The use of hormone assays and transvaginal ultrasound measurement of endometrial thickness in the management of recurrent postmenopausal bleeding.

In patients presenting with postmenopausal bleeding, once an initial hysteroscopy and curettage has excluded uterine pathology there is no need to repeat the procedure unless there are very strong grounds for suspecting an occult carcinoma. By carefully tracking oestrogen levels subsequently, it is possible to predict if and when recurrent episodes of bleeding will occur. A transvaginal ultrasound measured endometrial thickness of less than 5 mm provides additional reassurance that there is no sinister underlying pathology.

Vulval varicosities and labial reduction.

Vulval varicosities and hypertrophic labia minora are 2 conditions that receive relatively little attention in the literature. However, they may cause especially bothersome discomfort in some women. Appropriate surgical treatment is eminently successful if certain guidelines and attention to detail are followed. The treatment of both conditions is described based on illustrative case reports, and a review made of the surgical anatomy.

Treatment of cervical incompetence by transabdominal cervicoisthmic cerclage.

Cervical incompetence is a condition traditionally treated by cervical cerclage which in most cases is inserted via the transvaginal route. However the insertion of a transabdominal cervicoisthmic suture is indicated in those patients with recurrent mid-trimester losses due to an incompetent cervix where it is not technically possible to insert a transvaginal suture. Between 1987 and 1996, 12 women at the Royal Women's Hospital, Melbourne were treated with transabdominal cervicoisthmic cerclage (TCC). Eight patients had cerclage in the nonpregnant state, and 4 were pregnant at the time. The completed pregnancies thus far have resulted in 10 surviving infants, a successful pregnancy rate of 69.2%. This compares favourably with a corrected preTCC successful pregnancy rate of only 13%. There were minimal intraoperative complications in our series. Bleeding, chorioamnionitis and premature rupture of the membranes have been reported elsewhere and occurred in 2 of our patients. Our results and a review of the literature confirms that TCC has an important role in carefully-selected patients.

Long-term satisfaction with Sheares vaginoplasty for congenital absence of the vagina.

Although a number of surgical and nonsurgical techniques have been described for the formation of a neovagina in cases of congenital absence, there are few reports on long-term results, and especially coital function. At the Royal Women's Hospital, Melbourne, the modified Sheares technique has been used almost exclusively in cases of vaginal agenesis since 1972. This paper analyses the clinical details and surgical problems encountered, and assesses the long-term sexual satisfaction of the procedure. In 23 patients who were sexually active, satisfactory intercourse was occurring in 18, (78%), 3 patients had serious psychological problems and 1 was lost to follow up.

Management of vaginal agenesis with a functioning uterus. Is hysterectomy advisable?

Cryptomenorrhoea associated with vaginal agenesis is uncommon. However, when laparoscopy or ultrasound reveal the uterus to be present early laparotomy is mandatory unless there is clear evidence of haematocolpos, in order to define the cervix and undertake reconstructive surgery. Once a uterovaginal tract has been established prolonged use of a mould is necessary to maintain patency of the neovagina. If the cervix is absent or atretic then immediate hysterectomy is required.

Perinatal mortality in a tertiary obstetric institution.

At the Royal Women's Hospital, Melbourne in the 3 years 1987-1989 analysis of the records of 13,347 public patients revealed an overall perinatal wastage of 20.8 per 1,000 births. This seemingly high figure resulted from the fact that 45% of losses occurred in nonbooked and emergency admissions. Many patients were referred with major complications of pregnancy, especially gross prematurity, lethal congenital malformations and intrauterine deaths. During the 3-year period 74% of perinatal losses occurred before 33 weeks' gestation and only 10% were after 37 weeks. By comparison at a Victorian State level, 47% of perinatal deaths occurred before 33 weeks and more than 35% after 37 weeks' gestation. The major causes of perinatal wastage in both groups were similar. At the Royal Women's Hospital in the 3-year period lethal congenital abnormalities accounted for 19.1% of fetal wastage, premature labour, premature rupture of the membranes and cervical incompetence 16.2%, multiple pregnancy 14.7%, antepartum haemorrhage 14.0% and hypertensive disorders 9.7%. During the 3-year period 7.7% of hospital stillbirths were intrapartum compared to 27% for the State of Victoria. The stillbirth rate in Victoria has declined over the past decade, but to a lesser extent than the neonatal death rate. Over the 3-year period 1987-1989 the ratio of stillbirths to neonatal deaths was 3 to 2, and in 1989 there were nearly twice as many stillbirths as neonatal deaths (424 versus 240). Furthermore, 55% of stillborn infants in Victoria had birth-weights of more than 1,500 g compared to the Royal Women's Hospital figure of 36%.(ABSTRACT TRUNCATED AT 250 WORDS)

Group B streptococcus (GBS) and neonatal infections: the case for intrapartum chemoprophylaxis.

At the Royal Women's Hospital, Melbourne over an 8-year period (1981-1988) all public antenatal patients were screened at 32 weeks' gestation for group B streptococcus (GBS). In a total of 30,197 livebirths there were no early onset neonatal GBS infections in infants of treated asymptomatic carrier mothers. By contrast there were 27 infections with 8 deaths in an unscreened control group of private patients (total livebirths 26,915). It is recommended that GBS screening occur antenatally at 28 weeks and that intrapartum chemoprophylaxis be offered at least to those carriers with obstetric risk factors.

Presacral neurectomy--a reappraisal.

Between April 1984 and April 1990, 20 patients with a mean age of 27.9 years underwent presacral neurectomy at The Royal Women's Hospital, Melbourne, Australia. Overall, 11 of the 19 patients (58%) assessable for follow-up were totally cured of pain and 8 (42%) were partially cured. The most common indication for presacral neurectomy was secondary dysmenorrhoea, usually in association with endometriosis or pelvic adhesions. In 4 patients with uterine dysmenorrhoea not associated with pelvic pathology the operation produced a complete cure. The general consensus of gynaecological opinion is that presacral neurectomy should still be reserved for a limited number of carefully selected patients in whom other methods of treatment have been exhausted. It is imperative that a prior psychological assessment should be undertaken whenever a functional component is suspected. Whilst pain of uterine origin may be cured by presacral neurectomy, lateral pelvic pain of adnexal origin requires ovarian sympathectomy.

Perinatal mortality in Victoria, Australia: role of group B Streptococcus.

Group B beta-hemolytic streptococcus is the most common infective cause of neonatal morbidity and mortality. It is therefore surprising that no agreement exists for an approach to its prevention. There is also increasing evidence that occult infection may play an etiologic role in premature rupture of the membranes and preterm labor. In this report we review the role of group B beta-hemolytic streptococcal sepsis as a cause of perinatal wastage in the state of Victoria, Australia during the period 1982 to 1987. Group B beta-hemolytic streptococcus accounted for 1.7% of overall perinatal deaths, and for 30.3% (77 of 254) perinatal deaths directly attributable to infection. By comparison, over the same 6-year period, erythroblastosis accounted for 0.5% of perinatal wastage and there were only two deaths as a result of congenital syphilis. The true incidence of lethal group B beta-hemolytic streptococcal infection is probably greater because of the absence of histologic and bacteriologic studies in many perinatal deaths. We believe that intrapartum chemoprophylaxis with penicillin of all group B beta-hemolytic streptococcus-positive carrier mothers would significantly reduce neonatal morbidity and mortality from this cause.

When do perinatal deaths in multiple pregnancies occur?

Perinatal mortality for multiple pregnancy remains at least 5 times the rate for singleton births. The major causes are neonatal deaths due to gross immaturity before 30 weeks' gestation, and stillbirths due to intrauterine growth retardation at all gestations, but especially after 32 weeks. Sixty four per cent of perinatal losses before 30 weeks' gestation occur before 26 weeks, highlighting the need to commence prophylactic measures earlier than usually recommended. The perinatal mortality in infants in multiple births weighing more than 2,500g is the same as that of singletons, but is 10 times this rate in multiple births weighing between 500g and 2,500g. Because the stillbirth rate in twins proceeding beyond 38 weeks' gestation is 3 times that of singleton births, elective termination of pregnancy is recommended if spontaneous labour has not occurred by this time.

Congenital absence of the vagina. Surgical treatment and perioperative care.

A simple surgical technique is described for the correction of an absent vagina. It combines the positive features of the traditional approach of using a split-thickness skin graft from the thigh or buttock applied on a plastic mold with the intermittent-pressure method of vaginal development. Since 1975, the new isograft technique has been performed on 15 patients at the Royal Women's Hospital, Melbourne, with excellent results and no complications. With one exception, satisfactory coitus productive of orgasm has occurred following the procedure.

Congenital atresia of the vagina.

The correction of an absent vagina requires the creation of a canal either by surgical means or by the intermittent pressure technique of Frank. Both methods have drawbacks and, in our experience, it is difficult to persuade a patient to use a vaginal dilator alone, accurately and conscientiously for long enough to give a good result. A simple surgical alternative is described which gives good anatomic and functional results with minimal morbidity. It combines the positive features of the traditional McIndoe approach and the Frank method of vaginal development. The results of a study of 24 patients with vaginal agenesis confirmed that the condition is usually part of the Rokitansky-Kuester-Hauser syndrome with an absent or rudimentary uterus and tubes but normally functional ovaries (21 patients). There were three instances of testicular feminization with an XY karyotype, and the results of orchidectomy performed upon these patients after puberty showed the classical histologic findings. The uterus and tubes were absent. Since 1976, the new isograft technique has been performed upon 11 patients with excellent results and no complications.

Can anything be done about mid-trimester fetal wastage?

In Victoria in the triennium 1982-1984, perinatal losses between 22 and 28 weeks' gestation accounted for 32% of the overall perinatal wastage of 12.7 per 1,000 births. Over the same period only 1.2% of babies were delivered weighing less than 1,500g, but this group made up 40% of the total stillbirths and 50% of the neonatal deaths. By contrast the perinatal wastage was only 7 per 1,000 births in babies born weighing more than 1,500g and this included lethal congenital malformations. The major antenatal risk factors contributing to the high mid-trimester fetal wastage were premature labour (17.7%), multiple pregnancy (13.9%), cervical incompetence (12.9%), antepartum haemorrhage (12.9%), premature rupture of the membranes (11.5%), lethal congenital malformations (10.6%) and hypertensive disorders (7.4%). Cognizant of the frequency of preventable factors, the Consultative Council on Maternal and Perinatal Mortality and Morbidity in Victoria recommends that, where feasible, the mother of these high-risk pregnancies be transferred to a centre where facilities are available to monitor the pregnancy and labour, and which offers intensive care facilities for the baby.

Occult fetomaternal haemorrhage as a cause of fetal mortality and morbidity.

Spontaneous fetomaternal haemorrhage is an important, but usually overlooked, cause of perinatal mortality and morbidity. Although fetomaternal bleeding in the third trimester of pregnancy is common it is normally less than 0.1 ml. A fetal macrotransfusion (greater than 5 ml) is uncommon, but is important because it is insidious, unexpected and usually occurs in completely normal pregnancies. This paper analyses the perinatal mortality and morbidity associated with occult fetomaternal haemorrhage at the Royal Women's Hospital, Melbourne. It may lead to fetal distress before and during labour, unexplained stillbirth, or nonhaemolytic neonatal anaemia. A Kleihauer test on maternal blood will readily detect fetomaternal bleeding, and we describe a simple way of calculating the absolute volume of fetal red cells present. Greater awareness of the problem may eventually lead to diagnosis sufficiently early to permit effective treatment.