Experience with a gonadotrophin-releasing hormone agonist prior to myomectomy--comparison of twice- vs thrice-monthly doses and a control group

The aim of this randomised prospective study was to investigate the impact of preoperative gonadotrophin-releasing hormone agonist (GnRHa) compared with a control group with myomectomy. A total of 36 women (n = 36, group 1) with fibroids were randomised to receive either two monthly doses (n = 18/36, group 1a) or three monthly doses of goserelin (n = 18/36, group 1b) prior to myomectomy. The 32 women who received no treatment (group 2) comprised the controls. All patients had similar demographic features. There were no significant differences among the three groups with respect to: (1) mean intraoperative blood loss; (2) preoperative and postoperative blood transfusion or (3) length of hospital stay. The only advantage of administering GnRHa prior to myomectomy for symptomatic fibroids in our population was a higher haemoglobin level prior to surgery among the women who received three doses of the drug.

Knowledge, attitudes, practice on human papilloma virus and cervical cancer among Trinidadian women

Cervical cancer remains a major reproductive health problem among women especially in developing countries where about 190,000 women die from this disease annually. Despite efforts to reduce the burden of this disease, most attempts in low-resourced countries have not been successful partly from lack of awareness by women of this common cancer, as well as the role the human papilloma virus (HPV) plays in its aetiology and pathogenesis. To determine knowledge, attitudes and practice of women in Trinidad (a developing country) on HPV, cervical cancer and the HPV vaccine, we conducted a cross-sectional survey among 426 women in the reproductive age. A majority (58.4%) of participants had attained secondary level education. Whereas 326 (76.5%) women knew of cervical cancer, only 108 (25.4%) were aware of HPV and 68 (15.9%) knew of the association between HPV and cervical cancer. This study highlights the limited awareness of Trinidadian women with respect to HPV and its implication in cervical cancer aetiology. If the scourge of cervical cancer is to be adequately addressed, especially in low-resourced countries, then mass educational programmes on HPV, cervical cancer prevention, including screening and early detection and treatment of pre-cancerous lesions of the cervix, must be given high priority.

Correlation of fetal outcome with mode of delivery for breech presentation

The objective of this retrospective analysis of 344 singleton pregnancies of gestational ages greater than 24 weeks conducted at a tertiary hospital was to determine the fetal outcome in relation to the mode of delivery of the fetus with a breech presentation. Caesarean section was performed in 157 mothers, and 187 babies were delivered vaginally. There was no statistical difference in the perinatal outcome for breech fetuses delivered either abdominally or vaginally. Cord prolapse and arrest of the after-coming head were responsible for five fetal losses, four of which were delivered vaginally. Neonatal morbidity comprising nerve injury, birth asphyxia and seizures occurred in 11 newborns, nine of whom were delivered vaginally. One mother sustained a massive intra-operative haemorrhage during a caesarean section which necessitated an emergency hysterectomy. We conclude that a policy of planned vaginal birth for selected breech fetuses with a low threshold to proceed to caesarean section may be in the best interests of both mother and child.

Obstetric hazards of maternal obesity

To test the hypothesis that obesity represents a risk factor in pregnancy, we conducted a prospective case-control study to determine whether or not there was any divergence in the obstetric outcome among 132 obese women from that in a control group of 136 non-obese patients. Obese mothers had an increased incidence of pregnancy-induced hypertension and gestational diabetes but there was no significant difference in the duration of pregnancy or in the frequency of low Apgar score at 1 minute. The favourable fetal outcome in obese parturients reflects an increased awareness of the possible medical and obstetric complications and an early recourse to abdominal delivery.

Obstetric deaths in Trinidad

We determined the causal pathways of pregnancy-related deaths over a 16-year period. Pregnancy-induced hypertension was the chief contributor to our high maternal mortality rate of 36.9 per 100 000 births. Anaesthetic-related deaths were due to a combination of Mendelson's syndrome and faulty intubation technique. An improvement in the health-management system to identify high-risk mothers who need intensive emergency care and the availability of experienced personnel for obstetric anaesthesia appear to be indispensable requirements for reducing and minimising adverse maternal outcome in Trinidad.

Prevention of hypertensive disorders of pregnancy

A prospective randomised clinical trial comprising 510 pregnant patients was performed to determine whether supplementation with calcium, low-dose aspirin or a combination of calcium and low-dose aspirin can lower the incidence of hypertension in pregnancy. Greatest benefits were obtained with calcium. Perinatal mortality was lowest in the aspirin group.

Supracervical hysterectomy in Trinidad

With mounting evidence of the beneficial effects of the retained cervix, supracervical hysterectomy is gaining popularity worldwide. In this series of 123 patients, obesity and pelvic adhesions were the chief factors that prevented amputation of the cervix at the time of hysterectomy. We propose that these are cogent indications for planned supracervical abdominal hysterectomy in order to minimize damage to the adjacent viscera. This option is best justified by a risk/benefit analysis.

Vaginal breech delivery and perinatal mortality in twins

An objective analysis of our clinical experience with the intrapartum management of twin gestations was undertaken in order to determine whether or not routine caesarean section is justified when the first twin presents by the breech. The perinatal mortality rate for breech first twins delivered vaginally was not statistically different from vertex presentations. There was no perinatal loss among babies delivered vaginally by the breech. There was no difference in perinatal outcome for the breech first twin born abdominally or vaginally. Our findings have allayed the fear that non-vertex vaginal delivery of the first or second twin is dangerous. We conclude that in the absence of a uterine scar or a footling presentation, there is no valid reason to prohibit vaginal delivery when either twin presents by the breech.

Caesarean section delivery in Trinidad

A 7-year retrospective survey was conducted in order to determine local trends in caesarean section rates, maternal outcome and indications for the procedure. The annual rate of caesarean births has not exceeded 10.0% of deliveries. The overall rate, at 7.4% for the period of study, was not significantly different from that obtained a decade and a half ago. Significant procedure-related morbidity was uncommon. In view of preventable anaesthetic maternal deaths, a plea is made for an increased use of regional in preference to general anaesthesia in selected cases.

Eighteen years of maternity care in a new teaching hospital

A new maternity hospital was inaugurated in Trinidad in 1981 to provide access for pregnant women to specialist antenatal care and to trained attendants during childbirth. As an academic tertiary-care institution, it also became a referral centre for high-risk pregnancies and obstetric emergencies. The efficacy of the services provided since inception was evaluated by measurement of mortality statistics, which are the most sensitive indices of maternal care. Over a period of 18 years, there were almost 100,000 births. Although the caesarean section rate was low, the perinatal and maternal mortality rates suggest that there is still a wide gap in obstetric standards between the developed world and this country. Improved vigilance for high-risk groups is required to identify potentially preventable deaths.

An audit of perinatal mortality

Perinatal mortality rates are considered in the western world to be a quantitative barometer of maternity care. This 6-year prospective perinatal audit was conducted at a tertiary hospital in order to determine foetal outcome, and the common causes of foetal and early neonatal deaths. Of a total of 30,987 births, there were 469 stillbirths and 391 early neonatal deaths, giving a perinatal mortality rate of 27.7 per 1000 total births. The leading causes of stillbirths were the hypertensive disorders of pregnancy, abruptio placentae, diabetes mellitus, intrapartum foetal distress and lethal congenital anomalies. Neonatal deaths were mainly due to the respiratory distress syndrome (57.8%), birth asphyxia (22.2%) and sepsis (13.5%). A dedicated medical team, including a neonatologist, to manage pre-eclampsia, and more senior obstetric involvement in the labour ward are recommended.

Examination performance of medical students. A view from Trinidad

We analysed the outcome of the final MBBS (Bachelor of Medicine and Bachelor of Surgery) examinations at the St. Augustine Campus, University of the West Indies, for 686 students attempting them for the first time between 1975 and 1986. The mean failure rate was lowest in Medicine between 1975 and 1981, in Obstetrics & Gynaecology between 1982 and 1989 and in Surgery during the last 7 years. The students' poor performance in some areas indicates the need for recognizing the importance of creating and establishing an educational climate in which the quality of teaching comes under scrutiny. The marking system in Medicine should be reviewed.

Maternal deaths associated with caesarean section

Twelve Caesarean section-associated maternal deaths were encountered over a 15-year period. The major operative risk factors were pregnancy-induced hypertension, obesity and general anaesthesia. Severe preeclampsia was the forerunner to postoperative cardiac failure, consumptive coagulopathy and difficult airway manipulation. We conclude that pregnancy-induced hypertension and its ramifications pose the greatest threat to maternal survival from a Caesarean section.

Diabetes in pregnancy

OBJECTIVE

To determine whether there is an association between the level of glycemic control and perinatal complications in pregnant diabetic patients.

METHODS

Two hundred sixty confirmed cases of pre-existing diabetes, gestational diabetes and impaired glucose tolerance were analyzed to assess risk factors, modality of treatment, level of blood sugar control and effect on perinatal morbidity and mortality.

RESULTS

Risk factors for the development of diabetes included age ( > 25 years), East Indian ethnic origin, glycosuria, and a history of diabetes in a first-degree relative. Treatment consisted of diet alone or in combination with soluble insulin. There is a marked increase in perinatal mortality and maternal morbidity if normoglycemia is not maintained.

CONCLUSIONS

A greater emphasis must be placed on the detection of diabetes in pregnancy and effective treatment should be instituted as early as possible to achieve normoglycemia if associated complications are to be reduced.

The results of abdominal myomectomy

A survey of the records of 103 consecutive patients who underwent abdominal myomectomy revealed that menorrhagia and infertility were the commonest presenting complaints. The overall successful pregnancy rate was only 28.2%, but the procedure was corrective in two-thirds of patients with leiomyomata-related infertility. Intra-operative blood loss, post-operative adhesion formation and recurrence of tumour remain major drawbacks of myomectomy.

An audit of eclampsia

One hundred and three patients with eclampsia were managed during a period of eleven years. The perinatal mortality rate was 136 per 1000 total births and there were six maternal deaths. The maternal mortality rate was less among eclamptics delivered by Caesarean Section. Liberal use of diazepam and/or magnesium sulphate and early recourse to Caesarean Section were integral in the care of these women.

Risk factors and treatment of endometrial carcinoma

A twelve-year retrospective study of 54 consecutive cases of endometrial carcinoma revealed that post-menopausal bleeding was the commonest symptom, and the major associated risk factors were obesity and hypertension. Panhysterectomy was the corner-stone of treatment while adjunctive therapy was based on certain prognostic factors and the operator's preference.

Cold-knife cervical conization

Forty-six cervical conizations were performed over a ten-year period for diagnostic or therapeutic purposes. Twenty-nine women were under 45 years of age. The most common reason for conization was an abnormal Papanicolaou smear. The overall incidence of neoplasia was 80.4 per cent. The high complication rate of 28.4 per cent emphasizes the need for a less traumatic technique of excisional biopsy.

Is adolescent pregnancy hazardous?

A study of the pregnancy outcome in 3320 teenagers revealed a low incidence of pre-eclampsia and anaemia and high rates of eclampsia, prematurity and low birthweight. The perinatal loss was 2.2 per cent and there was one maternal death. A comprehensive programme designed to improve antenatal surveillance is recommended for adolescents.

Shoulder dystocia: an obstetrical nightmare

A nine-year review of 103 cases of shoulder dystocia identified obesity, diabetes mellitus and post-datism as important predisposing risk factors. There was a positive correlation with birthweight. Abnormal labour patterns were invariably absent and perinatal outcome was disastrous. The best strategy is to anticipate and avoid this obstetrical emergency.

Peripartum cardiomyopathy and arterial embolism

A severely pre-eclampic patient developed peripartum cardiomyopathy and bilateral femoral emboli. Medical therapy for cardiac failure was commenced prior to delivery by Caesarean Section. Bilateral femoral embolectomy was performed on the sixth postpartum day.

Therapeutic alternatives for the hirsute woman

A retrospective analysis of 21 hirsute women seen at a gynaecological endocrine clinic revealed a high incidence of infertility, menstrual irregularities and abnormal androgen profile. Polycystic ovarian syndrome (PCOS) was the underlying abnormality in the majority of cases. Cyproterone acetate (CPA) with ethinyl oestradiol in a reverse sequential regime was more effective and better tolerated but much more expensive than the combination of spironolactone and the oral contraceptive pill (OCP).

Maternal mortality at Mount Hope Women's Hospital, Trinidad

A ten-year survey of the magnitude and causes of obstetrical deaths at Mount Hope revealed a maternal mortality rate of 33.3 per 100,000 live births. The leading causes of death were the hypertensive disorders, and the most common identifiable factors were inadequate antenatal care and substandard clinical management.

Perinatal implications for macrosomic babies

A five-year record review was undertaken for all babies with a diagnosis of foetal macrosomia. The perinatal mortality rate of 23 per 1,000 total births was similar to the overall hospital rate. Neonatal morbidity was significant, and the most important contributory factor to foetal injury was impaction of the shoulders during parturition. In order to avoid this catastrophe, elective abdominal delivery may be prudent if the foetal weight is estimated at greater than 4,500 grams.

Postpartum shock and uterine inversion

A 21-year-old woman, para 1 + 0, developed profound postpartum shock secondary to acute inversion of the uterus. Fundal re-inversion was achieved by prompt manual replacement of the uterus from below. An aggressive approach to uterine inversion is the keystone of success.

The efficacy of cervical cerclage

A retrospective study of the outcome of pregnancy in 187 women with cervical cerclage revealed a three-fold increase in the crude perinatal survival rate. The McDonald and Shirodkar techniques produced comparable results. Mersilene was as effective as black silk. A significant number of pregnancies with cerclage insertion prior to 14 weeks ended in spontaneous abortions. Postcerclage morbidity was minimal, and abdominal delivery was indicated in only four patients for cervical dystocia. The continued use of this procedure, for selected cases, is justified.

The epidemiology and management of patients with hydatidiform mole

The epidemiology, clinical features and method of evacuating the uterus were reviewed in 30 patients with hydatidiform mole. The incidence was greatest in patients with blood group O and among young East Indians. There was no seasonal variation nor was there any progression to choriocarcinoma. Only one partial mole and one invasive mole were encountered. Evacuation was achieved chiefly by suction curettage and concomitant augmentation with a Syntocinon infusion.