Anaphylactoid reactions associated with menstruation affecting two sisters.

Cyclical anaphylactoid reactions associated with menstruation are exceedingly rare. We report two sisters who were both affected, one severely and one mildly. Treatment involved suppression of menstruation and use of a cyclooxygenase-2 (COX-2) inhibitor. An abnormal reaction to prostaglandins, perhaps produced by COX-2 enzyme activity in the endometrium, is a possible mechanism.

Differing influences on Aboriginal and non-Aboriginal neonatal phenotypes: a prospective study.

OBJECTIVE: To understand the differences, if any, in major influences on birth phenotype between Aboriginal and non-Aboriginal neonates. DESIGN: Prospective study of a cohort of pregnant Aboriginal women presenting for antenatal care before 20 weeks' gestation (ultrasound proven), and a reference cohort of pregnant non-Aboriginal women. Comparison of the phenotypic and demographic characteristics of the women, their pregnancies and their babies. PARTICIPANTS: 96 Aboriginal and 96 non-Aboriginal women with no known medical factors affecting fetal growth or gestation. SETTING: Four remote far north Queensland communities served by the Far North Regional Obstetric and Gynaecological Service (FROGS) and the antenatal clinic at Cairns Base Hospital. MAIN OUTCOME MEASURES: Neonatal birth weight, length, head circumference, abdominal circumference, mid-arm circumference and triceps skinfold thickness, and derived ponderal index (weight/length3), head:abdomen circumference ratio and head:mid-arm circumference ratio. RESULTS: The Aboriginal neonates were on average almost 450 g lighter than their non-Aboriginal counterparts. They were also slightly shorter, with smaller head, abdomen and mid-arm circumferences and lower mean ponderal indices and triceps skinfold thickness. The gestational characteristics of the two groups were not significantly different. Neonatal phenotype was significantly associated with maternal body mass index and maternal age in both groups. Alcohol use in pregnancy was associated with a significant reduction in Aboriginal neonatal size, while tobacco use was significantly associated with size reductions in non-Aboriginal babies. CONCLUSIONS: Culturally appropriate antenatal care programs targeting the effects of poor nutrition and excessive alcohol use are needed if the excess incidence of low birthweight in Aboriginal people is to be reduced.

A RACOG sponsored pilot study of a quality assurance program regarding management of labour by provincial Fellows. Royal Australian College of Obstetricians and Gynaecologists.

OBJECTIVE: To develop an effective and practical self-administered obstetric audit program for use by clinicians within their own practice. SETTING: The private and public practices of specialists in provincial practice. SAMPLE: Two periods of 3 months in each Fellow's practice, separated by a period of 3 months to allow for data review, resulting in the review of management of 6708 singleton births. METHODS: All provincial Fellows in active practice in Australia in early 1998 were invited to take part in a voluntary 'quality cycle' obstetric practice audit. The data from the first 3 month period was fed back to participating Fellows for review before a second 3-month audit period was undertaken. RESULTS: One hundred and twenty provincial Fellows were invited to take part; 62 registered for the study, 58 commenced the project, and 52 completed the entire cycle. 60.1% of the 6708 women studied laboured spontaneously, 25.8% had labour induced, and 14.1% had elective Caesarean sections. 87.8% of the 5759 women who laboured gave birth vaginally. There was little change in the incidence of intervention in labour between the first and second study periods. CONCLUSIONS: It is possible to design a worthwhile self-administered clinical audit in obstetric practice with which specialists in full-time practice can cope and which provides useful personalised feedback for the specialist.

Decrease in incidence of gestational diabetes mellitus in Far North Queensland between 1992 and 1996.

The pregnant population in Far North Queensland is at high risk of medical complications, such as diabetes, compared to the general Australian population (1,2). This retrospective observational study shows a true decline in the incidence of gestational diabetes mellitus (GDM) in this region over a 5-year period (1992-1996), contradicting the current belief that the incidence of GDM is increasing in non-Caucasian Australians. Although this change may be due to an improvement in medical and/or dietary intervention in this region, the real cause for the decline is yet to be recognized.

The therapeutic dilemma of an ectopic pregnancy in the setting of the severe ovarian hyperstimulation syndrome.

Severe ovarian hyperstimulation syndrome as a result of assisted reproductive therapy occurs rarely. However, this iatrogenic condition can result in a life threatening illness with difficult management dilemmas for the attending physicians. A patient with severe adult respiratory distress syndrome and septicaemia after in vitro fertilization required prolonged intensive care treatment and subsequently had a probable ectopic pregnancy treated with systemic methotrexate as an alternative to surgical management. A satisfactory outcome was obtained, followed by a spontaneous successful pregnancy some months after these events.

Study of cervicovaginal fetal fibronectin status to guide treatment of threatened preterm labour.

A sequential controlled pilot study of 48 women (16 study, 32 controls) was performed to explore the place of bedside fetal fibronectin testing in the management of apparent preterm labour; 80% of the study group were successfully managed without tocolytic therapy, on the basis of fetal fibronectin test results, without detriment to the babies. Rapid bedside fetal fibronectin testing holds promise that protocols for management of women in apparent preterm labour, with intact membranes and without significant cervical dilatation, may be altered so that most of the unnecessary use of tocolytic drugs is avoided.

Pregnancy outcome score: a clinical indicator of the childbirth process.

Clinical indicators associated with the process of childbirth are either gross (e.g. perinatal mortality rate) or measures of intervention (e.g. Caesarean section rate). Morbidity and process are rarely, if ever, addressed. We developed and piloted a simple pregnancy outcome score as a comparative indicator of outcome. This scoring system is easy to apply, and there was a positive and significant correlation between the pregnancy outcome score and the risk status of the patients.

Congenital syphilis: still a reality in 1996.

Despite the widespread use of penicillin for more than 50 years, syphilis continues to be a problematic health issue in many parts of the world. In Australia, congenital syphilis is again a significant cause of stillbirth, preterm labour and neonatal disease in some areas (including central and northern Australia). Control mechanisms based on screening, reliable treatment protocols, contact-tracing and adequate follow-up appear to be less effective than they were in the past. It is difficult to discuss such a socially stigmatizing disease when it is clear that some community groups are at high risk, and may be offended by and feel disempowered in the face of well-meaning medical debate. If congenital syphilis is to be eradicated, new approaches are required. These include public-awareness campaigns to stress the need for antenatal care in affected communities; involving the community in efforts to prevent syphilis; providing culturally appropriate services; improving notification and surveillance systems; improving the management of pregnant women who present to maternity units without prior booking; and improving the management of syphilis in pregnancy. There is a need to raise awareness that antenatal care is important not only for the mother's health but also for the wellbeing of the baby.

Low aboriginal birth-weight--prematurity or intrauterine growth restriction?

Two thousand, nine hundred and twenty-eight consecutive singleton public births at Cairns Base Hospital were studied retrospectively. Contrary to popular clinical belief, there was no statistically significant difference in the birth-weights, corrected for gestational age between Aboriginal babies and Caucasian babies. There was a highly significant excess of preterm Aboriginal births, when compared with Caucasian births. This study suggests that any attempt to reduce the high incidence of low birth-weight births in Aboriginal people should be directed at reducing the incidence of preterm birth, rather than the supposed high incidence of intrauterine growth restriction.

Efficacy of bupivacaine delivered by wound catheter for post-Caesarean section analgesia.

A prospective, randomized, double-blind trial was conducted to assess contribution to postoperative analgesia of intermittent instillation of 0.25% bupivacaine beneath the rectus sheath in 70 women delivered by lower uterine segment Caesarean section. The operations were performed via a Pfannenstiel incision under spinal anaesthesia. Background intravenous narcotic analgesia was provided with a patient controlled analgesia system (PCAS) using a standard morphine regimen. Overall (44 hr) mean morphine consumption was significantly greater in the placebo (saline) group compared to the treatment group (84.2 mg versus 63.3 mg. Two tailed t test p < 0.001). The most significant intergroup differences in narcotic use were found in the first 4 hours and between 24 and 36 hours after commencing PCAS (Two tailed t test p = 0.014 and 0.003 respectively). Subjective pain scores were assessed with a 10 cm visual analogue scale (VAS). The mean peak VAS score was greater in controls (5.37) than the treatment group (4.25) between 18 and 24 hours postoperatively (Mann-Whitney U = 424, p = 0.027). There were no intergroup differences in pain scores for any other time period. The overall incidence of nausea was lower in the treatment group compared to the control group (Chi squared with Yates' correction p = 0.046) and a lower degree of sedation was seen in those receiving bupivacaine between 4 and 8 hours after commencing PCAS (Mann-Whitney U = 427, p = 0.028). No differences in other narcotic related side-effects (vomiting and pruritus) were shown between groups. Regular instillation of 0.25% bupivacaine beneath the rectus sheath of women delivered by Caesarean section reduces their morphine requirements by 25% in the 44 hours after operation, with an associated reduction in both nausea and early sedation.

The beneficial use of risk scoring in a remote and high-risk pregnant population.

The Peninsula and Torres Strait Health Region in Far North Queensland is a large and remote region with a high incidence of at-risk pregnancies and few experienced caregivers to provide antenatal care. Pregnancy Risk Scoring was trialled as a means of best allocating meagre resources. All 3,679 women with singleton pregnancies who gave birth at Cairns Base Hospital were studied over a 30-month period, during which time the Hospital and Regional perinatal mortality rates fell by more than 50%. Risk scoring was applied to 2,875 of these pregnancies. Preterm birth, the birth of low birth-weight babies, and birth intervention were less likely to occur in those women with a low-risk score, with the lower likelihood of preterm birth reaching clear statistical significance. Where pregnancy care resources are scarce and large numbers of high-risk pregnant women are scattered throughout a remote area it would appear that risk scoring assists positively with decisions about the best use of resources.

FROGS (Far North Regional Obstetric and Gynaecological Service)--the development of a specialist outreach service.

The Peninsula and Torres Strait Health Region of Far North Queensland is a vast area with a widely scattered population. The Far North Regional Obstetric and Gynaecological Service (FROGS) is a cost-effective outreach service which provides equitable access to specialist care for remote people and aims to address many of the significant problems of women's health care in this region.

Undergraduate education in obstetrics and gynaecology in Australia and New Zealand, 1989.

Medical schools in Australia and New Zealand provide an average of 10.7 weeks for instruction in obstetrics abd gynaecology. The stated aims and objectives in 14 clinical schools vary from none at all to those which establish the programme with great clarity. The learning exercises provided vary from the conventional, ward and clinic-based to those with an accent on observing closely a mother, her baby and her family. Newer methods for learning about pelvic examination have not been widely adopted. Schools expect students to gain experience in an average of 9 vaginal deliveries. Competition with midwives for available deliveries was described by 9 clinical schools. The survey shows a need for greater emphasis in text books on communication skills and psychological aspects of patient care.

The relevance of antenatal cardiotocography.

In a prospective study of 3,083 patients having antenatal cardiotocography it was shown that ominous fetal heart rate traces were most likely to occur when the test was applied in specific 'at risk' situations rather than as a routine screening test, and when the need for monitoring was perceived relatively early in the pregnancy. The majority of ominous traces were not preceded by a normal trace.

Sinusoidal antenatal fetal heart rate patterns.

The sinusoidal fetal heart rate pattern is significantly associated with severe fetal anaemia when seen in the antenatal period. Strict adherence to definition is important, as pseudosinusoidal patterns do not have the same grave prognostic significance. If this fetal heart rate pattern is seen antenatally it is our contention that the baby should be delivered urgently by Caesarean section, unless the fetal anaemia can be treated in utero.