Antenatal loss of one of twins.

The antepartum loss of a twin with survival of the second twin to delivery was studied in the Tasmanian population from 1980 to 1989 inclusive. No previous study of an Australian population has been reported. This rare complication occurs in 3.5% of twin pregnancies. The outcome of these pregnancies and the outcome for the surviving twin are discussed.

Use of prescription drugs in the first trimester and congenital malformations.

A prospective survey of prenatal use of prescription drugs in Tasmania yielded detailed information on drug exposure, delivery and outcome for 56,037 births from 1982 to 1989. First trimester drug use was reported by 30.9% of women, and 17.9% used only supplements of vitamins and/or minerals; 40% used alcohol during the first trimester, and 28.8% smoked cigarettes. There were 1,035 (1.85%) congenital malformations, of which 885 (85.5%) were major. The malformation rate was not significantly different in the following exposure categories: supplements only (1.62%); other pharmaceuticals (1.92%); smokers (1.88%); alcohol users (1.89%); and maternal age 35 or more years (1.95%). Adjusting for alcohol use, smoking, maternal age and diabetes mellitus, significant associations [expressed as adjusted odds ratio and 95% confidence intervals (CI)] were found between aspirin and hypospadias (3.5, 95% CI 1.4 to 8.8); dicyclomine and phocomelia (4.4, 95% CI 1.0 to 19.5); and between oral contraceptive use and pes cavus (9.7, 95% CI 2.3 to 40.4). Although significant, these associations were based on very few cases and no direct supporting evidence could be found from other data sources.

Outcome of pregnancies complicated by epilepsy in Tasmania 1981-1988.

Epilepsy in pregnancy is associated with an adverse pregnancy outcome. In 347 pregnancies in an 8-year retrospective study of all private and public patients in Tasmania from 1981 to 1988, epilepsy was found to be associated with an increased risk of hypertension (21%), antepartum haemorrhage (4.9%), postpartum haemorrhage (11.2%), fetal abnormality (3.5%) and perinatal mortality (2.3%).

Abnormal uterine bleeding and cancer of the genital tract.

All patients in Tasmania admitted to hospital for investigation of abnormal uterine bleeding in 1987 and 1988 were studied. A total of 4,318 patients were investigated. Four of 539 (0.7%) patients with intermenstrual or postcoital bleeding and 31 of 538 (5.8%) patients with postmenopausal bleeding were found to have endometrial cancer. Of the 3,421 patients investigated for 'heavy' periods (menorrhagia) there was no case of endometrial cancer. The detection rate of endometrial cancer on dilatation and curettage before the menopause is extremely low. Patients presenting with menorrhagia should not be treated surgically in the first instance unless an obvious organic cause is present.

Primary postpartum haemorrhage in Tasmania 1982-1986.

Primary postpartum haemorrhage remains a significant problem in modern obstetric practice. The incidence and factors associated with postpartum haemorrhage in Tasmania over a 5-year period were studied. The mode of delivery, anaesthesia, birth-weight, induction and augmentation of labour, multiple pregnancy, antepartum haemorrhage and hypertension were found to be important factors. The incidence of retained placenta was not considered in this study.

Spontaneous pregnancies and pregnancies as a result of treatment on an in vitro fertilization program terminating in ectopic pregnancies or spontaneous abortions.

Five hundred three patients were accepted for the in vitro fertilization (IVF) program from 1983 to 1986. Two hundred ninety-nine patients had a total of 678 IVF treatment cycles during this period. Eighty-one clinical pregnancies resulted, of which 8 were ectopic pregnancies and 19 spontaneous abortions (group A). During this period 82 patients accepted for IVF became pregnant spontaneously: 44 before treatment and 38 after a failed IVF treatment cycle (group B). Of these, 14 were ectopic pregnancies and 8 were miscarriages. The main indications for acceptance on the IVF program were similar in the two groups if those patients who had a bilateral salpingectomy are excluded from group A. Causative factors for the high ectopic pregnancy rate are discussed. The authors suggest that after embryo transfer, migration of the embryo or embryos into the fallopian tubes occurs more frequently than realized, and the diseased tube is less likely than a normal tube to propel the embryo back into the uterus. The abortion rate in group B was similar to the rate in the general population.

Donor oocyte pregnancy with transfer of deep-frozen embryo.

An infertile woman suffering from premature menopause conceived on her eighth attempt of ET following the transfer of a single frozen-thawed embryo, the ovum being donated anonymously by a patient undergoing tubal sterilization.

The implementation of a statewide gynaecology audit in Tasmania.

A successful Statewide audit of Obstetric and Neonatal data has operated in Tasmania since 1974. The experience and goodwill gained from the conduct of the survey has been used to establish an audit of all hospital admissions in the State for gynaecological complaints. This paper outlines the methods used in setting up the survey, and some of the results of its first full year of operation to indicate the scope and potential of such a study.

PIP: Since 1974, the University of Tasmania's Department of Obstetrics and Gynecology has collected data on all deliveries in the state and prepared annual reports. The utility of this auditing process prompted the University also to attempt a survey of all hospital admissions in Tasmania for gynecological complaints. In 1986--the first year that the gynecological audit was implemented in all hospitals in the state--data were obtained on 7304 gynecological admissions. The combination of findings of the gynecological audit and data on the 8501 pregnancies identified in the 1986 Obstetric and Neonatal Survey enable production of an overall reproductive profile for Tasmania. 18% of pregnancies in 1986 ended before 20 weeks' gestation (9.0% in spontaneous abortion, 7.8% through induced abortion, and 1.4% were ectopic). 37% of the gynecological admissions reported involved hysteroscopy and laparoscopy. Another 9.5% of admissions were for hysterectomy, and the overall ratio of total abdominal hysterectomies to vaginal procedures was 5 to 1. Finally, postmenopausal bleeding accounted for 4% of admissions. Although coding of the gynecological discharge summaries must be performed by a medical professional and is a time-consuming task, findings of studies such as this can lead to a careful assessment of clinical practices in private and public hospitals and ultimately to improved standards of care.

Low birth weight in Tasmania 1975-1983: the effect of socioeconomic status.

An analysis of all births in Tasmania from 1975 to 1983 showed that social class differences in low birth weights were almost entirely restricted to infants between 1500 and 2500 g weight at birth. There was a marginal increase in very low birth weight infants (less than 1500 g) among women whose partners were unemployed or in unskilled work but extremely low birth weight infants (less than 1000 g) were evenly distributed across the whole social spectrum.

Cigarette smoking, alcohol consumption and fetal outcome in Tasmania 1981-82.

Analysis of cigarette smoking and alcohol consumption patterns recorded in pregnancy could not detect a harmful effect of alcohol at levels below 2 glasses a day. Total abstainers fared very slightly worse than those who drank occasionally. Smoking was associated with lower birth-weight and a worse fetal outcome independent of socioeconomic status, parity, maternal age or alcohol consumption. There was evidence of an interaction between smoking and adverse social and parity factors in low birth-weight.

PIP: Fetal outcome in all 15,000 births occurring in Tanzania in 1981-82 was analyzed on the basis of alcohol consumption, cigarette smoking, parity, socioeconomic status, and maternal age. Smokers tended to be concentrated in the lower socioeconomic groups, whereas alcohol consumption was more prevalent among women of higher socioeconomic status. The data failed to suggest any harmful effects on the fetus of alcohol consumption at levels below 2 glasses/day. Moreover, the infants of total abstainers were slightly lighter at birth than those of mothers who drank occasionally. On the other hand, infants of mothers who drank 2 or more glasses of alcohol/day were an average of 300 gm smaller than those of abstainers. There was no evidence of an association between congenital malformations and alcohol consumption, even among the heaviest drinkers. In contrast, the relationship between cigarette smoking and low birth weight was significant. The incidence of low birth weight (2.5 kg) deliveries increased from 3.3% among nonsmokers to 5.7% among light smokers to 8.1% among moderate smokers and to 10% among heavy smokers. Controlling for parity, socioeconomic status, gestational age at delivery, and alcohol consumption failed to eliminate the 200 gm birth weight difference between infants of smokers and nonsmokers. However, there was evidence of an interaction between smoking and adverse social and parity factors in low birth weight. Considering problems encountered in convincing women to give up smoking during pregnancy, it is recommended that preventive campaigns be directed at women of childbearing age who have not yet taken up the habit.

A review of primary caesarean sections in Tasmania.

In the years 1975-1982 inclusive there were 55,095 deliveries in Tasmania and of these 2,738 patients (4.9%) were delivered by primary Cesarean section. The primary Caesarean section rate increased from 4.3% in 1975 to 6.6% in 1982. This increase has been due to the increased incidence of primary Caesarean section associated with breech presentation and to a lesser extent fetal distress. Although the overall perinatal mortality rate fell from 19.5 per 1,000 births in 1975 to 10.8 per 1,000 births in 1982, there has been no corresponding fall in the perinatal mortality rate associated with primary Caesarean section. As an increase in Caesarean section will lead to an increase in maternal mortality and morbidity it is considered that an active review of the reasons for the rise in Caesarean section should be undertaken by those hospitals where the rate is unusually high.

Adolescent pregnancy in Tasmania.

The obstetric performance of 1719 pregnancies in mothers aged less than 18 years was compared to that of the rest of the obstetric population. There was a significantly poorer outcome in the adolescents in the mean birthweight, the prevalence of birthweight below 2500 g and of gestation period below 28 weeks, Apgar score, perinatal mortality and the occurrence of hypertension in pregnancy. When the primiparous adolescent group (1607) was compared with primiparas aged 18-34 years (16 220), these differences were less marked. The two groups (adolescent and adult primiparas) were matched by marital status and socioeconomic class, and no significant differences were found in these parameters. It is concluded that biological age per se does not confer an increased risk in pregnancy. The high proportion of primiparas in the adolescent group (93%), and the associated increased prevalence of high-risk factors in this group (single marital status, low socioeconomic class, and smoking) would explain the poorer obstetric outcome in comparison with that of the total adult group.