The surgical transversus abdominis plane block--a novel approach for performing an established technique.

Although the transversus abdominis plane (TAP) block has an established role in providing postoperative analgesia following caesarean section, the technique is not widely used by obstetric anaesthetists. The conventional TAP block is associated with significant technical difficulties and risk of peritoneal, hollow viscus and organ perforation. We report a much simpler technique in which the obstetric surgeon, during open surgery, is able to introduce the TAP block via an intra-abdominal approach, which is technically easier and also obviates the risks associated with the conventional TAP procedure. We believe our technique may be easier, safer and equally effective.

Titrated low-dose vaginal and/or oral misoprostol to induce labour for prelabour membrane rupture: a randomised trial.

OBJECTIVE: To evaluate the clinical effectiveness and safety of titrated low-dose misoprostol for induction of labour (IOL) in the presence of prelabour rupture of membranes (PROM). DESIGN: Randomised controlled trial. SETTING: Maternity units in the UK (9) and Egypt (1). POPULATION: Women >34 weeks of gestation with PROM, singleton viable fetus and no previous caesarean section. METHODS: Subjects randomised to IOL with a titrated low-dose misoprostol regimen (oral except if unfavourable cervix, where initial dose vaginal) or a standard induction method, namely vaginal dinoprostone followed by intravenous oxytocin if the cervix was unfavourable or intravenous oxytocin alone if the cervix was favourable. MAIN OUTCOME MEASURES: Primary outcome measures were caesarean section and failure to achieve vaginal delivery within 24 hours. Analysis was by intention to treat. RESULTS: The trial did not achieve the planned sample size of 1890 due to failure in obtaining external funding. Seven hundred and fifty-eight women were randomised (375 misoprostol and 383 standard). There were less caesarean section (14 versus 18%, relative risk [RR] 0.79; 95% CI 0.57-1.09) and less women who failed to achieve vaginal delivery within 24 hours in the misoprostol group (24 versus 31%, RR 0.79; 95% CI 0.63-1.00), but the differences were not statistically significant. Subgroup analysis showed that with unfavourable cervix, misoprostol may be more effective than vaginal dinoprostone. There was no difference in hyperstimulation syndrome. There were more maternal adverse effects with misoprostol, but no significant differences in maternal and neonatal complications. CONCLUSIONS: Titrated low-dose misoprostol may be a reasonable alternative for IOL in the presence of PROM, particularly in women with an unfavourable cervix. Safety and rare serious adverse events could not be evaluated in a trial of this size.

Congenital myotonic dystrophy.

We describe a case of severe congenital myotonic dystrophy (CDM). A 38-year-old primigravida, who was known to suffer from mild myotonic dystrophy (DM), conceived spontaneously and booked for confinement at 11 weeks in our unit. The couple had been fully counseled about the risks of transmission of this condition to their offspring before embarking on this pregnancy. Despite being fully aware of the risks, they declined prenatal diagnosis. The pregnancy was monitored by serial ultrasound scans. The diagnosis of CDM was suspected by ultrasound markers of borderline ventriculomegaly, polyhydramnios, and reduced fetal movements. The pregnancy ended prematurely at 33 weeks in an emergency caesarean section because of severe fetal compromise. The neonate died almost immediately after birth. The genetic analysis of cord blood confirmed severe DM. This case highlights the importance of ultrasound markers for the diagnosis of CDM in the absence of definitive prenatal diagnosis.

Effect of inhibiting the sarcoplasmic reticulum on spontaneous and oxytocin-induced contractions of human myometrium.

OBJECTIVE: 1. To assess the contribution of the sarcoplasmic reticulum calcium store in the generation of uterine smooth muscle contractions; 2. to evaluate the contribution of calcium induced calcium release or ryanodine gated calcium channels to myometrial force production. DESIGN: Laboratory scientific study. METHODS: Myometrial strips were obtained from women undergoing elective prelabour caesarean section at term. These were loaded with the calcium sensitive indicator Indo-1 allowing simultaneous assessment of intracellular calcium concentrations and force production. The effect of exposing the strips to ryanodine (which abolishes calcium induced calcium release), caffeine (which activates calcium induced calcium release) and cyclopiazonic acid (which abolishes the sarcoplasmic reticulum calcium store) was examined. RESULTS: Exposure to ryanodine had no appreciable effect on either the amplitude or the duration of the myometrial calcium and force transients but did increase the frequency of contractions (139+/-5%). Caffeine did not potentiate force. Cyclopiazonic acid increased frequency, duration and amplitude of both calcium and force transients. The ability of oxytocin to provoke calcium and force transients in the absence of extracellular calcium was abolished by cyclopiazonic acid but not by ryanodine. CONCLUSIONS: These results demonstrate that calcium induced calcium release does not play a significant role in human myometrium and that no functioning role for the ryanodine receptors in human myometrial tissue could be shown. These data suggest that the sarcoplasmic reticulum may act to limit contractions and act as a calcium sink, rather than to amplify contractions.

K(+) transport in red blood cells from human umbilical cord.

The current study was designed to characterise K(+) transport in human fetal red blood cells, containing mainly haemoglobin F (HbF, and termed HbF cells), isolated from umbilical cords following normal parturition. Na(+)/K(+) pump activity was comparable to that in normal adult human red cells (which contain HbA, and are termed HbA cells). Passive (ouabain-resistant) K(+) transport was dominated by a bumetanide (10 microM)-resistant component, inhibited by [(dihydroxyindenyl)oxy]alkanoic acid (100 microM), calyculin A (100 nM) and Cl(-) removal, and stimulated by N-ethylmaleimide (1 mM) and staurosporine (2 microM) - all consistent with mediation via the K(+)-Cl(-) cotransporter (KCC). KCC activity in HbF cells was also O(2)-dependent and stimulated by swelling and urea, and showed a biphasic response to changes in external pH. Peak activity of KCC in HbF cells was about 3-fold that in HbA cells. These characteristics are qualitatively similar to those observed in HbA cells, notwithstanding the different conditions experienced by HbF cells in vivo, and the presence of HbF rather than HbA. KCC in HbF cells has a higher total capacity, but when measured at the ambient PO(2) of fetal blood it would be similar in magnitude to that in fully oxygenated HbA cells, and about that required to balance K(+) accumulation via the Na(+)/K(+) pump. These findings are relevant to the mechanism by which O(2) regulates membrane transporters in red blood cells, and to the strategy of promoting HbF synthesis as a therapy for patients with sickle cell disease.

Risk management on the labour ward.

Risk management describes a process whereby the risk of adverse events is eliminated or where the effects of those events are reduced as far as possible. This is particularly relevant to the labour ward setting with respect to intrapartum care.

Amniotomy alone for induction of labour.

BACKGROUND: Amniotomy (deliberate rupture of the membranes) is a simple procedure which can be used alone for induction of labour if the membranes are accessible, thus avoiding the need for pharmacological intervention. However, the time interval from amniotomy to established labour may not be acceptable to clinicians and women, and in a number of cases labour may not ensue. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. OBJECTIVES: To determine the effects of amniotomy alone for third trimester labour induction in women with a live fetus. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled trials register and bibliographies of relevant papers. SELECTION CRITERIA: The criteria for inclusion included the following: (1) clinical trials comparing amniotomy alone for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random or pseudo-random allocation to the treatment or control group; (3) ideally adequate allocation concealment (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS: This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into the series of primary reviews arranged by methods of induction of labour. The data from the primary reviews will be incorporated into a series of secondary reviews, arranged by category of woman to reflect clinical scenarios. To avoid duplication of data in the primary reviews, the labour induction methods have been listed in a specific order, from one to 25. Each primary review includes comparisons between one of the methods (from two to 25) with only those methods above it on the list. This review includes comparisons between amniotomy alone (number 5 on the list) with only those methods above it on the list (no treatment / placebo; intravaginal prostaglandins; intracervical prostaglandins; and oxytocin alone). MAIN RESULTS: Two trials comprising 50 and 260 women respectively were eligible for inclusion in this review. No conclusions could be drawn from comparisons of amniotomy alone versus no intervention, and amniotomy alone versus oxytocin alone (small trial, only one pre-specified outcome reported). No trials compared amniotomy alone with intracervical prostaglandins. One trial compared amniotomy alone with a single dose of vaginal prostaglandins for women with a favourable cervix, and found a significant increase in the need for oxytocin augmentation in the amniotomy alone group (44% versus 15%; RR 2.85, 95% CI 1.82-4.46). This should be viewed with caution as this was the result of a single centre trial. Furthermore, secondary intervention occurred 4 hours after amniotomy, and this time interval may not have been appropriate. REVIEWER'S CONCLUSIONS: Data is lacking about the value of amniotomy alone for induction of labour. While there are now other modern methods available for induction of labour (pharmacological agents), there remain clinical scenarios where amniotomy alone may be desirable and appropriate, and this method is worthy of further research. This research should include evaluation of the appropriate time interval from amniotomy to secondary intervention, women and caregivers' satisfaction and economic analysis.

Intravenous prostaglandin for induction of labour.

BACKGROUND: Intravenous prostaglandin E2 and F2 alpha can be used to induce labour. The use of intravenous prostaglandins in this context has been limited by perceived unacceptable maternal side effect profiles. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. OBJECTIVES: To determine the effects of intravenous prostaglandin for third trimester cervical ripening or induction of labour. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register, The Cochrane Controlled Trials Register and bibliographies of relevant papers. SELECTION CRITERIA: The criteria for inclusion included the following: (1) clinical trials comparing intravenous prostaglandin used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS: A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involves a two-stage method of data extraction. The initial data extraction is done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will then be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. To avoid duplication of data in the primary reviews, the labour induction methods have been listed in a specific order, from one to 25. Each primary review includes comparisons between one of the methods (from two to 25) with only those methods above it on the list. MAIN RESULTS: Thirteen trials were eligible for inclusion in this review. Two trials (comprising 400 women) compared intravenous prostaglandin E2 to intravenous oxytocin, a further seven trials (comprising 590 women) compared intravenous prostaglandin F2 alpha to intravenous oxytocin. Two trials (comprising 115 women) each randomised women to one of three treatment arms namely intravenous oxytocin or intravenous prostaglandin F2 alpha or prostaglandin E2. One trial reported a comparison of combined oxytocin and prostaglandin F2 alpha and oxytocin alone in 20 women and lastly one trial compared extra amniotic prostaglandin E2 versus intravenous prostaglandin E2 (40 women). The use of intravenous prostaglandin was associated with higher rates of uterine hyperstimulation with changes in the fetal heart rate (relative risk (RR) 6.76, 95% confidence interval (CI) 1.23-37.11) and without (RR 4.25, 95%CI 1.48-12.24) compared to oxytocin. Use of prostaglandins was also associated with significantly more maternal side effects (gastrointestinal, thrombophlebitis and pyrexia, RR 3.75, 95% CI 2.46-5.70) than oxytocin. Prostaglandin was no more likely to result in vaginal delivery than oxytocin (RR 0.85, 95% CI 0.61-1.18). No significant differences emerged from subgroup analysis or from the trials comparing combination oxytocin/prostaglandin F2 alpha and oxytocin or extra amniotic versus intravenous prostaglandin E2. REVIEWER'S CONCLUSIONS: Intravenous prostaglandin is no more efficient than intravenous oxytocin for the induction of labour but its use is associated with higher rates of maternal side effects and uterine hyperstimulation than oxytocin. No conclusions can be drawn form the comparisons of combination of prostaglandin F2 alpha and oxytocin compared to oxytocin alone or extra amniotic and intravenous prostaglandin E2.

A comparison of the contractile properties of human myometrium obtained from the upper and lower uterine segments.

This study compared the contractile characteristics of myometrium taken from upper and lower uterine segments. Biopsies were obtained from women undergoing classical caesarean section. Myometrial strips were dissected and mounted in an organ bath, and the contractions were recorded. The cross sectional area of the contractile elements within the strips was measured enabling strips of differing dimensions to be compared. There were no significant differences in the contractile rate and force production produced by myometrium from the upper and lower segments. This study demonstrated that for contractile studies, the use of lower segment is appropriate. The results fail to demonstrate any functional regionality of the human uterus in terms of contractility.

The effects of inhibiting myosin light chain kinase on contraction and calcium signalling in human and rat myometrium.

The effect of inhibiting myosin light chain kinase on contractions of human and rat myometrium has been investigated, to determine whether force can be produced independently of myosin phosphorylation. Two inhibitors were used, wortmannin and ML-9, and their effects on spontaneous, high-K-depolarization-induced and oxytocin-induced force studied. Both inhibitors reduced and then abolished uterine force, irrespective of how it was produced; this was the case for both human and rat myometrium, and pregnant and non-pregnant tissue. The effects of wortmannin on intracellular [Ca2+] and inward Ca2+ current were examined. The data showed that the reduction in force produced by wortmannin occurs without a reduction of either the Ca2+ current or [Ca2+]. It is concluded that, under normal physiological conditions, myosin light chain kinase phosphorylation of myosin is essential for uterine force production and that there is little or no role for alternative force-producing pathways.

Intracellular calcium stores and agonist-induced contractions in isolated human myometrium.

OBJECTIVE: We hypothesized that the release of calcium from intracellular stores contributes to the contractions produced by the agonists oxytocin, carbachol, and prostaglandin F(2 )(alpha ) in human myometrium. STUDY DESIGN: Strips of myometrium were obtained at cesarean section and hysterectomy. The strips were loaded with the calcium-sensitive dye Indo-1 to enable simultaneous measurement of tension and intracellular calcium levels. Agonist-induced responses in the presence and absence of extracellular calcium were studied. RESULTS: Strips of myometrium were obtained from 48 women not in labor undergoing cesarean section and 6 women not pregnant undergoing hysterectomy. An increase in intracellular calcium level after agonist stimulation invariably preceded an increase in tension. Intracellular calcium level returned to baseline before myometrial relaxation. Oxytocin, carbachol, and prostaglandin F(2)(alpha) all gave both force and intracellular calcium responses in the absence of extracellular calcium, although both these responses were only 26% to 40% of the maximal response when extracellular calcium was present. CONCLUSIONS: Release of calcium from internal stores induced by oxytocin, carbachol, and prostaglandin F(2)(alpha) may contribute to agonist-induced myometrial force production.

The evaluation of the sperm migration test as a predictor for success with intrauterine insemination.

OBJECTIVE: The objective of this study was to prospectively evaluate the sperm migration test (SMT) as a discriminator in couples undergoing intrauterine insemination (IUI). PATIENTS AND METHODS: 261 couples underwent 797 IUI treatment cycles involving gonadotropin stimulation in the three year period. All had a diagnosis of unexplained infertility. All male partners underwent a repeat standard seminal analysis and SMT prior to the female partner undergoing controlled ovarian stimulation. RESULTS: Despite apparently normal seminal analyses before referral, in 22 samples the sperm concentration, motility or morphology were abnormal (WHO criteria). Of these, 20 couples underwent 109 cycles and achieved 2 pregnancies giving a pregnancy rate of 1.8% per cycle and a cumulative pregnancy rate of 10% per couple. From the remaining couples with normal seminal analyses, 71 had an SMT <5 million/mL and 168 had an SMT >5 million/mL. The suboptimal SMT group underwent 276 cycles (3.89 cycles per couple) and achieved 18 pregnancies giving a pregnancy rate of 6.5% per cycle and a cumulative pregnancy rate of 25.4%. The normal SMT group underwent 412 cycles (2.45 cycles per couple) and achieved 60 pregnancies giving a pregnancy rate of 14.6% per cycle and a cumulative pregnancy rate of 35.7%. CONCLUSIONS: We confirm that abnormal seminal analysis leads to poor pregnancy rates with IUI. However, an SMT <5 million/mL despite normal seminal analysis (WHO criteria) also leads to significantly worse pregnancy rates. We would recommend that prior to IUI, couples are screened using the SMT.

Second trimester serum free beta human chorionic gonadotrophin levels as a predictor of pre-eclampsia.

BACKGROUND: To prospectively assess maternal serum free beta human chorionic gonadotrophin (beta hCG) estimation between 15 and 18 weeks gestation, as a screening test for pre-eclampsia in primigravid women. METHODS: A prospective longitudinal study in a University Teaching Hospital. The study population was 430 primigravid women, who had maternal serum free beta hCG levels measured as part of antenatal serum screening for Down's Syndrome in the second trimester, who booked consecutively within the unit and went on to deliver on the unit's labor ward. These women were followed during their subsequent pregnancy and categorized into those who remained normotensive and those who developed pre-eclampsia on both clinical and biochemical grounds. The beta hCG levels were used to construct a receiver operator characteristics curve (ROC) to assess the screening potential for pre-eclampsia. RESULTS: Nineteen (4.4%) women in the study group developed pre-eclampsia. The median second trimester free beta hCG multiples of the median (MOM) was significantly elevated compared to that of the control group (1.52 vs 1.10, p=0.03). The ROC curve shows that for a sensitivity of 79%, the specificity was only 54%. CONCLUSIONS: Maternal serum free beta hCG alone measured in the second trimester is not clinically useful as a screening test for pre-eclampsia in primigravid women. It has, however, some predictive value.

Seminal plasma immunoglobulin concentrations in autoimmune male subfertility.

The presence of anti-sperm antibodies (ASAs) in seminal plasma is associated with infertility. They have been shown to reduce sperm motility, interfere with cervical mucus penetration and gamete interaction, and have been shown to reduce spontaneous fertilization and pregnancy rates. Although some causes can be determined, in the majority of cases the initial event causing the immune sensitisation and the reasons for the continuing antibody secretion remains unknown. Quantitative determination of total IgG, IgA and IgM within seminal plasma had not been previously reported in patients with and without specific ASAs. Semen samples from 512 men presenting with infertility were analyzed. One hundred and forty-six men (28.5%) had seminal fluid ASAs as determined by the MAR or TAT tests. The total seminal plasma IgG and IgA concentrations were significantly elevated in the ASA-positive groups compared with ASA-negative groups (IgG: 8.83 mg/100 ml vs. 7.15, P = 0.0008; and IgA: 2.88 mg/100 ml vs. 1.64, P = 0.0001). Only 19 samples showed seminal fluid IgM, and there was no difference between the ASA positive or ASA negative samples. The significance of these findings is discussed.

Fetal growth retardation and second trimester maternal serum human chorionic gonadotrophin levels.

Second trimester maternal serum human chorionic gonadotrophin (hCG) levels in women who remained normotensive but delivered an unexplained growth retarded infant were compared with those from a control group and a group of women who developed pre-eclampsia in a retrospective observational study. Our hypothesis was that the similar placental pathological changes shared by unexplained normotensive IUGR and pre-eclampsia would be reflected by elevated maternal serum hCG levels in the second trimester. Normotensive women delivering unexplained singleton growth retarded infants were identified (n=43) and their second trimester hCG levels, taken as part of antenatal screening for Down's syndrome, were obtained. These were compared with a control group of 625 women, and a group of 48 women who subsequently developed pre-eclampsia. There was no significant difference in the hCG levels expressed as multiples of the median (MOM) between the women who delivered growth retarded fetuses (median MOM 0.96) and the control group (median MOM 0.97). The levels of hCG in the women who subsequently developed pre-eclampsia were significantly higher (median MOM 1.3, P=0.008). There were no significant differences in AFP levels in the three groups; however, the trend was towards a higher level of AFP in the fetal growth retardation group. Maternal serum hCG in the second trimester does not appear to be elevated in normotensive women who later produce a growth retarded fetus, although human chorionic gonadotrophin levels are significantly higher in women who subsequently develop pre-eclampsia.

The effect of progestagens on the carotid artery pulsatility index in postmenopausal women on oestrogen replacement therapy.

Part of the cardioprotective effect of postmenopausal oestrogen replacement therapy has been attributed to arterial vasodilation. This effect is partially reversed in the uterine artery by the addition of a progestagen. This study was designed to compare the effects of the C21 progestagen, dydrogesterone and the C19 testosterone derivative, norethisterone on the carotid artery pulsatility index (PI) (thought to represent distal impedance to flow) using a randomized double blind cross-over trial. The addition of progestagen resulted in a significant increase in the carotid artery PI from a median value of 1.67 during the oestrogen only phase to 1.77 (P = 0.02) during the combined phase. This trend was seen with both dydrogesterone and norethisterone, but there was no significant difference in the size of the effect caused by either progestagen. The addition of cyclical progestagen to ERT partially antagonizes the reduction in the carotid artery PI.

Intraumbilical oxytocin for the management of retained placenta: a randomized controlled trial.

OBJECTIVE: To evaluate the ability of intraumbilical oxytocin injection as a treatment for retained placenta after vaginal delivery to reduce the incidence of manual removal and postpartum hemorrhage. METHODS: A randomized controlled trial was set up in a university and a district general hospital. We recruited 81 women with singleton pregnancies who underwent vaginal delivery and who failed to deliver the placenta after 20 minutes of active management of the third stage of labor. Study subjects were randomized to receive either 1) an intraumbilical injection of oxytocin (20 IU in 20 mL of saline); 2) an intraumbilical injection of saline (20 mL); or 3) no treatment. Outcome measures were expulsion of the placenta within 45 minutes of delivery, need for manual removal of the placenta under anesthesia, and postpartum hemorrhage (defined as a blood loss greater than 500 mL). RESULTS: Women given an intraumbilical injection of oxytocin had a significant increase in spontaneous expulsion of the placenta within 45 minutes of delivery and fewer manual removals of the placenta, compared with women without treatment (odds ratio [OR] 11.6, 99% confidence interval [CI] 1.4, 272.8; and OR 7.4, 99% CI 1.1, 86.5; respectively). When women given intraumbilical oxytocin were compared with women given only intraumbilical saline, the difference was not statistically significant (OR 6.6, 99% CI 0.9, 77.2 for spontaneous expulsion of the placenta; and OR 4.7, 99% CI 0.8, 39.5 for manual removal). There was no significant difference in the incidence of spontaneous expulsion and manual removal of the placenta between women given intraumbilical saline injection and women without treatment (OR 1.8, 99% CI 0.1, 53.9; and OR 1.6, 99% CI 0.1, 22.4; respectively). CONCLUSION: The results of our study suggest a clinically important beneficial effect of intraumbilical oxytocin injection in the management of retained placenta.