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  1. 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
  2. Kalok A, Sharip S, Abdul Hafizz AM, Zainuddin ZM, Shafiee MN
    PMID: 33212969 DOI: 10.3390/ijerph17228522
    The COVID-19 pandemic has resulted in a Movement Control Order (MCO) in Malaysia and the subsequent closure of all educational institutions. We aimed to examine the psychological impact of the MCO among clinical undergraduates. A cross-sectional study was conducted using self-reported questionnaires that were distributed online using the Depression, Anxiety and Stress Scale-21 (DASS 21), Short Warwick Edinburgh Mental Well-Being Scale (SWEMWBS), and the newly designed MCO effect questionnaire. Seven hundred seventy-two students completed the survey. The prevalence of psychological distress was 52.8%, with around 60% of respondents reporting disruption to their daily lives. Older (p = 0.015) and more senior students (p < 0.001) were less likely to be anxious than their younger and junior counterparts, respectively. A greater number of social support (three or more) was linked to a lower score of depression (p = 0.005) and stress (p = 0.045). Undergraduates who received family support demonstrated lower depression scores (p = 0.037) and higher mental wellbeing (p = 0.020) compared to those without. Government support was independently associated with a lesser risk of depressive symptoms (Adjusted odds ratio, AOR 0.68; 95% confidence interval, CI 0.47-0.99) and a greater sense of mental wellbeing (AOR 1.54; 95% CI 1.06-2.22). The present finding provides evidence of a high prevalence of psychological distress among clinical undergraduates during the COVID-19 pandemic. Appropriate social support is important in alleviating anxiety and stress and promoting greater mental wellbeing amongst students during the nationwide quarantine.
  3. Hatim H, Zainuddin AA, Anizah A, Kalok A, Daud TIM, Ismail A, et al.
    J Pediatr Adolesc Gynecol, 2021 Apr;34(2):161-167.
    PMID: 33189898 DOI: 10.1016/j.jpag.2020.11.009
    STUDY OBJECTIVE: To explore the effect of the diagnosis of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome on affected Malaysian women.

    DESIGN: Qualitative study with a quantitative component.

    SETTING: Pediatric and adolescent gynecology unit at Universiti Kebangsaan Malaysia Medical Centre, Malaysia.

    PARTICIPANTS: Twelve women with MRKH.

    INTERVENTIONS: Face-to-face interview and short questionnaire.

    MAIN OUTCOME MEASURES: Thematic analysis was used to understand participants' experiences.

    RESULTS: There were 7 themes identified: (1) delayed diagnoses; (2) doctors' roles and attitudes; (3) gender identity; (4) family and society's response; (5) reaction toward infertility; (6) managing sexual intimacy; and (7) coping mechanisms. Several participants consulted their physicians regarding their primary amenorrhea at an opportunistic setting. When they were referred to the gynecologists, they were dismayed at the lack of information given. The term, "MRKH" plays an important role to ease information-seeking. Participants felt that the doctors were insensitive toward them. Mental illness is a significant complication of MRKH. All participants acknowledged that infertility was the hardest part of the condition. The importance of blood lineage affects their outlook on childbearing options. Some were afraid of sexual intimacy and worried that they would not be able to satisfy their partners. Participants gained support and bonded with their counterparts in the MRKH support group.

    CONCLUSION: A multidisciplinary approach including medical, psychological, and social support is essential for the management of MRKH. Adequate information and sexual education plays the utmost importance in preventing social-related complications of MRKH.

  4. Syed Anwar Aly SA, Abdul Rahman R, Sharip S, Shah SA, Abdullah Mahdy Z, Kalok A
    Int J Environ Res Public Health, 2021 May 27;18(11).
    PMID: 34072017 DOI: 10.3390/ijerph18115762
    Pregnant women are susceptible to COVID-19 complications due to gestation-related physiological changes. We aimed to evaluate the level of maternal knowledge, perception, and practice during the pandemic. A cross-sectional study was conducted during the Malaysian Movement Control Order (MCO) between April and June 2020. A self-administered electronic questionnaire that included the knowledge and practice domains was distributed. A newly designed set of questions was used to evaluate (1) women's perception of MCO and (2) maternal experience, which was subdivided into clinical care provision and maternal anxiety. The survey response rate was 93% with the final number for analysis of 415. The majority of women (95%) demonstrated an adequate level of knowledge on COVID-19, whilst 99% had a good practice. We found that tertiary education (p < 0.001), employment status (p = 0.03), higher household income (p < 0.001), and multiple sources of information (p < 0.001) were independent predictors of adequate maternal knowledge on COVID-19. Women with adequate knowledge also reported a more positive perception of MCO (p < 0.001) and better obstetric care experience (p = 0.037), as did those of Malay ethnicity. Younger (p < 0.001) and nulliparous (p = 0.01) women demonstrated greater anxiety levels. The majority of our women reported good practice and adequate knowledge, which contributed to a positive perception of MCO and better maternal obstetric experience. First-time mothers may benefit from extra support and reassurance during the pandemic to alleviate maternal anxiety.
  5. Dasrilsyah RA, Kalok A, Ng BK, Ali A, Teik Chew K, Lim PS
    J Obstet Gynaecol, 2021 Feb;41(2):242-247.
    PMID: 32530340 DOI: 10.1080/01443615.2020.1740917
    This was a prospective randomised controlled trial comparing the effects of first-degree perineal tear repair using adhesive glue versus conventional suturing in terms of pain score, wound complication and patient's satisfaction. One hundred and twenty one women were randomised. The skin adhesive group had a significantly lower pain score at rest as well as during sitting, walking and micturition during the first week of delivery compared to the suture group. The time taken to become pain free was significantly shorter in the tissue adhesive group (3.18 vs. 8.65 days, p < .001). Only two patients who had skin glue experienced wound gaping. No significant difference was observed in the level of satisfaction between the adhesive and suture groups. Tissue adhesive is better than subcuticular suture for repairing first-degree perineal tear as it causes less pain and has shorter recovery time.Impact statementWhat is already known on this subject. First- and second-degree tears following vaginal delivery are common and involved a third of women. Suturing of these tears is advocated to avoid wound gaping and poor healing.What the results of this study add. For first-degree tear repair, tissue adhesive is better than conventional suture in terms of pain reduction and recovery time.What the implications are of these findings for clinical practice and/or further research. Skin adhesive is an ideal method for first-degree perineal tear repair especially in out of hospital settings such as home birth or midwifery-led centre. A larger scale study is needed to establish its feasibility for second- and third-degree tears repair.
  6. Arsad N, Abd Razak N, Omar MH, Shafiee MN, Kalok A, Cheah FC, et al.
    PMID: 35564596 DOI: 10.3390/ijerph19095201
    This exploratory study aimed to evaluate the effects of antenatal corticosteroids in singleton pregnancies of Asian women prior to elective cesarean section (CS) at early term on neonatal respiratory outcomes.

    METHODS: This is a pilot and pragmatic randomized trial conducted at a university hospital in Malaysia. Women with singleton pregnancies planned for elective CS between 37+0 and 38+6 weeks gestation were randomly allocated into the intervention group, where they received two doses of IM dexamethasone 12 mg of 12 h apart, 24 h prior to surgery OR into the standard care, control group, and both groups received the normal routine antenatal care. The primary outcome measures were neonatal respiratory illnesses, NICU admission and length of stay.

    RESULTS: A total of 189 patients were recruited, 93 women in the intervention group and 96 as controls. Between the steroid and control groups, the mean gestation at CS was similar, 266.1 ± 3.2 days (38 weeks) vs. 265.8 ± 4.0 days (37+6 weeks), p = 0.53. The mean birthweight of infants was 3.06 ± 0.41 kg vs. 3.04 ± 0.37 kg, p = 0.71. Infants with respiratory morbidities were primarily due to transient tachypnea of newborn (9.7% vs. 6.3%), and congenital pneumonia (1.1% vs. 3.1%) but none had respiratory distress syndrome. Only four infants required NICU admission (2.2% vs. 3.1%, p = 0.63). Their average length of stay was not statistically different; 3.5 ± 2.1 days vs. 5.7 ± 1.5 days, p = 0.27.

    CONCLUSIONS: Elective CS at early term before 39 weeks was associated with a modest overall incidence of neonatal respiratory illness (10.1%) in this Asian population. Antenatal dexamethasone did not diminish infants needing respiratory support, NICU admission and length of stay.

  7. Kalok A, Loh SYE, Chew KT, Abdul Aziz NH, Shah SA, Ahmad S, et al.
    Vaccine, 2020 02 24;38(9):2183-2189.
    PMID: 32001070 DOI: 10.1016/j.vaccine.2020.01.043
    BACKGROUND: Vaccine hesitancy is a complex behaviour which involves various degrees of indecision about specific vaccines or vaccination uptake. Access to antenatal care had been associated with positive vaccine behavior.

    OBJECTIVE: To determine the prevalence of vaccine hesitancy towards childhood immunisation amongst urban pregnant mothers and the associated socio-demographic factors.

    METHODS: A cross-sectional study was conducted among 1081 women who received antenatal care at a teaching hospital in Kuala Lumpur. Vaccine hesitancy was assessed using the Parent Attitudes about Childhood Vaccines (PACV) Survey in both English and validated Malay versions. The sociodemographic data of the mothers and their partners, source of vaccine information and reasons for hesitancy were analysed.

    RESULTS: Eighty-six (8.0%) pregnant mothers were vaccine hesitant. Ethnicity, religion, number of children, educational level and employment status were significantly associated with vaccine hesitancy. Multivariable analysis showed that a low level of education was the most significant risk factor (p 

  8. Kalok A, Zabil SA, Jamil MA, Lim PS, Shafiee MN, Kampan N, et al.
    J Obstet Gynaecol, 2018 Apr;38(3):339-343.
    PMID: 29017359 DOI: 10.1080/01443615.2017.1355896
    This was a prospective observational study to determine the predictive factors for a successful vaginal birth after caesarean section (VBAC) and to develop a relevant antenatal scoring system. Patients with one previous caesarean section were included in this study. All data including maternal demographics, obstetric history, pregnancy progress and outcomes were collected and analysed. A total of 142 out of the 186 women (76.3%) had successful VBAC. History of previous vaginal delivery and non-recurrent indications for previous caesarean section were the significant predictive factors for a successful VBAC. Five variables for our scoring tool were selected. By using a proposed mean score of 4 out of 7, the scoring system had a sensitivity of 81.0%, specificity of 52.3% and a positive predictive value of 84.6%. VBAC antenatal scoring system was potentially a useful predictive tool in antenatal counselling. Impact statement What is already known on this subject: Planned vaginal birth after caesarean section (VBAC) is an important strategy to limit the overall caesarean section rate, which is related to maternal morbidities. However, trial of vaginal delivery does involve potential complications including scar dehiscence, postpartum haemorrhage and emergency hysterectomy. What the results of this study add: Clinical predictors of a successful VBAC include non-recurrent indications for the previous caesarean section, previous vaginal delivery, spontaneous onset of labour and birthweight less than 4kg. There were multiple screening tools developed to predict the likelihood of successful VBAC. These scoring systems involved various variables such as age, ethnicity, Bishop's score and previous caesarean indication. We had prospectively developed an antenatal scoring system based on five variables. Our result showed that patient with a score of four and above will have around 85% chance of successful VBAC. What the implications are of these findings for clinical practice and/or further research: We have also found that, estimated foetal weight based on ultrasound scan is a potential predictor for successful VBAC. This simple scoring method will be useful in-patient counselling regarding mode of delivery after one previous caesarean section. A multicentre study involving large cohort of patients is ideal to validate our scoring system.
  9. Kalok A, Razak Dali W, Sharip S, Abdullah B, Kamarudin M, Dasrilsyah RA, et al.
    Front Public Health, 2023;11:1092724.
    PMID: 36908400 DOI: 10.3389/fpubh.2023.1092724
    INTRODUCTION: The coronavirus disease 2019 (COVID-19) caused a global pandemic that resulted in devastating health, economic and social disruption. Pregnant mothers are susceptible to COVID-19 complications due to physiological and immunity changes in pregnancy. We aimed to assess the maternal vaccine acceptance of the COVID-19 vaccine.

    METHODS: A multi-center study across four teaching hospitals in the Klang Valley, Malaysia was conducted between September 2021 and May 2022. A survey was conducted using a self-administered electronic questionnaire. The survey instruments included; (1) maternal perception and attitude toward COVID-19 vaccination, (2) COVID-19 pregnancy-related anxiety, and 3) generalized anxiety disorder.

    RESULTS: The response rate was 96.6%, with a final number for analysis of 1,272. The majority of our women were Malays (89.5%), with a mean age (standard deviation, SD) of 32.2 (4.6). The maternal vaccine acceptance in our study was 77.1%. Household income (p < 0.001), employment status (p = 0.011), and health sector worker (p = 0.001) were independent predictors of maternal willingness to be vaccinated. COVID-19 infection to self or among social contact and greater COVID-19 pregnancy-related anxiety were associated with increased odds of accepting the SARS-CoV-2 vaccine. Women who rely on the internet and social media as a source of vaccine information were more likely to be receptive to vaccination (adjusted odd ratio, AOR 1.63; 95% CI 1.14-2.33). Strong correlations were observed between maternal vaccine acceptance and the positive perception of (1) vaccine information (p < 0.001), (2) protective effects of vaccine (p < 0.001), and (3) getting vaccinated as a societal responsibility (p < 0.001).

    DISCUSSION: The high maternal vaccine acceptance rate among urban pregnant women in Malaysia is most likely related to their high socio-economic status. Responsible use of the internet and social media, alongside appropriate counseling by health professionals, is essential in reducing vaccine hesitancy among pregnant women.

  10. Kalok A, Ong MY, Hasrori A, Chiang KS, Yazim F, Baharuddin S, et al.
    PMID: 32987806 DOI: 10.3390/ijerph17196990
    Gestational diabetes mellitus (GDM) is associated with maternal and neonatal complications. We aimed to evaluate the relationship between the abnormalities of the oral glucose tolerance test (OGTT) and adverse pregnancy outcomes. This was a retrospective study of GDM patients over a five-year period in a Malaysian tertiary center. The diagnosis of GDM was based on the National Institute for Health and Care Excellence (NICE) guideline. The data on patients' demographics, OGTT results, GDM treatment, and pregnancy outcomes were analyzed. A total of 1105 women were included in the final analysis. The percentage of women with isolated abnormal fasting glucose, isolated two-hour abnormality, and both abnormal values were 4.8%, 87.1%, and 8.1%, respectively. Women with both OGTT abnormalities had a higher risk of preeclampsia (odds ratio (OR) 4.73; 95% confidence interval (CI) 1.45-15.41) and neonatal hypoglycemia (OR 8.78; 95% CI 1.93-39.88). Isolated postprandial abnormality was associated with an 80% lesser risk of neonatal hypoglycemia (OR 0.19; 95% CI 0.04-0.87). Both isolated fasting and multiple OGTT abnormalities were associated with insulin therapy. Multiple OGTT abnormalities were a positive predictor of adverse pregnancy outcomes, while isolated postprandial abnormality was associated with a lesser risk of neonatal complication. Further prospective study is essential to validate these findings.
  11. Indirayani I, Kalok A, Nik Ismail NA, Shah SA, Lim PS, Mohamed Ismail NA, et al.
    J Obstet Gynaecol Res, 2018 Aug;44(8):1458-1465.
    PMID: 29845672 DOI: 10.1111/jog.13686
    AIM: Sodium pentosan polysulfate (Na-PPS) is a plant-based agent that has similar action with low-molecular-weight heparin. It inhibits factor Xa, preventing blood clot formation. To date, its use in clinical practice as thromboprophylaxis agent is still limited. In addition, the efficacy and safety profile of this agent was not robustly reported globally, especially for countries with major Muslim population. We hypothesized that Na-PPS was equally effective as the standard thromboprophylaxis. We aim to compare the efficacy and safety of Na-PPS against standard agent (fondaparinux or enoxaparin).

    METHODS: This was a randomized control, open-label trial. Women underwent major gynecological surgery were randomized to receive either subcutaneous 50 mg of Na-PPS twice daily or subcutaneous enoxaparin 40 mg once daily. Fondaparinux 2.5 mg once daily was given to Muslim women as an alternative to enoxaparin. The treatment was started 6 h postoperatively, for at least 3 days. All the patients received thromboembolic deterrent stockings. The primary efficacy outcome was venous thromboembolism up to 3 days postsurgery. The main safety outcomes were minor and major bleeding.

    RESULTS: Among 109 participants, there was no incidence of venous thromboembolism. None of the women developed major bleeding. Minor bleeding was observed in 28.3% (15/53) and 5.4% (3/56) of Na-PPS and standard thromboprophylaxis group, respectively (P = 0.001).

    CONCLUSION: Na-PPS was associated with increased risk of minor bleeding. There was insufficient data to conclude its efficacy as thromboprophylaxis. Further research is needed to evaluate Na-PPS safety as a standard thromboprophylactic agent.

  12. Mohd Nafiah NA, Chieng WK, Zainuddin AA, Chew KT, Kalok A, Abu MA, et al.
    Int J Environ Res Public Health, 2022 Sep 01;19(17).
    PMID: 36078602 DOI: 10.3390/ijerph191710886
    Hyperemesis gravidarum is characterized by severe nausea and vomiting. This study aims to illustrate the efficacy of acupressure at P6 in treating nausea and vomiting in hyperemesis gravidarum. This parallel randomized controlled trial was conducted from 2016-2017 in a tertiary hospital. Hospitalized women with ≤16 weeks of gestation and moderate to severe nausea and vomiting classified using a modified PUQE score were randomly assigned in a 1:1 ratio to either apply an acupressure wristband at the P6 point three times daily or to receive regular doses of intravenous antiemetics. The primary outcome was differences in modified PUQE scores among the groups. The secondary outcomes were differences in the rate of urine ketone clearance and the frequency of requiring rescue antiemetics. Ninety women were equally randomized into two groups, with no dropout. There was a statistically significant difference in the degrees of nausea and vomiting between the groups at 8, 16, and 24 hours post-admission (p8hours= 0.001, p16hours = 0.006, and p24hours = 0.001). The requirement of antiemetics and the rate of urine ketone clearance between the two groups were also statistically significant, at p = 0.001 and p = 0.02 respectively. There were no side effects in either group. The P6 acupressure was efficacious in alleviating nausea and vomiting among hyperemesis gravidarum women. The trial was retrospectively registered on ClinicalTrials.gov (NCT05175079).
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