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Notes: Objective To determine whether antepartum X-ray pelvimetry (XRP) reliably identified women suitable for a trial labour or repeat elective caesarean section after one previous section.Design A prospective controlled trial in which women were randomly allocated to either an antepartum XRP group who had XRP at 36 weeks gestation to determine mode of delivery, or a control group who had a trial labour without antepartum XRP. Following delivery, all controls had postpartum XRP.Setting Department of Obstetrics and Gynaecology, King Edward VIII Hospital, Durban, South Africa.Subjects Three hundred-six women with a history of one previous caesarean section.Main outcome measures Mode of delivery, birthweight and maternal and perinatal mortality and morbidity in the two groups.Results In the antepartum XRP group, 23 of 144 (16%) of women delivered vaginally compared with 60 of 144 (42%) controls (P〈0.0001). Of the 84 women with adequate antepartum XRP only 23 (27.7%) delivered vaginally. In the control group, 33 of 60 (55%) women who had vaginal deliveries had inadequate postpartum XRP and would have had a caesarean section if this information was known in the antepartum period; 62 of 84 (74%) caesarean sections in the control group had adequate postpartum XRP. Birthweight of the infants was similar in the two groups. There were no maternal or perinatal deaths. Maternal morbidity was similar in the two groups. Neonatal morbidity was minimal.Conclusion Antepartum XRP is not necessary prior to a trial labour in women with one previous caesarean section. It increases the caesarean section rate and is a poor predictor of the outcome of labour.

Notes: Objective To define more clearly the neuropathophysiology of eclampsia.Design A prospective study relating to computerised cerebral tomography (CAT) scan and electroencephalogram (EEG) findings in eclampsia.Setting A large referral centre in a developing society.Subjects Thirty-two women with eclampsia.Main outcome measures Abnormalities in EEG and CAT scan findings.Results Approximately 45% of the women studied had CAT scan abnormalities, while 90% had EEG abnormalities. A burst suppression pattern on EEG examination was found in four women suggesting a temporary dissolution of cerebral function to the midbrain level as the cause of seizures.Conclusions EEGs are probably more sensitive than CAT scans in detecting the extent of the pathology in the brain in women with eclampsia.

Notes: Summary. Of the many complications which may develop after eclamptic seizures, prolonged unconsciousness is one of the most difficult for obstetricians to manage as the pathophysiology of this condition remains largely unknown. Computed axial tomography (CT scan) was performed on 20 unconscious eclamptic patients, and autopsy was obtained on an additional two patients. Changes compatable with cerebral oedema were demonstrated in 75% of patients; cerebral haemorrhage occurred in 9%. A programme of intensive neurological management aimed at optimizing cerebral perfusion and controlling intracranial pressure is outlined. We have reduced the mortality rate for unconscious eclamptic patients from 50% to 17% in our institution.

Notes: It has been suggested that gene aberrations may contribute to vascular endothelial dysfunction of pre-eclampsia in Caucasian and Japanese women. This study was undertaken to examine the association between pre-eclampsia in Black Zulu speaking South African women and the Factor 5 Leiden mutation. 100 patients with pre-eclampsia comprised the study group. The control group comprised 110 normotensive pregnant women of the same population group. Genotyping was performed to detect the G or A allele at residue 506 of the Factor V gene, and the C or T allele at residue 455 of the thrombomodulin gene. Our findings demonstrate that these particularly genetic loci are of little use in disease association studies for pre-eclampsia in homogenous Zulu speaking Africans.

Notes: Objective To evaluate prospectively mitral stenosis in pregnancy with emphasis on women with persistent symptoms.Setting King Edward VIII Hospital, a tertiary referral obstetric unit.Participants One hundred and twenty-eight consecutive women with mitral stenosis.Demographics The mean age was 27 years and 38 women (30%) were primigravidae. Seventy-eight (61%) women had their first cardiac evaluation in the third trimester. Fifty-four women (42%) of these women had mitral stenosis diagnosed for the first time in the index pregnancy. Twenty-nine (23%) had a previous mitral valvulotomy. Nineteen women (15%) developed hypertension during pregnancy, 10 of whom had pre-eclampsia. Sixty-three women (49%) had a mitral valve area of ≤ 1.2 cm2 with 11 having critical mitral stenosis (mitral valve area ≤ 0.8 cm2). Atrial fibrillation was present in 12 women. Most women (87%) required medical therapy to control the heart rate.Outcome in persistent symptomatic women Intervention was considered in 37 women (29%) who remained symptomatic, 11 (9%) of whom had a calcified mitral valve. The remaining 26 women were scheduled for balloon mitral valvulotomy during pregnancy, 20 of whom had balloon mitral valvulotomy with good effect (16 antepartum; 4 postpartum). In seven women, scheduled balloon mitral valvulotomy was not performed because of advanced preterm labour (n= 5), fetal distress (n= 1) and preterm labour with fetal distress (n= 1). These seven, together with the 11 with calcific mitral stenosis, were managed conservatively with good outcome.Maternal complications Fifty-one percent had maternal complications, the majority occurring at their initial admission to hospital. Pulmonary oedema was the most frequent. Multiple logistic regression analysis showed that the severity of stenosis assessed by measurement of the mitral valve area by echo-Doppler was the most powerful predictor of maternal pulmonary oedema. The other factors were late antenatal presentation, presence of symptoms prior to the index pregnancy and diagnosis of cardiac disease for the first time in the index pregnancy.Conclusion Despite serious disease, women with persistent symptoms treated either by balloon mitral valvulotomy where feasible, or conservatively with close noninvasive monitoring, had a satisfactory fetal and maternal outcome.

Notes: Objective To determine whether prophylactic antibiotic administration using cefoxitin at the time of elective caesarean section significantly reduces infectious morbidity.Setting A tertiary teaching hospital in a large urban city in South Africa.Participants Women undergoing elective caesarean section.Design A prospective, double-blind randomised placebo-controlled trial.Methods Four hundred and eighty women undergoing elective caesarean section had cefoxitin or placebo administration after umbilical cord clamping. Postpartum complications including febrile morbidity, wound infection, endometritis, urinary tract infection, pneumonia and transient postpartum fever were recorded, as were the duration of hospital stay and the need for therapeutic antibiotics.Results Wound infection was the most common complication occurring in 13.3% and 12.5% of women in the placebo and cefoxitin groups, respectively. Prophylactic antibiotics did not decrease febrile morbidity, wound infection, endometritis, urinary tract infection and pneumonia. Women who received cefoxitin stayed on average a day less in hospital than those who received placebo (6.9 vs 7.8 days, risk difference −0.94 CI 1.57 –−0.31 days). Eleven women (4.6%) in the placebo group and eight (3.4%) in the cefoxitin group had microbiological evidence of wound infection. Staphylococcus aureus was the most common pathogen (43%) isolated. Similar proportions in both groups (6.3% placebo and 5.1% cefoxitin) required a course of therapeutic antibiotics.Conclusion Antibiotic prophylaxis with cefoxitin in elective caesarean section did not reduce post-operative infectious morbidity in this double-blind randomised placebo controlled trial.

Notes: Objective To define more clearly the neuropathophysiology of eclampsia utilising single-photon emission computed tomography (SPECT), cerebral computerised tomography (CT) and transcranial Doppler (TCD) ultrasonography.Design A prospective study.Setting The obstetric unit in King Edward VIII Hospital, a large tertiary referral centre hi Kwa-Zulu Natal, South Africa.Participants Sixty-five women with eclampsia.Interventions Imaging and ultrasonographic investigations were performed within 48 hours postpartum. Unenhanced cerebral CT scans were performed in all the women and SPECT scans were performed on 63 women using Technetium-99m-hexamethylpropyleneamineoxime (99mTc-HMPAO) as a tracer of regional cerebral blood flow. Middle cerebral artery blood flow velocity waveforms were measured using 2 MHz pulsed Doppler ultrasound via the transtemporal approach.Main outcome measures Abnormalities in SPECT scan, CT scan and TCD ultrasound findings.Results SPECT scanning revealed perfusion deficits in the watershed areas in all women, 75% of whom had concomitant deficits in the parieto-occipital areas of the brain. Hypodensities (cerebral oedema) were reported in 38 CT scans (58.5%), with parieto-occipital involvement in 97.4% of cases. Increased flow velocity measurements in the middle and posterior cerebral arteries were recorded in 36 (85.7%) women in whom TCD ultrasound was performed.Conclusion The pathophysiological mechanism of eclamptic seizures is primary cerebral vasospasm with resultant ischaemia and cerebral oedema involving mainly the watershed areas and parieto-occipital lobes of the brain. SPECT scanning has been shown to be superior to CT scanning and TCD ultrasonography in detecting neuropathophysiologic alterations in eclampsia. However, each of the three investigative tools provide its own unique information and all three are necessary research techniques to improve our understanding of the neuropathophysiological mechanism of eclamptic seizures.

Notes: Objective To compare the antihypertensive effects of epoprostenol sodium (pros-tacyclin) with that of dihydralazine in acute hypertensive crises of pregnancy.Design A prospective randomized study. A minimum of 20 patients per group was considered statistically acceptable (alpha = 0.05, power = 0.9).Setting A large urban tertiary hospital.Subjects Forty-seven pregnant patients with diastolic blood pressures of 〉100 mmmHg were studied.Intervention Lowering of high blood pressure with either dihydralazine (n= 25), the standard drug for this purpose, or epoprostenol (n= 22).Main outcome measure A significant drop in high blood pressure was regarded as a fall of 15 mmHg diastolic and 30 mmHg systolic blood pressure.Results There were no statistically significant differences in the antihypertensive effects between the two treatment groups. Epoprostenol infusion caused less tachycardia; the mean pulse rate changed from 81.77 beats/min, before treatment to 88.36 at stabilization, compared with a change from 80.96 beats/min to 102.68 in the group treated with dihydralazine (P= 0.0024).Conclusion The place of epoprostenol in pregnancy might be in patients with severe hypertension and tachycardia and in those requiring acute control of severe hypertension on the operating table before general anaesthesia.

Notes: Objectives To investigate the efficacy of phenytoin in relation to total and free serum levels in patients with severe pre-eclampsia and eclampsia.Design Prospective descriptive study.Setting Labour Ward, King Edward VIII Hospital, Durban, South Africa. Tertiary referral centre serving an underprivileged community.Subjects Eleven patients admitted with a hypertensive crisis. Four patients had eclampsia and 7 had impending eclampsia.Main outcome measures Free and total phenytoin levels; efficacy of phenytoin as an anticonvulsant and side-effects of therapy.Results Although total phenytoin levels were within the therapeutic range, free phenytoin levels were abnormally high in all patients. Three patients (2 with eclampsia and 1 with imminent eclampsia) each had a seizure after phenytoin treatment had been initiated.Conclusion Neither total nor free phenytoin levels were good predictors of seizure control. It is postulated that the poor performance of phenytoin as an anticonvulsant in severe eclampsia may relate to inadequate distribution of the drug to the brain as a result of cerebral oedema and poor cerebral perfusion rather than paradoxical seizure activity associated with high free phenytoin levels.