Introduction
Haematopoietic stem cell transplantation (HSCT) has emerged as an increasingly safe and effective therapeutic procedure, with origins tracing back to the early 1960s.

Today, HSCT is a crucial curative strategy for patients with haematological malignancies, such as leukaemia, lymphoma, multiple myeloma, myelodysplastic syndrome, myeloproliferative neoplasm, and for some non-malignant blood disorders such as acquired bone marrow failure syndrome.

Summary of Indications for Haematopoietic Stem Cell Transplantation

• Acute myeloid leukaemia
• Acute lymphoblastic leukaemia
• Chronic myeloid leukaemia in blast crisis
• Primary myelofibrosis with intermediate or high DIPSS score
• Myelodysplastic syndrome with excess blasts, high-risk multilineage dysplasia
• Chronic lymphocytic leukaemia with high-risk disease, Richter’s transformation
• Hodgkin’s lymphoma
• Non-Hodgkin’s lymphoma
• Multiple myeloma & primary amyloidosis
• Very severe aplastic anaemia

Types of HSCT

• Autologous HSCT (patient’s own stem cells)
• Allogeneic HSCT (stem cells from a donor)

         –   HLA-matched related donor (sibling)

         –   HLA-matched unrelated donor (local or overseas)

         –   HLA-mismatched related donor

         –   HLA-mismatched unrelated donor

         –   Syngeneic transplant (identical twin, non-identical twin)

         –   Haplo-identical donor (half HLA-matched, parents or children)

         –   Umbilical cord blood

Peripheral Blood Stem Cell (PBSC) Apheresis
Stem cell apheresis is a unique procedure that collects stem cells from peripheral blood using a cell separator called an apheresis machine. The process begins with mobilising haematopoietic stem cells (HSCs) from the bone marrow into the bloodstream, typically through a growth factor called granulocyte colony-stimulating factor (G-CSF). Once enough stem cells circulate in the blood, they are collected through the apheresis machine.

Stem cells are transferred to a collection bag, while the remaining blood components are returned to the body through a catheter. Each session typically lasts 4 to 8 hours, and the procedure may be performed over one to two days, depending on the amount of stem cells required. This non-surgical procedure is generally well-tolerated by both patients and donors.

Basic Principles of Haematopoietic Stem Cell Transplantation
Before the infusion of HSCs, patients receive a combination of drugs with or without total body irradiation (TBI) as a conditioning regimen. Conditioning eradicates residual disease, creates “empty space” within the bone marrow cavity, and suppresses the immune system. Following the conditioning, HSCs are infused into the patient, migrating to the bone marrow to produce new blood cells. HSCs can regenerate blood components and reconstitute the immune system of patients whose bone marrow has been compromised due to disease or high-dose chemotherapy. Successful integration of transplanted cells is monitored, leading to the recovery of haematopoiesis and healthy bone marrow function.

Advantages and Risks of PBSC HSCT
Compared to traditional bone marrow transplantation (BMT), PBSC HSCT offers faster blood cell count recovery and a lower incidence of complications. Studies indicate that patients undergoing PBSC HSCT experience quicker haematopoietic recovery, resulting in shorter hospital stays. Additionally, PBSC use has become more common due to its availability and the relative ease of collection compared to bone marrow.

Despite its benefits, PBSC HSCT carries risks. Patients may encounter complications such as infections and organ dysfunction, particularly in the early post-transplant period. One significant complication of allogeneic HSCT is graft-versus-host disease (GVHD), where the donor’s immune cells (the graft) attack the recipient’s tissues, recognising them as foreign. Infections are another primary cause of morbidity and mortality, as the conditioning regimen and procedure significantly weaken the patient’s immune system, increasing susceptibility to bacterial, fungal, and viral infections. Managing these risks requires vigilance, effective prophylaxis, and timely treatment.

Conclusion
While HSCT can be a life-saving treatment, it also entails substantial risks, particularly with infection and graft-versus-host disease in allogeneic transplants. Careful patient selection, optimised conditioning protocols, effective anti-GVHD strategies, and robust anti-infective measures are critical for improving outcomes. Through these advancements, HSCT continues to offer hope for patients with otherwise incurable blood disorders, providing the potential for long-term remission and enhanced quality of life.

All images courtesy of LohGuanLye Specialists Centre

Dr. Teoh Ching Soon is the Clinical Haematologist & Physician in LohGuanLye Specialists Centre. He has a keen interest in the management of malignant haematological disorders such as leukaemia, lymphoma, multiple myeloma, myelodysplastic syndrome and myeloproliferative neoplasm. His clinical work also focuses on benign haematological diseases, red cell and platelet disorders, coagulation and haemostasis, consultative haematology and haematopoeitic stem cell transplantation.

by Dr. Tan Hoo Seong
Consultant Obstetrician & Gynaecologist

Perineal Lacerations
Each year, between 130 to 150 million babies are born worldwide. Many new mothers experience a tear in the area between their vagina and anus (called the perineum) during delivery. This can affect their physical, emotional, and mental well-being. It can also impact healthcare systems, as treating these injuries can be costly.

In Malaysia, these types of injuries are often not well-reported or managed, mainly due to a lack of awareness and guidelines among healthcare providers and mothers. This article aims to shed light on the issue and encourage better care for new mothers.

Overview
What is a vaginal tear?
A vaginal tear occurs during childbirth. Also called a perineal laceration, it is a tear in the tissue (skin and muscle) around the vagina and perineum. The perineum is the area between the vaginal opening and the anus.

During vaginal delivery, the skin of the vagina prepares for childbirth by allowing the skin around your vagina to stretch. While the vagina is designed to stretch to allow the baby’s head and body to pass through, it is very common for it to tear. Up to 90% of people who give birth experience some degree of tearing. Treatment for vaginal tears depends on their severity.

What are the four types of perineal lacerations?
There are four levels (or degrees) of vaginal tears, based on how deep the tear is:
Normal Anatomy

---

First-degree tear
The least severe type of tear, this small injury affects only the first layer of skin around the vagina and perineal area. It usually doesn’t require stitches, or only a few simple ones.
First-degree tear

---

Second-degree tear
This is the most common type of tear. It extends deeper through the skin into the underlying muscles of the vagina and perineum. This type of tear requires stitches.
Second-degree tear

---

Third-degree tear
A third-degree tear extends from the vagina to the anus. It affects the skin and muscles of the perineal area and causes damage to the anal sphincter muscles, which control bowel movements. Stitches are required for this type of tear.
Third-degree tear

---

Fourth-degree tear
This is the most severe and least common type of tear. It extends from the vagina, through the perineal area, the anal sphincter muscles, and into the rectum. Repairing a fourth-degree tear may require a procedure in the operating room rather than in the delivery room.
Fourth-degree tear

Second-degree tears are the most common type. They affect both the first layer of skin and some of the underlying muscles in the perineal area. In contrast, third- and fourth-degree tears are much less common, occurring in only about 5% of deliveries.

Who is more likely to tear during childbirth?
Certain factors can increase the risk of tearing during childbirth, including:

• First-time delivery
• Having a large baby (more than 3.5 kg)
• Use of forceps or vacuum during delivery
• Prolonged second stage of labor (pushing stage)
• Baby’s face-up position (malposition) during delivery
• Use of an epidural

It’s advisable to discuss potential risk factors for vaginal tearing with your healthcare provider.

What are the potential complications of vaginal tears?
While vaginal tears can be uncomfortable and painful, most small tears heal within two weeks. Discomfort may last a month or two for larger tears. Third- and fourth-degree tears are more severe and come with additional complications, such as:

• Infection
• Bleeding
• Painful intercourse
• Faecal incontinence
• Persistent pain and soreness

Can you feel yourself tear during birth?
Every birth experience is different, so there is no definitive answer. If you had an epidural or other pain relief during delivery, you likely won’t feel the tear or know how severe it is until your provider informs you. Even without pain medication, you may not feel a vaginal tear.

Management and Treatment
How are vaginal tears treated or repaired?

• First-degree tear: You may not need stitches, or only a few simple ones.
• Second-, third-, and fourth-degree tears: Stitches will be required to repair the tear. These stitches dissolve on their own within six weeks. 

All images courtesy of LohGuanLye Specialists Centre