Karl S. Oláh

The conservative management of patients with symptoms of stress incontinence: a randomized, prospective study comparing weighted vaginal cones and interferential therapy.

Sixty-nine female patients with symptoms of stress urinary incontinence were randomized to treatment with either interferential therapy or weighted vaginal cones. Fifty-four patients completed treatment (interferential therapy, 30 patients; weighted vaginal cones, 24 patients). Patients were assessed by subjective response, pad testing, continence charts, and the maximum weight of cone that could be held actively and passively. Forty-seven patients were reassessed at 6 months (19 cones; 28 interferential), five patients (9.26%) required surgery, and two patients (3.7%) could not be reassessed. Subjective response to treatment was good, with 80% to 90% of patients cured or improved after treatment. After 6 months, 41.67% in the cone group and 40% in the interferential group were subjectively cured, with improvement in 50% and 30%, respectively. Of those patients initially referred for treatment, greater than 30% in each group were cured of symptoms. There was an objective improvement in both groups. In the cone group 50% had improved after treatment and greater than 60% had improved at 6 months as assessed by pad testing, while in the interferential group 76% had improved after treatment and 73% had improved at 6 months. There was no significant difference in improvement between the two groups in any of the methods of assessment. However, the cones require less supervision by trained staff and can be used at home by the patient. Their use results in a savings in time for the physiotherapy department. The use of the cones is recommended as a cost-effective method of treatment that can be added to the present therapy options available to the physiotherapist.

The presence of fetal fibronectin in the cervicovaginal secretions of women at term - Its role in the assessment of women before labor induction and in the investigation of the physiologic mechanisms of labor

OBJECTIVE Our purpose was to determine whether the presence of fetal fibronectin in cervicovaginal secretions of patients undergoing induction of labor reflected the cervical state and ultimately the ease of induction of labor. STUDY DESIGN A prospective observational study of 103 patients undergoing induction of labor at term was conducted at Liverpool Maternity Hospital, a large university teaching hospital. We studied the women after 37 completed weeks of pregnancy. A Dacron (Adeza Biomedical, Sunnyvale, Calif.) polyester swab specimen was first taken from the endocervix for assessment of the presence of the fetal fibronectin. The cervix was then assessed by digital vaginal examination and scored with a modified Bishops score. The fetal fibronectin swab was processed at the bedside with a membrane immunoassay kit specific for fetal fibronectin. A score was ascribed depending on the strength of the fibronectin reaction determined by the intensity of the color change on the plate, the presence of fetal fibronectin resulting in a score of 1 to 4. The patient was subsequently managed according to the standard induction protocol of the unit. The clinicians involved in the patients care were blind to the result of the fetal fibronectin swab. RESULTS There was a good correlation between the modified Bishops score and the fetal fibronectin score (r = 0.58, p < 0.001). To predict a latent phase of < 8 hours, a fetal fibronectin score of 3 or 4 has a sensitivity of 73% with a specificity of 83% and a modified Bishop score of > or = 4 has a sensitivity of 75% and a specificity of 73%. For delivery within 12 hours of induction of labor a fetal fibronectin score of > or = 3 has a sensitivity of 61% and specificity of 83% compared with the modified Bishop score of > or = 4, which has a sensitivity of 76% and a specificity of 72.5%. CONCLUSIONS The fetal fibronectin score is as good as the modified Bishop score as an index of the ease with which induction of labor may be performed. This would imply that it also reflects the proximity of the onset of labor. The presence of fetal fibronectin cervicovaginal secretions is therefore a marker of the changes in the cervix and membranes that precede labor regardless of the gestational age.

The prevention of preterm delivery—can we afford to continue to ignore the cervix?

The search for safer retinoid drugs continues. Acitretin, a drug of comparable efficacy but much more rapidly excreted than etretinate, looked promising until it was found that a few patients seemed able to convert it to etretinate (Wiegand & Jensen 1991). There is some evidence from animal studies that not all biologically active retinoids are teratogenic (Teelmann 1989). For the present, hqwever, women with severe skin disease will continue to be treated with these powerful teratogens and all doctors involved with family planning or childbirth should be aware of their significance. Robert J. G. Chalmers Consultant Dermatologist T h e Skin Hospital Chapel Street Salfnrd Manchester M60 9EP

Cervical contractions: the response of the cervix to oxytocic stimulation in the latent phase of labour

Objective To assess the cervical response to myometrial activity in early labour.

Fetal heart block associated with maternal anti‐Ro (SS‐A) antibody—current management. A review

The relation between maternal connective tissue disease and complete congenital heart block (CCHB) in the fetus has been known for some time (Hogg 1957). Several groups have described serum antibodies to soluble ribonucleoproteins, anti-Ro (SS-A) and anti-La (SS-B), in the affected infants and their mothers (Kephart et al. 1981; Franco et al. 1981; Miyagawa et al. 1981). and subsequent studies have demonstrated thc almost universal association of CCHB with cithcr or both of these autoantibodies (Scott et ul. 1983; Watson et u1. 1984; Weston el al. 1982; Taylor et al. 1988; Gross et al. 1989; McCrcdie etul. 1990). The heart contains onc of the bodys highest concentrations of Ro (SS-A) antigen (Wolin & Steitz 1984; Harley et al. 1985; Deng et al. 1987). and IgG deposits have been found in the cardiac tissues of affected infants (Litsey et al. 19115; Lee et a/. 1987). Anti-Ro antibodics have also been implicated in the aetiology of myocarditis and conduction defects in adults (Logar et d. 1990). The cvidcnce suggests that a passivcly acquired autoantibody. probably anti-Ro (SS-A), binds to an antigen in the fetal heart and produces intlammation and fibrosis in the cardiac conduction system. The majority of fetuses with CCHB are dctected incidentally whcn the condition is established and irreversiblc. I t has bcen shown that CCHB is rarc in offspring of pregnant women with clinically apparent systcmic lupus

Management of Severe, Early Preeclampsia: Is Conservative Management Justified?

A retrospective analysis was performed to assess the fetal and maternal benefits of allowing women presenting with severe pre-eclampsia between 24 and 32 weeks to continue their pregnancy following treatment of their hypertension. Cases presenting in Oxford (conservative management) and in Birmingham (stabilisation and early intervention) were compared. Patients were considered to require treatment when their systolic blood pressure was > or = 170 mmHg systolic or > or = 110 mmHg diastolic, associated with at least 1+ proteinuria and hyperuricaemia. We compared gestation at delivery, birth weight and neonatal complications for each group, and any maternal morbidity. There were 28 patients in each group. Gestational age at delivery was significantly less in the group managed by early intervention. Those women managed conservatively gained a mean of 9.5 days (range 2-26 days; P < 0.05), and their birthweight was significantly greater (P < 0.05). There was a significant difference between the length of stay in the neonatal intensive care unit between the 2 groups (P < 0.05), the babies of those women managed conservatively staying a mean of 7.4 days less. There were fewer neonatal complications in those cases managed conservatively, the number of newborns with 1 or more complications in the early intervention group being 18 (64.3%), compared with 8 (28.6%) in the expectant management group (P = 0.0001). All of the women in the group managed by early intervention recovered with no severe complications. However, those women managed conservatively had a higher incidence of HELLP (2 cases) and ELLP syndrome (2 cases), 1 case requiring temporary renal dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Massive obstetric haemorrhage resulting from a conservatively managed cervical pregnancy at delivery of its twin

A 34 year old woman with a known twin pregnancy presented to the early pregnancy assessment unit at 12 weeks of gestation with vaginal bleeding. She had bilateral tubal occlusion as a consequence of severe peritonitis due to a ruptured appendix at the age of 12 and had conceived through in vitro fertilisation. Several earlier ultrasound scans had been reported as normal. On admission, the bleeding had settled and there was no evidence of any cardiodynamic compromise. The uterus felt to be appropriate for dates, and the cervix appeared closed. However, an ultrasound scan showed a heterotopic twin pregnancy, with one pregnancy implanted in the uterus, and the second pregnancy in the cervix (Fig. 1). The gravity of the situation was conveyed to the woman and her partner, and arrangements were made to perform selective feticide. Under a general anaesthetic and with transabdominal ultrasound guidance, the sac of the cervical pregnancy was aspirated and 3 mL of strong potassium chloride solution was injected into the fetus. The fetal heart ceased beating, and there was no significant haemorrhage. The patient remained in the hospital for a week, during which time there was a moderately heavy brownish vaginal loss. The brown discharge persisted throughout the pregnancy but monthly ultrasound confirmed the remaining fetus to be growing on the 50th centile with a fundal placenta. Steroids were administered at 24 weeks of gestation as a precautionary measure. At 34 weeks of gestation, the pregnancy appeared to be proceeding normally. At 36 weeks of gestation, the patient was admitted with a history of ruptured membranes. Clear amniotic fluid was draining from the cervix, although there was no uterine activity. The fetus was active, and the cardiotocograph was normal. Twenty-four hours later, it was decided to induce labour. The head was 3/5 palpable, and the cervix was soft, 1 cm long and 1 cm dilated with the forewaters intact. There was a palpable nodule or mass of about 1 cm diameter in the forewaters. When the forewaters were ruptured there was a 300 mL haemorrhage. The cardiotocograph remained normal initially, but the bleeding continued and later the cardiotocograph deteriorated with a reduction in variability and decelerations, so a decision was made to undertake a caesarean section. The baby weighed 2.6 kg and was delivered in good condition. The placenta appeared normal. The remains of the cervical pregnancy appeared as a brown mass in the cervical canal and were removed. Haemorrhage from the site of the cervical pregnancy was stemmed with sutures into the cervix, and the uterus was closed. However, on completing the operation, it was apparent that there was continuing haemorrhage from the cervix, and thus the abdomen was re-opened with a view to conducting a hysterectomy. The operation was difficult due to multiple adhesions from the uterus to the bowel and posterior wall of the pelvis. It was essential to remove the cervix as this was the site of haemorrhage. At the completion of the operation, the patient had developed a disseminated intravascular coagulapathy with a kaolin–cephalin clotting time

Multiple neuroectodermal tumors arising in a mature cystic teratoma of the ovary

Benign cystic teratomas are common, comprising 11-20% of all ovarian tumors. Neural elements can be identified in 38% of teratomas, but the development of a malignant neural neoplasm in an ovarian tumor of this type is rare. Multiple neuroectodermal tumor foci have not been previously described in association with a mature cystic teratoma of the ovary.

Massive subchorionic thrombohaematoma presenting as a placental tumour. Case report.

A 25-year-old Asian woman booked for her second pregnancy at 12 weeks gestation. Her first pregnancy 6 nionths previously had ended i n miscarriage after 6 weeks of xnenorrhoea. Pregnancy was uneventful until 25 weeks gestation when the patient complaincd of abdoniinal discomfort arid climinished fetal movements. On examination. tier uterus was large-for-dates, giving the clinical impression of polqhydramnios. An ultrasound scan showed a normal fetus. o f appropriate size and a thickened placenta with a multicystic cuperior margin. There was no polyhydratnnios. Serology (TPHA. Rhesus, auto-ininiune disorders) \vas negative. Mcasuremen t s of hi1 m a n place 11 tal lactogen, h timan chorionic gon:tdotrophin ancl alpha-fetoprotein wcre all within normal limits. Serial ultrasound scans showed normal fetal growth and ii rapidly increasing placental ‘turnour’. By 28 weeks, over half o f the uterine cavity was fillcd with an homogcncous echodense mass. 18cm in dianieter at its widest point, which was beginning to compress the fetus (Fig. 1 ) . The provisional diagnosis was that of chorioangioma, although the appearances were

Overlap syndrome and its implications in pregnancy. Case report

A 29-year-old woman booked for her second pregnancy at 16 weeks gestation. At 2 years of age shc had developed a seronegative juvenile chronic arthritis (Stills disease) requiring steroid therapy. Various corrective orthopaedic procedures had been performed in childhood, including staple insertions in both knees, correction of a valgus deformity and bilateral hip replacements. Steroids were stopped when she was 16 years of age, and her joint disease had been quiescent for over 10 years. However, a strongly positive anti-nuclear antibody titre had been noted with a raised IgG and a persistently raised ESR 7 years previously, although there was no evidence of active lupus. There had been no problems in the first pregnancy: labour had started spontaneously at 36 weeks, and she was delivered by elective caesarean section because of her extensive joint deformity and a suspicion of cephalopelvic disproportion. Intubation was reported to be difficult, but the procedure was otherwise uneventful, with the birth of a healthy 2.5 kg girl. In this pregnancy all appeared well at booking, and an ultrasound scan confirmed her dates. At 30 weeks she was admitted in labour. There was a persistent fetal bradycardia of 80 beats/ min, the maternal pulse being 100/min. The cervix was tightly closed. An ultrasound scan demonstrated an active, normally grown baby