P. Byrne

Planned abdominal compared with planned vaginal birth in triplet pregnancies.

resulted from confounding factors (Mamelle et al. 1987; McDonald et al. 1988). Even allowing for the exclusion criteria, the incidence of preterm delivery in this study group (3.7 YO) is low in comparison with reported rates for developed countries. Preterm delivery rates in the United States increased from 9 4 YO in 1981 in 10.6 Yo in 1989 (Creasy et al. 1993). During the nine-year period (1985-1993) in a relatively affluent region of the UK preterm delivery rates were 8.7% overall (Morrison et al. 1995). This disparity in incidence makes extrapolation to other populations difficult. Also, the use of preterm delivery frequency as a measure of adverse outcome in pregnancy is nonspecific and lacks meaning in current obstetric practice. Firstly, preterm delivery represents a heterogeneous group of disorders, with entirely different aetiologies, which must be considered separately from spontaneous preterm labour which may be amenable to preventative measures. Antepartum haemorrhage, pre-eclampsia, chorioamnionitis, fetal growth restriction, congenital abnormalities and a host of fetal diseases lead to elective preterm delivery and subsequent maternal and perinatal benefits. Spontaneous idiopathic preterm labour accounts for approximately one-quarter to one-half of all preterm deliveries (Main et al. 1985; Morrison 1995). Secondly, preterm delivery can occur at any time between 23 weeks and 36 weeks plus six days with vastly different implications for perinatal outcome. The majority of tertiary referral centres now report close to 100% survival for infants born after 32 weeks of gestation and the contribution of preterm delivery to adverse perinatal outcome is related mainly to the 30% to 40% of preterm births that occur before this time. We believe that inclusion of the reason for preterm delivery, and the gestational age at which it occurred, would make the findings more meaningful. Perhaps assessment of the perinatal outcome, rather than frequency of preterm delivery, in women with long hours of standing at work would provide more specific information.

A new predictor of cephalopelvic disproportion

Cephalopelvic disproportion (CPD) is a recognised obstetric problem with potential risk to both mother and infant. Identification of those mothers at risk of CPD is difficult and has concentrated in the past on such measurements as maternal shoe size and height. Our objective in this study was to examine new anthropomorphic parameters as indicators of CPD. This was a case controlled study of sixty consecutive women, and their partners, who had caesarean section performed for CPD and 60 case matched controls. Measurements included maternal and paternal head circumference, height, shoe-size, body mass index (BMI), infant weight and head circumference. Parity, gestation at delivery, and mode of onset of labour were recorded. Data were analysed using Stata Release 6. Prognostic factors were tested for association with CPD using conditional logic regression. The most important anthropomorphic risk factors for CPD were maternal head circumference in relation of height ( P < 0.001), and paternal head to height ratio ( P = 0.017). Head to height ratio is taken as the head circumference in centimeters divided by the height in metres. Body mass index was higher in CPD cases (maternal case mean = 27.1, control mean = 25.5; paternal case mean = 27.2, control mean = 26.2). Infant head circumference was not a predictor. Primiparity was an important independent predictor ( P <0.001), regardless of the mode of onset of labour. Maternal or paternal shoe-size, induction of labour and gestation at delivery were not predictors. The risk profile for CPD which emerges is one of a tall father where both mother and father have large head-to-height ratios.

Shoulder dystocia: risk factors and maternal and perinatal outcome.

Shoulder dystocia (S.D.) is an obstetric emergency which may be catastrophic for both mother and baby.The aims of this study were to determine the incidence of S.D., the maternal and perinatal outcome, and which risk factors were important. This was a retrospective review of all cases of S.D. during 1997 and 1998. Controls were selected as the next vaginal delivery following the S.D. case, matched for age, parity and gestation at delivery. Risk factors were compared between the two groups. There were 54 cases of S.D. over the study period, an incidence of 0·57% of 9541 vaginal deliveries. There were significant differences between cases and controls in birth weight, active phase of 1st stage of labour, 2nd stage of labour, episiotomy rate, third-degree tear rate, admission to SCBU and trauma to the baby at delivery. There were two infants with fractured clavicle and two with Erbs palsy.Shoulder dystocia (S.D.) is an obstetric emergency which may be catastrophic for both mother and baby. The aims of this study were to determine the incidence of S.D., the maternal and perinatal outcome, and which risk factors were important. This was a retrospective review of all cases of S.D. during 1997 and 1998. Controls were selected as the next vaginal delivery following the S.D. case, matched for age, parity and gestation at delivery. Risk factors were compared between the two groups. There were 54 cases of S.D. over the study period, an incidence of 0.57% of 9541 vaginal deliveries. There were significant differences between cases and controls in birth weight, active phase of 1st stage of labour, 2nd stage of labour, episiotomy rate, third-degree tear rate, admission to SCBU and trauma to the baby at delivery. There were two infants with fractured clavicle and two with Erbs palsy.

Fertility after abdominal myomectomy

This study aimed to evaluate the morbidity and pregnancy outcome of myomectomy in infertile women with uterine fibroids. This was a cross-sectional study. Records were reviewed for 100 consecutive women in the Rotunda Hospital who underwent myomectomy in the years 1995-1996. A questionnaire regarding subsequent fertility was sent. The study was carried out in the infertility unit at the Rotunda Hospital, Dublin, Ireland. Seventy-five women responded. Multiple myomectomy was performed in 52 (70%). Mean fibroid size was 6.8 cm (range 2-14.5 cm). Nine women (12%) developed complications; five had menstrual problems, two had wound discomfort and two had abdominal discomfort. Twenty-five women (33%) became pregnant. Seven (28%) were IVF pregnancies. Overall six (24%) miscarried. In 19 of 25, pregnancy occurred where fibroids were the only identifiable cause of infertility. We conclude that abdominal myomectomy is associated with a favourable outcome in infertile women particularly if no other confounding variable is present.This study aimed to evaluate the morbidity and pregnancy outcome of myomectomy in infertile women with uterine fibroids. This was a cross-sectional study. Records were reviewed for 100 consecutive women in the Rotunda Hospital who underwent myomectomy in the years 1995-1996. A questionnaire regarding subsequent fertility was sent. The study was carried out in the infertility unit at the Rotunda Hospital, Dublin, Ireland. Seventy-five women responded. Multiple myomectomy was performed in 52 (70%). Mean fibroid size was 6.8 cm (range 2-14.5 cm). Nine women (12%) developed complications; five had menstrual problems, two had wound discomfort and two had abdominal discomfort. Twenty-five women (33%) became pregnant. Seven (28%) were IVF pregnancies. Overall six (24%) miscarried. In 19 of 25, pregnancy occurred where fibroids were the only identifiable cause of infertility. We conclude that abdominal myomectomy is associated with a favourable outcome in infertile women particularly if no other confounding variable is present.

Uterine artery embolisation as an interval adjunct to conservative management of placenta praevia increta.

A 32-year-old gravida 3 who presented at 26 weeks’ gestation with antepartum haemorrhage underwent MRI examination. This identified a complete placenta praevia increta with no extension into the bladder. Her previous two deliveries were by caesarean section. At 36 weeks’ gestation, she underwent caesarean section and a conservative approach was adopted to minimise the risk of requiring peripartum hysterectomy. A classical uterine incision was made clear of the upper limit of the placenta, as identified by intraoperative ultrasound. An uncomplicated breech extraction of a female infant ensued and the placenta was left undisturbed. The umbilical cord was ligated near the chorionic plate and the uterine incision was closed. Intraoperative blood loss was minimal. Intravenous oxytocin, intracavitary and rectal misoprostol were administered for 24 h. Parenteral antibiotic cover (ampicillin, clindamycin and gentamicin) was instituted for 7 days. A secondary haemorrhage occurred 3 weeks later, necessitating referral for interventional radiology. An initial non-selective aortogram showed hypertrophied uterine arteries bilaterally feeding the highly vascular placental mass. The uterine arteries were embolised using Gelfoam pledgets (36 5 cm ‘Lyostypt, bovine collagen), 700 – 900 mic embospheres, and coils (3 mm6 3 cm), until there was no demonstrable flow into the placental mass. At 6 weeks postpartum she was readmitted with clinical sepsis and MRI revealed a 10610 cm necrotic mass (Figure 1) which required examination under general anaesthesia with transcervical piecemeal removal of necrotic placental tissue performed under ultrasound guidance. Her remaining postpartum course was uneventful and regular menses resumed after 12 weeks.

Teenage pregnancies and risk of late fetal death and infant mortality

This paper presents findings of a study of 2228 teenage pregnancies delivered in 1992-96 at the Rotunda hospital. About 17.2% of the total teenage population was delivered in the Republic of Ireland. The teenagers were divided into two groups those under 17 years of age and those aged 17 years or older. The authors findings were similar to those of Otterblad Olausson et al. in that prematurity increased when all teenagers were compared with a group of mothers aged 20-25 years. However unlike the Swedish study when mothers younger than age 17 were compared with those aged 17 or older there was no significant difference in the rate of premature deliveries. The authors investigated admission rates to the neonatal intensive care unit as a measure of early neonatal well-being because their figures were too small to interpret infant mortality. They found that only 2.7% of babies born to teenage mothers were admitted. The main reason for admission was low birth weight (72% of all cases) a possible reflection of prematurity. Another factor may be a tendency identified over the study period of an increasing number of low-birth-weight babies born to teenage mothers independent of gestation. The authors study therefore disagrees with that of Otterblad Olausson et al. Indeed the incidence of cesarean section in the authors 14-15 year olds was 5.5% compared with 13.5% in the 19-year olds. (full text modified)

Combination of vasa praevia, true umbilical cord knot and a subserosal hemorrhage

Sir, We would like to describe a remarkable combination of three potentially lethal obstetric complications, diagnosed postnatally. A 30-year-old primigravida presented at term with spontaneous rupture of membranes, following an uncomplicated pregnancy. After 6 h the liquor became bloodstained. Cardiotocograph monitoring was satisfactory. Labor commenced spontaneously but oxytocin was required after 2 h for slow progress. Epidural anesthesia was provided. Three hours later, a prolonged deceleration occurred lasting 4 min. Examination findings revealed a 4 cm dilatation and fresh vaginal bleeding. An emergency cesarean section was performed. A live male weighing 3.62 kg was delivered, (Cord pH of 7.34 BE-1.7 and 7.37 pH-1.7; Apgar scores 9 and 10). The neonatal hemoglobin was 19. Interestingly, at the time of operation, there were several unusual findings noted; (a) a spontaneous subserosal hematoma on the anterior aspect the lower segment of the uterus, (b) a true knot of the umbilical cord and (c) two ruptured vasa praevia. The latter were confirmed by histology. There were no further complications. The incidence of a true knot of the umbilical cord is 1.2% w3x. There is an increased risk (fourfold) of fetal death (1.9% vs. 0.5% P-0.0001) w3x. There is also a significantly inreased chance of fetal distress of 7% compared to 3.6% P-0.001 w3x. The incidence of a vasa praevia is estimated at 1:2,000 to 1 in 5,000 deliveries w2x. If these vessels are ruptured, there is a 75–100% fetal loss rate w2x, which has been associated with a sinusoidal heart-rate pattern. Antenatal diagnosis has been advocated by some centers with experience in color Doppler flow ultrasound scans. However, in practice, vasa praevia is not usually suspected antenatally. The literature suggests that a low-lying placenta in the second trimester is significantly associated with vasa praevia w1x, suggesting a potential role for scanning these women near term with color-flow imaging. The incidence of a spontaneous subserosal uterine hemorrhage is unknown. We present this case as an interesting collection of rare diagnoses, with a fortunate outcome. Considering the rarity of the diagnoses, we cannot recommend any change in obstetric practice.

Randomised clinical trial of suture compared with adhesive strip for skin closure after HRT implant

Sir, The paper by Daniel Selo-Ojeme and K.B. Lim has concluded that adhesive strips for implant skin incision closure is not recommended. They made no reference to the type of local anaesthetic which was used in their study. For the last five years, I have used bupivacaine hydrochloride with adrenaline (5 Ag/mL) for subcutaneous infiltration prior to inserting the hormone implant. Before this I used lignocaine hydrochloride without adrenaline. When using lignocaine, I always used sutures because of bleeding. However, having changed to bupivacaine with adrenaline, blood loss is insignificant at the time of the incision and adhesive strips are used as routine. I do not have to insert a suture since changing to bupivacaine with adrenaline and I have had no post-treatment haemorrhage. I would recommend that the authors consider a randomised trial comparing these two types of local anaesthetic combined with adhesive strips for skin closure.