Treatment of Cervical Incompetence by Transabdominal Cervicoisthmic Cerclage

Summary: Cervical incompetence is a condition traditionally treated by cervical cerclage which in most cases is inserted via the transvaginal route. However the insertion of a transabdominal cervicoisthmic suture is indicated in those patients with recurrent mid-trimester losses due to an incompetent cervix where it is not technically possible to insert a transvaginal suture. Between 1987 and 1996, 12 women at the Royal Women's Hospital, Melbourne were treated with transabdominal cervicoisthmic cerclage (TCC). Eight patients had cerclage in the nonpregnant state, and 4 were pregnant at the time. The completed pregnancies thus far have resulted in 10 surviving infants, a successful pregnancy rate of 69.2%. This compares favourably with a corrected preTCC successful pregnancy rate of only 13%. There were minimal intraoperative complications in our series. Bleeding, chorioamnionitis and premature rupture of the membranes have been reported elsewhere and occurred in 2 of our patients. Our results and a review of the literature confirms that TCC has an important role in carefully-selected patients.     

Second Twin: Quality of Survival if Born by Breech Extraction Following Internal Podalic Version

The intrapartum management of the vertex-breech and vertex-transverse twin gestation is controversial. The fall in perinatal mortality rate to a low level has resulted in this parameter failing to be an adequate gauge of the safety of breech extraction and the answer lies in the quality of survival of the infants. Fifty-one twin pairs, collected over 12 years at the Mercy Hospital for Women, Melbourne, occurred where twin 2 was born by breech extraction following internal inversion and the control (twin 1) did not have this procedure performed. In 8 pairs either a stillbirth or neonatal death occurred; in one pair childhood death due to an accident (fire) occurred; in 4 pairs the parents refused entrance to the study as they perceived both twins to be similar; in 2 sets the assessment was incomplete; 11 sets were untraceable leaving 25 sets fully assessed as children ranging in age from 2 to 12 years. Growth, and psychological scores were not significantly different between twins 1 and 2 but 2 children had cerebral palsy and both were born by breech extraction following internal version at 29.2 and 30.1 weeks' gestation, respectively. Because of small numbers the results failed to achieve statistical significance and this study was unable to answer the question regarding the safety of breech extraction following internal version but did show that the majority of infants so born do well.     

THE AUSTRALIAN & NEW ZEALAND JOURNAL OF OBSTETRICS & GYNAECOLOGY

During the years 1971-1984 urinary oestriol excretion was tested in 51,427 patients (group 1). One or more low oestriol value was found in 10.7% of patients; in this group the stillbirth rate was 6.8 times higher, the neonatal death rate 3.8 times higher, and fetal growth retardation rate 3.5 times higher than in patients with normal oestriol values (all p less than 0.00001). During the years 1985-1989 a further 20,635 patients were tested (group 2) and 7.6% had one or more low oestriol value. The perinatal mortality rate in patients with normal oestriol excretion fell from 0.8% in group 1 to 0.5% in group 2 (p less than 0.005), and in patients with low oestriol excretion from 4.2% in group 1 to 2.4% in group 2 (p less than 0.002). However, patients in group 2 with low oestriol values still had significantly unfavourable results, compared to those with normal oestriol values--stillbirth rate 3.3 times higher, neonatal death rate 4.6 times higher, and fetal growth retardation rate 3.2 times higher (all p less than 0.00001). Intravenous dextrose and aminoacid infusions were given to 967 patients who had persistently low oestriol values in spite of rest in hospital, in an attempt to correct fetoplacental function; the perinatal mortality rate was 0.9% in the 660 (68.3%) who responded favourably, and 9.8% in the 307 (31.7%) who did not respond (p less than 0.0001).     

Intrapartum Cardiotocography and the Expert Witness

Summary: Fetal heart rate changes occur in the majority of labours and correlate poorly with perinatal outcome and subsequent neurological development. Obstetricians giving expert evidence related to the interpretation of intrapartum cardiotocographs are advised to exercise caution when expressing their opinions.     

Update of Growth Percentiles for Infants Born in an Australian Population

Summary: Growth percentiles require periodic revision because of changes in the ethnic mix of a population and socioeconomic factors. Anthropometric measurements were derived from singleton livebirths, without lethal malformations, from 22 completed weeks' gestation, at the Mercy Hospital for Women, Melbourne, from 1980 to 1989 (49,429 infants). Infants were included if reasonable assessment of gestation was available. Birth-weight percentiles were derived for the study group, male and female infants separately and for infants whose mothers were born in South-East Asia (Vietnam, Laos and Cambodia). Percentile charts for length, head circumference and ponderal index were also prepared. When compared with the intrauterine birth-weight growth curves reported by Kitchen et al (4) there was generally an elevation of all percentiles. Male infants were larger than female infants. Infants delivered by mothers born in South-East Asia were smaller than the study group as a whole, although the 10th percentiles for birth-weight were similar to the study group especially from 36–39 weeks' gestation. Periodic review of local standards is required to correctly categorize newborn infants' growth characteristics; factors such as sex of the infant and ethnic origin of the mother should be considered.     

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 Donation of Oocytes to Known Recipients

The supply of donated oocytes from an in vitro fertilization programme has always been inadequate, especially following the successful cryopreservation of human embryos. There have been no previous reports of women donating their oocytes to known recipients. All of 7 women who donated all their oocytes to known recipients responded to a posted questionnaire. No differences in social characteristics between this group and another group of infertile women treated on an in vitro fertilization programme, who donated some of their excess oocytes anonymously were noted, except that the known donor group had a relatively high average parity, i.e. 3. No differences in attitudes towards donating oocytes were noted between these groups except that the known donor group felt a significantly greater connection towards the potential child.     

Can Anything Be Done About Mid-Trimester Fetal Wastage?

In Victoria in the triennium 1982-1984, perinatal losses between 22 and 28 weeks' gestation accounted for 32% of the overall perinatal wastage of 12.7 per 1,000 births. Over the same period only 1.2% of babies were delivered weighing less than 1,500g, but this group made up 40% of the total stillbirths and 50% of the neonatal deaths. By contrast the perinatal wastage was only 7 per 1,000 births in babies born weighing more than 1,500g and this included lethal congenital malformations. The major antenatal risk factors contributing to the high mid-trimester fetal wastage were premature labour (17.7%), multiple pregnancy (13.9%), cervical incompetence (12.9%), antepartum haemorrhage (12.9%), premature rupture of the membranes (11.5%), lethal congenital malformations (10.6%) and hypertensive disorders (7.4%). Cognizant of the frequency of preventable factors, the Consultative Council on Maternal and Perinatal Mortality and Morbidity in Victoria recommends that, where feasible, the mother of these high-risk pregnancies be transferred to a centre where facilities are available to monitor the pregnancy and labour, and which offers intensive care facilities for the baby.     

A Technique for Enrichment of Motile Spermatozoa from Oligozoospermic and Asthenozoospermic Patients

Summary: A system for rapid selection of normal motile spermatozoa from poor semen samples is described. Analysis of the selected samples shows that there are significant improvements in the percentage motility, velocity and morphology. The final spermatozoa suspension of 0,5 ml is sufficient for the purpose of intrauterine AIH and IVF.