00 1 0.04 0.00 Other 1,209 5 0.41 1 0.08 0.00 1,467 3 0.20 3 0.20 0.00 Foreigners 11,333 37 0.33 17 0.15 2 0.02 10,593 36 0.34 14 0.13 0.00 NA 413 1 0.24 0.00 0.00 517 1 0.19 0.00 0.00 Total 135,380 548 0.40 196 0.14 22 0.02 122,634 443 0.36 118 0.10 13 0.01 31 N a tio n a l O b st e tri cs R e g ist ry Table 3.3 Massive Primary PPH by age 2011 and 2012 Age 2011 2012 Total women who delivered Primary PPH Total women who delivered Primary PPH 1500 mls ≥1500 mls NA 1500 mls ≥1500 mls NA n n n n n n n n 10-14 127 0.00 0.00 0.00 126 0.00 0.00 0.00 15-19 6,731 24 0.36 2 0.03 0.00 5,736 8 0.14 0.00 0.00 20-24 26,048 80 0.31 19 0.07 3 0.01 22,513 55 0.24 3 0.01 1 0.00 25-29 46,963 158 0.34 32 0.07 5 0.01 43,421 145 0.33 23 0.05 4 0.01 30-34 33,305 147 0.44 66 0.20 9 0.03 30,830 120 0.39 46 0.15 4 0.01 35-39 17,052 106 0.62 51 0.30 4 0.02 15,404 84 0.55 33 0.21 2 0.01 40-44 4,765 30 0.63 25 0.52 1 0.02 4,262 31 0.73 13 0.31 1 0.02 45-49 362 3 0.83 1 0.28 0.00 314 0.00 0.00 1 0.32 50-54 26 0.00 0.00 0.00 26 0.00 0.00 0.00 55-59 1 0.00 0.00 0.00 2 0.00 0.00 0.00 Total 135,380 548 0.40 196 0.14 22 0.02 122,634 443 0.36 118 0.10 13 0.01 32 tio n a l O b st e tri cs R e g ist ry Table 3.4 Parity and Massive Primary PPH 2011 and 2012 Parity 2011 2012 Total women who delivered Primary PPH Total women who delivered Primary PPH 1500 mls ≥1500 mls NA 1500 mls ≥1500 mls NA n n n n n n 1 46,158 155 0.34 36 0.08 6 0.01 42,679 147 0.34 19 0.04 2 0.01 2 - 5 81,166 355 0.44 134 0.17 15 0.02 73,336 263 0.36 87 0.12 6 0.01 ≥ 6 7,840 38 0.48 26 0.33 1 0.01 6,537 33 0.50 12 0.18 5 0.08 NA 216 0.00 0.00 0.00 82 0.00 0.00 0.00 Total 135,380 548 0.40 196 0.14 22 0.02 122,634 443 0.36 118 0.10 13 0.01 Table 3.5: Risk factors for Massive Primary PPH 2011 and 2012 Risk Factor for PPH 2011 2012 Total women who delivered Primary PPH Total women who delivered Primary PPH 1500 mls ≥1500 mls NA 1500 mls ≥1500 mls NA n n n n n n Anaemia At Booking 42,096 153 0.36 57 0.14 8 0.02 35,859 108 0.30 34 0.09 3 0.01 Macrosomia 4,515 36 0.80 13 0.29 0.00 4,249 29 0.68 12 0.28 0.00 Multiple Pregnancy 2,695 42 1.56 14 0.52 4 0.15 2,584 26 1.01 12 0.46 0.00 Prolonged Labour 544 10 1.84 5 0.92 0.00 308 5 1.62 4 1.30 1 0.32 33 N a tio n a l O b st e tri cs R e g ist ry 37 Table 3.6: Cause of Massive Primary PPH 2011 and 2012 Cause of PPH 2011 2012 Total women who delivered Primary PPH Total women who delivered Primary PPH 1500 mls ≥1500 mls NA 1500 mls ≥1500 mls NA n n n n n n n n Uterine atony 97 43 44.33 24 24.74 0.00 42 19 45.24 4 9.52 1 2.38 Uterine inversion 2 0.00 0.00 0.00 6 0.00 0.00 0.00 Placenta preavia 1,422 39 2.74 42 2.95 1 0.07 1,425 25 1.75 31 2.18 1 0.07 Abruption placenta 299 8 2.68 7 2.34 0.00 323 8 2.48 7 2.17 0.00 Retained placenta 266 11 4.14 3 1.13 1 0.38 220 11 5.00 4 1.82 2 0.91 Genital trauma 29,056 138 0.47 12 0.04 6 0.02 27,640 76 0.27 12 0.04 2 0.01 Uterine rupture 7 2 28.57 0.00 0.00 10 0.00 2 20.00 0.00 Table 3.7: Massive Primary PPH in relation to mode of delivery 2011 and 2012 Mode of Delivery Total women who delivered 2011 Total women who delivered 2012 Primary PPH Primary PPH 1500 mls ≥1500 mls NA 1500 mls ≥1500 mls NA n n n n n n n n Vaginal 96,272 252 0.26 26 0.03 11 0.01 86,219 168 0.19 17 0.02 4 0.00 Instrumental 4,923 26 0.53 3 0.06 1 0.02 4,589 22 0.48 3 0.07 1 0.02 Caesarean 31,241 255 0.82 164 0.52 10 0.03 30,325 245 0.81 98 0.32 8 0.03 LSCS 31,029 253 0.82 159 0.51 10 0.03 30,138 242 0.80 97 0.32 8 0.03 Classical 130 0.00 4 3.08 0.00 132 1 0.76 1 0.76 0.00 Hysterotomy 17 1 5.88 0.00 0.00 22 2 9.09 0.00 0.00 Total 135,380 533 0.39 193 0.14 22 0.02 122,634 435 0.35 118 0.10 13 0.01 34 National Obstetrics Registry National Obstetrics Registry 38 DIABETES MELLITUS IN PREGNANCY National Obstetrics Registry National Obstetrics Registry 39

CHAPTER 4 DIABETES MELLITUS IN PREGNANCY Maizuriati Abd Rahman

1 , Zaridah Shaffie 1 , Noor Aini Harun 1 , SD Karalasingam 2 1. Tuanku Fauziah Hospital, Perlis 2. National Clinical Research Centre SUMMARY The incidence of Diabetes in pregnancy was 8.66 in 2011 and in 2012 there was a slight increase to 8.83 seen from the 14 tertiary hospitals in Malaysia. Highest incidence of Diabetic pregnancy was seen in Indians in both years. Diabetic pregnancy was high in age group 45-49 years in 2011 at 23.76 as compared to 2012 there was a higher incidence at 21.12 in age 40-44 years. Fetal macrosomia was high in both years which led to an increased CS rates.

4.1 INTRODUCTION The incidence of Diabetic pregnancy was 8.66 in 2011 and 8.83 in 2012.This was

slightly lower compared to previous report at 11.1 in 2009 and 9.9 in 2010. In 2011, tertiary hospital HSA,HTAA and Hospital Melaka had the highest incidence of Diabetes in pregnancy at around 12 and in 2012, higher incidence was seen in HKL, HSA and HTAA around 12. GDM rates were higher than pre-existing diabetes for both years. 4.2 PATIENT DERMOGRAPHICS Diabetes in pregnancy in 2011 in age group 40-44 years was 21.30 and in age group 45-49 years was at 23.76 . In 2012 , women aged 40-44 years had a rate of 21.12 whilst women in age group 45-49 years at 17.83. Diabetes in pregnancy was higher among the Indians for both years in 2011 at 13.55 and 13.05 in 2012. Incidence in Malays was 9.82 in 2011 and at 9.87 in 2012.Diabetic pregnancy was more common in para 6 and more for both years at 14.58 and 14.62 4.3 OUTCOMES CS rates in this group of patients were high in 2011 at 13.42 and at 13.1 in 2012. In both years approximately 16 babies born to Diabetic mothers weighed 4 kg and more. There was a 2 fold increase in macrosomia in diabetic patients in both years as compared to non-diabetics and this could have contributed to the increased CS rates in Diabetic patients. There was no difference in shoulder dystocia rates in Diabetics and 35 National Obstetrics Registry non-diabetic patients. Stillbirth rates in this group of patients were 8.05 per 1000 live births in 2011 and 8.27 per 1000 live births in 2012.

4.4 CONCLUSIONS The incidence of Diabetic pregnancy remained constant for both years at 8.7 in 2011

and 8.8 in 2012. This rate was lower compared to what was reported in 2009 and 2010. The overall prevalence of Diabetes mellitus in the National Health Morbidity Survey III was 11.6. Indians had a higher prevalence at 13.55 in 2011 and 13.05 in 2012, followed by the Malays at 9.82 in 2011 and 9.87 in 2012 4.5 RECOMMENDATION 1. Pre-pregnancy counselling is advocated in this group of women to ensure good glycaemic control before they embark on pregnancy. 2. We recommend universal screening instead of selective screening for GDM.

4.6 REFERRENCES

1. NICE Clinical Guideline 63 – Diabetes in Pregnancy, March 2008. 2. Prevalence of Diabetes in the Malaysian National Health Morbidity Survey III 2006. 3. National Obstetric Registry Report 2009 and 2010. 36