Obstetric emergencies: their practical management.

Collapse in an obstetric patient may be due to any of the causes listed in Table 1. If none of the specific treatments discussed are indicated the procedure should be: RESUSCITATE, TRANSFER AND DIAGNOSE--in that order.

Obstetric emergencies. Their practical management.

Many women in Australia, especially West Australians, receive their primary obstetric care from general practitioners. While most patients have normal pregnancies and confinements, emergencies will occur. While imminent dangers can usually be recognised and plans made to transfer the patient to suitably equipped and staffed specialist units, emergencies allow no time for review and successful treatment depends on early recognition of the problem and rapid management.

Delivery after caesarean section: review of 2176 consecutive cases.

A total of 2176 consecutive patients who had had one previous caesarean section were studied retrospectively. A repeat elective caesarean section was performed in 395 (18.2%). Labour started spontaneously in 1363 patients, 301 of whom were given oxytocin to accelerate inert labour, and was induced by amniotomy and infusion of oxytocin in 418 women; 1618 of these 1781 patients (90.8%) delivered vaginally. Patients who had had a previous vaginal delivery were more likely to deliver vaginally again. Those women in whom the initial caesarean section had been performed during labour before the cervix was 4 cm dilated were less likely to deliver vaginally than those who had progressed further in labour or those who had had an elective caesarean section. Similarly, those who received oxytocin to stimulate inert labour were more likely to require a repeat caesarean section than those who did not. The uterine scar ruptured in only eight (0.45%) of the 1781 patients allowed into labour. The risk of rupture of the scar was not increased by the use of oxytocin alone either to induce or to accelerate labour. The combination of oxytocin to accelerate labour and epidural analgesia to provide pain relief, however, was associated with an increased incidence of scar rupture. Labour may be safely allowed in women who have had a previous caesarean section, most of whom will deliver vaginally. Induction of labour does not increase the risk of either a repeat caesarean section or rupture of a uterine scar.

Ectopic pregnancy in a distal tubal remnant.

Ectopic pregnancy is a well-recognized complication of tubal reanastomosis (Young PE, Egan JE, Barlow JJ: Reconstructive surgery for infertility at the Boston Hospital for Women. Am J Obstet Gynecol 108: 1092, 1970 and Hodari AA, Vibhasiri A, Isaac AY: Reconstructive tubal surgery for midtubal obstruction. Fertil Steril 28: 620, 1977). We describe here, however, a case of tubal pregnancy occurring in a tubal remnant on the opposite side to a successful tubocornual reanastomosis.

Ovulation induction in clomiphene nonresponsive patients: the place of pulsatile gonadotropin-releasing hormone in clinical practice.

Seventy-three treatment courses of pulsatile gonadotropin-releasing hormone (GnRH) were given to 19 patients with clomiphene nonresponsive anovulatory infertility. Fifty cycles were given by the subcutaneous route, and 23 were given intravenously. Doses varied between 1 and 40 micrograms per pulse given at 60- or 90-minute intervals. Luteal support was either by continuation of the pulsatile GnRH or by human chorionic gonadotropin injections. In 16 cycles, potentially fertile ovulation occurred, and three pregnancies resulted, of which one continues normally. Only one of the three pregnancies occurred during intravenous GnRH treatment, and it is likely that this patient would have responded to subcutaneous treatment. The optimum dosage to induce ovulation ranged between 10 and 20 micrograms per pulse at a frequency of 60 to 90 minutes. Those patients who responded to treatment were all of normal or low body weight for their age and frame. Conversely, those who failed to respond to pulsatile GnRH with ovulation were obese except for one patient with the polycystic ovary syndrome. Because pulsatile GnRH treatment is simple and potentially safe to administer, a therapeutic trial is indicated in patients of low to normal body weight who fail to respond to clomiphene. Where patients are responsive to pulsatile GnRH, the ovulations produced are likely to be fertile, possibly because of the endogenous nature of the ovulatory luteinizing hormone surge.

Reproductive hormone profiles in regularly menstruating Sudanese women.

Venous blood samples were taken daily from 21 regularly menstruating Sudanese women throughout one complete menstrual cycle. FSH, LH, estradiol-17 beta and progesterone were assayed in all plasma samples and normal reference ranges were thus established. Fifteen subjects had a luteal phase of more than 12 days whilst in 3 subjects it was shorter. Two subjects were found to be hyperprolactinemic and one had an anovulatory cycle with an elevated LH. The plasma concentrations of estradiol-17 beta in the follicular phase and progesterone in the luteal phase were significantly lower in subjects with short luteal phase than in those with a luteal phase of more than 12 days. The hormonal profile of FSH, LH, estradiol-17 beta and progesterone throughout a normal menstrual cycle in regularly menstruating Sudanese women was similar to what has been reported in the literature for other ethnic groups.

Pathological mechanisms in polycystic ovary syndrome: modulation of LH pulsatility by progesterone.

The pulsatile discharge of luteinizing hormone (LH) in nine patients with polycystic ovary syndrome (PCO) and nine patients with amenorrhoea but without PCO, who exhibited LH discharge in response to oestrogen provocation, were studied by 4-h measurement of gonadotrophin pulsatility before and after a course of progesterone injections. No significant differences were found in the gonadotrophin pulsatility patterns of the two groups, although the LH/FSH ratio rose significantly in the patients without PCO after progesterone but not in the patients with PCO, suggesting an abnormality of FSH storage. The ability to discharge gonadotrophins in response to oestrogen provocation has been reported to be present in patients with greater than or equal to 3 LH pulses in a 4-h study period. This, however, was not demonstrated in five of the nine PCO patients despite the presence of 'normal' gonadotrophin pulsatility patterns.

Cycle initiation in amenorrhoea; the effect of progesterone and oestrogen administration on the pulsatile release of gonadotrophins.

The modulation of pulsatile gonadotrophin release by endogenous ovarian steroids during the normal menstrual cycle may be involved in the initiation of the following menstrual cycle. The absence of this cyclical variation may, in some cases, be the cause of, or contribute to the cause of, amenorrhoea. To assess this the modulatory effect of gonadal steroid administration on the pulsatile release of gonadotrophins was studied in fourteen amenorrhoeic and four oligomenorrhoeic women. Pulsatility was assessed by samples collected at 10 min intervals during a 4 h morning period before and after treatment with either progesterone or micronized oestradiol or a sequential combination of both. Ten patients with intact positive oestrogen-gonadotrophin feedback responded to progesterone treatment by both a significant reduction in LH pulse frequency, from a mean of 4.1 to a mean of 2.1 pulses within the 4 h study period and an increase in pulse amplitude. Progesterone therapy did not affect mean LH concentrations but there was a significant reduction in mean FSH concentrations. In the eight patients with absence of positive feedback, none of the treatment regimes elicited significant changes in LH release. No definable FSH pulses were detected before or after treatment in either group. Both the changes in LH and FSH concentrations and their release observed in this study, support the concept that cycle initiation may be related to a reduced pituitary exposure to LHRH associated with elevated progesterone concentration in the luteal phase of the cycle. This selectively induces FSH synthesis and storage. Release of this stored FSH may occur as a result of failure of the corpus luteum and falling progesterone concentrations.

LH pulse frequency in relation to positive oestrogen-gonadotrophin feedback in amenorrhoea.

The relationship between the pattern of pulsatile LH release and the response to oestrogen provocation was studied in twenty amenorrhoeic or oligomenorrhoeic subjects. In 12 subjects with positive oestrogen-gonadotrophin feedback a definite pulsatile pattern of LH release was demonstrated with a pulse frequency of 60--80 min and an increase from nadir to peak ranging between 30 and 58%. The mean basal LH concentration was significantly higher in this group (P less than 0.001). Of eight subjects who had absence of positive feedback, five showed infrequent pulses, 1--2 during the four-hour period. These were of low amplitude and with a percentage increase of 45--70 from nadir to peak. The remaining three did not have a pulsatile pattern of LH release. Positive feedback, as demonstrated by an oestrogen provocation test was thus found only in patient having 3 or more LH pulses in the 4 h study period; an LH pulse frequency similar to that in the early follicular phase in regularly menstruating women.