Is expensive always better? Comparison of two induction agents for term rupture of membranes.

The aim of this study was to compare the clinical safety and efficacy of sublingual misoprostol with vaginal prostaglandin E2 (Prostin(R)) as an induction agent after term rupture of membranes. This was a non-blinded randomised control study involving 57 women who were >24-48 h after term rupture of membranes. In total, 29 women received sublingual misoprostol and 28 received Prostin. The mean induction of labour to delivery time was 20.71+/-11.59 h in the Prostin group and 13.96+/-9.90 h in the misoprostol group, (p = 0.021). Some 46.4 % (13/28) of the Prostin group needed a second dose compared with only 20.7 % (6/29) of the misoprostol group (p = 0.039). Oxytocin infusion was used by 57% (16/28) of the Prostin group compared with 31% (9/29) of those who had received misoprostol, (p = 0.047). In our study, sublingual misoprostol when compared with vaginal prostaglandin E2 gel (Prostin) leads to a shorter induction to labour time, and less need for second dose of induction agent or oxytocin infusion. Women were given a satisfaction questionnaire to complete after delivery. Those who were given misoprostol were satisfied with the outcome, would use it again in the future, and recommend it to friends in similar circumstances.

Experience of delivering women with HIV in an inner city London hospital 1994-2004.

The objective of this study was to compare deliveries in women with HIV at Homerton University Hospital with those in the general antenatal hospital population. The study was a retrospective case-note review of deliveries from 1994 to 2004 at an Inner City London Hospital, UK (Homerton University Hospital). In all, 113 deliveries were studied in 98 women with HIV. Compared with the general antenatal population, women with HIV were more likely to be from African backgrounds, describe inadequate housing and be without the support of a partner or family; 79.8% of deliveries in women with HIV were by caesarean section in comparison with 22.4% in the overall hospital population. A majority of women with HIV received antiretroviral therapy in pregnancy. Intercurrent medical and antenatal complications were uncommon and in a majority the postpartum periods were uncomplicated. A significantly higher proportion of women with HIV infection described a previous history of depression than in the general hospital population. There were two instances of vertical transmission of HIV. In conclusion, our observations suggest that with appropriate monitoring and management strategies, successful pregnancy outcomes can be achieved in a complex HIV-positive patient population.

Is HTLV-1 status another antenatal screening test that we need?

Human T-lymphocytic virus type 1 (HTLV-1) carriage is associated with a 2% to 5% lifetime risk of developing a severe, if not fatal, disease. In our Inner London antenatal population, we found that the carrier rate was 0.3%. The antenatal transmission rate is known to be very low, but if the infant is breastfed the transmission rate is up to 25%. It is therefore possible to interrupt the transmission cycle by advising against breastfeeding. The ethical and fiscal issues surrounding antenatal testing are addressed.

Pneumonitis in a lupus twin pregnancy: a case report.

We describe a patient with systemic lupus erythematosus (SLE), whose pregnancy was complicated by fulminant lupus pneumonitis and pericarditis. Maternal disease responded to therapy and twin girls were delivered, both with thrombocytopenia, one of whom died of an intraventricular haemorrhage. Pneumonitis is a rare complication of lupus in pregnancy which may be fatal. We suggest patients with previous severe pneumonitis should have lung function tests at the onset of pregnancy, and treatment be modified to suppress flare if there is any indication of severe pneumonitis in early pregnancy.

Diagnosis and selective cure of Cushing's disease during pregnancy by transsphenoidal surgery.

The diagnosis of Cushing's Disease during pregnancy is complex because the biochemical features are obscured by changes in the normal hypothalamo-pituitary-adrenal axis that occur during gestation. To date, treatment has not been successful and there is a high incidence of maternal and fetal complications. We report the case of a 24-year-old woman with Cushing's disease who presented during her 16th week of pregnancy. Diagnosis was confirmed by the finding of elevated serum and urinary free cortisol levels with loss of the normal circadian rhythm of serum cortisol. Cortisol levels failed to suppress after a low-dose dexamethasone test but suppressed after a high-dose test. There was an exaggerated serum cortisol and plasma adrenocorticotrophin (ACTH) response to corticotrophin-releasing hormone (CRH). Magnetic resonance (MR) scanning demonstrated a pituitary tumour and cure was effected by transsphenoidal surgery where tumour immunostaining for ACTH was removed. Postoperatively the patient made an uncomplicated recovery; serum cortisol and plasma ACTH levels were undetectable at 9 days following surgery and recovery of the hypothalamo-pituitary axis occurred at 99 days after surgery. Caesarean section was performed at 38 weeks of pregnancy and a healthy but small female infant was delivered. This case illustrates the biochemical features of Cushing's disease during pregnancy and is the first report of the use of CRH testing and MR scanning in this clinical situation. The cure by surgery and successful outcome for mother and infant, with preservation of normal anterior pituitary function, suggest that transsphenoidal surgery may be the treatment of choice.

Severe polymorphic eruption of pregnancy occurring in twin pregnancies.

We describe three women pregnant with twins who developed severely symptomatic polymorphic eruption of pregnancy. In all of these women oral prednisolone treatment was indicated and administered to two of them with resulting remission. Both these women breast fed their twins and relapsed in the puerperium requiring further systemic steroid therapy. The third woman was cured by early elective delivery. It has not been previously suggested that the severity of polymorphic eruption is related to multiple pregnancy and this possibility is discussed. The safety of oral prednisolone in pregnancy and during lactation is also reviewed.

A request for antenatal advice.

An informed older woman in her first pregnancy often has greater than usual anxieties about the well-being of her baby. She is likely to seek advice about how to have a healthy pregnancy and which antenatal tests to have. Giving the correct guidance, however, is not so straightforward.

An altered ratio of 18:2 (9,11) to 18:2 (9,12) linoleic acid in plasma phospholipids as a possible predictor of pre-eclampsia.

As a part of a larger study, 15 healthy primigravidas were studied from 28 weeks gestation until 3 days after deliver. In 6 of these women pre-eclampsia (PET) developed; the remaining 9 subjects, who were age matched had normal pregnancies. Plasma phospholipid-esterified 18:2(9,11):18:2(9,12)fatty acids were measured by high performance liquid chromatography (HPLC). The ratio of 18:2(9,11):18:2(9,12)linoleic acid was significantly higher in the PET group than in the normotensive group at 28 weeks' gestation--that is before the onset of symptoms and signs of PET. The ratio remained significantly higher in the PET group than in the normotensive group until deliver, except at 30 weeks when the difference between the ratios just failed to reach statistical significance. It is suggested that measurement of the ratio of 18:2(9,11) to 18:2(9,12)linoleic acid in plasma phospholipids may be useful as a predictor of the likely development of PET.

Serial estimation of serum angiotensin converting enzyme activity during and after pregnancy in a woman with sarcoidosis.

Serum angiotensin converting enzyme activities were estimated during pregnancy and the puerperium in a woman with sarcoidosis and a series of normal women. In the patient with sarcoidosis angiotensin converting enzyme activity was raised during pregnancy, particularly at 21 weeks' gestation, yet she remained well with no symptoms to suggest relapse of sarcoidosis. Serum angiotensin converting enzyme activity may not be of value in monitoring sarcoidosis activity during pregnancy.