National Obstetrics Registry 3Rd Report

National Obstetrics Registry

NATIONAL OBSTETRICS REGISTRY

3RD REPORT

JAN 2011 – DEC 2012

Editors:

Ravichandran Jeganathan Shamala Devi Karalasingam

A publication of the National Obstetrics Registry and the Clinical Research Centre, Ministry of Health Malaysia National Obstetrics Registry National Obstetrics Registry

December 2015 ACKNOWLEDGEMENTS © National Obstetrics Registry

Publisher: The National Obstetrics Registry (NOR) would like to give its grateful appreciation to Jointly published by the National Obstetrics Registry and the Clinical Research Centre (CRC), Ministry of Health Malaysia. everyone who has helped make this report possible.

National Obstetrics Registry st 1 Floor MMA House, We would especially like to thank the following: 124, Jalan Pahang, 53000 Kuala Lumpur, Malaysia.  Director General of Health Malaysia for the support and approval to publish this Tel : (603) 4044 3060 / (603) 4044 3070 report Fax : (603) 4044 3080 Email : [email protected]  Our source data providers for their timely data collection and hard work. Website : https://www.macr.org.my/enor/  Steering committee members and governance board for their tireless effort and expertise dedicated to this registry Suggested citation: Ravichandran Jeganathan (Eds). Preliminary Report of National Obstetrics Registry, Jan 2011 – Dec 2012. Kuala Lumpur, Malaysia: National Obstetrics  Clinical Research Centre National for its leadership, supervision and technical Registry 2011-2012 support. Disclaimer:  The registry coordinating team and technical support team for their commitment and contribution in preparing this report. Data reported in this report were collected for 2 years period (from Jan 2011 to December 2012). This report is copyrighted. Reproduction and dissemination of this report in part or in whole for research, educational or other non-commercial purposes are authorized without any prior written permission from the copyright holders provided the source is fully acknowledged.

Electronic version The electronic version of this report may be downloaded at https://www.macr.org.my/enor/ or http://www.crc.gov.my/publication/report.

Funding The National Obstetrics Registry is funded with grants from the Ministry of Health Malaysia (MOH)

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December 2015 ACKNOWLEDGEMENTS © National Obstetrics Registry

Electronic version The electronic version of this report may be downloaded at https://www.macr.org.my/enor/ or http://www.crc.gov.my/publication/report.

Funding The National Obstetrics Registry is funded with grants from the Ministry of Health Malaysia (MOH)

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National Obstetrics Registry

NOR Web Application

 Go to www.acrm.gov.my and click on NOR  Login to NOR  Select Patient and fill up NOR notification and relevant details.  Print out reports.

Organization of NOR

The organizational structure for the registry is depicted below.

Sponsor

Governance Board

Expert Steering Panel Committee/Technic al Support Team

Source Data User group Providers

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NOR STEERING COMMITTEE NOR Web Application Dato' Dr Ravindran Jegasothy  Go to www.acrm.gov.my and click on NOR Advisors Department of Obstetrics & Gynaecology,  Login to NOR Kuala Lumpur Hospital  Select Patient and fill up NOR notification and relevant details.  Print out reports. Dato’ Dr. Mukudan Krishnan Department of Obstetrics & Gynaecology Raja Permaisuri Bainun Hospital, Perak

Chairman Dr J Ravichandran R Jeganathan Department of Obstetrics & Gynaecology, Sultanah Aminah Hospital, Johor

Project Manager Dr. Shamala Devi Karalasingam National Clinical Research Center, Kuala Lumpur Hospital Organization of NOR Dr Maimunah Bt Fadzi Department of Obstetrics & Gynaecology, The organizational structure for the registry is depicted below. Malacca Hospital

Sponsor Dr. Sukri Ahmad Department of Obstetrics & Gynaecology, Governance Board Raja Perempuan Zainab II Hospital, Kelantan Members Expert Steering Dr. Wan Abu Bakar Yusoff Panel Committee/Technic Department of Obstetrics & Gynaecology al Support Team Sultanah Nur Zahirah Hospital, Terengganu Dato‘ Dr.Sudesan Raman Department of Obstetrics & Gynaecology Source Tengku Ampuan Afzan Hospital, Pahang Data User group Providers Dr Malar Kandasamy Department of Obstetrics & Gynaecology Tengku Ampuan Rahimah Hospital, Selangor

Dr Muniswaran G Department of Obstetrics & Gynaecology Sarawak General Hospital

Dr Maizuriati bt Abd. Raman Department of Obstetrics & Gynaecology Tuanku Fauziahiii Hospital, Kangar, Perlis iii Sister Ruhaizan Bt Haron Department of Obstetrics & Gynaecology, Sultanah Aminah Hospital, Johor

Matroniv Anita Malek Department of Obstetrics & Gynaecology, Likas Hospital, Sabah

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THE EDITORIAL BOARD

Dr. J Ravichandran R Jeganathan Editors Principal Investigator National Obstetrics Registry Sultanah Aminah Hospital, Johor

Dr Shamala Devi Karalasingam Project Manager National Obstetrics Registry National Clinical Research Center, Kuala Lumpur Hospital Contributors Dato’ Dr.Sudesan Raman Tengku Ampuan Afzan Hospital, Pahang

Dr.Ganesh R Vaiyapuri Tengku Ampuan Afzan Hospital, Pahang

Sister Sariha Abd.Razak Tengku Ampuan Afzan Hospital, Pahang

Dr Rozihan Ismail Tengku Ampuan Afzan Hospital, Pahang

Dr.Shamala Devi Karalasingam National Clinical Research Centre Kuala Lumpur Hospital

Dato’ Dr.Ravindran Jegasothy Kuala Lumpur Hospital

Dr.J Ravichandran R Jeganathan Sultanah Aminah Hospital, Johor

Dr.Maizuriati Abd Rahman Tuanku Fauziah Hospital, Perlis

Dr. Zaridah Shaffie Tuanku Fauziah Hospital, Perlis

Dr. Noor Aini Harun Tuanku Fauziah Hospital, Perlis

Dr Malar Kandasamy Tengku Ampuan Rahimah Hospital, Selangor

Dr. Anil Krishna Dass Pulau Pinang Hospital

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Dr. Mohd.Rouse Abdul Majid Pulau Pinang Hospital

Dr. Nor Jumizah Abd Kadir Sultanah Nur Zahirah Hospital, Terengganu

Dr. Wan Abu Bakar Yusoff Sultanah Nur Zahirah Hospital, Terengganu

Dr. Halimatun Mansor Sultanah Nur Zahirah Hospital Kuala Terengganu

Dr.Chong Seong Tan Kuala Lumpur Hospital

Dr Tan Cheng Kuala Lumpur Hospital

Dr. Nasuha Yacoob Kuala Lumpur Hospital

Dr. Rohani Aziz Sultanah Bahiyah Hospital, Kedah

Dr. Rohana Ramli Sultanah Bahiyah Hospital, Kedah

Dr. Lee Pei Wei Sultanah Bahiyah Hospital, Kedah

Sister Zarina Man Sultanah Bahiyah Hospital, Kedah

Dr. Mohd Rushdan Mohd Noor Sultanah Bahiyah Hospital, Kedah

Dr. Bavanandan Naidu Sultanah Bahiyah Hospital, Kedah

Dr. Tham Seng Woh Malacca Hospital

Dr Maimunah Bt Fadzi Malacca Hospital Sister Chong Guan Khim Malacca Hospital

Sister Wan Jivi Nion Malacca Hospital

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NOR SOURCE DATA PROVIDERS 2011 - 2012

No. Hospital Site investigators Second person-in-charge 1 Kuala Lumpur Dr. S. Thillainathan Sister Rohana Bt Mat Noor Hospital 2 Raja Perempuan Dr. Sukri Ahmad Sister Sariah Bt Tais Zainab II Hospital ,Kelantan 3 Sultanah Nur Zahirah Dr. Wan Abu Bakar Sister Salmah Sulaiman Hospital ,Terengganu Yusoff

4 Tengku Ampuan Dr. Malar Kandasamy Sister Zaiton Rahimah Hospital, Sister Paramaswari Sinnathamby Selangor 5 Sultanah Bahiyah Dr Rohana Ramli Sister Zarina Man Hospital, Kedah 6 Sultanah Aminah Sister Ruhaizan Bt Haron Hospital ,Johor

7 Malacca Hospital Dr. Maimunah Bt Fadzil Sister Chong Guan Khim 8 Tuanku Fauziah Dr. Maizuriati Bt. Abd. Sister Azlina Bt Halip Hospital , Perlis Rahman 9 Raja Permaisuri Dr. Liza Ling Ping Sister Zalilah Zainal Bainun Hospital, Perak 10 Tengku Ampuan Dato‘ Dr.Sudesan Sister Noorlida bt Jusoh Afzan Hospital , Raman Pahang 11 Tuanku Ja’afar Dr. Nazura Bt. Karim Hospital Negeri Sembilan 12 Pulau Pinang Hospital Sister Norzuraini bt. Zulkifli Sister Sister Islyana bt. Azhar 13 Likas Hospital, Sabah Dr. Carol Lim Matron Anita Malek 14 Sarawak General Dr Muniswaran G Matron Melanti Liong Hospital

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THE CORE TEAM FROM CRC

Project manager : Dr Shamala Devi Karalasingam

Biostatistics Unit : Mohamad Adam Bin Bujang Shahrul Aiman Soelar Nadiah Sa’at Nurakmal Baharum

Research Officer : Nurul Shuhada Mohd Ali Aminah Salleh

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LETTER FROM THE PRINCIPAL INVESTIGATOR

The National Obstetrics Registry is presently one of the most active databases. Since its inception in 2009, the database has just expanded. As of December 2014 we have more than 600,000 datasets. Our data has aroused interest both within and out of the country and we have been recognised internationally as a reliable source of data. NOR data has been presented at local and international conferences and congresses. This 3rd report covers the years 2011 and 2012 and you will be able to see the data from new fields that we have added. A total of 43 posters and 2 oral presentations using this dataset was presented at local and international conferences namely, National Conference in Clinical Research, Diabetic Asia Conference, Asia Oceanic Congress of Obstetrics & Gynaecology in Sarawak, Controversies in Maternal Fetal Medicine in Shanghai and Royal college of Obstetrics and Gynaecology World Congress in Hyderabad, to name a few. Two manuscripts have also been sent to high impact journals for publication. The total data analysed in this report is 260,958 deliveries. Data cleaning and analysis of this enormous data was undertaken by the CRC team and it must be said that they have done a wonderful job. A congratulatory note is a very small token of appreciation to the authors, their associates and the core team from CRC for all the hard work to make this 3rd report a reality. The sustained growth of NOR would not have been possible without the dedication and hard work of the steering committee, site coordinators, the O&G heads of department of the participating hospitals and the CRC team. Our heartfelt thanks to the Director General of Health and the Clinical Research Centre, Malaysia for their continuous support for the National Obstetrics Registry.

Thank you Dr J. Ravichandran R. Jeganathan Principal Investigator National Obstetrics Registry Ministry of Health, Malaysia

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ABBREVATIONS

AIDS Acquired immunodeficiency syndrome CRC Clinical Research Centre CS Caesarean Section CEMD Confidential enquiry into maternal death DIVC Disseminated intravascular coagulopathy DVT Deep vein thrombosis ECV External Cephalic Version DM Diabetes Mellitus ECV External Cephalic Version FSB Fresh Stillbirth GDM Gestational Diabetes Mellitus HDP Hypertensive disorder in pregnancy HKL Kuala Lumpur Hospital HPP Pulau Pinang Hospital HPT Hypertension HL Likas Hospital HO House Officer HRPB Raja Permaisuri Bainun Hospital HRPZ Raja Perempuan Zainab Hospital HSNZ Sultanah Nur Zahirah Hospital HSA Sultanah Aminah Hospital HSB Tengku Fauziah Hospital HTAR Tengku Ampuan Rahimah Hospital HTAA Tengku Ampuan Afzan Hospital HTJ Tuanku Jaafar Hospital HL Likas Hospital HU Hospital Umum HIV Human Immunodeficiency virus ICU Intensive care unit

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IHD Ischaemic heart disease ITP Idiopathic thrombocytopenic purpura IUD Intrauterine Death IUGR Intrauterine growth restriction KPI Key Performance Index LCM Lethal Congenital Malformation LSCS Lower Segment Caesarean Section MO Medical Officer MOH Ministry of Health MMR Maternal Mortality rate MSB Macerated stillbirth NA Not Available NICU Neonatal Intensive care unit NOR National Obstetrics Registry NYHA New York heart association OA Orang Asli O&G Obstetrics and Gynaecology PIH Pregnancy induced hypertension PPH Postpartum Haemorrhage PPROMXCV Prelabour preterm rupture of membrane RCOG Royal college of Obstetrics and Gynaecology SDP Site Data Provider STD Sexually transmitted disease STI Sexually transmitted infection SVD Spontaneous vaginal delivery TB Tuberculosis VBAC Vaginal birth after Caesarean WHO World Health Organization

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CONTENT ii Acknowledgements iiiiii NOR Web Application iviiiii NOR Steering Committee viviii The Editorial Board viiviv NOR Source Data Providers 2011-2012 viiiixvii x The Core Team From CRC ixviii xi Letter From The Principal Investigator xix xii Abbreviations xiixi xiv Table Of Content xiixiii xiv List of Tables xvixiii List of Graph xviiixvii

List of Tables CHAPTER 1: Type of delivery Table 1.1 Distribution of Total delivery by SDP 2011 and 2012 334 Table 1.2 Distribution of Total delivery by Types 2011 and 2012 334 Table 1.3 Distribution of delivery by age 2011 and 2012 445 Table 1.4 Distribution of delivery type by SDP 2011 556 Table 1.5 Distribution of delivery type by SDP 2012 667 Table 1.6 Deliveries in relation to risk level at booking 2011 and 2012 778 Table 1.7 Delivery by ethnicity 2011 889 Table 1.8 Delivery by ethnicity 2012 9109 Table 1.9 Delivery by Parity 2011 and 2012 101110 Table 1.10 Deliveries in relation to Medical problems 2011 111211 Table 1.11 Deliveries in relation to Medical problems 2012 121312 Table 1.12 Apgar score in relation to delivery 2011 and 2012 131413 Table 1.13 Complication in relation to mode of delivery 2011 141514 Table 1.14 Complication in relation to mode of delivery 2012 151615

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CHAPTER 2: Caesarean section Table 2.1 CS rates by SDP 2011 and 2012 1921 Table 2.2 Distribution of CS by ethnicity 2011 and 2012 2123 Table 2.3 CS by Age and Parity 2011 and 2012 2224 Table 2.4 CS by risk level at booking 2011 and 2012 2325 Table 2.5 Distribution of medical problems and CS rates, 2011 and 2012 2426 Table 2.6 CS in relation to accoucher 2011-2012 2527 Table 2.7 Apgar score in relation to CS 2011 and 2012 2729

CHAPTER 3: Massive Primary Postpartum Haemorrhage Table 3.1 Massive Primary PPH by SDP 2011 and 2012 3033 Table 3.2 Massive Primary PPH by ethnicity 2011 and 2012 3134 Table 3.3 Massive Primary PPH by age 2011 and 2012 3235 Table 3.4 Parity and Massive Primary PPH 2011 3336 Table 3.5 Risk factors for Massive Primary PPH 2011 and 2012 3336 Table 3.6 Cause of Massive Primary PPH 2011 and 2012 3437 Massive Primary PPH in relation to mode of delivery 2011 and 34 Table 3.7 37 2012

CHAPTER 4: Diabetes Mellitus in Pregnancy Table 4.1 Incidence of Diabetic pregnancy by SDP 2011 and 2012 3842 Table 4.2 Diabetic pregnancy by Age 2011 and 2012 3943 Table 4.3 Diabetic pregnancy by Ethnicity 2011 and 2012 4044 Table 4.4 Diabetic pregnancy by Parity 2011 and 2012 4145 Table 4.5 Mode of delivery in Diabetic pregnancy 2011 and 2012 4246 Table 4.6: Birth weight in relation to Diabetic pregnancy 2011 and 2012 4347 Table 4.7 Macrosomia in Diabetic pregnancy 2011 and 2012 434448 Table 4.8 Shoulder dystocia in Diabetic pregnancy 2011 and 2012 4448 Table 4.9 Birth asphyxia in Diabetic pregnancy 2011-2012 4549 Table 4.10 Fetal outcomes in Diabetic pregnancy 2011-2012 4549

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CHAPTER 5: Breech Table 5.1 Deliveries by SDP 2011 and 2012 4853 Table 5.2 Breech delivery by ethnicity 2011 and 2012 4954 Table 5.3 Breech delivery by age 2011 and 2012 5055 Table 5.4 Breech delivery by Weight for 2011 and 2012 5156 Table 5.5 Breech and incidence of ECV 2011 and 2012 5257 Table 5.6 Vaginal Breech delivery in relation to complications 2011 and 2012 5257 Caesarean Breech delivery in relation to complications 2011 and 5852 Table 5.7 53 2012

CHAPTER 6: Stillbirth Table 6.1 Stillbirth rate from SDP 2011 and 2012 555763 Table 6.2 Distribution of stillbirth by age 2011 and 2012 565864 Table 6.3 Distribution of stillbirth by ethnicity 2011 and 2012 575965 Table 6.4 Stillbirth in relation to Diabetes and Hypertension 586066 Table 6.5 Stillbirth rate in relation to risk levels at booking 616759 Table 6.6 Stillbirth rate in relation to birth weight 626860

CHAPTER 7: Prematurity Table 7.1 Total number of premature births for 2010-2012 636572 Table 7.2 Preterm delivery by SDP 2011 and 2012 646673 Table 7.3 Distribution of preterm deliveries by age and parity 2011 and 2012 656774 Table 7.4 Distribution of preterm delivery by ethnicity 2011 and 2012 656774 Table 7.5 Preterm delivery in relation to accoucher 2011 and 2012 666875 Distribution of preterm in relation to medical disorders 2011 and Table 7.6 676976 2012 Table 7.7 Birth weight and preterm delivery 2011 and 2012 687077 Table 7.8 Mode of delivery and preterm delivery 2011 and 2012 687077 Table 7.9 Preterm outcome 2011 and 2012 687178

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CHAPTER 8 : Anemia Distribution of anaemia at booking and at delivery by SDP 2011 Table 8.1 717482 and 2012 Distribution of anaemia at booking and at delivery by ethnicity Table 8.2 7283 2011 and 2012 75 Table 8.3 Anaemia at booking and delivery by parity in 2011 and 2012 737684 Distribution of anaemia at booking and at delivery by age 2011 Table 8.4 747785 and 2012 Distribution of anaemia at booking and at delivery by mode of Table 8.5 757886 delivery 2011 and 2012 Distribution of anaemia at booking and at delivery and Table 8.6 7687 complications of delivery 2011 and 2012 79 Distribution of anaemia at booking and at delivery and Apgar Table 8.7 767987 scores 2011 and 2012

CHAPTER 9: Hypertensive Disorders in Pregnancy Table 9.1 Incidence of HDP by SDP 2011 and 2012 798291 Table 9.2 Type of HDP from 2011 and 2012 798291 Table 9.3 HDP by ethnicity from 2011 and 2012 808392 Table 9.4 HDP in relation to Parity 2011 and 2012 818493 Table 9.5 HDP in relation to Age 2011 and 2012 828594 Table 9.6 Mode of Delivery among HDP 2011 and 2012 838695 Table 9.7 HDP in relation to fetal weight 2011 and 2012 848796 Table 9.8 Apgar score and HDP in 2011 and 2012 858897 Table 9.9 Fetal Complications in HDP 2011 and 2012 868998 Table 9.10 Maternal complications in HDP 2011 and 2012 868998

CHAPTER 10: Heart Disease in Pregnancy

Table 10.1 Heart disease from SDP 2011 and 2012 1028992 Table 10.2 Types of heart disease and 2011 and 2012 1028992 Table 10.3 Heart disease by ethnicity 2011 and 2012 1039093 Table 10.4 Heart disease by age 2011 and 2012 1049194 Table 10.5 Heart disease by parity 2011 and 2012 1059295 Table 10.6 Mode of delivery in heart disease 2011 and 2012 1059295 Table 10.7 Severity of heart disease 2011 and 2012 1069396 Maternal and fetal complications in heart disease in pregnancy Table 10.8 1079497 2011 and 2012

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CHAPTER 11: Sexually Transmitted Disease in Pregnancy Table 11.1 Incidence of HIV by SDP 2011 and 2012 1119799 Table 11.2 Incidence of Syphilis by SDP 2011 and 2012 11298100 Table 11.3 HIV and Syphilis in pregnancy by ethnicity 2011 and 2012 11399101 Table 11.4 HIV and Syphilis in pregnancy by age 2011 and 2012 114100102 Table 11.5 HIV and Syphilis in pregnancy by Parity 2011 and 2012 115101103 HIV and Syphilis in pregnancy by mode of delivery 2011 and Table 11.6 115101103 2012 Table 11.7 HIV and Syphilis in pregnancy by complications 2011 and 2012 116102104

CHAPTER 12: Medical Disorder in Pregnancy

Table 12.1 Medical disorders in pregnancy by SDP 2011 120107105 Table 12.2 Medical disorders in pregnancy by SDP 2012 121108106 Table 12.3 Medical disorders in pregnancy by ethnicity 2011 122109107 Table 12.4 Medical disorders in pregnancy by ethnicity 2012 123110108 Table 12.5 Medical disorders in pregnancy by age 2011 and 2012 124111109 Table 12.6 Medical disorders in pregnancy by Parity 2011 and 2012 125112110 Table 12.7 Medical disorders in pregnancy by gestation 2011 and 2012 125112110 Table 12.8 Medical disorders in pregnancy and fetal outcome 2011 and 2012 126113111 Medical disorders in pregnancy and maternal outcome 2011 and Table 12.9 126113111 2012

List of Graph

Graph 2.1 CS rates from SDP 2011 and 2012 2022 Graph 2.2 Indications for CS 2011 and 2012 2628 Graph 4.1 Types of Diabetic Pregnancy in Malaysia 3741 Graph 7.1 Percentage of preterm births 2010-2012 636572 Graph 8.1 Anaemia at booking and anaemia at delivery 2011 and 2012 737684

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TYPE OF DELIVERY

National Obstetrics Registry

TYPE OF DELIVERY

National Obstetrics Registry National Obstetrics Registry

CHAPTER 1 TYPE OF DELIVERY

Sudesan Raman, Ganesh Raj Vaiyapuri, Sariha Abd.Razak, Rozihan Ismail.

Tengku Ampuan Afzan Hospital, Pahang

SUMMARY

There were a total of 136,863 deliveries in 2011 and 124,096 in 2012 from the 14 SDP in Malaysia. The vaginal deliveries accounted for 70.78 % whilst in 2012 it was at 69.98%.

1.1 INTRODUCTION

Vaginal delivery was the main mode of delivery .CS rates were 23.41% in 2011 and 25.08% in 2012. The highest delivery rate was from HL Sabah in both years

1.2 PATIENT DERMOGRAPHICS

Highest birth rates were seen in Malay ethnicity at 68.44% in 2011 and 69.78% in 2012. Foreigners had a higher birth rate in both years than the other two major ethnic group in the country. In both the years the age group with the highest delivery rate was in 25- 29 years. CS was 32.46% in 2011 and 33.20 % in this group and CS rates were higher among Indians in both years. CS rates were also higher in primi gravida and vacuum extraction was the instrument of choice in both years. Women who were color coded green had a higher rate of instrumental delivery.19.02 % of women color coded white 1 had CS in 2011 and similarly in 2012. Diabetes in pregnancy contributed to a higher CS rate in both years followed by hypertension in pregnancy.

1.3 OUTCOMES

More than 90% of babies had Apgar score >7 at 5 min of life. 51.21% of vaginal breech babies had Apgar> 7 at 1 min and 61.68% had Apgar score > 7 at 5 min in 2011. In 2012 vaginal breech babies had Apgar score > 7 at 1 min was 49.33% whilst Apgar score > 7 at 5 min was 63.62%.

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1.4 CONCLUSION Table 1.1 Distribution of delivery by SDP 2011 and 2012 14 tertiary hospitals in Malaysia contributed data to NOR. There were a total of 136,863 2011 2012 SDP deliveries in 2011 which accounted for 33.08% of all deliveries in the public hospitals. In n % n % 2012, NOR captured 124,096 deliveries which accounted for 32% all deliveries in the HTF, Perlis 4,119 3.01 3,954 3.19 public hospitals. HSB, Kedah 10,502 7.67 10,419 8.40 HPP 3,383 2.47 3,046 2.45 1.5 RECOMMENDATION HRPB, Perak 6,320 4.62 4,603 3.71 HTAR, Selangor 12,477 9.12 12,212 9.84 HKL 11,868 8.67 11,995 9.67 1. To make all the fields mandatory HTJ Negeri Sembilan 4,886 3.57 6,273 5.05 2. To recruit all hospitals in stages to provide data to NOR for a comprehensive Hospital Melaka 10,939 7.99 10,877 8.76 analysis of obstetric care in the country. HSA, Johor 12,641 9.24 12,466 10.05 HTAA, Pahang 9,431 6.89 8,823 7.11 HSNZ, Terengganu 12,181 8.90 12,945 10.43 1.6 REFERRENCES HRPZ 11, Kelantan 13,220 9.66 11,096 8.94 HU Sarawak 9,941 7.26 1,522 1.23 HL, Sabah 14,955 10.93 13,865 11.17 1. Preliminary report of National Obstetrics Registry 2009 Total 136,863 100 124,096 100 2. National Obstetrics Registry – 2nd Report 2010.

Table 1.2 Distribution of Total delivery by Types 2011 and 2012 2011 2012 Delivery Types n % n % SVD 96,312 70.37 86,080 69.37 Vaginal Breech 535 0.39 448 0.36 NA 24 0.02 16 0.01 Total 96,871 70.78 86,837 69.98

Vacuum 4,387 3.21 4,183 3.37 Instrumental Forceps 568 0.42 437 0.35 Total 4,947 3.61 4,616 3.72

LSCS 31,817 23.25 30,929 24.92 Classical 133 0.10 139 0.11 CS Hysterotomy 18 0.01 23 0.02 Hysterectomy 53 0.04 51 0.04 Others 10 0.01 10 0.01 Total 32,037 23.41 31,124 25.08

NA 3,007 2.20 1,519 1.22

Total 136,862 100.00 124,096 100.00

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1.4 CONCLUSION

1.4 CONCLUSION Table 1.1 Distribution of delivery by SDP 2011 and 2012 14 tertiary hospitals in Malaysia contributed data to NOR. There were a total of 136,863 2011 2012 TableSDP 1.1 Distribution of delivery by SDP 2011 and 2012 deliveries in 2011 which accounted for 33.08% of all deliveries in the public hospitals. In n % n % 14 tertiary hospitals in Malaysia contributed data to NOR. There were a total of 136,863 2011 2012 2012, NOR captured 124,096 deliveries which accounted for 32% all deliveries in the SDP deliveries in 2011 which accounted for 33.08% of all deliveries in the public hospitals. In HTF, Perlis 4,119 n 3.01 %3,954 3.19n % public hospitals. 2012, NOR captured 124,096 deliveries which accounted for 32% all deliveries in the HSB, KedahHTF , Perlis 10,502 4,1197.67 3.0110,419 3,9548.40 3.19 public hospitals. HPPHSB , Kedah 3,383 10,5022.47 7.673,046 10,4192.45 8.40 HRPB, Perak 6,320 4.62 4,603 3.71 1.5 RECOMMENDATION HPP 3,383 2.47 3,046 2.45 HTAR, Selangor 12,477 9.12 12,212 9.84 1.5 RECOMMENDATION HRPB, Perak 6,320 4.62 4,603 3.71 HKLHTAR , Selangor 11,868 12,4778.67 9.111,9952 12,2129.67 9.84 1. To make all the fields mandatory HTJ Negeri Sembilan 4,886 3.57 6,273 5.05 HKL 11,868 8.67 11,995 9.67 Hospital Melaka 10,939 7.99 10,877 8.76 2. To recruit1. To allmake hospitals all the fieldsin stages mandatory to provide data to NOR for a comprehensive HTJ Negeri Sembilan 4,886 3.57 6,273 5.05 HSA, Johor 12,641 9.24 12,466 10.05 analysis2. To of obstetricrecruit all care hospitals in the country.in stages to provide data to NOR for a comprehensive Hospital Melaka 10,939 7.99 10,877 8.76 HTAA, Pahang 9,431 6.89 8,823 7.11 HSA, Johor 12,641 9.24 12,466 10.05 analysis of obstetric care in the country. HSNZ, Terengganu 12,181 8.90 12,945 10.43 1.6 REFERRENCES HTAA, Pahang 9,431 6.89 8,823 7.11 HRPZ 11HSNZ, Kel,antan Terengganu 13,220 12,1819.66 8.9011,096 12,9458.94 10.43 HU Sarawak 9,941 7.26 1,522 1.23 1.6 REFERRENCES HRPZ 11, Kelantan 13,220 9.66 11,096 8.94 HL, Sabah 14,955 10.93 13,865 11.17 1. Preliminary report of National Obstetrics Registry 2009 HU Sarawak 9,941 7.26 1,522 1.23 Total 136,863 100 124,096 100 2. National Obstetrics Registry – 2nd Report 2010. HL, Sabah 14,955 10.93 13,865 11.17 1. Preliminary report of National Obstetrics Registry 2009 Total 136,863 100 124,096 100 2. National Obstetrics Registry – 2nd Report 2010.

Table 1.2 Distribution of Total delivery by Types 2011 and 2012 2011 2012 DeliveryTable 1.2 Types Distribution of Total delivery by Types 2011 and 2012 n %2011 n %2012 Delivery SVD Types96,312 70.37 86,080 69.37 n % n % Vaginal Breech 535 0.39 448 0.36 SVD 96,312 70.37 86,080 69.37 NA 24 0.02 16 0.01 Vaginal Breech 535 0.39 448 0.36 Total 96,871 70.78 86,837 69.98 NA 24 0.02 16 0.01 Vacuum 4,387 3.21 4,183 3.37 InstrumentalTotal 96,871 70.78 86,837 69.98 Forceps 568 0.42 437 0.35 Vacuum 4,387 3.21 4,183 3.37 TotalInstrumental 4,947 3.61 4,616 3.72 Forceps 568 0.42 437 0.35 LSCS 31,817 23.25 30,929 24.92 Total 4,947 3.61 4,616 3.72 Classical 133 0.10 139 0.11 LSCS 31,817 23.25 30,929 24.92 CS Hysterotomy 18 0.01 23 0.02 Classical 133 0.10 139 0.11 Hysterectomy 53 0.04 51 0.04 CS Hysterotomy 18 0.01 23 0.02 Others 10 0.01 10 0.01 Hysterectomy 53 0.04 51 0.04 Total 32,037 23.41 31,124 25.08 Others 10 0.01 10 0.01 NA 3,007 2.20 1,519 1.22 Total 32,037 23.41 31,124 25.08 Total 136,862 100.00 124,096 100.00 NA 3,007 2.20 1,519 1.22

Total 136,862 100.00 124,096 100.00

3 4 4

2 3 National Obstetrics Registry 59 59 - 1 0 0 0 0 0 2 0 0.00 0.00 0.00 0.00 0.00 0.00 0.01 0.00 55 - 55 54 54 - 2 7 3 1 8 0 14 17 0.01 0.04 0.02 0.10 0.02 0.02 0.03 0.00 50 - 50 49 49 - 6 6 7 6 222 128 200 101 0.23 0.12 0.40 0.20 0.23 0.15 0.32 0.39 45 - 45 44 44 - 88 58 100 103 3.14 2.02 4.74 3.43 3.07 1.91 4.65 3.82 3043 1519 2668 1448 40 - 40 39 39 - 360 415 332 196 7.28 7.19 5008 9963 4913 11.63 15.63 13.80 11.47 15.79 12.90 35 - 35 11269 Age 34 34 - 909 728 952 365 8597 8637 23.82 18.37 26.83 24.21 24.04 20.62 27.75 24.03 30 - 30 23071 20876 5 29 29 - 956 522 34.63 2,062 41.68 32.46 31.79 35.35 1,866 40.42 33.20 34.36 25 - 25 33,546 10,399 30,701 10,332 24 24 - 547 281 20.25 1,179 23.83 4,704 14.68 18.19 19.66 1,060 22.96 4,103 13.18 18.50 20 - 20 19,618 17,069 Table 1.3 Distribution of delivery by age by Table 2011 of delivery 1.3and 2012 Distribution 19 19 - 73 301 867 182 278 764 5.55 6.08 2.71 6.05 5.32 6.02 2.45 4.81 5,381 4,621 15 - 15 14 14 - 4 4 5 0 12 17 107 104 0.11 0.08 0.04 0.13 0.12 0.11 0.05 0.00 10 - 10 % % % % % % % % NA NA 2011 2012 Type Vaginal Vaginal Delivery Caesarean Caesarean Instrumental Instrumental

4 National Obstetrics Registry

89 %

8.90 3.55 3.01 7.68 2.47 4.62 9.11 8.68 8.00 9.24 6. 9.65 7.27 10.92 65.81

Total

n 4,856 4,124 3,387 6,323 9,435 9,947 12,187 10,506 12,470 11,873 10,945 12,647 13,212 14,952 90,077

% 1.33 3.64 0.78 2.18 4.66 2.17 0.72 0.77 0.89 2.56 0.81 0.89 9.57 2.43 2.22

n 32 90 91 97 76 162 177 229 158 137 324 118 952 364 1,996

% 18.91 21.19 23.08 24.84 43.22 46.01 23.22 28.61 22.30 26.44 24.11 17.37 23.5 11.83 35.56

n Caesarean 952 2011 2305 1029 2610 1464 2909 2895 3397 2441 3344 2275 2295 2346 1769

32031

% 0.21 0.27 0.10 0.09 0.44 0.13 2.04 0.14 0.56 0.70 0.16 0.11 0.38 0.03 0.21

4 9 8 4 n Forceps 26 13 15 17 61 89 15 14 38 255 186

% 2.89 5.35 1.56 0.36 4.80 1.64 3.62 7.45 4.20 0.41 3.85 2.88 2.54 0.71 3.05

Instrumental

n Vacuum 53 23 54 86 119 562 599 195 396 942 396 383 431 148 2,292

% 0.00 0.02 0.00 0.00 0.01 0.02 0.01 0.03 0.03 0.01 0.00 0.01 0.01 0.02 0.14 ribution of delivery type by SDP type by delivery ribution of NA

0 2 0 0 1 2 1 4 3 1 0 1 2 7 n 11

0.44 0.55 0.27 0.11 0.61 0.54 0.25 0.59 0.19 0.40 0.42 0.15 0.30 0.45 0.21

Table 1.4 Dist Breech 9 7 n 55 10 18 58 76 64 27 75 18 53 42 23 266 Vaginal

78.37 71.50 72.72 66.97 49.84 51.23 68.60 68.28 72.38 62.22 70.50 80.81 62.19 82.66 59.17

6 SVD

n 9,551 3,472 2,999 7,03 1,688 3,239 8,554 8,107 7,922 7,869 6,652 6,186 10,677 12,360 53,295

Melaka

HKL HPP SDP Total 2011 HSNZ,

Sembilan HL, Sabah HL, HTF, Perlis HSA, Johor HTJ, Negeri Terengganu HSB, Kedah HU Sarawak HU HRPB, Perak HTAA, Pahang Hospital HTAR, Selangor HRPZ II,HRPZ Kelantan

5 5 National Obstetrics Registry

% 8.92 9.11 7.62 8.11 7.95 4.58 6.45 2.89 2.23 9.92 9.46 8.77 1.11 3.37 90.48

Total

n 6,265 8,821 3,957 3,047 1,524 4,606 12,210 12,471 10,426 11,099 10,878 13,577 12,950 12,004 123,835

% 1.33 1.27 1.55 7.51 0.29 0.08 0.09 0.05 2.56 0.01 0.00 0.02 1.23 1.18 1.22

5 8 2 1 0 2 n 32 78 18 56 163 158 162 834 1,519

% 22.31 62.35 25.75 27.14 27.01 19.32 24.04 25.35 23.01 23.63 44.31 14.20 16.09 32.66 25.16

n Caesarean 340 935 2872 3144 3385 2816 2144 2615 1588 2030 1350 1928 2084 3921 31152

% 0.20 0.04 1.51 0.66 0.21 0.07 0.16 0.27 0.33 0.28 0.46 0.04 0.22 0.12 0.35

Forceps 3 2 8 5 n 82 22 17 17 29 11 14 28 15 184 437

% 6.98 6.92 0.89 3.25 3.40 4.02 2.70 1.74 2.04 1.31 2.65 3.38 2.89 0.26 4.82

7 Instrumental

Vacuum n 99 53 44 12 871 721 354 213 355 107 277 170 318 589 4,183

0.01 0.03 0.00 0.03 0.02 0.00 0.05 0.00 0.01 0.02 0.00 0.01 0.07 0.00 0.01 NA Distribution of delivery type by SDP type 2012 by of delivery Distribution

1 3 0 3 1 0 2 0 1 3 0 1 0 1 n 16

0.52 0.04 0.60 0.57 0.48 0.31 0.24 0.26 0.20 0.58 0.26 0.07 0.59 0.27 0.36 Table 1.5

Breech 8 2 8 9 n 73 71 50 34 26 16 18 23 77 33 448 Vaginal

.90 .34 %

72.83 36.08 65.98 63.37 63.80 71 71.99 70.63 72 72.71 50.67 83.64 81.76 64.27 69.51

SVD

n 1,110 1,662 8,056 7,903 6,652 7,980 7,831 4,425 6,381 2,877 1,544 7,715 11,356 10,588 86,080

II,

HKL SDP HPP Total 2012 HSNZ, HRPZ HRPZ Kelantan Sembilan HL, Sabah HL, HTF, Perlis HSA, Joh HTJ, Negeri Terengganu HSB, Kedah HU Sarawak HU HRPB, Perak HTAA, Pahang Hospital Melaka HTAR, Selangor

6 6 National Obstetrics Registry

2.25 3.68 4.73 2.51 5.76 3.46 3.85 10.57 52.75 12.40 13.62 15.15 57.59 11.68

Total

n 3,040 4,984 6,405 3,066 7,052 4,232 4,716 14,308 71,421 16,788 18,439 18,540 70,478 14,296

.17 %

2.89 9 3.84 7.71 2.66 3.66 4.53 2.20 48.61 13.59 14.20 18.92 56.36 11.66

n 85 40 55 68 33 270 113 400 227 418 284 846 175 1,431

% 37.60 34.74 24.11 11.62 19.02 18.08 16.13 39.07 33.89 24.40 13.44 19.03 24.50 20.53

2011 and 2012 n

193 Caesarean 579 948 968 1143 4971 3 1158 2974 1198 6283 2721 1037 17219 17198

% 3.36 2.30 4.78 5.84 3.46 2.54 4.16 2.77 10.09 56.28 17.35 17.55 53.58 15.94

Forceps

n 19 57 13 98 27 33 15 76 11 69 18 12 318 232

8 risk level at booking level risk %

2.47 9.32 2.43 4.92 2.50 4.18 3.13 3.08 53.80 16.72 10.33 14.76 56.61 15.75 Instrumental

Vacuum n 108 407 106 730 215 451 104 614 174 655 130 128 2,349 2,355

% 0.00 4.35 4.35 8.70 4.35 0.00 0.00 0.00 6.25 6.25 65.22 13.04 56.25 31.25 NA

0 1 1 2 1 3 0 0 9 0 1 1 5 n 15

Deliveries in relation in to Deliveries

2.99 9.43 4.83 9.43 4.20 3.64 9.24 9.80 6.44 51.95 10.80 10.57 10.36 56.30

Breech n 13 41 21 47 41 46 15 37 13 33 35 23 226 201 Vaginal Table 1.6

1.75 8.93 4.33 4.94 1.98 6.84 3.44 4.15 52.04 12.86 15.15 13.14 58.01 12.44

SVD

n 1,672 8,561 4,151 4,736 1,694 5,851 2,943 3,547 49,863 12,318 14,514 11,246 49,637 10,642

Risk 201 Level at Level Booking Red Yellow Green White II White I No Code NA 2012 Red Yellow Green White II White I No code NA

7 7 National Obstetrics Registry

% 1.99 6.23 4.72 2.96 0.25 2.33 0.09 1.59 1.16 0.67 8.37 0.89 0.30

68.44 100.00

Total 2

n 344 123 910 410 2,695 8,43 6,392 4,002 3,151 2,152 1,573 1,209 92,661 11,332 135,386

% 2.04 1.88 3.11 1.58 2.32 2.91 2.09 8.09 7.82 1.43 2.15 2.89 3.90 2.17

11.38

n 55 93 10 66 14 13 35 16 262 101 174 123 244 1,738 2,944

% 13.32 23.32 27.37 34.64 13.82 20.64 10.92 14.63 21.93 25.68 30.55 20.76 16.87 13.41 23.07

aesarean n 71 18 55 C 359 553 344 472 404 278 204 2308 2214 2352 21605 31237

0.19 0.39 0.71 0.80 0.02 0.00 0.06 0.00 0.37 0.45 0.33 0.50 0.50 0.49 0.42

5 1 0 2 0 8 7 3 6 2 n Forceps 60 51 57 363 565

43 % 2.89 3.00 4.54 3.99 3.12 2.03 3.11 0.81 3.67 3. 3.74 3.76 3.14 3.17 3.23

Instrumental

7 1 n

Vacuum 78 98 79 54 34 38 13 9 383 255 125 426 2,776 4,367

elivery by ethnicity 2011 by ethnicity elivery % 0.04 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.03 0.00 0.00 0.02 NA

1 0 0 0 0 0 0 0 0 0 3 0 0 n 19 23

Table 1.7 D 0.00 0.33 0.25 0.41 0.20 0.00 0.16 0.00 0.42 0.51 0.11 0.29 0.83 0.98 0.32

Breech 0 8 0 5 0 9 8 1 4 n 21 26 33 10 310 435 Vaginal

81.52 71.07 64.02 58.59 80.51 74.42 83.66 73.17 65.52 62.11 63.85 72.51 75.77 78.05 70.77

SVD

n 636 90 256 977 581 916 320 2,197 5,398 3,745 3,222 2, 1,410 8,217 65,850 95,815

Iban Total 2011 Murut Bajau Malay Indian Others Bidayuh Chinese Melanau unknown Ethnicity Foreigners

Kadazan/Dusun Sabah & Sarawak & Sabah OA (Peninsular Malaysia) Other indigenous group in in group indigenous Other

8 8 National Obstetrics Registry

% 1.88 6.06 5.01 2.95 0.21 2.36 0.03 0.62 0.29 0.61 8.60 1.18 0.41

69.78 100.00

Total

n 38 258 756 360 749 506 2,305 7,414 6,128 3,607 2,884 1,450 85,397 10,528 122,380

% 0.13 1.46 1.04 0.59 0.06 0.00 0.00 0.00 1.46 0.28 0.40 1.07 0.55 0.40 1.23

3 2 0 0 0 1 3 8 2 n 77 36 11 113 1,245 1,501

% 14.84 24.76 29.65 36.9 17.30 15.12 12.17 28.95 19.18 25.56 37.12 23.20 22.14 19.37 24.80

n 39 11 92 98 Caesarean 342 624 351 145 278 321 2198 2265 2443 21146 30353

0.09 0.33 0.62 0.59 0.08 0.00 0.21 0.00 0.13 0.00 0.13 0.55 0.14 0.00 0.35

2 3 0 6 0 1 0 1 2 0 n Forceps 46 36 58 278 433

% 2.00 3.25 4.94 4.18 1.77 1.16 2.15 7.89 3.17 3.06 2.40 4.34 3.31 5.53 3.40

Instrumental

by ethnicity 2012 by ethnicity

3 3 n

Vacuum 46 64 62 24 11 18 48 28

366 256 457 10 2,774 4,160

.00 % elivery 0.00 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.13 0.00 0 0.03 0.00 0.00 0.01 NA

0 0 0 0 0 0 0 1 0 0 3 0 0 n 12 16

0.04 0.31 0.27 0.38 0.06 0.39 0.07 2.63 0.13 0.56 0.40 0.29 0.07 0.20 0.29 Table 1.8 D

Breech 1 2 1 2 1 1 2 3 1 1 n 20 23 31 268 357 Vaginal

82.91 69.88 63.49 57.31 80.73 83.33 85.40 60.53 75.79 70.56 59.55 70.51 73.79 74.51 69.91

SVD

70 n 23 215 573 254 446 377 1,911 4,707 3,512 2,912 2,463 7,423 1,0 59,674 85,560

nau

Iban 2012 Total Murut Bajau Malay Indian Others Bidayuh Chinese Mela Unknown Ethnicity Foreigners

Kadazan/Dusun Sabah & Sarawak & Sabah OA (Peninsular Malaysia) Other indigenous group in in group indigenous Other

9 9 National Obstetrics Registry

% % 2.23 2.17 2.20 5.99 2.20 1.48 1.09 1.13 1.20 1.23

1 n n 13 75 175 638 805 1,038 1,781 3,007 1,519

% % 26.19 22.09 20.93 12.44 23.40 27.89 23.79 22.79 12.05 25.16

n n 27 10 Caesarean 1663 1506 12197 18144 32031 11998 17638 31152

% % 0.87 0.19 0.04 0.46 0.42 0.77 0.13 0.12 0.00 0.35

3 1 8 0 n n Forceps 98 406 158 568 331 437

% % 6.05 1.80 1.08 2.76 3.21 6.45 1.82 0.92 1.20 3.38

Instrumental

6 1 n n

Vacuum 86 61

2,818 1,477 4,387 2,773 1,348 4,183 11 by Parity 2011 and 2012 and 2011 Parity by

% % 0.02 0.02 0.00 0.00 0.02 0.01 0.01 0.00 0.00 0.01 very NA

7 0 0 6 0 0 n n 17 24 10 16 Deli

00 % %

le 1.9 0.34 0.40 0.58 0.00 0.39 0.32 0.39 0.32 0. 0.36

Tab Breech 0 0 n n 46 21 157 332 535 139 288 448 Vaginal

% %

64.30 73.33 75.16 78.34 70.37 63.07 72.77 74.72 85.54 69.51

SVD

n n 71 170 5,971 4,938 29,941 60,230 96,312 27,133 53,938 86,080

5 5

- - 1 1 ≥ 6 NA ≥ 6 NA 2 2 2011 Total 2012 Total Parity

10 10 National Obstetrics Registry

8 % 8.57 0.69 7.83 4.25 0.76 3.12 0.67 0.03 0.68 0.38 0.0 0.01 0.00 5.07 0.07 0.79 0.35 0.00 1.78 0.03

91.31 99.48

Total

1 5 n 46 18 97 37 948 918 926 514 112 474 5,823 1,036 4,270 6,941 1,081 2,442 11,736 10,716 124,973 136,148

% 7.78 0.76 6.52 3.86 0.83 2.56 0.30 0.07 0.47 0.17 0.13 0.03 0.00 3.56 0.73 0.43 0.13 0.00 1.63 0.00

92.38 99.67

9 2 5 4 1 0 4 0 0 n 23 25 77 14 22 13 49 234 196 116 107 2,720 2,934

% 1.17 8.13 1.39 5.84 1.94 0.12 0.83 0.35 0.12 0.04 0.00 5.50 0.06 0.78 0.37 0.01 2.19 0.04 13.09 11.85 84.51 97.01

0 1 2 n 37 39 13 20 13 Caesarean 374 446 620 267 111 249 12 701 4193 3795 2603 1872 1763 27068 31073

% 0.88 2.99 0.00 2.82 0.70 0.00 1.06 0.70 0.18 0.00 0.00 7.22 0.18 0.70 0.35 0.00 1.58 0.00 11.27 10.39 88.20 99.12

Forceps 5 0 4 0 6 4 1 0 0 1 4 2 0 9 0 n 64 59 17 16 41 501 560

% 8.09 0.84 7.20 4.03 0.91 2.71 0.52 0.00 1.41 0.82 0.16 0.00 0.00 5.04 0.05 0.73 0.34 0.00 1.39 0.05 91.47 98.95 Instrumental

Vacuum 0 7 0 0 2 0 2 n 37 40 23 62 36 32 15 61 355 316 177 119 221 4,013 4,323

% 4.17 0.00 4.17 0.00 0.00 0.00 0.00 0.0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 91.67 100.00 NA

1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 n 22 23 Deliveries in relation to Medical problems2011 Medical in relation to Deliveries

% 5.23 0.93 4.30 4.49 0.93 3.18 0.37 0.00 0.93 0.75 0.19 0.00 0.00 5. 0.00 0.93 0.19 0.00 1.31 0.00 92.34 99.07 ech

Bre 5 5 2 0 5 4 1 0 0 0 5 1 0 7 0 n Table 1.10 28 23 24 17 27 Vaginal 400 430

7.12 0.52 6.57 3.00 0.54 2.25 0.27 0.01 0.59 0.37 0.06 0.00 0.00 4.97 0.05 0.81 0.34 0.00 1.68 0.02 92.39 99.56

SVD

7 4 0 3 n 60 52 22 504 520 260 572 354 778 332 6,861 6,326 2,886 2,169 4,782 1,615 88,983 95,397

NA TB NA existing existing - - eclampsia Others - NYHA I NYHA Asthma NYHA II NYHA NYHA III NYHA

NYHA IV NYHA Diabetes Eclampsia Gestational Pre Pre Gestational Thalassemia Hypertension Pre Renal Disease Heart Disease Blood Disorder Collagen Disease Medical Problems

11 National Obstetrics Registry

% 8.72 0.60 7.52 3.78 0.63 2.73 0.62 0.04 0.56 0.30 0.07 0.01 0.00 4.89 0.06 0.80 0.42 0.00 1.67 0.04

91.52 99.36 83.50

7 Total

4 2 n 54 81 12 73 45 741 779 771 700 376 990 527 9,332 4,688 3,38 6,064 2,072 10,8 113,575 123,296 103,617

% 9.94 1.05 8.82 4.08 0.66 2.96 0.59 0.00 0.86 0.53 0.13 0.00 0.00 3.36 0.07 0.59 0.33 0.07 1.18 0.00

90.06 99.28 84.00

9 0 8 2 0 0 1 9 5 1 0 n 16 62 10 45 13 51 18 151 134 1,350 1,491 1,276

% 1.21 7.13 1.25 4.99 1.67 0.14 0.71 0.30 0.10 0.02 0.01 5.47 0.06 0.75 0.44 0.00 2.01 0.07 12.74 10.79 85.43 97.01 76.94

6 7 2 0 n 44 94 30 20 21 Caesarean 378 388 521 220 233 137 62 3968 3362 2221 1556 1704 26613 30220 23969

% 9.84 1.14 8.24 4.35 0.69 2.97 0.69 0.00 1.37 0.46 0.23 0.00 0.00 5.95 0.23 0.23 0.00 0.00 0.92 0.00 90.39 99.31 81.46

Forceps 5 3 3 0 6 2 1 0 0 1 1 0 0 4 0 n 43 36 19 13 26 392 430 356

% 8.49 0.38 7.34 3.73 0.38 3.01 0.57 0.02 1.36 0.81 0.26 0.00 0.00 5.40 0.05 0.79 0.33 0.00 1.89 0.02 92.25 98.92 82.84 Instrumental

Vacuum 1 0 0 2 0 1 n 16 16 24 57 34 11 33 14 79 355 307 156 126 226 3,837 4,115 3,465

% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100.00 100.00 177.78 NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 n 16 16 16 Deliveries in relation to Medical problems 2012 in relationDeliveries Medical to

1.11 %

4.91 0.22 4.69 4.46 0.00 3.57 0.89 0.00 0.00 0.00 0.00 0.00 0.00 3.79 0.00 0.45 0.45 0.00 1.79 0.00 93.97 84.15 100.00

Breech

Table 1 0 4 0 0 0 0 0 0 0 2 2 0 8 0 n Vaginal 22 21 20 16 17 326 357 377

3 %

7.30 0.38 6.36 2.57 0.42 1.89 0.24 0.01 0.47 0.28 0.04 0.01 0.00 4.69 0.06 0.8 0.43 0.00 1.55 0.03 93.21 99.67 86.15

SVD

9 5 2 1 n 37 49 23 325 362 210 404 238 712 369 6,286 5,472 2,210 1,631 4,040 1,337 79,762 85,2 74,158

NA NA TB existing existing - - None eclampsia Others - NYHA I NYHA Asthma

NYHA II NYHA NYHA III NYHA NYHA IV NYHA Diabetes Eclampsia Gestational Pre Pre Gestational Thalassemia Hypertension Pre Renal Disease Heart Disease Blood Disorder Collagen Disease Medical Problems

12 12 National Obstetrics Registry

% 6.06 3.36 1.90 3.95 5.35 1.55 1.32 1.61

90.58 94.16 93.11 97.07

Total

n 8,300 4,598 2,596 5,402 6,620 1,916 1,634 1,990 123,966 128,866 115,298 120,211

% 0.40

19.72 53.28 27.00 13.10 59.43 27.47 11.92 27.40 60.74 38.80 60.87

6 n 593 812 394 826 181 416 922 589 924 1,602 1,787

% 1.81 2.30 2.55 9.63 0.57 2.14 0.69 10.64 87.55 95.15 89.80 97.17

n Caesarean 581 738 817 178 666 216 nd 2012 3407 3000 28043 30476 27974 30270 a

% 1.94 4.23 2.46 0.69 4.58 1.37 13.91 84.15 93.31 15.10 84.21 94.05

Forceps

3 6 n

79 11 24 14 66 20 478 530 368 411

1.07 3.21 2.03 0.14 3.85 0.26 14 15.93 83.00 94.76 16.59 83.27 95.89 Instrumental

Vacuum

6 n 47 89 11 699 141 694 161 3,641 4,157 3,483 4,011

% 2.50 4.17 0.00 0.00 75.00 20.83 79.17 20.83 1 75.00 12.50 87.50 12.50 Apgar score in relation to delivery 2011 score indelivery relation to Apgar NA

1 5 0 5 2 2 0 2 n 18 19 12 14

Table 1.12 24.11 51.21 24.67 10.47 61.68 27.85 27.90 49.33 22.77 13.39 63.62 22.99

Breech

74 n 56 60 Vaginal 129 2 132 330 149 125 221 102 285 103

3.52 3.13 1.29 3.64 2.96 0.82 0.84 0.85 93.35 95.07 96.22 98.32

SVD

n 703 721 728 3,392 3,010 1,243 3,502 2,552 89,910 91,567 82,824 84,631

≤ 7 NA ≤ 7 NA ≤ 7 NA ≤ 7 NA > 7 > 7 > 7 > 7 min min min min 2011 2012 Apgar 1 at Apgar 5 at Apgar 1 at Apgar 5 at Apgar

13 13 National Obstetrics Registry

% 9.93 8.18 0.19 0.57 0.40 0.15 0.00 0.01 0.19 0.59 1.56 0.00 0.00 0.00 0.01 0.07 0.00 2.18

74.11

Total

4 4 1 2 7 0 n 19 262 776 554 199 259 813 100 2,136 2,977 13,586 11,201 101,434

% 0.01 1.40 0.83 0.53 0.01 0.03 0.76 1.53 1.45 0.01 0.00 0.00 0.02 0.16 0.00 7.18 15.37 32.48 65.00

2 2 9 3 1 0 7 0 n 50 Caesarean 446 266 169 243 488 462

4912 2296 10383 20778

% 8.10 0.18 1.23 0.70 0.53 0.00 0.00 0.00 0.35 2.64 0.00 0.00 0.00 0.00 0.18 0.00 2.11 17.96 69.19

Forceps 1 7 4 3 0 0 0 2 0 0 0 0 1 0 n 46 15 12 102 393

.50 % 4.44 0.16 0.55 0 0.02 0.00 0.02 0.11 0.16 2.39 0.02 0.00 0.00 0.00 0.16 0.00 2.10 13.97 67.02 Instrumental

Vacuum 7 1 0 1 5 7 1 0 0 0 7 0 n 24 22 92 195 613 105 2,940

% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25.00 87.50 NA

6 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 n 21

0.19 0.56 0.75 0.75 0.00 0.00 0.00 0.75 1.31 2.43 0.00 0.00 0.00 0.00 0.19 0.00 3.55 43.18 63.18 omplication in relation to mode of delivery 2011 of delivery in relationomplication mode to

Breech 1 3 4 4 0 0 0 4 7 0 0 0 0 1 0 n 13 19 231 338 Vaginal

1.13

8.51 0.11 0.26 0.31 0.27 0.03 0.00 0.01 0.01 0.32 1.60 0.00 0.00 0.00 0.00 0.04 0.00 0.58 79.91 Table

SVD

2 9 7 0 0 2 0 0 n 26 41 102 249 295 258 309 558 8,196 1,539 76,964

NA DVT PPH 2011 None IUGR Others PPROM Embolism ≥ 1500 mls≥ 1500 < 1500 mls 1500 < Prematurity Not Available Uterine Atony Uterine Amniotic Fluid Cord Prolapse Foetal Distress Complications Uterine Rupture Uterine Inversion Uterine Retained Placenta Thromboembolism

14 National Obstetrics Registry

0.00 8.81 0.18 0.47 0.36 0.10 0.00 0.01 0.17 0.64 1.55 0.00 0.00 0.01 0.03 0.00 1.77 11.44 80.49

Total

2 6 7 3 6 2 n 10 40 221 588 449 126 213 789 1,919 2,201 14,196 10,931 99,881

% 0.01 0.01 1.19 0.82 0.34 0.01 0.02 0.66 1.70 1.58 0.00 0.01 0.03 0.05 0.00 5.42 16.39 33.25 71.37

2 4 3 5 0 2 8 0 n 17 Caesarean 369 255 106 205 527 491 5096 1684

10337 22191

2012

% 0.00 8.47 0.69 1.83 1.37 0.46 0.00 0.00 0.00 0.23 3.89 0.00 0.00 0.00 0.00 0.00 2.52 10.98 77.80

Forceps 0 3 8 6 2 0 0 0 1 0 0 0 0 0 n 37 48 17 11 340

% 0.00 5.19 0.12 0.45 0.41 0.02 0.02 0.00 0.00 0.17 2.27 0.00 0.00 0.00 0.10 0.02 1.53 11.09 78.89 Instrumental

Vacuum 0 5 1 1 0 0 7 0 0 0 4 1 n 19 17 95 64 217 464 3,300

lation to mode of delivery lation mode to 16 00

% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.75 81.25 NA

0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 n 13

0.00 0.22 0.00 0.67 0.67 0.00 0.00 0.00 0.45 0.67 1.56 0.00 0.00 0.00 0.22 0.00 4.02 58.48 67.41

Complication in re Complication Breech 0 1 0 3 3 0 0 0 2 3 7 0 0 0 1 0 n 18 262 302 Vaginal

.49 %

0.00 9.97 0.09 0.24 0.22 0.20 0.02 0.00 0.00 0.01 0.29 1.52 0.00 0.00 0.00 0.02 0.00 0 85.66 Table 1.14

SVD

2 2 6 0 3 4 2 1 n 81 17 18 209 189 168 251 424 8,581 1,309 73,735

NA DVT PPH 2012 None IUGR Others PPROM Embolism ≥ 1500 mls≥ 1500 < 1500 mls 1500 < Prematurity Not Available Uterine Atony Uterine Amniotic Fluid Cord Prolapse Foetal Distress Complications Uterine Rupture Uterine Inversion Uterine Retained Placenta Thromboembolism

15 15 National Obstetrics Registry

CAESAREAN SECTION

National Obstetrics Registry

CAESAREAN SECTION

National Obstetrics Registry National Obstetrics Registry

CHAPTER 2 CAESAREAN SECTION

SD Karalasingam¹, R Jegasothy², R Jeganathan³

1. National Clinical research centre 2. Kuala Lumpur Hospital 3. Sultanah Aminah Hospital, Johor

SUMMARY

CS accounted for 23.41% of all deliveries in 2011 and 25.08% in 2012 from all participating hospitals. The rates were higher from the survey done from the National Healthcare Establishment and Workforce Survey in 2011 which was reported at 19.73 %. Women of Indian ethnicity and primigravida had the highest CS rates in both years. In 2011, women aged 45-49 years had higher CS rates whilst in 2012 the rates were higher in women aged 40-44 years. The top 5 indications for CS were fetal distress, diabetes complicating pregnancy, breech presentation, poor progress and hypertension complicating pregnancy.

2.1 INTRODUCTION

CS accounted for 23.41% of all deliveries in the 14 tertiary hospitals in Malaysia. It has remained the same since 2010 at 23.08%. We see a slight increase in 2012 at 25.08%. HL, Sabah had the lowest CS rate similar to the findings in 2010 as compared to the other hospitals at 11.85% in 2011 and 13.90% in 2012. CS rate in HRPB, Perak has been going up from 32.32% in 2010 to 45.88% in 2011 and 62.33% in 2012. These figures are alarmingly high and we need to identify factors that have given rise to the increasing CS rates.

2.2 PATIENT DERMOGRAPHICS

Among the three major ethnic groups in the country, CS was highest among the Indians at 35.03% in 2011 and 37.39% in 2012. These findings were similar to the findings in 2010.In 2011 we see a higher CS rates among the OA (Peninsular Malaysia) at 35.03% as compared to 2010 which was 27.03%. Of the foreigners that had obstetric care at our facility, a quarter of them had CS as the mode of delivery in 2011 as seen in Table 2.2. Among the 3 major ethnic groups in the country, CS rate was higher among the Indians in 2011 and 2012 and this was also seen in the 2010 report. In 2011 and 2012 we see

16 16 National Obstetrics Registry

pattern as in 2011.Rate of maternal request for LSCS has risen. In 2010 the rate was 1. Planned caesarean section versus planned vaginal birth for breech presentation 2.75% whilst in 2011 and 2012 it was 3.22% and 3.40% respectively. Fetal distress at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. accounted for the highest CS rate in both the years followed by Diabetes complicating Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Lancet pregnancy. 2000. 2. National Obstetric Registry 2nd Report 2010 Editors Ravichandran Jeganathan Table 2.7 shows 95.63% of CS were done by Specialist and MO of more than 6 months and Shamala Devi Karalasingam. experience in O&G in 2011 whilst in 2012, 96.60 % of CS were done by Specialist and 3. National Healthcare establishment and workforce survey statistics 2009 and MO of more than 6 months experience in O&G. 2011.

2.4 OUTCOME

In 2011 as seen from Table 2.8, about 2.25 % of babies were asphyxiated following CS and in 2012 , 2% of babies were birth asphyxiated following CS. Birth asphyxia was higher in babies following Classical section, Hysterotomy and Caesarean hysterectomies in both years.

2.5 CONCLUSION

CS rates has been gradually rising in Malaysia. There is a wide range of variation in the CS rates from the participating public hospitals. The main contributor to rising CS rates was fetal distress and diagnosis solely by electronic fetal monitoring has led to increase in CS rates. However, it is reasonable that a decision for intervention for a compromised fetus must not be delayed to avoid neonatal morbidity and mortality. CS rates due to breech presentation have increased following practice changes as a result of the Hannah Trial as well as a reluctance to perform ECV.

20 19

17 17 National Obstetrics Registry

that about a quarter of the primi gravida had CS as the mode of delivery. In 2011 we 2.6 RECOMMENDATION see that 1.83% of women with colour code White 11 for delivery at home or at an alternating birthing centre had a CS and this rate was higher in 2012 at 3.05%. This 1. To reduce CS rates we should reduce the primary section rates and would reflect the fact that risk is a retrospective diagnosis while the small numbers Obstetricians must be involved in decisions in deciding upon CS. undergoing CS in this category probably reflect the general validity of the white code. 2. It is probably timely now to consider whether cases requiring CS should be seen by obstetricians before this major decision is taken. This would also provide 2.3 INDICATION FOR CS guidance and teaching to MOs. 3. CS audits should be performed in all hospitals. CS rates were higher among women with GDM at 12.3% as compared to Gestational 4. More research is required to conclude if VBAC was considered or attempted in hypertension at 6.1% in 2011.Similar findings as in 2011 where the CS rates were the group of patients with a previous CS. higher among women with GDM at 12.3% as compared to Gestational hypertension at 6.1% in 2012. Fetal distress was the commonest indication for CS at 32.48%. Poor 2.7 REFERENCE progress accounted for 8.64% which was similar to 2010. In 2012 we see a similar pattern as in 2011.Rate of maternal request for LSCS has risen. In 2010 the rate was 1. Planned caesarean section versus planned vaginal birth for breech presentation 2.75% whilst in 2011 and 2012 it was 3.22% and 3.40% respectively. Fetal distress at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. accounted for the highest CS rate in both the years followed by Diabetes complicating Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Lancet pregnancy. 2000. 2. National Obstetric Registry 2nd Report 2010 Editors Ravichandran Jeganathan Table 2.7 shows 95.63% of CS were done by Specialist and MO of more than 6 months and Shamala Devi Karalasingam. experience in O&G in 2011 whilst in 2012, 96.60 % of CS were done by Specialist and 3. National Healthcare establishment and workforce survey statistics 2009 and MO of more than 6 months experience in O&G. 2011.

2.4 OUTCOME

2.5 CONCLUSION

20 19

1818 National Obstetrics Registry

23.32 26.78 43.92 61.81 25.40 32.09 25.15 23.61 26.81 22.71 15.76 18.91 22.14 13.67 24.73 LSCS Rates

0 2 0 0 1 1 3 0 0 0 2 0 11 43 63 NA

362 691 962 259 2,017 2,099 2, 3,035 1,096 1,791 2,617 1,505 1,411 1,738 1,553 23,136 2012 Total CS Total Emergency

76 223 741 360 687 699 765 458 746 679 477 596 332 285 7,124 Elective

who Total Total 3,920 3,010 4,507 6,192 8,728 1,513 10,307 12,056 11,843 10,746 12,295 12,803 10,955 13,759 women 122,634 delivered and 2012 and

2011 22.85 24.68 42.81 45.36 22.94 28.18 21.38 22.01 25.96 23.67 18.47 17.12 23.32 11.67 23.08 LSCS Rates SDP

0 0 0 1 1 0 8 0 0 3 2 1 1 0 17 NA

CS rates by

741 696 1,861 1,123 2,175 2,128 2,594 1,698 2,601 1,656 1,646 1,810 1,922 1,479 24,130 2011 Total CS Total Emergency Table 2.1

193 705 305 644 704 711 331 686 636 550 572 426 375 254 7,092 Elective

who Total Total 4,087 3,336 6,217 4,841 9,333 9,854 10,396 12,351 11,729 10,833 12,467 12,019 13,066 14,851 women 135,380 delivered

HKL SDP HPP Total

HL, Sabah HL, HTF, Perlis HSA, Johor HSB, Kedah HU Sarawak HU HRPB, Perak HTAA, Pahang HTAR,Selangor Hospital Melaka HRPZ II,HRPZ Kelantan HSNZ, Terengganu HTJ,Negeri Sembilan

19 National Obstetrics Registry

SDP 2011 and 2012

22 .1 CS from rates .1 Graph 2

20 20 National Obstetrics Registry

% 14.46 24.72 29.57 36.95 16.58 13.36 11.71 28.95 19.08 25.56 37.03 22.94 21.47 19.96 24.68 LSCS

4 3 1 4 8 0 0 0 0 4 0 n 18 13 10 65 NA

7 n 29 69 82 284 500 294 121 218 263 1,471 1,740 2,007 16,051 23,136 2012 Total CS Total Emergency

6 4 n 54 49 24 23 59 52 19 722 524 111 423 5,054 7,124

Elective

n 38 262 760 360 748 517 who Total Total 2,338 7,417 6,128 3,685 2,930 1,467 85,391 10,593 women 122,634 delivered

3.06 13.32 23.30 27.34 34.66 13.84 20.87 10.92 14.63 21.82 25.68 30.58 20.76 16.87 13.98 2 LSCS

0 0 4 0 0 0 0 0 0 0 0 0 0 n

13 17 NA 23

n 57 16 46 307 454 288 391 334 242 157 ibution of CS by ethnicity 2011 ethnicity and CS 2012 by ibution of 1,616 1,705 2,025 16,492 24,130 2011 Total CS Total Emergency Distr

2 n 52 15 56 78 70 36 47 12 688 513 100 328 5,095 7,092 Elective

Table 2.2

n 345 123 909 413 who Total Total 2,695 8,428 6,400 4,003 3,151 2,149 1,573 1,209 92,649 11,333 women 135,380 delivered

ous group in in group ous

NA Iban Total Murut Bajau Malay Indian Others Bidayuh Chinese Melanau Ethnicity Foreigners Kadazan/Dusun Sabah & Sarawak & Sabah OA (Peninsular Malaysia) Other indigen Other

2121 National Obstetrics Registry

% 13.49 13.32 18.23 23.79 28.01 31.89 33.97 32.17 30.77 27.51 23.34 22.35 12.20 LSCS 100.00

0 3 9 8 1 0 0 0 4 0 n 25 19 27 34 NA

6 2 8 n 13 72 693 3,549 8,397 6,097 3,280 1,027 1,094 2012 10,325 11,709 Total CS Total Emergency

4 2 0 2 n 68 29 545 420 363 1,910 2,521 1,625 1,387 5,372 Elective

2 n 26 82 126 314 who 2011 and 2011 and 2012 Total Total 5,736 4,262 6,537 22,513 43,421 30,830 15,404 42,679 73,336 women delivered

24 % 9.45 0.00 12.88 18.06 22.14 25.81 29.36 31.88 35.36 26.92 25.91 21.73 20.61 12.04 LSCS by Age and Parity and Parity by Age

0 0 3 9 2 3 0 0 0 0 6 8 3 0 n NA CS

6 0 n Table 2.3 10 89 16 797 4,070 8,494 6,175 3,416 1,073 1,235 10,564 12,315 2011 Total CS Total Emergency

2 1 0 n 70 39 10 631 446 378 1,896 2,420 1,587 1,388 5,316 Elective

1 n 26 127 362 216 who Total Total 6,731 4,765 7,840 26,048 46,963 33,305 17,052 46,158 81,166 women delivered

14 19 24 29 34 39 44 49 54 59

------rity - 1 ≥ 6 NA Age 2 10 15 20 25 30 35 40 45 50 55 Pa

22 22 National Obstetrics Registry

.01 % CS % 9.41 5.75 0.00 7.40 2.92 0.7 3.18 0.91 5.91 5.47 1.18 0.00 1.29 13 84.84 17.64 69.98 33.89 43.64 14.09 32.27 13.51 36.84

Rates 3.65 1.85 3.70 9.71 3.94 3.12 8.96 3.41 3.27 15.88 55.01 10.20 20.68 56.61

Total 2 0 2 0 0 4 1 3 2 0 0 0 0 0 0 0 0 1 0 0 0 1 0

1 NA

579 948 993

1,143 4,97 3,193 1,158 3,041 1,198 6,283 2,721 1,037 17,219 17,198

0 4 2 6 0 46 70 20 46 14 14 % 273 172 321 512 148 172 456 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,879 2,434 1,928 1,380 1,243 25.00 62.50 12.50 30.00 70.00 Emergency Others

Total CS 2012 CS Total 0 2 5 0 1 0 0 0 3 7 0 0 0 0 n

0 1 3 0 7 6 0 8

61 84 32 72 26 11 25 58

108 999 370 228 458 170

1,168

Elective %

7.55 1.89 3.77 9.43 1.96 0.00 5.88 0.00

13.21 52.83 11.32 11.76 21.57 58.82

0 4 2 57 82 12 16 73 46

747 767 805 799 705 379 212 987 2011 and 2011 and 2012

Total 9,460 4,803 3,464 6,064 2,074 4 7 1 6 2 5 6 1 0 3 0 10,974 n 28 11 30 delivery Hysterectomy

% CS 8.85 0.54 0.02 8.40 2.02 0.82 4.58 0.38 8.02 5.50 1.14 0.11 0. % 13.41 90.60 17.25 71.78 33.35 42.75 14.89 30.53 14.02 39.78 Rates

0.00 9.09 0.00 0.00 0.00 0.00 17.65 17.65 17.65 17.65 11.76 17.65 31.82 59.09

25 l of bookingl of

26 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0

3 3 3 0 3 2 3 2 7 0 0 0 0 n 13

Caesarean Hysterotomy

ical problems and CS rates, 2011 and 20112012 andical problems CS rates,

by risk leve risk by 1 8 0 9 0 9 15 38 71 20 57 13 259 350 593 162 184 528 % 3,074 2,799 2,226 1,632 1,340 5.38 1.54 3.85 7.69 3.79 3.79 2.27 6.82 10.00 61.54 10.00 17.42 53.79 12.12 CS

Emergency

Classical 7 2 5 5 5 3 9 n 13 80 13 10 23 71 16

Total CS 2011 CS Total

8 0 1 4 1 7 2 4 Table 2.4 51 41 19 23 12 63

121 464 114 299 100 421 173

Distribution of med Distribution 1,220 1,091

Elective

3.64 1.86 3.70 9.53 3.93 3.13 8.98 3.42 3.18 15.94 55.12 10.22 20.70 56.66 2.5

LSCS

2 1 5

60 49 17 25 77 37 ,942 957 950 931 518 113 257 Table n Total Total 5,943 1,060 4,356 6 1,079 2,443 11,899 10,880 576 942 959 1129 4946 3170 1149 2956 delivery 1,185 6,239 2,705 1,031 17103 17,077

Disease

N NA Red Red 2011 2012 TB NA NA existing existing Green Green Yellow Yellow White I White I White II White - - eclampsia No Code No Code Booking Others - NYHA I NYHA Missing Asthma NYHA II NYHA NYHA III NYHA NYHA IV NYHA Diabetes Eclampsia Risk Level Riskat Level Gestational Pre Pre Gestational Not Available Hypertension Pre Renal Disease Blood Disorder Heart Disease Collagen Medical Problems

23 23 National Obstetrics Registry

1 .01 % CS 9.41 5.75 0.00 7.40 2.92 0.7 3.18 0.91 5.91 5.47 1.18 0.00 1.29 13 84.84 17.64 69.98 33.89 43.64 14.09 32.27 13.51 36.84 Rates

0 2 2 0 0 4 1 3 2 0 0 0 0 0 0 0 0 1 0 0 0 1 0 NA

0 4 2 6 0 46 70 20 46 14 14 273 172 321 512 148 172 456 2,879 2,434 1,928 1,380 1,243 Emergency

Total CS 2012 CS Total

0 1 3 0 7 6 0 8 61 84 32 72 26 11 25 58 108 999 370 228 458 170 1,168 Elective

0 4 2 57 82 12 16 73 46 747 767 805 799 705 379 212 987 Total 9,460 4,803 3,464 6,064 2,074 10,974 delivery

74 % CS 8.85 0.54 0.02 8.40 2.02 0.82 4.58 0.38 8.02 5.50 1.14 0.11 0. 13.41 90.60 17.25 71.78 33.35 42.75 14.89 30.53 14.02 39.78 Rates

26 0 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 NA ical problems and CS rates, 2011 and 20112012 andical problems CS rates,

1 8 0 9 0 9 15 38 71 20 57 13 259 350 593 162 184 528 3,074 2,799 2,226 1,632 1,340 Emergency

Total CS 2011 CS Total

8 0 1 4 1 7 2 4 51 41 19 23 12 63 121 464 114 299 100 421 173 Distribution of med Distribution 1,220 1,091 Elective

2.5

2 1 5 60 49 17 25 77 37 ,942 957 950 931 518 113 257 Table Total Total 5,943 1,060 4,356 6 1,079 2,443 11,899 10,880 delivery

Disease

TB NA NA existing existing - - eclampsia Others - NYHA I NYHA Missing Asthma NYHA II NYHA NYHA III NYHA NYHA IV NYHA Diabetes Eclampsia Gestational Pre Pre Gestational Not Available Hypertension Pre Renal Disease Blood Disorder Heart Disease Collagen Medical Problems

24 24 National Obstetrics Registry

% % 2.57 3.36 5.86 0.05 0.14 0.17 6.49 0.15 0.04 0.20

89.77 90.11

Total Total

n n 16 45 55 47 13 63 799 1,077 1,876 2,022 Graph 2.2 Indications for CS 2011 and 2012 28,751 28,070

% % 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 80.00 20.00 100.00

Others Others

8 2 0 0 0 0 n n 0.00 0.00 0.00 0.00 0.00 10.00

00 % %

0.00 0. 0.00 0.00 1.96 0.00 0.00 0.00 35.85 25.49 62.26 72.55 2012 -

0 0 0 0 1 0 0 0 n n 19 13 33 37 Hysterectomy Hysterectomy

% % 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 47.06 31.82 52.94 68.18

27 8 9 0 0 0 0 0 0 n n Hysterotomy Hysterotomy 7.00 0.00 0.00 Caesarean 2011 Caesarean 15.00 Caesarean 2012 Caesarean

% % 0.00 0.00 0.75 0.72 0.00 0.00 3.60 1.50 72.93 66.19 24.81 27.34 CS in relation to accoucher to 2011 in relation CS

Classical Classical 0 0 1 1 0 0 5 2 n n 97 92 33 38

Table 2.6

% %

2.57 5.65 3.38 0.05 0.14 0.17 6.25 0.15 0.04 0.20 89.95 90.36

LSCS LSCS

28 n n 16 45 54 46 12 63 794 1,799 1,075 1,932 28,619 27,948

O&G

months O&G

Specialist Specialist Other MO Other MO Other experience experience experience experience Accoucher Other (HO) MO Other (HO) MO MO>6 monthsMO>6 MO<6 months O&G MO>6 MO<6 months O&G MO no O&G experience O&G no MO experience O&G no MO

25 25 National Obstetrics Registry

Graph 2.2 Indications for CS 2011 and 2012

26 National Obstetrics Registry

% 100 100 100 100 1.81 2.30 2.54 9.63 0.57 2.13 0.69 10.64 87.56 95.15 89.80 97.17

Total

n 579 738 815 178 665 216 3,407 2,999 28,043 32,029 30,476 32,029 27,973 31,150 30,269 31,150

100 100 100 100 0.00 0.00 0.0 0.00 0.00 10.00 90.00 10.00 90.00 10.00 90.00 100.00 Others

1 9 0 1 9 0 1 9 0 0 0 n 10 10 10 10 10

% 100 100 100 100 1.89 1.89 33.96 64.15 15.09 83.02 45.10 43.14 11.76 13.73 72.55 13.73

1 8 1 6 7 7 n 18 34 53 44 53 23 22 51 37 51 Hysterectomy

100 100 100 100

Caesarean 2011 Caesarean 5.88 2012 Caesarean

17.65 58.82 23.53 70.59 23.53 50.00 36.36 13.64 31.82 50.00 18.18 29

3 4 1 4 8 3 7 4 n

10 17 12 17 11 22 11 22 MASSIVE PRIMARY

Hysterotomy MASSIVE PRIMARY

Apgar score2012 and inCS relation2011 to Apgar % 100 100 100 100

2.26 8.27 3.01 2.88 3.60 2.88 POSTPARTUM HAEMORRHAGE

19.55 78.20 88.72 12.95 84.17 93.53 POSTPARTUM HAEMORRHAGE

3 4 4 5 4 n ssical 26 11 18 104 133 118 133 117 139 130 139 Table 2.7 Cla

% 100 100 100 100 1.79 2.25 2.53 9.53 0.53 2.09 0.65 10.56 87.65 95.21 89.94 97.26

n CS 571 717 806 165 646 201 3,359 2,946 27,886 31,816 30,293 31,816 27,817 30,928 30,081 30,928

otal ≤ 7 ≤ 7 ≤ 7 ≤ 7 NA NA NA NA > 7 > 7 > 7 > 7 min min min min Tot T Total Total Apgar at 1 Apgar at 5 Apgar at 1 Apgar at 5 Apgar

3030

2727 National Obstetrics Registry

MASSIVE PRIMARY POSTPARTUM HAEMORRHAGE

National Obstetrics Registry National Obstetrics Registry

CHAPTER 3 MASSIVE PRIMARY POSTPARTUM HAEMORRHAGE

SD Karalasingam¹, Ravindran J², R Jeganathan ³

1. National Clinical Research Centre 2. Kuala Lumpur Hopital 3. Sultanah Aminah Hospital, Johor

SUMMARY

The standards set by MOH for Massive Primary PPH was achieved by all 14 hospitals in 2011. In 2011 HSB Kedah had the highest incidence of Massive Primary PPH at 0.40% whilst in 2012 HTF Perlis had the highest rate of Massive Primary PPH at 0.54%. It was higher in women aged 40-45 years and parity ≥6. Macrosomia, multiple pregnancy and prolonged labour contributed to Massive primary PPH.

3.1 INTRODUCTION

KPI for Massive Primary PPH set by MOH, Malaysia is ≤ 0.5% of total deliveries. The total number of deliveries for 2011 was 135,380 and 0.14% of deliveries were complicated by Massive Primary PPH from the 14 tertiary hospitals that provide data to NOR. HL, Sabah had not reported any cases of Massive Primary PPH in 2011 but in 2012 there were 2 cases.The total number of deliveries for 2012 was 122,634 and 0.10 % of deliveries were complicated by Massive Primary PPH from the SDP. The highest rate was seen from HTF Perlis at 0.54% followed by HKL and HSNZ Terengganu at 0.19%.

3.2 PATIENT DERMOGRAPHICS

In 2011 Massive Primary PPH was highest among the Ibans at 0.23% followed by the Chinese at 0.21%. Women aged 40-45 years had a high rate of Massive Primary PPH at 0.52% and parity ≥ 6 had a rate of 0.33%.Similar findings were seen in 2012 where Massive Primary PPH was high in women aged 40-45 years at 0.35% and in parity ≥ 6 at 0.18 %.

3.3 RISK FACTORS FOR MASSIVE PRIMARY PPH

In both years risk factors for Massive Primary PPH were macrosomia, multiple pregnancy and prolonged labour.

28 28 National Obstetrics Registry

3.4 CAUSES OF POSTPARTUM HAEMORRHAGE

Uterine atony accounted for 24.74% of Massive Primary PPH in 2011 where else uterine rupture accounted for 20.0% of Massive PPH in 2012 followed by uterine atony at 9.52%.

3.5 MODE OF DELIVERY

Massive Primary PPH was higher with CS as compared to vaginal and instrumental delivery. In both years Classical CS contributed to the highest rate at 3.08% and 0.76% respectively.

3.6 CONCLUSION

The incidence of Massive Primary PPH from the SDP was 0.14% in 2011 and 0.10% in 2012 and this was higher than what was reported in the 2nd NOR report 2010. Women aged 40-44 years and Parity≥ 6 had the highest rate of Massive Primary PPH. Rates were higher following CS as compared to vaginal and instrumental deliveries and Classical CS contributed to the highest rate in both years.

3.7 RECOMMENDATION

1. Regular audit and discussion of cases with Massive Primary PPH should be carried out at Departmental level. 2. SDPs should capture all data accurately for a complete and comprehensive analysis.

3.8 REFERENCE

1. Manual National Indicator Approach and Key Performance Indicators. Obstetrics and Gynaecology, Ministry of Health 2010. 2. 2nd NOR Report 2010. Editors: Dr Ravichandran Jeganathan, Dr Shamala Devi Karalasingam

29 29 National Obstetrics Registry

3.4 CAUSES OF POSTPARTUM HAEMORRHAGE %

0.03 0.00 0.00 0.00 0.01 0.00 0.02 0.00 0.02 0.00 0.06 0.00 0.00 0.00 0.01

Uterine atony accounted for 24.74% of Massive Primary PPH in 2011 where else NA

1 0 0 0 1 0 1 0 2 0 8 0 0 0 n uterine rupture accounted for 20.0% of Massive PPH in 2012 followed by uterine atony 13 at 9.52%.

% 0.54 0.13 0.00 0.04 0.04 0.19 0.00 0.06 0.09 0.01 0.19 0.10 0.00 0.01 0.10 mls 3.5 MODE OF DELIVERY

mary PPH mary 0 2 5 0 6 1 0 2 n ≥1500 21 13 22 11 24 11 Massive Primary PPH was higher with CS as compared to vaginal and instrumental 118 Pri delivery. In both years Classical CS contributed to the highest rate at 3.08% and 0.76%

respectively. % mls 1.51 0.39 0.13 0.07 0.35 0.67 0.11 0.14 0.53 0.02 0.66 0.19 0.86 0.06 0.36

3.6 CONCLUSION

<1500 4 3 7 2 8 n 59 40 42 79 15 65 85 21 13

443

The incidence of Massive Primary PPH from the SDP was 0.14% in 2011 and 0.10% in

2012 and this was higher than what was reported in the 2nd NOR report 2010. Women

aged 40-44 years and Parity≥ 6 had the highest rate of Massive Primary PPH. Rates who Total Total 3,920 3,010 4,507 6,192 8,728 1,513 10,307 12,056 11,843 10,746 12,295 12,803 10,955 13,759 women 122,634 delivered were higher following CS as compared to vaginal and instrumental deliveries and 2012 2011 and

Classical CS contributed to the highest rate in both years.

SDP %

0.07 0.01 0.03 0.00 0.01 0.03 0.02 0.00 0.01 0.01 0.02 0.01 0.05 0.00 0.02

3.7 RECOMMENDATION NA

3 1 1 0 1 4 1 0 1 1 3 1 5 0 n 22

1. Regular audit and discussion of cases with Massive Primary PPH should be

carried out at Departmental level. % mls 0.39 0.40 0.00 0.21 0.06 0.13 0.04 0.09 0.12 0.06 0.22 0.17 0.20 0.00 0.14 2. SDPs should capture all data accurately for a complete and comprehensive

ive Primary PPH by PPH by Primary ive analysis.

0 8 2 6 0 n ≥1500 16 42 13 15 10 15 27 22 20

196 Primary PPH Primary Mass

3.8 REFERENCE

% mls 1.88 0.62 0.36 0.13 0.10 0.84 0.08 0.22 0.37 0.12 0.54 0.30 0.87 0.01 0.40 1. Manual National Indicator Approach and Key Performance Indicators. Obstetrics

and Gynaecology, Ministry of Health 2010. Table 3.1 8 4 1 n <1500 77 64 12 12 99 24 46 11 65 39 86 2. 2nd NOR Report 2010. Editors: Dr Ravichandran Jeganathan, Dr Shamala Devi 548

Karalasingam who Total Total 4,087 3,336 6,217 4,841 9,333 9,854 10,396 12,351 11,729 10,833 12,467 12,019 13,066 14,851 women 135,380 delivered

mbilan ah

Kedah

HKL HPP SDP Total 32 HL, Sab HTJ ,Perlis HSA, Johor HSB, HU,Sarawak HRPB, Perak HTAA, Pahang Hospital Melaka HTAR, Selangor HRPZ 11,HRPZ Kelantan HSNZ, Terengganu HTJ, Se Negeri

30 30 National Obstetrics Registry

.01 %

0.00 0.01 0 0.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.01 NA

0 1 1 0 0 0 0 0 0 0 0 0 0 n 11 13

% mls 0.04 0.11 0.04 0.03 0.03 0.00 0.00 0.00 0.00 0.00 0.00 0.20 0.13 0.00 0.10

1 3 2 1 0 0 0 0 0 0 3 0 n 94 14 ≥1500 118 Primary PPH Primary 2012

% mls 0.00 0.40 0.49 0.18 0.05 0.38 0.14 0.00 0.26 0.28 0.13 0.20 0.34 0.19 0.36

0 2 1 4 0 2 1 1 3 1 n 36 11 36 <1500 345 443

38 262 760 360 748 517 who Total Total 2,338 7,417 6,128 3,685 2,930 1,467 85,391 10,593 women 122,634 delivered

0.00 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.13 0.00 0.00 0.02 0.00 0.02 NA

0 1 0 0 0 0 0 0 2 0 0 2 0 n 17 22

% 34 mls 0.04 0.16 0.21 0.05 0.00 0.00 0.03 0.00 0.23 0.00 0.11 0.08 0.15 0.00 0.14

y PPH

1 3 0 0 1 0 5 0 1 1 0 n 18 17 ≥1500 149 196 Primar

2011

% 0.07 0.46 0.33 0.16 0.05 0.29 0.06 0.00 0.70 1.27 0.22 0.41 0.33 0.24 0.40 mls

Massive Primary PPH by ethnicity 2011 ethnicity PPH2012 by and Primary Massive

2 2 1 2 0 2 5 1 n 28 10 15 20 37 <1500 423 548

Table 3.2 345 123 909 413 who Total Total 8,428 6,400 4,003 3,151 2,149 1,573 2,695 1,209 92,649 11,333 women 135,380 delivered

NA Iban Total Other Murut Bajau Malay Indian Bidayuh Chinese Melanau Ethnicity Foreigners Kadazan/Dusun Sabah & Sarawak & Sabah ther indigenous group in in group indigenous ther OA (Peninsular Malaysia) O

3131 National Obstetrics Registry

01 .00 %

0.00 0.00 0 0.01 0.01 0.01 0.02 0.32 0.00 0.00 0. NA

0 0 1 4 4 2 1 1 0 0 n 13

% 0.00 0.00 0.01 0.05 0.15 0.21 0.31 0.00 0.00 0.00 0.10 mls

0 0 3 0 0 0 n ≥1500 23 46 33 13 118 Primary PPH Primary 2012

.73 % 0.00 0.14 0.24 0.33 0.39 0.55 0 0.00 0.00 0.00 0.36 mls

0 8 0 0 0 n <1500 55 84 31 145 120 443

2 n 26 126 314 who Total Total 5,736 4,262 22,513 43,421 30,830 15,404 women 122,634 delivered

35 %

0.00 0.00 0.01 0.01 0.03 0.02 0.02 0.00 0.00 0.00 0.02 NA

0 0 3 5 9 4 1 0 0 0 n 22

% mls 0.00 0.03 0.07 0.07 0.20 0.30 0.52 0.28 0.00 0.00 0.14

Massive Primary PPH by age PPH by 2011 and Primary 2012 Massive

0 2 1 0 0 n ≥1500

19 32 66 51 25 196 Primary PPH Primary

2011

Table 3.3 % mls 0.00 0.36 0.31 0.34 0.44 0.62 0.63 0.83 0.00 0.00 0.40

500

0 3 0 0 n 24 80 30 <1 158 147 106 548

1 n 26 127 362 who Total Total 6,731 4,765 26,048 46,963 33,305 17,052 women 135,380 delivered

14 19 24 29 34 39 44 49 54 59

------Age Total 10 15 20 25 30 35 40 45 50 55

32 32 National Obstetrics Registry

0.01 0.00 0.00 0.32

NA %

0.01 0.01 0.08 0.00 0.01 3 0 0 1 n

2 6 5 0 n 13 % 0.09 0.28 0.46 1.30

4 n % 34 12 12 ≥1500 mls 0.04 0.12 0.18 0.00 0.10 mls Primary PPH Primary

2012

% 0 n

0.30 0.68 1.01 1.62 19 87 12 ≥1500 118 Primary PPH Primary

2012

5 n

29 26

108 <1500 mls <1500 2012 %

0.34 0.36 0.50 0.00 0.36 mls

308 0 n who <1500 33 Total Total 4,249 2,584 147 263 443 35,859 women delivered

0.02 0.00 0.15 0.00 A 82 N who Total 6,537

42,679 73,336 women 122,634 8 0 4 0 n delivered

% %

mls 0.14 0.29 0.52 0.92 0.01 0.02 0.01 0.00 0.02 NA

5 n 6 1 0

n 57 13 14 15 22 ≥1500 ≥1500

Primary PPH Primary

2011

% % 0.08 0.17 0.33 0.00 0.14 0.36 0.80 1.56 1.84 Parity and Massive Primary PPH 2011 andPrimary and Massive Parity

n 0 n 36 42 10 36 26 153 ≥1500 mls <1500 mls <1500 134 196 Primary PPH Primary

2011

Table 3.4 % 0.34 0.44 0.48 0.00 0.40 : Risk factors for Massive Primary PPH 20112012 Primary and Table: for Massive 3.5 factors Risk 544 who Total Total 4,515 2,695

42,096

women

delivered 0 n 38 <1500 mls <1500 155 355 548

216 who Total 7,840 46,158 81,166 women 135,380

delivered PPH

Macrosomia 5

- 1 Risk for Factor ≥ 6 NA Prolonged Labour Prolonged 2 Multiple Pregnancy Total Parity Anaemia (At Booking)

33 33 National Obstetrics Registry

2.38 0.00 0.07 0.00 0.91 0.01 0.00

% NA

0.00 0.02 0.03 0.03 0.00 0.00 0.01

1 0 1 0 2 2 0 n NA

4 1 8 8 0 0 n

mls 9.52 0.00 2.18 2.17 1.82 0.04

20.00 %

mls 0.02 0.07 0.32 0.32 0.76 0.00 0.10

4 0 7 4 2 n ≥1500 31 12

2012

Primary PPH Primary

3 1 0 n 2012 ≥1500 17 98 97

118

Primary PPH Primary

mls 0.00 1.75 2.48 5.00 0.27 0.00

45.24

% 0.19 0.48 0.81 0.80 0.76 9.09 0.35 mls

0 8 0 n <1500 19 25 11 76

1 2 n <1500 22

168 245 242 435

6 n

42 10

323 220 who

Total Total 1,425

27,640

women 325 n deliver 22 132 who Total Total 4,589 86,219 30, 30,138

women 122,634 delivered %

0.00 0.00 0.07 0.00 0.38 0.02 0.00

NA %

0.01 0.02 0.03 0.03 0.00 0.00 0.02

0 0 1 0 1 6 0 n 37 NA

1 0 0 n 11 10 10 22

mls 0.00 2.95 2.34 1.13 0.04 0.00

24.74 %

0.03 0.06 0.52 0.51 3.08 0.00 0.14

0 7 3 0 n 24 42 12 ≥1500

2011

Primary PPH Primary 3 4 0 n

26 2011 ≥1500 mls

164 159 193

Primary PPH Primary %

mls 0.00 2.74 2.68 4.14 0.47

44.33 28.57 %

0.26 0.53 0.82 0.82 0.00 5.88 0.39

: Cause of Massive Primary PPH 2011 and 2012 and 2011 PPH Primary Massive of Table: Cause 3.6 0 8 2 n <1500 43 39 11

138

: Massive Primary PPH 20112012 delivery to mode Primary in andrelation of : Massive 0 1 n 26

<1500 mls <1500 252 255 253 533

2 7

n 97

299 266

who Total Total

1,422 Table 3.7 29,056 women n 17 delivered 130 who Total Total 4,923 96,272 31,241 31,029

women

135,380

delivered

Cause of PPH Total LSCS Vaginal Mode of of Mode Delivery Classical Uterine atony Uterine Caesarean Genital trauma Uterine rupture Instrumental Hysterotomy Placenta preavia Uterine inversion Retained placenta Abruption placenta

34 34 National Obstetrics Registry National Obstetrics Registry

DIABETES MELLITUS IN PREGNANCY

National Obstetrics Registry National Obstetrics Registry

CHAPTER 4 DIABETES MELLITUS IN PREGNANCY

Maizuriati Abd Rahman1, Zaridah Shaffie1, Noor Aini Harun1, SD Karalasingam2

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 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.

Graph 4.1 Types of Diabetic Pregnancy in Malaysia 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 36 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.

Graph 4.1 Types of Diabetic Pregnancy in Malaysia 4.4 CONCLUSIONS

4.5 RECOMMENDATION

4.6 REFERRENCES

37 National Obstetrics Registry

0.07

7.98 9.54 7.13 4.39 8.65 9.64 9.80 8.53 1.57 8.83 12.73 10.14 1 12.18 12.90

Total

n 788 374 735 132 457 129 216 1022 1214 1025 1036 1497 1126 1074 10825

0.08 0.02 0.03 0.03 0.00 0.04 0.02 0.02 0.00 0.01 8.38 0.00 0.00 0.01 0.61 NA

n 5 2 1 3 0 2 2 2 0 1 0 0 2 731 751

% 7.55 8.72 6.52 4.22 9.50 8.62 8.03 8.93 4.41 9.10 7.34 1.50 7.61 12.14 11.35 2012 pregnancy

n Gestational 752 967 342 672 127 428 951 960 385 997 111 207 9333 1,039 1,395

Diabetic %

ng - 0.50 0.41 0.79 0.58 0.17 0.60 1.43 0.61 0.71 0.82 0.11 0.70 1.19 0.05 0.60

Pre

n existi 5 7 31 60 27 72 76 10 77 18 31 53 173 101 741

2011 2012 and

n SDP

who Total Total 3,920 3,010 4,507 8,728 1,513 6,192 10,307 12,056 11,843 10,746 12,295 10,955 13,759 12,803 women by 122,634

delivered

06 %

7.14 4.68 9.57 7.73 7.89 0.72 8.66 7.77 11.16 10.23 10.78 12. 12.15 12.03 10.51

Total

n 456 742 156 636 777 107 509 934 1332 1122 1307 1515 1123 1010 11726

% 0.05 0.05 0.03 0.11 0.00 0.03 0.02 0.03 0.17 0.04 0.01 0.01 0.05 0.21 0.03 NA

n 2 5 1 7 0 4 2 4 5 1 1 4 16 62 10

% Incidence of Diabetic pregnancy of Incidence 9.86 6.63 4.53 9.51 9.32 8.94 7.01 7.15 0.69 7.92 9.52 6.72

11.49 11.13 11.35 2011

pregnancy

n Gestational 403 689 151 591 916 705 102 461 808 1,151 1,049 1,245 1,387 1,059 10717 Table 4.1

Diabetic

% - 0.78 1.02 1.25 0.46 0.12 0.61 1.47 0.59 0.55 0.99 0.51 0.68 0.72 0.03 0.70

Pre

n existing 4 4 38 51 48 38 69 60 48 89 71 122 181 124 947

n who Total Total 4,087 3,336 6,217 4,841 9,333 9,854 10,396 12,351 11,729 10,833 12,467 12,019 13,066 14,851 elivered women 135,380 d

HKL SDP HPP Total HSNZ rengganu Sembilan HL Sabah HTF Perlis HSA Johor HTJ Negeri HSB Kedah HSB Te HU Sarawak HU HRPB Perak HTAA Pahang HTAR Selangor Hospital Melaka HRPZ II,HRPZ Kelantan

38 38 National Obstetrics Registry

1.59 1.55 3.71 7.12 7.69 0.00 8.83

10.69 16.57 21.12 17.83

Total

2 2 0 n 89 56 836 900 3,091 3,297 2,552 10,825

0.00 0.10 0.35 0.48 0.75 1.01 1.67 0.64 0.00 0.00 0.61

0 6 2 0 0 n 79 71 207 230 156 751

% 1.59 1.39 3.11 6.21 9.27 7.69 0.00 7.61 14.18 17.88 14.65 2012

2 2 0 n 80 46 700 762 Gestational 9333 2,697 2,859 2,185

Diabetic pregnancy % - 0.00 0.05 0.25 0.43 0.67 1.37 1.57 2.55 0.00 0.00 0.60

Pre

0 3 8 0 0 n existing 57 67 187 208 211 741

011 and 2012 and 011

2 26 126 314 who Total Total 5,736 4,262 22,513 43,421 30,830 15,404 women 122,634 delivered

43 %

1.57 1.57 3.60 7.05 0.00 8.66

10.60 17.04 21.30 23.76 15.38

Total pregnancy by by Age pregnancy

2 4 0 n 86 106 939 3,313 3,529 2,905 1,015 11,726

Diabetic

0.00 0.03 0.02 0.05 0.05 0.09 0.06 0.00 0.00 0.00 0.05 NA

0 2 4 3 0 0 0 n 23 15 15 62

Table 4.2 % 0.79 1.41 3.26 6.39 9.49 0.00 7.92 15.30 19.29 21.27 15.38

2011

1 4 0 n 95 77 850 919 Gestational 3,003 3,159 2,609 10717

Diabetic pregnancy % - 0.00 0.12 0.27 0.52 0.88 1.43 1.72 2.21 0.00 0.00 0.70

Pre

0 8 8 0 0 n existing 70 82 244 292 243 947

1 26 127 362 who Total Total 6,731 4,765 26,048 46,963 33,305 17,052 women 135,380 delivered

14 19 24 29 34 39 44 49 54 59

------Age Total 10 15 20 25 30 35 40 45 50 55

39 39 National Obstetrics Registry

4.14 1.54 9.87 8.86 2.39 4.20 1.84 8.95 7.78 4.29 4.99 4.06 8.83

13.05 18.42

Total

7 n 31 36 88 11 54 68 28 63 21 657 800 529 8,432 10,825

0.80 0.80 0.27 0.21 0.03 0.00 0.10 0.00 0.26 0.00 0.14 0.12 1.74 0.61 0.04 NA

6 1 0 3 0 2 0 2 9 1 n 20 13 13 681 751

% 3.21 8.40 8.08 2.28 3.82 1.74 8.16 6.94 3.48 4.55 2.13 7.61 1.37 11.86 13.16 2012

in pregnancy in

5 n 24 84 10 51 62 25 51 11 32 Gestational 599 727 482 7,170 9,333

Diabetic

0.13 0.13 0.68 0.51 0.98 0.08 0.38 0.00 5.26 0.53 0.83 0.68 0.32 0.19 0.60 -

Pre

3 1 3 1 0 2 4 3 1 n existing 38 60 10 34 581 741

38 748 262 760 360 517 who 2338 7417 6128 3685 2930 1467 Total Total 2011 2012 2011 and 85391 10593

122634 women delivered

82 %

1.30 5.28 9. 9.03 1.52 1.74 0.98 7.32 6.65 5.85 5.13 4.38 4.60 8.66 13.55

Total

44 6 9 n 61 31 92 62 19 35 48 761 867 143 496 9,096 11,726

0.06 0.04 0.05 0.00 0.00 0.00 0.00 0.09 0.00 0.00 0.01 0.00 0.05 0.00 0.22 NA

3 3 0 0 0 0 2 0 0 1 0 0 2 n 51 62

Diabetic pregnancy by Ethnicity by pregnancy Diabetic

47 % 8.96 8.33 1. 1.45 0.95 6.50 6.28 5.28 4.55 4.08 3.87 7.92 1.26 4.95 12.28 2011

pregnancy Table 4.3

5 8 n 59 30 83 55 16 34 45 702 786 135 462 Gestational 8,297 10,717

Diabetic

- 0.04 0.11 0.81 0.66 1.22 0.05 0.29 0.03 0.81 0.28 0.57 0.58 0.29 0.73 0.70

Pre

existing 1 1 2 1 1 1 6 9 7 3 n 56 78 33 748 947

909 345 123 413 who 2695 8428 6400 4003 3151 2149 1573 1209 Tota 92649 11333 135380 women delivered

NA Iban Total Other Murut Bajau Malay Indian (Peninsular Bidayuh Chinese Melanau

Ethnicity Malaysia) Foreigners & Sarawak

OA Sabah in group Kadazan/Dusun Other indigenous indigenous Other

40 40 National Obstetrics Registry

6.67 9.57 4.88 8.83

14.62

Total

825 4 n 956 2,846 7,019 10,

0.46 0.65 1.19 0.00 0.61

0 n 78 196 477 751

% 5.76 8.26 3.66 7.61 12.44 2012

in preganacy in

3 n 813 Gestational 2,457 6,060 9,333

Diabetic % - 0.45 0.66 0.99 1.22 0.60

Pre

1 n existing 65 193 482 741

2011 and 2012

ty 82 who Total Total 6,537 42,679 73,336 women 122,634 delivered

6.41 9.38 5.09 8.66 45

14.58

Total

n 11 2,958 7,614 1,143 11,726

% 0.05 0.04 0.05 0.46 0.05 Diabetic pregnancy by Pari by pregnancy Diabetic

4 1 n

24 33 62

% 5.81 8.60 4.63 7.92 13.33 Table 4.4

2011

pregnancy

n 10 Gestational 2,681 6,981 1,045 10,717

Diabetic % - 0.55 0.74 1.20 0.00 0.70

Pre

0 n existing 94 253 600 947

216 who Total Total 7,840 46,158 81,166 women 135,380 delivered

- 1 ≥ 6 NA 2 Total Parity

41 41 National Obstetrics Registry

% 7.3 7.3 6.2 8.7 8.5 9.9 8.8

13.1 13.1 12.9 13.6 10.0 10.0

Total 3 1 n 22 43 17 397 355 150 6,313 6,286 3,965 3,941 10,825

0.57 0.57 0.00 0.74 0.77 0.46 0.75 0.75 0.76 0.00 0.00 0.00 0.61

0 2 1 0 0 0 n 34 32 489 489 228 227 751

% 6.38 6.40 5.88 7.45 7.38 8.31 9.85 8.93 7.61 11.08 11.09 13.64 10.00 2012 pregnancy

3 1 n

21 36 13 342 307 134 Gestational 5472 3341 9333 5,498 3,359

Diabetic % - 0.38 0.38 0.28 0.46 0.38 1.15 1.25 1.24 2.27 0.00 0.00 1.07 0.60

Pre

1 5 3 0 0 n existing 21 16 16 326 325 378 373 741 2011 2012 and

22 10 357 433 132 who 4589 4160 1501 Total Total 86219 85560 30325 30138 122634 women delivered

7.16 7.16 6.44 8.51 8.13 7.61 8.66

11.33 13.42 13.40 16.92 17.65 12.50 46

Total

3 1 n 28 64 22 419 355 224 6890 6861 4193 4159 11726

% 0.03 0.03 0.00 0.04 0.05 0.00 0.08 0.07 0.77 0.00 0.00 0.17 0.05 NA

0 2 2 0 1 0 0 5 n 31 31 24 23 62

% Mode of delivery in Diabetic pregnancy of delivery Mode 6.60 6.60 5.29 7.62 7.24 6.66 7.92 10.44 12.15 12.14 12.31 17.65 12.50

pregnancy

3 1 n 23 59 16 375 316 196 Gestational 6326 3768 Table 4.5 6,350 3,796 10717

2011

Diabetic % - 0.53 0.53 1.15 0.85 0.85 0.88 1.19 1.19 3.85 0.00 0.00 0.78 0.70

Pre

5 5 5 0 0 n existing 42 37 23 509 504 373 368 947

8 17 435 565 130 who 4923 4366 2944 Total Total 96272 95815 31241 31029 135380 women delivered

NA SVD Total LSCS Others Breech Vaginal Force Vacuum Mode of of Mode Delivery Classical Caesarean Instrumental Hysterotomy

42 42

National Obstetrics Registry 0.00 0.00 0.00 0.01 0.02 0.07 0.61 1.43 0.14

0 0 0 1 n 11 30 73 61

Without DM

176

7.50 7.93 8.00 7.58 7.72 9.05 8.84

11.78 15.95 %

3.2

96.8

Total

% n

89 0.00 0.00 0.00 0.00 0.00 0.02 0.17 0.42 0.04 2012 110 276 681 1,099 3,468 3,833 1,418

10,974 Shoulder Dystocia Non DM Non n

3588 109534 With DM 0 0 0 0 2 9 n % 20 18 49

0.34 0.29 0.46 0.53 0.49 0.66 1.13 0.73 0.62

NA 2012

4 4 n

16 77 31 % 218 281 136 767 6.2 93.8

2012

Total Total 1,187 1,388 3,451 4,269 DM

% 14,492 44,894 42,375 12,040 124,096 delivery 6.49 6.70 6.87 6.48 6.72 7.86 9.70 7.62

14.01 n

2012

681

10293

n 77 93 % 237 939 598

9460 Gestational 3,016 3,332 1,168

0.16 0.00 0.00 0.01 0.03 0.10 0.53 0.79 0.12

2011 2012 and

3.1

96.9 Diabetic pregnancy

% - 0.67 0.94 0.67 0.57 0.52 0.52 0.95 1.22 0.60 2 0 0 1 n

13 47 68 36 167 Without DM

Pre

2012 2011 and

existing 8 n Non DM Non n 13 23 83 52

234 220 114 747

3848 pregnancy pregnancy % 121116

0.00 0.00 0.00 0.00 0.01 0.03 0.22 0.52 0.05

2011

2011 in Diabetic pregnancy 2011 in Diabetic pregnancy

% Shoulder Dystocia 6.1

Total Total 1,187 1,388 3,451 4,269 93 .9

14,492 44,894 42,375 12,040

124,096 delivery With DM 0 0 0 0 3 n 12 29 24 68

% n

7.87 9.06 7.73 7.19 7.51 8.96 8.69

12.01 15.89 727

11172 47

Total

n ,899 98 Total Total 1,246 1,501 3,843 4,575

136 297 727 16,194 50,450 46,106 12,948 1,165 3,788 4,133 1,555 136,863 delivery 11

7 Macrosomia in Diabetic in Diabetic Macrosomia Shoulder dystocia

0.00 0.00 0.00 0.0 0.02 0.06 0.03 0.17 0.05

NA 1500 2000 2500 3000 3500 3999

< 4 kg ------≥ 4 kg ≥

0 0 0 4 8 n 11 12 27 62 Total Birth

≤ 1000 ≥ 4000

Weight Birth WeightBirth

1001 1001 1501 2001 2501 3001 3501

Table 4.7 Table 4.8 % 6.82 8.06 7.00 6.53 6.90 8.20 7.95 11.08 14.23 Birth weight in relation to Diabetic weightpregnancy in relation Diabetic to Birth

2011

n 85 121 269 651 Gestational 1,058 3,483 3,779 1,434 10880

Table 4.6

Diabetic pregnancy % - 1.04 1.00 0.73 0.59 0.58 0.71 0.90 1.49 0.70

Pre

n existing 13 15 28 96 68

293 327 117 957 44

Total Total 1,246 1,501 3,843 4,575 16,194 50,450 46,106 12,948 136,863 delivery

1500 2000 2500 3000 3500 3999

------Total Birth ≤ 1000 ≥ 4000 Weight 1001 1001 1501 2001 2501 3001 3501

43 43 National Obstetrics Registry

0.00 0.00 0.00 0.01 0.02 0.07 0.61 1.43 0.14

0 0 0 1 n 11 30 73 61 Without DM

176

3.2

96.8

0.00 0.00 0.00 0.00 0.00 0.02 0.17 0.42 0.04 2012

Shoulder Dystocia Non DM Non n

3588 109534 With DM 0 0 0 0 2 9 n 20 18 49

2012

% 6.2 93.8

2012 -

Total Total 1,187 1,388 3,451 4,269 DM

14,492 44,894 42,375 12,040 124,096 delivery n

681

10293

0.16 0.00 0.00 0.01 0.03 0.10 0.53 0.79 0.12

2011 2012 and

% 3.1

96.9

2 0 0 1 n

13 47 68 36 167 Without DM

Non DM Non n

3848 pregnancy pregnancy % 121116 0.00 0.00 0.00 0.00 0.01 0.03 0.22 0.52 0.05

2011

2011 in Diabetic pregnancy 2011 in Diabetic pregnancy

% Shoulder Dystocia 6.1

93 .9

With DM 0 0 0 0 3 n 12 29 24 68

DM n

727

11172 Total Total 1,246 1,501 3,843 4,575

16,194 50,450 46,106 12,948 136,863 delivery

Macrosomia in Diabetic in Diabetic Macrosomia Shoulder dystocia

1500 2000 2500 3000 3500 3999

< 4 kg ------≥ 4 kg ≥ Total Birth ≤ 1000 ≥ 4000 Birth WeightBirth Weight 1001 1001 1501 2001 2501 3001 3501

Table 4.7 Table 4.8

44 44 National Obstetrics Registry

0.06 0.24 0.00 0.14

0 48 11 %

Gestational 129 0.00 1.27 0.00 0.62 0.00 0.00 0.00 0.62

0 1 0 0 0 0 n 5min ≤ 7 5min ≤

766 767 - 0.01 0.00 0.00 0.02 Apgar Score Apgar

Pre

existing 9 0 0 % 18 7.61 3.92 3.54 7.63 20.98 10.13 12.05 15.92

ic pregnancy 8 2 4 n 0.22 1.21 0.66 0.57 86 40 32 ional Gestational 9412 9454 2012

2012

56 10 Diabet 187 532 % Gestat 2.68 2.53 0.90 0.60 1.00 1.96 5.31 0.60

existing

1min ≤ 7 1min ≤

- 2 3 2 1 6 n 0.02 0.13 0.13 0.06 11 Apgar Score Apgar 742 740 Pre 2012

Pre

- 2012

- 6 2 existing

17 59

79 51

410 332 201 113

elivery Total 123685 123932 d

1519 Total Total 4,616 elivery 86,837 92,972

d % 0.22 0.00 0.00 0.05 0.00 0.00 0.00 0.05

1 0 0 0 0 0 n 62 62 0.07 0.22 0.13 0.15

8.60 7.94 8.62 6.88 7.95 4

17.93 11.20 13.20 63 11 49 152 Gestational n Diabetic pregnancy 2011 pregnancy n Diabetic

8 5 n 5min ≤ 7 5min ≤ 83 41 33 11

Gestational - 0.01 0.02 0.00 0.02 10831 10864 yxia in Diabetic pregnancy 2011 in Diabeticyxia pregnancy Apgar Score Apgar

ph Pre

2011

Diabetic pregnancy existing % 6 1 0 - 16 1.94 4.30 1.09 0.70 2.40 1.72 0.63 0.70

Pre

9 4 4 6 1 1 n existing Birth as Birth Fetal i outcomes 949 955

0.23 1.07 0.73 0.29

2011

53 22 227 302 n Gestational 93 58 463 366 250 160 Table 4.9 Total Total elivery Table 4.10

136404 136645

d 1min ≤ 7 1min ≤ - 0.03 0.12 0.00 0.03 Apgar Score Apgar

Pre

6 0 existing 26 32

3007 Total Total 4,947 elivery 96,871

104,825 d NA NA FSB MSB

LCM absent LCM absent LCM LCM presentLCM presentLCM

Fetal Outcome

NA Total Vaginal Mode of of Mode Delivery

Instrumental

4545 National Obstetrics Registry

BREECH BREECH

National Obstetrics Registry

BREECH

National Obstetrics Registry National Obstetrics Registry

CHAPTER 5 BREECH

Malar Kandasamy1, SD Karalasingam2 ,Rosma Anida1

1. Tengku Ampuan Rahimah Hospital, Selangor 2. National Clinical Research Centre

SUMMARY

The incidence of breech presentation in 2011 was 3.1% and in 2012 was 3.4 %. The rate of CS with breech presentation was 11.49 % in 2011 and 11.19 % in 2012 Birth asphyxia in vaginal breech delivery among babies of less than 1000gms was higher as compared to Caesarean breech deliveries. More than 80% of cases with breech presentation had no ECV. 5.1 INTRODUCTION

The incidence of breech deliveries was 3.1 % in 2011 and 3.4% in 2012 and this is similar to 2010 reported in the 2nd NOR report. Majority of the cases were delivered by CS. ECV is advocated to reduce the CS rates due to breech presentation. The data collected here may not be accurate since ECV is done between 36-37 weeks and may have come in labour in cephalic presentation and delivered vaginally.

5.2 PATIENT DERMOGRAPHICS

Breech presentation was common among OA (Peninsular Malaysia) in both the years. Breech presentation was higher with increasing age in both years hence increase in CS rates among women aged 45-50 years.

5.3 OUTCOMES

8.3% of breech less than 1000 grams were delivered vaginally in 2011 and 9.1% in 2012. Overall the incidence of breech with extremely low birth weight was 10.4 % in 2011 and 12.1 % in 2012. Further analysis need to be done to see if these babies were premature. Breech babies weighing less than 1000 grams had a poorer outcome in both the years. Babies weighing more than 2000 grams delivered either vaginally or by CS had a good outcome.

46 46 National Obstetrics Registry

5.4 COMPLICATIONS

There were no births injuries reported for vaginal breech delivery and this was similar to the findings reported in NOR 2010 report. In both years slightly more than 5% of premature breech were delivered by CS.

11.8% in 2011 and 10.3% in 2012 of these babies died in utero and were delivered vaginally. Surprising to note that some of the breech with IUD were also delivered by CS. Further details need to be obtained before any conclusion can be made.

5.5 RECOMMENDATION

1. Accurate documentation of ECV by SDPs. 2. ECV to be offered to suitable patients.

5.6 REFERENCES

1. NOR report 2010

4747 National Obstetrics Registry 5.4 COMPLICATIONS

There were no5.4 birthsCOMPLICATIONS injuries reported for vaginal breech delivery and this was similar to

the findings reported in NOR 2010 report. In both years slightly more than 5% of % 2.9 3.4 5.6 6.3 3.4 3.4 2.7 2.7 3.4 3.4 3.0 2.7 3.4 1.3 3.4 premature breechThere were nodelivered births injuries by CS. reported for vaginal breech delivery and this was similar to

the findings reported in NOR 2010 report. In both years slightly more than 5% of

premature breech were delivered by CS.

Breech

11.8% in 2011 and 10.3% in 2012 of these babies died in utero and were delivered

05 n vaginally. Surprising to note that some of the breech with IUD were also delivered by 52 113 352 172 288 417 4 171 289 427 303 392 298 186 11.8% in 2011 and 10.3% in 2012 of these babies died in utero and were delivered 3,865 CS. Further detailsvaginally. need Surprising to be obtained to note thatbefore some any of conclusion the breech canwith be IUD made. were also delivered by

CS. Further details need to be obtained before any conclusion can be made. 2012

5.5 RECOMMENDATION

elivery

1. Accurate documentation of ECV by SDPs. n 3,954 3,046 4,603 6,273 8,823 1,522

2. ECV to be1. offeredAccurate to documentationsuitable patients. of ECV by SDPs. 10,419 12,212 11,995 10,877 12,466 12,945 11,096 13,865

124,096 2. ECV to be offered to suitable patients. Total d Total

5.6 REFERENCES 2012 5.6 REFERENCES

1. NOR report 2010 % 2.8 3.4 4.0 4.3 3.4 3.5 2.2 2.7 3.4 3.1 3.4 2.9 3.4 1.1 3.1 1. NOR report 2010 2011 and

SDP Breech

n 53 by 117 354 137 271 430 412 108 297 433 291 410 380 342 162

4,144 2011

Delivery

n 4,119 3,383 6,320 4,886 9,431 9,941 10,502 12,477 11,868 10,939 12,641 12,181 13,220 14,955 136,863 Table 5.1 Total deliveryTotal

HKL SDP HPP Total HL Sabah HTF Perlis HSA Johor HSB Kedah HSB HU Sarawak HU HRPB Perak HTAA Pahang HTAR Selangor Hospital Melaka HRPZ 11HRPZ Kelantan 52 HSNZ Terengganu HTJ Sembilan Negeri 52

47 48

48 National Obstetrics Registry

% 7.6 1.3 3.1 4.2 2.9 1.7 1.5 1.3 3.3 5.3 3.3 3.0 1.9 2.5 3.1

Total Breech 4 2 n 57 30 64 38 25 12 28 13 313 178 321 2,664 3,749

% 7 1.2 2.8 4.0 2.5 1.7 1.1 1.2 3.2 2.6 2.8 2.7 1.8 2.3 2.8

2012

Breech 3 1 n 54 29 62 36 24 10 27 12 293 155 290 Caesarean 2,396 3,392

% 0.0 0.4 0.3 0.3 0.4 0.1 0.4 0.1 0.1 2.6 0.6 0.3 0.1 0.2 0.3

1 3 2 1 2 1 1 2 1 1 Breech n Vaginal 20 23 31

268 357

2012

n 38 ,930 748 262 760 360 517 who Total Total 2,338 7,417 6,128 3,685 2 1,467 85,391 10,593 women 122,634 delivered

% 1.3 4.4 3.1 3.5 2.9 1.2 2.0 0.8 3.7 1.6 3.8 2.6 3.5 2.9 3.0

Total

Breech 7 2 n

34 40 49 25 79 60 42 12 297 188 292

2,899 4,026 54

% 1.3 4.3 2.8 3.3 2.5 1.0 2.0 0.6 3.3 1.6 3.3 2.3 2.6 1.9 2.7

2011

Breech eech delivery by ethnicity 2011 ethnicity by and delivery eech 7 2 8 n 34 39 41 20 70 52 32 276 162 259 Caesarean 2,589 3,591 Br

% 0.0 0.1 0.3 0.2 0.4 0.2 0.0 0.2 0.4 0.0 0.5 0.3 0.8 1.0 0.3 Table 5.2

Breech Vaginal 0 8 0 5 9 0 8 4 1 n 21 26 33 10 310 435

n 345 123 909 413 who Total Total 2,695 8,428 6,400 4,003 3,151 2,149 1,573 1,209 92,649 11,333 women 135,380 delivered

NA Iban Total Murut Bajau Malay Indian Others (Peninsular Bidayuh Chinese Melanau

Sarawak Ethnicity Malaysia) Foreigner OA

Kadazan/ Dusun Kadazan/ Other indigenous indigenous Other group in Sabah & Sabah in group

49 49 National Obstetrics Registry

2.4 2.2 2.7 3.0 3.2 3.6 3.4 6.4 3.8 3.1 50.0

Total

Breech 3 1 1 n 20 126 603 972 558 146 1,319 3,749

% 2.4 1.8 2.4 2.8 2.9 3.3 3.1 6.1 3.8 2.8 50.0

Breech

3 1 1 n 19 ,392 106 539 880 510 130 Caesarean 1,203 3 2012

% 0.0 0.3 0.3 0.3 0.3 0.3 0.4 0.3 0.0 0.0 0.3

Breech 4 Vaginal 0 1 0 0 n 20 6 92 48 16 116 357

2012

2 n 26 126 314 who Total Total 5,736 4,262 22,513 43,421 30,830 15,404 women 122,634 delivered

2.4 2.3 2.7 2.9 3.0 3.4 4.4 6.6 0.0 0.0 3.0

Total

Breech 3 0 0 n 24 157 716 983 585 210 1,348 4,026

% 1.6 1.9 2.5 2.6 2.6 3.1 3.7 5.8 0.0 0.0 2.7 Breech delivery by age by 2011 and delivery Breech

4 Breech 2 0 0 n 21 Caesarean 127 642 879 522 17 1,224 3,591 2011

Table 5.3

% 0.8 0.4 0.3 0.3 0.3 0.4 0.8 0.8 0.0 0.0 0.3

1 3 0 0 Breech n Vaginal 30 74 63 36 124 104 435

1 n 26 127 362 who Total Total 6,731 4,765 26,048 46,963 33,305 17,052 women 135,380 delivered

14 19 24 29 34 39 44 49 54 59

------Age Total 10 15 20 25 30 35 40 45 50 55

50 50 National Obstetrics Registry

% 0.9 1.4 0.3 0.1 0.0 0.0 0.0 0.0 0.0 0.9 0.8 0.3 0.1 0.0 0.0 0.0 0.0 0.0

5min ≤7

7 2 0 0 9 5 3 0 1 0 n 11 21 11 18 13 11 11 12

% 1.2 2.7 1.1 0.6 0.2 0.2 0.2 0.1 0.0 1.5 1.6 1.4 0.5 0.2 0.1 0.1 0.1 0.0 Apgar score Apgar

1min ≤7 4 0 4 0 n % 15 40 41 93 74 20 18 22 47 72 52 17

114 104

% 84.0 81.8 7.1 1.8 0.3 0.0 1.1

10.3

Not 9

Done %

2.1 4.2 4.0 4.0 2.9 2.1 1.8 2.5 0.0 3.0 3.3 5.5 4.7 2.9 2.1 1.8 1. 0.0

n Breech Vaginal

2012 0 n 3,018 2,774

20 84 261 101 466

Breech 2012 0 0 n

26 63 71 36 46 50

Caesarean 152 655 954 234 189 684 883 217 1,465 1,323

2011 2012 2011 and 9.1

12.1

% 34

NA 1.9 0.7 0.1 0.0 0.0 0.0 0.0 0.0 0.0 2.4 1.1 0.2 0.0 0.0 0.0 0.0 0.0 0.0 281 981

Total 14,641 27,821 43,758

n delivery 327 412

ght for 2011 andght

5min ≤7 5 5 5 2 0 0 0 7 2 3 3 1 1 0 n ECV 2011 2012 24 11 28 15

2011 2012 2011 and

% % 6.6 5.9

9.6 1.6 0.3 0.0 1.0 by Wei 11.8 56

% Not Not

2.8 1.4 0.4 0.1 0.0 0.0 0.0 0.0 0.0 3.0 1.5 0.5 0.1 0.0 0.0 0.0 0.0 0.0

Apgar score Apgar n

Breech

Vaginal

236 201 0 elivery n Successful 30 86

234 125 475

1min ≤7

57 0 0 0 2 1 0 n 2011 35 21 14 17 22 13 36 21 18 15 19 12

in relation to complicationsin relation to

0.3 0.1

Breech d Breech

.6 32 % 314 8.3 4.6 1.9 0 0.2 0.1 0.1 0.1 0.0 9.1 4.3 1.6 0.6 0.2 0.1 0.0 0.1 0.0

Total

1,055 14,967 29,244 45,612 5 n delivery 10 Successful

Breech Vaginal 9 3 0 3 2 0 n Table 5.4

69 72 99 46 60 56 81 85 42

103 123 108

3,591 3,392

Breech

Vaginal

rmality

Table 5.5 Breech and incidence of ECV and Table 5.5 Breech

Vaginal Breech delivery Breech Vaginal Total 1,246 1,501 3,843 2,853 1,722 1,187 1,388 3,451 2,678 1,591

16,194 50,450 46,106 12,948 14,492 44,894 42,375 12,040 : delivery IUD Total

Prematurity

Birth injuries and delivery of pregnancyof

Complications

2011 2012 Genital tract trauma Table 5.6 1500 2000 2500 3000 3500 4000 1500 2000 2500 3000 3500 4000

------Congenital Abno NA NA <1000 >4000 <1000 >4000 Weight 1001 1501 2001 2501 3001 3501 1001 1501 2001 2501 3001 3501

51 National Obstetrics Registry

Table 5.5 Breech and incidence of ECV 2011 and 2012 ECV Vaginal Successful Not NA Not Breech Successful Done n n % n % n % n % 2011 3,591 10 0.3 236 6.6 327 9.1 3,018 84.0 2012 3,392 5 0.1 201 5.9 412 12.1 2,774 81.8

Table 5.6: Vaginal Breech delivery in relation to complications 2011 and 2012

52 2011 2012 Complications Vaginal Vaginal of pregnancy Total Breech Total Breech and delivery delivery delivery n % n % Congenital Abnormality 314 30 9.6 281 20 7.1 Prematurity 14,967 234 1.6 14,641 261 1.8 IUD 1,055 125 11.8 981 101 10.3 Genital tract trauma 29,244 86 0.3 27,821 84 0.3 Birth injuries 32 0 0.0 34 0 0.0 Total 45,612 475 1.0 43,758 466 1.1

Table 5.7: Caesarean Breech delivery in relation to complications 2011 and 2012

2011 2012 Complications 57 of pregnancy Caesarean Caesarean and Total Breech Total Breech delivery delivery delivery n % n % Congenital Abnormality 314 12 3.82 281 11 3.91 Prematurity 14,967 832 5.56 14,641 826 5.64 IUD 1,055 8 0.76 981 15 1.53 Birth injuries 32 1 3.13 34 0 - Total 16,368 133 0.81 15,937 133 0.83 53

S 59 T

I L L B I R T H

National Obstetrics Registry

STILLBIRTHS

National Obstetrics Registry

STILLBIRTHS

National Obstetrics Registry National Obstetrics Registry

CHAPTER 6 STILLBIRTHS

Anil Krishna Dass1, Mohd. Rouse Abdul Majid1, SD Karalasingam2, R Jeganathan3

1. Pulau Pinang Hospital 2. National Clinical Research Centre 3. Sultanah Aminah Hospital, Johor

SUMMARY

The stillbirth rate in 2011 was 6.85 per 1000 births and in 2012 the rates were slightly higher at 6.99 per 1000 births.

6.1 INTRODUCTION

Stillbirth is defined as birth of an infant with a birth weight equal to or more than 500gm (or 22 weeks of pregnancy if birth weight is not known) with no signs of life. Overall, the number of MSB were almost two fold more than FSB. The national stillbirth for 2010 was 4.5 per 1000 births. The rates from the 14 tertiary hospitals were higher and this is probably due to the fact that they are referral centres, and deal with high risk cases.

HKL recorded the highest stillbirth rates at 10.47 per 1000 births in 2011 and 10.19 per 1000 births in 2012 and these findings were similar to the findings from the previous 2 reports. HL Sabah had the lowest stillbirth rates at 2.95 per 1000 births in 2011 and HRPB Perak in 2012 at 4.36 per 1000 births.

6.2 PATIENT DERMOGRAPHICS

Women in the late 30’s and beyond had increased incidence of stillbirth over the past few decades. As age increases beyond 40, the risk of stillbirth increases by 3 to 4 folds. This could be due to low uteroplacental perfusion caused by poor uterine vasculature in older women or chronic diseases, medical and obstetric complications experienced by these women .

The details of stillbirth among mothers of various ethnic groups in Malaysia is shown in Table 6.3. The highest stillbirth rate was seen among Orang Asli Peninsular Malaysia in 2011 and in the subsequent year it was higher in Bidayuhs at 16.17%. Among the 3 major ethnic groups, Indian mothers were found to have the highest stillbirth rates in both the years. 60

53 54 National Obstetrics Registry

The stillbirth rate among mothers with hypertension was 16.94 per 1000 live birth as 3. Provide more awareness and health education to the Indian and Orang Asli compared to diabetic mothers at 8.05 per 1000 live births in 2011 however in 2012 the women about care during pregnancy and contraception. rates were higher with diabetic mothers at 8.27 per 1000 live births and with hypertension in pregnancy the rates were 17.58 per 1000 live births. Pre-pregnancy 6.7 REFERENCE counselling and optimization of these medical conditions may help to reduce stillbirth rates in women. Those diagnosed during pregnancy need close surveillance and good 1. Huang L, Sauve R, Birkett N, Fergusson D, van Walraven C. Maternal age and glycemic control. risk of stillbirth: a systematic review. Cmaj. 2008;178(2):165-72. Epub 2008/01/16. 6.3 STILLBIRTH AND RISK LEVEL AT BOOKING

Colour coding at antenatal booking according to the risks levels and their association with stillbirth is shown in table 6.5. The highest stillbirth rates were among mothers who were coded red which was 18.47 per 1000 births in 2011 and 17.58 per 1000 births in 2012.

6.4 STILLBIRTH AND BIRTHWEIGHT

The highest rate of stillbirths were among babies with a birth weight of less than 1000g followed by babies weighing 1000-1500g.Babies weighing more than 4000g had a stillbirth rate of 8.16 per 1000 births in 2011 and in 2012 stillbirth rates were 4.64 per 1000 births

6.5 CONCLUSION

The stillbirth rate of 6.85 per 1000 births in 2011 and 6.99 per 1000 births although higher than the national rate, has reduced compared to the rate of 7.60 per 1000 births in 2010. HKL had the highest rate whereas HL Sabah had the lowest. The Orang Asli Peninsular Malaysia had the highest stillbirth rate, which was similar to the previous report. Women with hypertensive disorders had twice the number of stillbirth as compared to Diabetes. Maternal age of above 40 and infants weighing less than 2kg are risk factors for stillbirth. Women who had been tagged red at booking are at risk of delivering a stillbirth infant.

6.6 RECOMMENDATIONS

1. More awareness should be created regarding prenatal assessment and counselling to optimize medical conditions before pregnancy. 2. Advice contraception or sterilization to women above 40 who are at high risk of having a stillbirth. The stillbirth rate among mothers with hypertension was 16.94 per 1000 live birth as 3. Provide more awareness and health61 education to the Indian and Orang Asli compared to diabetic mothers at 8.05 per 1000 live births in 2011 however in 2012 the women about care during pregnancy and contraception. 62 rates were higher with diabetic mothers at 8.27 per 1000 live births and with hypertension in pregnancy the rates were 17.58 per 1000 live births. Pre-pregnancy 6.7 REFERENCE counselling and optimization of these medical conditions may help to reduce stillbirth rates in women. Those diagnosed during pregnancy need close surveillance and good 1. Huang L, Sauve R, Birkett N, Fergusson D, van Walraven C. Maternal age and glycemic control. risk of stillbirth: a systematic 55review. Cmaj. 2008;178(2):165-72. Epub 2008/01/16. 6.3 STILLBIRTH AND RISK LEVEL AT BOOKING

Colour coding at antenatal booking according to the risks levels and their association 54 with stillbirth is shown in table 6.5. The highest stillbirth rates were among mothers who were coded red which was 18.47 per 1000 births in 2011 and 17.58 per 1000 births in 2012.

6.4 STILLBIRTH AND BIRTHWEIGHT

6.5 CONCLUSION

6.6 RECOMMENDATIONS

56 National Obstetrics Registry

s 4.62 6.88 8.32 4.36 8.26 5.13 7.60 7.60 3.30 9.12 5.62 6.61 4.86 6.99 1000 1000 10.19 birth rate per Stillbirth

n Live Live birth 3,927 3,032 4,583 6,241 8,794 1,512 10,333 12,112 11,874 10,795 12,372 12,828 11,034 13,798 123,235

7 n 10 21 58 15 59 97 20 65 60 15 84 45 36 592 MSB 2012

4 6 5 3 n 28 41 24 12 17 34 14 33 17 31 269 FSB

n Total 3,046 3,954 4,603 6,273 8,823 1,522 10,419 12,212 11,995 10,877 12,466 12,945 11,096 13,865 124,096 delivery

2011 2012 2011 and

SDP 5.05 5.37 7.10 4.93 7.92 4.11 5.52 8.70 7.16 8.78 7.93 5.67 2.95 6.85 1000 1000 10.47 birth s rate per Stillbirth

n Live Live birth 4,097 3,366 6,289 4,866 9,364 9,885 10,428 12,379 11,745 10,879 12,532 12,075 13,116 14,911 135,932

Stillbirth rate from rate Stillbirth

n 10 19 46 15 63 77 15 39 76 48 79 90 35 21 633 MSB 2011

Table 6.1

3 7 5 n 28 16 35 46 21 33 19 27 14 21 23 298 FSB

939 n Total Total 4,119 3,383 6,320 4,886 9,431 9,941 10,502 12,477 11,868 10, 12,641 12,181 13,2 14,955 136,863 delivery

HKL SDP HPP Total HL Sabah HTF Perlis HSA Johor HSB Kedah HSB HU Sarawak HU HRPB Per HRPB HTAA Pahang

HTAR Selangor Hospital Melaka HRPZ IIHRPZ Kelantan HSNZ Terengganu HTJ Sembilan Negeri

5755 National Obstetrics Registry

1000 1000

0.00 6.79 6.24 6.00 6.83 8.98 0.00 0.00 6.99 14.82 16.08 livebirth per Stillbirth rate

2 n 26 126 311 5,747 4,251 22,590 43,651 31,052 15,479 123,235 Live birth Live

2012 0 5 0 0 n 22 86 95 45 188 151 592 MSB

0 0 0 0 n 17 55 74 61 44 18 269 FSB

ge 2011 and and 2012 ge 2011

2 n 26 126 316 Total Total 5,786 4,314 22,731 43,913 31,264 15,618 124,096 delivery

birth by a birth by

still -

6.98 5.78 5.89 6.15 9.70 0.00 6.85 1000 1000 15.75 14.56 30.90 rate per livebirth Stillbirth

0 n 26 127 356 Live Live birth 6,729 4,738 26,131 47,184 33,521 17,120 Distribution of Distribution 135,932

2 8 0 0 n 27 94 49 192 140 121 633 Table 6.2 2011 MSB

0 3 0 1 n 20 57 86 66 45 20 298 FSB

1 n 26 129 367 Total Total 6,776 4,807 26,282 47,462 33,727 17,286 136,863 delivery

9 14 1 24 29 34 39 44 49 54 59

------Age Total 10 15 20 25 30 35 40 45 50 55

5856 National Obstetrics Registry

birth .82 4.70 6.91 6.26 3.51 3 5.44 2.60 0.00 7.92 6.11 1.92 6.99 10.62 11.39 16.71 rate per Stillbirth 1000 1000

n 38 753 262 769 359 520 Live Live birth 2,340 7,505 6,148 3,705 2,940 1,472 85,814 10,610 123,235

7 7 3 1 9 1 0 2 6 0 n 30 49 58 2012 419 592 MSB

4 1 0 7 1 0 4 3 1 n 17 21 10 26 174 269 FSB

n 38 761 263 771 365 521 Total Total 2,351 7,552 6,218 3,718 2,956 1,481 86,407 10,694 124,096 delivery

birth 1.47 7.00 5.40 3.97 8.67 2.22 6.97 0.00 8.26 7.94 2.46 6.85 13.16 10.29 12.20 rate per Stillbirth 1000 1000

n 912 346 123 410 Live Live birth 2,716 8,526 6,411 4,032 3,159 2,153 1,573 1,218 93,014 11,339 135,93

3 6 9 0 2 7 0 9 3 3 n 2011 30 37 53 471 633 MSB Distribution of stillbirth by ethnicity 2011 ethnicity and 2012 of stillbirth by Distribution

1 6 7 3 5 8 0 4 0 2 n 16 29 37 180 298 FSB

Table 6.3

n 924 349 123 415 Total Total 2,720 8,572 6,477 4,048 3,166 2,168 1,586 1,221 93,66 11,429 136,863 delivery

NA Iban Total Murut Bajau Malay Indian Others Bidayuh Chinese Melanau Ethnicity Foreigner ndigenous group in in group ndigenous Kadazan/ Dusun Kadazan/

(Peninsular Malaysia) Sabah & Sarawak & Sabah

OA Other i Other

5759 National Obstetrics Registry

e per 1000 1000 8.27 7.67 birth 20.49 17.58 21.57 15.84 21.74 55.56 rat Stillbirth

20 n 54 Live Live 732 788 782 birth 9,388 4,7 3,410 10,884

n 6 1 66 58 59 14 38 11 2012 MSB

n 9 3 6 2 24 14 24 16 FSB

n 57 747 805 799 Total Total 9,460 4,803 3,464 10974 delivery

8.05 7.31 1000 1000 17.00 16.94 20.21 15.62 24.81 42.55 birth s rate per

Stillbirth

n 47 941 927 Live Live birth 5,844 1,039 4,289 11,804 10,801

0 n 76 14 62 70 15 47 19 MSB 2011 Stillbirth in relation to Diabetes and Hypertension and relation Diabetes in to Stillbirth

2 6 4 2 n 19 17 29 20 FSB

Table 6.4

n 49 957 950 Total Total 5,943 1,060 4,356 11,899 10,880 delivery

existing existing - - Eclampsia - Medical Diabetes disorders Eclampsia Gestational Pre Pre Gestational Hypertension Pre

58 National Obstetrics Registry

birth 7.19 5.85 4.09 5.74 6.99 19.59 15.58 15.49 rate per Stillbirth 1000 1000

n 3,063 7,089 4,237 4,712 18,780 71,065 14,289 123,235 Live birth Live

2012 n 42 97 16 66 41 39 291 592 MSB

n 18 38 13 16 25 34 125 269 FSB

n 123 Total Total 3, 7,118 4,303 4,785 18,915 71,481 14,371 124,096 delivery

birth s

7.68 5.87 7.26 5.25 7.37 6.85

18.47 12.84 67 rate per Stillbirth 1000 1000 in relation to risk levels at booking risk levels in relation to

n 3,032 4,961 6,385 14,449 71,894 16,763 18,448 135,932 Live birth Live birth rate birth rate

Still

n 40 81 29 63 47 90 283 633 MSB 2011 Table 6.5

7 n 16 30 25 35 46 139 298 FSB

n Total Total 3,088 4,997 6,467 14,560 72,316 16,851 18,584 136,863 delivery

NA Red Total

Green Yellow White I White II No Code Risk Level at Booking

61 59 National Obstetrics Registry

s 7.23 2.03 1.35 1.67 4.64 6.99 1000 1000 94.64 36.65 birth 383.45 rate per Stillbirth

n 858 Live Live birth 1,268 3,329 3,660

14,388 44,803 42,318 12,611 123,235

n 2012 84 85 72 56 36 13 13 233 592 MSB

8 4 n 96 36 37 32 35 21 269 FSB

n 388 Total Total 1,187 1, 3,451 3,677 14,492 44,894 42,375 12,632 124,096 delivery

68 6.28 2.17 1.48 2.07 8.16 6.85 1000 1000 98.83 33.34 birth 366.23 rate per Stillbirth

PREMATURITY

birth rate in relation to birth weight inbirth relation to birth rate n 912 Live Live birth 1,366 3,719 3,921 16,093 50,341 46,038 13,542 Still 135,932

n 99 88 68 68 38 20 26 226 633 2011 MSB Table 6.6

8 6 n 36 36 33 41 30 108 298 FSB

n Total Total 1,246 1,501 3,843 3,953 16,194 50,450 46,106 13,570 136,863 delivery

1500 2000 2500 3000 3500 4000

------Total Birth < 1000 < 4000 > Weight

69 1000 1000 1501 2001 2501 3001 3501

60 62 National Obstetrics Registry

PREMATURITY

National Obstetrics Registry National Obstetrics Registry

CHAPTER 7 PREMATURITY

Nor Jumizah Abd Kadir, Wan Abu Bakar Yusoff, Halimatun Mansor

Sultanah Nur Zahirah Hospital,Terengganu

SUMMARY

The incidence of preterm birth in 2011 and 2012 was 10.4 and 11.3 respectively and we see a rising trend from our previous reports. Main contributor to premature births were preeclampsia, eclampsia and heart disease with NYHA 111.It was more among the OA Peninsular Malaysia and Indian women and in women in their first pregnancy as well as in women who are para 6 and more.

7.1 INTRODUCTION.

HKL had the highest preterm births in 2010. In 2011 HKL had the highest preterm births at 14.2% and in 2012 HRPB Perak had the highest rate at 15.1%. HL Sabah had the lowest preterm birth rate for both years.

7.2 PATIENT DEMOGRAPHICS

Preterm births were higher in women in extremes of age. In 2011 preterm births was high in women aged 10-14 years at 20.2% and in 2012 in women aged 55 at 50%. Preterm births were high in women with parity 6 and more in both years. It was high among the OA Peninsular Malaysia followed by Indians in both the years. 28.9% of babies that were premature had weight less than 2000g in 2011 and there was a slight increase at 30.4% in 2012.

7.3 CONTRIBUTING FACTORS TO PRETERM DELIVERIES

The main contributing factor for prematurity was preeclampsia and eclampsia. In women with heart disease the premature deliveries were higher due to women’s worsening cardiac status

7. 4 MODE OF DELIVERY Table 7.1: Total number of premature births for 2010 and 2012

Majority of the preterm deliveries were conducted by MOs with more than 6 months 2010 2011 2012

O&G experience followed by staff nurses and HOs. About one third of the preterm Preterm birth 70 n % n % n % babies were delivered by CS. Total preterm 11,219 8.1 14,181 10.4 14,060 11.3 delivery 7.5 OUTCOMES Total delivery 138,315 100.0 136,863 100.0 124,096 100.0

Slightly less than 50% of the babies were admitted to NICU and the nursery for monitoring while the others were discharged to the mothers. There was fetal demise in Graph 7.1: Percentage of preterm births 2010-2012 4% of these babies in 2011 and 4.4% in 2012. 6163

7.6 CONCLUSION

Preventing preterm births is a challenge. The causes can be numerous and complex and not well understood. Prematurity is one of the major problems and it causes long term effects on the newborn. Two thirds of the babies were discharged to the mothers. To reduce preterm deliveries in adolescents and women above 40 years, women need access to contraception.

7.7 RECOMMENDATION

1. To prevent prematurity, women should be in good health before they embark on pregnancy and early antenatal care is important. 2. We should look into the association of smoking, drugs and assisted reproduction in relation prematurity in subsequent reports.

7.8 REFERRENCE

1. Green Top guideline No1b February 2011 RCOG.

71 72

64 7.4 MODE OF DELIVERY Table 7.1: Total number of premature births for 2010 and 2012

Majority of the preterm deliveries were conducted by MOs with more than 6 months 2010 2011 2012 O&G experience followed by staff nurses and HOs. About one third of the preterm National Obstetrics Registry Preterm birth n % n % n % babies were delivered by CS. Total preterm 11,219 8.1 14,181 10.4 14,060 11.3 delivery 7.5 OUTCOMES Total delivery 138,315 100.0 136,863 100.0 124,096 100.0

Slightly less than 50% of the babies were admitted to NICU and the nursery for

monitoring while the others were discharged to the mothers. There was fetal demise in Graph 7.1: Percentage of preterm births 2010-2012 4% of these babies in 2011 and 4.4% in 2012.

7.6 CONCLUSION

7.7 RECOMMENDATION

7.8 REFERRENCE

1. Green Top guideline No1b February 2011 RCOG.

71 72

62 7.4 MODE OF DELIVERY Table 7.1: Total number of premature births for 2010 and 2012

Majority of the preterm deliveries were conducted by MOs with more than 6 months 2010 2011 2012 O&G experience followed by staff nurses and HOs. About one third of the preterm Preterm birth n % n % Nationaln Obstetrics% Registry babies were delivered by CS. Total preterm 11,219 8.1 14,181 10.4 14,060 11.3 delivery 7.57.4 OUTCOMES MODE OF DELIVERY Total delivery 138,315 100.0 136,863 100.0 124,096 100.0 Table 7.1: Total number of premature births for 2010 and 2012

Majority of the preterm deliveries were conducted by MOs with more than 6 months Slightly less than 50% of the babies were admitted to NICU and the nursery for 2010 2011 2012 monitoringO&G experience while the followed others wereby staff discharged nurses andto the HOs mothers.. About There one thirdwas fetalof the demise preterm in Preterm birth n % n % n % Graph 7.1: Percentage of preterm births 2010-2012 4%babies of these were babies delivered in 2011 by CS. and 4.4% in 2012. Total preterm 11,219 8.1 14,181 10.4 14,060 11.3 delivery Total delivery 138,315 100.0 136,863 100.0 124,096 100.0 7.67.5 CONCLUSION OUTCOMES

Slightly less than 50% of the babies were admitted to NICU and the nursery for Preventing preterm births is a challenge. The causes can be numerous and complex monitoring while the others were discharged to the mothers. There was fetal demise in and not well understood. Prematurity is one of the major problems and it causes long Graph 7.1: Percentage of preterm births 2010-2012 4% of these babies in 2011 and 4.4% in 2012. term effects on the newborn. Two thirds of the babies were discharged to the mothers. To reduce preterm deliveries in adolescents and women above 40 years, women need access7.6 CONCLUSION to contraception.

Preventing preterm births is a challenge. The causes can be numerous and complex 7.7 RECOMMENDATION and not well understood. Prematurity is one of the major problems and it causes long term1. effectsTo prevent on the prematurity, newborn. Twowomen thirds should of the be babies in good were health discharged before they to the embark mothers. on To reducepregnancy preterm and deliveries early antenatal in adolescents care is important. and women above 40 years, women need access2. We to shouldcontraception. look into the association of smoking, drugs and assisted reproduction in relation prematurity in subsequent reports. 7.7 RECOMMENDATION 7.8 REFERRENCE 1. To prevent prematurity, women should be in good health before they embark on

1. Greenpregnancy Top guidelineand early No1b antenatal February care 2011is important. RCOG. 2. We should look into the association of smoking, drugs and assisted reproduction in relation prematurity in subsequent reports.

7.8 REFERRENCE

1. Green Top guideline No1b February 2011 RCOG.

71 72

6471 72

65 63 National Obstetrics Registry

% 7.2 4.9 10.4 12.1 11.6 15.1 13.4 13.1 13.4 10.9 12.9 12.2 11.8 11.8 11.3 elivery

32 n 413 353 695 842 4 180 994 1,261 1,635 1,577 1,187 1,613 1,573 1,305 Preterm d 14,060 2012

elivery n 3,954 3,046 4,603 6,273 8,823 1,522 10,419 12,212 11,995 10,877 12,466 12,945 11,096 13,865 124,096 Total d Total

2011 and 2012 and 2011

% 7.5 9.4 3.5 12.0 11.5 11.8 10.3 14.2 11.0 13.2 12.9 10.4 10.7 11.4 10.4 SDP elivery

n ,285 496 783 390 748 538 526 Preterm d 1 1,686 1,030 1,674 1,220 1,266 1,409 1,130 14,181 2011

Preterm delivery by delivery Preterm

livery

e n 4,119 3,383 6,320 4,886 9,431 9,941 10,502 12,477 11,868 10,939 12,641 12,181 13,220 14,955 136,863 ble 7.2 Ta Total d Total

HKL SDP HPP Total HL Sabah HTF Perlis HSA Johor HSB Kedah HSB HU Sarawak HU HRPB Perak HTAA Pahang HTAR Selangor Hospital Melaka HRPZ 11HRPZ Kelantan HSNZ Terengganu HTJ Sembilan Negeri

66 64 National Obstetrics Registry

Table 7.3 Distribution of preterm deliveries by age and parity 2011 and 2012 2011 2012 Age Total delivery Preterm Delivery Total delivery Preterm Delivery n % n % n % n % 10-14 129 0.1 26 20.2 126 0.1 22 17.5 15-19 6,776 5.1 933 13.8 5,786 4.7 849 14.7 20-24 26,282 19.3 2,803 10.7 22,731 14.1 2,719 12.0 25-29 47,462 34.7 4,548 9.6 43,913 20.6 4,533 10.3 30-34 33,727 24.6 3,613 10.7 31,264 17.8 3,568 11.4 35-39 17,286 12.6 2,238 12.9 15,618 10.8 2,191 14.0 40-44 4,807 3.5 745 15.5 4,314 3.4 695 16.1 45-49 367 0.2 56 15.3 316 0.3 59 18.7 50-54 26 0.0 5 19.2 26 0.0 4 15.4 55-59 1 0.0 - 0.0 2 0.0 1 50.0 Parity

1 46,573 34.0 5,051 10.8 43,121 34.7 5,268 12.2 2 - 5 82,133 60.0 7,939 9.7 74,266 59.8 8,177 11.0 ≥ 6 7,940 5.8 992 12.5 6,626 5.3 989 14.9 NA 217 0.2 10 4.6 83 0.1 6 7.2

Table 7.4 Distribution of preterm delivery by ethnicity 2011 and 2012 2011 2012 Total Preterm Total Preterm Ethnicity delivery delivery delivery delivery n n % n n % Malay 93,665 10,183 10.9 86,407 10,100 11.7 Chinese 8,572 896 10.5 7,552 870 11.5 Indian 6,477 893 13.8 6,218 892 14.3 Kadazan/ Dusun 4,048 171 4.2 3,718 283 7.6 Murut 349 12 3.4 263 21 8.0 Bajau 3,166 124 3.9 2,956 254 8.6 Melanau 123 9 7.3 38 2 5.3 Iban 2,168 286 13.2 771 101 13.1 Bidayuh 1,586 201 12.7 365 40 11.0 OA (Peninsular 924 175 18.9 761 117 15.4 Malaysia) Other indigenous group 2,720 94 3.5 2,351 153 6.5 in Sabah & Sarawak Foreigner 11,429 1,007 8.8 10,694 1,035 9.7 Others 1,221 93 7.6 1,481 141 9.5 NA 415 37 8.9 521 51 9.8

65 National Obstetrics Registry

Table 7.5: Preterm delivery in relation to accoucher 2011 and 2012 Table 7.6 Distribution of preterm in relation to medical disorders 2011 and 2012 2011 2012 2011 2012 Accoucher Total Preterm delivery Total Preterm delivery Total Total Preterm Total Total Preterm delivery n % delivery n % Medical Problems delivery delivery delivery delivery Specialist 3,454 781 22.6 3,582 965 26.9 n n % n n % MO with > 6 months O&G Diabetes 11,899 1,484 12.5 10,974 1,319 12.0 41,071 5,971 14.5 42,245 6,079 14.4 experience Pre-existing 957 151 15.8 747 131 17.5 MO with < 6 months O&G 6,597 864 13.1 3,782 524 13.9 Gestational 10,880 1,324 12.2 9,460 1,161 12.3 experience Hypertension 5,943 1,388 23.4 4,803 1,203 25.0 MO with no O&G 325 37 11.4 128 20 15.6 Pre-existing 1,060 238 22.5 805 193 24.0 experience Gestational 4,356 970 22.3 3,464 849 24.5 Staff Nurse 51,087 3,507 6.9 40,390 3,232 8.0 PIH without Community Nurse / 2,995 488 16.3 2,365 375 15.9 16,061 1,173 7.3 17,388 1,377 7.9 Proteinuria Government Midwife / JD Pre-Eclampsia 950 414 43.6 799 407 50.9 Trained Traditional Birth 143 13 9.1 268 14 5.2 Attendant Eclampsia 49 26 53.1 57 22 38.6 Untrained Traditional Birth Chronic HPT with 10 1 10.0 14 2 14.3 407 153 37.6 305 139 45.6 Attendant superimpose PE Unattended 136 20 14.7 117 19 16.2 Unclassified 49 12 24.5 36 6 16.7 Other MO 213 24 11.3 173 32 18.5 Heart Disease 907 135 14.9 689 117 17.0 HO 12,454 1,245 10.0 12,919 1,473 11.4 NYHA I 518 56 10.8 379 52 13.7 Others 1,778 147 8.3 886 48 5.4 NYHA II 113 25 22.1 82 17 20.7 NA 3,534 398 11.3 2,204 275 12.5 NYHA III 17 9 52.9 12 5 41.7 Total 136,863 14,181 10.4 124,096 14,060 11.3 NYHA IV 1 1 100.0 4 0 0.0 TB 77 13 16.9 73 14 19.2 Blood Disorder 1,079 128 11.9 987 105 10.6 Collagen Disease 5 2 40.0 2 0 0.0 Asthma 2,443 306 12.5 2,074 245 11.8 Renal Disease 37 17 45.9 46 25 54.3 Others 3,140 428 13.6 2,695 324 12.0

66 National Obstetrics Registry

Table 7.6 Distribution of preterm in relation to medical disorders 2011 and 2012 2011 2012 Total Total Preterm Total Total Preterm Medical Problems delivery delivery delivery delivery n n % n n % Diabetes 11,899 1,484 12.5 10,974 1,319 12.0 Pre-existing 957 151 15.8 747 131 17.5 Gestational 10,880 1,324 12.2 9,460 1,161 12.3 Hypertension 5,943 1,388 23.4 4,803 1,203 25.0 Pre-existing 1,060 238 22.5 805 193 24.0 Gestational 4,356 970 22.3 3,464 849 24.5 PIH without 2,995 488 16.3 2,365 375 15.9 Proteinuria Pre-Eclampsia 950 414 43.6 799 407 50.9 Eclampsia 49 26 53.1 57 22 38.6 Chronic HPT with 407 153 37.6 305 139 45.6 superimpose PE Unclassified 49 12 24.5 36 6 16.7 Heart Disease 907 135 14.9 689 117 17.0 NYHA I 518 56 10.8 379 52 13.7 NYHA II 113 25 22.1 82 17 20.7 NYHA III 17 9 52.9 12 5 41.7 NYHA IV 1 1 100.0 4 0 0.0 TB 77 13 16.9 73 14 19.2 Blood Disorder 1,079 128 11.9 987 105 10.6 Collagen Disease 5 2 40.0 2 0 0.0 Asthma 2,443 306 12.5 2,074 245 11.8 Renal Disease 37 17 45.9 46 25 54.3 Others 3,140 428 13.6 2,695 324 12.0

67 National Obstetrics Registry

Table 7.7 Birth weight and preterm delivery 2011 and 2012 Table 7.9 Preterm outcome 2011 and 2012 Birth 2011 2012 2011 2012 weight n % n % Outcome Total Total Preterm Total Total Preterm ≤ 1000 768 5.4 820 5.8 delivery delivery delivery delivery 1001 - 1500 1,100 7.8 1,120 8.0 n n % n n % 1501 - 2000 2,230 15.7 2,330 16.6 Mother 105,680 6,572 46.3 93,305 6,281 44.7 2001 - 2500 3,763 26.5 3,971 28.2 Admitted to NICU 10,503 3,432 24.2 10,556 3,580 25.5 2501 - 3000 3,865 27.3 3,654 26.0 Nursery 16,355 3,210 22.6 17,136 3,304 23.5 3001 - 3500 1,741 12.3 1,554 11.1 Mortuary 1,003 566 4.0 938 621 4.4 3501 - 4000 414 2.9 341 2.4 ≥ 4001 300 2.1 270 1.9 NA 3,322 401 12.1 2,161 274 12.7 Total 136,863 14,181 100 124,096 14,060 100

Table 7.8 Mode of delivery and preterm delivery 2011 and 2012 2011 2012 Delivery Total Preterm Total Preterm Type delivery delivery delivery delivery n n % n n % Vaginal 96,858 8,457 59.6 86,825 8,473 60.3 SVD 96,310 8,217 57.9 86,079 8,182 58.2 Breech 525 234 1.7 437 261 1.9

Not Available 24 6 0.0 16 3 0.0 Instrumental 4,943 238 1.7 4,616 236 1.7 Forceps 567 43 0.3 437 38 0.3

Vacuum 4,384 196 1.4 4,183 198 1.4 Caesarean 32,036 5,107 36.0 31,122 5,145 36.6 Classical 133 32 0.2 139 42 0.3 Hysterotomy 17 8 0.1 22 16 0.1 LSCS 31,816 5,050 35.6 30,928 5,079 36.1

Others 19 8 0.1 15 8 0.1 NA 3,007 371 2.6 1,518 198 1.4

Table 7.9 Preterm outcome 2011 and 2012

2011 2012 Outcome Total Total Preterm Total Total Preterm delivery delivery delivery delivery n n 77 % n n % Mother 105,680 6,572 46.3 93,305 6,281 44.7

Admitted to NICU 10,503 3,432 24.2 10,556 3,580 25.5 Nursery 16,355 3,210 22.6 17,136 3,304 23.5 78 Mortuary 1,003 566 4.0 938 621 4.4

NA 3,322 401 12.1 2,161 274 12.7 Total 136,863 14,181 70100 124,096 14,060 100

71 National Obstetrics Registry

ANAEMIA

National Obstetrics Registry National Obstetrics Registry

CHAPTER 8 ANAEMIA

Cheng Tan, Chong Seong Tan, Yacoob Nasuha, Ravindran J

Kuala Lumpur Hospital

SUMMARY

Anaemia at booking was 22.1% in 2009 and 29.03% in 2010, 2011 and 2012, there was a marked increase of anaemia at booking at 65.1% and 66.9% respectively and at delivery the rate reduced to 24.3% and 25.2% respectively. Indigenous groups had the highest rate of anaemia. The incidence of anaemia was higher among women in ages 25-29 years and in women para 5 and below in both years.

8.1 INTRODUCTION

WHO classification for anemia is haemoglobin <11g/ dL. The prevalence of anaemia in pregnancy varies considerably because of differences in socioeconomic conditions, lifestyles across different cultures. The most common causes of anaemia are poor nutrition and iron deficiency.

8.2 PATIENT DERMOGRAPHICS

There was a marked increase of anaemia in pregnancy across all centers when compared to data from 2010. We cannot explain the sudden increase seen in 2011 and 2012. We postulate that the implementation of compulsory data fields in the NOR has increased the detection rate. It may also be due to increasing awareness, that anemia is diagnosed when the haemoglobin was <11g/dl and not as <10g/dl as previously practiced.

The centers with the highest incidence of anaemia at booking in 2011 was HSB Kedah and in 2012 was HSNZ Terengganu. Anaemia incidence in HTF, Perlis for both years didn’t improve at delivery.

Bidayuh women had the highest rate of anaemia at booking in both years. Bajau women had the highest rate of anaemia at delivery in 2011 while other indigenous group in Sabah and Sarawak had the highest rate of anaemia in 2012. The lower socioeconomic background, poor dietary intake and lack of access to health care providers

6972 National Obstetrics Registry

may explain the high incidence rate among the indigenous groups in Sabah and

Sarawak.

% 5.2 0.2 8.2 9.7 4.2 The distribution of anaemia among different age groups is fairly constant.. Primigravida 74.9 25.7 51.8 43.1 11.1 38.4 29.1 32.7 46.5 25.2

had the highest incidence of anaemia at booking in both 2011 and 2012 but at delivery

44 this was reduced to 25.2% in 2011 and 26.3% in 2012. Anaemia n at delivery 22 63 325 719 2,938 2,650 1,559 1,944 1,333 4,5 3,128 4,184 1,066 6,394

30,869

8.3 OUTCOMES

% Anaemia is a risk factor for PPH. Approximately 32% of patients who had PPH were 70.1 74.9 65.2 68.2 61.7 60.3 67.7 69.3 68.0 69.6 75.7 68.4 66.9 56.3 66.9 anaemic at delivery in 2011 and in 2012 approximately 34% women who had PPH were 2012

anaemic at delivery. 63.5% of women in 2011 and 62.2% in 2012 who went into preterm Anaemia Anaemia 2011 and and 2012 2011 n at booking labour were anemic at booking 2,748 7,725 1,964 3,076 7,441 7,138 7,279 4,290 8,364 6,071 9,692 7,492 1,012 7,751 82,043 SDP

8.4 CONCLUSIONS

groups had the highest rate of anaemia incidence of anaemia by age groups and parity delivered

was not significant.

2.9 %

8.1 0.9 9.4 5.6 71.8 29.6 58.0 34.0 13.4 38.3 27.4 2 31.5 36.8 24.3

8.5 RECOMMENDATION

n Anaemia Anaemia 82 390 114 556 at delivery

1. Anaemia should be corrected before a women embarks on her next pregnancy. 2,935 3,074 1,936 2,111 1,650 4,488 2,973 2,137 3,788 1,227 5,464 32,843 Counselling should be given to all women during their postnatal follow up.

8.6 REFERENCE 69.4 75.2 64.4 65.6 59.9 58.7 67.6 66.9 66.1 71.8 74.1 67.6 73.4 43.5 65.1

ing

1. Antenatal care: routine care for the healthy pregnant woman, NICE Clinical 2011

Guideline (March 2008) Anaemia Anaemia at book 2. Hayley Willacy (2012) Anaemia in Pregnancy, retrieved from n 2,835 7,815 2,148 4,077 7,398 6,889 7,327 3,241 8,235 6,705 8,911 8,835 7,234 6,459 http://www.patient.co.uk 88,109

3. Ravichandran Jeganathan, Shamala Devi Karalasingam (2011) National

Obstetrics Registry – Preliminary Report of National Obstetrics Registry July –

Distribution of anaemia at booking and at delivery by and at delivery of anaemia at booking Distribution

851

December 2009, National Obstetrics Registry and the Clinical research Centre n who Total Total 4,087 3,336 6,217 4,841 9,333 9,854 10,396 12,351 11,729 10,833 12,467 12,019 13,066 14,

(CRC) women 135,380 4. Ravichandran Jeganathan, Shamala Devi Karalasingam (2012) National delivered

Obstetrics Registry – 2 Report 2010, National Obstetrics Registry and the Table 8.1

Clinical research Centre (CRC)

5. UNICEF/UNU/WHO Iron deficiency anaemia: assessment, prevention, and P control. Geneva, World Health Organization, 2001 HKL SDP HP 81 Total Sembilan HL, Sabah HL, HTF, Perlis HSA, Johor HSB,Kedah HTJ, Negeri HU, Sarawak HU, HRPB, Perak HTAA, Pahang Hospital Melaka HTAR, Selangor HRPZ II,HRPZ Kelantan HSNZ, Terengganu

70 73 National Obstetrics Registry may explain the high incidence rate among the indigenous groups in Sabah and

Sarawak.

% 5.2 0.2 8.2 9.7 4.2 The distribution of anaemia among different age groups is fairly constant.. Primigravida 74.9 25.7 51.8 43.1 11.1 38.4 29.1 32.7 46.5 25.2

had the highest incidence of anaemia at booking in both 2011 and 2012 but at delivery

44 this was reduced to 25.2% in 2011 and 26.3% in 2012. Anaemia n at delivery 22 63 325 719 2,938 2,650 1,559 1,944 1,333 4,5 3,128 4,184 1,066 6,394

30,869

8.3 OUTCOMES

8.4 CONCLUSIONS

In both years the incidence of anaemia was higher as compared to 2010. Indigenous who Total Total 3,920 3,010 4,507 6,192 8,728 1,513 10,307 12,056 11,843 10,746 12,295 12,803 10,955 13,759 women 122,634 groups had the highest rate of anaemia incidence of anaemia by age groups and parity delivered

was not significant.

2.9 %

8.1 0.9 9.4 5.6 71.8 29.6 58.0 34.0 13.4 38.3 27.4 2 31.5 36.8 24.3

8.5 RECOMMENDATION

n Anaemia Anaemia 82 390 114 556 at delivery

8.6 REFERENCE 69.4 75.2 64.4 65.6 59.9 58.7 67.6 66.9 66.1 71.8 74.1 67.6 73.4 43.5 65.1

ing

1. Antenatal care: routine care for the healthy pregnant woman, NICE Clinical 2011

3. Ravichandran Jeganathan, Shamala Devi Karalasingam (2011) National

Obstetrics Registry – Preliminary Report of National Obstetrics Registry July –

Distribution of anaemia at booking and at delivery by and at delivery of anaemia at booking Distribution

851

December 2009, National Obstetrics Registry and the Clinical research Centre n who Total Total 4,087 3,336 6,217 4,841 9,333 9,854 10,396 12,351 11,729 10,833 12,467 12,019 13,066 14,

(CRC) women 135,380 4. Ravichandran Jeganathan, Shamala Devi Karalasingam (2012) National delivered

Obstetrics Registry – 2 Report 2010, National Obstetrics Registry and the Table 8.1

Clinical research Centre (CRC)

74 71 National Obstetrics Registry

% 23.5 19.6 17.6 43.8 42.0 42.2 13.0 26.3 12.2 15.0 53.5 29.4 39.7 20.5 25.2

Anaemia Anaemia at delivery n 99 10 44 110 112 582 106 1,457 1,078 1,613 1,237 1,251 3,116 20,054 30,869

% 70.0 67.3 55.7 55.8 55.7 54 69.9 60.5 70.6 59.5 63.6 58.0 58.9 61.3 66.9 2012

2011 2012 and Anaemia Anaemia

n 988 at booking 23 146 531 254 445 864 317 4, 3,416 2,056 1,582 1,487 6,139 59,795 82,043

n 38 262 760 360 748 517 who Total Total 7,417 6,128 3,685 2,930 2,338 1,467 85,391 10,593 women 122,634 delivered

% 8.1 24.0 19.6 20.0 35.7 30.1 36.7 10.5 10.6 21.9 36.4 26.1 35.0 15.7 24.3

Anaemia Anaemia at delivery n 13 65 104 225 128 199 981 423 1,656 1,282 1,431 1,155 2,958 22,223 32,843

% 69.4 67.1 53.7 44.3 39.1 45.9 73.1 66.7 74.1 60.7 44.9 51.8 59.2 47.0 65.1 2011

n Anaemia Anaemia 82 at booking 135 552 716 194 5,657 3,439 1,773 1,445 1,570 1,165 1,210 5,868 64,303 88,109

n 345 123 909 413 wh Total Total Distribution of anaemia at booking and at delivery by ethnicity and at delivery of anaemia at booking Distribution 8,428 6,400 4,003 3,151 2,149 1,573 2,695 1,209

92,649 11,333 women

135,380 delivered

Table 8.2

s group s

tal

NA Iban To Murut Bajau Malay Indian Others Bidayuh Chinese Melanau Ethnicity Foreigner Kadazan/ Dusun Kadazan/ in Sabah & & in Sarawak Sabah Other indigenou Other

OA (Peninsular Malaysia)

72 National Obstetrics Registry

% 26.3 24.8 22.5 14.6 25.2

Anaemia at delivery n

12 1472 11,216 18,169 30,869

% 67.9 67.2 57.0 41.5 66.9

2012

Anaemia Anaemia n ,318 at booking 34 3,726 28,965 49 82,043

2011 and 2012 2011 and 2011 and 2011 and 2012

25.2%

% 2012 n Parity Parity 82 6,537 42,679 73,336 122,634 66.9% Total womenTotal who delivered

Anaemia at delivery

naemia at delivery naemia at delivery

% 5.1

25.2 24.1 20.9 24.3 84

n Anaemia Anaemia 11 at delivery 24.26% 1638 11,652 19,542 32,843 % Anaemia at booking at Anaemia 2011 Anaemia at booking and delivery and booking at Anaemia 65.08%

65.9 65.5 56.6 47.2 65.1 naemia at booking and at delivery by naemiabooking and at at delivery A

2011

10 80 70 60 50 40 30 20

Anaemia Anaemia ph 8.1: Anaemia at booking and booking at ph 8.1: A Anaemia at booking n 102 4,440 30,429 53,138 88,109 Table 8.3 Gra

n 216 7,840

46,158 81,166 135,380 ho delivered Total womenTotal w

- 1 ≥ 6 NA 2 Total Parity

76 73 National Obstetrics Registry

% 23.0 21.8 25.3 26.0 24.8 24.5 24.9 26.4 46.2 25.2 100.0

elivery

Anaemia Anaemia 2 n at d 29 83 12 1,249 5,701 7,644 3,780 1,060 11,309 30,869

38.9 48.9 64.0 70.3 68.8 65.8 63.1 60.2 61.5 66.9 100.0 2012

ooking

and 2012 2011 Anaemia Anaemia 2

n at b 49 16 189 2,807 2,689 14,415 30,520 21,220 10,136 82,043

y by age

2 n 26 126 314 who 5,736 4,262 22,513 43,421 30,830 15,404 122,634 delivered Total womenTotal

0.0 18.9 20.2 23.5 25.5 24.3 23.8 23.5 26.5 26.9 24.3

elivery

7 0 n Anaemia Anaemia 24 96 at d 1,361 6,119 8,098 4,055 1,121 11,962 32,843

46.5 48.7 62.1 68.6 66.7 64.6 61.8 57.2 53.8 65.1 100.0

2011

ooking

Anaemia Anaemia 1 n 59 14 at b 207 3,278 2,944 16,165 32,228 22,200 11,013 88,109 Distribution of anaemia at booking and at deliver of anaemia at booking Distribution

1 n 26 127 362 who 6,73 4,765 26,048 46,963 33,305 17,052 Table 8.4 135,380 delivered Total womenTotal

14 19 24 29 34 39 44 49 54 59

------Age Total 10 15 20 25 30 35 40 45 50 55

7477 National Obstetrics Registry

% 24.3 24.2 17.4 12.5 18.2 18.4 15.5 29.5 43.2 36.4 29.4 20.0 12.1 25.2

2 8 2 n Anaemia Anaemia 62 67 57 at delivery 833 767 181 8,932 8,863 20,923 20,727 30,869

66.4 66.8 76.2 56.3 69.3 69.8 64.2 67.9 62.1 54.5 67.9 60.0 68.6 66.9

2012

9 6 n Anaemia Anaemia 82 12 2011 and 2012 and 2011 272 278 at booking

1029 3,178 2,903 57,257 57,189 20,579 20,464 82,043

n 16 22 10 357 433 132 who 1501 4,589 4,160 86,219 85,560 30,325 30,138 122,634 delivered Total womenTotal

% 22.7 22.7 18.4 17.4 18.9 19.4 15.2 30.6 35.4 17.6 30.6 25.0 18.8 24.3

Anaemia Anaemia 4 3 2 n at delivery 80 86 46 86 931 849 553 9,548 9,488 21,811 21,727 32,843

% 64.4 64.4 59.2 87.0 66.8 67.2 64.6 66.9 70.8 52.9 66.9 37.5 65.2 65.1 2011 oking

Anaemia Anaemia 9 3 n at bo 20 92 257 365 1920 3,290 2,932 61,997 61,720 20,902 20,768 88,109

8 n 23 17 434 565 130 who 2944 4,923 4,366 96,272 95,815 31,241 31,029 135,380 delivered Distribution of anaemia at booking and at delivery by mode of delivery and at delivery of anaemia at booking Distribution Total womenTotal

Table 8.5

of NA NA reech SVD Total Mode Mode LSCS Others B Vaginal Forceps Vacuum Delivery Classical Caesarean Hysterotomy Instrumental

7578 National Obstetrics Registry

% 6.6 %

34.1 35.6 24.8 22.7

25.9 25.2 18.6 24.9 25.3 18.6

elivery

Anaemia Anaemia

n at delivery 42 67 151 198 Anaemia Anaemia

3,186

at d n nd 2012 389 432 401 1,739

29,112 30,407

% 71.8 64.4 63.2 62.2 28.3 2011 a

2012

66.5 66.9 64.8 64.9 66.9 65.0

2012 2011 and 2012 and 2011

Anaemia Anaemia n 76 at booking 318 504 286

8,746 ooking

Anaemia Anaemia

at b

4,456 1,352 1,124 1,403 77,140 80,421

n 443 118 798 who

1,010

14,060

delivered

Total womenTotal

n Total 6,705 2,086 1,733 2,160

115,305 120,203 delivery

% 6.6

32.8 32.7 26.3 23.1 HYPERTENSIVE

% 26.8 24.0 24.7 27.9 24.2 23.2

Anaemia Anaemia

at delivery n elivery 64 67

180 217

3,273 DISORDERS IN PREGNANCY

n Anaemia Anaemia 721 at d 2,223 1,137 1,252 29,813 31,200

% 67.9 67.3 66.7 63.5 28.3

2011

63.2 65.1 67.2 55.8 65.1 67.6

n Anaemia Anaemia at booking 372 132 551 286 2011 8,998 ooking

of anaemia at booking and at delivery and scores Apgar and at delivery anaemiaof at booking

Anaemia Anaemia

at b

5,233 3,091 1,443 3,651

80,680 83,910

n 548 196 826 who 1,010 14,181

delivered

Distribution Distribution

Total womenTotal

n Total 8,281 4,598 2,587 5,402 elivery Distribution of anaemia at booking and at delivery and complications of delivery and at delivery of anaemia at booking Distribution 123,984 128,874 d

Table 8.7

Table 8.6

IUGR ≥ 1500 mls≥ 1500

≤ 7 NA ≤ 7 NA > 7 > 7

Prematurity 88 score Apgar Apgar Fetal Demise Complications PPH PPH PPH < 1500 mlsPPH 1500 <

Apgar at 1 min Apgar at 5 min Apgar

7976 National Obstetrics Registry

HYPERTENSIVE DISORDERS IN PREGNANCY

National Obstetrics Registry National Obstetrics Registry

CHAPTER 9 HYPERTENSIVE DISORDERS IN PREGNANCY

Rohani Aziz, Rohana Ramli, Lee Pei Wei, Zarina, Mohd Rushdan Mohd Noor, Bavanandan Naidu

Sultanah Bahiyah Hospital, Kedah

SUMMARY

The incidence of HDP is 4.31% in 2011 and 3.83% in 2012 from the tertiary hospitals. Gestational Hypertension is the commonest type of hypertension in pregnancy.

9.1 INTRODUCTION

From 1997-2008 the average incidence of HDP related maternal death is 13.6%. It is the 4th leading cause of maternal mortality in Malaysia. It encompasses pre-existing hypertension, gestational hypertension and chronic hypertension with superimposed pre-eclampsia. These conditions range in severity from a mild increase in blood pressure to multisystem involvement. Therefore strategies and management is crucial to improve the maternal and fetal outcome.

The incidence of HDP in 2011 was 4.31% and in 2012 it was slightly lower at 3.83%. In both years, HRPB, Perak had the highest incidence of HDP.

9.2 PATIENT DERMOGRAPHICS

The mean age of patient with HDP was 28.6 years old in 2011 and 2012. Pre-existing hypertension and Gestational hypertension incidence was high in Malay women and in women aged 40 and more in both years.

9.3 MODE OF DELIVERY

The commonest mode of delivery in preexisting hypertension and Gestational hypertension in both years was CS.

9.4 OUTCOMES

Eclampsia was the commonest complication at 3.26% in 2011 and 3.24% in 2012 respectively, followed by postpartum haemorrhage at 1.40% in 2011 and 0.83 % in 2012. Incidence of abruption placenta in 2012 was 1.08% 89

80 77 National Obstetrics Registry

Intrauterine growth restriction was the commonest fetal complication for hypertensive Table 9.1 Incidence of HDP by SDP 2011 and 2012 disorders in pregnancy at 20.34% in 2011 & 15.29% in 2012 followed by prematurity at 2011 2012 9.60% in 2011 and 8.31% in 2012. The stillbirth rate in women with hypertensive SDP Total Total disorder is 16.94 per 1000 live births in 2011 and 17.58 per 1000 live births in 2012. women n % women n % In 2011, there was a higher incidence of fetal birthweight ranging 1001-1500 grams in who who women with preexisting and gestational hypertension. Babies of mothers with delivered delivered preexisting hypertension contributed to 1.24% of all low Apgar score ≤ 7 in 2011 and HTF, Perlis 4,087 151 3.69 3,920 123 3.14 1.00% in 2012. In 2011, babies of mothers with gestational hypertension contributed to HSB,Kedah 10,396 431 4.15 10,307 366 3.55 4.41% of all low Apgar score whilst in 2012 the incidence was 4.97%. HPP 3,336 57 1.71 3,010 44 1.46 HRPB, Perak 6,217 475 7.64 4,507 312 6.92 9.5 CONCLUSIONS HTAR, Selangor 12,351 483 3.91 12,056 504 4.18 HKL 11,729 526 4.48 11,843 444 3.75

HTJ, Negeri Sembilan 4,841 201 4.15 6,192 240 3.88 Gestational hypertension is the commonest type of Hypertensive disorder in Pregnancy. Hypertensive disorders was common in Malays followed by Chinese. Majority of babies Hospital Melaka 10,833 455 4.20 10,746 410 3.82 were delivered with good Apgar score. The commonest fetal complication was HSA,Johor 12,467 767 6.15 12,295 559 4.55 HTAA, Pahang 9,333 603 6.46 8,728 462 5.29 intrauterine growth restriction followed by prematurity. There was a higher incidence of HSNZ, Terengganu 12,019 634 5.27 12,803 633 4.94 birth weight ranging from 1001 gm to 1500gm. Eclampsia remained the commonest HRPZ11,Kelantan 13,066 475 3.64 10,955 386 3.52 maternal complication . HU,Sarawak 9,854 466 4.73 1,513 69 4.56 HL,Sabah 14,851 106 0.71 13,759 143 1.04 9.6 RECOMMENDATION Total 135,380 5830 4.31 122,634 4695 3.83

1. Early detection and optimal treatment for HDP plays a vital role in reducing both maternal and fetal morbidity and mortality. Table 9.2 Type of HDP from 2011 and 2012

Type of hypertensive disorder 2011 2012 9.7 REFERENCES n % n % Pre-existing 1082 18.56 824 17.55 1. VollebregtKC,Wolf H, Van der Wal MF et all. Does physical activity in leisure time Gestational 4238 72.69 3354 71.44 early pregnancy reduce the incidence of preeclampsia or gestational hypertension? Acta Obstet GynecolScand 2010; 89(2): 261-267. PIH without proteinuria 3127 53.64 2431 51.78 Pre-eclampsia 921 15.80 771 16.42 2. Hematram Yadav A review of maternal mortality in Malaysia, IeJSME 2012: 6 (Suppl 1): S142-S151 Eclampsia 190 3.26 152 3.24 Chronic hypertension with 390 6.69 294 6.26 3. Report on Confidential Enquiries into Maternal Deaths In Malaysia 2005 – 2008. superimposed pre-eclampsia 4. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Chronic Unclassified 49 0.84 34 0.72 hypertension in pregnancy. Obstet Gynecol. 2001; 98(1 suppl):177–185 NA 71 1.22 189 4.03

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Intrauterine growth restriction was the commonest fetal complication for hypertensive Intrauterine growth restriction was the commonest fetal complication for hypertensive TableTable 9.1 9.1 Incidence Incidence ooff HDPHDP by SDP 20112011 andand 2012 2012 disordersdisorders in pregnancy in pregnancy at 20.34% at 20.34% in 2011 in 2011& 15.29% & 15.29% in 2012 in 2012 followed followed by prematurity by prematurity at at 20112011 20122012 9.60% 9.60%in 2011 in and2011 8.31and% 8.31 in %2012. in 2012. The stillbirthThe stillbirth rate ratein women in women with with hypertensive hypertensive SDPSDP TotalTotal TotalTotal disorder is 16.94 per 1000 live births in 2011 and 17.58 per 1000 live births in 2012. disorder is 16.94 per 1000 live births in 2011 and 17.58 per 1000 live births in 2012. womenwomen nn % womenwomen n n %% In 2011In, there2011, wasthere a washigher a higher incidence incidence of fetal of fetalbirth weightbirthweight ranging ranging 1001 1001-1500-1500 grams grams in in whowho whowho womenwomen with preexistingwith preexisting and gestationaland gestational hypertension. hypertension. Babies Babies of mothersof mothers with with delivereddelivered delivereddelivered preexistingpreexisting hypertension hypertension contributed contributed to 1.24% to 1.24% of all of low all Apgarlow Apgar score score ≤ 7 ≤in 7 2011 in 2011 and and HTF,HTF, Perlis Perlis 4,0874,087 151151 3.69 3,9203,920 123123 3.143.14 1.00% 1.00%in 2012. in In2012. 2011, In 2011,babies babies of mothers of mothers with gestationalwith gestational hypertension hypertension contributed contributed to to HSB,KedahHSB,Kedah 10,39610,396 431431 4.15 110,3070,307 366366 3.553.55 4.41% 4.41%of all low of allApgar low Apgarscore scorewhilst whilst in 2012 in 2012the incidence the incidence was was4.97%. 4.97%. HPPHPP 3,3363,336 5757 1.71 3,0103,010 4444 1.461.46 HRPB, Perak 6,217 475 7.64 4,507 312 6.92 HRPB, Perak 6,217 475 7.64 4,507 312 6.92 9.5 CONCLUSIONS HTAR,HTAR, Selangor Selangor 12,35112,351 483483 3.91 12,05612,056 504504 4.184.18 9.5 CONCLUSIONS HKL 11,729 526 4.48 11,843 444 3.75 HKL 11,729 526 4.48 11,843 444 3.75 HTJ, Negeri Sembilan 4,841 201 4.15 6,192 240 3.88 Gestational hypertension is the commonest type of Hypertensive disorder in Pregnancy. HTJ, Negeri Sembilan 4,841 201 4.15 6,192 240 3.88 Gestational hypertension is the commonest type of Hypertensive disorder in Pregnancy. Hospital Melaka 10,833 455 4.20 10,746 410 3.82 Hypertensive disorders was common in Malays followed by Chinese. Majority of babies Hospital Melaka 10,833 455 4.20 10,746 410 3.82 Hypertensive disorders was common in Malays followed by Chinese. Majority of babies HSA,Johor 12,467 767 6.15 12,295 559 4.55 were delivered with good Apgar score. The commonest fetal complication was HSA,Johor 12,467 767 6.15 12,295 559 4.55 were delivered with good Apgar score. The commonest fetal complication was HTAA, Pahang 9,333 603 6.46 8,728 462 5.29 intrauterine growth restriction followed by prematurity. There was a higher incidence of HTAA, Pahang 9,333 603 6.46 8,728 462 5.29 intrauterine growth restriction followed by prematurity. There was a higher incidence of HSNZ, Terengganu 12,019 634 5.27 12,803 633 4.94 birth weight ranging from 1001 gm to 1500gm. Eclampsia remained the commonest HSNZ, Terengganu 12,019 634 5.27 12,803 633 4.94 birth weight ranging from 1001 gm to 1500gm. Eclampsia remained the commonest HRPZ11,Kelantan 13,066 475 3.64 10,955 386 3.52 maternal complication . HRPZ11,Kelantan 13,066 475 3.64 10,955 386 3.52 maternal complication . HU,Sarawak 9,854 466 4.73 1,513 69 4.56 HU,SarawakHL,Sabah 9,85414,851 466106 0.714.73 13,7591,513 14369 1.044.56

9.6 RECOMMENDATION HL,SabaTotalh 14,851135,380 5830106 4.310.71 122,63413,759 4695143 3.831.04 9.6 RECOMMENDATION Total 135,380 5830 4.31 122,634 4695 3.83 1. Early detection and optimal treatment for HDP plays a vital role in reducing both 1. Early detectionmaternal andand fetaloptimal morbidity treatment and morfor HDPtality. plays a vital role in reducing both Table 9.2 Type of HDP from 2011 and 2012 maternal and fetal morbidity and mortality. Type of hypertensiveTable 9.2 Type disorder of HDP from 20112011 and 2012 2012 9.7 REFERENCES Type of hypertensive disorder 2011 2012 9.7 REFERENCES n % n % Pre-existing 1082n 18.56% 824n 17.55% 1. VollebregtKC,Wolf H, Van der Wal MF et all. Does physical activity in leisure time PreGestational-existing 10824238 72.6918.56 3354824 71.4417.55 1. VollebregtKC,Wolfearly pregnancy H, Van reduce der Wal the MF etincidence all. Does ofphysical preeclampsia activity in leisureor gestational time Gestational 4238 72.69 3354 71.44 early hypertension?pregnancy reduce Acta Obstet the GynecolScandincidence of 2010; preeclampsia 89(2): 261- 267.or gestational PIH without proteinuria 3127 53.64 2431 51.78 hypertension? Acta Obstet GynecolScand 2010; 89(2): 261-267. PIH withoutPre-eclampsia proteinuria 3127921 15.8053.64 7712431 16.4251.78 2. Hematram Yadav A review of maternal mortality in Malaysia, IeJSME 2012: 6 PreEclampsia-eclampsia 921190 15.803.26 152771 3.2416.42 2. Hematram(Suppl Yadav 1): S142 A review-S151 of maternal mortality in Malaysia, IeJSME 2012: 6 ChronicEclampsia hypertension with 190390 6.693.26 294152 6.263.24 (Suppl3. Report 1): S142 on -ConfidentialS151 Enquiries into Maternal Deaths In Malaysia 2005 – 2008. Chronicsuperimposed hypertension pre-eclampsia with 390 6.69 294 6.26 3. Report on Confidential Enquiries into Maternal Deaths In Malaysia 2005 – 2008. 4. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Chronic superimposedUnclassified pre-eclampsia 49 0.84 34 0.72 hypertension in pregnancy. Obstet Gynecol. 2001; 98(1 suppl):177–185 4. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Chronic UnclassifiedNA 4971 1.220.84 18934 4.030.72 hypertension in pregnancy. Obstet Gynecol. 2001; 98(1 suppl):177–185 NA 71 1.22 189 4.03

90 91

81 79 National Obstetrics Registry

0.06 0.04 0.03 0.03 0.02 0.20 0.11 0.02 0.04 0.07 NA

3 2 5 3 8 1 4 9 n 58 167

% 0.04 0.02 0.03 0.03 0.02 0.04 0.00 0.02 0.01 0.01

2 2 5 2 0 1 1 1 n 38 31 Unclassified

% 0.33 0.32 0.23 0.15 0.15 0.29 0.12 0.15 0.05 0.16

with

Chronic

9 9 6 n 27 15 22 20 20 306 250 hypertension hypertension superimposed

% 3.61 3.03 2.33 1.69 1.81 3.17 2.53 1.80 1.23 1.65 011 2012 and

n 255 149 253 234 188 110 137 208 Gestational 2711 3,347

% 0.93 0.69 0.55 0.47 0.42 0.74 0.82 0.33 0.50 0.45

existing

n 58 35 71 54 61 20 56 56 864 631 Pre HDP by ethnicity from 2 ethnicity by HDP

n who 7417 6128 Total Total 8,428 6,400 85391 11121 12577 Table 9.3 92,649 14,948 12,955 women delivered

2011 20

Malay Malay Indian Indian Chinese Chinese Ethnicity Foreigner Foreigner in Sabah & & in Sarawak Sabah & in Sarawak Sabah Other indigenous group indigenous Other group indigenous Other

8380 National Obstetrics Registry

0.05 0.05 0.14 0.00 0.13 0.16 0.21 0.00

0 0 n 23 37 11 55 14 120

% 0.03 0.04 0.05 0.00 0.02 0.03 0.08 0.00

4 0 5 0 n Unclassified 12 33 10 19

% 0.23 0.29 0.65 0.00 0.19 0.23 0.63 0.00

Chronic

n 0 0 51 82 41 104 235 171 superimposed PE hypertension withhypertension Parity 2011 and 2012 2011 and Parity

% 2.93 3.03 5.37 1.85 2.55 2.65 4.90 1.22

Gestational 4 1 n 421 320 HDP in relation to to in relation HDP 1089 1944

1,353 2,460

% Table 9.4 0.62 0.80 1.81 0.00 0.51 0.72 1.19 1.22

existing -

0 1 n Pre 78 287 653 142 218 527

n 82 216 who 6537 Total Total 7,840 42679 73336 46,158 81,166 women delivered

5 5

- - 1 1 ≥ 6 ≥ 6 NA NA 2 2 2011 2012 Parit

84 81 National Obstetrics Registry

0.00 0.01 0.03 0.04 0.06 0.11 0.15 0.00 0.00 0.00 0.00 0.03 0.05 0.12 0.19 0.32 0.40 0.00 0.00 0.00

0 1 7 7 0 0 0 0 2 0 0 0 n 18 20 18 11 51 58 50 17

% 0.00 0.00 0.02 0.04 0.02 0.08 0.15 0.00 0.00 0.00 0.00 0.03 0.01 0.02 0.04 0.07 0.02 0.00 0.00 0.00

0 0 5 7 7 0 0 0 0 2 2 7 1 0 0 0 n 17 13 11 11 Unclassified

% 0.00 0.09 0.10 0.18 0.31 0.71 0.92 1.10 3.85 0.00 0.00 0.10 0.09 0.12 0.29 0.50 0.96 1.91 0.00 0.00

Chronic rtension with

2011 2012 and

0 6 4 1 0 0 6 6 0 0 n 27 84 44 21 53 90 77 41 103 121 ge superimposed PE hype A

% 0.79 1.37 1.65 2.41 3.53 5.76 8.12 9.12 3.17 1.12 1.45 2.12 3.13 4.67 7.93 5.73 0.00 0.00 11.54 100.00

1 3 1 4 0 0 n Gestational 92 33 64 18 430 983 387 327 920 964 719 338 1,132 1,176 HDP in relation to to in relation HDP

0 % 0.79 0.19 0.37 0.52 0.93 1.67 2.58 3.04 3.85 0.00 0.12 0.27 0.42 0.79 1.50 2.04 3.50 3.85 0.00

Table 9 . 5 existing

1 1 0 0 7 1 0 n 13 97 11 61 87 11 Pre 242 310 284 123 183 24 231

1 2

26 26 127 362 126 314 n 5736 4262 Total 6,731 4,765 22513 43421 30830 15404 26,048 46,963 33,305 17,052 delivered women who

14 19 24 29 34 39 44 49 54 59 14 19 24 29 34 39 44 49 54 59

------Age 2011 2012 10 15 20 25 30 35 40 45 50 55 10 15 20 25 30 35 40 45 50 55

82 National Obstetrics Registry

09 % 0.04 0.00 0.05 0.00 0. 0.10 0.11 0.00 0.17 0.23 0.26 0.07

0 2 0 3 0 7 1 1 n 38 28 98 80

% 0.03 0.00 0.05 0.00 0.06 0.00 0.02 0.28 0.02 0.00 0.05 0.07

0 2 0 0 1 1 0 1 n

28 19 17 14 Unclassified

0.13 0.46 0.32 0.18 0.75 0.37 0.12 0.56 0.14 0.46 0.59 0.33 PE with

Chronic

2 1 2 6 2 5 n 14 11 128 234 100 179 hypertension hypertension superimposed

% 2.24 3.68 2.66 2.83 5.96 2.58 1.89 4.48 3.00 3.23 5.08 2.93

n 16 16 76 16 14 44 116 125 Gestational 2151 1863 1615 1539 elivery among 2011 HDP 2012 and elivery

% 0.47 1.38 0.98 0.00 1.49 0.88 0.44 0.28 0.41 0.69 1.36 0.73 Mode of D Mode

existing -

6 0 1 3 n Pre 43 26 17 11 451 466 380 411 Table 9.6

n 435 565 357 433 who 4366 2944 4160 1501 Total Total 95815 31241 85560 30325 women delivered

CS NA CS NA SVD SVD 2011 2012

Breech Breech Forceps Forceps Vacuum Vacuum Mode of Mode Delivery

86 83 National Obstetrics Registry

0.11 0.05 0.09 0.04 0.05 0.09 0.12 0.16 0.10 0.17 0.16 0.14

% 0.08 0.07 0.05 0.07 0.05 0.04 0.05 0.21 0.17 0.58 0.41 0.19 0.14 0.12 0.13 0.34 NA

9 4 1 5 8 2 3 3 NA n 58 65 183 187

1 1 2 6 6 2 8 9 n 12 24 19 14 28 64 52 16

% 0.02 0.04 0.07 0.00 0.03 0.09 0.01 0.03 0.05 0.00 0.03 0.05

0.16 0.13 0.05 0.04 0.03 0.03 0.05 0.07 0.00 0.07 0.06 0.03 0.03 0.02 0.03 0.07

2 3 0 5 1 1 0 1 n 44 44 33 34 Unclassified

Unclassified

2 2 2 7 6 2 0 1 2 5 9 4 2 n

15 13 12 % 0.69 0.26 0.37 0.70 0.28 0.39 0.64 0.21 0.53 0.81 0.23 0.56 tension with d PE

Chronic

57 17 18 21 43 11 14 12

superimpose hyper 326 361 244 272 % ic

1.44 3.40 1.22 0.51 0.20 0.13 0.26 0.32 1.60 2.09 1.22 0.40 0.16 0.11 0.16 0.41

with

Chron

4.41 3.03 4.26 3.05 3.11 4.18 4.97 2.61 4.07 5.19 2.70 4.35

9 n hypertension hypertension 18 51 47 82 59 34 19 29 42 58 74 46 19 11

superimposed 100

97 96

79 85 90 94 Gestational

365 196 226 333

3755 4011 3009 3243 .57 % 7.30 7.49 4.31 2.80 2.40 2.76 6.34 6 7.71 4.04 2.36 2.06 2.31 5.64 12.06 10.01

1.24 0.75 1.59 0.93 0.78 1.44 1.00 0.66 1.25 1.21 0.67 1.25 Apgar scoreand 2012 2011 and in HDP Apgar

n 91 78 Gestational 181 288 698 358 181 139 266 586 871 278 151

1058 existing

HDP in relation to fetal weight2012 2011 fetal and relation to in HDP 1,41 1,106

n 73 24 78 67 26 21 27

103 931 757 802

Pre 1005

% Table 9 .8

2.17 2.53 1.67 1.01 0.71 0.64 0.84 1.93 2.11 1.80 2.00 1.03 0.62 0.50 0.54 1.05

Table 9.7

Pre

n existing 27 38 64 55 25 25 69 65 28 6705 2086 1733 163 358 293 109 149 277 212 Total Total 8,281 4,598 2,587 5,402 2,160 115305 120203 123,984 128,874 delivery

who 1246 1501 3843 2853 1187 1388 3451 Total Total 2,678 16194 50450 46106 12948 14492 44,894 42,375 12,040 women delivered

7 7 7 7

≤ 7 NA ≤ 7 NA ≤ 7 NA ≤ 7 NA > > > t

2011 2012 1500 2000 2500 3000 3500 3999 1500 2000 2500 3000 3500 3999

------2012 Apgar Score Apgar 2011 Birth Birth

≤1000 ≥4000 ≤1000 ≥4000 weigh 1001 1001 1501 2001 2501 3001 3501 1001 1501 2001 2501 3001 3501 Apgar scoreatApgar 1 min Apgar score min Apgar at 5 score min Apgar at 1 score min Apgar at 5

87 84 National Obstetrics Registry

% 0.11 0.05 0.09 0.04 0.05 0.09 0.12 0.16 0.10 0.17 0.16 0.14

9 4 1 5 8 2 3 3 n 58 65 183 187

% 0.02 0.04 0.07 0.00 0.03 0.09 0.01 0.03 0.05 0.00 0.03 0.05

2 3 0 5 1 1 0 1 n 44 44 33 34 Unclassified

% 0.69 0.26 0.37 0.70 0.28 0.39 0.64 0.21 0.53 0.81 0.23 0.56 tension with d PE

Chronic

n 57 17 18 21 43 11 14 12 superimpose hyper 326 361 244 272

% 4.41 3.03 4.26 3.05 3.11 4.18 4.97 2.61 4.07 5.19 2.70 4.35

n 79 85 90 94 Gestational 365 196 226 333 3755 4011 3009 3243

% 1.24 0.75 1.59 0.93 0.78 1.44 1.00 0.66 1.25 1.21 0.67 1.25 Apgar scoreand 2012 2011 and in HDP Apgar

existing

n 73 24 78 67 26 21 27 103 931 757 802 Pre 1005 Table 9 .8

n 6705 2086 1733 Total Total 8,281 4,598 2,587 5,402 2,160 115305 120203 123,984 128,874 delivery

7 7 7 7

> ≤ 7 NA ≤ 7 NA ≤ 7 NA ≤ 7 NA > > > 2011 2012 Apgar Score Apgar Apgar scoreatApgar 1 min Apgar score min Apgar at 5 score min Apgar at 1 score min Apgar at 5

8588 National Obstetrics Registry

Table 9.9 Fetal Complications in HDP 2011 and 2012 Table 9.9 Fetal Complications in HDP 2011 and 2012 2011 2012 2011 2012 Fetal outcome Total delivery n % Total delivery n % Fetal outcome Total delivery n % Total delivery n % 1. Prematurity 13992 1343 9.60 14440 1200 8.31 1. Prematurity 13992 1343 9.60 14440 1200 8.31 2. Intrauterine growth 2. Intrauterine growth 826 168 20.34 798 122 15.29 restriction 826 168 20.34 798 122 15.29 restriction 3. Intrauterine death 3. Intrauterine death - FSB 250 21 8.40 201 18 8.96 - FSB 250 21 8.40 201 18 8.96 - MSB 463 35 7.56 410 32 7.80 - MSB 463 35 7.56 410 32 7.80

Table 9.10 Maternal complications in HDP 2011 and 2012 Table 9.10 Maternal complications in HDP 2011 and 2012 Complications 2011 % 2012 % Complications 2011 % 2012 % 1. Abruptio placenta 31 0.52 52 1.08 1. Abruptio placenta 31 0.52 52 1.08 2. Pulmonary embolism 6 0.10 1 0.02 2. Pulmonary embolism 6 0.10 1 0.02 3. Post-partum hemorrhage 83 1.40 40 0.83 3. Post-partum hemorrhage 83 1.40 40 0.83 4. DIVC 0 0.00 0 0.00 4. DIVC 0 0.00 0 0.00 5.Pulmonary oedema 4 0.07 8 0.17 5.Pulmonary oedema 4 0.07 8 0.17 6.Maternal collapse 4 0.07 0 0.00 6.Maternal collapse 4 0.07 0 0.00

HEART DISEASE IN PREGNANCY

98 98

99 99

8689 National Obstetrics Registry

Table 9.9 Fetal Complications in HDP 2011 and 2012 2011 2012 Fetal outcome Total delivery n % Total delivery n % 1. Prematurity 13992 1343 9.60 14440 1200 8.31 2. Intrauterine growth 826 168 20.34 798 122 15.29 restriction 3. Intrauterine death - FSB 250 21 8.40 201 18 8.96 - MSB 463 35 7.56 410 32 7.80

Table 9.10 Maternal complications in HDP 2011 and 2012 Complications 2011 % 2012 % 1. Abruptio placenta 31 0.52 52 1.08 2. Pulmonary embolism 6 0.10 1 0.02 3. Post-partum hemorrhage 83 1.40 40 0.83 4. DIVC 0 0.00 0 0.00 5.Pulmonary oedema 4 0.07 8 0.17 6.Maternal collapse 4 0.07 0 0.00

HEART DISEASE IN PREGNANCY

National Obstetrics Registry National Obstetrics Registry

CHAPTER 10: HEART DISEASE IN PREGNANCY

SD Karalasingam1, R Jeganathan 2

1. National Clinical Research Centre 2. Sultanah Aminah Hospital, Johor

SUMMARY

Heart disease in pregnancy was captured in general as acquired, congenital, IHD and unknown causes in this report. There were 2 maternal deaths due to heart disease in pregnancy during the study period.

10.1 INTRODUCTION

CEMD reports have shown that maternal deaths due to heart diseases is the main non obstetric cause of maternal mortality in Malaysia. From NOR we have captured one maternal death in 2011 and another in 2012 due to heart disease. The prevalence of heart disease in pregnancy from the tertiary hospitals in 2011 was 0.68% and in 2012 was 0.57%. HSNZ, Terengganu had the highest prevalence in both years.

10.2 PATIENT DERMOGRAPHICS

In 2012 the prevalence was high among the OA (Peninsular Malaysia) and Bidayuh at 1.20% and 1.11% respectively. Acquired heart disease was higher among women aged 40-44 years in 2011 whilst in 2012 it was higher in women aged 45-49 yrs. IHD was common in women aged 40-44 years in both years. Women who were para≥ 6 had a higher prevalence of acquired heart disease and IHD during the study period.

10.3 OUTCOMES

There were no reported case of women with cardiogenic shock, thromboembolism in 2011 and 2012 .The popular mode of delivery was instrumental delivery.

100

87 90 National Obstetrics Registry

Table 10.1 Heart disease by SDP in 2011 and 2012 10.4 CONCLUSION Total women who Heart disease in pregnancy SDP delivered Heart disease in pregnancy prevalence was higher among OA (Peninsular Malaysia) 2011 2012 2011 % 2012 % and Bidayuh ethnic group in 2012.Women aged 40-49years and para more than 6 had HTF, Perlis 4,087 3,920 29 0.71 23 0.59 a higher prevalence of acquired heart disease and IHD during the study period. HSB, Kedah 10,396 10,307 123 1.18 98 0.95 HPP 3,336 3,010 13 0.39 13 0.43 10.5 RECOMMENDATION HRPB, Perak 6,217 4,507 34 0.55 23 0.51 HTAR, Selangor 12,351 12,056 85 0.69 90 0.75 1. Involvement of cardiologist and anaesthetist in managing women with cardiac HKL 11,729 11,843 78 0.67 86 0.73 disease. HTJ, Seremban 4,841 6,192 17 0.35 25 0.40 2. Implementation of pre conception clinics Hospital Melaka 10,833 10,746 38 0.35 29 0.27 3. In subsequent reports to capture the different types of heart disease complicating HSA, Johor 12,467 12,295 136 1.09 95 0.77 Pregnancy HTAA Pahang 9,333 8,728 87 0.93 17 0.19 HSNZ, Terengganu 12,019 12,803 158 1.31 132 1.03 10.6 REFERRENCES HRPZ II, Kelantan 13,066 10,955 58 0.44 39 0.36 HU Sarawak 9,854 1,513 51 0.52 9 0.59 1. CEMB 2006-2008 HL, Sabah 14,851 13,759 14 0.09 18 0.13 Total 135,380 122,634 921 0.68 697 0.57

Table 10.2: Types of heart disease and 2011 and 2012 Types of Heart disease heart disease 2011 2012 n % n % Acquired 181 19.7 159 22.8 Congenital 179 19.4 133 19.1 IHD 39 4.2 37 5.3 NA 522 56.7 368 52.8 Total 921 100.0 697 100.0

102 101

88 91 National Obstetrics Registry

Table 10.1 Heart disease by SDP in 2011 and 2012 10.4 CONCLUSION Table 10.1Total Heart women disease who by SDP in 2011Heart and d 2012isease in pregnancy 10.4 CONCLUSION SDP Totaldelivered women who Heart disease in pregnancy Heart disease in pregnancy prevalence was higher among OA (Peninsular Malaysia) SDP 2011delivered 2012 2011 % 2012 % and BidayuhHeart diseaseethnic group in pregnancy in 2012. Wprevalencomen agede was 40 higher-49years among and OApara (Peninsular more than Malaysia)6 had HTF, Perlis 4,0872011 3,9202012 201129 %0.71 201223 %0.59 a higherand prevalence Bidayuh ethnicof acquired group heartin 2012. diseaseWomen and aged IHD 40 during-49years the andstudy para period. more than 6 had HSB,HTF, Kedah Perlis 10,3964,087 10,3073,920 29123 0.711.18 2398 0.590.95 a higher prevalence of acquired heart disease and IHD during the study period. HSB,HPP Kedah 10,3963,336 10,3073,010 12313 1.180.39 9813 0.950.43 HPP 3,336 3,010 13 0.39 13 0.43 10.5 RECOMMENDATION HRPB, Perak 6,217 4,507 34 0.55 23 0.51 10.5 RECOMMENDATION HRPB, Perak 6,217 4,507 34 0.55 23 0.51 HTAR, Selangor 12,351 12,056 85 0.69 90 0.75 HTAR, Selangor 12,351 12,056 85 0.69 90 0.75 1. Involvement of cardiologist and anaesthetist in managing women with cardiac HKL 11,729 11,843 78 0.67 86 0.73 1. Involvement of cardiologist and anaesthetist in managing women with cardiac HKL 11,729 11,843 78 0.67 86 0.73 disease. HTJ, Seremban 4,841 6,192 17 0.35 25 0.40 disease. HTJ, Seremban 4,841 6,192 17 0.35 25 0.40 Hospital Melaka 10,833 10,746 38 0.35 29 0.27 2. Implementation2. Implementation of pre ofconception pre conception clinics clinics Hospital Melaka 10,833 10,746 38 0.35 29 0.27 HSA, Johor 12,467 12,295 136 1.09 95 0.77 3. In subsequent3. In subsequent reports reports to capture to capture the different the different type stype of sheart of heart disease disease complicating complicating HSA, Johor 12,467 12,295 136 1.09 95 0.77 HTAA Pahang 9,333 8,728 87 0.93 17 0.19 PregnanPregnancy cy HTAA Pahang 9,333 8,728 87 0.93 17 0.19 HSNZ, Terengganu 12,019 12,803 158 1.31 132 1.03 HSNZ, Terengganu 12,019 12,803 158 1.31 132 1.03 HRPZ II, Kelantan 13,066 10,955 58 0.44 39 0.36 10.6 REFERRENCES10.6 REFERRENCES HRPZ II, Kelantan 13,066 10,955 58 0.44 39 0.36 HU Sarawak 9,854 1,513 51 0.52 9 0.59 HU Sarawak 9,854 1,513 51 0.52 9 0.59 1. CEMB1. CEMB2006- 20082006 -2008 HL,HL, Sabah Sabah 14,85114,851 13,75913,759 1414 0.090.09 1818 0.130.13 TotalTotal 135,380135,380 122,634122,634 921921 0.680.68 697697 0.570.57

TableTable 10.2 10.2: :Types Types of of heart heart diseasedisease and 20112011 andand 2012 2012 TypesTypes of of Heart diseasedisease heartheart disease disease 2011 20122012 nn % nn %% Acquired 181 19.7 159 22.8 Acquired 181 19.7 159 22.8 Congenital 179 19.4 133 19.1 Congenital 179 19.4 133 19.1 IHD 39 4.2 37 5.3 IHD 39 4.2 37 5.3 NA 522 56.7 368 52.8 NA 522 56.7 368 52.8 Total 921 100.0 697 100.0 Total 921 100.0 697 100.0

102 101 102 101

91 89 National Obstetrics Registry

Table 10.3 Heart disease by ethnicity 2011 and 2012 2011 2012 Total Heart Total Heart Ethnicity women disease in women disease in who delivered pregnancy who delivered pregnancy n n % n n % Malay 92,649 731 0.79 85,391 553 0.65 Chinese 8,428 57 0.68 7,417 38 0.51 Indian 6,400 39 0.61 6,128 32 0.52 Kadazan/Dusun 4,003 5 0.12 3,685 11 0.30 Murut 345 1 0.29 262 1 0.38 Bajau 3,151 5 0.16 2,930 2 0.07 Melanau 123 0 0.00 38 0 0.00 Iban 2,149 17 0.79 760 5 0.66 Bidayuh 1,573 11 0.70 360 4 1.11 OA (Peninsular Malaysia) 909 6 0.66 748 9 1.20 Other indigenous group in 2,695 8 0.30 2,338 5 0.21 Sabah & Sarawak Other 1,209 3 0.25 1,467 8 0.55 Foreigners 11,333 34 0.30 10,593 27 0.25 NA 413 4 0.97 517 2 0.39 Total 135,380 921 0.68 122,634 697 0.57

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Table 10.3 Heart disease by ethnicity 2011 and 2012

0 0 0 Table 10.3 Heart disease2011 by ethnicity 2011 and 2012 2012 % 0.3

0.28 0.31 0.25 0.42 0.44 0.63 Total 2011 Heart Total 2012 Heart NA

Ethnicity womenTotal diseaseHeart in womenTotal diseaseHeart in 0 2 0 0 n 16 68 91 64 19 Ethnicity who deliveredwomen pregnancydisease in whowomen delivered diseasepregnancy in 108

who delivered pregnancy who delivered pregnancy n n % n n % 14

0 0 0 0 0 n n % n n % % Malay 92,649 731 0.79 85,391 553 0.65 0.02 0.02 0.04 0.04 0. IHD

Malay 92,649 731 0.79 85,391 553 0.65 Chinese 8,428 57 0.68 7,417 38 0.51 0 0 5 9 7 5 0 0 0 n Chinese 8,428 57 0.68 7,417 38 0.51 11

Indian 6,400 39 0.61 6,128 32 0.52

Kadazan/Dusun 4,003 5 0.12 3,685 11 0.30 0 0 0 0 %

Kadazan/Dusun 4,003 5 0.12 3,685 11 0.30 0.1 0.1 Murut 345 1 0.29 262 1 0.38 0.11 0.12 0.12 0.09 Murut 345 1 0.29 262 1 0.38 2012

Bajau 3,151 5 0.16 2,930 2 0.07 0 6 4 0 0 0 Bajau 3,151 5 0.16 2,930 2 0.07 n 25 45 36 17 Melanau 123 0 0.00 38 0 0.00 Congenital

Melanau 123 0 0.00 38 0 0.00

Iban 2,149 17 0.79 760 5 0.66

Iban 2,149 17 0.79 760 5 0.66 0 0 0 %

Bidayuh 1,573 11 0.70 360 4 1.11 0.09 0.08 0.13 0.14 0.18 0.19 0.32

Bidayuh 1,573 11 0.70 360 4 1.11

OA (Peninsular Malaysia) 909 6 0.66 748 9 1.20 6 0 5 8 1 0 0 OA (Peninsular Malaysia) 909 6 0.66 748 9 1.20 n Acquired Other indigenous group in 2,695 8 0.30 2,338 5 0.21 18 5 43 28 Other indigenous group in 2,695 8 0.30 2,338 5 0.21

Sabah & Sarawak Sabah & Sarawak

2 Other 1,209 3 0.25 1,467 8 0.55 n Other 1,209 3 0.25 1,467 8 0.55 26 126 314 who 5736 4262 Total 22513 43421 30830 15404 ForeignersForeigners 11,33311,333 3434 0.300.30 10,59310,593 2727 0.250.25 women NA 413 4 0.97 517 2 0.39 delivered

NA 413 4 0.97 517 2 0.39 ge 2011 2011 and

Total 135,380 921 0.68 122,634 697 0.57 0 Total 135,380 921 0.68 122,634 697 0.57 % 0.6 2.33 0.19 0.34 0.35 0.42 0.45 1.09 3.85

104

2 7 2 1 0

n 35 99 91 47 17

0 0 0 0 % 0.01 0.02 0.03 0.02 0.05 0.08

IHD Heart disease by Heart by disease

0 1 6 7 8 4 0 0 0 n 13

0 0 0 0 % 0.07 0.14 0.11 0.13 0.21 0.08 Table 10.4

2011

0 5 4 0 0 0 n 37 52 44 37 Congenital

0 0 0 % 0.03 0.11 0.11 0.15 0.21 0.29 0.27

0 2 1 0 0 n Acquired 28 54 47 36 13

1 n 26 127 362 who 6731 4765 Total Total 26048 46963 33305 17052 women delivered 103

103 14 19 24 29 34 39 44 49 54 59

------Age

10 15 20 25 30 35 40 45 50 55

94 93 91 National Obstetrics Registry

% 0.02 0.04 0.05 0.07 0.03 0.02 0.03 0.08 0.00 0.03 IHD IHD

2 1 n 8 5 0 n 19 15 37 24 37

% % 0.08 0.37 0.15 0.13 0.11 0.11 0.11 0.09 0.00 0.11

2 n 6 0 n 70 17 44 45 82 Congenital 133 Congenital 133

2012 2012 % % 0.11 0.44 0.13 0.13 0.13 0.09 0.15 0.21 1.22 0.13

2 n 1 n Acquired Acquired 99 20 38 37 14 159 107 159

n n 82 6,537 4,589 1,501 42,679 73,336 86,219 30,325 122,634 122,634 Total womenTotal Total womenTotal who delivered who delivered

% %

0.02 0.03 0.05 0.00 0.03 0.02 0.06 0.04 0.03 0.03

IHD IHD

in heart disease 2011 and 2012 in heart and 2011 disease 105 3 1 n

22 13 39 8 4 0 n 27 39

% % 0.11 0.37 0.16 0.20 0.13 0.15 0.13 0.08 0.00 0.13

Heart disease by parity 2011 parity 2012 and Heart by disease

6 n 18 51 6 0 n 104 179 Congenital 68 105 179

Congenital

Mode of delivery Mode of

% 2011 2011 % 0.12 0.28 0.17 0.03 0.13 0.09 0.15 0.24 0.00 0.13 Table 10.5

1 n Acquired 14 53 0 n 113 181 42 19 Acquired Table 10.6 120 181

n n 4,923 2,944 96,272 31,241 216 135,380 7,840 46,158 81,166 135,380 Total womenTotal ho delivered who delivered

Total womanTotal w

- CS NA 1 Total ≥ 6 NA 2 Vaginal Total delivery Parity Mode Mode Instrumental

92 95 National Obstetrics Registry

n 39 37 181 179 522 159 133 368 Total Total

12.15 23.46 12.82 40.23 11.95 28.57 32.43 42.12

5 n 22 42 19 38 12 210 155

0 0 0 0 % 2.7 0.55 1.26 0.27

NYHA IV 1 0 0 0 2 0 1 1 n

% 1.66 5.59 2.56 0.57 3.77 0.75 8.11 0.54

NYHA III NYHA 3 1 3 6 1 3 2 n

10 106

% 16.2 9.39 20.3 7.61 14.92 17.95 11.95 18.92

Severity of heart disease 2011 and 2012 and 2011 of disease heart Severity

NYHA II 7 7 n 27 29 49 19 27 28

able 10.7

.46 T % 70.72 54.75 66.67 49.81 71.07 50.38 37.84 49

NYHA 1 n 98 26 67 14 128 260 113 182

NA IHD IHD 2011 2012 Acquired Acquired Unknown Congenital Congenital

93 National Obstetrics Registry

% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.7 IHD

0 0 4 0 0 1 0 0 0 0 n 29

% 0.1 0.0 0.0 0.1 0.5 0.0 0.0 0.0 0.0 0.0 0.0

0 0 9 2 0 0 0 0 0 0 n Congenital 105 2012

% 0.1 0.0 0.0 0.1 0.5 0.0 0.0 0.0 0.0 0.0 0.0 uired

0 0 5 2 0 0 0 0 0 0 n Acq 118

n pregnancy 2011 and 2012 2011and pregnancy n 1 6 2 0 2 i 82 42 443 118 9386 Total Total who 100335 women delivered

% 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0 0.0 0.0 0.0

IHD

0 0 2 0 1 0 0 0 0 0 n 32

107 % 0.1 0.0 0.8 0.1 0.4 0.0 0.0 0.0 0.0 1.0 25.0

0 1 2 0 1 0 0 0 1 n 13

129 Congenital

SEXUALLY TRANSMITTED 2011 SEXUALLY TRANSMITTED % 0.1 0.0 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.0 25.0

0 0 4 5 0 1 0 0 0 0 n Acquired 132 DIDSEISAESAES IEN IPNR PERGENGANNACYN CY

3 4 8 0 0 97 130 548 196 Total Total who 10050 Maternal and fetal complications and disease in heart fetal complications Maternal 102709

women

delivered

Table 10.8

labour

NA cardiogenic None – ≥1500mls <1500mls Uterine atony Uterine Preterm Complications Thromboembolism Shock Pulmonary embolism Pulmonary Failed instrumentation

PPH PPH Anaesthetic complication

108 108 97 94 National Obstetrics Registry

SEXUALLY TRANSMITTED DISEASE IN PREGNANCY

108 National Obstetrics Registry National Obstetrics Registry

CHAPTER 11 SEXUALLY TRANSMITTED DISEASE IN PREGNANCY

Tham.S.W, Maimunah.F, Nurrul.S.A, Chong.G.K, Wan.J.N

Melaka Hospital

SUMMARY

HIV in pregnancy incidence was low in 2011 at 0.26% and 0.22% in 2012 from the 14 participating hospitals in Malaysia. The incidence of syphilis in pregnancy was 0.15% in both years. HIV incidence was higher in unmarried women in 2011 and in 2012 it was seen more in women who were divorced.

11.1 INTRODUCTION

STIs in pregnancy can lead to prematurity, stillbirth, and neonatal infections. Screening and treatment for syphilis and HIV in pregnancy could prevent syphilis-related stillbirths, perinatal deaths and also prevention of vertical transmission mother to her foetus. In Malaysia women can opt out from doing a HIV screening.

HIV infection in pregnancy accounted for 0.24% of all deliveries in the 14 SDPs in Malaysia 0.26% in 2011 and 0.22% in 2012. HU, Sarawak had the highest incidence at 0.53% in 2011 and 0.59% in 2012. Lowest incidence was from HL, Sabah at 0.03% in 2011and 0.09 % in 2012. Incidence of syphilis in pregnancy was 0.15% in both years from the 14 SDPs in Malaysia.

11.2 PATIENT DERMOGRAPHICS

HIV in pregnancy didn’t show are age preference in both years.Syphilis in pregnancy was higher in women aged 50 years and more.HIV in pregnancy was higher among unmarried women in 2012 it was higher among divorcee. Incidence of HIV in pregnancy in Melanaus was 0.81% in 2011.HIV and Syphilis in pregnancy was high among the Melanaus in 2012.For both HIV and Syphilis in pregnancy there was no difference between parity in both years

109

95 98 National Obstetrics Registry

11.3 CONCLUSION

Incidence of HIV and syphilis in pregnancy rate was low for both years. Continuous effort and advances need to detect, manage and prevent STDs that will move us closer to our goal of an HIV/AIDS-free generation. With the fields to capture HIV and Syphilis in pregnancy have been made mandatory, we may have a true incidence rate in subsequent report.

11.4 RECOMMENDATION

1. Future NOR reports should include documentation of other sexually transmitted disease in pregnancy

11.5 REFERRENCES

1. UNAIDS (2012) ‘Global Report: UNAIDS Report on the Global AIDS Epidemic 2012’. 2. WHO Bulletin, March 2013. Early antenatal care: does it make difference to outcomes of Pregnancy associated with syphilis? A systematic review and meta- analysis. 3. NOR 2nd Report 2010.

110

9698 National Obstetrics Registry 11.3 CONCLUSION

Incidence of HIV and syphilis in pregnancy rate was low for both years. Continuous

effort and advances need to detect, manage and prevent STDs that will move us closer %

to our goal of an HIV/AIDS-free generation. With the fields to capture HIV and Syphilis 0.28 0.41 0.13 0.24 0.16 0.24 0.15 0.11 0.28 0.16 0.34 0.15 0.59 0.09 0.22 in pregnancy have been made mandatory, we may have a true incidence rate in subsequent report.

4 9 9 n 11 42 11 19 28 12 34 14 44 16 12 11.4 RECOMMENDATION 265

2012 1. Future NOR reports should include documentation of other sexually transmitted

disease in pregnancy

women who

11.5 REFERRENCES 3,920 3,010 4,507 6,192 8,728 1,513 10,307 12,056 11,843 10,746 12,295 12,803 10,955 13,759 122,634 delivered 2011 2012 and Total Total 1. UNAIDS (2012) ‘Global Report: UNAIDS Report on the Global AIDS Epidemic 2012’.

SDP

in pregnancy 2. WHO Bulletin, March 2013. Early antenatal care: does it make difference to % by 0.51 0.34 0.36 0.27 0.23 0.20 0.25 0.17 0.32 0.35 0.29 0.21 0.53 0.03 0.26

outcomes of Pregnancy associated with syphilis? A systematic review and meta- HIV analysis. 3. NOR 2nd Report 2010.

4 n 111 21 35 12 17 28 24 12 18 40 33 35 27 52 358 in pregnancy in pregnancy

2011

women who

4,087 3,336 6,217 4,841 9,333 9,854 10,396 12,351 11,729 10,833 12,467 12,019 13,066 14,851 135,380 delivered Total Total Incidence of HIV

Table 11.1

Selangor

HKL SDP HPP Total HTF,Perlis HL, Sabah HL, HSA, Johor HSB,Kedah HRPB,Perak HU, Sarawak HU, HTAA, Pahang Hospital Melaka SNZ, Terengganu SNZ, HTAR, HRPZ 11,HRPZ Kelantan H 110 HTJ,Negeri Sembilan

97 National Obstetrics Registry

% 0.18 0.26 0.20 0.13 0.15 0.26 0.18 0.09 0.16 0.05 0.15 0.02 0.46 0.07 0.15

7 6 6 4 2 7 n 27 18 31 11 10 20 19 10

178

2012

who 3920 3010 4507 6192 8728 1513

10307 12056 11843 10746 12295 12803 10955 13759 122634 2011 and 2012 and 2011

delivered Total womenTotal

SDP

% 0.39 0.30 0.12 0.18 0.11 0.21 0.17 0.08 0.16 0.15 0.09 0.11 0.21 0.01 0.15 Syphilis in pregnancy

4 8 9 1 n 16 31 11 14 25 20 14 11 14 21

199 112 in pregnancy in pregnancy 2011 is

who 4087 3336 6217 4841 9333 9854 10396 12351 11729 10833 12467 12019 13066 14851 135380 delivered Total womenTotal

Incidence of Syphil

Perak

Table 11.2 HKL SDP HPP Sarawak Total HL, Sabah HL, HTF, Perlis HSA, Johor HSB, Kedah HU, HRPB, HTAA,Pahang RPZ 11 Kelantan Hospital Melaka HTAR, Selangor H HSNZ, Terengganu HTJ, Sembilan Negeri

100

98 National Obstetrics Registry

0.14 0.27 0.04 0.13 0.07 0.33 0.00 0.03 2.63 0.39 0.56 0.21 0.14 0.58 0.15

2012

78 5 2 1 5 0 1 1 3 2 2 3 n Syphilis in pregnancy 20 22 111 1

% 0.02 0.22 0.07 0.14 0.12 0.27 0.00 0.00 0.00 0.19 0.06 0.25 0.00 0.24 0.15

2011

1 2 2 0 0 0 4 1 0 1 n Syphilis in pregnancy 10 17 28 133 199 2012 2011 and

0.08 0.27 0.00 0.22 0.11 0.28 0.00 0.07 2.63 0.13 0.56 0.35 0.48 0.19 0.22

HIV in

3 2 0 8 0 2 1 1 2 7 1 n

17 37 184 265 pregnancy 2012

113

n 38 748 262 760 360 517 who Total Total 3,685 2,338 7,417 6,128 2,930 1,467 85,391 10,593 women 122,634 delivered ilis in pregnancy by ethnicity ethnicity ilisby in pregnancy

% 0.05 0.22 0.04 0.27 0.24 0.28 0.00 0.00 0.81 0.33 0.45 0.39 0.33 0.24 0.26

HIV in

2 2 1 0 0 1 7 7 4 1 n 20 18 44 pregnancy 25 358 HIV and Syph HIV and

2011

n 345 123 909 413 who Total Total 8,428 6,400 4,003 3,151 2,149 1,573 2,695 1,209 Table 11.3 92,649 11,333 women 135,380 delivered

NA Iban in Sabah & Total Murut Bajau Malay Indian Dusun Others Bidayuh Chinese Melanau Sarawak Ethnicity Kadazan/ Malaysia) Foreigner OA (Peninsular Other indigenous indigenous Other group

101 99 National Obstetrics Registry

0.00 0.10 0.14 0.16 0.13 0.17 0.09 0.32 0.00 0.15 % 50.00

2012

0 6 4 1 0 1 n 32 68 41 26 Syphilis in pregnancy 179

0.00 0.24 0.12 0.15 0.15 0.15 0.15 0.00 3.85 0.00 0.15

2011

0 7 0 1 0 n 16 30 72 50 25 Syphilis in pregnancy 201

2011 and 2012

0.00 0.30 0.24 0.19 0.22 0.23 0.26 0.00 0.00 0.00 0.22

HIV in

pregnancy 0 0 0 0 n 17 54 81 67 36 11

266

2012 114

2 n 26 126 314 who 5736 4262 Total Total 22513 43421 30830 15404 122634 women delivered

HIV and Syphilis in pregnancy by age by in pregnancy and Syphilis HIV

0.00 0.28 0.28 0.28 0.26 0.20 0.36 0.00 0.00 0.00 0.27

% HIV in

pregnancy 0 0 0 0 n 19 74 87 34 17 Table 11.4 131 362

2011

1 n 26 127 362 who 6731 4765 Total Total 26048 46963 33305 17052 135380 women delivered

14 19 24 29 34 39 44 49 54

------≥55 Age Total 10 15 20 25 30 35 40 45 50

102

100 National Obstetrics Registry

17 % %

0.14 0.15 0.14 0.00 0.15 0.14 0. 0.15 0.00 0.15

2012

9 0 n 61 8 0 n Syphilis in Syphilis Syphilis in pregnancy pregnancy 108 178 46

124 178

0.17 0.14 0.14 0.00 0.15 % 0.16 0.14 0.12 0.10 0.15

2011

2011 and 2012 0 n 2011 78 11

110 199

Syphilis in pregnancy

Syphilis in Syphilis pregnancy 7 3 n

38 151 199 2012 2011 and

0.23 0.21 0.15 0.00 0.22

0.17 0.07 0.37 0.47 0.22

2012

HIV in

0 n 10

100 155 265 HIV in pregnancy

3 7 n 144 111 265 pregnancy

2012

115

who Total Total 6,537 n 42,679 73,336 women 122,634 who delivered 1501 Total Total 4,589 86,219 30,325 women 122,634

delivered

0.26 0.27 0.20 0.00 0.26 % 0.19 0.10 0.52 0.20 0.26

HIV and Syphilis in pregnancy by Parity by in pregnancy Syphilis HIV and

HIV in

HIV in 0 n regnancy 16 5 6 n 119 223 358

p 186 161 358 pregnancy HIV and Syphilis in pregnancy by mode of delivery mode delivery of by in pregnancy and Syphilis HIV 2011

2011

Table 11.5

n ho n 216 who w Total Total 2944 7,840 Total Total 4,923 46,158 81,166 96,272 31,241 women 135,380 women 135,380 delivered Table 11.6 delivered

- 1 f

≥ 6 NA 2 o Total NA Parity Total Type Type Vaginal Delivery caesarean Instrumental

103

101 National Obstetrics Registry

% 0.18 0.00 0.00 0.22 0.35 0.13

2012

Syphilis in Syphilis pregnancy

0 0 5 2

n 20 35

0.07 0.00 0.33 0.20 0.13 0.16

2011

8 0 1 6 1 n Syphilis in pregnancy 45 2011 and 2012 and 2011

% 0.21 0.00 0.30 0.56 0.52 0.16 HIV in

0 1 3 n pregnancy 23 12 45

2012

4 7 n 116 308 323 5 who Total Total 2,145

10,880 26,823 women delivered

MEDICAL DISORDER IN

% 0.24 0.18 0.33 0.29 0.50 0.21 MEDICAL DISORDER IN HIV in

1 1 8 4 n 27 58 pregnancy PREGNANCY

2011

PREGNANCY HIV and Syphilis in pregnancy by complications by in pregnancy and Syphilis HIV

n 544 299 766 who Total Total 2,753 11,192 27,555 women deliveried

Table 11.7

tions PPH Pregnancy Fetal distress Preterm labour complica Prolonged labour Abruptio placenta Genital tract trauma

117

104 117

102 National Obstetrics Registry

MEDICAL DISORDER IN PREGNANCY

117

National Obstetrics Registry National Obstetrics Registry

CHAPTER 12 MEDICAL DISORDER IN PREGNANCY

Halimatun M1, Wan Abu Bakar Y1, Nur Jumizah AK1, SD Karalasingam2

1. Sultanah Nur Zahirah Hospital,Terengganu 2. National Clinical Research Centre.

SUMMARY

Most women in pregnancy are healthy however those with medical disorders require expert care. Medical disorders in pregnancy is one of the principal causes of maternal deaths in this country along with obstetric embolism, postpartum haemorrhage and hypertensive disorders in pregnancy. There was one maternal death associated with Bronchial Asthma in 2011.

12.1 INTRODUCTION

More than half a million maternal deaths occur every year in the world due to complications related to pregnancy or childbirth. The maternal mortality ratio (MMR) is an important measure of women’s health and indicative of the performance of health care systems of a country.

The incidence of all medical disorders complicating pregnancy in 2011 was 8.47% and in 2012 it was 7.8%.

This chapter looks at prevalence of thyroid disease, Bronchial Asthma, haematological disorder particularly Thalassemia and ITP, renal disease and mental disorders in pregnancy. Hypertension, Diabetes and Heart disease have been discussed in separate chapters in this report.

Bronchial asthma is the commonest chronic medical illness to complicate pregnancy.1.79% of pregnant women had history of Bronchial asthma in 2011 and 1.67% in 2012.Highest incidence was seen in HKL followed by HSA, Johor in both years.

12.2 PATIENT DERMOGRAPHICS

In both years more than 2/3rd of deliveries were among the Malays. Foreigners constituted to 8.37% and Chinese accounted for 6.23% of deliveries in 2011 and we see 118

103 105 National Obstetrics Registry

similar trends in 2012.Highest incidence of Bronchial Asthma is seen in the Indian ethnicity in both years followed by the Melanau’s. Thalassemia incidence was highest among the Chinese in both years. There was a very low incidence of renal disease and mental disorders in pregnancy in both years and this could be under reporting. Women aged between 35-39 years in 2011 had a higher incidence of Bronchial Asthma whilst in 2012 the incidence was higher among the adolescents aged 10-14 years. Bronchial Asthma was higher among women Para> 5 in both years.There were no association seen between parity and other medical disorders in both years.

12.3 OUTCOMES

In 2011, 2.16% of women with Bronchial Asthma had a preterm delivery but in 2012, most women with Bronchial Asthma had a term deliveries.1.91% of babies died and 1.78% were admitted to NICU in mothers with Bronchial Asthma in 2011 as compared to 1.68 % were admitted to NICU whilst 1.57 % died in 2012 in mothers with Bronchial Asthma. There was one maternal death due to Bronchial Asthma in 2011.

12.4 CONCLUSION

Pregnancy is considered high risk when complications affect health and safety of both mother and fetus. Among the medical disorders discussed in this chapter there was one maternal death associated with Bronchial Asthma. Bronchial Asthma contributed to preterm deliveries and it increased incidence of fetal morbidity and mortality in both years.

12.5 RECOMMENDATION

1. Pre-conception care should be provided to all women with medical conditions. They should be informed about the potential impact of their medical condition on pregnancy. 2. Combined care of pregnant women with medical disorders by Obstetricians and Physicians early to plan management. 3. There must be involvement of senior doctors in the care of these patients. 4. Contraceptive counselling for high risk patients is crucial as studies have shown than increasing the contraceptive prevalence rate reduces maternal mortality rate.

12.6 REFERRENCES

1. Report on the Confidential enquires into maternal deaths in Malaysia 2006-2008. 119

104106 National Obstetrics Registry similar trends in 2012.Highest incidence of Bronchial Asthma is seen in the Indian

similarethnicity trends in in both 2012.Highest years followed incidence by the of Melanau’s. Bronchial ThalassemiaAsthma is seen incidence in the was Indian highest % ethnicityamong in boththe Chin yearsese followed in both years.by the ThereMelanau’s. was a Thalassemia very low inci denceincidence of renal was diseasehighest and 0.02 0.03 0.03 0.00 0.05 0.05 0.02 0.06 0.01 0.02 0.06 0.01 0.04 0.00 0.03

among the Chinese in both years. There was a very low incidence of renal disease and mental disorders in pregnancy in both years and this could be under reporting. Women Others 1 3 1 0 6 6 1 7 1 2 7 1 4 0 n 40 mentalaged disorders between in 35pregnancy-39 years in in both 2011 years had aand higher this incidencecould be underof Bronchial reporting. Asthma Women whilst in

aged2012 between the 35incidence-39 years was in 2011higher had among a higher the incidence adolescents of Bronchial aged 10 Asthma-14 years. whilst Bronchial in % 2012Asthma the incidence was higher was amonghigher amongwomen thePara> adolescents 5 in both agedyears .There10-14 years.were noBronchial association 0.07 0.05 0.03 0.00 0.01 0.08 0.06 0.04 0.06 0.01 0.04 0.01 0.06 0.00 0.03

Asthma was higher among women Para> 5 in both years.There were no association Mental Mental 3 5 1 0 1 9 3 4 7 1 5 1 6 0 seen between parity and other medical disorders in both years. n disorder 46 seen between parity and other medical disorders in both years.

12.3 OUTCOMES %

12.3 OUTCOMES 0.00 0.03 0.03 0.02 0.02 0.03 0.04 0.04 0.06 0.06 0.01 0.01 0.05 0.00 0.03

Renal

In 2011, 2.16% of women with Bronchial Asthma had a preterm delivery but in 2012, disease 0 3 1 1 3 3 2 4 7 6 1 1 5 0 n In 2011,most 2.16% women of withwomen Bronchial with Bronchial Asthma Asthmahad a term had deliveries.1.91%a preterm delivery of butbabies in 2 died012, and 37 most women with Bronchial Asthma had a term deliveries.1.91% of babies died and

1.78% were admitted to NICU in mothers with Bronchial Asthma in 2011 as compared

1.78% were admitted to NICU in mothers with Bronchial Asthma in 2011 as compared % to 1.68 % were admitted to NICU whilst 1.57 % died in 2012 in mothers with Bronchial 0.12 0.02 0.06 0.18 0.08 0.09 0.10 0.07 0.12 0.05 0.08 0.00 0.03 0.01 0.07 2011 ITP to 1.68 % were admitted to NICU whilst 1.57 % died in 2012 in mothers with Bronchial

Asthma. There was one maternal death due to Bronchial Asthma in 2011. 5 2 2 5 8 5 0 3 1 n Asthm a. There was one maternal death due to Bronchial Asthma in 2011. 11 10 11 15 10 88 SDP

12.4 CONCLUSION

12.4 CONCLUSION % 1.08 0.49 0.48 0.55 0.46 0.45 0.29 0.44 0.38 0.34 0.36 0.24 0.17 0.11 0.37

Pregnancy is considered high risk when complications affect health and safety of both

Pregnancy is considered high risk when complications affect health and safety of both n

mother and fetus. Among the medical disorders discussed in this chapter there was one 44 51 16 34 57 53 14 48 47 32 43 31 17 17 504 Hematological disorder mothermaternal and fetus. death Among associated the medical with disordersBronchial discussedAsthma. Bronchialin this chapter Asthma there contributed was one to Thalassemia

maternal death associated with Bronchial Asthma. Bronchial Asthma contributed to

preterm deliveries and it increased incidence of fetal morbidity and mortality in both 50 %

preterm deliveries and it increased incidence of fetal morbidity and mortality in both 2.89 2.21 1.02 1.59 1.87 3.53 1.09 1.72 3.15 1. 2.02 0.99 1.35 0.13 1.79 years. 120

years.

n asthma

34 99 53 20 118 230 231 414 186 393 140 243 129 133 Bronchial

12.5 RECOMMENDATION 2,423

12.5 RECOMMENDATION

1. Pre-conception care should be provided to all women with medical % 1. Pre-conception care should be provided to all women with medical 0.69 0.29 0.15 0.14 0.36 0.46 0.25 0.52 0.39 0.29 0.44 0.15 0.23 0.01 0.30

conditions. They should be informed about the potential impact of their medical Medical disorders in pregnancy by by in pregnancy Medical disorders

5 9 2 conditions. They should be informed about the potential impact of their medical n Thyroid Thyroid disease 28 30 45 54 12 56 48 27 53 19 23

condition on pregnancy. 411 condition on pregnancy. 2. Combined care of pregnant women with medical disorders by Obstetricians and

2. CombinedPhysicians care ofearly pregnant to plan women management. with medical disorders by Obstetricians and %

Physicians early to plan management. 3.02 7.68 2.46 4.59 9.12 8.66 3.58 8.00 9.21 6.89 8.88 9.65 7.28 10.97 3. There must be involvement of senior doctors in the care of these patients. Table 12.1 3. There must be involvement of senior doctors in the care of these patients. 100.00 women

4. Contraceptive counselling for high risk patients is crucial as studies have shown

4. Contraceptive counselling for high risk patients is crucial as studies have shown delivered than increasing the contraceptive prevalence rate reduces maternal mortality than increasing the contraceptive prevalence rate reduces maternal mortality n Total Total

rate. who 4,087 3,336 6,217 4,841 9,333 9,854 10,396 12,351 11,729 10,833 12,467 12,019 13,066 14,851 rate. 135,380

12.6 REFERRENCES

1. Report on the Confidential enquires into maternal deaths in Malaysia 2006-2008. Perak

Perlis

Kedah

Selangor

1. Report on the Confidential enquires into maternal deaths in Malaysia 2006-2008. Sabah

119

HKL SDP HPP Total Terengganu

119 Sembilan HL, HSA Johor HTF, HTJ, Negeri HSB, HU, Sarawak HU, HRPB, HTAA, Pahang Hospital Melaka HTAR, HRPZ 11HRPZ Kelantan

HSNZ,

106 105 107 National Obstetrics Registry

% 0.08 0.06 0.00 0.04 0.00 0.08 0.03 0.04 0.03 0.02 0.02 0.03 0.00 0.01 0.03

Others 3 6 0 2 0 2 4 4 2 2 3 0 1 n 10 39

3 % 0.03 0.05 0.03 0.00 0.05 0.07 0.06 0.02 0.07 0.00 0.0 0.01 0.00 0.02 0.04

Mental Mental 1 5 1 0 6 8 4 2 9 0 4 1 0 3 n 44 disorder

% 0.05 0.02 0.03 0.00 0.07 0.08 0.05 0.01 0.04 0.01 0.04 0.05 0.13 0.00 0.04

Renal 2 2 1 0 9 3 1 5 1 5 5 2 0 n disease 10 46

% 0.20 0.03 0.07 0.11 0.04 0.08 0.11 0. 0.15 0.05 0.05 0.00 0.07 0.01 0.06 2012 ITP

8 3 2 5 5 7 2 4 6 0 1 1 n 10 19 73

SDP

% 1.38 0.46 0.60 0.29 0.36 0.37 0.58 0.41 0.55 0.56 0.76 0.14 0.07 0.28 0.46 disorder

Hematological

1 n 54 47 18 13 43 44 36 44 68 49 97 15 38 567 Thalassemia

in pregnancy by by in pregnancy 59

s 2.50 1.66 1.63 1.22 1. 2.94 1.24 1.31 2.81 1.84 1.88 0.88 1.92 0.31 1.67 121

n asthma 98 49 55 77 96 29 43 171 192 348 141 346 161 241 Bronchial 2047

% 0.41 0.36 0.37 0.31 0.32 0.44 0.36 0.47 0.42 0.48 0.41 0.17 0.46 0.11 0.35

Medical disorder Medical

7 n Thyroid Thyroid disease 16 37 11 14 39 52 22 51 52 42 52 19 15 429

% 3.20 8.40 2.45 3.68 9.83 9.66 5.05 8.76 7.12 8.93 1.23 10.03 10.44 11.22 100.00 Table 12.2

women

n Total 3,920 3,010 4,507 6,192 8,728 1,513 who delivered 10,307 12,056 11,843 10,746 12,295 12,803 10,955 13,759 122,634

edah

HKL SDP HPP Total Sembilan HL, Sabah HL, HTF, Perlis HSA, Johor HTJ, Negeri HSB, K HU, Sarawak HU, HRPB, Perak HTAA, Pahang Hospital Melaka HTAR, Selangor HRPZ 11,HRPZ Kelantan HSNZ, Terengganu

108 106 National Obstetrics Registry

% 0.00 0.00 0.04 0.02 0.02 0.00 0.00 0.00 0.81 0.00 0.13 0.00 0.00 0.00

Others 0 0 2 1 0 0 0 1 0 2 0 0 0 n 34

% 0.22 0.00 0.04 0.08 0.02 0.00 0.00 0.00 0.00 0.05 0.06 0.00 0.00 0.24 der

Mental Mental 2 0 7 1 0 0 0 0 1 1 0 0 1 n 33 disor

% 0.00 0.00 0.03 0.01 0.06 0.00 0.00 0.00 0.00 0.19 0.00 0.01 0.00 0.00

Renal 0 0 1 4 0 0 0 0 4 0 1 0 0 n disease 27

% 0. 0.00 0.06 0.07 0.22 0.02 0.00 0.00 0.00 0.00 0.06 0.08 0.00 0.00 ITP

1 0 6 1 0 0 0 0 1 9 0 0 n 56 14

% 0.11 0.11 0.39 1.09 0.13 0.40 0.00 0.10 0.00 0.00 0.06 0.09 0.41 0.00 disorder

Hematological

1 3 8 0 3 0 0 1 5 0

n 92 16 10 365

Thalassemia 122

17 % 0.77 0.07 2.13 1.19 3. 0.20 0.58 0.16 2.44 1.12 1.08 0.49 1.32 1.21

7 2 8 2 5 3 5 n asthma 24 17 56 16 100 203 Bronchial 1,975

% Medical disorders in pregnancy by ethnicity 2011 ethnicity by in pregnancy Medical disorders

0.33 0.04 0.35 0.49 0.33 0.02 0.00 0.06 0.00 0.09 0.45 0.08 0.17 0.00

3 1 1 0 2 0 2 7 9 2 0 n Thyroid Thyroid disease 41 21 322

Table 12.3

% 6.23 4.73 2.96 0.25 2.33 0.09 1.59 1.16 8.37 0.89 0.31 0.67 1.99 68.44

women

who

n delivered 345 123 909 413 8,428 6,400 4,003 3,151 2,149 1,573 2,695 1,209 Total Total 92,649 11,333

Iban Other Other Murut Bajau Malay Indian Other Bidayuh Chinese Melanau Unknown Ethnicity Ethnicity Malaysia) Foreigner & Sarawak indigenous OA (Peninsular Sabah in group Kadazan/ Dusun Kadazan/

107 109 National Obstetrics Registry

% 0.00 0.00 0.04 0.05 0.03 0.00 0.00 0.00 0.00 0.00 0.00 0.01 0.07 0.00

Others 0 0 4 2 0 0 0 0 0 0 1 1 0 n 31

% 0.00 0.04 0.03 0.07 0.07 0.03 0.00 0.03 0.00 0.00 0.00 0.04 0.07 0.00

Mental Mental 0 1 5 4 1 0 1 0 0 0 4 1 0 n 27 disorder

% 0.00 0.00 0.05 0.04 0.00 0.00 0.00 0.00 2.63 0.00 0.00 0.02 0.00 0.00

Renal 0 0 3 0 0 0 0 1 0 0 2 0 0 n disease 40

% 0.13 0.09 0.05 0.13 0.15 0.00 0.00 0.00 0.00 0.13 0.28 0.06 0.07 0.00 ITP

1 2 9 0 0 0 0 1 1 6 1 0 n 42 10

.40 % 0 0.26 0.50 1.08 0.16 0.49 0.38 0.34 0.00 0.13 0.00 0.08 0.14 0.39 disorder

Hematological

3 6 1 0 1 0 8 2 2

n 80 10 18 10 426

Thalassemia 123

% 0.53 0.38 1.97 0.86 2.89 0.24 0.00 0.38 2.63 1.32 2.50 0.48 1.36 0.39

4 9 9 0 1 9 2 n asthma 64 11 10 51 20 177 Bronchial 1,680

% Medical disorders in pregnancy by ethnicity 2012 ethnicity by in pregnancy Medical disorders

0.27 0.04 0.39 0.49 0.39 0.24 0.00 0.03 2.63 0.13 0.28 0.14 0.34 0.00

2 1 9 0 1 1 1 1 5 0 n Thyroid Thyroid disease 36 24 15 333

Table 12.4 % 6.05 5.00 3.00 0.21 2.39 0.03 0.62 0.29 0.61 8.64 1.20 0.42 1.91 69.63

women

who

n delivered 38 262 760 360 748 517 7,417 6,128 3,685 2,930 2,338 1,467 Total Total 85,391 10,593

NA Iban Other Other Murut Bajau Malay Indian Other Bidayuh Chinese Melanau Ethnicity Ethnicity Malaysia) Foreigner & Sarawak indigenous OA (Peninsular Sabah in group Kadazan/ Dusun Kadazan/

108 110 National Obstetrics Registry

% 0.00 0.00 0.03 0.03 0.02 0.05 0.00 0.00 0.00 0.00 0.00 0.02 0.03 0.03 0.04 0.03 0.02 0.00 0.00 0.00

Others 0 0 8 8 8 0 0 0 0 0 1 6 5 1 0 0 0 n 16 15 11

% 0.00 0.03 0.03 0.03 0.03 0.06 0.06 0.00 0.00 0.00 0.00 0.00 0.01 0.04 0.05 0.06 0.05 0.00 0.00 0.00

Mental Mental

disorder

0 2 8 3 0 0 0 0 0 3 9 2 0 0 0 n 13 10 10 16 14

% 0.00 0.01 0.02 0.03 0.03 0.02 0.02 0.00 0.00 0.00 0.00 0.03 0.02 0.04 0.04 0.05 0.02 0.00 0.00 0.00 sease Renal

0 1 6 3 1 0 0 0 0 2 5 8 1 0 0 0 n 15 11 17 13

% 0.79 0.04 0.07 0.07 0.06 0.05 0.06 0.00 0.00 0.00 0.79 0.05 0.11 0.05 0.06 0.03 0.02 0.00 0.00 0.00

ITP

1 3 9 3 0 0 0 1 3 4 1 0 0 0 n 17 35 20 24 23 17

% 0.00 0.22 0.35 0.39 0.46 0.28 0.25 0.00 0.00 0.00 0.00 0.26 0.38 0.51 0.50 0.47 0.40 0.00 0.00 0.00

124

Hematological disorder

0 0 0 0 0 0 0 0 n 15 92 48 12 15 86 72 17 183 154 223 154 Thalassemia

62 % 0.00 1.57 1. 1.80 1.84 1.98 1.95 1.38 0.00 0.00 3.17 1.66 1.48 1.59 1.78 1.96 2.16 1.91 0.00 0.00

asthma

0 5 0 0 4 6 0 0 n Bronchial 93 95 92 106 422 845 614 338 334 691 550 302 Medical disorders in pregnancy by age 2011and by 2012 in pregnancy Medical disorders

% 0.00 0.04 0.18 0.32 0.37 0.41 0.36 0.55 0.00 0.00 3.17 1.64 1.46 1.57 1.75 1.95 2.14 1.91 0.00 0.00

Thyroid Thyroid disease

0 3 2 0 0 4 6 0 0 n 46 70 17 94 91 149 124 329 682 540 301 Table 12.5

% 0.09 4.97 3.52 0.27 0.02 0.00 0.10 4.68 3.48 0.26 0.02 0.00 19.24 34.69 24.60 12.60 18.36 35.41 25.14 12.56

delivered

1 2 n 26 26 Total womenTotal 127 362 126 314 who 6,731 4,765 5,736 4,26 26,048 46,963 33,305 17,052 22,513 43,421 30,830 15,404

14 19 24 29 34 39 44 49 54 59 14 19 24 29 34 39 44 49 54 59

------Age 2012 2011 10 15 20 25 30 35 40 45 50 55 10 15 20 25 30 35 40 45 50 55

109 111 National Obstetrics Registry

0.08 0.02 0.01 0.03 0.08 0.03 0.02 0.00

% 0.04 0.03 0.03 0.00 0.04 0.03 0.02 0.00

Others

Others 1 2 0 n 10 19 10 11 26

2 0 1 0 n 17 21 17 21

0.07 0.03 0.02 0.04 0.03 0.04 0.02 0.04

% 0.03 0.03 0.09 0.00 0.04 0.03 0.06 0.00

Mental Mental 9 2 4 2 4 n 22 13 34 disorder

Mental Mental 7 0 4 0 n

15 24 15 25 disorder

0.13 0.02 0.02 0.02 0.17 0.02 0.01 0.04

% 0.03 0.02 0.03 0.00 0.04 0.04 0.02 0.00

Renal

2 7 1 4 n disease

16 12 23 18

Renal

2 0 1 0 n disease 16 19 15 30

0.13 0.07 0.04 0.04 0.09 0.06 0.05 0.03

% ITP

0.07 0.07 0.04 0.00 0.08 0.05 0.02 0.00

4 5 3 n ITP

16 56 16 12 54

3 0 1 0 n

32 53 36 36

0.32 0.45 0.24 0.29 0.36 0.50 0.51 0.18

% disorder 0.38 0.38 0.20 0.93 0.46 0.48 0.28 0.00 disorder

Hematological

41 25 48 52 19 Hematological

345 105 453 125

2 0 n Thalassemia 16 18 176 310 196 353

Thalassemia

2.16 1.92 1.71 1.40 1.71 1.77 1.58 0.84

1.58 1.88 2.12 0.00 1.51 1.73 2.05 0.00

n asthma 89

275 179 514 228 161 Bronchial

1,475 1,596 0 0 n asthma 268 729 166 645 134 Bronchial

1,528 1,

Medical disorders in pregnancy by Parity 2011 Parity 2012 and by in pregnancy Medical disorders 0.34 0.37 0.19 0.20 0.51 0.37 0.19 0.15

% Medical disorders in pregnancy by gestation 2011and 2012 by in pregnancy Medical disorders

0.23 0.35 0.29 0.00 0.28 0.39 0.34 0.00

n Thyroid Thyroid disease

43 20 74 68 19 16

282 337

le 12.6 0 0 n Thyroid Thyroid disease 23 22 105 283 120 287

Tab

Table 12.7 %

9.32 7.63 8.20 8.55

56.28 26.77 10.73 72.51 % 5.79 0.16 5.33 0.07

34.10 59.95 34.80 59.80 women 3 who

women

n delivered delivered

Total Total n 12,756 77,022 10,448 36,637 13,319 89,983 10,181 10,61 82 216 7,840 6,537 Total Total

46,158 81,166 42,679 73,336 who

36 40 36 40

12 - - - -

5 5

NA NA - - >40 >40 1 1 2011 20 22 37 22 37 NA ≥ 6 NA ≥ 6 2 2 2011 2012 (weeks) Parity Parity Gestation

112 110 National Obstetrics Registry

% % 0.03 0.00 0.03 0.03 0.00 0.00 0.03 0.1 0.06 0.03 0.10 0.00

Others Others

0 1 0 0 n 2 1 1 0 n 39 39 37 38

% % 0.03 0.00 0.00 0.04 0.00 0.00 0.03 0.19 0.00 0.04 0.00 0.00 ntal ntal

Mental Mental

0 0 0 0 Me n 2 0 0 0 n 45 43 disorder 43 44 disorder

% % 0.03 0.00 0.00 0.04 0.00 0.00 0.03 0.10 0.00 0.04 0.10 0.00

Renal

0 0 0 0 n 1 0 1 0 n disease disease 37 45 36 45

% %

0.06 0.29 0.11 0.06 0.00 0.18 0.06 0.00 0.11 0.06 0.00 0.15 ITP ITP

0 4 0 4 n

3 2 0 2 n 84 69 87 72 al disorder al

% 0.38 0.00 0.19 0.46 0.00 0.39 0.38 0.38 0.11 0.46 0.42 0.36

and 20112012 fetal outcome and

0 7 0 n

and maternal outcome 2011 and 20112012 and maternal outcome 4 2 4 4 n 497 557 Hematologic

Thalassemia Hematological disorder 510 564

Thalassemia

126

1.79 0.00 1.69 1.68 0.00 1.16 % 1.78 1.91 0.00 1.68 1.57 0.09

in pregnancy in pregnancy

0 0 n asthma

61 30

Bronchial

asthma 7 0 8 1 n in pregnancy 2,362 2,017 20 15

Bronchial 2,38 2,04

0.31 0.00 0.25 0.35 0.00 0.15 % 0.27 0.38 0.00 0.35 0.63 0.18

0 9 0 4 n

Thyroid Thyroid disease

4 0 6 2 n Thyroid Thyroid disease 402 425 367 432

Medical disorders Medical

% 0.02 2.64 0.02 2.09 0.76 1.29 0.77 0.89 96.26 96.71 97.95 98.34

women

delivered

n Table 12.8 n 21 28 956 3,620 2,593 Total Total 1,046 1,761 1,110 Table 12.9 Total womenTotal who who delivered 131,739 120,013 134,056 122,030

NA NA NA NA 2011 2012 2012 NICU NICU 2011 mortality mortality Maternal Maternal Maternal Maternal pregnancy pregnancy pregnancy morbidity ICU morbidity ICU Outcomes of Outcomes of Fetal mobidity Fetal mobidity Fetal mortality Fetal mortality

113 111