The fetal inflammatory response syndrome and cerebral palsy: yet another challenge and dilemma for the obstetrician.

There is increasing evidence demonstrating a relationship between intrauterine infection and the development of neonatal intraventricular haemorrhage and periventricular leukomalacia with the subsequent occurrence of cerebral palsy, which is thought to be mediated through the generation of pro-inflammatory cytokines by the fetus. In the light of this relationship, a review of the current management of intrapartum infection and the associated complications of intrauterine infection such as preterm labour and preterm premature rupture of the membranes would seem timely along with the development of potential strategies which might prevent or ameliorate the effects of the fetal inflammatory response syndrome. The suggested changes in the understanding and management of the fetal inflammatory response syndrome provide a challenge and pose a dilemma for the practising obstetrician.

Women's role and satisfaction in the decision to have a caesarean section.

OBJECTIVE: To examine women's role in the decision to perform caesarean section (CS). DESIGN: Cross-sectional survey. Written questionnaires were completed seven weeks after giving birth by CS. SETTING: An obstetric tertiary referral hospital (Women's and Children's Hospital, Adelaide, South Australia), July to December 1996. PARTICIPANTS: A consecutive sample of women who underwent CS over a six-month period. To be eligible, women had to be at least 18 years old, able to complete a questionnaire in English and well enough to consent to study participation. MAIN OUTCOME MEASURES: Women's involvement in decision making, stated preference for CS, and satisfaction with obstetric care. RESULTS: 278 women (76.4%) returned questionnaires: 171 women (61.5%; 95% confidence interval [CI], 55.8%-67.2%) reported being involved in the decision to have a CS. Factors influencing their decision were physical duress and partner's reaction during labour (emergency CS), considerations about recovery, planning for the event and pain (elective CS), and information from the doctor (both groups). Half the women "strongly agreed" that they were satisfied with the decision to have a CS, but 40.9% only "agreed" and 4.7% were "not sure". About 20% reported they needed more information on other options, and only 28.8% "strongly agreed" that they had been given good information to prepare for the possibility of CS. 27.9% of women (95% CI, 22.5%-33.2%) "agreed" or "strongly agreed" that they had "insisted on a CS" and 21.3% (95% CI, 16.4%-26.2%) that they had told the staff they were "keen to have a CS". Given the option of a vaginal delivery, 37.8% of women (95% CI, 22.5%-55.2%) with a breech presentation, and 34% of women (95% CI, 21.2%-48.8%) who had had a previous CS, chose a CS. CONCLUSIONS: It is of concern that over a third of women felt they had not been involved in the decision to have a CS; others were very positive about CS, but an appreciable proportion may not have received sufficient information. A broad-based strategy of providing more information to women and their partners could be one way of ensuring appropriate CS rates and should be tested in a randomised controlled trial.

Paroxysmal nocturnal haemoglobinuria and pregnancy.

A woman with paroxysmal nocturnal haemoglobinuria (PNH) who was successfully delivered of 3 healthy infants after 4 pregnancies is reported. The obstetric literature of women with PNH is reviewed and the consequent view presented that judicious advice should not preclude pregnancy in such women.

A normal 46,XX infant with a 46,XX/69,XXY placenta: a major contribution to the placenta is from a resorbed twin.

A predominantly triploid 69,XXY placenta was found associated with a normal 46,XX infant. Therefore, a triploid placenta is apparently capable of supporting normal fetal development. The chromosome and pathological results support the conclusion that the triploid placenta originates from a 'vanishing twin' pregnancy. This case is unusual in that persistence of the placenta from the vanished twin has virtually replaced most of the normal placenta.

Silastic cup vacuum extractor or forceps: a comparative study.

A retrospective analysis over a 2-year period was carried out to compare the limitations in the use of the Silastic Cup vacuum extractor and forceps as the preferred instrument for operative vaginal delivery. Whilst the use of the vacuum extractor was associated with less maternal morbidity (54.9% episiotomy rate; 20.9% nil analgesia) and comparable neonatal problems, an increased failure rate (6.5%) was demonstrated in comparison to forceps delivery (0.7% failed vaginal delivery rate). A comparison of their use for rotational vaginal delivery failed to reveal any significant difference in maternal or neonatal outcome apart from an increased failure rate (30%) to complete vaginal delivery after application of the vacuum extractor. It is concluded that the vacuum extractor is a comparable instrument for midcavity or lift-out instrumental delivery but Kielland's forceps may still be a more appropriate instrument for rotational vaginal delivery.

Osteodysplastic primordial dwarfism: report of a further case with manifestations similar to those of types I and III.

We describe a male infant with microcephalic osteodysplastic primordial dwarfism. The clinical and radiological manifestations most closely resemble those of the patient described by Winter et al. to have manifestations overlapping with both osteodysplastic primordial dwarfism types I and III. The classification of the patient within the spectrum of osteodysplastic primordial dwarfism is discussed and the distinctive neuropathology documented.

Early midtrimester oligohydramnios: a sign of poor fetal prognosis.

The outcome of 6 pregnant women with second trimester oligohydramnios in the absence of ruptured membranes before 20 weeks' gestation is reported. The overall prognosis of these pregnancies was poor with only 2 survivors. Review of the literature confirms the poor outcome of such pregnancies.

Epilepsy and pregnancy.

A retrospective study of 75 pregnant epileptic women compared with a parity, age and socioeconomic matched control group of women is presented. Deterioration of control of epilepsy during pregnancy occurred in 24% of women. Statistically significant obstetric complications noted were anaemia, premature labour, premature rupture of the membranes and postpartum haemorrhage. There was 2.5-fold increase in the incidence of congenital anomalies in the neonates, an increase in feeding difficulties and a reduced incidence of jaundice. There was no maternal or perinatal death. Refinements in management may further reduce the maternal and fetal morbidity in epileptic women who choose to become pregnant.

The macrosomic infant: a high risk complication.

A retrospective analysis was made of 110 macrosomic infants in an effort to detect predictive factors which may influence the management of labour and delivery of such infants. Clinical suspicion of a macrosomic infant by the obstetrician was the most constant predictive factor antenatally. Measures to reduce the increased maternal and fetal morbidity and mortality in the delivery of such infants are discussed.

The influence of insemination timing and semen characteristics on the efficiency of a donor insemination program.

The analysis of accumulated data from conceptional and nonconceptional ovulatory menstrual cycles of patients undertaking artificial donor insemination has allowed some observations to be made on the practical aspects which may influence the efficiency of the program. The evidence suggests that with the use of preserved semen, accurate timing of insemination is essential, and that days 0 and +1 with respect to the luteinizing hormone surge appear to be advantageous as compared with closely related days. When the numbers of motile spermatozoa which were inseminated over a critical 4-day interval were analyzed, the results also suggested that improved conception rates occurred when larger numbers of active spermatozoa were used. A comparison was made between those patients who had been inseminated on a single occasion and those inseminated on more than one occasion during the periovulatory period. The results obtained from those cycles inseminated on a single occasion were inferior to those obtained from cycles inseminated more than once. Finally, some limited comparison is drawn between the established insemination programs of bovine husbandry and the relatively inefficient human experience. One explanation may lie in the wider spectrum of donor semen desirable for the human programs.

Prognostic aspects of endometrial carcinoma.

A retrospective analysis of 91 patients with endometrial carcinoma is presented with emphasis on important factors in relation to survival. Patients with Stage 1 carcinoma were treated with a standardized mode of preoperative radiation and extended abdominal hysterectomy. An 87.1% 5-year survival rate was obtained for patients with well differentiated lesions, with only 1 patient developing a vault metastasis. The assessment of residual tumour after intracavity radiotherapy proved reliable in predicting prognosis and should prove of benefit in directing additional therapy for endometrial carcinoma.

The characterisation of thawed semen, and the timing and route of insemination associated with conception in the human.

The temporal and qualitative aspects of the conceptual process of a small number of pregnancies achieved by donor insemination have been analysed to understand the semen values required and the optimal insemination timing and route.

PIP: The insemination of stored semen to wives of consistently azoospermic husbands for the purpose of achiving conception pvoides a unique opportunity to study some of the temporal and quantitative requirements for the conceptual process. 28 conceptions were analyzed with regard to the spermatozoal characteristics responsible for the pregnancy and with reference to the timing of insemination relative to the surge of luliberin (LH) in the recipient plasma. Some conceptions were achieved by intrauterine insemination and information is presented on the usefulness of this route. Where practical, wives provided daily venous blood samples between the hours of 0800 and 0900 during the periovular period. Serum LH was estimated by a rapid radioimmunoassay utilizing a shortened incubation period and charcoal separation of bound and free species under nonequilibrium conditions. Experience with such an assay allowed a clear detection of the day of maximal LH values (Day 0), although a lack of sensitivity precluded the accurate assessment of low serum LH values. Values on Day 0 were not less than 40 mlU/ml and represented at least a 2-fold rise from the previous day's values. Semen produced and stored in straws by a modified Matheson method was inseminated either pericervically or within the uterine cavity. Representative straws of the identical ejaculate were characterized to the standards of Eliassen within 14 days of the insemination, and the assumption made that each straw contained similar values. No conception occurred when the insemination procedure took place more than 24 hours from Day 0, although 5 conceptions occurred from single inseminations on either Day -1 or Day +1. The range of spermatozoa inseminated during the 28 conceptual cycles was 18-253. The estimated range of morphologically normal spermatozoa was 17-236, and the range of motile spermatozoa responsible was calculated to be 8-125. 8 pregnancies were achieved by the use of intrauterine insemination. 1 pregnancy occurred to each group by the use of 10 million motile spermatozoa. The mean number of ovular cycles necessary before conception occurred was not different in the 2 groups (2.9 compared to 3.0 cycles). There is growing acceptance of the importance of the qualitative aspects of the seminal fluid rather than the prediction of fertility from the results of a standard analysis. The data presented lend general support to that concept.

Phaeochromocytoma and pregnancy: a case report.

A case of maternal death associated with phaeochromocytoma is reported. Diagnostic difficulty and the poor maternal and fetal prognosis are discussed. A note of caution about inadvertent use of sympathomimetic agents in such patients is included in the discussion.

Assessment and treatment of female urinary incontinence by cystometrogram and bladder retraining programs.

One hundred female patients complaining of urinary incontinence without evidence of associated disease or urinary infection were assessed by clinical appraisal and by simple cystometrogram. Discrepancies were apparent between the two methods of patients assessment. Treatment was primarily based on cystometrogram patterns, and included the surgical correction of the urethrovesical defect, the institution of a program of micturition retraining, or a combination of both methods. Based on a short follow-up assessment period, of those 68 patients chosen for surgery, 78% were cured and 91% were markedly improved. Bladder retraining programs alone were instituted for 32 patients, and a marked (72%) improvement rate was demonstrated. It is suggested that the cystometrogram has an integral and essential place in the assessment of female urinary incontinence and may be easily integrated into practice. Bladder retraining programs may be most usefully employed for some patients found to have bladder dysfunction.

Linear and quantitative migration of stored sperm through cervical mucus during the periovular period.

The ability of stored spermatozoa to penetrate fresh samples of cervical mucus obtained from 23 patients during 47 menstrual cycles was studied, utilizing an in vitro test. The determination of daily hormonal and gonadotropin values allowed an accurate realationship to be established between the results of sperm-mucus interaction and the environmental milieu. Cervical mucus was found to be effectively penetrable only on day -1 and day 0 when considered with respect to the plasma luteinizing hormone surge. Correlation was apparent between the ability of sperm to penetrate and the favorable clinical parameters of cervical assessment.