The treatment of gynaecological malignancy in a general public hospital.

OBJECTIVE: To assess the adequacy of treatment of gynaecological cancer in a public hospital and to determine the influence of referral patterns on patient outcome. DESIGN: A retrospective analysis of clinical histories. SETTING: A tertiary-level general public hospital. PATIENTS: 89 patients admitted between 1 January 1979 and 31 December 1987 for primary treatment of a gynaecological malignancy. MAIN OUTCOME MEASURES: The primary study parameter was patient survival. During data analysis, the study parameters were altered to include the adequacy of initial surgery and survival time in relation to the involvement of the Gynaecology Unit. RESULTS: Initial presenting symptoms had a major influence on the referral patterns of patients with a gynaecological malignancy. All patients who presented with abnormal vaginal bleeding were managed by the Gynaecology Unit. Patients with ovarian cancer who presented with non-specific abdominal symptoms and ascites were often managed by other units. There was a statistically significant difference in the adequacy of initial surgery depending on whether the patient was managed by the Gynaecology or the Surgical Unit (P < 0.05). The median survival time of patients managed by the Gynaecology Unit was 20 months; this was considerably longer than the figure of 14 months for other units (P < 0.05). CONCLUSIONS: Patients with ovarian cancer who are managed by a specialised gynaecology unit are more likely to have adequate initial surgery and a longer median survival time. Female patients presenting with non-specific abdominal symptoms, ascites and other signs of intra-abdominal malignancy should be reviewed by a gynaecology unit before initial surgery.

Long-term implications of gestational diabetes for the mother.

Women with GDM have a greater risk of developing diabetes in the future compared with those women who have normal glucose tolerance during pregnancy. Using life table techniques, 17 years after the initial diagnosis of GDM, 40% of women were diabetic compared with 10% in a matched control group of women who had normal glucose tolerance in pregnancy. The incidence of diabetes was higher among women who were older, more obese, of greater parity and with more severe degrees of glucose intolerance during pregnancy. Diabetes also occurred more commonly among women who had a first-degree relative who was diabetic, in women born in Mediterranean and East Asian countries, and in those who had GDM in two or more pregnancies. Despite differing testing techniques and varying criteria for the diagnosis of GDM, follow-up studies from across the world consistently show a higher rate of subsequent diabetes among GDM mothers. NIDDM is associated with increased morbidity and a higher mortality rate, especially in women. Cardiovascular and cerebrovascular diseases are the leading causes of death. High lipid levels, hypertension and obesity are often already present when diabetes is diagnosed and may antedate the development of overt diabetes; treatment of diabetes at this stage may therefore be too late to prevent complications occurring. A follow-up programme for women with GDM facilitates screening of a group known to be at increased risk of developing diabetes so that the diagnosis can be made before associated risk factors for complications develop. Intervention in the form of counselling regarding cigarette smoking, exercise and a healthy, high-residue, unrefined carbohydrate, low cholesterol diet, given together with weight monitoring, may prevent the onset of both diabetes and its associated cerebrovascular and cardiovascular problems.

Polyhydramnios and associated maternal and fetal complications in singleton pregnancies.

During the 10-year period 1 January 1979 to 31 December 1988, polyhydramnios occurred in 537 patients with singleton pregnancies delivered at the Mercy Maternity Hospital. Associated maternal and fetal complications and the perinatal outcome of these pregnancies with polyhydramnios were analysed. In 248 of the 537 pregnancies (46%) in this group there were no maternal complications or fetal malformations and the perinatal mortality (PNM) rate was 2.4%. The PNM rate increased significantly to 13.1% when there was associated pre-eclampsia, 10% with gestational diabetes, and to 7.6% with miscellaneous complications. When polyhydramnios was associated with a fetal or placental malformation the PNM rate was 61.4%. The commonest malformations were central nervous system (31%), musculoskeletal (12%) and gastrointestinal system anomalies (10%). Placental chorioangioma occurred in two patients (0.4%) and both babies died. In women with low oestriol excretion (18% of the 455 tested) the PNM rate increased five times to 22.7%.

When is a maternal death a maternal death? A review of maternal deaths at the Mercy Maternity Hospital, Melbourne.

The limiting of the reporting of maternal deaths to those that are included in the criteria of the World Health Organization excludes deaths which yield useful information for further improvements in clinical performance. In this series of 22 maternal deaths, six deaths would have been excluded from reporting: one "direct" obstetric death of pre-eclampsia; one "indirect" death as a result of renal and cardiac failure; two deaths as a result of postnatal depression which led to suicide three and four months postpartum, respectively; and two deaths of cancers, where diagnostic delay may have been a result of the coexistent pregnancy. The importance of primary pulmonary hypertension, cardiomyopathy and psychiatric illness is emphasized. We endorse the recent recommendation of the International Federation of Gynaecology and Obstetrics (FIGO) that all maternal deaths that occur more than 42 days after the end of a pregnancy should be assessed for possible relationships with childbirth, and suggest that a time limit of one year would include all deaths that are worthy of scrutiny.

Incidence and severity of gestational diabetes in Bahrain and Australia.

The incidence and severity of gestational diabetes in a series of 5,199 predominantly Arab patients in Bahrain, and 2,643 of mixed racial origin in Australia were studied. The incidence of gestational diabetes in Bahrain (5.4%) was less than in Australia (7.2%) but the more severe degrees were 3 times more common in Bahrain (p less than 0.001). The incidence of gestational diabetes was significantly increased with increasing maternal age and parity. A notable difference between the 2 populations occurred in the groups weighing less than 70 kg. Although Bahrain had a higher proportion of patients weighing less than 70 kg (64.7% versus 55.9%; p less than 0.001) there was a significantly higher incidence of gestational diabetes in this group in the Australian series (13.9% versus 3.7%, p less than 0.001). Postnatal testing of 165 gestational diabetics in Bahrain and 194 in Australia indicated that although the severe degrees of glucose intolerance were more likely to persist postnatally, it was impossible to predict in the individual patient the change in glucose tolerance that would occur after delivery. All gestational diabetics should therefore have a postnatal glucose tolerance test.

Cervical pregnancy: hysterectomy avoided with the use of a large Foley catheter balloon.

A case of cervical pregnancy in the late first trimester is reported where hysterectomy was avoided, when it seemed inevitable in the face of heavy uncontrolled haemorrhage. Having read the cases reporting easy control of massive haemorrhage from the expanded cervix in such cases by a Foley catheter, we decided to try this recently reported technique - it was magically effective.

Primary malignant fibrous histiocytoma of the uterus--ultrastructural and immunocytochemical studies of two cases.

The clinical and pathological features, including ultrastructural and immunocytochemical findings, of 2 cases of primary malignant fibrous histiocytoma of the uterus are reported. One patient had pulmonary metastases at the time of hysterectomy: she developed pelvic recurrence and died 3 mth after operation. The other patient was well and apparently free of disease 6 mth after hysterectomy. Histologically both tumours resembled pleomorphic leiomyosarcoma, and the diagnosis of a malignant fibrous histiocytoma was confirmed only after electron microscopic and immunocytochemical studies. Hormone receptor assay for estrogen and progesterone was positive in both tumours. Anti-estrogen treatment was started in one case but was ineffective.

The outcome of pregnancies complicated by narcotic drug addiction.

The incidence of known narcotic drug addiction at 2 Maternity Hospitals in Melbourne was 0.06% (45 of 80,950 confinements). The obstetric results of these 45 pregnancies were unexpectedly favourable, the main complications being fetal growth retardation (27%) and premature birth before 37 weeks (27%). There were no fetal malformations and only 1 perinatal death. Follow-up information is necessary to ascertain if the main hazard to these infants lies in the environment to which they return.

Hysterectomy in obstetric practice.

A 9-year review (1971-1979) is presented of patients undergoing hysterectomy in the course of pregnancy. The incidence was 1 in 1,044 pregnancies (34 in 35,506). The principal indications were ruptured uterus (9), postpartum haemorrhage (8), placenta accreta (5) and neoplastic trophoblastic disease (4). In spite of the high incidence of hysterectomy in our community, the procedure was undertaken during pregnancy with great reluctance and usually only as a life-saving procedure.

Fetal growth and placental function assessed by urinary estriol excretion before the onset of pre-eclampsia.

In a series of 1,316 patients with pre-eclampsia 744 had urinary estriol excretion measured before and 366 after the onset of clinical signs of the disease. Low estriol excretion had a highly significant association with fetal growth retardation and perinatal death both before and after the onset of clinical signs (p less than 0.001). As assessed by the incidences of low estriol excretion, fetal growth retardation, and perinatal wastage, pre-eclampsia of early onset (before 37 weeks) was a malignant disease in comparison with pre-eclampsia of late onset (after 37 weeks). Patients destined to develop early-onset pre-eclampsia had a high incidence of subnormal estriol excretion (25.4%; p less than 0.001). Although further deterioration of placental function occurred after the onset of clinical signs (41.3%; p less than 0.01), fetal growth and prognosis were already determined.