Variations in oxytocin regimes in Scottish labour wards in 1998

Oxytocin (Syntocinon, Sandoz Pharmaceuticals) is a commonly used drug in the modern management of labour. A recently published British survey found that 38% of low risk primigravid labours were augmented, most commonly by intravenous syntocinon. Unfortunately the misuse of syntocinon can lead to potentially serious problems for the fetus and mother. Despite the frequency of usage there appears to be no consensus as to the optimal dose and mode of administration. This paper explores the extent of this variation among Scottish obstetric units, the reasons for any variation in its use and makes some suggestions as to the way forward based on the current literature.

Regulation of sulphotransferase expression in the endometrium during the menstrual cycle, by oral contraceptives and during early pregnancy

The endometrium plays a key role in reproduction, and this function is tightly regulated by endogenous and xenobiotic steroids. Sulphation, catalysed by members of the sulphotransferase (SULT) enzyme family, is a major deactivating mechanism for steroid hormones and we have investigated the expression and regulation in vivo of SULT in the human endometrium. In the normal cycling endometrium, expression of the phenol sulphotransferases SULT1A1 and SULT1A3 and the oestrogen sulphotransferase SULT1E1 were observed, with SULT1A1 and SULT1E1 expression being higher in the luteal phase than in the follicular phase. No expression of the hydroxysteroid sulphotransferase SULT2A1 was detected at any time in the endometrium. In endometrium from women taking the combined oral contraceptive pill (OCP), SULT1E1 expression was virtually absent, and SULT1A1 expression was substantially reduced. Similarly, in early pregnancy (i.e. first trimester) endometrium, SULT1E1 expression was absent, although SULT1A1 and SULT1A3 expression were unaffected. Our results with normal endometrium support in-vitro data showing that SULT1E1 expression is regulated by progesterone. However, the data obtained from OCP and early pregnancy endometrium suggest that factors other than the concentration of circulating progesterone are involved in the regulation of the expression of this important enzyme in the endometrium.

Fetal size and growth velocity in the prediction of intrapartum caesarean section for fetal distress

OBJECTIVE

To evaluate and compare third trimester ultrasound measurements of fetal size and growth velocity in the prediction of intrapartum operative delivery for fetal distress and admission to the special care baby unit in a low risk antenatal population undergoing labour at term.

DESIGN

Retrospective analysis of prospectively collected ultrasound data.

SETTING

Ninewells Hospital, Dundee, Scotland.

POPULATION

Three hundred and ninety-eight women previously enrolled in a longitudinal study of intrauterine volume undergoing labour at a gestational age of > 37 weeks.

METHOD

Fetal abdominal area (FAA) standard deviation scores (Z scores) were calculated for size at 32 and 36 weeks of gestation together with the growth velocity Z scores between these two gestational ages. Receiver-operator characteristics were calculated for fetal abdominal area Z scores at 32, 36 weeks and velocity Z scores in the prediction of caesarean section for fetal distress and/or admission to the special care baby unit.

MAIN OUTCOME MEASURES

Intrapartum caesarean section for fetal distress and admission to the special care baby unit with a diagnosis of perinatal hypoxia.

RESULTS

Pregnancies ending in caesarean section for fetal distress or admission to the special care baby unit (n = 17) had significantly lower fetal abdominal area Z scores at 36 weeks of gestation (mean Z score -0.71 vs -0.18) and lower fetal abdominal area growth velocity (mean Z score - 1.31 vs -0.01). Taking a cutoff Z score of -1.2 derived from the receiver-operator characteristic curve, fetal abdominal area velocity has a sensitivity of 65% and specificity 75% for caesarean section for fetal distress and/or admission to the special care baby unit.

CONCLUSION

Growth velocity of the fetal abdominal area in the third trimester is superior to a single measurement of the fetal abdominal area at either a mean of 32 or 36 weeks of gestation in the prediction of caesarean section for fetal distress and admission to the special care baby unit in low-risk women labouring at term. These results support the hypothesis that in the third trimester at least, growth rate in utero is more relevant to intrapartum performance and immediate perinatal outcome than estimates of fetal size alone.

Treatment and prognosis in congenital club foot

One hundred and twenty-nine unselected club feet were classified at birth into three grades of severity; 123 were followed up. The results of primary treatment were analysed and it is shown that the bad feet did worst. Serial splinting in plasters achieved lasting correction in nine in ten mild club feet, in half of the moderately deformed, but in only one in ten of the severely affected. Surgical correction succeeded in two out of three of the resistant feet, but had to be repeated in the others.

Limited intertransverse fusion using iliac grafts

Fusion of the lower lumbar spine or lumbosacral joint can be achieved by the use of limited intertransverse iliac grats inserted by a lateral approach. The method offers certain special advantages and is no less successful than other techniques in common use.

Prognosis and early management of birth injuries to the brachial plexus

Twenty-four cases of birth injury to the brachial plexus were seen in 21 infants over 15 years. Obstetric complications were common, and in 11 cases traction was needed to deliver the shoulders. Three out of every four arms fully recovered after exercises. Splints were not needed. Reconstructive procedures were performed on three permanently paralysed arms when the children were aged about 4. There was no way of predicting which patients would recover. The muscles supplied by the suprascapular nerve were paralysed in all patients, and this paralysis persisted in those whose arms failed to recover fully.

CONGENITAL VERTICAL TALUS IN INFANCY

1. Eight cases of congenital vertical talus in infancy are reported. The principal differential diagnosis at this age is from talipes calcaneo-valgus.

2. The deformity is primarily a dorsal dislocation of the talo-navicular joint.

3. Closed reduction can be achieved if treatment begins at birth. Open reduction is indicated for the deformity uncorrected by the age of three months.

RIGID VALGUS FOOT FROM FIBROUS CONTRACTURE OF THE PERONEI

1. A child with a rigid valgus foot caused by fibrous contracture of the peronei muscles is described.

2. The probable cause of the contracture is discussed.