David M. Hay

Gastric emptying time in late pregnancy and labour.

Gastric emptying was measured in non‐pregnant, pregnant and labouring women.

UTERUS UNICOLLIS AND ITS RELATIONSHIP TO PREGNANCY

I WOULD first like to thank the President and Council of the College for honouring me in the award of this Memorial Lectureship to the late Professor Blair Bell. This distinction for the year 1960 is obviously unique since this lecture will be one of the first Blair Bell lectures to be delivered in this new college-building, a college which is the ultimate expression of Blair Bell’s aspirations. I am, therefore, the more deeply conscious of the significance of this lecture. Uterine abnormalities and particularly their aetiology was one of the many subjects in which Blair Bell was interested. His writings have material is based on the hysterographic evidence of 295 cases of uterine abnormality and of 121 cases whose interior uterine contour I have come to regard as normal for the human uterus. These latter cases make an important comparative study. The histories of a further 90 cases whose hysterograms I have extracted from the hospital files will be referred to. In all, therefore, we shall be considering the obstetrical and in some cases the gynaecological histories of some 500 cases, the interior shape of whose uteri has been proved by hysterography. From consideration of these many cases I hope:

THE DIAGNOSIS AND SIGNIFICANCE OF MINOR DEGREES OF UTERINE ABNORMALITY IN RELATION TO PREGNANCY

I N this paper are presented 65 cases of uterine abnormality found in association with pregnancy during an investigation carried out over a period of eighteen months from July, 1954, until December, 1955. The cases were confirmed by hysterography and the skiagrams are presented. A further 28 cases were diagnosed but not confirmed radiologically and yet a further 107 cases are referred to in the text. The probable incidence of the condition appears to be in the neighbourhood of 1.0 per cent. This contrasts with the previously reported probable incidence of 1 in 78 cases (Way, 1947); 155 cases of “arcuate uterus” in 7,553 deliveries (Falls, 1939); 1 in 1,500 cases (Smith, 1931); 62 in 60,788 cases (Fenton and Singh, 1952). It is possible that the incidence is even higher than suggested, as it is proved in the text of this paper that the majority of women with uterine abnormalities go through pregnancy and labour quite normally, unless some accident in the course of either draws the attention of the obstetrician to the abnormality. In the past, most cases of the condition have been diagnosed accidentally in this manner and a false association between the incidence of the condition and its related dangers to mother and baby has therefore been formed. It is intended to present and prove certain diagnostic criteria by which the condition can be more easily recognized. In the literature there is a singular lack of emphasis on this aspect of the subject. The aetiology of abnormalities of the uterus due to anomalies in development or fusion of the Miillerian duct system will not be dealt with in this paper. The embryology and comparative anatomy of their origin has already been well recorded by Jarcho (1946), to whose classic paper the reader is referred. Jarcho’s classification of uterine abnormalities will be used in this article as it appears to be the simplest and yet the most truly representative of the condition as found in this investigation.

OBSERVATIONS ON BREECH PRESENTATION AND DELIVERY

THIS paper represents a four-years study of 218 single breech deliveries at St. David’s Hospital. The corrected foetal loss was two stillbirths, both in parous patients, in babies weighing 3 pounds 10 ounces and over in a corrected series of 165 cases-an incidence of I .2 per cent. Six cases of prolapse of the cord are included. The Caesarean section rate was 16 per cent. Eighty per cent of the cases (92 per cent in the corrected series) were booked cases in that they attended the antenatal clinics in the area. The period chosen, from 1st April, 1954 till 31st March, 1958, represents the official life span of the writer in his capacity of Senior Registrar at the hospital. It also represents the first period in his training, during which he had a long enough interval to devote to a subject which, to him, has always been of primary interest. During the period he was privileged to act as a member of a team representing the obstetric unit of the St. David’s Hospital. The results represent the co-operative participation of all members of the team from the Senior Consultant to the most junior midwife on duty, with the active co-operation of the General Practitioners and District Midwives in the area, in a system which advocates: (1) Reference to and delivery of all breech presentations in hospital. (2) Careful prenatal assessment of cases. (3) Expectant supervision of all cases in labour. (4) Experienced obstetrical supervision of all breech deliveries. (5) The teaching of house-surgeons and the application in practice of the principle that a knowledge of various methods for the delivery of the arms and after-coming head is safer than the knowledge of one method only carried out as a routine. (6) Insistence on at least two members of the resident staff and, if possible, a paediatrician being called and attending each breech delivery. (7) The delivery of the baby being carried out as quickly as possible consistent with the avoidance of traumatic injury to the foetus and mother, as soon as the buttocks have been delivered by the mother’s effort. (8) The employment of a wide episiotomy. (9) Readiness to carry out Caesarean section on : (a) Babies above 74 pounds if there is any doubt about the pelvic-foetal relationship but believing in and practising “trial labour”. (6) Labours exhibiting inco-ordinate uterine action. Cox (1950) states that 3 to 5 per cent corrected foetal loss should be a good result for any teaching hospital in view of the varying medical personnel that has to be instructed in the art of breech delivery. That this need not be so is illustrated by the St. David’s figures. Seventy-six per cent of the vaginal breech deliveries at the hospital were carried out by a changing resident obstetrical and gynaecological staff of two Senior House Officers and one (usually preregistration) House Surgeon. Although it is advocated that all breech deliveries by the junior staff should be attended by a more senior member of the staff this obviously has not been always possible in practice because of other duties and maintenance

Myasthenia Gravis and Pregnancy

MYASTHENIA gravis is rare in association with pregnancy and the incidence of 1 in approximately 20,000 pregnancies obtained from the records of the Scottish teaching centres is probably a universal average. The incidence of the disease appears to be increasing in recent years because more cases are reported under treatment, but this is not due to a real increase in the number of cases but rather to an increasing awareness of the condition (Osserman, 1961). As the decade of most frequent onset of the disease is 20 to 30 years and the sex incidence is two females to one male it is likely that myasthenic women will come under the care of obstetricians. Guidance as to the management of such patients in pregnancy is lacking in most standard British textbooks and false information may be found-“The effect of pregnancy on the symptoms is variable but in the majority of patients there is improvement. The course of labour is not interferred with and the baby is never affected” (Browne and Browne, 1963).

Shirodkar suture: A review of 10 years' experience

Abstract The outcome of 103 Shirodkar sutures was studied. The results were analyzed in 3 groups according to the criteria for insertion of the suture. Highly significant successes were obtained in each group and in the whole series. The operation is safe for mother and fetus provided no contraindication exists.

Postgranulomatous epidermoid carcinoma of the vulva

Abstract Clinical details and tumor histology from 34 patients who were treated for postgranulomatous epidermoid carcinoma of the vulva at the University Hospital, Kingston, Jamaica, between 1953 and 1968 were studied. Differences in important clinical features are presented. Carcinoma in situ was found also in more than half of those patients whose operation specimens were submitted to further histologic study. The importance of this finding is discussed. Reappraisal of current treatment is suggested and surgical management of the chronic lesions of granulomatous disease of the vulva is advocated.

A study of the obstetric performance of the adolescent Jamaican primigravida

Obstetrical outcome of a series of 226 primigravid Jamaican teenagers, less than 16 years old, was evaluated. All of the study subjects delivered at the University Hospital, Kingston, Jamaica, and their obstetrical outcomes were compared with the outcomes of older primigravidas delivering at the same institution. Incidence of preeclampsia was lower among the teenagers (8.4%) vs. older patients (9.8%). Incidence of antepartum hemorrhage was .9% in the teenage group vs. 3% among the older women. Spontaneous premature rupture also occurred less frequently among the teenagers (1.8%) vs. the older women (2.4%). 15.5% of older women suffered from anemia and so did the same percentage of teenagers. Postpartum hemorrhage had a higher incidence among the teenagers (12.8%) compared with the older women (9.3%). A low operative delivery rate was associated with a low incidence of fetal distress and babies with good Apgar scores among the teenagers. This overall good obstetrical performance is attributed to better antenatal care among the teenage mothers.