Non-puerperal uterine inversions. A two case report and review of literature.

Chronic non-puerperal uterine inversions are rare but the occasional case has to be managed without previous experience. Of the 77 cases reported, 75 (97.4%) were tumour produced and 20% of these tumours were malignant. The importance of taking biopsies from tumours before definitive surgery is highlighted. Adequate surgical management requires experience in vaginal surgery.

Eclampsia at Ga-Rankuwa Hospital.

OBJECTIVES: To study the epidemiology of eclampsia and the maternal and fetal outcome of the disease. DESIGN: Observational study. SETTING: Ga-Rankuwa Hospital, a tertiary institution. SUBJECTS: Patients admitted with the diagnosis of eclampsia from 1 January 1994 to 31 December 1995. OUTCOME MEASURES: Age, parity, booking status, fits, blood pressure, gestational age, mode of delivery, fetal outcome, maternal complications and outcome. RESULTS: Out of 18145 women delivered, 66 had eclampsia (3.6/1000). Of the 36 maternal deaths in the same period, 14 (38.9%) were caused by eclampsia. The case fatality rate was 21.2%. Maternal mortality was significantly higher in the unbooked population, women aged 30 years and above, and those with multiple fits. The mean (SD) maternal age was 22.3 (6.8) years and fits occurred in the presence of high diastolic blood pressure (mean 113.7 +/- 15.6 mmHg). The majority of fits (90.1%) occurred at home and in 70.3% of patients, this happened before 37 weeks (mean gestational age 33.2 (3.9) weeks). In 77.3%, eclampsia was antepartum while it occurred postpartum in 4.5% of cases. The caesarean section rate of 66.7% is justified. The perinatal mortality rate was 47.7% and maternal complications were varied and severe. It is disturbing that health care providers failed to act on warning signs in 14 (46.7%) of the 30 booked patients that were evident long before they developed fits. CONCLUSION: Eclampsia is a problem and is responsible for a significant proportion of maternal deaths. The epidemiological factors responsible are identified and some recommendations are made. Patient and physician education, together with improved socio-economic conditions, are likely to improve the situation.

Surgical management of retroperitoneal necrotising fasciitis by planned repeat laparotomy and debridement.

Mortality remains high in patients with necrotising fasciitis despite use of modern powerful antimicrobial drug therapy and advances in the care of the critically ill. This is particularly so in patients with intra-abdominal retroperitoneal lesions. While necrotising fasciitis of the integument has been well described, its retroperitoneal (extraperitoneal) location has not been highlighted. Planned repeated laparotomies and debridement have been used in 10 recent patients with only 2 deaths. The initiating incident was caesarean section in 3 patients; perineal sepsis, trauma or intra-uterine death in 2 patients each; and uterine instrumentation to induce early abortion in the remaining patient. All patients received empirical antimicrobial therapy, which was changed when microbial isolates and their sensitivity indicated. Mechanical ventilation support was given to 60% of the patients early on during the illness. All received nutritional supplementation either parenterally or enterally throughout their inhospital treatment. This report focuses on intra-abdominal extraperitoneal necrotising fasciitis and the use of planned repeated laparotomy and debridement in the treatment of retroperitoneal (extraperitoneal) necrotising fasciitis per se and we recommend it as an essential part of the management of this condition.

Induction of labour in twin pregnancy.

Labour was induced in 32 high-risk twin pregnancies and the outcome compared with that in 32 twin pregnancies ending in spontaneous labour. No significant differences were found between the groups in terms of duration of labour and mode of delivery, and there were no failures of induction. Perinatal outcome was compared by measuring Apgar scores and cord arterial blood pH levels. There were no significant differences between the groups. Problems of management of labour are discussed and it is considered that induction of labour is an acceptable form of management of high-risk twin pregnancy.

Septicaemic low birthweight neonates treated with human antibodies to endotoxin.

In a double blind controlled study antilipopolysaccharide gammaglobulin given intramuscularly did not reduce mortality in low birthweight babies suffering from septicaemia. It did, however, reduce the recovery period of survivors from 310 to 120 hours.

Umbilical artery concentrations of androstenedione increased in early labour in the leading twin fetus.

Umbilical artery concentrations of androstenedione, progesterone, pregnenolone, pregnenolone sulphate and dehydroepiandrosterone sulphate were measured at birth in twin pairs, born by caesarean section. In the group born before the onset of labour, there were no significant differences in concentration of any of the steroids between the leading twin (twin I) and the second twin (twin II). In the group born during the latent phase of labour, levels of umbilical artery progesterone were significantly less in twin I (mean 501, SE 112 nmol/l) than in twin II (mean 887, SE 131) (P less than 0.05), while concentrations of androstenedione were increased in twin I [9.9 (SE 1.7) vs 4.7 (SE 0.7) nmol/l, P less than 0.01]. In patients delivered during active labour, androstenedione levels were consistently increased in twin I compared with twin II [11.7 (SE3.4) vs 4.3 (SE 0.7) nmol/l, P less than 0.01]. It is suggested that the rise in umbilical artery levels of androstenedione is derived from the fetal adrenal gland and may have an important role in the onset of labour.

Pregnancy-induced hypertension in twin pregnancy.

A prospective study of 54 primigravid twin pregnancies in Durban showed that pregnancy-induced hypertension occurred in 37%. This was more than twice the expected rate for singleton pregnancies in this Black African population. The babies born in the group of patients with pregnancy-induced hypertension were significantly lighter and had a higher rate of fetal growth retardation than the babies born in a normotensive control group of patients matched for age and parity. Monozygotic twins, identified by HLA typing, occurred significantly more often in the group with pregnancy-induced hypertension than in the control group. A possible immunological explanation for this finding is presented.

Carbohydrate metabolism in African women with twin pregnancy.

Carbohydrate metabolism was evaluated in 21 twin pregnancies and in 21 women with singleton pregnancies. The groups were matched for age, weight, parity, and period of gestation. A 100-g oral glucose tolerance test was performed on all 42 subjects. No significant differences in venous plasma glucose responses were found between singleton and twin pregnancies. The only significant difference between the insulin responses of the two groups was a lower plasma insulin concentration at 60 min in the twin group (P less than 0.03).

Twin pregnancy as a model for studies in fetal cortisol concentrations in labour: relation to prostaglandins, prolactin and ACTH.

Cortisol and prostaglandins were measured in umbilical cord blood obtained from 50 twin pregnancies at caesarean section performed either before or during labour. Umbilical artery cortisol concentrations did not differ between twin I and II before labour or in the latent stage. During active labour cortisol levels were significantly higher in twin I than in twin II. Maternal cortisol levels did not correlate with cord blood cortisol levels in either twin before active labour, nor did the rise in maternal cortisol correlate with the cortisol level in twin I; maternal cortisol levels did, however, correlate with cortisol levels in twin II during active labour. Prostaglandins E(PGE), F 2 alpha (PGF 2 alpha), 13,14-dihydro-15-keto F 2 alpha (PGFM) and ACTH were measured in cord vein blood. PGE values did not differ between twin I and II before active labour. During active labour PGE levels were significantly greater in twin I and correlated with raised cortisol levels. No differences were seen at any stage in PGE and PGFM levels between twins I and II although PGFM levels increased in both twins during active labour. ACTH and prolactin levels did not increase during labour and were similar in twins I and II. The rise in fetal cortisol during active labour is primarily of fetal origin and PGE may be involved in stimulating cortisol production in the fetus.

Amniotic fluid phospholipids and glucocorticoids in multiple pregnancy.

The phospholipid composition of amniotic fluid has been examined in 30 twin pregnancies with a mean gestation of 37.7 weeks. Before the onset of labour there was no difference in ratios of lecithin (L), phosphatidylinositol (PI), phosphatidylethanolamine (PE) and phosphatidylglycerol (PG) to sphingomyelin (S) between the first and second twin. With the start of contractions (6 patients) there was a significant increase in the L/S and PE/S ratios in the first twin (L/S ratio twin I 10.8 +/- 5.2, twin II 7.0 +/- 3.8; PE/S ratio twin I 0.7 +/- 0.2, twin II 0.4 +/- 0.1). Growth retardation of one fetus did not alter the phospholipid profile in the amniotic fluid. Amniotic fluid concentrations of glucocorticoids, measured before and during labour in both twins by specific immunoassay, were the same in both sacs before labour. During labour concentrations of unconjugated and conjugated glucocorticoids were significantly increased in the first sac (twin I unconjugated 113.2 +/- 16.6, conjugated 505.1 +/- 115.9; twin II unconjugated 69.5 +/- 41.4, conjugated 284.3 +/- 124 nmol/l). Amniotic fluid from growth retarded fetuses did not show higher glucocorticoid levels. In subsequent studies the glucocorticoids were separated by chromatography and only cortisol reacted significantly with the antibody used under the conditions of the assay.

Maternal prostaglandin levels after vaginal examination in two pregnancy.

Plasma 13,14-dihydro-15-keto-prostaglandin F2 alpha (PGFM) levels were measured in patients with twin pregnancies in come of whom the cervix was dilated and effaced. Significant rises in PGF M values were observed 5 and 10 minutes after vaginal examination in those patients who had a negative cervical score; these changes were abolished by prophylactic oral use of the beta-sympathomimetic drug fenoterol (Berotec; Boehringer Ingelheim). Patients who went into labour within 72 hours of examination had a greater percentage rise in PGFM levels than those in whom the onset of labour was delayed. Beta-sympathomimetic drugs such as fenoterol may be of value in preventing prostaglandin release and delaying the onset of labour.

Factors associated with preterm labour and changes in the cervix before labour in twin pregnancy.

A total of 132 twin pregnancies in black African women were studied prospectively after 30 weeks gestation. Delivery occurred before 37 weeks in 32%. There was a trend (0.1 greater than P greater than 0.05) towards a higher preterm delivery rate in nullipara (57%), in women under the age of 20 years (60%) and in those with a height/weight ratio of greater than 2.5 (50%). The cervix was assessed with a score based on the length of the canal minus the dilatation of the internal os. In both term and preterm labour there was a significant relation between a cervical score of 0 or a decrease in cervical score and the onset of labour within the subsequent 14 days (P less than 0.001). By these criteria to predict impending labour, 60% of all labours that ensured within 14 days of the assessment would have been predicted with a 20% false positive rate. When nulliparae were excluded the predictive value of cervical assessment for preterm labour was 80% with a false positive rate of less than 5%. Plasma oestriol levels were significantly higher in the preterm labour group but had no clinical prognostic value.

The prediction of fetal growth retardation in twin pregnancy.

A total of 132 twin pregnancies first seen at less than 36 weeks gestation were studied prospectively to determine the epidemiological and anthropomorphic factors associated with single or dual fetal growth retardation; the clinical, biochemical and ultrasound serial measurements that are predictive of single or dual fetal growth retardation, and to design scoring systems for the prediction of fetal growth retardation. A number of factors were associated with an increased risk of fetal growth retardation, but the highest risk was present when there was an abnormality in both plasma oestriol and placental lactogen, and the biparietal diameter growth rates were divergent. Scoring systems were derived using multi-variant discriminant analysis for three clinical situations: the patient seen for the first or second time; where only clinical facilities exist and the patient was seen on three or more occasions; and where facilities exist for the biochemical tests of placental function and ultrasonic measurement of the biparietal diameters. The scoring system for the last situation had the highest predictive rate and the lowest false positive rate.

Effect of prophylactic outpatient administration of fenoterol on the time of onset of spontaneous labor and fetal growth rate in twin pregnancy.

A double-blind trial was conducted on outpatients with twin gestations to assess the effect of prophylactic administration of fenoterol on the fetal growth rate and the timing of the spontaneous onset of labor. No significant differences could be shown between the fenoterol-treated group of patients and the control group given a placebo. It is concluded that prophylactic administration of fenoterol does not have a significant effect upon the incidence of preterm labor or growth retardation in twin pregnancy.

Treatment of the ruptured uterus.

Three hundred and thirty-five patients with ruptured uterus were reviewed. The incidence of this condition is increasing, probably owing to poor antenatal care and lack of facilities. The most common site of rupture in the previously unscarred uterus was found to be longitudinal on the lateral aspects of the lower and upper segments. When the ruptures were in these areas, total hysterectomy proved to be best. Repair of the rupture should only be considered when the tear is simple, transverse in the lower segment, and in the absence of infection.