Prolonged Induction to Delivery Time in Termination of Pregnancy Using 16,16-dimethyl-PGErmethyl ester (gemeprost) for Fetuses with a Neural Tube Defect or Hydrocephalus

Summary: A retrospective study is reported comparing the induction to delivery interval using gemeprost for termination of pregnancy, in the second trimester, in 3 groups of patients. It was observed that the mean induction to delivery interval was significantly longer in 75 pregnancies where there was a fetus with a neural tube defect and or hydrocephalus (31.7 hours) compared with 88 pregnancies with other fetal abnormalities (19.7 hours) and 84 pregnancies where there was an intrauterine death (113 hours). There was also an increase in the requirements for further intervention to obtain delivery in the group with a neural tube defect or hydrocephalus (n=33) compared with where there was an intrauterine fetal death (n=4) and other abnormality (n=14). We believe these results should be considered when counselling patients who have requested termination of pregnancy for fetal abnormalities.     

Health care experiences among women diagnosed with gestational breast cancer

Gestational breast cancer (GBC) presents many challenges for women and the clinicians who care for them. The aim of this study was to explore the health care experiences of women diagnosed with GBC to inform and improve clinical care of women in this predicament. Semi‐structured interviews were conducted with 17 women who had been diagnosed with GBC in the previous 5 years. The overarching themes for perceived quality of care were “communication” and “comprehensive care.” “Communication” had two sub themes: “interdisciplinary communication” (the way health professionals from different disciplines communicated with each other about the management of the woman's care) and “patient communication” (how they communicated this to the woman). The “comprehensive care” theme incorporated three sub themes: “the spirit” (psychological care); “the mind” (information provision); and “the body” (management of treatment side effects). Women's own accounts of positive and negative experiences of GBC care provide unique and specific insights which improve understanding of their concerns and needs. The findings can inform advances in quality and efficacy of clinical care; offer guidance for obstetricians, oncologists and allied health professionals about the needs of women diagnosed with GBC and how care can be optimised; and inform the development of resources to assist women and their families.     

Pregnancy Loss Rates Following Second Trimester Genetic Amniocentesis

Data from 3,953 consecutive second trimester genetic amniocenteses were analysed to determine pregnancy loss rates up to 6 weeks after the procedure. Information was prospectively collected on a cohort of 3,685 women in 3,896 singleton and 50 twin pregnancies, from 2 operating sites in Perth, Western Australia, using 9 operators over the 6-year period, 1989 to 1995. Complete information regarding pregnancy outcome was obtained for 3,643 of the 3,685 women (98.9%). There were 27 identified singletons and 1 set of twins lost within 6 weeks following amniocentesis. The overall pregnancy loss rate in this cohort was 29 of 3,911 (0.74%). The pregnancy loss rate associated with genetic amniocentesis is not excessive in comparison to the calculated background pregnancy loss rate of 1%, and it is suggested that each prenatal diagnostic team should determine their own complication rates for the purpose of counselling prior to amniocentesis.     

Interstitial Ectopic Pregnancy—Management with Laparoscopically-guided Local Methotrexate Infiltration

EDITORIAL COMMENT: This issue of the journal contains 2 case reports of interstitial ectopic pregnancies, both treated by injection of methotrexate, by intramuscular injection in one case, and by laparoscopically-guided injection into the ectopic pregnancy mass in the other. The methods were not equally successful. Parker and colleagues reviewed the published data and concluded that single-dose intramuscular methotrexate for treatment of ectopic pregnancy is associated with a high failure rate, and serious complications have occurred (11). The authors of this report advocate the use of laparoscopically-guided local methotrexate infiltration. The selection of which cases of ectopic pregnancy warrant this regimen is not yet established in the editor's opinion. Ironically one of the reviewers of this case report, selected because of his known experience with ultrasonographically-guided direct local methotrexate injection into early tubal ectopic pregnancies, stated that, because of the risk of causing haemorrhage, that he had preferred methotrexate by intramuscular injection in 2 women with interstitial ectopic pregnancies, who then, at a later date, had excision of the ectopic pregnancies performed laparoscopically.
Summary: This case describes the use of ultrasound to diagnose an interstitial ectopic pregnancy and the subsequent management and ultrasound follow-up. Interstitial pregnancy is a rare but potentially life-threatening complication of pregnancy. Management options depend upon the timing of diagnosis, and the desire for maintenance of fertility. Methotrexate injection, under ultrasonographic or laparoscopic guidance, seems to be the management of choice when the ectopic is diagnosed at an early stage.     

Nuchal Translucency in the First Trimester

Summary: All fetuses reported as having nuchal (nape of the neck) thickening or translucency detected by a first trimester ultrasound at 2 centres were reviewed to determine the incidence of aneuploidy. Twenty nine pregnancies were registered, amongst which 12 (41%) had an abnormal karyotype, the most common aneuploidy being trisomy 21 (5 fetuses). The likelihood of aneuploidy increased with increasing thickness of the translucency. Where the karyotype was found to be normal, there was complete resolution of this ultrasound appearance by the second trimester in 15 of the 16 ongoing pregnancies: 9 have delivered normal neonates and 6 pregnancies are continuing. The other fetus developed evidence of a skeletal dysplasia by the second trimester.     

Indomethacin for the Treatment of Polyhydramnios: A Case of Constriction of the Ductus Arteriosus

Prenatal administration of indomethacin for the treatment of polyhydramnios at 27 weeks' gestation resulted in the rapid restoration of normal amniotic fluid volume. However, after 16 days therapy, fetal echocardiography revealed constriction of the fetal ductus arteriosus which did not reverse during the 17 days after the therapy was discontinued. The constriction resulted in right heart failure but no long-term effects on the infant after birth. Indomethacin is a powerful treatment for polyhydramnios but its use requires close monitoring of the fetal heart.     

Uterine Arteriovenous Malformation - A Rare Cause of Uterine Haemorrhage

Summary: Uterine arteriovenous malformation (AVM) is a rare cause of massive uterine bleeding, with 70 cases reported in the English literature. Although uterine AVM is a rare cause of menorrhagia or postmenopausal bleeding, it is important to consider in the assessment of a patient with abnormal (especially heavy) uterine bleeding because accurate diagnosis can allow appropriate treatment to be planned and avoid hysterectomy in women who wish to retain their reproductive capacity. Until relatively recently this condition was difficult to diagnose and management almost always required hysterectomy. Special investigations (hysteroscopy, Doppler flow ultrasound and pelvic angiography) are important for diagnosis and assessment. Transcatheter embolization has replaced hysterectomy as the treatment of choice in women who wish to retain their fertility. Curettage may precipitate life-threatening haemorrhage and is therefore contraindicated when uterine AVM is suspected.     

Accuracy of Estimated Fetal Weight below 1,000g

EDITORIAL COMMENT: We accepted this paper for publication because it gives useful information on the interpretation of ultrasonographic estimates of fetal weight when considering whether fetal viability is such that Caesarean section is indicated on fetal grounds as the method of delivery in a complicated pregnancy.
Summary: The Wars of formula is 1 of 3 currently recommended by the Australian Society for Ultrasound in Medicine for the routine estimation of fetal weight. However, this formula was derived using mostly large fetuses, and its accuracy in extremely low birth-weight fetuses is not known. Using this formula, we studied 184 infants delivering within 14 days of an estimated fetal weight (EFW) <1,000 G, The mean percent error in EFW was 11.7% underestimation, with 80% of infants underestimated and 61% of estimates within 15% error. The percent error was consistent at 9.6% throughout the first 9 days, but increased to 32% after 10 days post scan (p<0.0001). There was a significant association between the accuracy of EFW and maternal height, but not with placental position, liquor volume or multiple pregnancy. EFW underestimated birth-weight on average by 9.6% during the first week, and this error appeared to be mainly due to the formula. The error in EFW became unacceptable after 9 days and repeating the estimate before 10 days is recommended. A different formula may be more suitable for extremely low birth-weight fetuses.