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Prevalence of teenage pregnancy in 2015-2016 and its obstetric outcomes compared to non-teenage pregnancy at Hospital Tuanku Ja'afar Seremban (HTJS), Negeri Sembilan, Malaysia: A retrospective case-control study based on the national obstetric registry

Nagandla K, Kumar K

Malays Fam Physician, 2020;15(2):2-9.
PMID: 32843939

OBJECTIVE: To determine the prevalence of teenage pregnancy and compare its obstetric and perinatal outcomes with those of non-teenage pregnancy.
METHOD: This retrospective hospital-based case-control study was conducted in the Department of Obstetrics and Gynaecology in Hospital Tuanku Ja'afar Seremban. The study made use of the Malaysian National Obstetric Registry (NOR) records of teenage pregnant women aged 11-19 at Hospital Tuanku Ja'afar Seremban over a 12-month period between May 2015 and May 2016 (n=164). Socio-demographic profiles, obstetric outcomes, and perinatal outcomes were detailed for each pregnant woman. The results were compared to a control group of 169 pregnant women aged 20-30 who also delivered in hospital Tuanku Ja'afar Seremban during the same period. The aim of this study was to assess the obstetric outcomes of teenage pregnancy and to compare them with those of the control group. A chi-squared test was used to identify the statistical significance of the relationship between teenage pregnancy rates and obstetric outcomes. Results with p <0.05 was considered statistically significant.
RESULTS: The prevalence of teenage pregnancy was 2.8%. The mean age of the teenage group was 17.9; that of the control group was 26.4. Teenage mothers had a significantly higher risk of anemia (p<0.05), episiotomy (p<0.001), preterm labor (p<0.001), and delivering low-birthweight babies (p<0.001). There were no significant differences between the two groups in mode of delivery, antenatal complications, birth outcomes, APGAR scores at 5th minute, or neonatal complications.
CONCLUSION: The prevalence of teenage pregnancy in this study is relatively low but is associated with an increased risk of some perinatal complications. The primary care physician's role is pivotal in educating adolescents on sexual health, providing continual care in hospitals, and empowering teenagers in their reproductive health decisions.
Musculoskeletal symptoms and orthopaedic complications in pregnancy: pathophysiology, diagnostic approaches and modern management

Bhardwaj A, Nagandla K

Postgrad Med J, 2014 Aug;90(1066):450-60.
PMID: 24904047 DOI: 10.1136/postgradmedj-2013-132377

Low back pain is a common musculoskeletal symptom in pregnancy that can present as lumbar pain or pelvic girdle pain, with significant physical and psychosocial implications. Pelvic girdle pain is more prevalent and results in greater disability than lumbar pain. It is possible to distinguish between these two conditions from a detailed history based on the site of the pain, its intensity, disability and pain provocation tests. Management of low back pain in pregnancy is conservative, with physical exercise for lumbar pain and minimising activities that exacerbate pain, analgesics and bed rest for pelvic girdle pain, as well as avoiding abduction beyond the pain-free zone in labour. There is evidence that stabilising exercises in patients with pelvic girdle pain postpartum have a beneficial effect. Other treatment modalities that have been shown to be safe and effective include pelvic belts, transcutaneous electrical nerve stimulation, spinal manipulative therapy, acupuncture and complementary therapy with yoga. Other orthopaedic complications in pregnancy such as carpal tunnel syndrome, pubic symphysis rupture, transient osteoporosis and osteonecrosis are usually self-limiting with a satisfactory outcome. However, a lack of awareness and failure to recognise these complications can result in long-term morbidity. Knowledge of the preoperative diagnostic investigations, surgical approaches and intraoperative positioning of the mother to avoid gravid uterus compression is vital in orthopaedic emergencies such as lumbar disc herniation, cauda equina syndrome, fractures and acute compartment syndrome of the lower limb to ensure a safe maternal and fetal outcome and to prevent serious disability. Pregnancy is not contraindicated in women with pre-existing orthopaedic complications such as kyphoscoliosis and total hip arthroplasty as there is no evidence to suggest increased maternal or fetal risks.
Restless legs syndrome: pathophysiology and modern management

Nagandla K, De S

Postgrad Med J, 2013 Jul;89(1053):402-10.
PMID: 23524988 DOI: 10.1136/postgradmedj-2012-131634

Restless legs syndrome (RLS) is a common sensory motor neurological disorder that is characterised by an irresistible urge to move the legs that significantly affects the quality of life of the patient. Prevalence in the general population is 5-25% and it is twice as prevalent in women as in men. RLS is the most common movement disorder in pregnancy with a fourfold increased risk of developing this disorder later in life. The pathophysiology of RLS is centred on dopaminergic dysfunction, reduced central nervous system iron, genetic linkages, or alteration in neurotransmitters such as hypocretins, endorphins levels and immune dysfunction and inflammatory mechanisms. With the emergence of new evidence, there are changes to the previous treatment recommendations for RLS. There is sufficient evidence to conclude that dopamine agonists such as rotigotine transdermal patch, pramipexole, ropinirole, gabapentin enacarbil, pregabalin and gabapentin are effective in the short-term treatment of RLS and rotigotine, followed by gabapentin enacarbil, ropinirole, pramipexole and gabapentin for long-term treatment. Based on expert consensus, the recommendation for daily RLS is dopamine agonists or gabapentin or low-potency opioids. Levodopa is less preferred for treating daily RLS due to its high risk of augmentation. For intermittent RLS, it is levodopa or dopamine agonists or low-potency opioids or benzodiazepines. For refractory RLS, the choice is to change to gabapentin or a different dopamine agonist, addition of a second agent like gabapentin or benzodiazepine to the existing drug or changing to a high-potency opioid or tramadol. Medications with safety record in pregnancy include opioids and antiepileptics such as carbamazepine and gabapentin. There are concerns that patients with RLS are at risk for metabolic deregulation, autonomic dysfunction and cardiovascular morbidity. However, a recent study concluded that RLS is not associated with increased risk of cardiovascular complications.
Fulltext Sickle cell disease in pregnancy – a rare condition with detrimental outcome: a case report

Nik Sumayyah, N. M. N., Shafiee, M. N., Kalok, A., Nagandla, K.

Medicine & Health, 2017;12(2):352-356.
MyJurnal

Sickle cell disease (SCD) in pregnancy is uncommon in Malaysia. We present a case of sickle cell disease in pregnancy with maternal and fetal complications. The patient presented with acute pain crisis and hemolysis in the third trimester. Despite thromboprophylaxis, she developed deep vein thrombosis. The pregnancy was further complicated by severe pre-eclampsia and intrauterine growth restriction which require preterm caesarean section. The baby was admitted to Neonatal Intensive Care Unit due to prematurity and low birth weight. Multidisciplinary
approach in managing pregnant patient with SCD is essential in achieving good obstetrics outcome.
Keywords: anemia, sickle cell disease, pregnancy outcomes
Fulltext Acceptability of Just-in-Time Teaching amongst medical students: a pilot study

De S, Nagandla K, Kanagasabai S

Education in Medicine Journal, 2014;6(1):11-19.
MyJurnal

Introduction: Just-in-Time Teaching (JiTT) is a novel method of teaching-learning used in various disciplines of science and humanities. It is a technique that scaffolds the students learning process by reducing the cognitive load which is the load related to the executive control of working memory. Just in time teaching underpins the concept that expertise in learning originates from the knowledge already stored in long term memory and with subsequent interaction between the learner and teacher motivates enhanced active learning and optimizes the intellectual performance.
Objective: The objective of the study is to assess the acceptability of JiTT over traditional lecture teaching among the medical students.
Method: In a cross sectional pilot study, three hundred thirty five students participated in a questionnaire based study that grades the various aspects of the traditional lecture series. After the implementation of JiTT method for a period of four months, three hundred two students completed the questionnaire, grading the same variables for JiTT. The analysis was done by using SPSS version 11 applying Paired t test and McNemar's Test.
Result: The results of our study highlighted that JiTT technique was perceived superior to traditional teaching with statistically significant outcomes in the clarity of the topic (p=0.003,) duration of the session (p=0.002), knowledge gained and orientation for exams (p=0.044). The students perceived JiTT method as less monotonous (p=0.005) increasing their alertness during these sessions (p=0.002).
Conclusion: We therefore propose that Just-in-Time Teaching method is a more interactive and acceptable teaching-learning tool shifting the nature of teaching to a more student-centric approach as perceived by the medical students. This is the first pioneer study on JiTT to be performed on undergraduate medical students so far.
Online formative assessments: exploring their educational value

Nagandla K, Sulaiha S, Nalliah S

J Adv Med Educ Prof, 2018 Apr;6(2):51-57.
PMID: 29607332

Introduction: Online formative assessments (OFA's) have been increasingly recognised in medical education as resources that promote self-directed learning. Formative assessments are used to support the self-directed learning of students. Online formative assessments have been identified to be less time consuming with automated feedback. This pilot study aimed to determine whether participation and performance in online formative assessments (OFA's) had measurable effects on learning and evaluate the students' experience of using the OFA's in the department of Obstetrics and Gynaecology.
Methods: This is a cross-sectional study conducted among fourth year medical students (n=92) during their seven week postings in Obstetrics and Gynaecology. Five sets of online formative assessments in the format of one best answers (OBA), Objective structured practical examination (OSPE) and Short answer question (SAQ) with feedback were delivered over five weeks through the online portal. The mean scores of the end of posting summative exam (EOP) of those who participated in the assessments (OFA users) and of those who did not (non-OFA users) were compared, using Students t test. The frequency of tool usage was analysed and satisfaction surveys were utilized at the end of the course by survey questionnaire using the five point Likert scale.
Results: The mean scores of the students in end of posting summative examination marks for students who had participated in the online formative assessment (OFA users) and for those who had not (non OFA users) showed no significant difference in all the three components OBA, SAQ and OSPE (p=0.902, 0.633, 0.248). Majority of the students perceived that OFAs fulfilled the stated aims and objectives and so they would persuade their peers to participate in the OFAs.
Conclusions: Online formative assessments are perceived as tools that promote self-directed learning, improved knowledge and tailor learning for individual learning needs and style.
Academic Staff Perspectives Towards Adoption of E-learning at Melaka Manipal Medical College: Has E-learning Redefined our Teaching Model?

Bhardwaj A, Nagandla K, Swe KM, Abas AB

Kathmandu Univ Med J (KUMJ), 2015 12 2;13(49):12-8.
PMID: 26620743

BACKGROUND: E-learning is the use of Information and Communication Technology (ICT) to provide online education and learning. E- Learning has now been integrated into the traditional teaching as the concept of 'blended learning' that combines digital learning with the existing traditional teaching methods to address the various challenges in the field of medical education. Structured e-learning activities were started in Melaka Manipal Medical College in 2009 via e-learning platform (MOODLE-Modular Object-Oriented Dynamic Learning Environment).
OBJECTIVES: The objective of the present study is to investigate the faculty opinions toward the existing e-learning activities, and to analyse the extent of adopting and integration of e-learning into their traditional teaching methods.
METHODS: A cross sectional study was conducted among faculties of Medicine and Dentistry using pre-tested questionnaires. The data was analyzed by using the statistical package for social science, SPSS, version 16.0.
RESULTS: The result of our survey indicates that majority of our faculty (65.4%) held positive opinion towards e-learning. Among the few, who demonstrated reservations, it is attributed to their average level of skills and aptitude in the use of computers that was statistically significant (p<0.05).
CONCLUSION: Our study brings to light the need for formal training as perquisite to support e-learning that enables smooth transition of the faculty from their traditional teaching methods into blended approach. Our results are anticipated to strengthen the existing e-learning activities of our college and other universities and convincingly adopt e-learning as a viable teaching and learning strategy.
Fulltext Teaching and learning in workplace: contemporary perspectives

Bhardwaj A, Nagandla K, Das Gupta E, Ibrahim S

Education in Medicine Journal, 2015;7(3):67-72.
MyJurnal

Workplace learning is essentially informal that is unstructured, unintended and opportunistic from educational view point. Recall of factual knowledge and applying skills is central in workplace so learning becomes meaningful and evidence based. To maximise their learning, the learners must take active participation in their own learning, set goals and march towards achieving these goals. The objective of the teacher at this juncture is obliging to the needs of the learners and of the patients. This review aims to address the teaching and learning theories that impact the workplace learning, factors influencing workplace based learning, identifying opportunities for learning to occur parallel with work and strategies that maximise successful workplace learning.
Fulltext Role of microRNAs as biomarkers of cervical carcinogenesis: a systematic review

Nagandla K, Lin KH, Chitra E, Jamli MFBM

Obstet Gynecol Sci, 2021 Sep;64(5):419-436.
PMID: 34384196 DOI: 10.5468/ogs.21123

We performed a systematic review to identify the role of microRNAs (miRNAs) as biomarkers in the progression of cervical precancerous lesions. A comprehensive search of the Cochrane Controlled Register of Trials, PubMed, ScienceDirect, and Embase databases was performed for articles published between January 2010 and June 2020. The following Medical Subject Headings (MeSH) terms were searched: "microRNA" and "cervical" and "lesion." All study designs that aimed to evaluate the correlation of miRNA expression with different precancerous cervical staging and/or cervical cancer were included, except for case reports and case series. Approximately 82 individual miRNAs were found to be significant in differentiating the stages of cervical carcinogenesis. Among the miRNAs, miR-21 is the most prevalent, and it is consistently upregulated progressively from normal cervical to worsening cervical lesion stages in both cell and serum samples. miR-205 has been shown to have a higher specificity than human papilloma virus testing in predicting the absence of high-grade squamous intraepithelial lesions (HSILs) in exfoliated cell samples. The tumor suppressor miRNAs miR-34, let-7, miR-203 miR-29, and miR-375 were significantly downregulated in low-grade squamous intraepithelial lesions, HSILs, and cervical cancer. We found significant dysregulated miRNAs in cervical carcinogenesis with their dynamic expression changes and ability to detect viral persistency, risk prediction of low-grade lesions (cervical intraepithelial neoplasia [CIN] 2) to high-grade lesions (CIN 3), and progression of CIN 3 to cancer. Their ability to discriminate HSILs from non-dysplastic lesions has potential implications in early diagnosis and reducing overtreatment of otherwise regressive early preinvasive lesions.
Fulltext Performance of medical students in final professional examination: Can in-course continuous assessments predict students at risk?

Nagandla K, Gupta ED, Motilal T, Teng CL, Gangadaran S

Natl Med J India, 2019 7 4;31(5):293-295.
PMID: 31267998 DOI: 10.4103/0970-258X.261197

Background: Assessment drives students' learning. It measures the level of students' understanding. We aimed to determine whether performance in continuous assessment can predict failure in the final professional examination results.
Methods: We retrieved the in-course continuous assessment (ICA) and final professional examination results of 3 cohorts of medical students (n = 245) from the examination unit of the International Medical University, Seremban, Malaysia. The ICA was 3 sets of composite marks derived from course works, which includes summative theory paper with short answer questions and 1 of the best answers. The clinical examination includes end-of-posting practical examination. These examinations are conducted every 6 months in semesters 6, 7 and 8; they are graded as pass/fail for each student. The final professional examination including modified essay questions (MEQs), 1 8-question objective structured practical examination (OSPE) and a 16-station objective structured clinical examination (OSCE), were graded as pass/fail. Failure in the continuous assessment that can predict failure in each component of the final professional examination was tested using chi-square test and presented as odds ratio (OR) with 95% confidence interval (CI).
Results: Failure in ICA in semesters 6-8 strongly predicts failure in MEQs, OSPE and OSCE of the final professional examination with OR of 3.8-14.3 (all analyses p< 0.001) and OR of 2.4-6.9 (p<0.05). However, the correlation was stronger with MEQs and OSPE compared to OSCE.
Conclusion: ICA with theory and clinical examination had a direct relationship with students' performance in the final examination and is a useful assessment tool.
Fulltext Recurrent haemorrhagic ovarian cyst and anticoagulant therapy: a case report with review of treatment modalities

Nagandla K, Jamli MFBM, Hanim F, Xu Mei JL, Din SFS

Pan Afr Med J, 2021;40:52.
PMID: 34795832 DOI: 10.11604/pamj.2021.40.52.30961

The common gynaecological causes of acute pelvic pain include ruptured ectopic pregnancy, haemorrhagic corpus luteal cyst or torsion of an ovarian cyst. Ovarian vascular accidents are reported in women on oral anticoagulation presenting as an acute pelvic pain. Although such vascular accidents with anticoagulation therapy are an unusual entity, a meticulous history, clinical examination, and laboratory workup to confirm the diagnosis and timely intervention is needed to reduce attending morbidity and mortality. However, a standard algorithm for management is not described in the literature. We hereby report successful management of recurrent hemorrhagic ovarian cyst due to coagulopathy in a woman with mechanical heart valves with timely surgical intervention. This case report discusses operative versus non operative management approach and may provide value addition to readers encountering such cases in their clinical practice.

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