J. M. Stronge

The miscarriage clinic: an audit of the first year

Summary. We preview the results of the first year in a Miscarriage Clinic set up in 1989 in an effort to improve the support and counselling of women who have a miscarriage. Of 381 patients referred, 79% attended. The only statistically significant difference between the women who attended and those who did not attend was in the proportion of women who had planned their pregnancies (65% versus 33%, P<0.01). Of the 300 patients who attended, 4% reported no grief reaction; 75% experienced a reaction which had resolved within one month and 21% experienced a reaction which had not resolved. No factor was identified which could predict the duration of the grief reaction. This audit demonstrates that there is a strong demand and need for this service for couples who experience a miscarriage.

Shoulder dystocia — is it predictable?

An unmatched comparative study is described to determine if routine clinical indicators are useful predictors for shoulder dystocia. Parity, maternal weight gain during pregnancy, and a history of a previous large baby and increased operative vaginal delivery rate were more often associated with shoulder dystocia. No other significant associations were found. However, shoulder dystocia can not be predicted accurately antepartum using routinely available clinical factors.

Pregnancy in the diabetic patient: timing and mode of delivery.

The clinical outcome of 141 consecutive diabetic pregnancies managed in the National Maternity Hospital between January 1, 1979, and October 31, 1982, is described. Patients with gestational diabetes were excluded. There were 12 spontaneous abortions, and the perinatal mortality in 129 viable pregnancies was 31/1000. The malformation rate was 6.4%. Significant perinatal morbidity occurred in 20% of infants. The incidence of cesarean section was 20%. Spontaneous labor after 38 weeks occurred in 30% because there was a deliberate policy to allow all uncomplicated pregnancies to continue to term. This policy had benefits for the infant as well as the mother because there was a notable reduction in neonatal morbidity. Possible explanations of high cesarean section rates in other centers are discussed.

Cesarean section and perinatal outcome: Response from the House of Horne

A direct comparison between Parkland Memorial Hospital in Dallas, Texas, and the National Maternity Hospital in Dublin, Ireland, on the basis of limited numbers taken from one year only (1983) led to the conclusion that the liberal use of cesarean section in Dallas was associated with a sevenfold decrease in intrapartum fetal deaths and a twofold decrease in neonatal seizures. However, when the scope of the survey is extended to include the year before (1982) and the year after (1984), a different picture emerges. During this extended period there were almost four times as many cesarean sections performed in Dallas with no significant difference in overall perinatal mortality, while for two of three years the incidence of neonatal seizures was twice as high in Dallas when compared with Dublin. The fact that high cesarean rates continue to rely on evidence of such a tenuous nature must remain a matter of concern.

Outcome of diabetic pregnancy with spontaneous labour after 38 weeks

One hundred and forty-eight patients with well controlled insulin dependent diabetes that were allowed to labour spontaneously from 1981 to 1994 were reviewed. There were 2 perinatal deaths, giving a perinatal mortality rate of 13.5/1000. One hundred and twenty-four patients (84 per cent) had a normal vaginal delivery, 13 (9 per cent) forceps delivery and 11 (7 per cent) caesarean section. Twenty-one infants (14 per cent) required admission to a Special Care Baby Unit. One third of infants weighed 4 Kg or more, however there was only 1 case of shoulder dystocia. We compared these results with those of the general hospital population of 1987. The 2 main differences are; 1) the Caesarean section rate in labour was higher for this diabetic group than for the general hospital population, 7 per cent versus 3.4 per cent, 2) the birth weight was heavier, 33 per cent of infants of the diabetic group weighed 4 Kg or more versus 18 per cent of the general hospital population. The other parameters were comparable. We conclude that conservative management of pregnancy in well controlled diabetic women is advantageous, resulting in a high vaginal delivery rate without an increase in shoulder dystocia, and a low perinatal morbidity and mortality rate.

Is amniotic fluid quantitation of value in the diagnosis and conservative management of prelabour membrane rupture at term

Summary. This study examined the hypothesis that ultrasound quantitation of amniotic fluid depth is of value in the diagnosis and management of prelabour rupture of the membranes (PROM) at term. The deepest vertical pool was measured in 151 consecutive patients with a history of suspected PROM for at least 10 h before labour. In 100 patients the diagnosis of PROM was confirmed by the collection of amniotic fluid at the vulva. There was no difference in mean depth of amniotic fluid in 100 patients with confirmed PROM, compared with 51 in whom PROM was not confirmed (48.5 mm SD 16.4 vs. 60.1 mm SD 16.5); the frequency of oligohydramnios (fluid depth <30mm) was 5% and 5.8% respectively. There was no relation between ultrasound amniotic fluid quantitation and the onset of labour, the duration of labour nor the frequency of oxytocin augmentation in labour. The results show that ultrasound quantitation of amniotic fluid is of no value in the diagnosis and conservative management of PROM at term.

Pregnancy and vaginal delivery following bilateral total hip replacement

We report a case of pregnancy with spontaneous vaginal delivery in a patient who had bilateral total hip arthroplasty. Guidelines for management of such patients are discussed, as this is a clinical situation which is likely to be seen more frequently. Orthopaedic consultation is important, if possible with the surgeon who performed the operations.

Active Management of Labour and Occipito‐Posterior Position

Summary: A reappraisal of the clinical significance of the occipito‐posterior position is needed in the altered circumstances which derive from a policy of active management of labour. In a series of 1,000 consecutive primigravidae, the occiput was posterior at the time of delivery on 38 occasions. This had an adverse effect on the conduct of labour in approximately 3 cases (0.3%). It is concluded that the occipito‐posterior position has been reduced to a low level of clinical significance in current practice.

Persistent hyperemesis gravidarum complicated by wernicke’s encephalopathy

SummaryWemicke’s encephalopathy is a serious neurological manifestation of vitamin Bl deficiency. We report a case occurring secondary to hyperemesis gravidarum.

Blood viscosity in umbilical cord blood from babies of diabetic mothers

SummaryCompared with normal babies, whole blood viscosity and packed cell volume were significantly higher in cord blood from the newborn of diabetic mothers. The differences were most marked in macrosomic diabetic babies. Whole blood viscosity and packed cell volume are suggested as retrospective fetal markers of the quality of diabetic control in pregnancy. The concept of hyperviscosity in utero as a cause of intra-uterine death in infants of diabetic mothers is discussed