Clomiphene Citrate and Pregnancy Outcome

Summary: Data from Australia and elsewhere have shown consistently that adverse perinatal outcomes such as preterm birth and perinatal mortality are more common in pregnancies resulting from assisted conception with IVF and GIFT than normally conceived pregnancies. Factors that may contribute to the excess of poor outcomes include maternal factors, the assisted conception procedures themselves and possibly the influence of drugs used to induce superovulation. This review examines the medical literature describing pregnancies following ovulation induction with one of the drugs used to induce superovulation, clomiphene citrate, and compares their outcomes with Australian IVF and GIFT pregnancy outcomes.
The review shows that whilst some studies have suggested higher rates of ectopic pregnancy, spontaneous abortion and congenital malformations in clomiphene citrate induced pregnancies, the findings are inconsistent and the data are flawed. There are only very poor data available on the incidence of preterm birth. Multiple pregnancy is a well-recognized adverse outcome of clomiphene citrate induced pregnancies. Attempts to improve perinatal outcomes of pregnancies following assisted conception will be helped by a better understanding of the relative contributions of maternal and treatment factors and further studies of pregnancy outcome after ovulation induction are needed.     

Fetal Arrhythmias: A 3-Year Experience*

Eight cases of fetal arrhythmia were seen over a 3-year period. Two had atrial and/or ventricular extrasystoles, 1 had complete atrioventricular block and 5 had tachyarrhythmias--3 supraventricular tachycardia, 1 atrial flutter and 1 ectopic atrial tachycardia. All had structurally normal hearts. Nonimmune hydrops fetalis was the initial presentation in 3 of the 5 cases with tachyarrhythmias. There were 2 deaths--a stillbirth and a neonatal death, while 2 others required neonatal intensive care. The 6 survivors have remained well and are now off treatment. The diagnosis, careful assessment and management of a fetal arrhythmia may lead to a successful outcome. The complexity of the problems experienced may warrant early referral to a tertiary centre where the overall management of the mother, fetus and neonate, may be undertaken.     

Prospective Study of the Quality of Survival of Infants with Critical Fetal Reserve Detected by Antenatal Cardiotocography

From 1981 to 1986 antenatal cardiotocographic monitoring was performed on 9,992 high-risk pregnancies selected from a total obstetrical population of 31,518 patients (31.7%). A critical fetal reserve pattern was detected in 89 patients (0.9%) whose pregnancies resulted in 68 surviving infants, 19 perinatal deaths and 2 sudden infant deaths. Since 47.4% of the infants who died in the perinatal period did so because of a related congenital malformation, such a defect should be excluded in the fetus with critical fetal reserve, by ultrasonography, before delivery (there is usually insufficient time for fetal karyotyping). Sixty-three (92.6%) of the surviving children were assessed at our Growth and Developmental Clinic and disabilities were detected in 16 (25.4%); however, the disability was major in only 5, including 2 children with Down syndrome. The quality of survival of infants born from pregnancies complicated by critical fetal reserve was satisfactory as 60 of 63 children (95.2%) had neither a major disability related to intrauterine hypoxia identified by the cardiotocographic pattern, or had one likely to significantly interfere with their quality of life. Our results suggest that pregnancies can be continued until the cardiotocographic pattern becomes critical in order to gain fetal maturity, without compromise to the fetal brain.     

The Prevalence and Timing of Obstetric Ultrasound in Victoria 1991–1992: a Population-based Study

Summary: A statewide study to ascertain the number of ultrasound scans received by women in pregnancy, to identify the proportion having a scan at 16 to 20 weeks' gestation, and to establish where the scan at 16 to 20 weeks was performed was carried out between January, 1991 and June, 1992 in Victoria. Additional data were collected by midwives and entered on the perinatal morbidity statistics form routinely completed for all births. Of 52,319 women providing responses, 3.1% did not have a scan. Of the remaining 96.9% who had a scan, 73.5% were scanned at 16 to 20 weeks'gestation. Predictors of not having a scan were maternal birthplace and higher parity: previous perinatal death(s), and attendance at nonteaching hospitals predicted the opposite. Predictors of being scanned were location of hospital (country), maternal birthplace, higher parity and maternal age (< 20 years). Substantial differences in frequency and timing were found between hospitals attended. Factors associated with the pattern of scanning are not readily explicable in terms of risk of malformations or women's choices.     

Fetus-placenta-newborn

OBJECTIVE: Our purpose was to determine whether third-trimester maternal serum α-fetoprotein predicts adverse perinatal outcome and whether use of both second- and third-trimester maternal serum α-fetoprotein enhances the positive predictive value for various abnormal outcomes.STUDY DESIGN: A cohort study with obstetric outcome assessed by chart analysis after delivery was performed at Regional Medical Center (Memphis, Tennessee), a hospital staffed by university-based physicians saving a large urban population with many indigent patients. A total of 650 women attending prenatal clincis in the above setting with a singleton pregnancy without a neural tube defect, contributing a maternal blood samples in both the second and third trimesters, and delivered in the above hospital participated. Various pregnancy outcomes were correlated with maternal serum α-fetoprotein levels in the second the third trimesters and in both.RESULTS: In the third trimester no significant associations were found between maternal serum α-fetoprotein elevations and pregnancy complications. In the second trimester elevation (≥2.0 multiples of the median) were, by contrast, significantly associated with preterm premature rupture of the membranes, preterm birth, and low birth weight. No association was found with certain other complications. When second-trimester data were grouped according to the types of complications occurring in individual women, only preterm premature rupture of the membrane proved statistically significant.CONCLUSIONS: Second-trimester but not third-trimester maternal serum α-fetoprotein is significantly elevated with preterm premature rupture of the membranes, preterm birth, and low birth weight; in this conhort study no association was found with preeclampsia, oligohydramnios, or polyhydramnios.     

Magnetic resonance imaging of defects in DeLancey's vaginal support levels I, II, and III

Objective: The air was to demonstrate paravaginal defects at DeLancey's levels I, II, and III by pelvic magnetic resonance imaging scanning in patients with symptomatic pelvice relaxation preoperatively and to demonstrate the disappearance of such defects after surgical repair.Study design: Magnetic resonance imaging scans of the pelvis were performed in 12 patients exhibiting cystourethroceles and symptomatic urinary stress incontinence.Results: Magnetic resonance imaging scans of bilateral fascial defects at the upper third of the vagina (level 1) were unremarkable except for the constant “chevron sign,” whereas the middle third of the vagina (level II) displayed the “saddlebags sign,” and the lower third of the vagina (level III) displayed the “mustache sign.” These defects disappeared postoperatively.Conclusions: Bilateral defects in the paracolpium at vaginal support levels I, II, and III may be found by magnetic resonance imaging scans before surgery in certain patients with symptomatic pelvic relaxation. Postoperative scans after paravaginal repair demonstrate the disappearance of these defects.     

Systemic candidiasis and pneumonia in preterm infants

Twenty-two preterm infants with systemic candidiasis are reported, of which seven cases were presumed to be antenatally acquired and 15 postnatally acquired. All except one were of very low birthweight. Fifteen infants had positive cultures of blood, cerebrospinal fluid or urine and seven had candida pneumonia only. Clinical features included general instability, respiratory deterioration and a necrotizing enterocolitis-like presentation. The incidence of leukocytosis, shift to the left, eosinophilia and thrombocytopenia were not different from those with bacterial infection. The diagnosis was made after death in two infants. In the remaining 20 infants, treatment was initiated between 5 and 97 days of age, with a median delay of 4 days after the first positive cultures were taken. Complications of amphotericin and 5-flucytosine therapy which developed in five infants resolved on cessation of treatment. The mortality rate was 18% and impairment rate among the 17 very low birthweight survivors was 18%. A high index of suspicion is required for systemic candidiasis, especially in infants of less than 1000 g birthweight. If recognized early, effective and safe antifungal therapy is possible with favourable short- and long-term outcome.     

Maternal determinants of birthweight in normal pregnancy

Partial and multiple regression analysis was performed to find out the correlation between birthweight and maternal anthropometric variables. Pearson regression analysis revealed significant dependence of birthweight on gestation of pregnancy, maternal weight, symphysis-sternal distance and height, but not on armspan and skin thickness. However, the only maternal variable bearing significant influence on birthweight in partial regression analysis was bodyweight. The effects of maternal determinants on birthweight, though some of them were statistically significant, were clinically unimportant.     

Primary vitrectomy for rhegmatogenous retinal detachment: an analysis of failure

PURPOSE: To find the cause of failure in primary vitrectomy for rhegmatogenous retinal detachment. METHODS: Retrospective review of 171 consecutive cases of RRD treated by primary pars plana vitrectomy (PPV) from a tertiary referral centre to identify the 25 cases in which surgery had failed. Detachments with giant or macula breaks at initial presentation, with proliferative diabetic retinopathy or with PVR greater than grade B were excluded. RESULTS: The failure rate after the first operation was 14.6% and the commonest cause of failure was missed retinal breaks, accounting for 64.3% of failures. CONCLUSION: Missed retinal breaks are the commonest cause of failure of primary PPV for RRD although proliferative vitreoretinopathy may contribute to surgical failure. This re-emphasises the importance of assiduous peroperative retinal examination.