Coagulation screening for spinal anaesthesia in pre-eclampsia at the University Hospital of the West Indies [abstract]

OBJECTIVE: To determine whether pre-eclamptic patients receiving spinal anaesthesia require prior coagulation screening studies. METHODS: This was a retrospective study of all patients with pre-eclampsia receiving spinal anaesthesia during the period January 1995 to March 2001. The control group was patients without pre-eclampsia who also received spinal anaesthesia. A total of 240 patients were studied, 134 in the pre-eclamptic group and 106 controls. The results reported are the mean ñ standard deviation, and range; p< 0.005 was considered significant. RESULTS: The mean age of the pre-eclamptic women was 28 ñ 5.7 years compared with 30 ñ 5.4 years for the controls (p= 0.029). The mean platelet count for the pre-eclamptics was 205.7 ñ 68.0 x 10/1 (range 23.0-394.0 x 10/1) while the mean platelet count of the controls was 204.5 ñ 43.6 x 10/1 (range 150.0-339.0 x 10/1) (p= 0.873). Differences between mild pre-eclamptic and severe pre-eclamptic subgroups were also evaluated. Mean age and haemoglobin levels between the two subgroups were no different (p= 0.370 and p= 0.310, respectively) but the mean platelet count was significantly lower (p= 0.002) in the severe pre-eclamptic subgroup. Coagulation testing included prothrombin time (PT) and partial thromboplastin time (PTT). There was a significant difference in PTT between mild and severe pre-eclamptics (p= 0.013) but no correlation between abnormally low platelet counts and abnormal coagulation times was demonstrated (p= 0/751. r= -0.063). Overall, there was no difference between the groups in outcome variables, including any intermediate or long-term neurological deficits. CONCLUSIONS: Data from this study therefore support limiting the coagulation screening in pre-eclamptics to patients who demonstrate a diminished platelet count. (AU)

Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in black women with postmenopausal bleeding

OBJECTIVES: To determine whether a postmenopausal endometrial thickness of 5 mm excludes endometrial pathology in the black woman with postmenopausal bleeding. METHODS: Seventy-five black women with postmenopausal bleeding participated in this prospective study between August 1, 1998 and July 31, 1999. The patients had a questionnaire administered, which sought to obtain general information about their age, gynaecological, obstetric and social history. The patients then had a transvaginal ultrasound with double layer measurement of their endometrium; this was followed by hysteroscopy and suction curettage. The curettings were sent for histopathological analysis. The local hospital ethics comittee approved the study. RESULTS: Correlation between the endometrial thickness and endometrial pathology was not very reliable. Fifty per cent of the patients with endometrial cancer had an endometrial thickness of 3-4 mm. Seventy per cent of the women with endometrial thickness of greater than 5 mm had benign pathology. Additionally, the following characteristics were found to be more strongly associated with endometrial cancer: age over 65 years (p = 0.015; relative risk (rr) 1.406), 5 or more years since menopause (p = 0.0176; rr = 1.295) and primary infertility (p = 0.0124; rr = 0.438). CONCLUSION: A double layer endometrial thickness of less than 5 mm, as measured by transvaginal ultrasound, does not exclude endometrial cancer as a cause of postemnopausal bleeding in the black female. A black, postmenopausal female with transvaginal ultrasound measured double layer endometrial thickness of 3 mm or greater and postmenopausal bleeding needs further investigation. Age, time since menopause, endometrial thickness and infertility are strongly associated with endometrial cancer in postmenopausal black women.(Au)

Status of the thyroid gland in pregnancy and its relation to postpartum depression

OBJECTIVES: Adequate adjustments by the hypothalamic-pituitary-thyroid axis during pregnancy allow women to remain euthyroid with only slight changes in thyroid volume and other thyroid functions. In approximately 10 percent of women, the challenge of thyroid economy results in sub-clinical hypothyroidism. This study is to elucidate the association between such hypothyroidism and postpartum depression, if any. METHOD: Blood samples were collected from 73 healthy subjects attending the antenatal clinc of the University Hospital of the West Indies, at booking, 28 weeks, 36 weeks of gestation, and 1 day and 6 weeks postpartum. Serum level of total thyroxine, free tri-iodothyronine, and thyroid stimulating hormone (TSH) were determined by radioimmunoassays. The thyroid volume was estimated by ultrasonography in some subjects. A self-rating depression scale was administered at 28 weeks of gestation and at 6 weeks postpartum for quantitative measurement of depression. The preliminary results revealed that 22 subjects (30 percent) had postpartum depression, 12 (16 percent) had mild depressin and 10 (14 percent) had moderated to marked depression. Of these, only 2 subjects had total thyroxine values less than 5.5g/100 ml and TSH values greater than 2.5 IU/ml. There were no significant changes between postpartum and antepartum thyroid volumes. CONCLUSION: Although a significant number of women in this study had postpartum depression, no significant relationship between depression and the serum levels of thyroid hormones was established.(Au)

Outpatient versus inpatient cerclage for cervical incompetence

The traditional treatment of cervical incompetence is a cervical cerclage in the early second trimester with bed rest in hospital for at least three days. The main complications are premature labour and premature delivery, which are believed to be reduced by bed rest in hospital. The aim of this study was to determine if patients who had cervical cerclage as outpatients had a different pregnancy outcome from those with cerclage done as inpatient. Fifty patients were randomised to each group. Four were lost to follow-up and results for 46 patients were analysed. The patients included were all diagnosed as cervical incompetence clinically, and in some cases, by investigation with ultrasonography. Cerclage was done with sedation and para cervical block only, in all cases. In one group, the patients were allowed home on bed rest for three days. In the other group, the patients were kept in hospital on bed rest for three days. Both groups were also given salbutamol orally. Variables examined included: the age and parity of the patients, the type of cerclage done, a history and previous cerclage, the gestational age at the time of cerclage and the gestational age at delivery. The efficacy of the procedure was determined by the delivery of a live infant. The results showed that the two groups were similar in all pre-operative variables. There was also no group difference in the type of cerclage done. The complications were also similar in frequency in the two groups, except for the occurrence of premature contractions - which were significantly more frequent in the outpatient group 6/23 versus 1/23 (p=0.04). The frequency of premature delivery and live births were however no different in the two groups. The occurrence of more premature labour in patients sent home is worrying, as because this study is small, it is possible that a larger study may find that this may lead to premature delivery and fewer living infants (AU)

Correlation between histopathology evaluation by curettage and diagnostic hysteroscopy in patients with abnormal uterine bleeding

Diagnostic hysteroscopy was performed on a total of 54 patients with abnormal uterine bleeding, comprising 42 premenopausal and 12 postmenopausal patients. The commonest finding on hysteroscopy in the premenopausal patients was submucous fibroid accounting for 28.6 percent of cases, while endometrial polyp was the commonest finding in postmenopausal patients constituting 33.3 percent of cases. After excluding submucous fibroids, the concordance rate between hysteroscopy and histopathology was found to be 74 percent, even in the absence of targeted biopsy, thus confirming is diagnostic accuracy. A sensitivity of 87 percent and a specificity of 85 percent were obtained.(AU)

Successful pregnancy outcome after hysteroscopic adhesiolysis in Asherman's syndrome

Asherman's syndrome is an uncommon finding at hysterosalpingography for infertility. Modern day management entails hysteroscopic confirmation and adhesiolysis. We present one such case of a young woman who had secondary infertility after dilatation and curettage, and who was diagnosed and treated with a successful outcome.(AU)

Insulin response and gestational diabetes related to maternal age? - abstract

Most cases of gestational diabetes are found in women older than 30 years. Insulin response generally decreases with increased age. To correlate the relationship between maternal age; insulin response and subsequent development of gestational diabetes, 120 pregnant women were classified into three age groups; ages 18-24 years, 25-29 years and o30 years. All women were classified as normal weight when adjusted for expected pregnancy weight gain. The three groups were administered a 50g glucose screen at 27 weeks of gestation. Blood samples were taken 1 hour after ingesttion. Analyses were done for glucose, c-peptide and insulin. Patients in the age group in 18 - 24 years had mean ñSD glucose concentration of 5.6ñ 1.0 mmol/l and showed the greatest insulin response with a mean ñSD of 160ñ 24æU/ml. Patients in the age group 25 - 29 years had a mean glucose value of 6.4ñ 1.0 mmol/l and the mean insulin value of 148ñ 31æU/ml was less than that of the younger group. The oldest women had the lowest mean insulin value of 100ñ 49æU/ml and showed some general glucose intolerance with mean glucose value of 8.1ñ 1.0mmol/l. A significant difference (p=0.001) was formed in insulin values when the women in the age groups 18-24 years and 25-19 years were compared. However the difference was greater (p=0.000002) when the women in the age groups 18 - 24 years and o30 years were compared. A 4.25 percent prevalence rate of gestational diabetes was found among the oldest women. Our findings that glucose tolerance and insulin response are lowest in older pregnant women support the concept that gestational diabetes in more prevalent in older gravidas. (AU)

The glucose tolerance test in pregnancy: at which gestational age should it be performed

Gestational diabetes is defined as intolerance detected during pregnancy. To investigate the effect of time on the screening test for gestational diabetes, patients were administered a 50g oral glucose screening test at 7-13; 24-36 weeks of gestation. There was an increase in the plasma glucose value up to 32 weeks of gestation and a gradual decrease to term. Of the 850 patients screened between 7 and 13 weeks of gestation, 22.2 percent were positive, and of these 2.9 percent were confirmed to be diabetic by the two-hour 75 g oral glucose tolerance test. Patients with negative screen or confirmatory tests between 7 and 13 weeks were rescreened at 24 weeks; 8.3 percent were positive, and of them 3.5 percent were confirmed as gestational diabetics. Patients who tested negative at 24 weeks were retestet between 28 and 36 weeks; 7.5 percent were positive, and of these 0.5 percent were confirmed as having gestational diabetes was found to be 4.25 percent. Currently, glucose screening for gestational diabetes is recommended between 24 and 28 weeks of gestation. From the data collected most cases were detected (3.5 percent) at 24 weeks. This study supports screening of all patients without any previous history of diabetes mellitus at or around 24 weeks of gestation (AU)

Gestational diabetes, the UHWI experience

Between 1985 and 1991, 1,276 patients with diabetes mellitus in pregnancy were either supervised or personally managed by the author at the University Hospital of the West Indies (UHWI). The perinatal mortality rate (PMR) was 60/1000 for this group of high-risk patients. There were eight cases of congenital malformation and 22.5 percent of the deliveries were preterm. The caesarean section rate was 33.6 percent which is twice that for the general obstetric population. Using the diagnostic criteria set by WHO (1980), 184 patients were classified as gestational diabetes mellitus (GDM). The principles of management of diabetes mellitus in pregnancy are reviewed. Population studies from the UDOP suggest the prevalence of diabetes to be 17 percent. In light of this, a pilot study of routine testing of all antenatal mothers at UHWI was initiated in January 1994. One thousand (1000) consecutive patients were enlisted and the protocol of testing is shown. The results will be discussed. (AU)

Transcervical resection of the endometrium (TCRE) using the rollerball resectoscope - abstract

Objective: To assess the efficacy of transcervical resection of the endometrium using the rollerball resectoscope in Jamaican women complaining of menorrhagia. Methods: From January 1st 1994 to December 31st 1994, 16 women underwent TCRE using a 27 fr CIRCON-ACMI uterine resectoscope with a rollerball electrode and 5 per cent dextrose/water as the irrigation medium. All patients had previous diagnostic hysteroscopy with endometrial sampling that demonstrated benign pathology. Details of operative time, fluid absorption and complications were recorded on prepared forms. Menstrual status was enquired at follow-up visits at 1, 3 and 6 months after the procedure. Results: The average operative time was 43 minutes and the average fluid absorption 308 ml. Complications included endometritis in 2 patients and one uterine perforation. Eight patients were amenorrheic at the 1st visit and remained so at 6 months, 2 women reported spotting to 3 months followed by amenorrhea. A further 3 continued to menstruate but with reduced loss. The remaining 3 were not satisfied and 2 chose hysterectomy. Conclusion: TCRE using the rollerball resectoscope can be an alternative therapy for women with menorrhagia, however, complications need to be addressed by proper patient selection, skilled training in operative hysteroscopy and a larger study population followed long term (AU)

Amniotic fluid index in the management of the postdates pregnancy

This is a prospective evaluation of the relationship between the amniotic fluid index (AFI) and perinatal outcome in 55 postdates pregnancies. The gravid abdomen was divided into four quadrants, using real-time ultrasound with a 3.5 mHz transducer, the largest pocket of amniotic fluid in each quandran was measured and their sum totalled to arrive at the amniotic fluid index. AFI in this study ranged from 2.8 cm to 22.6 cm. The mean for 41 weeks was 13.52 ñ 4.6 cm and for 42 weeks, 9.93 ñ 4.37 cm. Oligohydramnios was noted in four patients, AFI less than 5.3 cm. Two of these cases developed intrapartum foetal distress and had caesarean section. All four babies were admitted with meconium aspiration and one died from this complication. (AU)

Amniotic fluid index in the management of the postdates pregnancy

This is a prospective evaluation of the relationship between the amniotic fluid index (AFI) and perinatal outcome in 55 postdates pregnancies. The gravid abdomen was divided into four quadrants, using real-time ultrasound with a 3.5 mHz transducer, the largest pocket of amniotic fluid in each quandran was measured and their sum totalled to arrive at the amniotic fluid index. AFI in this study ranged from 2.8 cm to 22.6 cm. The mean for 41 weeks was 13.52 ñ 4.6 cm and for 42 weeks, 9.93 ñ 4.37 cm. Oligohydramnios was noted in four patients, AFI less than 5.3 cm. Two of these cases developed intrapartum foetal distress and had caesarean section. All four babies were admitted with meconium aspiration and one died from this complication.

Diabetic retinopathy in pregnancy - abstract

Diabetic retinopathy is the leading cause of blindness between the ages of 24 and 64 years. The first half of this period corresponds to the childbearing age in women. The effects of pregnancy on diabetic retinopathy (DR) are unclear. However, the concensus is that pregnancy is an independent risk factor accelerating DR. Co-existing hypertension also potentiates this condition. The duration of diabetes mellitus and the status of the retina prior to pregnancy influence the rate of acceleration of retinopathy. Rapid normalization of blood glucose recommended for optimal obstetric outcome leads to worsening of DR. A baseline opthamological evaluation is recommended at the beginning of each pregnancy and follow-up in each trimester as well as three months post-partum. If there is no, or minimal, non-proliferative diabetic retinopathy (NPDR) at the initial examination, deterioration is unlikely. However, 50 per cent of women with severe NPDR or proliferative diabetic retinopathy (PDR) will worsen during pregnancy. PDR that has been adequately treated by laser photocoagulation prior to pregnancy does not deteriorate and as such it is no longer a contraindication to childbearing. Female diabetic patients ideally should have a planned pregnancy. A team approach has shown significant improvements in maternal and foetal outcome. By the inclusion of the opthalmologist in the team, the effects of pregnancy on DR. can be monitored (AU)

Diabetes in pregnancy - abstract

Two hundred and seventy-six patients with diabetes mellitus in pregnancy, either supervised or personally managed by the author, are reviewed. The perinatal mortality rate (PMR) was 60/1000 for this group of high-risk patients. There were eight cases of congenital malformation and 22.5 percent of the deliveries were preterm. The Caesarian Section rate was 33.6 percent, which is twice that for the general obstetrical population. The diagnostic criteria and the principles of management of diabetes mellitus in pregnancy are reviewed. The challenges to better management and outcome include pre-pregnancy assessment and close collaboration between the internist, dietitian, obstetrical and neonatal teams throughout the pregnancy and post-partum period (AU)

Amniotic fluid index (AFI) in postdates pregnancy - abstract

This a prospective evaluation of the relationship between the amniotic fluid index (AFI) and perinatal outcome in 55 patients managed at the Obstetrical Unit at the University Hospital of the West Indies. The subjects had an otherwise uncomplicated pregnancy and early confirmation of gestational age by ultrasound. Forty-two patients had delivered by 41 weeks and the remaining thirteen by 42 weeks. The gravid abdomen was divided into four quadrants, using realtime ultrasound with a 3.5 Mhz transducer, the largest pocket of amniotic fluid in each quadrant was measured and their sum totalled to arrive at the AFI. The pregnancies were managed without knowledge of this evaluation. Perinatal outcome was assessed by the presence of meconium-stained liquor and its aspiration, intrapartum foetal delivery, low APGAR scores at delivery, the need for admission to the nursery and perinatal death. AFI in this study ranged from 2.8 cm to 22.6 cm. The mean for 41 weeks was 13.52 ñ 4.6 cm and for 42 weeks was 9.93 ñ 4.37 cm. Oligohydramnios was noted in four patients, AFI < 5.3 cm. Two of these cases developed intrapartum foetal distress and had Caesarian Section. All four babies were admitted with meconium aspiration, and one died from this complication (AU)

Amniotic fluid index (AFI) in post-dates pregnancy

This is a prospective evaluation of the relationship between the amniotic fluid index (AFI) and perinatal outcome in 55 patients managed in the Obstetric Unit at the UHWI. The subjects had an otherwise uncomplicated pregnancy and early confirmation of gestational age by ultrasound. Forty-two patients had delivered by 41 weeks and the remaining thirteen by 42 weeks. The gravid abdomen was divided into four quadrants, using real-time ultrasound with a 3.5 Mhz transducer, the largest pocket of amniotic fluid in each quadrant was measured and their sum totalled to arrive at the amniotic fluid index. The pregnancies were managed without knowledge of this evaluation. Perinatal outcome was assessed by the presence of meconium stained liquor and its aspiration, intrapartum fetal distress, low APGAR scores at delivery and the need for admission to the nursery. AFI in this study ranged from 2.8 cm to 22.6 cm. The mean for 41 weeks was 13.52 +/- 4.6 cm and 42 weeks 9.93 +/- 4.37 cm. Oligohydramnios was noted in four patients, AFI less than 5.3 cm. Two of these cases developed intrapartum fetal distress and had caesarian section. All four babies were admitted with meconium aspiration and one died from this complication. Evaluation of the AFI can be useful in the monitoring of post-dates pregnancy. (AU)

Thrombocytopenia in severe pre-eclampsia and eclampsia - abstract

A retrospective study was conducted on 15 cases of eclampsia and 9 cases of severe pre-eclampsia to record the incidence of thrombocytopenia in these cases and to evaluate its clinical significance. Thrombocytopenia occurred in 8 of the 15 eclamptics and 5 of 9 severe pre-eclamptics. Tests for other coagulation defects revealed the frequent association of thrombocytopenia, hypofrinogenaemia and prolonged prothrombin time. The clinical significance is discussed (AU)

Hysteroscopic assessment of abnormal uterine bleeding in users of the intrauterine contraceptive device

Sixty users of the IUD who complained of abnormal menstural blood loss were evaluated by hysteroscopy, and the findings were compared with a matched group who had this investigation for "missing strings". Submucous fibroids and endometritis were more frequent in the study group whereas malposition of the IUD was commoner in the controls (p<0.05) (AU)

Hysteroscopic assessment of abnormal uterine bleeding in users of the intrauterine contraceptive device

Sixty users of the IUD who complained of abnormal menstural blood loss were evaluated by hysteroscopy, and the findings were compared with a matched group who had this investigation for "missing strings". Submucous fibroids and endometritis were more frequentl in the study group whereas malposition of the IUD was commoner in the controls (p<0.05).

Surgery for post-hysterectomy vaginal prolapse

Nine cases treated by surgery for post-hysterctomy vaginal prolapse are reviewed. The mean time between presentation and the antecedent hysterectomy was 12.8 years. Two patients who had abdominal sacral colpopexy alone developed recurrence of prolapse. Additional culdoplasty and colposuspension improved the cure rate but prolonged the mean operating time. Restoration of vaginal anatomy and function is best achieved with the combination operation. (AU)