Ernst W.W. Sonnendecker

Maternal-infant vitamin D relationships during breast-feeding

To evaluate the effect of maternal dietary vitamin D intake on infant vitamin D status in a country with a temperate climate, but where the commercial milk supply is not vitamin D fortified, this randomized, double-blind study was conducted on term mother-infant pairs during the winter months. Well-nourished, white nursing mothers were given a placebo, 500 IU vitamin D/day or 1,000 IU vitamin D/day; their infants were not given supplemental vitamin D. After six weeks, mothers receiving supplemental vitamin D had higher levels of 25-hydroxyvitamin D than had mothers receiving placebo. A direct relationship was observed between maternal and infant levels of 25-hydroxyvitamin D at six weeks, implying that maternal vitamin D intake directly affects the vitamin D concentration in breast milk. A control group of infants who had received 400 IU vitamin D/day had even higher concentrations of 25-hydroxyvitamin D, suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation. Despite the favorable climate in South Africa, during winter breast-fed infants have low serum vitamin D values if maternal dietary vitamin D intake is low.

A clinical comparison of sonographic hydrotubation and hysterosalpingography

Objective— To assess the value of vaginal sonographic hydrotubation as a pre‐liminary test of uterine configuration and tubal patency in infertility inves‐tigation, and to compare this new test with hysterosalpingography.

Splenectomy during primary maximal cytoreductive surgery for epithelial ovarian cancer

Six patients with epithelial ovarian cancer underwent splenectomy as part of their extensive primary cytoreductive surgical management at the Johannesburg University Hospital. These patients represented 7.6% (6 of 79) of advanced-disease patients (stages III and IV) followed during the study period. Five splenectomies were performed because of metastatic disease confirmed on microscopy. One of these showed parenchymal involvement and represented only the third case in the world literature. The remaining patient required splenectomy for capsular avulsion injury and resultant bleeding. Late thrombotic complications occurred in 4 of 6 (67%) patients, resulting in death of one patient from massive pulmonary embolism 20 days after surgery. Three patients (50%) currently have no evidence of disease 14, 25, and 32 months after surgery. The remaining 2 patients died of recurrent disease 19 and 58 months following primary operation. This, the largest reported series in the English literature, indicates that splenectomy, albeit potentially hazardous, is justified when it permits optimal cytoreductive surgery.

Cardiotocographic changes after external cephalic version

Summary. Cardiotocographic tracings before and after 53 attempts at external cephalic version (ECV) in 52 patients were analysed. Hexoprenaline (Ipradol) was used to facilitate ECV in 25 of the 53 attempts. There was a significant decrease in fetal movements and fetal heart rate (FHR) variability and reactivity after external cephalic version; temporary baseline bradycardia occurred in five patients. The most likely explanation for the changes observed is that they represent the fetal response to a period of stress caused by decreased uteroplacental blood flow during the procedure.

NOFSA Guideline for the Diagnosis and Management of Osteoporosis

This document is an update of the clinical guideline published by the National Osteoporosis Foundation of South Africa (NOFSA) in 2000, which aims to improve the overall efficacy of the diagnosis and management of patients with, or at risk for, osteoporosis. The guideline is not limited to any particular patient group and targets all health care workers. This is a detailed summary, which is cross-referenced to the full guideline and is available on the NOFSA (www.osteoporosis.org.za) and JEMDSA (www. jemdsa.co.za) websites.

Evaluation of preoperative investigations in patients admitted for ovarian primary cytoreductive surgery

Consistent with universally established practice, it has been customary in our unit to subject patients with clinically suspected or biopsy proven ovarian cancer to a large number of preoperative investigations. This is in order to determine metastases, surgical strategy, and exclusion of pelvic kidney. This study presents a comparison of the preoperative ultrasonography, computerized tomography, intravenous pyelography, chest X-ray, liver and bone scintigraphy, and barium enema results performed in 100 cases with the operative findings. These investigations were found to have marginal value in determining extent of disease, upper gastrointestinal metastatic deposits, and the need for or extent of bowel resection. It is concluded that such a standard workup, which is time-consuming and distressing for an already anxious patient, is not cost effective for a surgical procedure which is ultimately determined at laparotomy.

Is routine second-look laparotomy for ovarian cancer justified?

Thirty-nine patients with epithelial ovarian malignancy underwent second-look laparotomy (2LL), as part of their plan of management at the Johannesburg University Hospital. Twenty-eight patients (71.8%) were found to have no gross or microscopic evidence of disease. Only 1/12 (8.3%) of patients with initial Stage I disease had evidence of persistent disease and after a median follow-up of 53 months (range 29-77) after 2LL, the remaining 11 remain free of relapse. Second-look laparotomy is regarded as unjustified in this subgroup of patients. Twenty-nine percent of the patients with advanced disease (Stage III and IV) who were disease-free at 2LL subsequently developed recurrent disease and died. In this group 2 additional patients died of nonmalignant disease. All 3 of the patients with original Stage II disease were disease-free at 2LL, but subsequent recurrence developed in 1 patient. On the basis of the findings in this study and evidence in the literature, the practice of submitting patients who are in complete clinical remission to 2LL as part of their management plan is questioned and challenged.

Screening for liver metastases from ovarian cancer with serum carcinoembryonic antigen and radionuclide hepatic scintiphotography

The association between pre‐operative serum carcinoembryonic antigen (CEA) and liver scanning employing technetium (99mTc)‐tin colloid was investigated in 30 women subsequently proven to have primary epithelial ovarian carcinoma to determine whether these two investigations improve the detection of hepatic mtastases. The uer limit of normal for CEA (≥ 5 ng/ml) did not represent the optimal levels for use in predicting ovarian carcinoma nor the presence of liver metastases. But with CEA levels> 10 ng/ml sensitivity for liver metastases was 57%. Liver scanning alone demonstrated metastases in five out of seven patients (71%) with parenchymal liver metastases. The combination of CEA and liver scan was positive in six out of these seven patients (86%).

Pseudosinusoidal fetal heart rate patterns

The sinusoidal fetal heart rate (FHR) pattern was originally described as a regular fluctuation of the FHR with a frequency of 2-5 cycles/min usually occurring in the antepartum period in association with fetal anaemia and severe compromise (Kubli el al. 1972; Manseau el al. 1972). Confusion has arisen from the designation of the same term to certain fluctuating FHR patterns which occur during labour and bear a superficial resemblance to the true sinusoidal pattern but do not reflect the same pathophysiological events or significance. The commonest of these patterns is that frequently seen following administration of analgesics and is compatible with good fetal condition (Gray et al. 1978); it is usually distinguishable by the presence of fetal movements, retention of short-term variability or pointing of the peaks (Hofmeyr & Sonnendecker 1983a).

Characterirtics and management of intrapartum prolonged fetal bradycardia

Summary. Twenty‐five patients had intrapartum prolonfed fetal bradycardia, defined as a drop of the fetal heart rate (FHR) by ≥50 beats/min maintained for ≥3 min; 10 were deliverdd by caesarean rection and 15 vaginally. The only neonatal death occurred in thd group delivered abdominally. Statistical analysis showed no difference in amplitude or duration of deceleration in the two groups but the 1 and 5 min Apgar scores were higher in the group delivered vaginallx (P<0·01), wherdas the onset of deceleration to delivery interval was shorter in the group delivered by caesarean section (P<0·005). Appropriatd management of prolonged bradycardia is outlined and the characteristics of the FHR tracings ard identified that are of prognostic value in detdrmining whether or not immediatd delivery is indicated.