Ergot alkaloids. Current status and review of clinical pharmacology and therapeutic use compared with other oxytocics in obstetrics and gynaecology.

Ergot alkaloids are well known preparations. Ergot alkaloids used in obstetrics and gynaecology are ergometrine (ergonovine; EM), methylergometrine (methergine; ME) and bromocriptine. The pharmaceutical properties of ME EM) are critical. To guarantee stability, ME and EM ampoules should be stored in a cool, dark place. ME and EM tablets are unstable in all conditions and they show an unpredictable bioavailability, which prevents oral use of the drugs for any purpose. ME and EM are known for their strong uterotonic effect and, compared with other ergot alkaloids, for their relatively slight vasoconstrictive abilities. ME and EM do have a place in the management of the third stage of labour as they are strong uterotonics. They act differently from oxytocin and prostaglandins, and have different adverse effects. Oxytocin should be used as prophylaxis or a the drug of first choice; next, ME or EM should be used, and if none of these drugs produce the desired effects, prostaglandins should be used to control bleeding. Ergot alkaloid use in gynaecology has been limited and today is discouraged even in essential menorrhagia. It is suggested that EM and ME be used (parenterally) only in first trimester abortion curettage, to reduce blood loss. Bromocriptine has been used for lactation suppression. However, alternatives such as cabergoline, which possess fewer adverse effects, are now available and therefore preferred for this indication. In sum, there is no place for the prophylactic use of ME and EM in obstetrics or gynaecology. They can be used for therapeutic purposes in the third stage of labour. During use, the practitioner must be alert for adverse effects.

Pregnancy in a patient with homozygous familial hypercholesterolemia treated with long-term low-density lipoprotein apheresis.

The pregnancy and delivery of a subject with homozygous familial hypercholesterolemia (FH) and coronary artery disease (CAD) were monitored closely for signs of maternal and fetal distress. Biweekly treatment with low-density lipoprotein (LDL) apheresis using dextran-sulfate cellulose columns was continued throughout the pregnancy, and lipid and lipoprotein levels were evaluated. During the course of the pregnancy and delivery, no signs of maternal coronary insufficiency developed. Serial ultrasonographic measurements of fetal growth indices and the blood flow velocity waveforms (FVWs) of the uterine and umbilical artery did not reveal any sign of fetal growth retardation or insufficiency of the uteroplacental circulation, respectively. During pregnancy, time-averaged concentrations of serum total cholesterol (TC), LDL cholesterol (LDL-C), apolipoprotein (apo) B, and lipoprotein(a) [Lp(a)] showed a gradual decline. Notwithstanding LDL apheresis, a gradual twofold increase of serum triglyceride (TG) levels was found. In the second and third trimester, high-density lipoprotein cholesterol (HDL-C) levels showed a 55% increase that coincided with a 75% reduction in hepatic lipase activity in postheparin plasma, normalizing after parturition. After delivery, lp(a) levels showed an almost twofold increase, which could not be explained by the interruption of LDL apheresis alone, and may be caused by changes in gonadal steroids. Histologic examination of the placenta and the umbilical arteries revealed no atherosclerotic changes, infarctions, or lipid deposits. In general, long-term LDL apheresis in homozygous FH can delay the onset and complications of severe CAD. In case of a pregnancy, LDL apheresis seems feasible and should be continued during the pregnancy to prevent superimposed hyperlipidemia and placental insufficiency.

Successful pregnancy after ZIFT in a patient with congenital cervical atresia.

We report the third patient with a successful pregnancy following operative correction of congenital cervical atresia. The pregnancy was achieved through zygote intrafallopian transfer (ZIFT). Although stenosis of the newly formed cervical canal causes considerable morbidity, therapy should be aimed at the creation of a conduit for menstrual blood and for possible future pregnancy. New techniques in assisted reproduction such as in vitro fertilization-embryo transfer, gamete intrafallopian transfer, and ZIFT increase the chances of pregnancy in patients with congenital cervical atresia. A hysterectomy, as advocated until very recently, should not, in our opinion, be the first treatment of choice.

Sickle cell trait, malaria and anaemia in pregnant Zambian women.

In a sample of 424 pregnant Zambian women a series of tests was carried out: sickle cell test, haemoglobin estimation and screening of a thick blood smear for malarial parasites. More anaemia was found in the primigravidae than in the multigravidae. The haemoglobin level was found to be lower with primigravidity and, independently of this gravidity effect, also with malaria. Taking into account the higher malaria frequency in primigravidae, this group must be considered as a high risk group for development of anaemia. There was no significant interaction between sickle cell trait, anaemia and malaria. In addition to the tests during pregnancy, the placentae and umbilical cords of 155 women were screened for malaria as were the mothers just before delivery. More malaria parasites were detected in the placentae of the primiparous than in those of multiparous women. Peripheral parasitaemia was strikingly less prevalent than infestation of the placenta.

Differential diagnosis and causes of nonimmunological hydrops fetalis: a review.

Twenty-five babies with nonimmune hydrops fetalis were born during a 20-year period from 1967 to 1987 (1/1475). Sixteen were live-born, only three survived. Although hydrops can be caused by a myriad of diseases, a simple classification is proposed in order to allow efficient diagnostic workup. For the majority of cases of nonimmune hydrops no cause can be found. Vascular causes are most frequent, followed by chromosomal, placental, hematological, infectious, and a miscellaneous group of causes. Of the cases reviewed fetal causes dominate in 95 per cent of cases. Maternal causes are relatively rare and consist mainly of infections and diabetes. In order to reduce the high mortality rate of 98 per cent one should aim at early diagnosis of hydrops fetalis, extensive investigation of both the fetus and the mother, and referral to a center for intensive perinatal care.

Prenatal ultrasound diagnosis of conjoined twins.

Four cases of conjoined twins are presented. On the basis of these cases and a review of the literature we present the ultrasonographic features to diagnose this rare condition prenatally in its various forms. Recommendations to avoid misdiagnosis are given. Consequences of this diagnosis and assessment of shared organs are discussed for counselling and obstetrical care.

Comparison of the bioavailability and pharmacokinetics of oral methylergometrine in men and women.

OBJECTIVE: To assess and compare the pharmacokinetics and bioavailability of methylergometrine (ME) in men and non-pregnant women. DESIGN: A cross-over design was used for an oral dose of 0.125 mg and an intravenous dose of 0.200 mg of ME in 6 men and 6 non-pregnant women (parallel-design in gender). RESULTS: After intravenous administration, the pharmacokinetic profile of ME was described with a 2-compartment model. The distribution half-life (t1/2 alpha) in men was 0.19 +/- 0.27 h, in women 0.10 +/- 0.04 h, the elimination half-life (t1/2 beta) 1.85 +/- 0.28 h, respectively, 1.94 +/- 0.34 h and the total body clearance (CL) 33.2 +/- 11.8 l.h-1, and, respectively, 22.18 +/- 3.10 l.h-1. For these intrinsic pharmacokinetic parameters differences between men and women were not statistically significant. After oral administration, the pharmacokinetic profile was described with a 1-compartment model. The lag time was subject dependent and was significantly longer in men 0.33 +/- 0.09 h than in women 0.09 +/- 0.07 h. T1/2 beta in men was 2.08 +/- 0.43 h and was longer than in women 1.42 +/- 0.31 h (p = 0.012). In both men and women a large variation of bioavailability was shown ranging between 22% and 138%. CONCLUSION: This study with oral methylergometrine showed a comparable large interindividual variability in bioavailability in both men and women.

Diagnosis of Fitz-Hugh-Curtis syndrome by ultrasound.

UNLABELLED: Chlamydiae are often responsible for the development of perihepatitis and/or diffuse peritonitis after salpingitis in sexually active women, the so-called Fitz-Hugh-Curtis syndrome (FHC). The definitive diagnosis can be made by direct culture, serological evidence and laparoscopy/laparotomy. Violin-string adhesions between the liver surface and the abdominal wall can be seen. Two patients are described in whom the diagnosis was made by ultrasound: the violin strings and ascites were clearly seen. Serological and operative evidence verified the diagnosis. CONCLUSION: ultrasound may become an extra tool to diagnose the FHC-syndrome in an early and non-invasive way.

Transabdominal cerclage.

The procedure of the transabdominal cerclage (TAC) is outlined. Sixteen cases of TAC are described in detail. The fetal salvage rate increased from 36% before to 96% after the operation. Caesarean section has to be performed at term after TAC has been applied. The transabdominal method of cerclage seems to be very promising, especially for women with severely damaged or practically absent cervices.

History of ergot alkaloids from ergotism to ergometrine.

Epidemics of ergotism occurred frequently in the Middle Ages. They were a source of inspiration for artists and were popularly known as 'St. Anthony's Fire', resulting in gangrene, neurological diseases and death. It was caused by eating rye bread contaminated with the fungus claviceps purpurea. In 1582 it was described that a delivery could be hastened by administering a few spurs of the secale cornutum. The dosage was, however, very inaccurate resulting in frequent uterine ruptures. The nickname of the preparation of 'pulvis ad partum' was changed to 'pulvis ad mortem'. Therefore, after 1828 the ergot alkaloids were no longer used during delivery but only as a measure to prevent postpartum haemorrhage. From 1875 onwards many derivatives of ergot alkaloids were found. Dudley and Moir isolated ergometrine in 1932. It proved to have a very specific uterotonic action. However, because of severe and unpredictable side effects and the instability of the drug, ergometrine is not the drug of choice for either the prevention or the treatment of postpartum haemorrhage.

The Zavanelli manoeuvre in shoulder dystocia: case report and review of published cases.

A case of severe shoulder dystocia is reported in which, after other methods had failed, cephalic replacement succeeded but was very difficult. The infant suffered severe damage. A review of methods to relieve shoulder dystocia is given, with special attention to published cases of the Zavanelli manoeuvre. It could only be used when all other methods fail.

Torsion of the pregnant uterus with a change in placental localization on ultrasound; a case report.

An unexpected uterine torsion at term was found during Caesarean section. In retrospect, a changing placental localization on ultrasound from the left to the right side was recorded just before the operation. This may be a useful sign to diagnose uterine torsion earlier.

Idiopathic thrombocythemia and pregnancy; a case report.

A 28-year-old women with idiopathic thrombocytosis was treated with melphalan before pregnancy, which resulted in a normal platelet count. During pregnancy 80 mg acetylsalicyclic acid was given daily to prevent microcirculatory thrombotic complications. Fetal outcome was normal.

Hypermobility in two Dutch school populations.

OBJECTIVE: To determine the presence of hypermobility and differences between females and males in a Dutch population. STUDY DESIGN: Joint mobility was measured in a primary and a secondary school population. Beighton and Biro measurements were used. The data were evaluated statistically. RESULTS: Using the Beighton score, 15.5% of group I (n = 252; 4-13 years) and 13.4% of group II (n = 658; 12-17 years) were hypermobile. Hypermobility was found more in females than in males, the difference being significant in the older group. Overall, hypermobility did not significantly diminish with ageing, although the individual joints did not show a significant decrease in mobility with ageing. Hypermobility was significantly more pronounced at the non-dominant body side in both groups. The Quetelet-index did not show a significant relation to hypermobility. CONCLUSION: Hypermobility was found more in females than in males, with a trend of decrease of hypermobility with ageing. The non-dominant body side proved to be more hypermobile and the Quetelet-index did not show a relation to hypermobility. Beighton's measurements proved best, since Biro considers the two body sides being equal.

Gunshot uterine rupture: a case report.

A case report of gunshot uterine rupture from which the mother and fetus survived is presented for the first time. Management was guided by pre-operative ultrasound diagnosis of traumatic anhydramnios.

Joint hypermobility in African non-pregnant nulliparous women.

OBJECTIVE: To investigate the prevalence of joint hypermobility in non-pregnant nulliparous women and the influences of age and Quetelet-index in a rural, female population in Tanzania. STUDY DESIGN: A cross-sectional study. Joint mobility was measured according to the scoring systems of Beighton and Biro. RESULTS: According to the Beighton criteria with a score of 0 to 9 points, 50.5% of 705 non-pregnant nulliparous women scored 3, while 30.8% scored > or =4 and 18.6% > or =5. There were no correlations between hypermobility and age or Quetelet-index. The prevalence of hypermobility at the dominant body side was significantly lower (19.2%) than at the non-dominant side (23.4%) (p<0.001). CONCLUSION: This study confirms that there are ethnic differences in the prevalence of hypermobility. The prevalence of hypermobility in Tanzanian non-pregnant nulliparous women is about 1.5-times higher as compared to Dutch non-pregnant nulliparous women. Prevalence of hypermobility was higher at the non-dominant body side. The most predictive test for the diagnosis of hypermobility was the hyperextension of the elbows >10 degrees.

Survey of the management of third stage of labour in The Netherlands.

UNLABELLED: The standard practice during the third stage of labour of Dutch midwives and obstetricians was elucidated by a questionnaire mailed to all Dutch midwives and obstetricians. Prophylactic oxytocics in the third stage are used as a routine by 55% of the obstetricians and only 10% of the midwives. Oxytocin is the drug of first choice. CONCLUSION: Routine use of prophylactic oxytocics in the third stage is not the standard practice in the Netherlands. Obstetricians are much more likely to use prophylaxis than midwives.

The accuracy of ultrasonic measurement of fetal crown-rump length.

Routine ultrasonic crown-rump length measurements were retrospectively evaluated in an antenatal clinic using maternal body temperature graphs as reference to ovulatory age. A comparison with the original figures of Robinson is made. Potential errors are discussed. The conclusion is that one should be very careful in interpreting an ultrasonic CRL measurement before 10 weeks menstrual age because of both measurement and operator errors.

Reduced blood loss during caesarean section due to a controlled stapling technique.

Blood loss during Caesarean section is mainly due to the hysterotomy. A new technique to reduce this blood loss has been evaluated in a prospective controlled clinical trial in 89 patients. The operation technique was standardized according to Joel-Cohen. In the control group (n = 45) the low transversal incision was enlarged by scissors in an upward swing, in the staple group (n = 44) the incision was enlarged by introducing the poly CS 57 instrument with absorbable staples. A double row of staples sealed blood vessels and secured the three uterine layers just before the instrument's blade cut the uterine wall. The two groups were comparable as to the indications for the CS, first or repeat CS, primary or secondary CS, maternal age and parity. The duration of the operation, postoperative complications and hospital stay was equal. However, the blood loss in the 'staple' group was significantly less than in the control group. The conclusions are that this new technique reduced blood loss during Caesarean section, and moreover, it appeared to be extremely useful in patients with varicose veins in the lower uterine segment or placenta praevia.

Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period.

OBJECTIVES: This study was performed to assess the intra-operative surgical complications and postoperative maternal morbidity rate of caesarean section. STUDY DESIGN: A total of 2647 women, delivered by caesarean section in our department between 1983 and 1992, were studied retrospectively. Three caesarean section groups were formed: (1) primary elective, (2) primary acute, without any effort to deliver vaginally, and (3) secondary acute, due to a failed vaginal delivery. The Student's-t-, Fisher-exact- and chi 2-test were used for statistical analysis. RESULTS: The overall maternal intra-operative complication rate was 14.8%. The most common complications were lacerations of the uterine corpus (10.1%) and bloodloss > or = 1000 ml (7.3%). The complication rate of the secondary group (23.4%) was significantly higher (p < 0.001) compared to both primary groups (7.4%). The overall maternal postoperative morbidity rate was 35.7%. Fever (24.6%), bloodloss between 1000 and 1500 ml (4%), haematoma (3.5%) and urinary tract infections (3.0%) were the most frequent complications. The primary elective group showed significantly (p < 0.001) lower major (2.6%) and minor (23.7%) complication rates compared to the emergency groups (major 5.2%, minor 34%). CONCLUSION: Emergency caesarean sections carried the greatest risks regarding maternal complications compared to elective procedures.