A combination of misoprostol and estradiol for preoperative cervical ripening in postmenopausal women: a randomised controlled trial.

OBJECTIVE: To compare the impact of 1000 microg of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after 2 weeks of pretreatment with estradiol vaginal tablets in postmenopausal women prior to day-care operative hysteroscopy. DESIGN: Randomised, double-blind, placebo-controlled sequential trial. SETTING: Norwegian university teaching hospital. POPULATION: Sixty-seven postmenopausal women referred for day-care operative hysteroscopy. METHODS: The women were randomised to receive either 1000 microg of self-administered vaginal misoprostol or self-administered vaginal placebo on the evening before day-care operative hysteroscopy. All women had administered a 25-microg vaginal estradiol tablet daily for 14 days prior to the operation. PRIMARY OUTCOME: preoperative cervical dilatation at hysteroscopy. SECONDARY OUTCOMES: difference in dilatation at recruitment and before hysteroscopy, number of women who achieved a preoperative cervical dilatation of 5 mm or more, acceptability, complications and adverse effects. RESULTS: The mean cervical dilatation was 5.7 mm (SD, 1.6 mm) in the misoprostol group and 4.7 mm (SD, 1.5 mm) in the placebo group, the mean difference in cervical dilatation being 1.0 mm (95% CI, 0.2-1.7 mm). Self-administered vaginal misoprostol of 1000 microg at home on the evening before day-care hysteroscopy is safe and highly acceptable, although a small proportion of women experienced lower abdominal pain. CONCLUSIONS: One thousand micrograms of self-administered vaginal misoprostol, 12 hours prior to day-care hysteroscopy, after 14 days of pretreatment with vaginal estradiol, has a significant cervical ripening effect compared with placebo in postmenopausal women.

Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design.

OBJECTIVE: To compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoperative cervical ripening in both premenopausal and postmenopausal women before operative hysteroscopy. DESIGN: Two separate but identical parallel, randomised, double-blind, placebo-controlled sequential trials, one in premenopausal women and one in postmenopausal women. The boundaries for the sequential trials were calculated on the primary outcomes of a difference of cervical dilatation > or = 1 mm, with the assumption of a type 1 error of 0.05 and a power of 0.95. SETTING: Norwegian university teaching hospital. SAMPLE: Eighty-six women referred to outpatient operative hysteroscopy. METHODS: The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before outpatient operative hysteroscopy. MAIN OUTCOME MEASURES: Preoperative cervical dilatation (primary outcome), number of women who achieve a preoperative cervical dilatation > or = 5 mm, acceptability, complications and adverse effects (secondary outcomes). RESULTS: In premenopausal women, the mean cervical dilatation was 6.4 mm (SD 2.4) in the misoprostol group and 4.8 mm (SD 2.0) in the placebo group, the mean difference in cervical dilatation being 1.6 mm (95% CI 0.5-2.7). Among the premenopausal women receiving misoprostol, 88% achieved a cervical dilatation of > or = 5 mm compared with 65% in the placebo group. Twelve percent of the women who received misoprostol were difficult to dilate compared with 32% who received placebo. Dilatation was also quicker in the misoprostol group. Misoprostol had no effect on cervical ripening in postmenopausal women compared with placebo, and 43% of the women were difficult to dilate. The trials were terminated after analysis of 21 postmenopausal women and 65 premenopausal women after reaching a conclusion on the primary outcome with only 28% of the number of women needed in a fixed sample size trial. Three of 45 women who received misoprostol experienced severe lower abdominal pain, and there was an increased occurrence of light preoperative bleeding in the misoprostol group. Most women did not experience misoprostol-related adverse effects. The majority (83% of premenopausal and 76% of postmenopausal women) found self-administered vaginal misoprostol at home to be acceptable. There were two serious complications in the premenopausal misoprostol group: uterine perforation with subsequent peritonitis and heavy postoperative bleeding requiring blood transfusion, but these were not judged to be misoprostol related. Complications were otherwise comparatively minor and distributed equally between the two dosage groups. CONCLUSIONS: One thousand micrograms of self-administered vaginal misoprostol 12 hours prior to operative hysteroscopy has a significant cervical ripening effect compared with placebo in premenopausal but not in postmenopausal women. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before operative hysteroscopy is safe and highly acceptable, although a small proportion of women experienced severe lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is very cheap and easy to use.

Does self-administered vaginal misoprostol result in cervical ripening in postmenopausal women after 14 days of pre-treatment with estradiol? Trial protocol for a randomised, placebo-controlled sequential trial.

OBJECTIVE: To compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after pre-treatment with estradiol vaginal tablets at home in postmenopausal women prior to day-care operative hysteroscopy. DESIGN: Randomised double-blind placebo-controlled sequential trial. The boundaries for the sequential trial were calculated on the primary outcomes of a difference of cervical dilatation > or = 1 millimetre, with the assumption of a type 1 error of 0.05 and a power of 0.95. SETTING: Norwegian university teaching hospital. POPULATION: Postmenopausal women referred for day-care operative hysteroscopy. METHODS: The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before day-care operative hysteroscopy. All women had administered a 25-microgram vaginal estradiol tablet daily for 14 days prior to the operation. MAIN OUTCOME MEASURES: Preoperative cervical dilatation (difference between misoprostol and placebo group, primary outcome), difference in dilatation before and after administration of misoprostol or placebo, number of women who achieve a preoperative cervical dilatation > or = 5 millimetres, acceptability, complications and side effects (secondary outcomes). RESULTS: Intra-operative findings and distribution of cervical dilatation in the two treatment groups: values are given as median (range) or n (%). Difference in dilatation before and after administration of misoprostol and placebo: values are given as median (range) of intraindividual differences. Percentage of women who achieve a cervical dilatation of > or = 5 mm, percentage of women who were difficult to dilate. Acceptability in the two treatment groups: values are given as completely acceptable n (%), fairly acceptable n (%), fairly unacceptable n (%), completely unacceptable n (%). Pain in the two treatment groups: pain was measured with a visual analogue scale ranging from 0 (no pain) to 10 (unbearable pain): values are given as median (range). Occurrence of side effects in the two treatment groups. Values are given as n (%). Complications given as n (%). FUNDING SOURCES: No pharmaceutical company was involved in this study. A research grant from the regional research board of Northern Norway has been awarded to finance Dr K.S.O.'s leave from Hammerfest hospital as well as travel expenses between Hammerfest and Oslo, and research courses. The research grant from Prof B.I.N. (Helse Øst) funded the purchase of estradiol tablets, the manufacturing costs of misoprostol and placebo capsules from the hospital pharmacy, as well as the costs incurred for preparing the randomisation schedule and distribution of containers containing capsules to hospital. Prof B.I.N.'s research grant also funded insurance for the study participants. CONCLUSIONS: Estimated completion date 31 December 2008.

Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design.

OBJECTIVE: To compare the impact of 1000-microgram self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoperative cervical ripening in both premenopausal and postmenopausal women prior to outpatient resectoscopy. DESIGN: Randomised, double-blind, placebo-controlled sequential trial. SETTING: Norwegian university teaching hospital. SAMPLE: Premenopausal and postmenopausal women referred to outpatient resectoscopy. METHODS: The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before outpatient resectoscopy. MAIN OUTCOME MEASURES: Preoperative cervical dilatation, acceptability and complications. RESULTS: (a) Intraoperative findings and distribution of cervical dilatation in the two treatment groups. Values are given as median (range) or n (%). (b) Acceptability in the two treatment groups. Values are given as completely acceptable, n (%); fairly acceptable, n (%); fairly unacceptable, n (%) and completely unacceptable, n (%). (c) Pain in the two treatment groups. Pain was measured with a visual analogue scale score, scale ranges from 0 (no pain) to 10 (unbearable pain). Values are given as median (range). (d) Occurrence of adverse effects in the two treatment groups. Values are given as n (%). (e) Complications, given as n (%).

Action of beta-adrenoceptor antagonists on the response to isoprenaline in the oestrogen dominated rabbit uterus.

1. Log dose-response curves to isoprenaline from spontaneously contracting muscle strips from rabbit uterus have been obtained. The effects of the alpha-adrenoceptor antagonists phentolamine and phenoxybenzamine, the beta- adrenoceptor antagonists propranolol and practolol, and (+)-propranolol on the log dose-response curves were studied. 2. Phentolamine 5.3 times 10- minus 7 M had a stimulating effect on the muscle strips, moving the log dose-response curve of isoprenaline to the right. Phenoxybenzamine 2.9 times 10- minus 5 M had no effect on the curves. 3. Propranolol 3.4 times 10- minus 6 M had no effect on the curves from circular muscle strips, with either phentolamine 5.4 times 10- minus 7 M or with phenoxybenzamine 2.9 times 10- minus 5 M as alpha-blocker. The curves from the longitudinal muscle strips were shifted somewhat to the right, the same shift, however, being obtained with (+)-propranolol 3.4 times 10- minus 6 M. 4. Practolol 3.8 times 10- minus 6, 3.8 times 10- minus 5 and 3.8 times 10- minus 4 M was without effect on the curves, either in the circular or in the longitudinal strips. 5. It is concluded that neither propranolol at 3.4 times 10- minus 6 M nor practolol act as beta-adrenoceptor antagonists in oestrogen dominated rabbit uterus. In all other tissues investigated, propranolol or practolol block the effect of isoprenaline. Whether the effect of isoprenaline in this tissue may be termed a beta-effect, is then a question of definition. In addition there is no evidence for any extraneuronal uptake mechanisms for isoprenaline. 6. Variations in sensitivity to beta-stimulation with the time of the year were observed, the sensitivity being greatest in the winter and lowest in the summer.

Role of cyclic adenosine 3',5'-monophosphate in the isoprenaline-induced relaxation of the oestrogen dominated rabbit uterus.

1. The role of cyclic adenosine 3',5'-monophosphate (cyclic AMP) in the relaxation produced by isoprenaline in muscle strips from the oestrogen dominated rabbit uterus has been investigated. 2. Isoprenaline 2 times 10- minus 8 M produced an inhibition of the mechanical activity but no increase in cyclic AMP. Isoprenaline 2 times 10- minus 6 M produced both inhibition of mechanical activity and increase in cyclic AMP. 3. The increase in cyclic AMP, but not the inhibition of mechanical activity, was blocked by propranolol 3.4 X 10-MINUS 6 M. 4. Dibutyryl-ccylic AMP produced a relaxation which mimicked that produced by isoprenaline, in that the longitudinal strips were more sensitive than the circular ones. 5. It is concluded that cyclic AMP may be a mediator of the beta-adrenergic effect in the oestrogen dominated rabbit myometrium. However, it seems not to be an obligatory link between stimulation of beta-adrenoceptors and relaxation. Other mechanisms may also exist.

Changing paternity and time since last pregnancy; the impact on pre-eclampsia risk. A study of 547 238 women with and without previous pre-eclampsia.

BACKGROUND: Long time interval between pregnancies has been found to increase the risk of pre-eclampsia in second pregnancy. Our aim was to investigate whether this effect is influenced by a history of pre-eclampsia or a change in paternity. METHODS: We studied 547 238 women with a first and second pregnancy registered in the Medical Birth Registry of Norway, 1967-1998. The relative risk of pre-eclampsia in the second delivery according to time interval between deliveries was estimated as odds ratios (OR) in logistic regression models, controlling for changing paternity, maternal age and calendar time period in women with and without previous pre-eclampsia. RESULTS: A change of paternity for the second pregnancy was associated with a reduced risk of pre-eclampsia after controlling for the time since first delivery (adjusted OR = 0.80, 95% CI : 0.72-0.90), but the interaction between change in paternity and time between deliveries was significant only for women with no previous pre-eclampsia. The interaction between history of pre-eclampsia and time interval between the two deliveries was highly significant, and for women with no previous pre-eclampsia the risk of pre-eclampsia in second pregnancy increased with increasing time interval (for intervals longer than 15 years the adjusted OR was 2.11, 95% CI : 1.75-2.53). For women with previous pre-eclampsia the risk tended to decrease with increasing time interval between deliveries. CONCLUSIONS: The protective impact of a new father for the second pregnancy challenges the hypothesis of primipaternity, and implies that the increase in pre-eclampsia risk ascribed to new father by others is due to insufficient control for interpregnancy interval.

Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive unit associated with understaffing, overcrowding and mixing of patients.

Over the period May-June 1999, an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) was registered in eight newborns in a neonatal intensive care unit (NICU) at the Department of Pediatrics, Ullevål University Hospital (UUH) in Oslo. Seven were infected or colonized with an indistinguishable strain, detected at the NICU, and one patient with a slightly different PFGE type (i.e. a subtype) was registered at the outpatient clinic. The MRSA strains resembled the sensitive, inbred 'Norwegian type' described four years earlier at UUH, showing a relatively low and heterogenic methicillin resistance (MIC 12-96 mg/L), and susceptibility to most other anti-staphylococcal agents. Before and during the outbreak, there was high activity, understaffing, overcrowding and a mix of patients; 42% of the staff were relatively untrained, and up to 62% (during weekends) were extra nursing staff, partly from other Scandinavian countries. All cases were isolated (air and contact isolation), and all other patients and personnel were treated as being exposed to MRSA (isolated from other departments) until the last patient had been identified, disinfection of all rooms was complete, and all screening samples from staff and other patients were negative. The NICU and the delivery suite were closed for one week for disinfection and screening. The outbreak ended after 34 days. Since then, two years later, no further cases have been detected in the NICU or the delivery suite.

Changes in skin blood flow and body temperatures during climacteric hot flushes.

Blood velocity changes in the radial, temporal and lateral thoracic arteries have been measured quantitatively during climacteric hot flushes by means of an ultrasonic velocity meter. In the radial artery the median increase in velocity was 6 times greater than the basal velocity (range 4-10); in both the temporal and the lateral thoracic arteries the median increase was 1.5 (1.5-3). Simultaneous temperature measurements showed a fairly high increase in finger temperatures. An initial increase in temperature on the forehead was followed by a decrease. The core temperature measured on the tympanic membrane decreased. The pattern of blood velocity which increases during hot flushes, is identical to the pattern seen when someone is transferred to an uncomfortably high temperature. This similarity points to the hot flush as a time in which a heat loss occurs. As temperature measurements show no accumulation of heat prior to the flushes, it is reasonable to assume that hot flushes are the result of a central disorder of temperature regulation.

Which local anesthetic is best suited for paracervical blocks?

In a prospective, randomized study the duration and effectiveness of four different regimens of PCB were studied: Bupivacaine both with and without adrenaline, and chloroprocaine with and without adrenaline. The pain relief was immediate and almost complete in most patients in all four treatment groups. The duration of the effect of bupivacaine was the same whether adrenaline was added or not. The labors were significantly prolonged with adrenaline, however. The duration of the effect of chloroprocaine was substantially shorter than bupivacaine, but with this short-lasting anesthetic the duration was prolonged by the addition of adrenaline. It is concluded that bupivacaine without the addition of adrenaline is the drug of choice for PCB.

Induced abortion by the suction method. An analysis of complication rates.

3036 induced abortions from the years 1977, 1978, 1979 and 1980 were analysed. They included all abortions performed with the suction method at Akershus Central Hospital, except for those done in combination with a sterilization procedure. The main determinants of complication rates were parity, period of gestation and, for minor complications, whether the patient was treated as an in-patient or an out-patient. Women who had not previously given birth had a higher complication rate than parous women. Complication rates were lowest during weeks 7-10. Out-patients had fewer readmissions, repeat curettages, and infections, than in-patients. There was a tendency to cause a larger dilatation of the cervical canal than was technically necessary.

PIP: Complication rates among all 3036 patients who had pregnancies terminated by suction techniques, under general anesthesia, at Akershus Central Hospital in Norway between 1977-80 were analyzed. Abortions performed in conjuction with sterilizations were not included in the study. Almost all of the abortions were performed during the 1st trimester. A few early 2nd trimester suction abortions were included. Information for the analysis was obtained from medical records. Registered complication variables included prolonged hospital readmissions, perforations, cervical laceratios, blood transfusions, laparotomies, repeat curettages, temperature rises of 38 degrees celsius or more, antibiotic treatments, and infections with or without a palpable pelvic mass. 29.3% of the patients had outpatient sterilizations, and 70.7% had inpatient sterilizations. The only criteria used to select inpatients were age and parity. Outpatient sterilizations were performed by the same medical teams and in the same operating theater as the inpatient sterilizations. Complications were registered for 7.1% of the patients. Complication rates varied by parity, outpatient and inpatient status, and gestational length. The complication rate was 9.2% for nulliparous women, and 5.3% for parous women. The difference was significant (p0.001). Nulliparous women has a higher number of registered temperature rises, antibotic treatments, and infections without palpable pelvic masses than parous women. When only hospitalized nulliparous and parous women were compared the difference in complication rates was smaller, but still significant (p0.03). Hospitalized patients had higher complication rates for minor complications than inpatients, and similar rates for major complications. Only parous patients were compared in regard to inpatient and outpatient differences since there were very few nulliparous outpatients. The complication rate for the 798 parous outpatients was 3.6%, and for the 872 parous inpatients the rate was 6.9%. The difference was significant (p0.001). Even when the length of gestation was controlled, the parous inpatients still had a significantly higher rate of complications than the parous outpatients. Perhaps hospitalized patients were more likely to seek medical attention for minor complaints than outpatients, or perhaps hospitalized patients were more likely to acquire infections than oupatients. In regard to gestation length, the lowest complication rates were observed for abortions performed during the 7th to 10th gestation weeks. After 10 weeks gestation, complication rates tended to increase and the highest rates were observed during the 14 gestation week. Rates at 6 week gestation were also high, especially among nulliparous women. The rate of retained tissue was higher during the 6th week of gestation than during any other week.

Fetal heart rate patterns preceding intrauterine death during labor.

A fetus of 37 weeks died in labor during recording of the fetal heart rate patterns. Five hours earlier a reactive non-stress test had been obtained. No other cause of death than a tight nuchal cord was found.

[Contraception, abortion and sexually transmitted diseases]. / Prevensjon, abort og seksuelt overførbare sykdommer.

PIP: Contraceptives that protect against pregnancy tend to offer the least protection against sexually transmitted diseases (STDs), particularly needed by young people who change partners frequently. Oral contraceptive (OCs) protect best against pregnancy and salpingitis, but they do not protect against infections of the cervix; thus, there is a higher incidence of Chlamydia trachomatis and Neisseria gonorrhea among OC users. The IUD is also very effective, but there is an elevated risk of infections during the first 20 days after fitting, as bacteria may move up to the uterus from the cervical canal during insertion. The effectiveness of the condom depends on the users, and studies show that when used consistently it provides significant protection against STDs. The diaphragm also protects against STDs, but it is insignificant from a quantitative point of view. In Norway, in 1977, 30% of 18-19 year old women used OCs, and 21% used IUDs. In contrast, in 1988, 65% of 20-year old women used OCs and 5% used IUDs. Condom use remains unchanged. The rate of abortion has not changed since 1977; it is highest among women aged 18-29 (about 30/1000 women per year), although safe contraception use has increased from 50% to 70% among women aged 18-19. Free-service health clinics with evening hours have met a clear need for counseling in the past 20 years. In the 1970s the demand was high for induced abortion, safe contraceptives, and IUD insertion. Later, OCs had lower hormone content and fewer site effects, and their dispensation became more widespread among general practitioners. Nowadays a large proportion of women seek advice on STDs, and 65% of them attend because the consultation is free. It is an important task of these clinics to provide guidance, examination, and treatment to high-risk people to help them avoid STDs and unwanted pregnancy.^ieng

[Oral contraceptives with lower hormonal dosis]. / P-piller med lavere hormondose

PIP: A new combination preparation, Microgynon, consists of .15 mg D'L-norgestrel and .03 mg ethinyl estradiol. This dosage of estrogen is much lower than the .05 mg maximum set on combination preparations in Norway. Microgynon has a Pearl index of .12-.34 pregnancies/100 woman-years. Low estrogen dosage causes more spotting and breakthrough bleeding (1-3%), but should decrease toehr side effects markedly, especially thromboembolic disorders.^ieng

[New preparations for treatment of climacterial disorders]. / Nye preparater til behandling av klimakterielle plager.

PIP: 3 sequential preparations have been introduced in Norway to treat women with menopausal disorders: Cyclabil, Trisekvens, and Trisekvens forte. All 3 contain natural estrogens; gestagens are used to reduce the risk of endometrial hyperplasia. In treating menopausal women with such preparations, those with the lowest dosages of hormones should be tried first. If spotting or irregular bleeding occurs, higher dosages should be used. Otherwise the same guidelines should be followed as for prescribing other similar hormone preparations.^ieng

Duration of labor. An analysis of influencing factors.

9703 labors at Akershus Central Hospital during the period January 1979 to January 1984 were analysed to see which factors influenced the duration of labor. Median duration was 8.2 h for nulliparas, 5.3 h for multiparas. Parity greater than one had no influence on duration. Induced labors were 1.9 h (nulliparas) and 1.4 h (multiparas) shorter than those with spontaneous onset. Stepwise linear regression showed that duration of labor was positively correlated with the weight of the infant, duration of pregnancy, weight gain and prepregnant weight. It was negatively correlated with mother's height. Mother's age did not influence duration of labor. Occiput posterior presentation and extensions of the head prolonged labor in nulliparas, but not in multiparas, while breech presentation had no influence.

The use of transcutaneous nerve stimulation for pain relief during labor. A controlled clinical study.

Seventy parturient women were randomized into two groups, one receiving transcutaneous nerve stimulation, the other mock stimulation with an identical looking apparatus. The patients' assessment of pain relief and the use of analgesics during labor were recorded. There was no difference between the two groups in the degree of pain relief. There was no reduction in the need for analgesics which could be ascribed to the use of nerve stimulation. The use of analgesics in each patient was correlated to the duration of labor.

[Contraception and abortions]. / Prevensjon og aborter.

PIP: A Norwegian investigation from 1987-88 indicated that 25% of the women who were interviewed at a maternity ward stated that their pregnancy had not been planned. That means that 15,000 of the annual total of 60,000 births in Norway are not planned. This is roughly the same figure as the number of abortions (14,000 per year). 93% of women who carry out an unplanned pregnancy have not used contraception according to a 1991 study, but even a 1999 study showed that half of women seeking abortion had not used contraception. A 1994 investigation revealed that only 8% of women in the 20-24 age group did not use contraception and 5% used unsafe methods (coitus interruptus, safe periods, spermicides), while the rest used effective contraceptives (60% used OCs). There are 144,000 women in this age group in Norway, of which 12,000 give birth within a year. In theory the remaining 132,000 would have 2600 pregnancies. In 1996 there were 3883 abortions in this same age group; half of them would originate from that 8% of women who did not use contraception and the other half owing to contraceptive failure. Two studies among students in Oslo in 1997 demonstrated that even if a young woman started using OCs it did not mean that she would continue using them. A number of them discontinued because their relationship with their partner ended, they neglected to visit their doctor, forgot to take their pills, or thought that they could not get pregnant right after stopping OC use.^ieng

The use of isoxsuprine in essential dysmenorrhea. A controlled clinical study.

The "uterus-specific" beta-adrenoceptor stimulator isoxsuprine was used for the treatment of primary dysmenorrhea in a double-blind controlled clinical study. No significant beneficial effect of the drug was evident.

Monochorionic monoamniotic twins--the most precarious of twin pregnancies.

Monochorionic monoamniotic twins have a high perinatal mortality rate. Death usually occurs before 24 weeks' gestation, mainly because of cord entanglement, prematurity, congenital anomalies or twin-to-twin transfusion. These possibilities should be taken into account when twin pregnancies are detected at the ultrasound screening between 17 and 20 weeks' pregnancy. We report here a case where monochorionic monoamniotic twins were born at 34 weeks, with massive cord entanglement and we describe the antenatal care at our clinic.