Indications for induction of labour.

Induction of labour is an important prophylactic procedure in the obstetric practice. Two major types of indications developed: induction because of advanced relevant obstetric complication, and the so called elective induction.

Macroethical responsibilities of societies of gynaecologists and obstetricians.

The theme of maternal mortality and morbidity is of transcending macroethical importance. High rates of maternal mortality and morbidity can be significantly reduced by cost-effective means that are not dependent on advanced biotechnology. It has been shown that a major cause of maternal mortality comes from women (i) bearing children too early or too late in their reproductive lives, (ii) too frequently or at insufficiently spaced intervals. If women were able to control their fertility in order not to have children at unwanted times in periods of their life when pregnancy is inimical to their health, the incidence of maternal mortality and morbidity would drop. Improved standards of women's education, both in general and in particular regarding women's reproductive health, would reinforce the understanding of how to protect and improve one's reproductive health, and would accelerate the decline of maternal mortality and chronic morbidities. Accordingly, the macroethical demands of respect for autonomy, beneficence and justice would coincide. The value of justice would be served not only regarding women themselves, particularly those who have traditionally been vulnerable by virtue of their growing age, or dependent status in their communities, but also regarding the children dependent on such women, and families also dependent on the services of such women, like mothers, wives, daughters and grand-daughters.

Clinical experiences with intrauterine devices inserted with and without tail.

Nova T and TCu 200 Ag IUDs were inserted with or without a tail in order to study the possible role of the thread on the occurrence of PID. The five-year gross cumulative termination rate for infection was 3.7 in the group with a tail and 1.3 in the group without a tail. The results indicate a lower risk of genital infection if the device is inserted without the tailstrings.

Treatment of vulvar craurosis and leucoplakia by split skin grafting.

In the treatment of a 72-year-old patient with vulvar craurosis and leucoplakia which had been proven resistant to earlier surgical and medical treatment attempts--the authors employed a split-skin graft from the forearm. The methods of the successful treatment with regard to the skin and its grafting, as well as the post-operative case, are described.

The redistribution of the blood flow under nifedipine treatment in the sheep foetuses.

The Ca(++)-antagonist nifedipine has been successfully employed in the treatment of non-gravid hypertension, and was found to inhibit uterine contractions in the perimenstrual period, as well as during premature labour in animal models. The use of antihypertensive drugs in pregnancy introduces the possibility of iatrogenic foetal distress. It has been established that nifedipine crosses the placental barrier in the sheep and causes a fall in mean arterial pressure and tachycardia in both the ewe and the foetus. This paper examines the effects of nifedipine on the foetus when administered to the pregnant ewe. Catheters and electrodes were implanted by surgical procedures in 15 ewes and foetal lambs between days 118 and 122 of gestation. The redistribution of foetal blood flow was measured by the radioactive microsphere injection technique. The infusion of nifedipine caused a 9% increase in the combined ventricular output (CVO) from 446 to 509 ml/min/kg in the foetus. Foetal lung blood flow increased from 29 +/- 6 to 69 +/- 14 ml/min/kg while figures for the skeletal muscle flow were 109 +/- 34 and 141 +/- 41.6 ml/min/kg. Heart and brain blood flow, expressed as percentages of CVO showed variations of 4.3 and 5.6 percent, respectively. Blood flow in the gut, placental membranes, skin, kidney and spleen was reduced. The present results show that nifedipine, in addition to its known effects causes a redistribution of the foetal circulation.

Effects of prostaglandin E2 on the newborn respiratory system.

To test the hypothesis that prostaglandin (PG) E2 is a respiratory depressant in the newborn lamb, 12 chronically catheterized, unanesthetized lambs (age 2 to 6 days) were infused with progressively increasing doses of PGE2 (0.1, 0.5, 1.0 and 5.0 ug/kg/min: 30 min for each dose) into the ascending aorta. PGE2 caused significant, progressive decrease in ventilation (due to decreased tidal volume and breathing rate) heart rate, blood pressure and percent of the time spent in low voltage electrocortical activity (LVA). PGE2 also caused respiratory acidosis, hypoxemia and increased frequency and duration of apneic events (greater than 3 sec). During the infusion, there was a dose related increase in plasma concentration of PGE2. At 30 min post-infusion, all measured variables showed recovery, although arterial pH carbon dioxide tension and plasma PGE2 remained significantly different from control values and the percent time in LVA was even higher than during control. Infusion of the vehicle alone (n = 5) caused no significant changes in any of the measured variables. The results, taken in combination with previous fetal studies, indicate that PGE2 has marked inhibitory effects on breathing movements both before and after birth.

Randomised trial comparing combinations of cyclophosphamide and cisplatin without or with doxorubicin or 4'-epi-doxorubicin in the treatment of advanced ovarian cancer.

Forty-eight patients with FIGO stage III and IV epithelial carcinomas of the ovary were entered in this randomised trial. Radical surgery was performed and no residual tumor with a diameter greater than 2 cm was left behind. Of these patients 62.5% (10/16) had a complete or partial response on cyclophosphamide + cisplatin (CP) 87.5% (14/16) on cyclophosphamide + doxorubicin + cisplatin (CAP) and cyclophosphamide + 4'-epi-doxorubicin + cisplatin (CEP). The median time to progression was 3.5 months on CP, 12.5 months on CAP and 11.0 months on CEP. Patients treated with CAP combination chemotherapy had generally longer progression-free survival (log rank chi 2 = 5.4; P = 0.04). No significant difference was found, however, between patients on CAP and CEP. The median survival times were 12.5 months on CP, 26.5 months on CAP and 14.0 months on CEP. Patients treated with CAP combination chemotherapy had generally longer survival (logrank chi 2 = 9.08; P = 0.0099). No significant difference was found, however, between patients on CAP and CEP in terms of survival. Asymptomatic mild-to-moderate laboratory test toxicity occurred in 6-12% of patients on CP, 6-12% on CAP and no toxicity of this type and grade on CEP. Nausea and vomiting were also less severe and less frequent in the CEP group. Cardiotoxicity was seen in 12.5% (2/16) only in the CAP group.

Uterine surgery of sterility.

Based on personal experience and illustrated by selected case reports, the author gives an account of the modern development of surgical techniques used for the treatment of uterine causes of sterility and infertility. Three main groups of pathology of the uterine body are dealt with: uterine myoma, malformations and the Asherman syndrome. Advances in the surgical methods and instrumentation are discussed in the light of improving success rates.

Blood flow redistribution during isocapnic hypoxia in foetal lamb.

Circulatory responses to hypoxaemia were studied in 16 foetal lambs in 120-129 and 135-145 days of gestation (term: 147 days). Under general anaesthesia catheters were inserted into the foetal vessels and the umbilical blood was measured during antipyrine infusion by the Fick steady-state diffusion method. The combined ventricular output and actual organ blood flows were calculated from injections of radionuclide-labelled microspheres into a forelimb and a hindlimb vein. Isocapnic hypoxia was produced by giving the ewe a breathing gas mixture of 9% O2 and 3% CO2 in N2 for 30 min. A significant increase was found in the blood flow of the myocardium, the lungs, the brain and in the combined ventricular output between 0.80 and 0.95 gestation times. Under isocapnic hypoxaemia blood flow increased to the brain, heart and adrenals, whilst it decreased to the lungs, kidneys, gut and carcass. The observed changes were different at the two measurement times. Under hypoxia, depending on the gestation time, the blood flow increased in the diencephalon, midbrain, hypophysis and in the cervical cord. In the cerebral, cerebellar and lumbosacral cord it remained unchanged, while decreasing in the chorioid plexus and in the hippocampus. In the gestation period under examination the foetal circulation undergoes significant redistribution.

Effects of ethanol infusion on foetal EEG and breathing movements.

Ethanol (0.3 g/kg and 0.5 g/kg administered over 2 hours) was infused intravenously into 15 chronically instrumented pregnant ewes between 128 to 135 days of gestation (0.85 to 0.92 gestation time, term 147 days). Brainstem dissection above the pons was made in 7 foetuses. Foetal breathing movements were suppressed for 7 hours following a 30 ml ethanol infusion. Low voltage foetal electrocortical activity was suppressed or replaced by an intermediate voltage electrocortical activity for 5 and 3 hours following the 60 ml and 30 ml ethanol infusions, respectively. In brainstem dissected foetuses the effects of ethanol infusion on the foetal EEG were similar. Foetal blood gases and pH were not altered. These data suggest that ethanol moves across the foetal blood-brain barrier and suppresses foetal breathing movements by a direct central mechanism.

Effects of calcium channel-blocker tokolysis on the foetal circulation.

The Ca++-antagonist nifedipine has been successfully employed in the treatment of non-gravid hypertension, and was found to inhibit uterine contractions in the perimenstrual period, as well as during premature labour in animal models. The use of antihypertensive drugs in pregnancy introduces the possibility of iatrogenic foetal distress. It has been established that nifedipine crosses the placental barrier in the sheep and causes a fall in mean arterial pressure and tachycardia in both the ewe and the foetus. This paper examines the effects of nifedipine on the foetus when administered to the pregnant ewe. Catheters and electrodes were implanted by surgical procedures in 15 ewes and foetal lambs between days 118 and 122 of gestation. The redistribution of foetal blood flow was measured by the radioactive microsphere injection technique. The infusion of nifedipine caused a 9% increase in the combined ventricular output (CVO) from 446 to 509 ml/min/kg in the foetus. Foetal lung blood flow increased from 29 +/- 6 to 69 +/- 14 ml/min/kg while figures for the skeletal muscle flow were 109 +/- 34 and 141 +/- 41.6 ml/min/kg. Heart and brain blood flow, expressed as percentages of CVO showed variations of 4.3 and 5.6 per cent, respectively. Blood flow in the gut, placental membranes, skin, kidney and spleen was reduced. The present results show that nifedipine, in addition to its known effects causes a redistribution of the foetal circulation.

Cardiorespiratory effects of nifedipine in pregnant sheep.

Four concentrations of nifedipine (AdalatR, Bayer) were infused into 25 pregnant sheep of 123-140 days of gestation (term, 147 days) and the effects on the ewe and the foetus have been studied. At all doses of nifedipine infused, maternal diastolic pressure fell by about 15% and maternal heart rate increased by 33%. There was no change in blood gases or pH. Uterine activity, as measured by uterine electromyographic recordings, was reduced due to an increase in the interval between periods of activity. The duration of a burst of activity remained unaffected. The effects of nifedipine on the foetus, were similar. Mean foetal arterial pressure fell by 4-5 mmHg and heart rate rose by 15 to 50%, both changes being maintained for the duration of the infusion and the increased heart rate for longer. The electrocorticogram of the foetal sheep was unaffected by nifedipine. The effects on foetal breathing movements were small. At the concentration of 5 micrograms/kg/min for either 2 or 4 hours the breathing pattern changed so that the episodes of breathing were shorter and more frequent. The total amount of breathing per hour was unaffected. Control infusion of ethanol had little effect on the ewe except for a significant increase in lactate production. In the foetus breathing was reduced at the highest concentration used.

Clinical experience with intrauterine contraceptive devices (IUDs) inserted with and without tail.

Between 1982 and 1984, two comparative clinical trial for testing new types of IUDs, were initiated at the Family Planning Center (Debrecen, Hungary) in collaboration with the Leiras Research Laboratories (Turku, Finland). 685 Nova T and 500 TCu 200Ag IUDs with and without tail were inserted in a randomized manner in order to study the possible role of the thread of the device in generating pelvic inflammatory disease (PID). Because there were no statistically significant differences between the corresponding rates of the devices, the data regardless of the type of the IUD, were pooled, then separated into two new groups: the study group (IUD without tail) consisted of 581 cases, while the control population (IUD with tail) included 602 insertions. The age and parity distribution was the same in both groups (mean age 29.4, mean parity 1.9). In the study group 300 patients completed the two-year follow-up, and 9675 womanmonths of use were evaluated. The corresponding figures for the control population were 304 and 9935, respectively. The two-year gross cumulative termination rates for the study and the control group were as follows: pregnancy 4.4 and 4.6; expulsion 1.9 and 2.9; bleeding/pain removals 6.3 and 6.0, removal for infection 0.2 and 2.7; removal for other medical reason 2.1 and 1.9; removal for planning pregnancy 4.6 and 6.6; removal for other personal reason 1.6 and 0.6. The pregnancy, expulsion and removal rates, except infection, were almost the same in both groups. There was a statistically significant difference only between the rates of removals for PID (p less than 0.05): during the two-year period of use 12 devices were removed for infection and out of these only 1 was inserted without tail! Although these findings are promising, to draw a final conclusion more cases and a longer follow-up are needed.

Eosinophilic endomyometritis associated with diagnostic curettage.

Histological study of hysterectomy specimens removed for noninflammatory and nonneoplastic disease revealed 15 severe cases and many more slight cases of eosinophil leukocytic endomyometritis, the degree of which appeared to correlate with injury from preoperative diagnostic curettage. In each case of severe eosinophilic endomyometritis, circumferential mucosal and extensive myometrial damage together with an occluding blood clot at the level of the inner orifice was confirmed. The massive eosinophilia appeared any time between 18 h and 21 days after curettage, and it is proposed that the probable causative agents are eosinophil chemotactic substances liberated from the myometrial mast cells and from the degrading blood clot filling the uterine cavity. There were no clinical signs or symptoms that appeared to correlate with the histological changes observed in this study. This phenomenon may serve as a model for studying the dynamics and functions of eosinophilic leukocytes in humans.

Ovarian function immediately after the menarche.

Estrone and pregnanediol-glucuronide values of early morning urine samples collected from young girls in the perimenarche were determined by radioimmunological technique. A total of 58 teenage girls started collecting urine samples after their menarche at various times. Of these, 9 completed collection within 100 days of the onset of the first menstrual period. In 3 cases, insignificant changes in estrone and pregnanediol levels were noted. Normal estrone values were found in 3 cases together with pregnanediol levels suggestive of ovulation. In 2 further cases the possibility of ovulation without follicular release was suggested. The results indicate that ovarian activity is unpredictable immediately following the menarche. Between very low levels of sexual steroid hormone production and those normally observed in adult females, all transitional values could be found.

Elective induction of labour in the obstetrical practice.

Maternal and foetal results of 2020 elective inductions of labour are presented, compared with those of 2750 pregnancies in which labour was not induced during the 40th week of gestation, awaiting for its spontaneous onset. The morbidity, mortality, and the frequency of obstetric operations during labour were compared. In all the parameters compared, there were better results in the electively induced group. The author attributed this difference to the establishment of careful selection criteria for elective induction. These criteria are: reliable estimate of gestational age, mature foetus over 3000 g of body weight, ripe cervix, proven myometrial sensitivity to oxytocin. Following these rules, the elective induction of labour can be a valuable and safe method of prevention of maternal and foetal complications.

Effect of oxytocin infusion during labor: indocyanin green elimination and serum bilirubin levels.

The elimination of indocyanin green (IGG) in selected mature newborn babies (n = 50) was investigated on the first postnatal day. The IGG dose was 2 mg/kg body weight. The half time (t1/2), the elimination constant (K2), the dye distribution volume (ml/kg), as well as the level of serum indirect bilirubin on the third postnatal day were measured and calculated. Healthy, mature newborns from spontaneous labor served as controls (n = 14): the two study groups consisted of either growth-retarded (n = 8) or acidotic (n = 8) neonates. According to the management of deliveries, they were spontaneous, assisted by oxytocin drop infusion (n = 10) or under lumbal peridural anaesthesia + oxytocin drop infusion (n = 8). In the acidotic neonates the elimination constant was significantly lower and the half time significantly longer. In the growth retarded newborn babies the difference was not significant. The increase of the level of indirect bilirubin in serum appearing in the acidotic group on the third postnatal day was significantly greater.