Misoprostol and termination of pregnancy: is there a need for ultrasound screening in a general population to assess the risk for adverse outcome in cases of uterine anomaly?

PURPOSE AND METHODS: We reviewed the existing literature on medical termination of pregnancy in cases of congenital uterine malformation. Is medical termination of pregnancy safe in the presence of a uterine anomaly? Can termination of pregnancy still be performed when information concerning the presence of congenital uterine malformation is not available? RESULTS: The risk of adverse outcome, i.e. uterine rupture, was high in class 2 uterine anomalies, whereas the risks in classes 3-6 were negligible. However, the very low incidence of class 2 anomalies in pregnant women results in a calculated risk of uterine rupture in medical termination of pregnancy on the basis of this anomaly of 1 in 300,000 pregnancies. Ultrasound scanning is of limited diagnostic value to diagnose congenital uterine malformations. CONCLUSIONS: The implications of uterine anomalies are not an argument in the discussion whether to use misoprostol for termination of pregnancy in developing countries with scarce diagnostics tools.

Severe pre-eclampsia and HELLP syndrome after massive fetomaternal hemorrhage following blunt abdominal trauma.

Severe pre-eclampsia and HELLP syndrome developed within 24h after a 31year old nulliparous woman suffered a blunt abdominal trauma with massive fetomaternal hemorrhage and fetal intracranial bleeding. This is the first case reported of fulminating pre-eclampsia and HELLP syndrome following maternal exposure to a large amount of fetal cells and/or fetal cell debris as DNA or microparticles.

Arterio-arterial anastomoses do not prevent the development of twin anemia-polycythemia sequence.

Monochorionic twin pregnancies are associated with increased perinatal morbidity and mortality. The vascular placental anastomoses in these pregnancies can cause severe complications. We describe a case of twin anemia-polycythemia sequence (TAPS) with an atypical placental angioarchitecture. During pregnancy serial ultrasound examinations of both twins revealed no amniotic fluid discordance and no abnormal Doppler ultrasound measurements (umbilical cord pulsatility index and middle cerebral artery peak systolic velocity). The twins, born at 33 + 3 weeks gestation after spontaneous onset of labour, were found to be anemic and polycythemic, respectively. Placental examination with colored dye injection showed, apart from small ateriovenous anastomoses, an arterio-arterial anastomosis. As arterio-arterial anastomoses have not been described in cases with spontaneous TAPS to date, it was postulated that such anastomoses carried a protective effect against the development of this complication.

Computerised analysis of the fetal heart rate and relation to acidaemia at delivery.

OBJECTIVE: To identify the individual features of the computerised analysis of the cardiotocograph that relate to arterial pH and base deficit at delivery. DESIGN: Retrospective observational study. SETTING: Teaching hospital labour wards. PARTICIPANTS: 679 women requiring continuous intrapartum fetal monitoring. METHODS: Fetal heart and uterine contraction data were obtained using the Nottingham Fetal ECG monitor. Fetal heart rate patterns for the last half-hour preceding delivery were analysed using a computer algorithm developed for intrapartum application. The significance of the areas under receiver operator characteristic curves were calculated. MAIN OUTCOME MEASURES: Umbilical arterial pH and base deficit at delivery. RESULTS: Three parameters, fetal bradycardia, total deceleration area and the deceleration area after a contraction had receiver operator characteristic curves that significantly predict a low umbilical arterial pH and base deficit at delivery (areas under receiver-operator characteristic curves = 0.53, SD 0.01 P = 0.03; 0.60, SD 0.03 P = 0.002; 0.62 SD 0.04 P < 0.001, respectively). Tachycardia, accelerations and variability did not. CONCLUSIONS: The individual components of the computerised analysis of the fetal heart rate that predict acidaemia at delivery are identified.

Laparoscopic supracervical hysterectomy with Filshie clips.

We conducted a retrospective study to evaluate the efficacy of Filshie clips for pedicle ligation during laparoscopic subtotal hysterectomy. The procedure was a combination of endoscopic stapling with lateral movement of the cartridge to the infundibulopelvic or ovarian ligaments, Filshie clips to uterine arteries, cutting diathermy to transect the cervix, and motorized morcellator to remove the uterine body. Two patients had postoperative spotting from the stump. Median return to home activity was 7.5 weeks (range 2-24 wks) and to work was 9.5 weeks (range 2-12 wks). Based on a questionnaire survey, all 12 women were satisfied with the operation. In those who were sexually active it was associated with improved sexual functioning in six and no change in four. (J Am Assoc Gynecol Laparosc 8(1):137-142, 2001)

Cardiotocography only versus cardiotocography plus PR-interval analysis in intrapartum surveillance: a randomised, multicentre trial. FECG Study Group.

BACKGROUND: There is a need to improve the sensitivity and specificity of fetal monitoring during labour. We compared the gold standard, cardiotocography, with cardiotocography plus time-interval analysis of the fetal electrocardiogram in fetal surveillance. The aim was to find out whether time-interval analysis decreased the need for operative intervention due to fetal distress. METHODS: We did a randomised, prospective trial in five hospitals in the UK, Hong Kong, the Netherlands, and Singapore. 1038 women undergoing high-risk labours were randomly assigned fetal monitoring by cardiotocography alone, or cardiotocography plus fetal electrocardiography (ECG). Outcomes measured were rates of operative intervention, and neonatal outcome. Analysis was by intention to treat. FINDINGS: 515 women were assigned management by cardiotocography, and 523 cardiotocography plus fetal ECG. There was a trend towards fewer operative interventions for presumed fetal distress in the time-interval analysis plus cardiotocography group (63 [13%] vs 78 [16%]), but this was not significant (relative risk 0.80 [95% CI 0.59-1.08], p=0.17). There was no significant difference between groups in the proportion of babies who had an umbilical arterial pH of 7.15 or less (51 [11%] vs 49 [11%]; 1.01 [0.7-1.47]), or in the frequency of unsuspected acidaemia (42 [9%] vs 35 [8%]; 1.17 [0.76-1.79]). INTERPRETATION: The addition of time-interval analysis of the fetal electrocardiogram during labour did not show a significant benefit in decreasing operative intervention. There was no significant difference in neonatal outcome.

The PR interval-fetal heart rate relationship during repetitive umbilical cord occlusions in immature fetal sheep.

OBJECTIVE: To evaluate the relationship of the PR interval and fetal heart rate during repetitive umbilical cord occlusions in immature sheep fetuses. STUDY DESIGN: In seven chronically cannulated immature sheep fetuses [gestational age 90.6 days (mean)], we analyzed continuous fetal electrocardiogram recordings during repetitive cord occlusions for 2 out of every 5 min until fetal mean arterial pressure dropped to 50% of baseline value. PR interval-fetal heart rate correlation coefficients (Pearson) was measured on consecutive blocks of 2.5 min. R-values of the baseline and the repetitive occlusion period were compared by Fisher's exact test. RESULTS: Repetitive cord occlusions resulted in acidosis and hypotension. Two fetuses died at the end of the repetitive occlusion period. Four out of seven fetuses showed a significant change from a negative relationship between the PR interval and fetal heart rate during baseline to a predominantly positive relationship during the repetitive occlusion period. CONCLUSION: In immature fetal sheep, a change from a negative relationship between the PR interval and fetal heart rate to a predominantly positive relationship between the PR interval and fetal heart rate was observed in four out of seven fetuses following the initiation of repetitive umbilical cord occlusions.

The fetal electrocardiogram: relationship with acidemia at delivery.

OBJECTIVE: This study was undertaken to analyze the relationship between the fetal electrocardiogram and arterial pH and base excess at delivery. STUDY DESIGN: In the labor wards of three teaching hospitals a retrospective observational study was conducted on fetal monitor recordings of 679 women for whom there was an indication for continuous fetal monitoring during labor. These women had been recruited as part of either observational studies or a prospective randomized trial related to the Nottingham fetal electrocardiographic project. Fetal heart and uterine contraction data were obtained with the Nottingham fetal electrocardiographic analyzer. Morphologic and time interval analyses of the fetal electrocardiogram were performed. Evaluation was carried out for the last half hour before delivery. Main outcome measures were umbilical arterial pH and base excess at delivery. RESULTS: The study demonstrated a relationship between time interval analysis of the fetal electrocardiogram and a low umbilical arterial pH and base excess at delivery. Analysis of the morphologic characteristics of the fetal electrocardiogram (ST segment and T-wave height) showed no significant relationship. CONCLUSIONS: Time interval analysis of the fetal electrocardiogram during labor is related to relative acidemia at delivery.

Improving intrapartum surveillance: an individualised T/QRS ratio?

OBJECTIVES: To test the T/QRS ratio of the fetal electrocardiogram for normal distribution and assess the potential value of an individualised T/QRS ratio threshold to depict abnormality in the detection of fetal compromise during labour. STUDY DESIGN: A retrospective analysis of twenty intrapartum fetal electrocardiogram recordings obtained on the labour ward of the Queen's Medical Centre, Nottingham. RESULTS: In two of the twenty cases the T/QRS ratio was normally distributed. An increase in the T/QRS ratio over the 97.5th and 99.5th centile for 2 consecutive minutes, calculated on an individual basis, would appear to discriminate best between biochemically compromised and non-compromised fetuses. In no case was the T/QRS ratio seen to exceed 0.25 for periods previously described to be related to poor outcome. CONCLUSION: T/QRS ratio changes with individually calculated criteria for abnormality may be of benefit in the detection of fetal compromise but the effect on the intervention rate remains to be established. The use of an absolute threshold for T/QRS ratio abnormality which is based on the assumption of a normal distribution needs to be viewed with caution.

Classification of discordant fetal growth may contribute to risk stratification in monochorionic twin pregnancies.

OBJECTIVES: To determine whether classification of discordant growth between fetal twins allows risk stratification in monochorionic twin pregnancies. METHODS: In 12 twin-to-twin transfusion syndrome (TTTS) pregnancies and 12 cases that were suspected of developing the syndrome, fetal growth was determined by serial standard sonography. Fetal growth was expressed as the difference-average-ratio (DAR), defined as the difference in estimated fetal weight between both twins divided by their average weight. In each case, we determined the maximum value of DAR and the rate of change of DAR using a least squares linear fit of the estimated fetal weights. RESULTS: For the TTTS cases the maximum value of DAR was 0.44 +/- 0.21 versus 0.52 +/- 0.13 for the suspected TTTS cases (P = 0.25). The rate of change of DAR was 0.052 +/- 0.034 per week for the TTTS versus 0.0055 +/- 0.0092 for the suspected TTTS cases (P = 0.0004). After laser therapy, DAR decreased in four successful cases, with a rate of change of -0.0146 +/- 0.0093 per week, but increased further in one unsuccessful case, due to patent anastomoses. In the seven TTTS cases treated with amnioreduction, DAR did not decrease; in one of two suspected TTTS cases the DAR decreased slightly. In the nine amnioreduction cases, the average rate of change of DAR was 0.067 +/- 0.083 per week. This was significantly different from the four successful laser cases (P = 0.01). CONCLUSIONS: The rate of change of DAR, but not DAR itself, has prognostic value for the development of suspected TTTS pregnancies, for the onset and severity of TTTS and for the efficacy of therapy. This parameter is derived from routine sonography examination and may contribute to risk stratification in monochorionic twin pregnancies.

Changes in the PR interval--fetal heart rate relationship of the electrocardiogram during fetal compromise in chronically instrumented sheep.

OBJECTIVES: The evaluation of the changes in the relationship of the PR interval and fetal heart rate during prolonged fetal compromise in sheep at levels of acidosis comparable to those seen during human fetal compromise and to see whether these changes are potentially of use in the detection of fetal distress. STUDY DESIGN: A retrospective analysis of continuous fetal electrocardiogram recordings during graded fetal hypoxemia in 20 chronically cannulated fetal sheep was performed. Baseline recordings during normoxemia were compared with recordings during hypoxemia by use of Fisher's exact test and the Student t test. RESULTS: Sixteen of the 20 cases could be used for final analysis. Twelve showed a statistically significant change from a predominantly negative relationship between the PR interval and the fetal heart rate during normoxemia to a predominantly positive relationship during hypoxemia. Two cases showed an obvious trend in the same direction, which was statistically not significant. In two other cases no change in the relationship was observed. CONCLUSION: A changing relation between the PR interval and the fetal heart rate is of potential use in the detection of fetal compromise.

The fetal electrocardiogram.

Advances in microprocessing technology have made fetal ECG analysis a feasible adjunct to fetal surveillance. Time interval and morphology changes of the FECG occur during fetal hypoxia. The use of these changes to detect a fetus at risk of intrapartum asphyxia awaits validation in terms of both future and ongoing clinical trials. Recognition of FECG changes during decelerations may improve the sensitivity of EFM. Antepartum FECG analysis has potential for the detection of a number of pathological fetal conditions, including intrauterine growth retardation, but remains hampered by low signal-to-noise ratios, rendering successful signal acquisition unreliable.

Improved intrapartum surveillance with PR interval analysis of the fetal electrocardiogram: a randomized trial showing a reduction in fetal blood sampling.

OBJECTIVE: Our goal was to test the hypothesis that the addition of fetal electrocardiogram time-interval analysis to conventional electronic fetal monitoring would significantly reduce the number of cases requiring fetal scalp blood sampling without an increase in adverse outcome. STUDY DESIGN: A randomized prospective trial was performed in 214 women with high-risk labor. RESULTS: There was a significant reduction in the number of cases that had fetal blood sampling performed in the fetal electrocardiogram plus electronic fetal monitoring group (risk ratio for electronic fetal monitoring alone 3.53; p < 0.01, 95% confidence interval 1.39 to 8.95). The fetal blood samplings performed in the electronic fetal monitoring alone group were less likely to be abnormal (pH < 7.25, base excess < -8.0) than those performed in the fetal electrocardiogram plus electronic fetal monitoring group (risk ratio for electronic fetal monitoring alone 0.62, p = 0.05, 95% confidence interval 0.35 to 1.10). There was a trend of more infants with an arterial umbilical pH < 7.15 and a base excess less than -8.0 mmol/L at birth being unsuspected and more instrumental deliveries for presumed fetal distress being performed in the electronic fetal monitoring alone than in the fetal electrocardiogram plus electronic fetal monitoring group. CONCLUSION: The addition of fetal electrocardiogram analysis to conventional electronic fetal monitoring during labor can reduce significantly the number of parturients undergoing fetal scalp blood sampling and can simultaneously increase its efficiency without an increase in adverse outcome.

Screening for cervical neoplasia in Dundee and Angus: 10 years on.

OBJECTIVE: To evaluate the effect of changed cervical screening policies on a steady population with low migratory tendencies. DESIGN: A retrospective analysis study. SETTING: Dundee and Angus, Scotland. SUBJECTS: All women who developed cervical carcinoma between 1957 and 1992. MAIN OUTCOME MEASURES: The incidence of and mortality from cervical cancer after the introduction of organised cervical screening in 1962, according to age, stage, histology and screening history. RESULTS: The initial fall in incidence of cervical cancer seen in women between 35 and 54 years after the introduction of cervical screening was not sustained during the last 10 years of our study and appears to have been transferred to women aged 55 years and older instead. After 1976 an increase in the incidence of cervical cancer was seen in women under 35 years. The reduction in mortality from cervical cancer appears to have reached a plateau since 1976. No effect of cervical screening was seen on the incidence of adenocarcinoma of the cervix. CONCLUSIONS: The effect of changed cervical screening policies has been shown for a small population for a period of 35 years. The incidence of the higher stages of squamous cervical cancer continues to fall. The increase in incidence of cervical cancer in women under 35 years confirms similar trends seen in other countries. A background mortality rate refractory to further intensification of screening appears to have been reached. Adenocarcinoma of the cervix appears to gain in importance as cervical screening policies are shown to have their effect on its squamous counterpart.

Rationale for stopping cervical screening in women over 50.

OBJECTIVE: To investigate whether the currently recommended age at which to stop cervical screening (64) can be lowered and what criteria should be used for safely doing so. DESIGN: Retrospective case analysis study. SETTING: Dundee and Angus districts of Scotland. SUBJECTS: Women diagnosed as having cervical intraepithelial neoplasia and microinvasive or invasive cancer of the cervix in 1989 and 1990 (798 cases). MAIN OUTCOME MEASURE: History of cervical cytology results according to age (age groups of five years) and screening interval (three years and five years). RESULTS: Cervical intraepithelial neoplasia was most common in women under 45 (711 cases in women of 45 and under v 38 cases in those of 46 and over). Cervical intraepithelial neoplasia occurring de novo was not seen in women over 50 who had been screened every three years. Microinvasive or invasive cancer of the cervix was diagnosed in 26 women over 50. None of these women had participated adequately in the cervical screening programme. CONCLUSION: Cervical intraepithelial neoplasia typically occurs in younger women. All women over 50 with an adequate history of negative results on smear testing every three years may be safely discharged from further screening if these findings are confirmed in other populations.