Obstetrics and Gynaecology Forum - Volume 18, Issue 3, 2008
Volume 18, Issue 3, 2008
Author S.C. MoodleySource: Obstetrics and Gynaecology Forum 18, pp 61 –63 (2008)More Less
In the last 25 years, major technological advances have been made resulting not only in the improvement of image quality but also in an increased use of transvaginal scanning to diagnose pelvic pathology and early pregnancy complications. The development of the endoanal probe has revolutionised the management of sphincteric damage and recently translabial ultrasound is gaining popularity in urogynaecological scanning for pelvic floor disorders.
Source: Obstetrics and Gynaecology Forum 18, pp 67 –70 (2008)More Less
Preterm labour (PTL) before 34 weeks gestation which complicates 3-4% of pregnancies is one of the most challenging problems in modern maternity are. It is the single most important cause of neonatal morbidity and mortality and disability in children and adults. About 75% of neonatal deaths occur in infants born prematurely, with over two thirds of these arising in the 30-40% of preterm infants who are delivered before 32 weeks gestation. Although there has been an overall increase in the survival rate, there has been an increase in the short-term morbidity and long term physical and mental disability in infant survivors of very preterm birth. Reduction in the consequences of PTL can either be through strategies involving primary or secondary prevention. Primary prevention in the form of alterations in lifestyle has failed to have any impact on the incidence of PTL. Consequently the only real strategy has to be based on secondary preventative strategies. These involved early diagnosis and improved secondary / tertiary care. This review article focuses on the imaging aspect of secondary prevention and highlights the evidence to support the use of ultrasound in preterm labour.
Author S.R. RamphalSource: Obstetrics and Gynaecology Forum 18, pp 73 –78 (2008)More Less
Urogynaecology and pelvic floor disorders are common conditions with increasing prevalence worldwide. The evaluation of these conditions include a detailed history with a thorough assessment of the lower urinary tract, bowel and sexual symptoms, a detailed physical examination as well as accurate objective information which among others may include imaging techniques. It is important to note that imaging may not be necessary in all patients, and with the current, restricted financial climate that we all work in, one has to select the least expensive imaging test to get the maximum information which improves the patients' diagnosis and management.
Author L. GovenderSource: Obstetrics and Gynaecology Forum 18, pp 81 –85 (2008)More Less
Intra-amniotic band-like structures are seen fairly commonly on routine obstetric scans, especially during the first and second trimesters of pregnancy. It is important to establish the cause for such findings in order to determine their clinical significance and to assess prognosis. The vast majority of band-like structures are uterine synechiae, which are benign and have no clinical significance. These are usually detected as an incidental finding and do not interfere with growth and development of the fetus. Visualisation of these band-like structures must not be confused with the Amniotic Band Syndrome, especially when the fetal anatomy is normal. True amniotic bands are rare, but are usually associated with a range of anatomic abnormalities and have a poor prognosis. Other, less common types of amniotic band-like structures may also be detected.
Although the precise diagnosis may not always be evident, misdiagnosis of synechiae as an amniotic band is quite common. This results in undue concern and anxiety about the development and outcome of an otherwise perfectly normal baby. Correlation of the ultrasound findings with the patients' history is also important. An overview of the different types of band-like structures detected sonographically, their classification and clinical significance are presented.
Author M. AdhikariSource: Obstetrics and Gynaecology Forum 18, pp 87 –90 (2008)More Less
Introduction: Periventricular-intraventricular haemorrhage is the most common, well known acute perinatal brain injury in low birth weight infants (LBWI). It is the major cause of death and disability in this group of babies. The other major lesion is periventricular leucomalacia (PVL). The non-invasive technique of cranial ultrasound clarified the diagnosis and assisted in documenting the decline in the 1980's from 34-39% < 1500gms or < 35 wks GA with intraventricular haemorrhage (IVH) to 15- 20% in most centres by the 1990s. Pathogenesis: Prematurity is the major factor with the associated complications of respiratory distress, with pneumothorax, hyper- and hypotension, hypoxia and ischaemia and reperfusion injury contributing to the development of PVH / IVH. IVH occurs in the first two days and virtually all by one week. IVH occurs in the periventricular region, the germinal matrix which is very vascular with immature blood vessels, poor tissue support for vessels which rupture easily and is associated with coagulopathy. PV haemorrhagic infarction, the grade IV IVH is severe IVH & intense venous congestion. Periventricular leucomalacia results from a complex interaction of cerebral vascular and cerebral blood flow disturbances following hypoxia, ischaemia and a cytokine cascade. Focal necrotic lesions develop in the periventricular white matter. Other modalities of assessing the brain are by MRI. Diffuse weighted magnetic resonant imaging can detect PVL by day five. Antenatal doppler measurements are a further technique which has shown correlation between fetoplacental blood flow, brain injury and brain volumes in VLBWI. Abnormal umbilical artery / middle cerebral artery pulsatility index was associated with reduced brain volume and reduced cerebral volume. Outcomes: Of those LBWI who die, 50% have IVH. Of the survivors 20- 40% have IVH. Of those with severe IVH 50% die, moderate IVH 15% die and mild / small IVH 5% die. The outcomes for PVL are related to the duration of oxygen dependency, septicaemia, necrotising enterocolitis (NEC) and are worse with NEC and surgery. The extent of the PVL determines the outcome. Prevention: Maternal factors include aspects of maternal health, health access and antenatal steroids. Neonatal factors include improved neonatal care, correction of metabolic acidosis, careful fluid administration, careful oxygen delivery, appropriate feeding and management of infections.
Author K. MoodleySource: Obstetrics and Gynaecology Forum 18, pp 93 –95 (2008)More Less
Technological advances in medicine have changed the landscape of fetal medicine considerably. Growing knowledge in fetal physiology, ultrasound, antenatal screening and an emphasis on preventive medicine promotes the detection of a wide range of abnormalities leaving both parents and obstetricians with difficult choices at various stages during pregnancy.
Early terminations are ethically controversial. However, late terminations (>20 weeks gestation) and feticide (including post-viable fetuses) have advanced the debate on the ethics of abortion. Poignant ethical questions surround the status of the fetus as opposed to that of the newborn.While most regulations regard severe fetal abnormalities as being incompatible with life and having the potential to cause severe pain and suffering after birth, slippery-slope arguments are raised when feticide is performed for abnormalities like cleft lip and palate.
Respecting the autonomy of the mother who may request a termination late in her pregnancy raises enormous ethical conflict for the treating obstetrician who must balance this request against the principle of non-malfeasance (doing no harm) inherent in killing a viable fetus. There is a clear moral distinction between actively killing an abnormal viable fetus and allowing an abnormal newborn to die after birth. This distinction may be lacking in policy-making in countries with a permissive feticide policy and a restrictive neonatal policy in respect of non-treatment. Furthermore, where feticide is concerned, do obstetricians have a right of conscientious objection globally?
At a more complex level, destruction of a viable fetus with significant abnormalities raises concerns of eugenics. Is feticide and late termination of pregnancy discriminatory towards people with disabilities and a veiled attempt to create a genetically pure population?
This paper explores the ethical conflict and legal inconsistency in feticide and late termination of pregnancy at a global level and argues for a universal policy based on fetal status and acknowledgment of the moral distinction between killing and letting die.
Source: Obstetrics and Gynaecology Forum 18, pp 97 –100 (2008)More Less
Fetal ovarian cysts represent cystic lesions confined to the lower abdomen of a female fetus, when the stomach, bladder and both kidneys appear normal. We report on a rare case of a complicated fetal ovarian cyst measuring approximately 5cm detected at 34 weeks gestation. Based on the sonographic features a diagnosis of a complicated fetal ovarian cyst (either torsion or haemorrhage or both) was made. A haemorrhagic fetal ovarian cyst and possible torsion was confirmed post delivery at surgery and an oophorectomy had to be performed. Ovarian cysts greater than 4 cm are prone to complicate resulting in compromise of this organ system. Decompression of cysts >4cm in fetuses remote from term may reduce the complication rate of these larger fetal ovarian cysts. An approach to the diagnosis and management of fetal ovarian cysts is presented.
Author Johann CoetzeeSource: Obstetrics and Gynaecology Forum 18 (2008)More Less
Urogynaecology and Reconstructive pelvic surgery (URPS) is the Cinderella subspecialty of Obstetrics and Gynaecology. The other three subspecialties of Obstetrics and Gynaecology, namely Oncology, Fetal-maternal medicine and Reproductive medicine, all enjoy peer recognition, examination credentialing and board certification in South Africa, as in many other countries in the world.