Ectopic Pregnancy in Lower Segment Uterine Scar

Summary: A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.     

A Letter of Importance

EDITORIAL COMMENT: We have published this letter in the position of an article to make sure that readers do not overlook it. The letter is signed by a number of specialist medical obstetrician ultmsonologists in Melbourne and they clearly state a different point of view to that expressed by Burrows, Ramsden and Frazer. (Aust NZ J Obstet Gynaecol 1993; 33:262–264).     

Maternal Serum Screening and Routine 18-week Ultrasound in the Detection of all Chromosomal Abnormalities

Summary: Over a 15-month period, maternal serum screening (alpha fetoprotein, oestriol, chorionic gonadotrophin) and ultrasound were evaluated in the detection of all chromosomal abnormalities. Of the 981 screened, there were 8 chromosomally abnormal pregnancies. Six of these were considered to be at increased risk on serum screening, all of which were detected. Of the remaining 2, one was detected by ultrasound and the other resulted in a liveborn baby with trisomy 21. The positive and negative predictive values for serum screening for all chromosomal abnormalities was 7.8% and 99.9% respectively. The sensitivity and specificity were 87.5% and 91.5% respectively. Serum screening is useful in the detection of many chromosomal abnormalities, not just Down syndrome. The combination of maternal serum screening and ultrasound has a high negative predictive value and is valuable in providing reassurance of no underlying chromosomal abnormality. With a positive predictive value of 7.8% a chromosomal abnormality will be found once in every 13 amniocenteses performed.     

Antepartum and Postpartum Complications of Twin-Twin Transfusion

Summary: Twin-twin transfusion is a condition that was previously associated with close to a 100% perinatal mortality. Recent reports suggest that a survival rate of about 60% can be achieved with serial amniocentesis and modern neonatal care. However, it is now apparent that the survivors of this condition have multisystem complications that can result in neonatal mortality and long-term morbidity. Fourteen cases of twin-twin transfusion were examined to determine the antenatal findings that may predict the postnatal outcomes of these infants. The overall survival was 61% (17 of 28). The mean gestation at diagnosis was 23.0 weeks (range 18–34 weeks) and the mean gestation at delivery was 29.0 weeks (range 23–37 weeks). The mean number of amniocenteses was 2.9 and the average total volume of amniotic fluid removed was 6,114 mL. Different patterns of complications were seen in the donor and recipient twins. Hypertrophic cardiomyopathy affected 9 of the recipient twins. Anuria/oliguria was found in 4 of the donor twins and none of the recipients. Periventricular leukomalacia was found in 8 twins and 7 also had mild ventriculomegaly; of the surviving 17 twins, 5 had either periventricular leukomalacia, mild ventriculomegaly or both. Amniotic fluid leakage and perforation of the intervening membrane subsequent to serial amniocentesis were seen in 5 cases. Severe intrauterine growth retardation and abnormal cardiotocographs were a common feature. These complications directly resulted in neonatal mortality and long-term morbidity in the survivors. Not all complications were detected antenatally and the severity was not able to be anticipated.     

Mid-trimester Ultrasound Diagnosis of Isolated Talipes Equinovarus: Accuracy and Outcome for Infants

Summary: Seventeen fetuses were diagnosed with isolated congenital talipes equinovarus (CTEV) on mid-trimester ultrasound at the Royal Women's Hospital, Melbourne, between January, 1992 and December 1995. Sixteen of the 17 cases had an amniocentesis performed and all karyotypes were normal. The remaining case was phenotypically normal, except for a clubfoot. None of the pregnancies was complicated by any of the recognized intrauterine environmental causes of CTEV. Four of the babies were delivered prematurely and all survived the neonatal period. Six (35%) infants did not have CTEV at birth, although 2 had postural varus feet. Nine of the 11 infants who did have CTEV at birth were treated within days of birth with plaster of Paris for periods of 6 to 12 weeks. Two infants required no further treatment, 5 required orthotics and 2 required surgery. The other 2 infants with CTEV at birth were treated with orthotics at 8 weeks of age. All infants were considered to have an excellent result at the 2 year follow-up. Seven (41%) of the prospective parents received antenatal counselling by an orthopaedic surgeon and the lack of study on outcome following an ultrasound diagnosis of CTEV was the impetus for our work.     

Ultrasound-Guided Fetal Intravascular Transfusions for Severe Erythroblastosis, 1984–1993

Summary: The results of the first 10 years' experience in ultrasound-guided fetal intravascular transfusions at the Royal Women's Hospital were reviewed. Since the first transfusion, a variety of techniques have been employed in 78 fetuses, all with severe erythroblastosis. A total of 288 intrauterine transfusions have been attempted with an overall survival rate of 75.6% (59 of 78). The overall survival rate for delivered fetuses improved from 64.3% (18 of 28) in 1984–1987, to 82.0% (41 of 50) in 1988–1993. There was a total of 33 hydropic fetuses, of whom 20 (60.6%) survived, significantly fewer compared with 86.7% (39 of 45) of the nonhydropic fetuses (odds ratio {OR] 0.25, 95% confidence interval [CI] 0.09 to 0.70, p <.01). Fetuses who were sicker at the time of transfusion, as reflected by larger haemoglobin deficits, had lower survival rates, as did those requiring transfusions at earlier gestational ages. When these variables were allowed for, the survival rate significantly improved over time (OR 6.3, 95% CI 1.3 to 30.4, p<0.05), probably reflecting the increased skill of the ultrasonologists, but the presence of hydrops per se was no longer important. Variations of the technique employed, such as exchange or intraperitoneal transfusion, or different sites for transfusion, were not significantly related to survival. Ultrasound-guided fetal intravascular transfusions are associated with good fetal outcome, even in the most severe cases of erythroblastosis.     

Ectopic Pregnancy in Lower Segment Uterine Scar

Summary: A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.     

Amnion Rupture in the Second Trimester

Summary: Two cases of amnion rupture are presented in 'low-risk' pregnancies. One case ended in fetal death in utero at 21 weeks. The other resulted in the preterm delivery of an otherwise normal male with mild amniotic band syndrome.     

Saline Infusion Sonohysterosalpingography, an Underutilized Technique

Summary: Saline infusion sonohysterography (SIS) is an important gynaecological diagnostic tool which is little used in Australia. We herein report the findings in 60 women referred for SIS, the procedure being uneventfully performed in 55. Forty-nine of the 60 referrals were for investigation of abnormal uterine bleeding. The technique described allows examination of the uterine cavity and the Fallopian tubes. In 26 of the patients information was obtained which improved or altered the diagnosis made on B mode and colour Doppler ultrasound. Unlike hysteroscopy, SIS is always performed as an outpatient procedure, appropriate disinfection procedures are relatively simple to implement (1), and vasovagal reactions are rare. Hysteroscopy was avoided in 11 patients, there were other benefits in 4 patients, and in only 1 of 16 patients did the hysteroscopy findings differ with SIS. If diagnostic pitfalls are avoided by careful attention to detail, SIS offers a powerful new gynaecological investigative tool in the investigation of bleeding disorders (including menorrhagia, intermenstrual and postmenopausal bleeding), uncertain endometrial Findings on vaginal ultrasound, infertility, and in the investigation of congenital and acquired uterine abnormalities.