Abortion after 24 weeks.

PIP: British law is based on the principle that the informed consent of the woman is necessary for any investigation or treatment of the fetus at any point in pregnancy. The pregnant woman, not the fetus, is regarded as the patient. Conflicts have arisen, however, between women and their obstetricians in cases where abortion of a fetus with a serious congenital abnormality is requested, especially at gestational ages of 25 weeks or more. The proportion of abortions in England and Wales performed at 20-24 and 25 or more weeks are only 1.2% and 0.05%, respectively. Anecdotal evidence suggests that UK physicians believe the grounds for abortion for fetal abnormality should be more limited in the third trimester. However, there is no legal barrier to abortion after 24 weeks to prevent the birth of a child with a serious mental or physical handicap. The Royal College of Obstetricians and Gynecologists has recommended that measures be taken to ensure the death of the fetus in utero whenever a termination is performed after 21 weeks. Although abortion after 24 weeks should be necessary only on the rare occasions when a fetal abnormality has not been discovered earlier in pregnancy, it should be regarded as ethical regardless of its timing.^ieng

Comparison of the Foley catheter and dinoprostone pessary for cervical preparation before second trimester abortion.

The Foley catheter and a 3 mg dinoprostone pessary (Prostin E2) were compared as methods for cervical preparation before second trimester dilatation and evacuation. The catheter was well tolerated and provided significantly greater change in cervical dilatation and improved cervical compliance. The Foley catheter would seem to provide a readily available and efficacious means of cervical preparation.

PIP: A Foley catheter with the balloon inflated above the internal cervical os, and a 3 mg dinoprostone pessary (Prostin E2) were compared for cervical dilatation before early second trimester dilatation and evacuation. Experimental subjects were 21 women given PGE2 and 23 having catheters, comprising all women between 12-16 weeks' gestation presenting consecutively for termination, allocated at random. Cervical preparation was done after an antiseptic swab, 24 hours before surgery. The size 14-Foley catheter was inserted 3-4 cm into the cervix and inflated with 25 ml water; the pessary was inserted into the posterior fornix. Under general anesthesia, dilatation, measured using largest dilators 1st, averaged 10.4 mm compared to 3.2 mm before treatment in the catheter group, but 8.7 in the PG group compared to 3.7. The increase in dilatation was 7.2 mm in the catheter group, and 5.0 in the PG group (p0.003). Cervical compliance, estimated on a scale of 1-5 by the surgeon, averaged 4.4 in the catheter group, and 2.8 in the PG group (p,0.001). 4 women complained of pain after catheters, 1 after PG. There was 1 case of cervical tear and rigid cervix, requiring hysterotomy. In this protocol, the Foley catheter seems to be the most efficient means of dilating the cervix.

Aldosterone is secreted intermittently during pregnancy.

Saliva aldosterone concentration was measured in samples collected at hourly intervals from healthy pregnant women (approximately 26 and 36 weeks gestation) who were going about their normal daily activities, and from some women hospitalized for disorders of pregnancy. In the healthy women diurnal saliva aldosterone fluctuated considerably, the highest values being 2-22 times the lowest on a given day. Because of the known correlation between saliva and plasma aldosterone concentrations we believe that the fluctuating salivary level is indicative of fluctuating plasma levels and that this is due to the intermittent secretion of aldosterone. The rate of decline of saliva aldosterone from peak levels indicated a half life (t 1/2) of 72 (SD 31) min which was not significantly different from that in non-pregnant subjects. The temporal pattern of saliva aldosterone suggests an enhanced response of the zona glomerulosa to the factors that cause aldosterone secretion to fluctuate in non-pregnant subjects, rather than the development of a more potent stimulus to the zona glomerulosa during pregnancy. In addition to hour-to-hour variation there is also substantial day-to-day variation, so that estimation of aldosterone in a single sample of saliva or plasma is of little value during pregnancy. The mean diurnal aldosterone concentration can be estimated from five saliva samples so this measurement presents a convenient technique for the assessment of aldosterone status in pregnancy. In contrast to healthy pregnancy, a patient with pre-eclampsia at 39 weeks gestation showed no elevation of saliva aldosterone above non-pregnant levels at any time during the day.

The relation between aldosterone concentrations in plasma and saliva during pregnancy.

The concentrations of aldosterone and glucocorticoids (cortisol + cortisone) were measured in saliva and plasma samples obtained from healthy women during early (11-19 weeks), mid (24-29 weeks) and late (32-37 weeks) pregnancy. There was a progressive increase in mean aldosterone levels in both saliva and plasma throughout pregnancy, though at each stage of pregnancy the range was very wide. Glucocorticoid levels increased up to mid-pregnancy and then remained constant. At no stage were aldosterone and glucocorticoid levels significantly correlated. The proportion of free (non-protein bound) aldosterone in plasma, and the saliva:plasma ratio of aldosterone did not differ from the non-pregnant range at any stage of pregnancy. We conclude that measurement of aldosterone concentration in saliva is a convenient and valid method for the estimation of plasma free aldosterone in pregnancy and so provide a non-invasive technique for assessing aldosterone status throughout pregnancy.

Legal abortion in England and Wales.

Ninety-eight per cent of abortions on British women resident in England or Wales are performed for social reasons. The Abortion Act (1967) insists on the opinion of two doctors but is broadly phrased and, by allowing that abortion can protect mental health, permits abortion when social factors are causing or likely to cause significant stress. The abortion rate has been stable at 11-12 per 1000 women aged 15-44 since 1973, suggesting that factors causing unplanned pregnancy are remaining constant for women in the fertile years and that, overall, the available facilities are adequate. However, only 49% of women obtain a free abortion in the National Health Service (NHS) and there are wide regional variations. Serious delays in the NHS are associated with inadequate access to pregnancy tests, attitudes of medical staff to abortion, and gynaecological units that are fully occupied with other problems. Women can choose to pay for abortions in services run either by charities or by commercial organizations. These services are used electively by a minority of women but most would prefer an NHS abortion if it was easily available. Women who seek help outside the NHS receive prompt and efficient management.

Inhibition of 3-beta-hydroxy steroid dehydrogenase activity in first trimester human pregnancy with trilostane and WIN 32729.

The effects of equivalent doses of two inhibitors of the 3-beta-hydroxy steroid dehydrogenase enzyme system--WIN 24540 (trilostane) and WIN 32729--on the secretion of progesterone in early human pregnancy are described. Patients and controls less than 12 weeks pregnant were given a single dose of either drug and the resultant hormonal changes monitored for 7 1/2 h. A consistent fall in plasma progesterone concentrations occurred at all doses and, at the highest dose, they fell to less than 50% of pre-treatment levels. However, whilst with trilostane the associated increase in plasma concentrations of pregnenolone was always accompanied by a rise in plasma DHA concentrations, with WIN 32729 there appeared to be no adrenal effect at the lower dosage levels. These data demonstrate inhibition of progesterone secretion in human pregnancy using non-hormonally active steroids. The pattern of steroid precursors indicates that while both drugs inhibit 3-beta-hydroxy steroid dehydrogenase activity, WIN 32729 is more selective and only interferes with adrenal steroid biosynthesis at high doses.

Diflunisal in post-episiotomy pain: a preliminary report of a double-blind comparative study.

An on-going double-blind study was carried out in women requiring pain relief after episiotomy to compare the efficacy of 500 mg diflunisal twice daily, 65 mg dextropropoxyphene plus 650 mg paracetamol 3-times daily, and placebo. Fifty-seven patients, allocated at random to receive 2-days' treatment with one or other of the trial drugs, have been studied to date. The preliminary results, as assessed by descriptive rating scales, showed that all three treatments were equally effective in relieving spontaneous pain and pain at night. Patients' overall opinion showed no difference between treatments although the investigator assessed diflunisal to be better than the combined preparation and both to be better than placebo. A visual analogue scale of assessment is to be used for the remainder of the trial.

Effect of abortion on obstetric patterns.

PIP: The statement of A.F. Pentecost that "it is an established fact that 1 or more terminations of pregnancy are liable to result in more women coming in at 26 weeks with ruptured membranes" needs to be challenged. The study he quotes to support his view indicates that 7 out of 8 women who had premature rupture of the membranes had previously been aborted of pregnancies exceeding 10 weeks' gestation and most likely with the traumatic techniques in use at that time. In the 1960s Hegar dilators of larger than Size 12 were used in the majority of cases, and dilation to such a degree was likely to result in frequent damage to the internal os, causing subsequent cervical incompetence and premature rupture of the membranes. However, the modern aspiration techniques now in use rarely require the cervix to be dilated to more than Hegar 10. Consequently, subsequent premature labor because of cervical incompetence is unlikely. Evidence is frequently quoted from a number of papers in support of Mr. Pentecost's position. It does not seem possible that a clinical trial will ever be conducted that will finally resolve the issue because of the problem of obtaining matched controls, difficulties of follow-up, and variable abortion techniques. Available evidence does indicate that modern legal abortion generally increases the risks of prematurity in a subsequent pregnancy. The remaining question is whether the reduction in the incidence of low birth weight can be ascribed to legal abortion.^ieng

A comparison of the performance of three multiple choice question papers in obstetrics and gynaecology over a period of three years administered at five London medical schools.

Four, and later five, of the medical schools in the one multiple choice question (MCQ) paper in Obstertrics and Gynaecology to their students at the end of the Obstetrics and Gynaecology courses. The paper was amended twice after intervals of approximately 12 months. The results showed differences in performance between the five schools on questions and alternatives within questions, which were common to all editions of the paper (the "short" paper). These differences were also shown in the first two editions of the full paper (the "long" paper), but were not apparent in the third. There was a significant improvement in performance from the first to the second paper edition of the long by approximately 11%, but this was reversed from the second to the third edition, where there was a significant decrease in performance by approximately 4%. We cannot here exclude the possibility that this decrease in the third edition has resulted from sample bias. The rank order of the schools may result from differences in methods of teaching. It seems that such relative performance between London medical schools in contributed to by the differences in course legnth and by the occurence of mid-course test. It appears also that student performance in any of the schools has not been uniform over the period of the study, there being a peak during the period when the second edition of the paper was used. Variations in student selection occuring between schools may effect some of these differences. There was also a marked difference in students' performance between Obstetrics and Gynaecology. The short papers appeared easier than the full papers. Whilst this may due to the greater clarity of phrasing for the questions of the short paper, we also believe the subject matter of the short paper may be more relevant. A distinct effect could also be shown, over the period, due to improvements in the wording of the questions. It is possible that students perform better at Obstetrics than at Gynaecology.