Stillbirths in Western Australia 1980–1983: Influence of Race, Residence and Place of Birth

All stillbirths in Western Australia from 1980-83 weighing 1,000 g and over were identified from perinatal death certificates, and their causes and demographic correlates described. The stillbirth rate was 4.91 per 1,000 total births; nearly 65% were antepartum, 25% intrapartum and in 10% the time of death was unknown. The cause of death of most stillbirths was unknown (52%) or associated with lethal congenital malformations (13%), antepartum haemorrhage (12%) or maternal hypertension (8%). Whilst Aboriginal women had much higher stillbirth rates (10.80) than non-Aboriginal women (4.57), their patterns of time and causes of death were similar. Both antepartum and intrapartum stillbirth rates were much higher at low birth-weights and low gestational ages in both racial groups. Women living in rural areas who delivered in the metropolitan area had much higher antepartum (11.02) and intrapartum (3.31) stillbirth rates than either rural women delivering in rural areas (1.89 and 1.34) or metropolitan women delivering in the metropolitan area (2.72, 0.98). This reflects the transfer of rural high risk pregnant women or those with fetal death in utero, for delivery in metropolitan specialist hospitals.     

Does division of the left renal vein during aortic surgery adversely affect renal function?

Between July 1980 and July 1988, 478 consecutive patients underwent aortic aneurysm operations at Royal Prince Alfred Hospital. Renal function was assessed by measurement of serum creatinine levels. The left renal vein was divided in 28 (8%) of the 355 patients undergoing elective aneurysm resection. The mean immediate postoperative creatinine values were significantly higher after left renal vein division, 193±174 mol/L, compared to 133±93 mol/l for those whose left renal vein remained intact (p < 0.05 by Mann-Whitney U test). After one month, serum creatinine levels had decreased but were still significantly higher in those patients in whom the left renal vein had been divided, 170±166 mol/l, compared to those in whom it was left intact 109±49 mol/l (p<0.05 by Mann-Whitney U test). The suprarenal aorta was cross-clamped in seven (25%) of the 28 patients in whom the left renal vein was divided, compared to 21 (6%) of the 327 with the left renal vein intact. A rise in creatinine level was observed after suprarenal aortic cross-clamping. The left renal vein was divided in 17 (14%) of the 123 patients having emergency surgery for ruptured aortic aneurysm, 61 (49%) of whom survived more than 30 days. The mean immediate postoperative creatinine values were significantly higher after left renal vein division, 426±277 mol/l, compared to those in whom the vein was left intact, 178±136 mol/l (p < 0.05 by Mann-Whitney U test). After one month, serum creatinine levels were still significantly higher in those patients in whom the left renal vein had been divided. Although division of the left renal vein is a useful way to improve exposure of the juxtarenal aorta, the maneuver is associated with an adverse effect on renal function.Presented at the Annual Meeting of the Peripheral Vascular Surgical Society, New York, New York, June, 1989.     

Transabdominal Ultrasound as an Aid to Advanced Hysteroscopic Surgery

Summary: At the Nepean Hospital transabdominal ultrasound has been used to assist the hysteroscopic surgeon when performing complicated transcervical operations. The 2 main areas of use appear to be either to direct the surgeon within the uterus to the site of pathology or to prevent inadvertent perforation of the uterine wall. The cases vary from haematometra following endometrial ablation to Asherman syndrome and subseptate uteri.     

The Use of 16.16-dimethyl-PGEl- A-methyl ester (Cervagem) Vaginal Pessaries for Cervical Dilatation Prior to Evacuation for Second Trimester Termination

The results of a study of 101 consecutive second trimester terminations by Dilatation and Evacuation (D & E) under ultrasound control is presented. All had a Cervagem pessary inserted into the vagina prior to the procedure. The PGE1 analogue was assessed as 'effective' in 97% of patients. Concomitant ultrasound resulted in no patient leaving the operating table with retained products. The high efficacy of the single pessary associated with a low incidence of side-effects makes this combination the method of choice for nearly all second trimester terminations.     

Nerve Entrapment - An Important Complication of Transverse Lower Abdominal Incisions

Summary: Eleven patients with atypical lower abdominal pain following gynaecological surgery were clinically assessed for the features of nerve entrapment syndrome. Eight iliohypogastric nerves in 6 patients were subsequently explored and divided with satisfactory results in all patients. Diagnostic criteria for this syndrome are suggested, and the surgical management is described.     

Maternal Features of Obstetric Cholestasis: 20 Years Experience at King George V Hospital

Between 1965 and 1984, 139 pregnancies in 125 women were complicated by obstetric cholestasis (OC). Prevalence increased from 0.1% in the first 10-year period to 0.2% in the second (p less than 0.001), following recognition of the adverse fetal risks of this condition. Perinatal data from both series, 1965-1974 and 1975-1984 have previously been published. Mothers in the latter series were more likely to be of Anglosaxon than Mediterranean origin (p less than 0.001) and did not have underlying haemolytic conditions. Diagnostic criteria changed considerably over the 20 years, such that liver biopsy was no longer needed, gastroenterological consultation was sought less frequently (p less than 0.001) and newer diagnostic criteria of increased bile acids with negative hepatitis serology were increasingly employed. Biochemical data were broadly similar in the 2 groups. An understanding of the clinical and laboratory features of this disease facilitates early diagnosis, which is imperative if intensive fetal surveillance is to reduce the high stillbirth rate in OC.     

Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 ±0.21 to 0.70 ± 0.20 (p < 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 ± 0.22 to 0.65 ± 0.27, ns). Combined iliac percutaneous transluminal angioplasty and femorofemoral bypass is a safe alternative to aortobifemoral bypass for selected patients with aortoiliac arterial occlusive disease. Presented at the Royal Australasian College of Surgeons, General Scientific Meeting, May 1989, Melbourne, Australia.