Norman A. Beischer

FETAL GROWTH RETARDATION AND PRE‐ECLAMPSIA

In a series of 2434 patients with pre‐eclampsia, the prevalence of fetal growth retardation was 8.7 per cent compared with 8.6 per cent in the total hospital population. The prevalence was increased in early‐onset pre‐eclampsia (18.2 per cent) (P <0.001) and reduced in late‐onset pre‐eclampsia (5.6 per cent) (P <0.00l). In patients who later developed early‐onset pre‐eclampsia with fetal growth retardation, the prevalence of subnormal oestriol excretion was significantly increased (79.5 per cent) (P <0.001) as was the prevalence of hypoglycaemia (33.3 per cent) (P <0.001) suggesting that fetal growth retardation in these pregnancies preceded the clinical signs of pre‐eclampsia. The prevalence of placental abruption (8.3 per cent) and the prevalence of perinatal deaths (28.7 per cent) were both significantly higher in pregnancies with early‐onset pre‐eclampsia and fetal growth retardation (P <0.001).

ACUTE POLYHYDRAMNIOS—A COMPLlCATION OF MONOZYGOUS TWIN PREGNANCY

Eight patients with acute polyhydramnios were encountered in 31 103 pregnancies, an incidence of 1 in 3888. All patients with acute polyhydramnios had monozygous twin pregnancies and 14 of the 16 infants were normal. The condition occurred in the second trimester and usually ended in premature delivery within a few days. The perinatal mortality was 100 per cent and accounted for 14.9 per cent of the perinatal mortality in twins.

PLACENTAL HYPERTROPHY IN SEVERE PREGNANCY ANAEMIA

A prospective combined study of consecutive patients with severe pregnancy anaemia (haemoglobin value less than 8 g. per 100 ml.) was performed in five countries to determine the relationship between maternal anaemia and placental weight. Data were recorded in 732 pregnancies and the important finding was that placental hypertrophy was associated with maternal anaemia in all centres. There was a positive correlation between maternal anaemia and placental weight which was statistically highly significant; Melbourne and Thailand, P = 0·01; India, P<0·025; Singapore and New Guinea, P<0·001.

Mortality and Morbidity of Fetal Growth Retardation

Summary: This study reports the fetal outcome in 500 pregnancies when the baby weighed less than the 10th centile for gestational age at birth, compared with that in a series of 500 pregnancies where there was a normal weight for gestation. Fetal growth retardation (0‐9th centile) had a significant positive association with perinatal mortality (5.2% versus 1.2%, P > 0.001) and low oestriol excretion (42.4% versus 15%, P > 0.001), but not with major fetal malformations or fetal asphyxia. In the study group, 20 of the 26 perinatal deaths were associated with subnormal oestriol excretion. When severe fetal growth retardation was considered (less than the 5th centile), the associations with perinatal mortality (19%) and subnormal oestriol excretion (63%) were stronger and a significant correlation with major malformations emerged (17%, P > 0.001). Detection of subnormal oestriol excretion allows identification and appropriate treatment of severe fetal growth retardation which should improve survival and neurological development in these infants. This study confirms that birth‐weight below the 10th centile is an appropriate definition of fetal growth retardation in terms of perinatal mortality and morbidity.

The Long‐Term Follow‐up of Women with Gestational Diabetes

Summary: Four hundred and forty‐seven women who had gestational diabetes have been retested at intervals from 1 to 12 years following diagnosis; 49 (11%) were found to be diabetic and 35 (7.8%) had impaired glucose tolerance using the WHO criteria. An abnormal glucose tolerance test in the puerperium and obesity at the time of retesting had significant associations with abnormal glucose tolerance at follow‐up. However, the best predictive factor of the likelihood of the development of significant hyperglycaemia was the recurrence of gestational diabetes in a subsequent pregnancy, since 28% of these women were diabetic and a further 4% had impaired glucose tolerance at the time of follow‐up. These findings indicate that the criteria used for the diagnosis of gestational diabetes at the Mercy Maternity Hospital, Melbourne (1‐hour ≥ 9 mmol/1 together with a 2‐hour ≥ 7 mmol/1) are appropriate for an Australian population.

Acute Polyhydramnios in Twin Pregnancies

Summary: This paper reports the experience with acute polyhydramnios complicating twin pregnancies at the Mercy Maternity Hospital for the 10‐year and 2‐month period from January, 1979 to February, 1989 during which time there were 13 such cases, an incidence of 1 in 4,044 pregnancies. Acute polyhydramnios complicated 1.7% of all twin pregnancies. The perinatal mortality rate was 88.5% and accounted for 16.7% of the perinatal deaths in twins. No major fetal malformations were found. One case of acute polyhydramnios was successfully managed with ultrasonographically guided serial amniocenteses. The management of this rare condition is considered.

Non‐immune hydrops fetalis: changing contribution to perinatal mortality

Summary. During the decade to 1979, 203 hydropic infants died in the State of Victoria, Australia. Non‐immune hydrops fetalis (NIHF) became more common than immune hydrops fetalis as a cause of fetal hydrops, and its contribution to the total perinatal mortality increased from 0.1% to 3%. The perinatal mortality rate of infants with NIHF was virtually 100%. The most consistent finding at post‐mortem was pulmonary hypoplasia which was probably due to compression from serous cavity effusions. Survival may be improved by early diagnosis and termination of the pregnancy in selected patients with viable infants before the development of gross serous cavity effusions The most constant clinical sign associated with hydrops fetalis was polyhydramnios which is an indication for ultrasonography and cardiotocography to detect cases of NIHF and to select the optimum time for delivery.

THE SIGNIFICANCE OF ANAEMIA IN AN OBSTETRIC POPULATION IN AUSTRALIA

In a series of 15 321 consecutive patients 568 (3.7 per cent) had haemoglobin values below 9.2 g. per 100 ml. before delivery. The commonest causes of amaemia were iron deficiency (49 per cent) and β‐thalassaemia minor (28 per cent), the latter being explained by a high proportion of patients of Mediterranean origin. The most important cause of anaemia, in terms of maternal morbidity and perinatal mortality, was chronic renal disease which had an incidence of 7 per cent (39 of 568). Maternal age and parity were significantly higher in the anaemia series than in a control series of non‐anaemic patients. The incidence of twin pregnancy was 5.2 per cent or five times that of whole obstetric population.

The effect of rest and intravenous infusion of hypertonic dextrose on subnormal estriol excretion in pregnancy

Abstract The effects of rest in bed and intravenous infusion of hypertonic dextrose were evaluated in a consecutive series of 42 patients with persistently low estriol excretion. Estriol excretion rose above the lower limit of normal in 10 of 30 patients treated by rest in bed in the lateral position. Estriol excretion increased in 6 of 12 patients treated by hypertonic dextrose infusion, the rate of improvement being greater than in those who responded favorably to rest in bed alone. Neither method resulted in improvement of estriol excretion when the patient had pre-eclampsia. Hypertonic dextrose infusion appeared to improve fetal nutrition and well-being even when the fetus was malformed and clinically growth retarded.

Hysterectomy in Obstetric Practice

Summary: A 9‐year review (1971–1979) is presented of patients undergoing hysterectomy in the course of pregnancy. The incidence was 1 in 1,044 pregnancies (34 in 35,506). The principal indications were ruptured uterus (9), postpartum haemorrhage (8), placenta accreta (5) and neoplastic trophoblastic disease (4). In spite of the high incidence of hysterectomy in our community, the procedure was undertaken during pregnancy with great reluctance and usually only as a life‐saving procedure.