Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item GDF15 linked to maternal risk of nausea and vomiting during pregnancy(Nature Pub. Group, 2024) Fejzo, M.; Rocha, N.; Cimino, I.; Lockhart, S.M.; Petry, C.J.; Kay, R.G.; Burling, K.; Barker, P.; George, A.L.; Yasara, N.; Premawardhena, A.; Gong, S.; Cook, E.; Rimmington, D.; Rainbow, K.; Withers, D.J.; Cortessis, V.; Mullin, P.M.; MacGibbon, K.W.; Jin, E.; Kam, A.; Campbell, A.; Polasek, O.; Tzoneva, G.; Gribble, F.M.; Yeo, G.S.H.; Lam, B.Y.H.; Saudek, V.; Hughes, I.A.; Ong, K.K.; Perry, J.R.B.; Sutton, C.A.; Baumgarten, M.; Welsh, P.; Sattar, N.; Smith, G.C.S.; Charnock- Jones, D.S.; Coll, A.P.; Meek, C.L.; Mettananda, S.; Hayward, C.; Mancuso, N.; O'Rahilly, S.GDF15, a hormone acting on the brainstem, has been implicated in the nausea and vomiting of pregnancy (NVP) including its most severe form, Hyperemesis Gravidarum (HG), but a full mechanistic understanding is lacking [1-4]. Here we report that fetal production of GDF15, and maternal sensitivity to it, both contribute substantially to the risk of HG. We confirmed that higher GDF15 levels in maternal blood are associated with vomiting in pregnancy and HG. Using mass spectrometry to detect a naturally-labelled GDF15 variant we demonstrate that the vast majority of GDF15 in the maternal plasma is derived from the feto-placental unit. By studying carriers of rare and common genetic variants we found that low levels of GDF15 in the non-pregnant state increase the risk of developing HG. Conversely, women with beta-thalassemia, a condition where GDF15 levels are chronically high [5], report very low levels of NVP. In mice, the acute food intake response to a bolus of GDF15 is influenced bi-directionally by prior levels of circulating GDF15 in a manner suggesting that this system is susceptible to desensitization. Our findings support a putative causal role for fetally-derived GDF15 in the nausea and vomiting of human pregnancy, with maternal sensitivity, at least partly determined by pre-pregnancy exposure to the hormone, being a major influence on its severity. They also suggest mechanism-based approaches to the treatment and prevention of HG.Item Clinical practice of vitamin D screening and supplementation in pregnancy in Asia-pacific countries: A cross-sectional study(Elsevier, 2023) Lee, R.W.K.; Chng, A.L.B.; Tan, K.H.; Shub. A.; Tan, T.; Ling, L.S.; Kuma, K.; Siew, C.Y.; Ting, W.; Myint, S.S.; Judistiani, R.T.D.; Shah, M.; Madulid-Sison, L.; Andres-Palencia, B.; Pagilagan-Palma, E.; Banu, L.A.; Boriboonhirunsarn, D.; Dias, T.D.BACKGROUND: Vitamin D deficiency is common in pregnant women. There is scarce information in the Asia-Pacific region on the understanding of vitamin D screening and supplementation in pregnancy among health care professionals. METHODS: We performed a cross-sectional study among health care professionals who are part of the Integrated Platform for Research in Advancing Metabolic Health outcomes of Women and Children (IPRMAHO) international study group on their understanding and perception of Vitamin D screening and supplementation in pregnancy. The cross-sectional survey comprised 4 main sections: demographics, existing policies, nutrient supplementation in pregnancy and various practices on screening, treatment and perceptions, with a total of 22 questions. A total of 15 responses were obtained from attendees from distinct health facilities across eleven participating Asia-Pacific countries. RESULTS: Majority of the surveyed hospitals (11/15, 78.6 %) did not have a national policy or regional guideline regarding Vitamin D screening and supplementation in pregnancy. More than half of respondents were (9/14, 64.3 %) were unsure of the percentage of women seen with Vitamin D deficiencies each year and were unsure of Vitamin D dosage prescribed to pregnant women with (8/15, 53.3 %) or without (6/14, 42.9 %) Vitamin D deficiency. Vitamin D was rarely prescribed in pregnancy when compared to other nutrient supplements such as folic acid and iron. Majority of respondents (9/11, 72.7 %) indicated that their hospital did not screen for Vitamin D deficiencies in pregnancy, even amongst high risk pregnant women. Nevertheless, majority of respondents indicated a need (12/15, 80.0 %) for a guideline or consensus regarding Vitamin D screening and supplementation in pregnancy. CONCLUSION: While majority of the surveyed hospitals did not have a national policy or regional guideline regarding Vitamin D screening and supplementation in pregnancy, majority of respondents indicated a need for the policy or guideline. There were varying clinical knowledge gaps and different perceptions on Vitamin D screening and supplementation in pregnancy among healthcare professionals.Item Upper gastro intestinal endoscopy in pregnancy: A single centre experience(Sri Lanka college of Obstetricians & Gynaecologists, 2023) Abeysuriya, V.; Dodampahala, H.S.; Chandrasena, L.INTRODCTION: Upper gastro intestinal (GI) endoscopy is advisable to perform when strongly indicated during pregnancy. This study was to evaluate the outcomes of upper GI endoscopy during pregnancy. METHODS: A single centre retrospective study was carried out. Randomly selected 500 medical records of the pregnant mothers who were referred as out patients and hospitalized from 2012 to 2022 were retrieved. Inclusion criteria for retrieving data of the patients who underwent upper GI endoscopy were; Major or continued bleeding, severe or refractory nausea and vomiting or abdominal pain, dysphagia or odynophagia. Endoscopic findings were recorded in a computer based database. Ethical approval was obtained from the Ethical Review Committee of Nawaloka Hospitals of Sri Lanka. No conflict of interest. RESULTS: A total of 16 records of patients underwent upper GI endoscopy were retrieved during 2012 to 2022. The mean age of the patients was 25.48 ± 6.5 years. Ten patients (62.5%:10/16) were primigravida. During the first, second and third trimester of pregnancy, number of patients who underwent upper GI endoscopy were 8 (50%), 4 (25%), and 4 (25%) respectively. The major indication was persistence epigastric pain (75%: 12/16) followed by dysphagia (18.7%:3/16) and hematemesis in one patient. All patients had undergone conservative treatment without any therapeutic upper GI endoscopy. There were no records that were found to have ERCP, capsular endoscopy or enteroscopy during pregnancy among our patients. No records were found of having endoscopy related adverse effects on mothers or foetuses. CONCLUSION: The upper GI endoscopy especially oesophago-gastro-dudenoscopy (OGD) may be performed without a major risk to the mother and the baby. However, further prospective multicentre research studies are strongly recommended.Item The usefulness of flexible sigmoidoscopy in bleeding per rectum during pregnancy: an observational study(Sri Lanka College of Obstetricians & Gynaecologists, 2023) Abeysuriya, V.; Dodampahala, S.H.; Chandrasena, L.INTRODUCTION: Bleeding per rectum is not an infrequent complaint during pregnancy, which may require endoscopic evaluation and treatment. Flexible sigmoidoscopy is a relatively simple, quick procedure. The current study was aimed to assess the usefulness of flexible sigmoidoscopy in bleeding per rectum during pregnancy from a single tertiary care centre. METHODS: A single centre retrospective study was carried out. Randomly selected 1000 medical records of the pregnant mothers who were referred as out patients and hospitalized from 2012 to 2022 were retrieved. All patients had the passage of fresh blood as their chief complaint. All of them had not undergone any prior diagnostic workup for their presentation. All had undergone flexible sigmoidoscopies and patients with significant additional bowel symptoms underwent colonoscopy following sigmoidoscopy. Endoscopic findings were recorded in a computer based database. Ethical approval was obtained from the Ethical Review Committee of Nawaloka Hospitals of Sri Lanka. No conflict of interest. RESULTS: A total of 48 pregnant women had undergone lower GI endoscopies. The mean age of the patients was 25.3 ± 6.5 years. Twenty-four patients (50%) were primigravida. Majority was in the second trimester of pregnancy 89.5% (43/48). The mean (±SD) gestational age at the time of procedure was 18(±2) weeks. All had undergone sigmoidoscopy, and an additional colonoscopy were done in 2 patients. Bleeding per rectum was the main indication. All flexible sigmoidoscopies were done without sedation. Wiliest, the colonoscopies were performed under conscious sedation. Majority of the pregnant mothers found to have haemorrhoids followed by anal fissures (46/48; 95.8%). Ulcerative colitis and a sigmoidal cancer were found in two patients (4.2%). None had an immediate post procedure-related complication. CONCLUSION: Flexible sigmoidoscopy is useful and safe to be performed in pregnancy with clinically significant bleeding per rectum. It has a good diagnostic yield. Further prospective multicentre research studies are strongly recommended.Item Acute appendicitis in pregnancy(Sri Lanka College of Obstetricians & Gynaecologists, 2023) Abeysuriya, V.; Dodampahala, H.S.; Chandrasena, L.INTRODUCTION: The early diagnosis and management of appendicitis in pregnancy are essential in maternal and fetal morbidity and mortality. In this 20-year retrospective study, we aimed to assess the outcomes of pregnant patients diagnosed with acute appendicitis. METHODS: A single-center retrospective study was carried out. Randomly selected 2000 medical records of pregnant mothers referred as outpatients and hospitalized from 2002 to 2022 were retrieved. Six pregnant patients who were diagnosed and treated in Nawaloka Hospital with the diagnosis of acute appendicitis during 2002-2022 were examined retrospectively. Ethics Committee approval was received. No conflicting interest. RESULTS: The age range of our patients was 22 to 31 years, mean of 26± 3.4. The mean gestational week was 20±5.3 weeks, and most were in the second trimester 4 (68%). All patients were admitted with the complaint of abdominal pain, the majority of them had the right iliac fossa pain (RIF). All had elevated inflammatory markers. No computed tomography (CT) was performed. One patient was diagnosed clinically of having acute appendicitis without any imaging. Acute appendicitis was diagnosed in 3/5 patients who underwent ultrasound scan examination. The other two patients (one from 2nd trimester and one in the third trimester) were diagnosed with acute appendicitis on MRI examination. All patients underwent open appendectomy under general anaesthesia. No maternal or foetal morbidity or mortality was noted during pre or post-surgical and anaesthesia procedures. The mean hospital stay was 3.9±0.9 days. All appendixes were pathologically proven to have acute appendicitis. Except for minor superficial surgical site infection rest of the mothers and foetus had no morbidity or mortality recorded in the follow-up. CONCLUSION: Although appendicitis is not frequent during pregnancy, it is a disease that requires urgent surgical and obstetrics care for timely diagnosis and treatment.Item Incisional herniae following lower segment caesarean section: A 20-year chart review(Sri Lanka College of Obstetricians & Gynaecologists, 2023) Dodampahala, S.H.; Chandrasena, L.; Abeysuriya, V.INTRODUCTION: The rates of caesarean delivery is increasing worldwide as well as in Sri Lanka. Incisional hernia is a known complication of abdominal surgery. To our knowledge there has been no study to assess the incidence of incisional hernia following caesarean section in Sri Lanka. This study was to assess the incidence of incisional hernia requiring surgical repair after lower segment caesarean section (LSCS) in a cohort during a 20-year period. METHODS: This was a chart review based on tertiary care private sector hospital in Sri Lanka. Hernia repairs performed during 2002 to 2022 were identified. The data was retrieved from computer based data base and previous bed head tickets. The main inclusion criterion was a caesarean delivery from the 01st of January 2002 to 31st of December 2022 in women with no history of previous abdominal surgery. The cohort was assessed from their first caesarean delivery until 20 years in the inclusion period for an event of hernia repair. The following exclusion criteria for the hernia repairs were used: Diastasis rectiwithout hernia, hernia not in the caesarean incision, and no hernia. The study was approved by the Research and Ethical Committee of Nawaloka Hospital Sri Lanka. The patient records and the data-set were anonymized before analysis. No conflict of interest. RESULTS: There were 2675 records retrieved. The mean age of the patients was 28±7.5 years. There were 10/2675 (0.37%) patients were found to incisional herniae following LSCS. The majority (7/10) of patients with incisional hernia had lower midline incisions for their LSCS. The average time duration of the occurrence of incisional hernia following a single LSCS was 19.5±2.3 months and it was 14.3±1.6 and 12.3±1.5 months for following second and third LSCS respectively. Majority of the incisional herniae were done as routine cases. Following the incisional hernia repair one patient had a recurrence after year. CONCLUSION: The overall incidence of having an incisional hernia requiring repair of a caesarean delivery was 0.37%. Most herniae appeared within the first two years and associated with the lower midline incisions.Item Whole-body hypothermia, cerebral magnetic resonance biomarkers, and outcomes in neonates with moderate or severe hypoxic-ischemic encephalopathy born at tertiary care centers vs other facilities: A nested study within a randomized clinical trial(American Medical Association, 2023) Thayyil, S.; Montaldo, P.; Krishnan, V.; Ivain, P.; Pant, S.; Lally, P.J.; Bandiya, P.; Benkappa, N.; Kamalaratnam, C.N.; Chandramohan, R.; Manerkar, S.; Mondkar, J.; Jahan, I.; Moni, S.C.; Shahidullah, M.; Rodrigo, R.; Sumanasena, S.; Sujatha, R.; Burgod, C.; Garegrat, R.; Mazlan, M.; Chettri, I.; Babu, S.P.; Joshi, A.R.; Swamy, R.; Chong, K.; Pressler, R.R.; Bassett, P.; Shankaran, S.IMPORTANCE: The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown. OBJECTIVE: To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn). DESIGN, SETTING, AND PARTICIPANTS: This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020. EXPOSURE: 3T MR imaging, MR spectroscopy, and diffusion tensor imaging. MAIN OUTCOMES AND MEASURES: Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months. RESULTS: Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41). CONCLUSIONS AND RELEVANCE: In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs.Item Prevalence and some selected characteristics of asymptomatic gallstones among pregnant women. A retrospective chart review(Sri Lanka College of Obstetricians & Gynaecologists, 2022) Abeysuriya, V.; Dodampahala, S.H.; Chandrasena, L.Introduction During pregnancy, it is often associated with gallstones and biliary sludge. Gallstone disease is the second most common indication for non-obstetric surgical intervention in pregnancy. Methods A retrospective chart review was carried out to determine the prevalence and characteristics of asymptomatic gallstones among selected sample of pregnant women in a private hospital in Colombo, Sri Lanka. Data was retrieved form the available records at hospitals from 2016 to 2022.There were 329 patients recode during the study period. An exclusion criteria was applied to select the subjects. Data pertains to demographic, haematological, bio-chemical and hepatobiliary sonography was retrieved. The study data were analysed using STATA (StataCorp LLC Texas, USA) software version 16 for Windows. Normality was determined using the Kolmogorov-Smirnov’s test. Categorical variables like gallbladder status and blood group were presented using frequency tables. The mean values of age, gestational age, and gravidity were compared t-test and ANOVA. Gallbladder status was compared to age group, gravidity, trimester, and blood group using Chi-squared test. P values of <0.05 were considered significant. Results The study sample consists of 300 pregnant women records. The means age of pregnant mother with gall stone and sludge was statistically higher than the normal gallbladder. Multigravida was higher among the study sample (63%).The most of the study subject were in third trimester (68%). Majority (97%) had normal gallbladder, 2% had gallstones and 1% had sludge. A higher proportion of gallstones were identified among mothers age more than 30 years. Muliti-gravid had higher proportion of gallstones and sludge. The third trimester was identified as higher proportion of gallstones and sludge. All the cases who had gallstone and sludge were Blood group type “O”. Conclusion This sample shows that a higher proportion of gallstones and sludge were identified among mothers whose age more than 30 years, muliti-gravid, in their third trimester and blood group of type “O”. Further studies are needed to generalized this study finds to Sri Lankan setting.Item Gallstone-related complications and evidence base treatments. A scoop review(Sri Lanka College of Obstetricians & Gynaecologists, 2022) Abeysuriya, V.; Dodampahala, S.H.The incidence of gallstones is 10-15%, making it one of the most common causes of surgical admissions. The number of admissions and operations for gallstone disease is increasing. Commonly gallstones are formed in the gallbladder but can also develop in the biliary tree. Commonly, gallstones are made of cholesterol. Even though the exact cause of supersaturation of bile is not known, there are multiple associate factors for gallstone formation. Most patients with gallstones never experience any symptoms, but the risk of presenting with complications related to gallstones is 1%-4% a year. Patients with gallstones can present with pain or other more severe complications that demand surgical treatment and follow-up. This article looks into epidemiology, basic pathophysiology, complications, pregnancy and gallstones, diagnosis and recent evidence base treatment of gallstone disease.Item Management of anaemia in pregnancy: experience from a Sri Lankan tertiary hospital unit(Wiley-Blackwell, 2015) Palihawadana, T.; Dias, T.; Motha, C.; Thulya, S.D.; Herath, R.; Wijesinghe, P.S.INTRODUCTION: Higher rates of pregnancy complications have been reported among anaemic pregnant women. Universal iron supplementation during pregnancy is recommended in countries where iron deficiency anaemia (IDA) prevalence rates are high. Sri Lanka also carries out a policy of such supplementation. The effectiveness of such programmes in different settings is variable. A retrospective analysis of the effectiveness of our current policy on prevention and treatment of anaemia was done for programme evaluation. METHODS: The North Colombo Obstetric Database (NORCOD) was used retrospectively to analyse the data between March and August 2014, at the university obstetric unit of the North Colombo Teaching Hospital, Sri Lanka. All singleton pregnancies without medical comorbidities were included in the analysis. Those who did not have haemoglobin (Hb) recording in the first trimester or in the third trimester were excluded at the data cleaning stage. An Hb level of <11 g/dL and a level of <10.5 g/dL were considered as anaemia in first and third trimesters respectively. The prevalence of anaemia at booking, and the Hb status in the third trimester were assessed. RESULTS: A total of 1340 singleton pregnancies were included in the analysis and 74 were excluded from the analysis due to incomplete data. 28.9% (n = 366) were found to be anaemic at booking while 63.9% (n = 809) were with a normal Hb and 7.1% (n = 91) were with an Hb of >13 g/dL. In the third trimester the prevalence of anaemia was 11.5% (n = 146) while 64.7% (n = 820) were with normal Hb and 23.6% (n = 300) were with an Hb of >13 g/dL. Among the anaemic women at booking, 22% (n = 81) persisted to be anaemic in the third trimester while 65% (n = 238) became normal and 12.8% (n = 47) developed a higher Hb level. Among those with a high Hb at booking only 1% became anaemic by third trimester while 40.6% persisted to have a high Hb level. CONCLUSION The prevalence of anaemia in this population was of moderate severity (>20% but <40%) as defined by the WHO. Major shortcoming in our practice is that we were unable to successfully treat nearly quarter of women who present with anaemia at booking, thus highlighting sub-optimal treatment. Furthermore, a policy of universal supplementation seems to over treat women with a high Hb at booking. Therefore, a more individualised supplementation and treatment policy should be encouraged in routine clinical practice.