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Webster, M. A.; Linder‐Pelz, S.; Martins, J.; Greenwell, J.
doi: 10.1111/j.1479-828X.1988.tb01602.xpmid: 3214384
EDITORIAL COMMENT: I commend the aim of the paper, that of assessing the ability of an obstetric risk score protocol to predict low risk pregnancies thus enabling patients to attend alternative birth centres. It is salutory to note that this retrospective study was not selective in predicting low neonatal morbidity for patients confined in birth centres. If a risk‐scoring protocol could be devised which would adequately predict low perinatal, intrapartum and neonatal risks, then births at alternative birth centres could be recommended on more scientific grounds than is possible at this time. Data predictive of the need for birth centre beds and of the need for support services for birth centres could be obtained. This might reduce the load on labour ward beds for level II and III patients and could assist the organization of obstetric services in the community. Summary: A retrospective study using an obstetric risk score protocol was applied to a stratified sequential sample of 843 singleton livebirths, occurring in the Royal Hospital for Women, Sydney, over a 12‐month period (March, 1985‐February, 1986). Data collection included 53 prenatal factors, 41 intrapartum factors and 37 neonatal factors. The study was comprised of 346 women admitted to the hospital birth centre and 497 women admitted to labour ward. In labour ward admitted women there was a significant association between high prenatal scores, high intrapartum scores and high neonatal morbidity scores. Women admitted to the birth centre were subjected to a screening procedure which resulted in low prenatal and relatively low intrapartum risk scores. However, neonatal morbidity scores were similar for both groups. The risk scoring protocol used in this study requires further revision to allow the adequate selection of low risk women delivering infants with a low risk of neonatal morbidity in a low risk obstetric setting.
Nicolas, T.; Nicholls, E. M.; Robertson, R. D.; Bonifacio, M.; Sinosich, M.; Field, B.; Saunders, D. M.
doi: 10.1111/j.1479-828X.1988.tb01603.xpmid: 2463829
EDITORIAL COMMENT: In this careful study, 6 of 7 mothers carrying fetuses with neural tube defects were found to have raised serum alphafetoprotein levels (more than 2.5 multiples of the median) in the second trimester, out of 3,182 pregnancies tested. In the other 65 patients with elevated AFP levels there were 4 fetuses with major malformations and many with other important clinical complications. All of these fetal malformations were identifiable by ultrasonography. This paper does not consider the association between low AFP levels and Down syndrome, although this is another reason why screening maternal serum AFP levels could be advocated, since it can offer a detection rate of 28% by selecting less than 3% of unaffected pregnancies for amniocentesis, a better yield than using maternal age alone (Cuckle HS, Wald NJ, Thompson SG. Estimating a woman's risk of having a pregnancy associated with Down's syndrome using her age and serum alphafetoprotein level. Br J Obstet Gynaecol 1987; 94: 387 ‐ 402 — this review concluded that screening for Down syndrome using both maternal age and serum AFP is more efficient than using age alone and that, where antenatal serum AFP screening programmes are in progress, there is no justification for not using both). The authors leave it to the reader to ponder whether or not maternal serum AFP screening should be offered to all patients. At present it is not performed routinely in any of the teaching hospitals in Melbourne. Should it be? If so, must the patient be counselled regarding the reasons for screening before being offered the test? Is the test less important now that ultrasonography performed at 16 ‐ 18 weeks' gestation can identify all neural tube defects and many other major malformations — but not Down syndrome, regardless of the fact that several ultra‐sonographic stigmata of Down syndrome have been reported. At present ultrasonography is performed in 60 ‐ 80% of pregnancies and a structured referral screening programme for fetal malformations is being introduced in some hospitals. Nonetheless the benefits of routine ultrasonography remain in order of merit: (i) determination of gestational age (ii) diagnosis of multiple pregnancy (iii) siting of the placenta and (iv) recognition of fetal anomalies. It is estimated that routine screening will detect a major fetal malformation in 0.3% of low risk pregnancies i.e. approximately 90% of fetuses with major malformations will escape identification by such a programme. A recent issue of this journal (1987; 27:92) enumerated the antenatal investigations currently judged to be ‘essential’ or ‘recommended’. The case for inclusion of hepatitis B antigen and group B beta haemolytic streptococcus testing has been reemphasized (Cruz AC, Frentzen BH, Belinke M. Hepatitis B: A case for prenatal screening of all patients. Am J Obstet Gynecol 1987; 156: 1180–1183; Morales WJ, him DV, Walsh AF. Prevention of neonatal group B streptococcal sepsis by the use of a rapid screening test and selective intrapartum chemoprophylaxis. Am J Obstet Gynecol 1986; 155:980–983). Should maternal serum alphafetoprotein screening be added to the list of antenatal tests? Summary: A retrospective study covering the period from January 1, 1980 up to June 30, 1982 was conducted, producing the first definitive normal range for maternal serum alphafetoprotein from the Royal North Shore Hospital in Sydney. The normal range established is based on and applicable to the pregnant women tested at this NSW laboratory. Maternal serum alphafetoprotein levels had been determined by radioimmu‐noassay for 3,182 pregnancies between 13 and 20 weeks' gestation. Five anence‐phalics and 2 open spina bifidas were noted in the study. Only one of these abnormalities (spina bifida) was associated with maternal serum alphafetoprotein levels within the normal range, the remainder all having elevated levels. Low false positive and false negative rates of 1.16% and 0.03% respectively were obtained in this study.
doi: 10.1111/j.1479-828X.1988.tb01604.xpmid: 3214378
Summary: In an attempt to overcome some of the undesirable side‐effects and sequelae traditionally associated with epidural analgesia, various mixtures containing bupivacaine and pethidine have been examined during labour. Preliminary investigations suggested that a mixture containing bupivacaine 0.125% was the most promising combination, and accordingly a prospective survey was conducted in order to assess this mixture further; 100 mothers were included in the survey and clinical assessment included analgesic efficacy, side‐effects, degree of mobility, obstetric outcome and patient satisfaction.
Doyle, L. W.; Hughes, C. D.; Guaran, R.L.; Quinn, M. A.; Kitchen, W. H.
doi: 10.1111/j.1479-828X.1988.tb01605.xpmid: 3214379
EDITORIAL COMMENT: This paper concludes that the vaginal route is appropriate, in terms of perinatal mortality and immediate morbidity, for the delivery of approximately 80% of twins born before 33 weeks' gestation. The trend towards Caesarean section in multiple pregnancy should be scrutinized as for singleton pregnancies. Falling perinatal mortality rates associated with increased Caesarean section rates do not prove a cause and effect relationship. The following statistics for multiple pregnancy at a State and Hospital level are quoted for perspective (tables 1A and IB). At the Mercy Maternity Hospital the Caesarean section rate for multiple pregnancy (triplets and quadruplets included) has quadrupled to 32% in 16 years, during which time the overall Caesarean section rate increased from 9 to 16%; this was associated with a modest (25%) improvement in the perinatal mortality rate. Comparable figures for the State of Victoria are not available, but from 1976 ‐ 1985, the total perinatal mortality rate has fallen approximately 30%, and multiple pregnancy continues to account for about 10% of perinatal deaths. In 1985, in Victoria, 2.3% of all infants (1,422 of 61,176) were bom from multiple pregnancies and they accounted for 8.2% (61 of 741) of all perinatal deaths in infants born with birth‐weight of 500g or above. Summary: At one high‐risk perinatal centre over a 9‐year period, 83.1% (103/124) sets of liveborn twins with gestational ages less than 33 weeks were delivered vaginally. Mortality in vaginal births was 26.7% (55/206), almost double that of Caesarean births of 14.3% (6/42), a non‐significant difference. When gestational age discrepancies were corrected, however, the trend favouring survival of Caesarean births disappeared. Furthermore, there were no significant associations between mode of delivery and the condition of the infants at birth, or the presence of respiratory distress in the nursery. Because Caesarean section carries substantial risks for the mother our practice of predominantly vaginal deliveries for preterm twins should continue.
Rachagan, S.P.; Sivanesaratnam, V.; Kok, K.P.; Raman, S.
doi: 10.1111/j.1479-828X.1988.tb01606.xpmid: 3214380
EDITORIAL COMMENT: This paper carries the important messages about acute inversion of the uterus. Firstly do not pull on the umbilical cord unless the uterine fundus is contracted and palpable — it is the abdominal, not the cord‐pulling hand, that provides the ‘control’ in delivery of the placenta by controlled cord traction. Likewise the traction should not be excessive — if the placenta does not quickly deliver, pass a catheter, and the miracle occurs (and so it seems, so prompt is the response, even though it is an everyday experience), the placenta no longer being imprisoned either in uterine fundus, or lower segment by cervical oxytocin‐induced contraction. The second message is to replace the inverted uterus as soon as it is diagnosed and before removing the placenta if it is still attached — this gives a firmer ‘fundus' for the fist to push against after general anaesthesia relaxes the uterus for correction of the inversion. With incomplete inversion (11 of the 15 cases in this report) the placenta has usually been delivered by strong (? too strong) controlled cord traction and the dimple in the still palpable uterine fundus has not been noted — the inversion is felt in the upper vagina like a large broad‐based endocervical polyp when vaginal examination is performed because of postpartum haemorrhage. In the editor's experience of one such case the inversion was rapidly manually corrected once the uterus was relaxed by halothane, with immediate cessation of haemorrhage. Summary: Over a 17‐year period, 15 patients with acute puerperal inversion of the uterus were managed at the University Hospital, Kuala Lumpur, an incidence of 1 in 4,836 delveries. Injudicious traction on the umbilical cord before the uterus was well contracted, was probably the most important causative factor. Haemorrhage was more severe when removal of the placenta was done prior to correction of the inversion. Either the hydrostatic method or manual replacement were used but more often a combination of both techniques was found necessary. With careful management of the third stage of labour, this complication can be avoided.
doi: 10.1111/j.1479-828X.1988.tb01607.xpmid: 3063248
Summary: Amniotic fluid embolism (AFE) is a dramatic, rare and frequently lethal complication of pregnancy. Perusal of the National Health and Medical Research Council reports on Maternal Deaths in the Commonwealth of Australia for the years 1964–1984 (1–7) shows that there have been 1,193 maternal deaths in this 21‐year period, of which 54 (4.5%) were due to AFE. This paper presents data regarding these deaths and also describes 2 cases of AFE which occurred at Caesarean section performed for placenta praevia, one of which was lethal.
doi: 10.1111/j.1479-828X.1988.tb01608.xpmid: 2975168
EDITORIAL COMMENT: In 1982–1984 the maternal mortality rate in Australia was 13.16 per 100,000 confinements; of the 94 deaths 42 were directly attributable to pregnancy and childbirth, 25 were indirect and 25 were from incidental causes. There was only 1 death associated with abortion, the numbers in the 6 previous triennia beginning 1964–1966 being 45, 25, 25, 2, 5 and 3. These figures are provided for the reader to contrast with those presented in this paper from Burma which considers, without equivocation, the clinical details of 44 maternal deaths in one major hospital, 1978–1982. Abortions accounted for 50% of the deaths. Excluding these the maternal mortality rate was 98 per 100,000 maternities. The author has firm views on proper definitions of parity, abortion and maternal mortality and these are stated. This paper has been published with minimal editorial interference — it was considered that readers would appreciate the unabridged case histories, especially that of the death resulting from falling astride a bamboo spike. Summary: The maternal deaths between the years 1978 and 1982 were studied. There were 22,468 maternities and 10,623 abortion patients treated at the hospital. There were 44 maternal deaths; 22 due to abortion and 22 due to other causes. The maternal mortality rate including abortions was 1.33 per 1,000 maternities and that excluding abortions 0.98 per 1,000. The abortion was 2.0 per 1,000 abortions treated at the hospital. To reduce maternal mortality, ways and means should be found to reduce the abortion deaths, most of which were avoidable.
Ei‐Shafei, Affaf Mohammed; Sandhu, Amarjit Kaur; Dhaliwal, Jagajeevan Kaur
doi: 10.1111/j.1479-828X.1988.tb01609.xpmid: 3214381
EDITORIAL COMMENT: This paper reports an analysis of 37 maternal deaths in a predominantly Arab population. Bahrain has excellent obstetric hospitals but not all patients avail themselves of these facilities — a situation not unknown in so called developed countries! Sickle cell disease has a maternal mortality rate of about 2% in Bahrain and accounted for 12 of the 37 deaths; the information regarding these cases should interest readers who have little experience of this important disease. The authors set high standards for themselves in their assessment of whether the cases considered had avoidable factors that might have minimized the risk of death. The maternal mortality rate was 33.9 per 100,000 livebirths; this figure is about double that in Australia, although it should be noted that incidental deaths (e.g. accidents, suicides, murders, malignancies), which account for about 30% of maternal deaths in Australia, were not considered. The authors' task was not made easier by the fact that autopsies were not performed because of the prevailing religious beliefs. Summary: The maternal mortality in Bahrain during the 10‐year period, 1977 ‐ 1986, was 33.9 per 100,000 livebirths; the second 5‐year period showed a significant reduction (26.9) compared to the first 5‐year period (42.3). Haemorrhage, pulmonary embolism, hypertensive diseases of pregnancy and infection were the main causes of maternal mortality. Sickle cell disease was found to be an underlying cause in about one third of the maternal deaths. Avoidable factors were present in 38% of the cases, the majority being due to the failure of the patients to seek medical care or follow medical advice. Health education, premarital counselling and family planning were identified as significant factors in reducing the maternal mortality rate.
Kornman, L.; Jacobs, V.; Hodgson, R. P.; Godfrey, J.; Dunlevy, L.; Tyler, J. P. P.; Baird, P. J.; Hudson, C. N.
doi: 10.1111/j.1479-828X.1988.tb01610.xpmid: 3214382
Summary: This study was designed to derive the predictive value of C‐reactive protein (CRP) in peripheral venous serum of patients admitted to hospital with suspected premature rupture of the membranes (PROM). CRP was assayed by each of 4 separate methods and the results have been compared for accuracy and practical value with respect to clinical outcome and the histopathology of the placenta. Of the 4 techniques used only the latex test had characteristics suitable for a diagnostic screen. While the results were only semiquantitative, when comparisons were made to other techniques no significant change in clinical diagnosis would have been made. The results have confirmed that chorioamnionitis and preterm labour are often associated, but in some instances the extent of inflammatory infiltration was greater than might have been expected from the short time interval between documented membrane rupture and delivery. Thus it may be speculated that some cases of PROM are secondary to, rather than causative of, infection. Finally it is suggested that a controlled therapeutic trial of active intervention in those cases of PROM with elevated CRP in the absence of other clinical parameters suggestive of intra‐uterine infection should be undertaken.
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