bluuebunny/crossref_metadata_2025 huggingface dataset:
CO2 Laser Laparoscopic Salpingotomy for Treatment of Tubal Ectopic Pregnancies: Potential Limitations
Authors: O'Shea Robert T. , Thompson Graeme R. St J.
Published: February 2008

EDITORIAL COMMENT: In appropriate selected cases (no shock, no active bleeding, no significant adhesions and no very high HCG levels) the treatment of choice of tubal ectopic pregnancy is by laparoscopic conservative surgery (salpingotomy). A laparoscopic approach compared to laparotomy, has proven economic advantages (shorter hospital stay and convalescence and earlier resumption of normal occupation) and suspected clinical advantages (less adhesion formation and better subsequent viable pregnancy rates) awaiting randomized prospective controlled studies for verification. Laparoscopic salpingectomy can also be performed with laser, as in this paper, or with cutting/coagulation diathermy (which is much, much cheaper) which yields comparative results. Salpingotomy can be performed laparoscopically with safety and could have been considered for one of the patients in this series who returned to theatre. The persistence of trophoblastic tissue requiring further treatment (usually methotrexate) occurs in about 10% of cases. Raphael Kuhn, Melbourne

Summary: Linear salpingotomy was performed on 16 patients using the CO2 laser laparoscopically directed. Median operating time was 60 minutes (range 40–100) and all patients were discharged on the first postoperative day. There were 4 patients in whom persistence of trophoblast activity was detected, 2 of whom were treated surgically and 2 by oral methotrexate therapy.

Conservative techniques for the treatment of ectopic pregnancy have proliferated since 1953 (1–4) being made possible because of the early presentation of patients and the more sensitive methods of intrauterine pregnancy detection. In the past decade laser technology has been added to the armamentarium of infertility surgeons and there have been 2 reports (5,6) of its successful use in cases of ectopic pregnancy. The present study aimed to examine the application of this technique in our patient population and to investigate any associated problems.
The Effect of Condom Use on Cervical Intraepithelial Neoplasia Grade I (CIN I)
Authors: Thomas Ifor , Wright Gordon , Ward Bruce
Published: February 2008

EDITORIAL COMMENT: This study shows how necessary it is for any research finding relevant to patient care or clinical belief to be verified before enshrinement in the regimens of clinical practice — the more important the finding, the more necessary the verification. This paper will not be the last word on the effect of condom use on prevention of initiation or progression of cervical intraepithelial neoplasia, but it does make one wonder if the role of seminal fluid in the pathogenesis of carcinoma of the cervix should be reexamined — or is the die cast and the role of seminal fluid as carcinogenic factor complete once there is histological evidence of intraepithelial neoplasia Grade 1?

Summary: A prospective, controlled study of condom use in patients with histologically‐proven CIN I was undertaken. Forty‐six patients were studied, 22 by random allocation and 24 by nonrandom allocation to either condom use or non‐condom use for 6 months. At the end of this time, patients were reassessed cytologically, colposcopically and histologically. There was no significant difference between the groups with respect to outcome. Six patients' lesions (13%) progressed in this period, 5 (11%) to CIN III. Condom usage is not an effective treatment for CIN I.
Medical Management of Phaeochromocytoma in Pregnancy
Authors: Oliver M. D. , Brownjohn A. M. , Vinall P. S.
Published: February 2008

EDITORIAL COMMENT: The 2 papers in this issue of the journal on secondary hypertension amenable to treatment were accepted for publication to remind readers that patients with hypertension, especially in early pregnancy when pregnancy‐included hypertension is a less likely cause, require investigation to exclude the rare curable causes — renal artery stenosis, coarctation of the aorta, phaeochromocytoma, Conn syndrome. Case 1 in this paper highlights the need to investigate thoroughly cases of recurrent preeclampsia despite the fact that hypertension settles between pregnancies. The need for localizing the tumour necessitates a separate operation postpartum. Not all phaeochromocytomas are in the adrenal gland; localization therefore requires nuclear medicine scanning and CT scanning.
A Randomized Controlled Trial of Extra‐amniotic Ethinyloestradiol for Cervical Ripening in Multiparas
Authors: Peedicayil Abraham , Jasper Padmini , Balasubramaniam N , Jairaj Prabha
Published: February 2008

EDITORIAL COMMENT: It is a pity that this study did not include a third group of patients with a Foley catheter alone passed into the extra‐amniotic space—since, as the authors note, it could be that a Foley catheter is as effective as ethinyloestradiol in ripening the cervix and shortening the induction‐delivery interval. Another comment made by the referee was that since both groups of patients had mean induction‐delivery intervals of less than 5 hours, the results of this study suggest that an unfavourable cervix is not an important prognostic entity for the ease of induction of labour in multiparas. It should be noted that all patients also had amniotomy and oxytocin infusions 12 hours after the extra‐amniotic introduction of the Foley catheter.

AUTHORS' COMMENTS ON OUR COMMENT: Though the oestradiol and control groups had induction‐delivery intervals under 5 hours, both had shown improvement in cervical score before amniotomy. We cannot conclude from this study that an unfavourable cervix is not an important factor in multiparas. Studies with only amniotomy and oxytocin in multiparas revealed a Caesarean section rate of 7 to 8% (Aust NZ J Obstet Gynaecol 1985: 25: 190–193) and induction delivery intervals that often exceed 8 hours (Obstet Gynecol 1976, 48: 635–641; J Obstet Gynaecol India 1984; 34:972–979). Of course induction is much easier in multiparas than in primiparas but whether we can altogether do without ripening, we are uncertain. The Foley catheter is an effective cervical ripener (Br J Obstet Gynaecol 1980; 87: 281–286) and was probably responsible for the cervical change in the control group. Therefore it turned out that oestradiol did not have any extra advantage.

ABSTRACT A double‐blind randomized controlled trial was carried out to determine if ethinyloestradiol applied extra‐amniotically would ripen the unfavourable cervix at term. Twenty five multiparas were given 150 mg ethinyloestradiol gel while 25 multiparas were given gel alone. There was no difference between the ethinyloestradiol and control groups in either mean change of Bishop score or the induction‐to‐delivery interval.
Rupture of a Splenic Artery Aneurysm in Pregnancy
Authors: Hayde S. M. , Gillett W. R. , Thompson I. A.
Published: February 2008

EDITORIAL COMMENT: This case of ruptured splenic artery aneurysm had a fortunate outcome for mother and baby since Caesarean section was performed promptly, because of critical fetal condition, when acute abdominal pain was thought to be due to placental abruption. The Pfannenstiel incision was inappropriate but did not preclude successful management. We accepted this case report for publication to remind readers that this uncommon cause of acute abdominal pain has a predilection to occur during pregnancy and the puerperium — the condition should be considered in any pregnant woman who experiences acute abdominal pain and/or collapse when there is no revealed haemorrhage. This case seems to be another of live(s) saved by cardiotocography.
Single Intrauterine Fetal Death in a Suspected Monozygotic Twin Pregnancy
Authors: Cattanach Stephen A. , Wedel Maura , White Susan , Young Michela
Published: February 2008

EDITORIAL COMMENT: We accepted this case for publication because the management of a patient with intrauterine death of one twin is an interesting problem and recent literature has, in our opinion, overemphasized the risk of intravascular coagulopathy in the surviving twin i.e. we consider these patients are managed too aggressively. The authors have reviewed the literature and the experience in their own institution and concluded that conservative management is indicated, especially in a preterm pregnancy. Although fear of litigation is a factor, the management of these patients is not clearcut. This is because the condition is uncommon and the complication may be unrecognized—e.g. in this series the time of fetal death was known in only 2 of 13 cases in which the dead fetus succumbed before the onset of labour (i.e. was macerated). With modern methods of diagnosis of twin pregnancy (ultrasonography) and fetal condition (cardiotocography), death of one t win is much more likely to be recognized and so provide the obstetrician with a management decision. Ultrasonography as reported by Cheung et al in this issue may indicate the presence of monochorionic twins and hence the greater risk of intravascular coagulopathy—however, since prematurity is the greatest hazard in the majority of cases, we would favour conservative management until 37 weeks' gestation, if fetal movements are normal and cardiotocography and ultrasonography reveal no abnormalities. We consider that intrauterine death of one twin does not constitute an indication for elective Caesarean section as the method of delivery in the absence of signs of fetal distress, unless there is ultrasonographic evidence that the twins are of the rare monoamniotic variety with the 25% risk of cord entanglement or knotting.

ABSTRACT The antepartum death of a fetus in a twin pregnancy is associated with significant risk of mortality and morbidity in the surviving infant. A recent case of single intrauterine death in a suspected monozygotic twin pregnancy at a regional hospital prompted a study of similar cases in the hospital's recent experience and a review of the current literature. We report the successful conservative management of fetal death in a monozygotic twin pregnancy.
Uric Acid in Pregnancy and Preeclampsia: An Alternative Hypothesis
Authors: Fay Roger A.
Published: February 2008

EDITORIAL COMMENT: This hypothesis that the rise in serum uric acid in patients with preeclampsia is secondary to placental damage rather than alteration in renal function will interest readers. A major problem with the hypothesis is acceptance that raised serum uric acid levels are a feature of normal pregnancy although this was the finding in a careful study recently reported in this Journal (Carter J, Child A. Serum uric acid levels in normal pregnancy. Aust NZ J Obstet Gynaecol 1989; 29: 313–431). This hypothesis could be tested by performing uric acid clearance studies in normal pregnancy and in patients with preeclampsia and relating it to creatinine clearance.
Major Gynaecological Surgery in Patients with Severe Coronary Artery Disease — the Combined Approach
Authors: Kantian P. , Sivanesaratnam V. , Jeyamalar R. , Delilkan A. , Ong Grade
Published: February 2008

EDITORIAL COMMENT: It is generally concluded that despite advanced age, and associated medical problems, very elderly women can usually tolerate major gynaecological surgery, after careful preoperative medical evaluation and therapy. This paper considers the particular problem presented by severe coronary artery disease, and the necessary precautions during surgery are elaborated. The decision whether or not to operate in elderly patients will depend upon how pressing is the indication (it seemed imperative in the 2 cases presented here), and how willing is the patient (how distressing are her symptoms)!—in other words the same considerations as in younger women. It is remarkable how well elderly women tolerate major gynaecological surgery as long as extra care is taken to avoid complications (blood loss, tissue trauma, infection, tight sutures in vaginal epithelium). However, in the editor's experience, coronary artery disease is the most common absolute contraindication to major gynaecological surgery in middle‐aged and elderly patients.

ABSTRACT The gynaecologist today is likely to encounter elderly patients with severe coronary heart disease requiring major gynaecological surgery. The successful outcome in 2 such patients with compromised coronary circulation and impaired left ventricular function emphasized the importance of combined care with the cardiologist and the anaesthetist. The insertion of a Swan‐Ganz catheter for close perioperative monitoring is vital. The intra‐and postoperative problems are discussed.
The Role of Bowel Surgery in the Primary Treatment of Epithelial Ovarian Cancer
Authors: Hammond R.H , Houghton C.R.S
Published: February 2008

Summary: Between January 1, 1979 and May 1, 1988, 24 of 192 patients treated for epithelial ovarian cancer underwent bowel surgery during primary therapy. It was found that survival was independent of this variable and depended largely upon the amount of residual disease following laparotomy. There was a major complication rate of 8% after primary bowel surgery, and this did not protect against the subsequent development of bowel obstruction. In conclusion, it is felt that bowel resection and anastomosis should only be undertaken if the patient is to be left with minimal or no macroscopic disease at completion of surgery.
Possible Causes Linking Asphyxia, Thick Meconium and Respiratory Distress
Authors: Coughtrey H. , Jeffery H. E. , Henderson‐Smart D. J. , Storey B. , Poulos V.
Published: February 2008

Summary: : The cause of fetal distress and neonatal respiratory distress (RD) in association with meconium‐stained liquor is not always clear. To clarify this, a prospective study was undertaken in a tertiary referral maternity hospital for 1 year. In all infants born after meconium‐stained liquor who developed RD, evidence was sought for 1) fetal distress (from the cardiotocograph (CTG), the cord blood pH, the Apgar score and the asphyxial complications in the neonate) 2) causes of fetal distress (including maternal risk factors, fetal infection and fetal malnutrition) 3) causes of respiratory distress (including meconium aspiration syndrome (MAS), persistent pulmonary hypertension of the newborn (PPHN) and infection).

Of 4,026 livebirths, 717 (17.8%) had meconium‐stained liquor and 44 term and 5 preterm infants developed RD. In the 44 term infants, there was frequent evidence of fetal distress possibly caused by previously unrecognized factors such as fetal malnutrition with reduced neonatal skinfold thickness in 35% triceps and 41% subscapular measurements, and histological chorioamnionitis (CA) in 74%. The cause for respiratory distress was identified in only 48% of infants, and included clinical evidence of PPHN (41%), MAS (16%) and infection (2%). However in preterm infants, 80% had definite or suspected infection.

The findings indicate that fetal distress is common in infants who develop respiratory distress after meconium‐stained liquor. A role for histological CA and reduced nutrition in the fetus, as factors contributing to the vulnerability of the term infant to intrapartum fetal distress, is suggested.
The Short‐term Outcome of Infants of Multiple Pregnancies Delivered Before 28 Weeks' Gestation
Authors: Nicholl Michael C. , Giles Warwick B.
Published: February 2008

Summary: : The short‐term outcomes of 29 multiple pregnancies delivered at Westmead Hospital between 20 and 28 weeks' gestation, during a 5‐year period are reported. The earliest gestation at which there was a survivor was 24 weeks. The overall survival rate was 25%. Of deaths, 11.1% occurred in the delivery suite, 85.2% in the neonatal period with a further 3.7% in the postneonatal period in hospital. The outcomes for second twins were generally poor. Of survivors at 12 months, 44% were judged to have a major impairment. Extremely preterm multiple pregnancies have a high mortality and morbidity rate.
Second Twin: Quality of Survival if Born by Breech Extraction Following Internal Podalic Version
Authors: Drew J. H. , McKenzie J. , Kelly E. , Beischer N. A.
Published: February 2008

Summary: : The intrapartum management of the vertex‐breech and vertex‐transverse twin gestation is controversial. The fall in perinatal mortality rate to a low level has resulted in this parameter failing to be an adequate gauge of the safety of breech extraction and the answer lies in the quality of survival of the infants. Fifty‐one twin pairs, collected over 12 years at the Mercy Hospital for Women, Melbourne, occurred where twin 2 was born by breech extraction following internal inversion and the control (twin 1) did not have this procedure performed. In 8 pairs either a stillbirth or neonatal death occurred; in one pair childhood death due to an accident (fire) occurred; in 4 pairs the parents refused entrance to the study as they perceived both twins to be similar; in 2 sets the assessment was incomplete; 11 sets were untraceable leaving 25 sets fully assessed as children ranging in age from 2 to 12 years. Growth, and psychological scores were not significantly different between twins 1 and 2 but 2 children had cerebral palsy and both were born by breech extraction following internal version at 29.2 and 30.1 weeks' gestation, respectively. Because of small numbers the results failed to achieve statistical significance and this study was unable to answer the question regarding the safety of breech extraction following internal version but did show that the majority of infants so born do well.
Management of Infective Endocarditis in Pregnancy
Authors: Jeyamalar R. , Sivanesaratnam V.
Published: February 2008

EDITORIAL COMMENT: : We accepted this paper for publication to remind readers that bacterial endocarditis can occur in pregnancy and requires prompt diagnosis and treatment for favourable results. Fever and/or urinary symptoms should suggest the diagnosis especially when the women is known to have a cardiac murmur. We were interested to read how echocardiography can reveal the presence of vegetations on affected valves. Our cardiologist reviewer was not 100% convinced that the diagnosis was proven in Case 1 since ‘many patients would have bacteraemic episodes with a known cardiac lesion which does not necessarily go on to produce endocarditis’. Our reviewer considered the diagnosis in Case 2 to be clear‐cut, but was surprised how successful antibiotic therapy alone was in view of the evidence of peripheral embolization.
A Case Controlled Study of Pregnancy Complicated by Severe Maternal Anaemia
Authors: Duthie S. J. , King P. A. , To W. K. , Lopes A. , Ma H. K.
Published: February 2008

Summary: : The perinatal outcome of 96 patients who had an antenatal haemoglobin value of less than 8.0 g/dl was compared with that of a similar number of controls who were matched for age and parity. Sixty‐one patients (63%) had iron deficiency anaemia, 25 (26%) had alpha or beta thalassaemia minor, 7 (7.3%) had iron deficiency and thalassaemia trait, 2 had idiopathic pancytopenia and 1 had naemolytic anaemia due to systemic lupus erythematosus. Patients in the study group attended the antenatal booking clinic later, had less weight gain during pregnancy and their babies had lower birth‐weights (2,984 g versus 3,177 g p<0.01) although there was no significant difference in the period of gestation at delivery. Six patients in the study group had placental abruption and another 2 patients had stillbirths but neither of these complications occurred in the control group. Although 37 patients (39%) in the study group received an antenatal blood transfusion, 53 (55%) of this group also had postnatal anaemia.
Occasional Review: Allergy to Coitus
Authors: Jones W. R.
Published: February 2008

Summary: : Acute systemic hypersensitivity reactions to semen are rare but may be life‐threatening. Chronic or recurrent local reactions are more common and may be misdiagnosed as infective or nonspecific vaginitis. The antigen(s) involved in these reactions reside in a glycoprotein fraction of seminal plasma. Allergic vulvovaginitis may also occur in sensitized women when they are exposed to exogenous allergens such as drugs, food and infective agents during sexual activity.

Skin testing and other relevant investigations are indicated when these disorders are suspected. Condom usage will prevent symptoms of coital allergy. Desensitization has had variable success in acute systemic hypersensitivity. Precoital antihistamines may modify local reactions.
Treatment of a Patient with Severe Menstrual Migraine Using the Depot LHRH Analogue Zoladex
Authors: Holdaway I. M. , Parr C. E. , France J.
Published: February 2008

EDITORIAL COMMENT: : We accepted this case because of the unusual finesse of inducing reversible hypogonadism to decide if bilateral oophorectomy was indicated in a 38‐year‐old women with menstrual migraine. It seems strange that preoperative continuous oestrogen and/or progestogen regimens did not control her migraine which however did not return with oestrogen replacement therapy after bilateral oophorectomy and hysterectomy had been performed.

Summary: : Migraine occurring at menstruation is frequently difficult to treat. A 38‐year‐old woman with exceptionally severe menstrual migraine was treated by temporary ovarian suppression using Zoladex, a long acting luteinizing hormone‐releasing hormone agonist. There was prompt relief of headache, and after several months of treatment the patient elected to undergo surgical oophorectomy with subsequent resolution of her migraine. A trial of reversible hypogonadism using an LHRH agonist may thus be helpful in predicting the result of surgical castration in this situation.
An Aeardiac Twin
Authors: Comerford John A.
Published: February 2008

EDITORIAL COMMENT: : We accepted this case for publication because it nicely reviews the rare problem of an aeardiac twin which can be a cause of nonimmune hydrops in the ‘normal’ twin ‐ apparently the normal twin develops cardiac failure because of the extra circulatory burden. Such cases when diagnosed antenatally present the problem of timing of delivery, especially if the parasitic twin ‘dies’ (cessation of blood flow as assessed by Doppler study). In addition to serial ultrasonography to detect the onset of hydrops in the normal twin, regular cardiotocography is indicated since twin to twin transfusion may result in signs of severe fetal distress (type 2 decelerations, loss of beat to beat variation or sinusoidal pattern typical of fetal anaemia/ warranting prompt delivery.
Multifocal Endometrial Type Carcinoma Involving 5 Primary Sites in the Pelvis
Authors: Nelmes Peter , Delprado Warick , Cope Ian
Published: February 2008

Summary: : A case of widespread endometrioid carcinoma is reported. The concept of multifocal carcinoma in the pelvis is discussed.
Transabdominal Chorion Villus Sampling: A Safe and Reliable Procedure
Authors: Robinson H. P. , de Crespigny Ch. , Ngu A. C. , Robertson A. , J. L. Hallida B Sc(Hon)
Published: February 2008

Summary: A complete follow‐up of the first 578 patients undergoing transabdominal chorion villus sampling (TACVS) in our combined practices was undertaken to determine the pregnancy loss rate. Factors contributing to losses and the problems incurred in achieving a clinically relevant result were also examined.

It was found that increasing experience led to fewer procedural difficulties but that there persisted a higher problem rate in those women with a retroverted uterus. In 98.1% of patients an adequate volume of tissue was obtained and in 95.5% a clinically relevant result was achieved. This second figure rose to 96.3% in the latter part of the study. There was a total fetal loss rate of 2%, with only 0.5% (3 patients) having a missed abortion within 4 weeks of the procedure.

It is concluded that TACVS is a reliable procedure with a high level of safety.
Evaluation of Plasma Fructosamine as a Screening Test for Gestational Diabetes
Authors: Menon U. , Ranjan M. , Jasper P. , Oommen A.
Published: February 2008

EDITORIAL COMMENT: This study of 234 patients with indications for glucose tolerance testing in pregnancy indicates that although plasma fructosamine is elevated in patients with severe hyperglycaemia, the test is not a useful screening test to identify gestational diabetics.
Doppler Flow Velocity Waveform Analysis in Postdate Pregnancies
Authors: Stokes Helen J. , Roberts Rae V. , Newnham John P.
Published: February 2008

Summary: This study examines the efficiency of Doppler flow velocity waveform analysis in the evaluation of the postdate pregnancy. Seventy women whose pregnancies were at or beyond 41 weeks' gestation were assessed by calculating the systolic/diastolic ratios from umbilical and uteroplacental arteries. Waveform ratios from pregnancies associated with fetal compromise and abnormal neonatal outcome were similar to those from pregnancies in which the outcome was normal. These findings indicate that the pathophysiology of placental insufficiency in postdate pregnancies differs from that observed in cases of fetal growth retardation at earlier gestational ages. Doppler flow velocity waveform analysis is unlikely to be of benefit in the routine assessment of the postdate pregnancy.
The Second Stage of Labour: Durational Dilemmas
Authors: Dei‐ham Roger J. , Crowhurst John , Crowther Caroline
Published: February 2008

EDITORIAL COMMENT: We commend this essay on the second stage of labour to all readers since it will encourage them to rethink their management of the patient who is in the second stage of labour, without evidence of fetal or maternal distress. The editorial committee firmly agrees with the authors'belief that midforceps delivery is a dangerous manoeuvre and should be performed only when indicated, rather than because the patient is deliverable or because the second stage has exceeded a statutory period of 1–2 hours. We were taught many years ago, when difficult manipulative deliveries were more often resorted to, and when the Caesarean section rate was less than half of the present rate land the perinatal mortality rate was more than double the present rate J that ‘distress plus dystocia is dangerous for the fetus’ and we consider that this adage remains true. The permissible duration of the second stage of labour, when the head is on view, and where delivery can be readily effected by episiotomy, with or without low forceps delivery, is another mailer. In this instance the obstetric philosophy of the accoucheur will determine whether to act or to wait.

(A) Cacsaican section rate6.2%: perinatal mortality rale 3 5%, Medical and Clinical Report, Royal Women's Hospital. Melbourne, 1970.

Summary: The optimal management of prolonged second stage of labour remains a confused area of thought and action. This confusion is particularly evident when epidural analgesia is also being used. A review of the literature indicates that prolonged duration of the second stage, i.e. from full dilation of the cervix until delivery, with or without epidural analgesia, has little adverse effect on perinatal outcome. More attention should be paid to the expulsive phase of the second stage and greater efforts made to reduce unnecessary interventions.
The Impact of Multiple Induced Abortions on the Outcome of Subsequent Pregnancy
Authors: Lopes A. , King P. A. , Duthie S. J. , To W. K. , Ma H. K.
Published: February 2008

Summary: The obstetric outcome of 285 women with a history of previous multiple induced abortions is compared to that of 285 age matched primigravidas. In the study group, 219 women had 2 previous induced abortions and 66 had 3 or more, the maximum number being 8. There was a higher incidence of unmarried women and smokers in this group but a lower incidence of uneducated women. There was no difference in the incidence of antenatal complications between the 2 groups. The mean gestation at delivery, duration of labour and mode of delivery were comparable. There was an increased incidence (p<0.01) of retained placenta in the subgroup of women with 3 or more previous induced abortions. There were no maternal or perinatal deaths. The mean birth‐weight was comparable and there were no infants weighing < 1,500 g in cither group.

We conclude that multiple previous induced abortions appear to have minimal impact on the obstetric outcome of subsequent pregnancy in this population, and in the absence of other risk factors there is no need to alter standard obstetric management in this group of women.
The Use of 16.16‐dimethyl‐PGEl‐ A‐methyl ester (Cervagem) Vaginal Pessaries for Cervical Dilatation Prior to Evacuation for Second Trimester Termination
Authors: Bennett M. J. , .Horrowitz S. D. , Wass D. M.
Published: February 2008

Summary: The results of a study of 101 consecutive second trimester terminations by Dilatation and Evacuation (D & E) under ultrasound control is presented. All had a Cervagem pessary inserted into the vagina prior to the procedure. The PGE1 analogue was assessed as ‘effective’ in 97% of patients. Concomitant ultrasound resulted in no patient leaving the operating table with retained products. The high efficacy of the single pessary associated with a low incidence of side‐effects makes this combination the method of choice for nearly all second trimester terminations.
Second Trimester Abortion by Extra‐Amniotic PGF2 alpha Infusion: Experience of 178 Cases
Authors: Peat B.
Published: February 2008

EDITORIAL COMMENT: The need for second trimester termination of pregnancy is a reality in modern obstetric practice. However, in spite of the increasing advocacy of routine 17–18 week ultrasonography to identify major fetal malformations, and the increasing use of genetic counselling amniocentesis when indicated, the majority of second trimester terminations are performed for ‘psychosocial’ indications ‐ in 102 of 178 case in Peat's series and 87 of 101 cases in the preceding article by Bennett and colleagues. These 2 papers are complementary and both conclude, after reporting different methods, that surgical evacuation after cervical dilatation with a vaginally inserted prostaglandin pessary is a more satisfactory technique than that using extraamniotic infusion of prostaglandin F2 alpha. It is a well known and important fact that the operation of dilatation and piecemeal evacuation of the fetus and placenta is abhorrent to both the operator and all members of the nursing staff in attendance. The performance of the procedure under ultrasound control as described in the previous paper seems a major improvement in terms of avoiding damage to the uterus, and problems due to incomplete removal of the conceptus. Hopefully this is not the last word, and further refinement of technique will allow spontaneous expulsion in second trimester abortion ‐ the use of an orally administered antiprogesterone in addition to vaginal Cervagem pessaries (Rodger and Baird, 11), may, by shortening the induction‐abortion interval, result in a regimen more acceptable than surgical evacuation.

Summary: here is a continuing need for second trimester induced abortions, most recently due to the increase in the use of antenatal diagnostic procedures, amniocentesis, high resolution ultrasound and cordocentesis. To evaluate the efficacy and safety of extraamniotic infusion of PGF2 alpha for this purpose a retrospective review of 178 procedures was undertaken. There were 4 failures of the technique and the major complication rate was 5.6%. This rate was independent of gestational age The mean induction to abortion interval was 29.6 (+/‐ 16.3) hours. The conclusion reached after comparison with other published data is that extraamniotic PGF2 alpha infusion is a slow and painful but safe and effective technique, but that at gestational ages less than 17 weeks, a comparative trial of Dilatation and Evacuation versus extraamniotic PGF2 alpha infusion would be justified.
Was That Hysterectomy Really Necessary? Audit of Operative Justification at the Aga Khan University Medical Centre, Karachi
Authors: Rizvi Javaid H. , Afzal Wasim , AH Amjad , Khan Khalid S.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because readers may wish to use it as a model for scrutiny of their own hospital statistics, especially in Australia where the hysterectomy rate is probably considerably higher than in Pakistan.

Summary: Hysterectomy in Pakistan, like in other parts of the world is considered to be overused in a number of cases. As a part of a quality assurance process at the Aga Khan University Medical Centre, Karachi, 376 hysterectomies performed between January, 1987 and December, 1989 were retrospectively analysed and the results are presented. In 250 (66.5%) cases, where pathology was expected to be found, the hysterectomy was considered justified if the preoperative diagnosis was verified by the pathology report of if significant alternate pathology was present. In 126 (33.5%) cases, where no pathology was expected to be found ‘validation criteria’ were used to ascertain justification of the procedure. The results showed justification rates of 83% for recurrent uterine bleeding, 85% for adenomyosis, 90% for adnexal masses and endometrial carcinoma, 95% for fibroids, 97% for pelvic relaxation and 100% each for pregnancy catastrophe, endometriosis, chronic pelvic inflammatory disease and premalignant disease of uterus and cervix. In general 92.0% of all hysterectomies in this series were justified.
Pelvic Lymph Node Metastases in Early Invasive Carcinoma of the Cervix ‐ Histopathological ‘Risk’ Factors
Authors: Jayalakshmi P. , Sivanesarathnam V.
Published: February 2008

EDITORIAL COMMENT: The findings in this series of patients with early invasive carcinoma of the cervix supports other reports regarding the importance of depth of invasion and vascular space permeation in terms of lymph node metastasis. This paper in contrast to the preceding series reported from India showed a lower rate of positive lymph nodes in patients with adenocarcinoma than in those with squamous cell lesions. In neither of these papers was follow‐up sufficient to allow comment regarding survival. It is generally considered that adenocarcinoma of the cervix is likely to be associated with poorer prognosis when endocervical extension of the tumour is extensive before symptoms result in presentation and diagnosis.

Summary: Histopathological features in 89 cases of Stage IB and early 2A invasive carcinoma of the cervix who underwent Wertheim radical hysterectomy and pelvic lymphadenectomy were studied. Depth of tumour invasion and lymphatic/vascular space permeation by tumour cells were significantly associated with lymph node metastases. The other features such as tumour type, and stromal leucocytic reaction showed no significant relationship to the presence of lymph node metastases.
Incidence and Management of Obstructed Labour in Eastern Nigeria
Authors: Ozumba Benjamin C. , Uchegbu Herbert
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication to remind readers of the maternal and fetal hazards of obstructed labour in communities where obstetric hospitals still receive a high proportion of unbooked patients referred with intrapartum complications. The results reported for booked patients are also noteworthy; although the incidence of obstructed labour was only 1.7%, the 10,202 booked cases provided 19 cases ofCaesarean hysterectomy and 10 others where uterine rupture was treated by repair. The Caesarean section rate of all booked patients in this series is not provided but was presumably very low by western standards. The discussion provides a rare insight into the difficulties which occur in obstetric practice in other lands; even booked patients may refuse to go into hospital until it is too late to deliver them safely.

The maternal mortality rate in this series for the entire hospital population was 11 per 1,000 births, somewhat less than the 12.2 per 1,000 reported from the Royal Women's Hospital, Melbourne for the years 1939–1947A ‐ at this time the perinatal mortality rate at the Royal Women's Hospital was 68.6 per 1,000 or approximately 50% higher than in this series reported for Nigeria. It is interesting to note that the Caesarean section rate at the Royal Women's Hospital during these years was 2%; it may be that conditions in the developing world are not all that different from the so called developed world of 40 years ago

Summary: Over a five year period (1985–1989) 527 cases of obstructed labour were recorded while 11,299 deliveries were conducted giving an incidence of 4.7%.

The majority of the patients (59%) were primigravidae. The incidence of obstructed labour was much higher for the unbooked patients (33 %) than for the booked patients (1.7%). Cephalopeivic disproportion was the greatest cause of obstructed labour (67%), while Caesarean section was the main method of delivery (85%).

The leading complications of obstructed labour were puerperal sepsis (57%), post partum haemorrhage (15%), uterine rupture (14%), and genital tract laceration (14%). A maternal mortality rate of 32 per 1000 and a perinatal mortality rate of 294 per 1000 were recorded.

Education of primary health providers and traditional birth attendants on the dangers of obstructed labour and the need for early referral is suggested to reduce the incidence of this condition. Governmental assistance is also required to improve existing health facilities so that antenatal and delivery services will be affordable to all pregnant women in the society.
Induction of Labour in Nulliparas with Poor Cervical Score: Oxytocin or Prostaglandin Vaginal Pessaries?
Authors: Kurup A. , Chua S. , Arulkumaran S. , Tham K. F. , Tay D. , Ratnam S. S.
Published: February 2008

EDITORIAL COMMENT: This study is important and unusual, the latter because the control series of nulliparas with an unfavourable cervix having labour induced by amniotomy and oxytocin infusion were managed by the same authors and reported in this journal in 1985 (1). One could argue that the 2 groups should not be compared because the indicatons for induction of labour were different, and other clinical regimens had changed. Nonetheless this paper is important because it reaffirms that induction of labour, by amniotomy and oxytocin infusion, in nulliparas with an unfavourable cervix is likely to result in Caesarean section; in 43.5% in the previous study and 48.6% in the present subgroup. Patients may well elect to be managed by elective Caesarean section if counselled regarding the prospects of vaginal delivery with such a regimen when the cervical score is poor. The takeaway message is that prostaglandin vaginal pessaries (2 doses of 3 mg of PGE^, 4 hours apart) in such women reduces the Caesarean rate significantly, especially in those who come into established labour within 24 hours of insertion of the pessaries, or when the cervical score improved within 24 hours of their insertion.

Summary: In a previous study nulliparas with poor cervical score (≤ 5 out of 10) had a 43.5% Caesarean section (CS) rate of which 55% were for failed induction when labour was induced by artificial rupture of membranes and oxytocin infusion. In this study induction of labour by 2 doses of 3 mg prostaglandin E2 (PGE2) vaginal pessaries, 4 hours apart, and if necessary by artificial rupture of membranes and oxytocin infusion 24 hours later, resulted in a CS rate of 23.7% of which 38.9% were for failed induction. The latter regimen resulted in a significantly lower CS rate compared with labour induced by oxytocin infusion and rupture of membranes without the use of prostaglandins (p < 0.001). In the prostaglandin group 53.3% were established in labour within 24 hours of inserting the pessary and in these patients the CS rate was 18.5%. In those who did not start labour and needed rupture of membranes and oxytocin infusion 24 hours after the first pessary, 34 (47.9%) had a good cervical score (≥ 6 out of 10) and 37 (52.1%) had a poor cervical score (≤ 5 out of 10) at the time of amniotomy. The CS rates in these groups were 8.8% and 48.6% respectively (p < 0.001). In nulliparas with poor cervical score induction is better performed with vaginal prostaglandin pessaries in order to reduce the high CS rate associated with artificial rupture of membranes and oxytocin infusion.
Completed Follow‐up of 1,000 Consecutive Transcervical Chorionic Villus Samplings Performed by a Single Operator
Authors: Wass Debbie M. , Brown Gillian A. , Warren Peter S. , Saville Toni A.
Published: February 2008

Summary: Completed follow‐up data on 1,000 patients undergoing transcervical chorionic villus sampling (CVS) performed by a single operator at the Royal Hospital for Women is presented. Prior to the introduction of CVS, approximately 750 amniocenteses were performed annually in this unit. Over the past 5 years the total number of patients having CVS or amniocentesis has increased by Vi and almost Vi of procedures are now done by CVS.

We have persisted with the transcervical route believing that once the learning curve is past, this route compares favourably with the transabdominal method in loss rate and perinatal outcome. We feel the transcervical approach is better tolerated by our patients and that less procedural difficulties are encountered. With increasing operator experience the total fetal loss rate to 20 weeks' gestation in our series declined to 2.1% and late complications were no more frequent than expected. In 98.4% of patients, sufficient villi were obtained for analysis. Culture failure was extremely uncommon, occurring only twice in our series. In 1.5% of patients, a follow‐up amniocentesis was required, which compares favourably with other published series.

It appears that many units abandoned the transcervical route before loss rates were stabilized. In units where transcervical CVS is still performed the transabdominal route is also utilized. The reverse is not true. The authors feel that both procedures have a role in modern antenatal diagnosis.
The Role of Hysteroscopy in Patients Having Failed IVF/GIFT Transfer Cycles
Authors: Kirsop R. , Porter R. , Torode H. , Smith D. , Saunders D.
Published: February 2008

Summary: Fifty patients who had undergone 2 or more failed in vitro fertilization (IVF) embryo transfer (ET) cycles or failed GIFT cycles where fertilization had been demonstrated, underwent hysteroscopy; 28% were found to have intrauterine abnormalities which may have been responsible for the failure of the IVF‐ET or GIFT. Patients with an abnormality found at hysteroscopy had undergone a significantly higher mean number of transfer cycles. These results suggest that intrauterine abnormalities may be a cause for failure of IVF‐ET or GIFT and therefore hysteroscopy should be part of the infertility work‐up of all patients prior to undergoing IVF treatment.
Factors Associated with Failure to Receive Antenatal Care
Authors: Lumbiganon Pisake , Laopaiboon Malinee , Panamonta Manat , Pothinam Somporn
Published: February 2008

EDITORIAL COMMENT: We seldom read why women in our community present late for antenatal care, fail to attend regularly or, heaven forbid, have no antenatal care at all. There are many countries where a large section of the population receives no antenatal care, even in nations where oil‐earned riches abound. It is an accepted fact that lack of antenatal care results in higher perinatal and maternal mortality nates. In Australia the causes of poor attendances are mainly socioeconomic (working mother, no baby minder, cost of fares), apart from general unreliability, and drug dependency with its associated problems. There is also the problem of communication with immigrant women who, in the editor's experience, are very cooperative and willing attenders when the aforementioned factors are not operative (some will attend only when accompanied by their husbands who speak better English, even when the hospital provides a good interpreter service). Nonattendance seems related more to poverty than ignorance ‐ this statement is an opinion and is not the result of the painstaking investigation that characterizes this paper from Thailand. The authors found that education of the husband is needed for his wife to receive the care she deserves; the details of maternal age and parity, and affluence of the family of these dwellers in 120 villages, in terms of antenatal attendance, should please readers with an interest in the problems faced by our colleagues in other lands. It also suggests that a careful audit of the causes of poor antenatal attendance and its sequelae should be undertaken in every community. The editor was surprised and dismayed to learn that at the Mercy Hospital for Women where he works such a study has not been conducted; provoked by this paper we will try to do better ‐ perhaps improvement of antenatal creche facilities may be the first priority required.

Summary: A community‐based case‐control study was conducted to characterize pregnant women who did not receive antenatal care. 1,274 deliveries over a 1‐year period were documented by weekly visits to 120 study villages. Eighty five women (6.7%) received no antenatal care. By univariate analysis, factors found to be associated with failure to receive antenatal care included maternal age, paternal age, paternal education, home ownership, availability of toilet, annual income, housing condition, gravidity, parity, history of infant death and birth intervals. After logistic regression analysis, only paternal age, paternal education, parity and lack of toilet in the household were found to be associated with failure to receive antenatal care.
Ovarian Tumours in Pregnancy
Authors: El‐Yahia Abdul Rahman , Rahman Jessica , Rahman Mohammad Sayedur , Al‐Suleiman Suleiman A.
Published: February 2008

EDITORIAL COMMENT: We agree with the authors of this paper that routine ultrasonography in the first trimester will diagnose many ovarian cysts that have been missed on clinical examination. However, we consider that the possibility of finding an unrecognized ovarian tumour is not an important item in the case for routine ultrasonography in pregnancy. Most cysts found incidentally are less than 5–10 cm in diameter, are asymptomatic, and can be treated conservatively; most are probably cysts of the corpus luteum. If the cyst is large, symptomatic or suspicious of malignancy (solid elements or complicated echos), then laparotomy is indicated as recommended by the authors. It should be noted that follicular and corpus luteum cysts, of which only 10 were included in this series, can occasionally reach large dimensions. In the rare patient who has rapid growth of an ovarian tumour during pregnancy, the histology is usually benign, mucinous cystadenoma. Figures 1A and B and the following mini‐case report are included in this comment to illustrate that even a huge cyst can be overlooked on clinical examination.

Summary: Ovarian tumours associated with pregnancy were reviewed for the period 1982–1991. The overall incidence of this complication was 1:653 deliveries; 62.7% of the tumours were diagnosed in the first and second trimesters of pregnancy. The value of routine pelvic examination and ultrasonic scan as a diagnostic aid in early pregnancy is emphasized; 25.4% of patients presented as an acute emergency; 23.9% of the tumours were incidentally discovered at Caesarean section which underlines the importance of examining the ovaries at operation. Benign cystic teratomas were the most common ovarian tumours found, followed by serous cystadenomas. The incidence of malignant tumours was 4.5%. Whenever an ovarian tumour is found, the possibility of malignancy should always be borne in mind. Treatment of ovarian tumours in pregnancy should be tailored according to the age of the patient, parity, clinical presentation, gestational age and biology of the tumour.