Assessment of fetal myocardial performance in severe early onset pre-eclampsia (EO-PET) with and without intrauterine growth restriction across deteriorating stages of placental vascular resistance and links to adverse outcomes.

OBJECTIVE: To determine whether fetuses in severe early onset pre-eclampsia (EO-PET) with or without intrauterine growth restriction has cardiac dysfunction across deteriorating stages of placental vascular resistance and whether this dysfunction influences perinatal outcome. STUDY DESIGN: This was a prospective cross-sectional study performed in a tertiary care university medical centre. Sixty pregnant patients with severe early-onset pre-eclampsia between 27 and 32 weeks were recruited and matched with 60 patients having normal pregnancies. An analysis of cardiac function using the myocardial performance index (MPI) and early ventricular filling (E) and late active atrial contraction (A) ratios (E/A ratios) in the study group was performed compared to controls and further analysis was performed based on worsening placental vascular resistance and presence of growth restriction. RESULTS: MPI values were increased in the pre-eclamptic group, irrespective if growth restriction co-exists, compared to controls (0.61 vs 0.38, p<0.001). Its median value progressively increased with worsening placental vascular resistance. For adverse perinatal outcome cut-off MPI values have been suggested. The E/A ratios were significantly decreased in the pre-eclamptic group compared to controls (0.66 vs 0.79, p<0.0001). No adverse outcomes were noted in the control group. CONCLUSION: Fetal cardiac function is significantly impaired in pregnancies complicated by severe early onset pre-eclampsia, irrespective if growth restriction co-exists and worsens with deteriorating grades of placental vascular resistance. The MPI can potentially be integrated into routine fetal surveillance techniques.

Determination of the myocardial performance index in deteriorating grades of intrauterine growth restriction and its link to adverse outcomes.

AIM: The aim of this study is to determine the fetal modified myocardial performance index (Mod-MPI) and E-wave/A-wave peak velocities (E/A ratio) in deteriorating grades of intrauterine growth restriction (IUGR) and its link to adverse outcomes defined as perinatal death, hypoxic ischemic encephalopathy, neonatal resuscitation, neonatal cord pH <7.15, intraventricular hemorrhage and bronchopulmonary dysplasia. METHOD: Forty three pregnant women with IUGR defined as the abdominal circumference <10th percentile for gestational age and umbilical resistance index >2 standard deviations in the third trimester of pregnancy were matched for gestational age and maternal age with 43 women with appropriate-for-gestational-age fetuses. The IUGR group was subdivided on the basis of multivessel Doppler anomalies into different grades of growth restriction. Mod-MPI and E/A ratio were determined and linked to perinatal outcome. RESULTS: The median Mod-MPI was significantly higher in growth-restricted fetuses compared with controls (0.59 vs 0.37, p < 0.001) and increased with severity of IUGR, the classification of which was based on degree of abnormality of the umbilical resistance index, presence of arterial redistribution and degree of abnormality of the ductus venosus (DV) Doppler indices. A cut-off Mod-MPI value of 0.54 conferred a sensitivity of 87% [confidence interval (CI): 66-97%], specificity of 75% (CI: 55-91%) and a likelihood ratio (LR) of 3.47 for an adverse outcome. A cut-off Mod-MPI value of 0.67 conferred a sensitivity of 100% (CI: 54-100%), specificity of 81% (CI: 65-92%) and LR of 5.28 for perinatal death. No abnormal outcomes occurred in controls. In logistic regression analysis, the MPI remained a significant predictor of adverse outcome after adjusting for gestational age of delivery, fetal weight, E/A ratio, maternal age, DV Doppler indices, amniotic fluid index and umbilical artery resistance index [adjusted odds ratio, 95% CI: 2.60 (1.15-5.83), p-value 0.02]. MPI fared significantly better than the E/A ratio as a predictor of adverse outcome (area under the receiver operating characteristic curve of 0.94 and 0.76, p < 0.001). CONCLUSION: Fetal myocardial performance deteriorates with severity of growth restriction. There is an association between severity of the MPI elevation and rates of adverse perinatal outcome. The Mod-MPI and E/A ratio have the potential to be integrated into routine surveillance techniques of the growth-restricted fetus. © 2014 John Wiley & Sons, Ltd.

South African Menopause Society revised consensus position statement on menopausal hormone therapy, 2014.

The South African Menopause Society (SAMS) consensus position statement on menopausal hormone therapy (HT) 2014 is a revision of the SAMS Council consensus statement on menopausal HT published in the SAMJ in May 2007. Information presented in the previous statement has been re-evaluated and new evidence has been incorporated. While the recommendations pertaining to HT remain similar to those in the previous statement, the 2014 revision includes a wider range of clinical benefits for HT, the inclusion of non-hormonal alternatives such as selective serotonin reuptake inhibitors and serotonin noradrenaline reuptake inhibitors for the management of vasomotor symptoms, and an appraisal of bioidentical hormones and complementary medicines used for treatment of menopausal symptoms. New preparations that are likely to be more commonly used in the future are also mentioned. The revised statement emphasises that commencing HT during the 'therapeutic window of opportunity' maximises the benefit-to-risk profile of therapy in symptomatic menopausal women.

Reference intervals of gestational sac, yolk sac and embryo volumes using three-dimensional ultrasound.

OBJECTIVES: To create reference intervals of gestational sac volume (GSV), yolk sac volume (YSV), embryo volume (EV), crown-rump length (CRL) and gestational sac diameter (GSD) in the first trimester of pregnancy using three-dimensional ultrasound. METHODS: Women in the first trimester of pregnancy were invited to participate in the study. Inclusion criteria were well-established dates, and that the women were non-smokers and healthy, without any medical disorders. Three-dimensional ultrasound volumetric data (GSV, YSV, EV) were collected together with standard two-dimensional measurements of CRL and GSD. For each measurement separate regression models were fitted to estimate the mean and SD at each gestational age. The 5(th), 50(th) and 95(th) centiles were derived using a combination of these regression models. RESULTS: One hundred and sixty-six women at between 6 and 12 weeks' gestation were scanned once. The mean ( +/- SD) maternal age was 29.4 ( +/- 5) years. There were no miscarriages and no congenital abnormalities were noted. Mean gestational age at delivery was 39.3 ( +/- 1.4) weeks and mean birth weight was 3.3 ( +/- 0.4) kg. The CRL centiles fitted a cubic model and the GSD centiles fitted a linear model. The centiles for YSV fitted a quadratic model on the modified log-transformed data. The centiles for GSV and EV were modeled using quantile regression. CONCLUSION: Reference intervals and centile charts for first-trimester GSV, YSV and EV have been created in addition to CRL and GSD using rigorous methodology.

Medical vs. surgical evacuation of first-trimester spontaneous abortion.

OBJECTIVE: To determine whether management of incomplete first-trimester abortion with vaginal misoprostol in an under-resourced setting is a viable treatment option. METHODS: A total of 94 women were randomized to 600 microg of misoprostol intravaginally or to surgical curettage. The women receiving misoprostol were administered a second dose if the abortion was incomplete; and if still not complete after a week, evacuation of retained products of conception was performed. All women had a follow-up visit 2 weeks following complete abortion. RESULTS: The overall success rate of medical management was 91.5%, with 15 of 47 successful cases after 1 dose of misoprostol; 8.5% of the 47 women required evacuation of retained products of conception after 1 week because of treatment failure. The success rate in the surgical arm was 100%. Patients in the medical arm had a longer duration of bleeding and a greater need for analgesia. There were no differences in hemoglobin levels, white blood cell count, adverse effects, pain score, and satisfaction with treatment at the follow-up visit. However, more women who received the medical treatment would recommend it or choose it in the future. CONCLUSION: Medical management using 600 microg of misoprostol in 2 doses is effective to treat incomplete first-trimester abortions in an under-resourced setting when there is no evidence of uterine sepsis.

A randomized controlled trial comparing medical and expectant management of first trimester miscarriage.

BACKGROUND: We aimed to determine whether outpatient treatment of miscarriage with vaginal misoprostol is more effective than expectant management in reducing the need for surgical evacuation of retained products of conception (ERPC). METHODS: Of 131 eligible women with first trimester miscarriage, 104 agreed to randomization to either 600 microg misoprostol or placebo intravaginally. They were assessed the following day and administered a second dose of their allocated treatment if miscarriage was not complete. Those not successful after two doses were seen on day 7, and, if miscarriage was not complete, an ERPC was performed. RESULTS: The success rate of medical management was 88.5% (46/52) compared with 44.2% (23/52) for expectant management. There was no significant difference in success rate (100 versus 85.7%) in women treated with an incomplete miscarriage. Women with early pregnancy failure had a success rate of 87% with misoprostol compared with 29% with expectant management [odds ratio (OR) 15.96; 95% confidence interval (CI) 5.26, 48.37]. The complete miscarriage rate was achieved quicker in the medical group than the expectant group by day 1 (32.7 versus 5.8%) and by day 2 (73.1 versus 13.5%) of treatment. There were no differences in side-effects, bleeding duration, analgesia use, pain score and satisfaction with treatment. Women in the expectant group made more outpatient visits (5.06 versus 4.44%; OR = -0.62, 95% CI -1.04, -0.19). More women in the medical group (90.4 versus 73.1%; OR 1.26, 95% CI 1.05, 1.50) would elect the same treatment in the future. CONCLUSIONS: Medical management using 600 microg misoprostol vaginally is more effective than expectant management of early pregnancy failure. Misoprostol did not increase the side-effect profile and patient acceptability was superior to expectant management.

Medical management of uterine fibroids with medroxyprogesterone acetate (Depo Provera): a pilot study.

The aim of this study was to determine the effectiveness of medroxyprogesterone acetate (Depo Provera) in the treatment of menorrhagia attributed to uterine fibroids and to determine whether it reduces fibroid volume. Twenty premenopausal women with menorrhagia attributed to uterine fibroids received Depo Provera (150 mg/month) for 6 months. Control of bleeding was assessed by menstrual diary, haematologic parameters (Hb) and uterine and fibroid size measured sonargraphically. Following a period of 6 months after the initiation of Depo Provera, 30% became amenorrhoeic, 70% noticed improvement in their bleeding pattern and 15% had an increase in their haemoglobin levels. The mean uterine and fibroid volume was also reduced by 48% and 33%, respectively. Medical therapy with Depo Provera with symptomatic fibroids causes significant improvement in bleeding pattern as well as a reduction in fibroid volume.

A randomised controlled trial of antibiotic prophylaxis in elective caesarean delivery.

OBJECTIVE: To determine whether prophylactic antibiotic administration using cefoxitin at the time of elective caesarean section significantly reduces infectious morbidity. SETTING: A tertiary teaching hospital in a large urban city in South Africa. PARTICIPANTS: Women undergoing elective caesarean section. DESIGN: A prospective, double-blind randomised placebo-controlled trial. METHODS: Four hundred and eighty women undergoing elective caesarean section had cefoxitin or placebo administration after umbilical cord clamping. Postpartum complications including febrile morbidity, wound infection, endometritis, urinary tract infection, pneumonia and transient postpartum fever were recorded, as were the duration of hospital stay and the need for therapeutic antibiotics. RESULTS: Wound infection was the most common complication occurring in 13.3% and 12.5% of women in the placebo and cefoxitin groups, respectively. Prophylactic antibiotics did not decrease febrile morbidity, wound infection, endometritis, urinary tract infection and pneumonia. Women who received cefoxitin stayed on average a day less in hospital than those who received placebo (6.9 vs 7.8 days, risk difference 0.94 CI 1.57 - 0.31 days). Eleven women (4.6%) in the placebo group and eight (3.4%) in the cefoxitin group had microbiological evidence of wound infection. Staphylococcus aureus was the most common pathogen (43%) isolated. Similar proportions in both groups (6.3% placebo and 5.1% cefoxitin) required a course of therapeutic antibiotics. CONCLUSION: Antibiotic prophylaxis with cefoxitin in elective caesarean section did not reduce post-operative infectious morbidity in this double-blind randomised placebo controlled trial.

Drainage at caesarean section--a randomised prospective study.

OBJECTIVE: To determine the efficacy of wound drainage at caesarean section with a view to reducing postoperative wound morbidity. SETTING: King Edward VIII Hospital, Durban, South Africa. METHOD: Four hundred and forty women undergoing emergency caesarean section using the transverse suprapubic incision were randomised to receive either drainage or non-drainage of the wound. Wound drains were removed 48 hours after surgery and patients were seen daily until the time of discharge from hospital. Wound inflammation, wound infection and duration of hospital stay were assessed in both groups. RESULTS: Seventy-two of the 440 patients (16.4%) developed wound morbidity ranging from induration, serous, sanguinous and purulent discharge to haematoma formation and wound dehiscence. Of the 217 patients who received drains, 37 showed evidence of wound morbidity (17.1%), as opposed to 35 of the 223 who were not drained (15.7%) (P = 0.701). CONCLUSIONS: No significant advantages could be demonstrated for routine drainage in terms of wound inflammation, wound infection, haematoma formation or duration of hospital stay.

Membranous fat necrosis in mature cystic teratomas of the ovary.

We identified and documented the occurrence of membranous fat necrosis (MFN) in 217 mature cystic teratomas (MCTs) of the ovary. Cysts lined by an eosinophilic and scalloped membrane with pseudopapillary infoldings, the characteristic histologic features of MFN, were identified in 9 tumors. The membranes had the histochemical staining properties of ceroid, as evidenced by periodic acid-Schiff, sudan black, and long Ziehl Neelsen (ZN) positivity, diastase resistance, and autofluorescence. The causes and pathogenesis of MFN are enigmatic, but trauma, torsion, and ischemia are probable factors. MFN is a distinct entity in ovarian MCTs and heightened awareness will increase its histopathologic recognition.

Comparison of highly purified FSH (metrodin-high purity) with pergonal for IVF superovulation.

PURPOSE: The use of highly purified follicle-stimulating hormone (Metrodin-HP) was compared with that of a preparation containing follicle-stimulating hormone and luteinizing hormone (Pergonal) for production of superovulation in an IVF program. METHODS: We used the Oxford Fertility Unit database to identify patients undergoing their first cycle of IVF, using either Metrodin-HP or Pergonal. Patients were treated with a standardized drug protocol and were stratified by age and cause of infertility. Ovarian stimulation with either Metrodin-HP (Serono Laboratories) or human menopausal gonadotropin (hMG; Pergonal; Serono Laboratories) after pituitary desensitization commenced in the midluteal phase of the preceding cycle. Monitoring was performed by ultrasound and serum estradiol measurement prior to transvaginal oocyte recovery, followed by IVF and transfer of no more than three embryos. RESULTS: For Metrodin-HP versus Pergonal, the rates of egg retrieval (98 vs 94%), fertilization (89 vs 92%), clinical pregnancy (32.9 vs 23.4%), miscarriage (4.1 vs 4.5%), live birth (26 vs 18.5%), and ovarian hyperstimulation syndrome (5.5% vs 5.9%) were similar in both groups. The apparent increase in clinical pregnancy and live birth with Metrodin-HP did not reach statistical significance. The dosages of gonadotropins used were comparable. Estradiol levels measured on day 8 of stimulation were significantly lower in the Metrodin-HP group than in the Pergonal group, but the difference did not reach statistical significance on the day of hCG administration. Significantly more follicles (greater than 12 mm) were obtained in the Metrodin-HP group, but the numbers of eggs recovered and fertilized were similar in the two groups. CONCLUSIONS: These findings demonstrate that highly purified FSH (Metrodin-HP) is as effective and successful as hMG (Pergonal) for ovarian stimulation in a standard IVF regimen. Exogenous luteinizing hormone (LH) is not required for satisfactory ovarian stimulation in IVF. Measurement of estradiol may be less helpful in the monitoring of Metrodin-HP cycles, but the level reached on the day of hCG administration can still be used to predict, and hence avoid, ovarian hyperstimulation syndrome.

Synthetic laminaria tent for cervical ripening.

The efficacy and safety of a synthetic laminaria tent (Lamicel; Cabot) in ripening the cervix before induction of labour was compared with prostaglandin E2 (PGE2) oral tablets used intravaginally. Eighty patients were randomly assigned to use of the laminaria tent (N = 40) or PGE2 (N = 40). There were an equal number of primigravidas and multigravidas in each group. The only significant difference between the groups was the higher frequency of uterine hypertonicity (29 v. 5 : PGE2 v. tent) and consequent fetal distress (5 v. 1 : PGE2 v. tent) in the PGE2 group. However, the duration of labour was shorter in the PGE2 group than in the tent group (10, 14 h v. 11,61 h). These findings indicate that the synthetic laminaria tent is the preferred agent for cervical ripening in high-risk pregnancies and in developing countries.