N. A. Beischer

NON‐IMMUNOLOGICAL HYDROPS FETALIS

In a consecutive series of 182 cases of hydrops fetalis 33 (17·6 per cent) were due to causes other than blood group incompatibility, the incidence of non‐immunological hydrops fetalis being 1 in 3538 deliveries. Of the 33 cases, 13 were idiopathic, 6 were associated with twin pregnancies, 7 had major malformations and the remaining 7 had a variety of associated diseases.

The Value of Urinary Oestriol Measurements During Pregnancy

The excretion of oestriol in the maternal urine increases approximately a thousandfold from conception to term. During the first weeks of pregnancy, the oestriol is derived from the metabolism of oestrone and oestradiol produced by the corpus luteum. Later, the placenta becomes the major site of oestrogen production, and synthesises oestriol as well as oestrone, oestradiol and other oestrogens. From this time, the urinary oestriol is derived in two ways—directly from placental oestriol and indirectly from the metabolism of the other oestrogens. The placenta, in turn, derives many of the steroid precursors required for oestrogen synthesis from other sites, the most important being the foetus. The levels of oestriol in the urine therefore reflect the combined functional capacity of the foeto‐placental unit.

Growth and Malignancy of Ovarian Tumours in Pregnancy

A series of 164 ovarian tumours diagnosed during pregnancy or the puerperium is presented. The commonest were the benign cystic teratoma (45 cases) and the mucinous cystadenoma (40 cases). Rapid growth of the tumour during pregnancy was observed in 5 of the 41 patients (12%) in whom assessment was possible; in none of these was the lesion malignant. The incidence of malignancy was 2.4% (4 of 164 cases) or 10 times less than that of ovarian tumours in non‐pregnant patients. This difference was accounted for by the variation in age distribution in pregnant and non‐pregnant patients with ovarian tumours.

Studies in prolonged pregnancy: II. Clinical results and urinary estriol excretion in prolonged pregnancy

In a series of 339 prolonged pregnancies, 18.2 per cent of infants weighed more than 4,000 grams, the incidence of fetal distress was significantly increased, and the cesarean section rate was more than doubled. The influences of race, parity, maternal age, and duration of pregnancy on birth weight are presented. The fetal deaths all occurred in primigravidas, and 3 of the 5 were due to disregarded distress and dystocia. Low urinary estriol excretion (less than 12 mg. per 24 hours) was commoner in primigravidas (26 per cent) than multigravidas (14.6 per cent) and showed a significant correlation with fetal distress in labor. In 9 of 46 patients with low estriol excretion the values were consistently low. The correlation between estriol excretion, placental and fetal birth weights, and the appearance of the infant at birth is presented.

Studies in prolonged pregnancy

In a series of 2,972 patients who were studied prospectively from the first trimester of pregnancy, the incidence of prolonged pregnancy (42 weeks and beyond) was 11.4 per cent. Prolonged pregnancy was found to have a significant correlation with maternal age and race and with vaginal bleeding during the first 13 weeks of pregnancy. The difficulties in the diagnosis of the duration of pregnancy during the first trimester are discussed.

EXCRETION OF URINARY OESTROGENS IN PREGNANT PATIENTS TREATED WITH CORTISONE AND ITS ANALOGUES

MEASUREMENT of urinary oestriol excretion during pregnancy is now a well established method for assessing placental function and fetal well-being. It is therefore important to investigate any exception to the general rule that a low oestriol excretion indicates that the fetus is in jeopardy. Recently there have been several reports that low oestrogen excretion occurs in patients treated with cortisone or its analogues and that in these cases the fetus does not appear to be at risk (Baulieu, Bricaire and Jayle, 1956; Hammerstein and Nevinny-Stickel, 1965 ; Badarau, 1966; MacLeod et al., 1967; Michie, 1967). This finding also has great theoretical importance when considering the sources of the oestrogens excreted during pregnancy. There is now good evidence that the maternal and fetal adrenals produce C 19 precursors which are aromatized to oestrogens by the placenta (Frandsen and Stakemann, 1961, 1964; Siiteri and MacDonald, 1963, 1967; Baulieu and Dray, 1963; Colas et al., 1964). Treatment with cortisone might therefore be expected to reduce oestrogen output by reducing production of the precursors, particularly by the maternal adrenals. To provide further information on these phenomena, we here report a study of oestrogen excretion in 26 patients who received cortisone analogues during their pregnancies.

Hydatidiform Mole with Coexistent Foetus

“All the world knows that the celebrated Beclard was the result of a hydatidiform pregnancy”-Depaul, 1886. Uncommon medical conditions may arouse interest purely as clinical curiosities or because they provide unusual difficulties in diagnosis and treatment. Hydatidiform mole with associated foetus merits attention not only for these reasons but also because of the possible development of choriocarcinoma, either during or after the pregnancy. Bland (1927), Acosta-Sison (1954) and Nilsson (1957) have reported cases of mole with foetus where the patient died as a result of this complication. These cases illustrate that choriocarcinoma may supervene when a mole involves either part of a single placenta or the whole of one of binovular twin placentae. A further reason for the study of this condition is that it stimulates thought concerning the aetiology of hydatidiform mole. The following report features a most unusual placenta, approximately 75 % of which consisted of a vesicular mass; the case is one of extensive molar change in a single but possibly uniovular twin placenta.

Studies in prolonged pregnancy: III. Amniocentesis in prolonged pregnancy

The results of amniocentesis in 231 patients with prolonged pregnancy are presented. Meconium was present in the liquor in 6.9 per cent of patients before the onset of labor and in this group the incidence of fetal heart rate abnormality was significantly increased (p

THE VALUE OF URINARY OESTRIOL ESTIMATION IN PATIENTS WITH ANTEPARTUM VAGINAL BLEEDING

PATIENTS having episodes of minor antepartum vaginal bleeding provide an important practical problem in obstetrics. These pregnancies may be complicated by placental insufficiency and intrauterine foetal death because of extensive placental damage from separation and infarction (Ziel, 1963). Although the main concern is the high perinatal mortality, the question also arises as to whether prolonged hospitalization can be avoided with safety in these patients once placenta praevia has been confidently excluded (Scott, 1960; Hedberg and Radberg, 1966). It would seem that urinary oestriol estimation, which is a test of placental function, may be of value in the management of patients who have mild antepartum bleeding when spontaneous labour does not occus within 48 hours. The foetal mortality rates in patients with placenta praevia and accidental haemorrhage are well known, but the perinatal wastage when the cause of bleeding is undetermined, even after delivery, is less well recognized (Table I). Murdoch and Foulkes (1952) have emphasized the importance of this group, which receives scant reference in the literature. A review of the reports of large maternity hospitals leaves no doubt that the problem is a real one (Table 11). Although by definition a retroplacental clot had not been identified in these cases, placental separation was the probable cause of many of the deaths. It is not the cause of the bleeding which is important but rather the possibility that it has led to the development of placental insufficiency, and a decision must be made whether termination of the pregnancy should be performed because of this.

Hydatidiform mole and its complications in the state of Victoria.

In a series of 328 consecutive molar pregnancies in the State of Victoria the incidence of malignant sequelae was 4·3 per cent.