First Trimester Screening for Down Syndrome

Dr Kenneth Kwek, Head and Senior Consultant of Peripartum Unit, shares with Special Delivery a technique that can better assess the risk of Down Syndrome in pregnant women.

Whilst the vast majority of babies are normal, all women, whatever their age, have a very small risk of delivering a baby with Down Syndrome. Locally, this occurs in 1 out of every 700 pregnancies (i.e. 1 in 700 risk). The risk is not uniform throughout the population and can be individualised in any specific woman using several factors.

In recent years, doctors have been able to screen women for the risk of Down Syndrome more accurately in the first trimester (between 11 and 14 weeks).

The screening programme entails a combination of three factors to more accurately assess risk- maternal age and background history, ultrasound findings and blood tests.

A detailed history of past pregnancies, prior abnormal births in the family, among other factors, is taken. An ultrasound examination is performed during which the following are assessed:

1) Nuchal Translucency (NT)

Thickness of skin at the back of the neck is assessed; the thicker the skin, the higher the risk of Down Syndrome

2) Presence of Nasal Bone (NB)

Presence of the nasal bone decreases the risk of Down Syndrome

Blood from the mother is drawn for assessment of PAPP-A and b-HCG. The levels of these compounds in the mother's blood can help to give an indication of the risk of Down Syndrome.

The results of all these evaluations are then combined to accurately calculate the risk of Down Syndrome in the pregnancy. The result of the screening is reported in the form of a probability. This is divulged to couples and they are encouraged to participate in the discussion of management decisions.

Analysis of data from around the world has shown that such a screening programme offers a detection rate of 90 per cent with a false positive rate of 5 per cent.

If couples feel that there is a high risk of Down Syndrome after the evaluation of these factors, the option of an invasive diagnostic test (amniocentesis or chorionic villous sampling) is discussed.

Some couples may choose to be tested for Down Syndrome during pregnancy as it may either help them prepare psychologically for the birth of a child with disabilities or to help them reach a decision regarding the continuation of the pregnancy. Others may not choose the test, particularly if they are willing to accept their inherent background risk of delivering a child with disabilities.

The first trimester screening will help couples make an informed decision on whether to proceed with the invasive diagnostic test as it carries the risk of a miscarriage (less than 0.5 per cent). At KKH, couples can be assured that the screening is done by prenatal consultants accredited by the Fetal Medicine Foundation.

Managing Pain - The 5th Vital Sign

In hospitals worldwide, patients are generally checked for four major health indicators, i.e. pulse, temperature, respiration and blood pressure. Over recent years, much interest has been generated to recognize the 5th vital sign - pain.

Pain management involves studying the causes of pain, the body's reaction towards pain, how medications can eliminate the pain and how other forms of treatments can be used to relieve painful conditions.

Managing pain in patients has its benefits - to facilitate recovery process, prevent complications resulting from immobility, improve function and prevent disability. These factors prompted KKH to include pain as the 5th vital sign in patient care. The initiative is timely, given the increasing awareness of the prevalence of chronic pain in children.

There are two kinds of pain - acute and chronic. Acute pain is related to injuries resulting from trauma or surgery which will resolve during the healing period.

Unrelieved acute pain after surgery and trauma increases the risk of post-operative or post-traumatic complications such as pneumonia and ileus (poor movement of the intestines which may cause intestinal obstruction), and may even act as triggers of chronic pain.

Chronic pain, on the other hand, can either be cancer-related pain or non-cancer related such as chronic headache, recurrent abdominal pain, muscle and joint pain and pain related to the nerves.

If left unmanaged, chronic pain can lead to functional disability, school absenteeism, sleep disturbance, inability to participate in sports and social isolation.

Even though there is a lack of local figures, data from the West indicates that chronic pain syndromes in children are common. The prevalence of chronic headache in children is reported to be 20 per cent in preschoolers.

This increases to 50 per cent for children at the age of nine; by adolescence, it is 70 per cent. For recurrent abdominal pain, it is found to be between 10.8 per cent to 36 per cent in children aged 5 to 18 years.

"Pain in children is often under treated. Some reasons for this include difficulty in assessing pain in children, misconception about pain medication and treatments, and lack of appropriate facilities to manage pain in children.

Unlike adults, children generally do not possess strategies to cope with pain," said Dr Michelle Tay, Consultant with Department of Paediatric Anaesthesia who heads the children's pain service.

To address all the issues surrounding pain syndrome, an integrated multidisciplinary approach is vital. In March 2005, KKH formalized a collaboration with the Children's Medical Fund (CMF) of the National Kidney Foundation (NKF) and launched the NKF CMF - KKH Pain and Palliative Care Programme.

The programme is the first in Singapore to provide a multidisciplinary approach towards managing chronic pain in children.

New Use for Stomach Soother

Cimetidine (also known by the brand name Tagamet®) appears to be gaining popularity for another reason besides fighting heartburn.

An Australian study has shown that cimetidine has the ability to stir the fighter cell lymphocytes of the immune system to penetrate the malignant tumors in individuals with colon cancer who underwent surgery.

This direct assault on tumor cells by the immune system gives the body a fighting chance to eliminate cancer.

The researchers earlier had found differences in the rates of survival following colon surgery: 93 per cent for cimetidinetreated cancer patients versus 59 per cent for non-cimetidinetreated cancer patients.

Another cimetidine trial was conducted in Japan's Fugita Health University with rectal and colon cancer patients.

Rectal cancer patients undergoing chemotherapy following surgery who took cimetidine had a 100 per cent survival rate; cimetidinetreated colon cancer patients who did not receive chemotherapy had a 96.3 per cent survival rate.

For those contemplating colon surgery, the above studies suggest it may be advisable to start cimetidine one week prior to surgery through one year following the procedure. Of course, as with any health information, it's wise to discuss this with your physician.

Artificial Sweeteners - Watch out!

Do artificial sweeteners such as aspartame and sucralose help dieters successfully lose weight?

Consumers' Research magazine states, "There is no clear cut evidence that sugar substitutes are useful in weight reduction. On the contrary, there is some evidence that these substances may stimulate appetite."

The sweeteners are found in many foods today besides diet sodas. They are used in baked goods, salad dressings, jams and jellies, frozen desserts, processed fruit juices, and more.

Are they safe for longterm consumption? Three doctors weigh in on that question. Dr. H.J. Roberts, Director of the Palm Beach Institute for Medical Research, has gathered evidence that the use of aspartame products may cause breathing difficul-ties and pulmonary hypertension, especially in weight conscious women.

According to Dr. Nan Fuchs, headaches are the most frequent complaint from aspartame consumers, followed by vision problems and mood disorders.

Sucralose, which is 600 times sweeter than table sugar, is produced by chlorination, a process used as the basis for pesticides such as DDT.

Although the longterm safety of these products is unknown, there is currently no provision for long-term monitoring. Perhaps it's time to rethink our options for sweeteners.

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