Significance of sporadic deceleration during antepartum testing in term pregnancies.

We have investigated the significance of single sporadic deceleration during reactive nonstress testing in normal pregnancies at term. A prospective study was performed during a 1-year period including 4742 nonstress tests performed between the 38th and 42nd weeks of pregnancy in patients referred to our department for antepartum testing and without any complication or pathology. Nonstress test (NST) was carried out with the patient lying on her left side, and was defined as reactive if at least two accelerations of 15 beats/min (bpm) or more lasting 15 sec were observed in a 20-min period. Sporadic deceleration was defined as a decrease in the fetal heart rate to less than 90 bpm or a decrease of 40 bpm below the baseline, lasting at least 2 min. The sporadic deceleration was considered as single when only one appeared in the first 20 min of monitoring and repeated when observed again once in at least one subsequent monitoring. Thirty-four cases of single sporadic deceleration were observed among women with reactive NST. In 14 cases there were repeated sporadic decelerations. The patients were divided into two groups according to the presence or absence of repeated decelerations. Outcomes of patients with repeated sporadic decelerations were compared with a group of 34 patients where sporadic decelerations were not observed during the antepartum testing. A significantly higher percentage of pathological fetal heart rate traces during labor were observed in the group of repeated decelerations. In conclusion the presence of repeated sporadic decelerations during a reactive NST suggests that the cause of cord compromise is persistent and recurrent cord compression is possible. Therefore, in these cases an increased fetal risk could be expected.

Comparative study of extra-amniotic prostaglandin F2 alpha infusion and increasing intravenous oxytocin for termination of second trimester missed abortion.

Extra-amniotic infusion of prostaglandin F2 alpha (PGF2 alpha) and intravenous (IV) oxytocin in increasing doses were compared in a retrospective study to establish the efficacy of the two methods for termination of pregnancies with second trimester missed abortion. Sixty women with this complication underwent pregnancy termination, 28 by extra-amniotic infusion of PGF2 alpha and oxytocin augmentation, if necessary, and 32 by IV oxytocin in increasing doses. All patients in the PGF2 alpha group aborted within 24 hours from onset of infusion and seven of them needed oxytocin augmentation. There were nine failures in the oxytocin group and the other 23 aborted within 17 hours. The mean (plus or minus standard error of the mean) induction-abortion interval was significantly less in the oxytocin group (6.9 +/- 3.4 hours) than in the PGF2 alpha group (12.6 +/- 5.7 hours) p < 0.001. Eight patients in the group had mild side effects, such as nausea, flushes or transient hypotension. Uterine hypertonus was observed in two women receiving PGF2 alpha and treated by temporary interruption of the infusion. In the oxytocin group, one patient had coagulation disturbances and one, hemorrhage. We conclude that extra-amniotic PGF2 alpha infusion is more effective than IV oxytocin in increasing doses, for termination of second trimester missed abortion, but takes effect more slowly. We can assume that further use of IV oxytocin immediately after termination of the PGF2 alpha administration can shorten the induction-abortion interval.

Outcome of pregnancies associated with marked gestational thrombocytopenia.

The purpose of this prospective study was to investigate the outcome of pregnancies associated with marked gestational thrombocytopenias (< 100,000/mm3) including postpartum resolution and neonatal influence. Over a period of 18 months, 20 cases of thrombocytopenia were observed; of them 19 were diagnosed as gestational thrombocytopenia with platelet values of < 100,000/mm3. Fifteen women returned to a normal platelet count within two weeks after delivery and four within four weeks. No cases of thrombocytopenia were found among the infants and no cases of coagulation disturbance were observed in the mothers at delivery or in the postpartum period. The findings of the present study indicate that in cases of gestational thrombocytopenia, apart from a careful maternal and fetal surveillance, no intervention is necessary during pregnancy or delivery if there is no obstetrical indication.

Intrauterine PGF2 alpha infusion for termination of pregnancies with second-trimester rupture of membranes.

Intrauterine prostaglandin (PG) F2 alpha infusion and intravenous (IV) oxytocin infusion were compared to evaluate the effectiveness of the two methods for termination of pregnancies with second-trimester rupture of membranes. Twenty-two women with this complication were randomly allocated to receive either 20 mg PGF2 alpha, diluted in 500 mL of NaCl 0.9% and administered through a Foley catheter inserted through the cervix, or IV oxytocin infusion in increasing doses. All subjects in the PGF2 alpha group aborted after the first administration. Repeat infusion was necessary in three oxytocin-treated subjects. The mean (+/- SD) induction-abortion interval was significantly shorter in those receiving PGF2 alpha (6.7 +/- 1.2 hours) than in those receiving oxytocin (8.8 +/- 2.7 hours). Minor side effects, such as nausea and vomiting, were observed in three women during PGF2 alpha infusion and were treated symptomatically and by temporary interruption of the infusion. Uterine hypertonus, observed in one subject in each group, was treated by temporary cessation of the infusion. We conclude that intrauterine PGF2 alpha infusion seems more effective than IV oxytocin for termination of pregnancies with second-trimester rupture of membranes.

Protein/creatinine ratio in random urine specimens for quantitation of proteinuria in preeclampsia.

Protein/creatinine ratio (mg/g) in random urine samples was measured in 35 preeclamptic patients and 70 healthy pregnant women. We found a close correlation between the protein/creatinine ratio in random urine samples and both the 24-hour protein excretion and the 24-hour protein/creatinine ratio in the preeclamptic patients. The ratio did not exceed 200 mg/g in any of the 70 healthy pregnant women; therefore, ratios below this value can be considered normal. We conclude that determination of the protein/creatinine ratio in random urine specimens may be a simple method for quantitation of proteinuria in preeclampsia.

A scoring system for induction of labor using prostaglandin E2 vaginal tablets.

A randomized controlled trial was carried out in order to establish the efficacy of a scoring system for calculating the dose of vaginal prostaglandin E2 tablets for the induction of labor. One hundred ten women were included in the study. The patients received a dose of prostaglandin E2 calculated according to a scoring system based on the Bishop's score, or the standard dose of 3 mg repeated 6 h later if labor did not start. The percentage of inductions achieved was the same with both regimens (92.7%). The mean total dose used in the scoring system-group (2.7 mg) was significantly lower than that used in the 3-mg group (3.5 mg, P less than 0.025). Thirty-seven of 55 women receiving the scoring dose delivered with amounts of 2.5 mg prostaglandin E2 or less. Three cases of uterine hyperstimulation were observed in the 3-mg group whereas no cases were observed in the scoring group. The scoring system is proposed as a method for calculating the dose of vaginal prostaglandin E2 for induction of labor and minimizing the risk of overdosage.

Prostaglandin F2 alpha for prevention of urinary retention after vaginal hysterectomy.

The delay in spontaneous micturition after pelvic surgical procedures is a significant complication. This study was performed to establish the validity of intravesical instillation of prostaglandin F2 alpha in the prevention of urinary retention after vaginal surgery. For this purpose 102 patients were randomly and alternatively allocated to receive either 16 mg of prostaglandin F2 alpha diluted in 40 mL of saline or saline only given intravesically. Similar numbers of patients with vaginal hysterectomy (27 versus 31), vaginal repair (12 versus 11), and repair with Kelly urethral plication (12 versus 9) were included in the study and control group, respectively. The frequency of urinary retention in the women treated with prostaglandin F2 alpha was decreased significantly as compared with those treated with saline alone (P less than .02). But this was true for women undergoing vaginal hysterectomy only. There was also a significantly shorter hospitalization of women receiving prostaglandin F2 alpha (P less than .05) and there were no side effects.

Is term breech presentation in primigravida an absolute indication for cesarean section?

Excessive perinatal loss is associated with breech presentation, this loss being accounted for by prematurity, congenital anomalies and birth trauma. In the endeavor to exert an effect on two of these problems, cesarean section has been resorted to increasingly. We have compared two management regimes of primigravida term breech presentation corresponding to two 4-yr periods. During the first period every case was evaluated carefully and, if no other pathology was found, a trial vaginal delivery was allowed. During the second period all the cases were delivered by elective cesarean section. Of the 108 cases of the first period, 46 delivered vaginally and 62 underwent cesarean section. 119 cases were scheduled for abdominal delivery during the second period. Immediate infant outcome for each group was determined by the 1 and 5 min Apgar scores. Analysis of 5 min Apgar scores demonstrated no significant differences in immediate outcome between infants delivered vaginally and by cesarean section. Fetal morbidity related to birth trauma was higher in the vaginal delivery group but there were no perinatal deaths. Maternal morbidity was observed only in the cesarean section groups. This study suggests that properly selected primigravid term breech infants could be delivered vaginally without increased perinatal mortality and with immediate outcomes comparable to those found with cesarean section.

Risk in the vaginal delivery of the large fetus.

The problem of the excessively weighted fetus was studied. For this purpose, over a period of 2 years, each delivery with fetal weight of 4,500 g or more was included in the study. The history and examination findings of the present pregnancy were reviewed following delivery. The postpartum outcome and later complications in both mothers and infants were investigated prospectively. A total of 82 deliveries of large babies were included in the study and the outcome was compared with that of parallel deliveries of babies within the normal weight range (2,500-4,000 g). Factors frequently associated with excessive fetal weight were identified. A relatively high perinatal mortality and morbidity relating to vaginal delivery were observed among the large infants. In all those cases who developed delay in the second stage of labour, Caesarean section is proposed when macrosomia is clinically suspected and confirmed by ultrasonic assessment. Moreover elective Caesarean section should be considered before labour, when macrosomia is associated with hyperglycaemia or other pathology.

Increased decidual prostaglandin E concentration in human abortion.

Prostaglandin E (PGE) concentration was measured in decidual tissue after spontaneous and missed abortion and compared with that obtained from induced abortion. Tissues were obtained by curettage from groups of 10 patients each and PGE was estimated by radioimmunoassay. After spontaneous and missed abortions decidual tissue contained significantly higher mean concentrations of PGE, (486.3 and 66.7 ng/g wet tissue respectively) than after induced abortion (18.6 ng PGE/g wet tissue). It is suggested that an increased rate of PGE biosynthesis or reduced breakdown, or both, may play a role in the mechanism of human abortion.

Extraamniotic infusion of prostaglandin F2 alpha in normal saline for termination of midtrimester missed abortion.

A combined method consisting of extraamniotic infusion of normal saline with prostaglandin F2 alpha was used in 20 patients for termination of midtrimester missed abortion. All 20 patients aborted within 12 h. The mean infusion abortion interval was 7.34 h. Side effects were observed only in 5 patients (25%), a low percentage when compared with other prostaglandin methods. The possibility of adjusting or stopping the infusion permitted the rapid control of side effects and the intensity of uterine contractions. According to the results obtained in this series, the proposed method seems to be more suitable than other procedures reported for termination of midtrimester missed abortion.

Etiological aspects of double monsters.

Four cases of double monsters are reported, including a rare case of craniofacial duplication (diprosopus). Based on the findings observed, etiological factors of these malformations are discussed. We suggest that exogenous (environmental) factors such as habits, way of life or religious practices of certain populations can influence the development of double monsters.

Epidural analgesia in labour performed by obstetricians.

The use of epidural analgesia by obstetricians in 2,645 women in labour is reported. The use of this technique as one of the routine methods is proposed even in those centres where no anaesthetist for pain relief is available for the 24-hour period. This is possible by the previous training of obstetricians. Advantages, side-effects and complications of epidural analgesia are discussed.

Human chorionic gonadotropin in intrauterine device users.

Measurements of human chorionic gonadotropin (HCG), luteinizing hormone (LH), and progesterone were carried out by means of radioimmunoassays in 21 women with regular menstruating cycles, using an intrauterine device (IUD). Serum HCG was undetectable in 10 women. In 11 women very small amounts of HCG were detected, all under 3 mIU/ml. HCG curves were inactive and flat; in one case the highest level of HCG coincided with the LH peak; in another case HCG was detected in spite of lack of ovulation. These facts suggest a cross-reactivity of LH and no real presence of HCG.

PIP: It has been reported that HCG (human chorionic gonadotropins) found in IUD users is a sign of an implantation of fertilized ovum, and that irregular bleeding in the IUD users may be a sign of an early abortion. Other authors contend, however, that HCG levels found in IUD wearers coincide with the peak of LH (luteinizing hormone) and are therefore a sign of cross reaction rather than the actual presence of real HCG. This study was conducted to investigate the presence of HCG during the luteal phase of 21 IUD wearers (aged 22 to 39 years) with menstrual cycles ranging from 25 to 33 days. A total of 80 blood samples was collected and analyzed for levels of HCG B-subunit, LH, and progesterone using radioimmunoassays. 10 women did not exhibit measurable amounts of B-subunit of HCG. In the other 11, very small amounts of HCG were detected (all under 3 mIU/ml. In 1 case, level of progesterone measured (0.6 to 0.7 ng/ml) pointed to a lack of ovulation while in another case, the highest level of HCG (2.5 mIU/ml paralleled the peak of LH reached at 44.6 mIU/ml. The findings suggest that cross reactivity causes the presence of small amounts of HCG in the blood of IUD wearers.

A technique for management of obstructed labour with antenatal fetal death.

A technique for management of obstructed labour associated with fetal death is presented. The new method makes it possible to decrease fetal head size by evacuation of brain tissue by suction using thoracic-type trocar. Three patients with obstructed labour and fetal death were managed successfully using this technique. The method permits a decrease of fetal head size easily and rapidly, avoiding the risks of other techniques. Moreover, its use makes it possible to eliminate craniotomy from obstetric practice. The method should be equally suitable for cases of major hydrocephaly.

The treatment of postmenopausal syndrome by monthly oral doses of quinestrol.

Seventy patients between the ages of 37 and 59 suffering from the menopausal syndrome were included in a clinical trial and treated for a period of 6 to 18 months. Out of the seventy, 43 were suffering from spontaneous and 27 from surgical menopause. Forty of them were given 1 mg of quinestrol and 30 received placebo. The drug was administered orally in a one-tablet dose once a month. An improvement took place in 35 (87.5%) of the women receiving quinestrol but in only 15 (50%) of those receiving placebo. Among the patients with spontaneous menopause an improvement was seen in 22 out of 25 (88%) receiving quinestrol, compared with 9 out of 18 (50%) receiving placebo. Tolerance of the drug was good and most of the laboratory tests as well as blood pressure and body weight showed statistically non-significant changes. This kind of treatment is expecially suitable when daily intake is undesirable.

PIP: Use of small daily doses of quinestrol, a synthetic estrogen consisting of 3 cyclopenthyl-ether of ethinyl estradiol, has been reported to result in remission of postmenopausal symptoms in many patients. This study used quinestrol in 1 mg monthly oral doses in a group of women (N=70) suffering from the menopausal syndrome (43 from spontaneous and 27 from surgical menopause). 40 women received quinestrol 1 mg and 30 were given placebo. Of the 40 who were given quinestrol, 25 had spontaneous menopause and 15 were surgically induced. In the placebo group, 18 had spontaneous menopause and 12 were surgically induced. Treatment lasted from 6-18 months; none of the patients knew whether they had quinestrol or placebo. Blood samples were taken in 10 patients before treatment and 6 months later. As a whole, improvement was observed in 87.5% of the quinestrol-treated group, in contrast to 50% of the placebo-treated group. For women with spontaneous menopause, an improvement was observed in 88% of the quinestrol group and 50% of the placebo group. With respect to the effectiveness of quinestrol, no significant difference in the relief of symptoms was observed between the 2 groups (spontaneous and surgical menopause). Observed side effects were skin rash in 2 patients, thrombophlebitis in 1 patient, vaginal bleeding in 3 patients and nausea in 4 patients. It was concluded that quinestrol therapy is especially suitable in surgical menopause where substitutive therapy is indicated, as well as in cases where daily intake is not favored.

Extraperitoneal translocation of a Copper-T device into the space of Retzius.

A case of probable cervical perforation and extra-peritoneal migration of a Copper-T device into the space of Retzius is hereby reported. The mechanism of this exceptional kind of translocation, its outcome and the management of the patient are discussed.

PIP: The case report of a 20-year-old female, gravida 5, para 2, abortus 3, presents an unusual instance of presumed cervical perforation by a Copper-T IUD and extraperitoneal migration into the space of Retzius. After suction curettage for an IUD failure, the IUD was not locatable. Hystograms, cystograms, and roentgenograms were made, and the device was visualized far anterior to the uterus. A low transverse incision of the abdominal wall was performed, a mass was located below the insertion of the rectus muscle on the symphysis pubis. Blunt dissection into the Retzius space exposed the IUD, which was easily removed. It is speculated that such migration into the space of Retzius is due to the dilatation-contraction movements of the bladder.

Fertility following adnexal surgery.

A total of 154 patients after adnexal operations between 1969-1973 were queried in order to establish fertility rate after operation. Out of the 154 questioned 122 submitted their reply. i.e. 69.2 per cent. These women were divided into three groups. The first one comprised 46 patients operated because of extrauterine pregnancy, the second consisted of 50 patients operated because of ovarian cyst and the third one included 18 women operated because of bilateral adnexal pathology. In the first group 90 per cent of the patients who desired so succeeded to become pregnant. In the second group 87 per cent succeeded and 66.6 per cent in the third group. The possible ethyological factors of sterility after adnexal operations were discussed and conservative operations were proposed as the most convenient policy in cases of bilateral adnexal pathology.