Susan M. Tuck

Pregnancy in sickle cell disease in the UK: results of a multicentre survey of the effect of prophylactic blood transfusion on maternal and fetal outcome

Objective To determine the outcome of pregnancies complicated by sickle cell disease in the UK during 1991‐1993 and the effect of prophylactic blood transfusion programmes on maternal and fetal outcome.

Fertility in β thalassaemia major: a report of 16 pregnancies, preconceptual evaluation and a review of the literature

Objectives To examine the pregnancies, mode of delivery and outcomes, review the literature on fertility and discuss preconceptual guidance for women with β thalassaemia major.

Spontaneous uterine rupture during subsequent pregnancy following non‐excision of an interstitial ectopic gestation

A 35 year old woman with nine weeks amenorrhoea was admitted to hospital complaining of painless vaginal bleeding; her first pregnancy had resulted in a spontaneous miscarriage at eight weeks gestation, and it did not require evacuation of retained products. She had a regular 28 day menstrual cycle and had not been using contraception. Vital signs were normal and pelvic examination revealed a normal sized uterus and no adnexal tenderness. A urine test for human chorionic gonadotrophin (hCG) was positive, and transvaginal ultrasound scan showed a thickened endometrium of 12 mm and a corpus luteal cyst on the left side. A diagnostic laparoscopy was performed at which a smooth left-sided ovarian cyst approximately 5 cm x 5 cm, was the only abnormality. The uterus was not curretted at this time. The patient was reviewed two weeks later when a repeat urinary hCG was still positive. Transvaginal ultrasound scan showed echogenic areas in the right fundal region compatible with retained products of conception. Attempted evacuation of retained products of conception (ERPC) the same day failed to yield either endometrial or trophoblastic tissue. A repeat serum P-hCG remained elevated at 889 iu/ml two weeks following the ERPC ; in view of this and the persistent ovarian cyst, a laparotomy was performed eight weeks after initial presentation. The operative finding of a right cornual cystic enlargement was thought to be compatible with an interstitial ectopic pregnancy and a corpus luteal cyst measuring 4 cm x 2-5 cm x 1.5 cm. It was decided to excise the corpus luteal cyst in order to induce regression of the ectopic pregnancy. Histology confirmed the benign nature of the cyst, and there was no evidence of an ovarian ectopic gestation. Post-operatively, the serum P-hCG returned to within normal limits after two weeks. Although the presence of an interstitial ectopic pregnancy was not confirmed histologically, the presumptive diagnosis was

The effects of subcutaneous hormone implants during the climacteric

Climacteric symptoms in 120 women were treated with a total of 469 hormone implants (oestradiol 50 mg and testosterone 100 mg) over a period of four years. All patients with a uterus were given an oral progestogen to prevent endometrial hyperplasia. There was a marked response to treatment, hot flushes being improved in all patients, depression in 99% and loss of libido in 92%. Patient acceptability of this type of treatment was good and there were few side effects or complications. After therapy, the serum oestradiol exceeded the serum oestrone but remained within normal limits. When climacteric symptoms returned and re-implantation occurred the serum levels of oestrone, oestradiol, luteinising hormone (LH), follicle stimulating hormone (FSH) and testosterone were within the normal range for the reproductive age. This indicates that the return of symptoms is due to a change in the hormone levels rather than absolute hypo- oestrogenism .

Prophylactic blood transfusion in maternal sickle cell syndromes.

Summary. An assessment of the benefits of prophylactic blood transfusion during 51 pregnancies in women with haemoglobin SS, haemoglobin SC and haemoglobin S‐β‐thalassaemia in a retrospective study from 1978 to 1984 has failed to demonstrate any clear conclusions as to their efficacy. Of the transfused patients, 22% developed atypical red cell antibodies and 14% had immediate minor transfusion reactions. Our data show no significant difference in fetal or maternal outcome between those patients who were transfused prophylactically and those who were not. A prospective study to clarify the appropriate place of this important aspect of management in women with sickle cell disease in pregnancy is suggested.

Obstetric characteristics in different racial groups

Summary. A detailed analysis of 2632 consecutive pregnancies in white, black and Asian women, who were delivered during the period 1978 to 1980, found significant differences between the three ethnic groups. Asian primiparae had the longest first and second stages of labour, with the highest incidence of prolonged latent phase (14%) and primary dysfunctional labour (30%). Black primiparae and multiparae had the highest incidence of secondary arrest in the first stage of labour (10% and 4% respectively) and of primary dysfunctional labour, with the greatest recourse to emergency caesarean section (13% and 4% respectively). The mean birthweight for singletons born between 37 and 42 weeks was 3.37 kg for white babies, 3.25 kg for black babies and 3.14 kg for Asian babies. There was no racial difference in perinatal mortality or morbidity in this survey.

Fertility and Pregnancy in Thalassemia Major

Abstract: Over the last 15 years, 22 women with thalassemia major have completed 29 pregnancies at the Royal Hospital in London. The major pre‐pregnancy issues, medications, and pregnancy care are reviewed. Experience suggests that, with proper care and guidance, pregnancies among women with thalassemia major are practical and can have successful outcomes.

Elevated concentrations of retinol-binding protein-4 (RBP-4) in gestational diabetes mellitus: Negative correlation with soluble vascular cell adhesion molecule-1 (sVCAM-1)

Background. Retinol-binding protein-4 (RBP-4) may increase insulin resistance (IR) in animals, with elevated levels reported in humans with obesity and type 2 diabetes. There are, however, few data on concentrations of RBP-4 in gestational diabetes mellitus (GDM). Methods. We measured fasting serum levels of RBP-4, soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) in 50 women at 28 weeks of gestation, divided according to the results of a 50 g glucose challenge test (GCT) and a 75 g oral glucose tolerance test (OGTT): (1) controls (n = 20), normal responses to both GCT and OGTT; (2) intermediate group (IG) (n = 15): false positive GCT, but normal OGTT; and (3) GDM group (n = 15), both GCT and OGTT abnormal. IR was assessed by homeostasis model assessment (HOMA-IR) and by insulin resistance index (IRI) based on glycemia and insulinemia during OGTT. Results. All groups were matched for age and body mass index (BMI). RBP-4 levels (μg/ml, mean±standard deviation) were higher in women with GDM vs. controls (53.9 ± 17.9 vs. 29.7 ± 13.9, p ≤ 0.001), with a trend towards higher RBP-4 in GDM compared with IG (38.0 ± 19.3, p = 0.07). There was no significant correlation between RBP-4 and age, BMI, insulin, IRI or HOMA-IR, but there was a moderate, significant negative correlation between RBP-4 and sVCAM-1 (r2 = 0.20, p = 0.001). Conclusions. RBP-4 levels are elevated in women with GDM, but do not correlate with IR indices and correlate negatively with sVCAM-1. The physiological significance of RBP-4 rise in women with GDM remains to be elucidated.

Pregnancy in women with sickle cell trait

Summary. The complications and outcome of 334 pregnancies in women with sickle cell trait beween 1975 and 1981 are reviewed. The perinatal mortality rate was 6 per 1000. The main maternal complications were recurrent urinary tract infections (6%) and haematuria (16.5%). Fetal distress in labour was seen in 17% and 11.5% were delivered by emergency caesarean section. Compared with a comparable group of women without sickle cell trait, the mean birthweight of the babies (3202 g) was not reduced. The mean age of the mothers (25 years), their mean parity (1.46) and the percentage who were para 4 or more (13%) were all significantly increased, with important implications for the continuing transmission of the sickle cell gene.

Red cell deformability in oral contraceptive pill users with sickle cell anaemia

The use of the combined oral contraceptive pill (COCP) in women with sickle cell anaemia (SCA) is controversial, as contraceptive steroids are thought to adversely affect erythrocyte deformability. This observational study was performed to investigate whether hormonal contraception influenced erythrocyte deformability in women with SCA. 30 women with SCA using various contraceptive modalities: COCP (n = 10); progestogen only (PO) contraception (n = 10) and non‐hormonal contraception (n = 10) were recruited. Erythrocyte deformability was assessed using the clogging rate (CR) and red cell transit time (RCTT). There was no statistical difference in the mean CR and RCTT between the three groups of women (one‐way ANOVA). Current contraceptive steroids do not appear to impair red cell deformability in women with SCA.