Umbilical artery Doppler velocimetry as a labor admission test.

Doppler ultrasound of the umbilical artery flow velocity waveform was studied prospectively as an admission test at the labor ward. Recordings were made in 575 women in various stages of labor before, during, and after uterine contractions, and evaluated in relation to intrapartum and fetal outcome variables. No association was found between abnormal flow velocity waveforms and cord complications, meconium-stained amniotic fluid, or abnormal fetal heart rate tracing, nor was there any association with operative delivery for fetal distress or low Apgar scores at 1 and 5 minutes. Small for gestational age fetuses had significantly more abnormal flow velocity waveforms than appropriate for gestational age fetuses, and so had those with umbilical artery acidemia compared with those with normal pH. The results indicate that Doppler recording of the umbilical artery flow velocity waveform as an admission test at the labor ward is not a good predictor of fetal distress in an unselected population.

Disposable menstrual regulation kits in a non-throw-away economy.

The directions for use that are packaged with plastic menstrual regulation kits state that the kits are designed to be durable for approximately 50 procedures when used as directed. However, in much of the developing world, directions for use are ignored, equipment is not maintained properly and nothing (including disposable medical equipment) is discarded until it is unless. Therefore, it is of interest to know for how many procedures the disposable menstrual regulation kit can safely be used. This paper describes a study conducted in Singapore to determine the durability of three menstrual regulation kits manufactured by different companies and comments on how cleaning and sterilizing affects the durability of these kits.

PIP: Directions on plastic menstrual regulation kits indicate they are designed for approximately 50 procedures and should then be discarded. In many parts of the developing world, directions for use are ignored, equipment is not properly maintained, and nothing is discarded until it is useless. A comparative study was conducted to determine how long such kits can safely be used. 3 MR (menstrual regulation) kits from different manufacturers--Rocket of London, Burnet of Lawrence, Kansas, and International Projects Assistance Services (IPAS) of Chapel Hill, North Carolina--were evaluated at Kandang Kerbau Hospital in Singapore. Each kit was evaluated under 6 different cleaning procedures. Results are tabulated. It was found that all 3 brands can safely be used longer than advertised. The Burnett and IPAS syringes lasted substantially longer than the Rocket syringes. Durability was not affected by the type of soap used in cleaning. All 3 disinfectants used performed poorly. Even though 1/4-l/3 of the cannulae tested showed positive cultures, no cases of infection were reported in the women in the study. Manufacturers should understand the MR kits will be used as long as possible in developing areas. Parts most likely to wear out should be easily replaceable. Preferably, procedures should be adopted to minimize wear on these parts.

Induction of abortion with 15(S)-15-methyl PGF2alpha (Tham) vaginal suppositories.

The repeated administration of vaginal suppositories containing 1 mg 15(S)-15 methyl PGF2alpha (Tham) sucessfully induced abortions in 60 of 62 patients. Among patients who successfully aborted, the mean abortion time was 19.0 hours. The mean abortion time was not related to gestational age or parity. Sixty (96.8 precent) aborted within 48 hours, and 53 (85.5 percent) aborted within 24 hours. Gastrointestinal side effects occurred for 33.9 percent of the patients. Diarrhea was the most frequent side effect. The abortion was complete for 40.3 percent of the patients.

A comparison of the clip and ring techniques for laparoscopic sterilization of postabortion and postpartum patients.

The spring-loaded clip and the tubal ring techniques of laparoscopic female sterilization are compared for ease of performance, safety and effectiveness at the Kandang Kerbau Hospital in Singapore. The two techniques were randomly assigned to 299 postpartum patients and 300 postabortion patients. The assigned procedure could not be performed for two of the ring cases and three of the clip cases. Bleeding and equipment problems made laparotomy necessary in two clip cases and equipment problems caused a change in technique in the other clip case. Hydrosalpinx and adhesions were responsible for a change to laparotomy in the two ring cases. Surgical difficulties, chiefly the result of equipment problems, were significantly higher for both postpartum and postabortion clip procedures. Complications and complaints reported immediately after surgery and at the 7- to 21-day follow-up visit were low for all four groups. For both postabortion and postpartum patients, six- and 12-month data show that pregnancy rates are significantly higher for patients sterilized with the clip than with tubal rings.

A comparison of D & C and vacuum aspiration for performing first trimester abortion.

In a study of techniques for first trimester abortion conducted at Kandang Kerbau Hospital in Singapore from September 1973 to April 1975, 420 physically healthy gravidas were randomly assigned to one of two treatment groups either by D & C or vacuum aspiration. Half of the patients in each group were 6 to 10 menstrual weeks' gestation and half were 11 to 12 week's gestation. The numbers of women with one or more complications were the same for the two treatment groups, but were significantly less when termination was carried out at 11 to 12 weeks' gestation. Estimated blood loss was significantly lower for patients treated by VA (32.3 ml) than for patients treated by D & C (39.0 ml) at 6 to 10 week's gestation, but the difference in blood loss was not statistically significant at 11 to 12 weeks' gestation. Time from insertion to removal of the speculum was significantly less with VA than D & C at 6 to 10 weeks' gestation but not at 11 to 12 weeks' gestation. Since vacuum aspiration is at least as safe as D & C, and appears to be more convenient and costeffective, it should on the basis of this experience be accepted over D & C as the standard method for treatment of first trimester abortion.

Estrogen-progesterone withdrawal bleeding in diagnosis of early pregnancy.

This study was designed to evaluate the efficacy of an exogenous estrogen-progesterone preparation for inducing "withdrawal bleeding" in non-pregnant women, a procedure used in some areas for the diagnosis of early pregnancy. Three hundred patients not desiring to be pregnant and with no signs of pregnancy other than menses delayed by 14 days or less were randomly assigned to treatment or control groups. The treatment group received an intramuscular injection of 50 mg progesterone and 3 mg oestradiol benzoate in oil. The control group received no hormonal injection. There was no significant difference between the two groups in the incidence of uterine bleeding within 7 days. Thus, the hormonal preparation was ineffective in inducing "withdrawal bleeding". Its use as a diagnostic test for pregnancy is not recommended.

An evaluation of intramuscular progesterone for the diagnosis of early pregnancy.

PIP: The efficacy of administering progesterone alone for the early diagnosis of pregnancy was evaluated in a study of 296 women presenting to an outpatient clinic because of a recently missed menstrual period and requesting termination of the suspected pregnancy. Subjects met 4 criteria: 1) no preexisting medical or gynecological condition; 2) regular menstrual cycles with a range of 21-35 days; 3) no more than 14 days past the expected date of menstrual onset; and 4) no immediate request for oral contraceptives or the IUD. 148 patients in the treatment group received an intramuscular injection of 100 mg progesterone, while the 143 controls were given no hormonal injection. At the 1st follow-up visit 10 days later, the pregnancy test (Pregnosticon Dri-Dot) was repeated, and vacuum aspiration performed if the patient was still amenorrhetic, with the contents submitted for pathological study. The 2nd follow-up was 2-4 weeks later. 33.8% of women in the treatment group and 34.9% of controls menstruated within 10 days of the initial visit. Those in the treatment group were significantly more likely (57.4%) than controls (35.7%) to report at least 1 complaint. There were no significant differences between groups in the number of women who were pregnant or underwent menstrual regulation, implying that progesterone does not act as an abortifacient. Since the failure of progesterone to induce withdrawal bleeding is presumed to indicate pregnancy, its false-positive rate as a hormonal test of pregnancy was 15.3% in the treatment group, compared with 24.3% for the urine pregnancy test at the initial visit but 6.9% for the Pregnosticon test at 10 days. A false-negative rate of 4.1% was associated with the hormonal pregnancy test, compared with 29.3 and 18.8%, for the Pregnosticon test at the initial and 10-day follow-up visits, respectively. The study design contained 2 limitations: 1) histologic specimens of uterine contents were obtained only from those who seemed pregnant; and 2) no placebo injection was given to controls. It is concluded that progesterone administration offers no clear-cut advantage to immunologic pregnancy tests, and carries possible disadvantages in terms of increased risks of birth defects.^ieng

Maternal mortality--a review at the Department of Obstetrics and Gynaecology, Alexandra Hospital, Singapore.

Maternal mortality rate is a sensitive index of the prevailing health conditions and general socio-economic development of the country. The present study was undertaken to see the trends in maternal mortality at the Department of Obstetrics and Gynaecology, Alexandra Hospital during a 11-year period from January 1978 until December 1988. There were 14 maternal deaths during this period.

Shoulder dystocia-a review at the Department of Obstetrics and Gynaecology, Alexandra Hospital, Singapore.

Shoulder dystocia is associated with a high incidence of perinatal morbidity, mortality and maternal morbidity. The present study was undertaken to review all the cases of shoulder dystocia at the Department of Obstetrics and Gynaecology, Alexandra Hospital during a 11-year period from January 1978 until December 1988. The incidence of shoulder dystocia in this series was 1:1739 deliveries or 0.05%. The constant awareness of the possibility of rapid development of shoulder dystocia with its potentially dangerous consequences should always be kept in mind. Shoulder dystocia drills should be held regularly in the resident training programme.

Induction of labour using a concentrated oxytocin infusion administered in geometric progression in a peristaltic infusion pump.

A new regime for oxytocin titration was introduced into the Labour Ward, Alexandra Hospital, Singapore. It utilises an oxytocin infusion of 10, 20 or 40 mU/ml administered in geometric progression in a peristaltic infusion pump. A total of 91 patients classified according to parity and cervical score were studied. An overall vaginal delivery rate of 92.3% was obtained. The mean induction-delivery time for nulliparous and multiparous patients was 5.3 hrs (+/- 2.6 hrs) and 3.6 hrs (+/- 1.9 hrs) respectively. Almost 90% of patients who had a successful induction required only one pint of infusion. Of those babies who were delivered vaginally, all had an Apgar score of 7 or more at 5 minutes.

A low dose oxytocin regime for induction and augmentation of labour.

A low dose oxytocin regime was used in Labour Ward, Alexandra Hospital for the induction and augmentation of labour. It utilised an oxytocin infusion administered in an arithmetic progression from 1 to 16 mU in a peristaltic infusion pump. A total of 100 patients (67 for augmentation and 33 for induction of labour) classified according to parity were studied. An overall vaginal delivery rate of 87% was obtained. The overall mean durations of labour for nulliparous and multiparous patients were 6.6 hours (S.D. +/- 2.9 hours) and 4.9 hours (S.D. +/- 2.8 hours) respectively. The mean induction delivery time for nulliparous patients was 6.4 hours (S.D. +/- 3.2 hours) and for multiparous patients it was 4.0 hours (S.D. +/- 2.2 hours). About 69% of the nulliparae and 94% of the multiparae who were induced delivered within 9 hours. All the induced patients delivered within 12 hours. Neonatal outcome was good as assessed by Apgar score.

Psychological effects of abortion (a study of 1739 cases).

PIP: A 6-month prospective study was conducted among 1739 women who underwent therapeutic abortion at Kandang Kerbau Hospital in Singapore to ascertain the aftereffects of abortion. Results of the study indicate that induced abortion has no observable bad effects on the mental health of the patients. In fact, somatic and psychiatric complaints were reduced and sexual adjustment increased 6 months postoperative. Those who were also sterilized at the time of the abortion showed a slightly lower rate of somatic symptom reduction than the rest of the group.^ieng

Nausea and vomiting after termination of pregnancy as day surgery cases: comparison of 3 different doses of droperidol and metoclopramide as anti-emetic prophylaxis.

Frequency of nausea and vomiting following day case termination of pregnancy was found to be rather high (42%) without anti-emetic prophylaxis. Droperidol in doses of 2.5 mg, 1.25 mg and 0.25 mg were found to be equally effective as prophylactic anti-emetic, but not metoclopramide 10 mg. This study confirms that low dose droperidol 0.25 mg is effective as a prophylactic anti-emetic, without any delay in immediate recovery and hence suitable for day surgery cases.

PIP: 325 outpatients at Alexandra Hospital in Singapore received intravenously either 2.5 mg droperidol, 1.25 mg droperidol, 0.25 mg droperidol, 10 mg metoclopramide, or a placebo before undergoing surgical abortion. Nursing staff assessed their condition 4-6 hours postoperatively. 42.3% of the women in the untreated group experienced nausea and vomiting after the operation compared to 25.6% for women who received 0.25 mg droperidol (p.05), 23.7% for those who received 1.25 mg droperidol (p.05), and 15.6% for those who received 2.5 mg (p.01). Yet women who received 2.5 mg droperidol were more likely to require sedation 2 hours postoperatively than the other groups and the untreated group (p.05). Even though the percentage of women who experienced nausea and vomiting and received 10 mg metoclopramide was less (37.9%) than those who received the placebo, the difference was not significant. In another study, 1 mg of droperidol slowed perceptual speed and ambulatory recovery. Since 0.25 mg of droperidol resulted in faster recovery in this study and other studies, it was the most effective prophylactic antiemetic.

Successful outcome in antepartum pulmonary embolism--a case report and review of incidence, diagnosis and management.

Antepartum pulmonary embolism is a condition carrying a high maternal mortality, yet treatment with anti-coagulation can reduce the mortality to less than 1%. The true incidence is difficult to establish because of problems in confirming the clinical diagnosis. We report here a case of maternal pulmonary embolism complicating pre-eclampsia and hypertension. The difficulties in establishing a firm diagnosis are high-lighted. A brief review of the incidence, predisposing factors, diagnosis and management is presented. The total management of the patient is discussed in some detail.

An in vitro assessment of human fetal pancreatic islets of Langerhans in culture.

The human fetal pancreas is a potential source of islets for transplantation into insulin-dependent diabetic patients. In this study, 35 human fetal pancreas obtained from prostaglandin-induced abortions (12-26 weeks gestation), were placed in culture to determine their capacity to secrete insulin over 30 days. Culture media were sampled twice weekly for insulin and histology was performed serially. Of the 35 pancreases cultured, six were lost due to bacterial contamination, five discarded due to undetectable levels of insulin in culture, nine are still under study, whilst 15 pancreases have been cultured for one month, and insulin studies completed. Three patterns of insulin release were observed: (a) progressive decline (n = 6), indicating non-viable tissue at the onset; (b) delayed decline, indicating significant tissue damage before organ culture (n = 5); and (c) insulin production in vitro over 30 days (n = 4), with viable islets detected histologically. Factors such as gestational age and cold ischaemia time did not correlate with the pattern of insulin secretion observed. This was probably due to a more important variable, not easily assessed, of the period of intrauterine (warm) ischemia. These data suggest: (1) that a small number of fetal pancreases procured from prostaglandin-induced abortuses do yield islets which remain viable in culture over 30 days, and (2) the functional status of islets can be monitored in vivo by measuring insulin secretion, thereby providing a means of identifying tissue suitable for transplantation.

Management and outcome of gestational diabetes in Alexandra Hospital, Singapore.

We analysed 216 patients with gestational diabetes over a 3 year period. These patients were managed by a diabetic team under a standardised protocol. Forty percent of these patients required insulin therapy. The incidence of pregnancy hypertension was 14.4%, macrosomia 8.8% and major congenital malformation 3.7%. The Caesarean Section rate was 34% and the overall Perinatal Mortality Rate was 1.9%. However, neonatal morbidity rate remained high--44% of infants have had one neonatal complication and 17.6% had 2 or more complications. Pregnancy outcome was further analysed among patients with different degrees of glucose intolerance at diagnosis. We noted that both macrosomic rate, neonatal morbidity rate, as well as proportion of patients requiring insulin were higher in the group with a higher degree of glucose intolerance. There was, however, no difference in incidence of hypertension or hydramnios in the different subgroups.