Tze K. Lau

Amnioinfusion for the Prevention of Meconium Aspiration During Labour

EDITORIAL COMMENT: We accepted this paper for publication to appear in the same issue of the Journal as Risk Factors for Meconium‐Aspiration Syndrome (A) because this Hong Kong study has the considerable advantage for readers in that it gives the results obtained in a modern obstetric hospital with implementation of the regimen of amnioinfusion in patients with meconium‐stained liquor when delivery is not imminent and there is no indication for immediate Caesarean section. This carefully written study also is, as the authors indicate, a warning for those who are doing clinical trials. Although the patients were matched with a control series, these women were not appropriate controls because they tended to deliver soon after the observation of meconium‐stained liquor and hence the different outcomes in the 2 groups are probably explained by factors other than whether amnioinfusion was used. However, this series does indicate that amnioinfusion is associated with a reduced incidence of meconium‐aspiration syndrome in comparison with the previous incidence in the institution prior to the initiation of this technique. As the authors state in their conclusion, the incidence of cardiotocographic abnormalities and need for Caesarean section in these patients indicate that amnioinfusion is no guarantee that labour will proceed uneventfully or safely. We leave it for readers to decide whether we have reached the stage that amnioinfusion can be recommended in patients with meconium‐stained liquor where it is thought safe to allow labour to proceed or whether there should be a further, larger, controlled trial of patients with meconium‐stained liquor to see whether amnioinfusion is as valuable as this paper suggests may be the case. Our reviewers literature search revealed that amnioinfusion has been evaluated when there is umbilical cord compression (potential, or diagnosed by variable fetal heart rate decelerations during labour) or when there is intrapartum evidence of oligohydramnios as well as when there is meconium‐stained liquor. It may be noted that amniotic fluid embolism has been reported after saline amnioinfusion (B). A review of practice in the United States representing 644,910 deliveries and 22,833 amnioinfusions concluded that the procedure is performed nationwide with neither the method employed nor the number of infusions performed having a significantly increased risk of having a complication (C).

Re: Effects of rosiglitazone on hormonal profile and ovulatory function in Chinese women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a disorder characterised by chronic anovulation, hyperandrogenism and hyperinsulinaemia. Treatment using insulin-sensitizing agents had yielded promising results. Rosiglitazone is a relatively new insulin-sensitizing agent belonging to the thiazolidinedione class. There are only limited data concerning the therapeutic efficacy of rosiglitazone in women with PCOS, especially in a Chinese population. We conducted a prospective observational study to evaluate the effects of rosiglitazone in seven Chinese women with PCOS (defined by the National Institutes of Health (NIH) criteria). The study consisted of four menstrual cycles. The first cycle was observational only without any treatment. Rosiglitazone 4 mg daily was given throughout the second to fourth cycles. Preand post-treatment hormonal and biochemical profiles were compared by the paired t-test. The mean age and body mass index were 28.1 years and 24.5 kg/m, respectively. After rosiglitazone therapy, there was a significant increase in day 21 progesterone levels (2.3 ± 0.7 vs. 12.5 ± 8.4 nmol/L, P = 0.019) and a significant reduction in luteinizing hormone to follicular stimulating hormone ratios (1.3 ± 0.8 vs. 0.7 ± 0.5, P = 0.049). Three out of seven (42.9%) cycles required progestogen induced withdrawal before commencement of rosiglitazone; this reduced to 3 out of 21 cycles after treatment (14.3%) (P = 0.14). There were no differences in free testosterone (T), androstenedione, dehydroepiandrosterone sulphate, sex hormone binding globulin, fasting insulin and glucose before and after treatment. There is also no significant difference in hirsutism score and acne score before and after rosiglitazone therapy. Recent studies suggested that rosiglitazone is effective in correction of hyperandrogenism and reversal of anovulation in women with PCOS. However, these data mainly studied Caucasian patients. Because there are known differences in presentation and biochemical profile of PCOS patients of different ethic origins, we conducted the present study to evaluate the effects of rosiglitazone in Chinese women. In the present study, we found that there is a significant increase in luteal phase progesterone levels and reduction of luteinizing hormone/follicular stimulating hormone ratios after rosiglitazone therapy. This translates to a higher percentage of spontaneous menstruation without the need of progestogen withdrawal therapy, although the difference did not reach statistical significance because of the small number. However, there was no significant change in male hormonal profile after rosiglitazone therapy. Similarly, in the study by Ghazeeri et al., treatment with rosiglitazone resulted in the resumption of ovulation but no significant changes in testosterone and dehydroepiandrosterone sulphate. On the other hand, significant reduction in androgen levels was reported in other recent studies. The lack of change in androgen levels in our study may be the result of the small sample size or ethnic different in participants; further studies are required to explore this area. Nevertheless, the present study shows that the use of rosiglitazone may lead to the resumption of ovulation and menstruation in Chinese women suffering from PCOS. Although the present study involves only a small number of patients, it shows that the option of rosiglitazone is feasible, and further study with a larger sample size and longer followup to evaluate the effects of rosiglitazone alone in PCOS women would be worthwhile.

Re: Reasons for requesting pregnancy termination and attitude of women when request is being refused: A face‐to‐face interview study

We would like to report this magnetic resonance urography (MRU) image, showing bilateral ureterohydronephrosis in a 22-week pregnant patient carrying twins (Figure 1). This is, to our knowledge, the first reported MRU image of such a condition during twin pregnancy. Both obstructions of the ureters seem to be due to the proximal baby (shoulder on the right side, white arrow, and feet on the left side, black arrow). Since it has not been surely ruled out that X-rays are harmful to the fetus in late pregnancy, MRU provides excellent imaging of the urinary tract, without exposure to X-rays or the need to use intravenous contrast enhancement, especially in case of ureterohydronephrosis. Moreover, it offers information about the position of the fetus or associated interesting maternal or fetal conditions as in this case.

Pyometra: What Is Its Clinical Significance?

OBJECTIVE To evaluate the clinical outcomes of pyometra. STUDY DESIGN Retrospective study conducted between 1993 and 1999 in two regional hospitals. RESULTS Pyometra represented 0.038% of gynecologic admissions. Of the 27 women with pyometra, 6 (22.2%) cases were associated with malignancy, 1 (3.7%) was associated with genital tract abnormality, and 20 (74.1%) were idiopathic. Patients with idiopathic pyometra tended to be older and had a higher incidence of concurrent medical conditions. Five (18.5%) women experienced spontaneous perforation of pyometra. A preoperative diagnosis was correctly made in 17 of 22 (77.3%) patients without spontaneous perforation. Most women were treated with dilatation of the cervix and drainage. Nine women (33.3%) had persistent or recurrent pyometra; three of them were asymptomatic. CONCLUSION Pyometra is an uncommon condition, but the incidence of associated malignancy is considerable, and the risk of spontaneous perforation is higher than previously thought. Dilatation and drainage is the treatment of choice, and regular monitoring after initial treatment is warranted to detect persistent and recurrent disease.