H. Gordon

Twin pregnancy complicated by single intrauterine death. Problems and outcome with conservative management

Summary. During an 11‐year period we encountered 16 pregnancies in which one twin died in utero and the pregnancy continued. Eight of these twin pregnancies were monochorionic. None of the women developed severe disseminated intravascular coagulation. The fetal outcome indicates that the prognosis for a surviving dichorionic twin is relatively good, with immaturity the main hazard. By contrast the surviving monochorionic twin has a poor prognosis with a high frequency of neurological damage. This damage is not related to intrapartum or neonatal problems and at present cannot be diagnosed before birth. There is no evidence that birth of the surviving twin by caesarean section will improve the prognosis. Early diagnosis of monochorionic twins and subsequent ultrasound follow up should identify fetal growth discrepancy and possible twin to twin transfusion requiring early delivery.

Management of female genital mutilation : the Northwick Park Hospital experience

Objective To outline the problems associated with female genital mutilation and to highlight the need for deinfibulation before delivery.

PERINEAL MUSCLE FUNCTION AFTER CHILDBIRTH

Perineal muscle function was measured in a group of European women 1 year after childbirth by means of a perineometer. There was no correlation between the degree of perineal trauma and subsequent muscle function. The efficiency of the perineal muscles was found to be significantly related to the extent to which women took regular exercise.

Primary aldosteronism in pregnancy — Should it be treated surgically ?

We report a case of primary aldosteronism in pregnancy that was treated surgically by removal of the adenoma in the 2nd trimester. Only a few cases have been reported in the English literature due to the rarity of the condition. Primary aldosteronism follows a variable course in pregnancy. In the majority of cases the hypertension and hypokalaemia are made worse, necessitating antihypertensive medication to control the blood pressure. Some of the drugs required for treatment are known to affect the fetus. In a minority of cases the hypertension improves with pregnancy. This is thought to to be due to the high levels of progesterone which is an aldosterone antagonist. Primary aldosteronism invariably gets worse in the post partum period, irrespective of the ante natal course of the disease. Surgery seems to be the treatment of choice for this condition, provided the adenoma is localised. It has the advantage of offering an immediate solution, avoids fetal complications of medical treatment and possible deterioration in the post partum period.

Pregnancy outcome following large loop excision of the transformation zone

SummaryThis retrospective study reviews the outcome of subsequent pregnancy following large loop excision at the transformation zone (LLETZ) for the treatment of cervical intra-epithelial neoplasia. Twenty-six pregnancies in 24 patients were reviewed. The results suggest that LLETZ has no effect on subsequent fetal loss, preterm delivery and operative delivery rates nor labour length. Larger prospective studies are required to properly assess the effects of this procedure on pregnancy and fertility.

Transmission of the maternal electrocardiograph via a fetal scalp electrode in the presence of intrauterine death. Case report

A 35-year-old Nigerian patient, para 3+ 1, booked for confinement at 26 weeks gestation. The only abnormality noted on examination was a loud, late systolic murmur. Referral for cardiological opinion resulted in a diagnosis of ‘floppy valve syndrome’ and mild mitral incompetence. There was no evidence of cardiac failure and antibiotic cover for labour was advised. Routine booking investigations were normal. The antenatal course was normal until 33 weeks, when the patient was admitted to hospital after the confirmation of spontaneous rupture of the membranes. Fetal movements were occurring normally and the fetal heart was heard (and recorded). She was managed conservatively and put t o bed. Twenty-four hours after admission clear amniotic fluid continued to drain, and a small blood clot was passed vaginally. The uterus remained non-tender and non-contractile, and the cardiotocograph was satisfactory. Clear fluid continued to drain intermittently and 4 days after admission regular, uterine contractions occurred associated with slight fresh vaginal bleeding. The patient remained apyrexial and blood pressure was 110/70 mmHg but the maternal pulse had risen to a sinus tachycardia of 120 beatdmin. The uterus was soft and nontender between contractions. The mother thought the fetus had been less active for the previous 2 h, and the fetal heart was inaudible with a Pinard stethoscope and a Sonicaid. At vaginal examination the cervix was partially effaced and 4 cm dilated. The presentation was cephalic and unengaged, and bloodstained amniotic fluid drained freely. A fetal scalp electrode (Copeland) was applied and an apparent fetal heart was recorded. The heart rate varied between 110 and 140 beats/min (Fig. I ) and was synchronous with the maternal pulse rate at the wrist. The diagnosis of probable abruptio placentae with intrauterine death was made and labour was allowed to continue without further intervention. Six hours later the cervix had dilated only to 5 cm and labour was augmented by intravenous oxytocin infusion. After a first stage of 9 h the patient was delivered spontaneously of a fresh. stillborn male infant, weighing 2.78 kg. The scalp clip was correctly sited. The placenta was pale and weighed 6 8 0 g ; no evidence of retroplacental bleeding was found. but 200 ml of fresh blood clot followed the delivery of the placenta. Immediately after delivery of the baby the patient’s heart rate was 100/min in sinus rhythm and her temperature, which had remained apyrexial throughout, now rose to 37.8”C. A full infection screen was taken and combined antibiotic therapy was started. The cultures proved negative and the patient’s postpartum course was uneventful. A post-mortem examination of the fetus revealed no congenital abnormality. There was no evidence of air in the lungs or intrauterine pneumonia. Modest maceration of the tissues was present. These features combine to suggest intrauterine fetal death, probably of a few days duration, and certainly pre-dating the start of the fetal ECG recording.

OVARIAN CANCER: THE TEN YEAR EXPERIENCE OF A DISTRICT GENERAL HOSPITAL

Ninety‐seven cases of ovarian cancer were diagnosed and treated at Northwick Park Hospital between 1970 and 1980. In this retrospective study data are presented about symptomatology and certain aetiological factors. The survival with different treatment regimens is compared, with particular reference to the improved figures resulting from a policy of aggressive surgery followed by multiple chemotherapy.

Rates of episiotomy. Conclusions and validity of data cannot be judged.

EDITOR,—Tine Brink Henriksen and colleagues fail to give adequate clinical information so that we can judge the validity of their data and their conclusions on changes in the use of episiotomy.1 First and foremost is their failure to analyse their results for primigravidas and multigravidas separately. As most parturients who require episiotomy are primigravidas, combining the results for both groups may mask important underlying differences and outcomes. The high incidence of pudendal …

Epidural bupivacaine concentration and forceps delivery in primiparae

SummaryThis study of 383 consecutive primiparae given epidural analgesia in labour was conducted to examine the influence of the concentration of bupivacaine on the mode of delivery. The epidural technique and the management of labour were both standardised and the bupivacaine concentration was decided arbitrarily by the duty anaesthetist. Primiparae given 0·25 per cent bupivacaine throughout labour (n = 122) were less likely to require a forceps delivery than primiparae (n = 261) given more than 0.25 per cent bupivacaine at any stage during labour (P < 0·05). This was due mainly to a reduction in the incidence of rotational forceps deliveries and occurred despite a higher incidence (P < 0·05) of oxytocin augmentation of contractions during the second stage of labour in mothers receiving high concentration bupivacaine. Low concentration bupivacaine may not only reduce the incidence of forceps deliveries but may also have analgesic benefits if the number of mothers with forceps related pain in the puerperi...

Prolonged pregnancy and fetal energy supply: amniotic fluid concentrations of erythropoietin, hypoxanthine, xanthine and uridine in uncomplicated prolonged pregnancy

SummaryIn prolonged pregnancy the adequacy of fetal energy supply before delivery has been studied by measuring in amniotic fluid hypoxanthine and xanthine which are intermediates in the metabolism of the energy currency of the cell ATP; these measurements can indicate ATP depletion. In addition erythropoietin has been measured as an indicator of oxygen delivery since after hypoxia this hormone stimulates red blood cell production. Such sensitive biochemical measurements may reflect events over the 24 h preceding amniotic fluid sampling.One hundred and seven mothers and fetuses with uncomplicated pregnancies were studied at gestational ages of 40-42 weeks by amniotic fluid sampling at the induction of labour.In pregnancies with babies of 4 kg or more, there were significant correlations between gestational age over 40 weeks and amniotic fluid hypoxanthine, xanthine and uridine concentrations, suggesting that fetal oxygen supply may be becoming inadequate.Otherwise, in first and later pregnancies there was...