Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section.

OBJECTIVE: To establish whether the timing of delivery between 37 and 42 weeks gestation influences neonatal respiratory outcome and thus provide information which can be used to aid planning of elective delivery at term. DESIGN: All cases of respiratory distress syndrome or transient tachypnoea at term requiring admission to the neonatal intensive care unit were recorded prospectively for nine years. SETTING: Rosie Maternity Hospital, Cambridge. SUBJECTS: During this time 33,289 deliveries occurred at or after 37 weeks of gestation. MAIN OUTCOME MEASURES: This information enabled calculation of the relative risk of respiratory morbidity for respiratory distress syndrome or transient tachypnoea in relation to mode of delivery and onset of parturition for each week of gestation at term. RESULTS: The incidence of respiratory distress syndrome at term was 2.2/1000 deliveries (95% CI; 1.7-2.7). The incidence of transient tachypnoea was 5.7/1000 deliveries (95% CI; 4.9-6.5). The incidence of respiratory morbidity was significantly higher for the group delivered by caesarean section before the onset of labour (35.5/1000) compared with caesarean section during labour (12.2/1000) (odds ratio, 2.9; 95% CI 1.9-4.4; P < 0.001), and compared with vaginal delivery (5.3/1000) (odds ratio, 6.8; 95% CI 5.2-8.9; P < 0.001). The relative risk of neonatal respiratory morbidity for delivery by caesarean section before the onset of labour during the week 37+0 to 37+6 compared with the week 38+0 to 38+6 was 1.74 (95% CI 1.1-2.8; P < 0.02) and during the week 38+0 to 38+6 compared with the week 39+0 to 39+6 was 2.4 (95% CI 1.2-4.8; P < 0.02). CONCLUSIONS: A significant reduction in neonatal respiratory morbidity would be obtained if elective caesarean section was performed in the week 39+0 to 39+6 of pregnancy.

Second-trimester maternal serum screening using alpha-fetoprotein, human chorionic gonadotrophin, and unconjugated oestriol: experience of a regional programme.

Over a 2-year period from January 1991 to December 1992, second-trimester maternal serum screening for Down's syndrome using alpha-fetoprotein (alpha FP), human chorionic gonadotrophin (hCG), and unconjugated oestriol (uE3) was made available to five health districts in East Anglia, with a total population of 1.2 million. Amniocentesis was offered when the risk of Down's syndrome at term was 1:200 or greater. 25,359 singleton pregnancies were screened, representing an uptake of 77 per cent. The recall rate for the 24 per cent of women who had not had a dating scan prior to the test was 9.4 per cent compared with 3.9 per cent for those who had been scanned (P < 0.0005). Seventy-five per cent (36/48) of Down's syndrome pregnancies were detected for a false-positive rate of 4.0 per cent. Twenty-five out of 36 of detected Down's syndrome pregnancies were dated by scan prior to sampling, and in the 11 remaining cases, the dates were confirmed by scan after a high-risk result was obtained. The exclusion of uE3 from the screening protocol would have reduced the detection rate to 52 per cent (25/48) for the same false-positive rate. Eighty-five per cent of women identified at high risk accepted the offer of an amniocentesis. Other fetal abnormalities detected were trisomy 18 (3), trisomy 13 (2), 45,X (6), 69,XXX (5), other chromosome abnormalities (9), open neural tube defects (26), hydrocephalus (7), abdominal wall defects (4), and steroid sulphatase deficiency (6).

Prenatal diagnosis from maternal blood: simultaneous immunophenotyping and FISH of fetal nucleated erythrocytes isolated by negative magnetic cell sorting.

Fetal nucleated cells in the maternal circulation constitute a potential source of cells for the non-invasive prenatal diagnosis of fetal genetic abnormalities. We have investigated the use of the Magnetic Activated Cell Sorter (MACS) for enriching fetal nucleated erythrocytes. Mouse monoclonal antibodies specific for CD45 and CD32 were used to deplete leucocytes from maternal blood using MACS sorting, thus enriching for fetal nucleated erythrocytes which do not express either of these antigens. However, significant maternal contamination was present even after MACS enrichment preventing the accurate analysis of fetal cells by interphase fluorescence in situ hybridisation (FISH). To overcome this problem, we used simultaneous immunophenotyping of cells with the mouse antifetal haemoglobin antibody, UCH gamma, combined with FISH analysis using chromosome X and Y specific DNA probes. This approach enables selective FISH analysis of fetal cells within an excess of maternal cells. Furthermore, we have confirmed the potential of the method for clinical practice by a pilot prospective study of fetal sex in women referred for amniocentesis between 13 and 17 weeks of gestation.

The induction of ovulation using pulsatile luteinizing hormone releasing hormone in clinical practice.

Until recently induction of ovulation in patients resistant to clomiphene has required gonadotrophin therapy. This has entailed intensive biochemical monitoring to ascertain the correct dosage and to avoid ovarian hyperstimulation. Described here is a simple, safe effective method of ovulation induction, using pulsed luteinizing hormone releasing hormone and requiring only minimal, readily available monitoring methods.

A regimen for obtaining mature human oocytes from donors for research into human fertilization in vitro.

Patients awaiting laparoscopic sterilization were canvassed to allow oocytes to be aspirated from their ovaries at the time of operation for the purpose of testing the fertilizing capacity of spermatozoa from clinically infertile men. Because these patients were volunteers, the standard techniques for stimulation, ovulation prediction, operation, and oocyte recovery had to be modified for maximum safety and for convenience to both patient and staff. Superovulation was induced with 100 mg or 150 mg clomiphene citrate on days 2 to 6 or 5 to 9 of the menstrual cycle. Final maturation of oocytes was stimulated with 5000 IU of human chorionic gonadotropin administered between days 11 and 15 of the cycle, and the operation was performed 34 to 36 hours later on the routine gynecology operation lists. Of the 157 patients canvassed , 47% were willing to donate oocytes to the project. Despite the variability of the stimulation regimens, the simplified operative technique, and the fact that more than half the patients were on oral contraceptives in the previous cycle, one or more oocytes were retrieved in 75% of the patients. At the initial assessment, 83% of these were considered suitable for in vitro fertilization.

The infrequent occurrence of mycoplasmas in amniotic fluid from women with intact fetal membranes.

As human genital mycoplasmas have been associated with various forms of reproductive failure, the present study was undertaken to investigate whether M. hominis and U. urealyticum organisms (ureaplasmas) are capable of crossing intact fetal membranes. Nearly 300 women in Denmark and England were investigated. Most of them were seen at about the fourth month of gestation and the remainder towards or at the time of birth, all with unruptured membranes. A swab was taken from the uterine cervix or vagina and M. hominis was isolated from 9% of the women and ureaplasmas from half of them. The presence of these mycoplasmas was not associated with an abnormal outcome of pregnancy. In contrast to the frequent presence of mycoplasmas in the lower genital tract, amniotic fluids obtained by transabdominal amniocentesis or at cesarean section did not contain M. hominis and ureaplasmas were isolated from only one of them. This was associated with the same ureaplasmas serotype being recovered from the cervix and also from the blood of both infant and mother, whose case differed from the others as labor had already started when the amniotic fluid was obtained. Thus, in our populations, we have no evidence that mycoplasmal invasion of the amniotic fluid occurs before the onset of labor. During labor, despite intact membranes, it seems that genital mycoplasmas may occasionally invade the fetal--placental unit, probably by the hematogenous route after strong uterine contractions, or otherwise directly after membrane rupture. Since both these events are followed usually by immediate delivery, there would seem to be insufficient time for the genital mycoplasmas to cause fetal damage.

The value of laparoscopy in the management of cystic paravaginal masses.

Gartner's duct cysts and unilateral hematocolpos are unusual conditions presenting as a paravaginal cystic mass. They are frequently mismanaged. Previous authors have cast doubt on the value of laparoscopy and have suggested that primary vaginal drainage is contraindicated. Laparotomy has been performed invariably. In our experience, laparoscopy and primary vaginal drainage has been a safe and successful method of treatment. Three recent cases are reported together with an earlier case.

Disopyramide in pregnancy: a case report.

Disopyramide (200 mg 8-hourly) was given to a pregnant patient from the 26th week onwards for the treatment of bigeminy and paroxysmal ventricular tachycardia. Labour was spontaneous and normal. Although disopyramide was demonstrated in the foetal blood there was no evidence of congenital abnormality or growth retardation. The drug treated the mother satisfactorily with no apparent ill effects to the child.

Purification of oestradiol receptor from human uterus by affinity chromotrgraphy.

The oestrogen receptor from human myometrium has been extensively purified by affinity chromatography and isoelectric focusing. The latter step is necessary to remove contaminating sex-steroid-binding globulin. The unpurified 3.7-S cytoplasmic receptor has a molecular weight of 41,000, a Stokes radius of 27.0 A and a frictional ratio (f/f0) of 1.19; the KD (4 degrees C) for [3H]oestradiol-17 beta was 1.03 X 10(-10) M. After purification, the molecular weight was 30,000, the Stokes radius 23.6 A, frictional ratio 1.15 and isoelectric point 6.15.

Successful pregnancy after conservative surgery and radiotherapy for disgerminoma of the ovary.

A 19-year-old patient was treated for disgerminoma of the right ovary by right salpingo-oophorectomy and pelvic radiotherapy in 1967. The left ovary was shielded after the first two treatments and the patient has since conceived three times and has shown no evidence of recurrence of the tumour.

Laparotomy during pregnancy: an assessment of diagnostic accuracy and fetal wastage.

In a series of 48,482 pregnancies laparotomy was undertaken 74 times for conditions not associated with pregnancy (1 in 655 pregnancies). It showed no abnormality in 26 cases; ovarian cysts and acute appendicitis were the commonest pathological findings. The preoperative diagnosis was proved correct in 53% of cases, and in 66.2% laparotomy proved to be necessary for an alternative diagnosis.The fetal loss rate after surgery was 23%. Spontaneous abortion was more likely in the presence of peritonitis, with fluid in the peritoneal cavity, or when operative procedures involving the ovary were performed within the first trimester. The risk of precipitating labour following diagnostic laparotomy is negligible, provided no unnecessary surgical manoeuvres are undertaken.