OBSTETRICS AND GYNÆCOLOGY

s from ~enical Literature. OBSTETRICS AND GYNJECOLOGY. Cervical Incompetence as a Cause of Freta1 Loss. E. S. TAYLOR AND R. R. HANSEN (J. Amer. med. Aaa., November 7, 1959) discuss the diagnosis, treatment and results in 40 patients with incompetence of the cervical os treated during the past two years at three Colorado hospitals. This condition was found to be a significant cause of repeated abortions between the sixteenth and twenty-eighth weeks of gestation and had an incidence of 1 in 500 pregnancies Although it is usually due to past obstetrical or gynseeologieal trauma, a few cases are found in which no trauma has occurred and no physical defect of the cervix is apparent. A congenital abnormality has been postulated in such cases. The history of a patient with cervical incompetence is usually one of recurrent middle trimester abortions characterized by the sudden painless passage of amniotic fluid between the sixteenth and twenty-eighth weeks, followed by almost immediate expulsion of the conceptus. In one-half of the patients in this series there was a history of past gyneecological or obstetrical trauma. An apparently normal delivery at term rarely interferes with the functional integrity of the cervix. Presumptive evidence of incompetence of the cervical os can be demonstrated by the painless passage of a 7 mm, Hegar dilator through the internal os in the non-pregnant woman. The authors do not consider hysterographic confirmation of the incompetent os to be necessary, but a hysterogram is valuable for the demonstration of abnormalities of the uterine body which are to be considered in the differential diagnosis. Incompetence of the cervix is stated to become apparent between the fourteenth and twentieth weeks of gestation, and the diagnosis is confirmed when the cervix begins to dilate and the membranes can be observed or palpated in the cervical canal. The authors stress the importance of a careful selection of patients and choice of operation. Incompetence due to a deep laceration into the cervical canal requires trachelorrhaphy when the patient is not pregnant. The operative technique employed is a modification of the Shirodkar operation, using a single. thickness, 8 mm. "Mercilene", pursestring suture anchored by silk sutures at the level of the internal os. The 40 patients in the series had previously had 182 pregnancies with only 35 surviving children (19% survivals). Only 15 of the living infants were born at term, and these were all first pregnancies. Twenty of the surviving infants were premature, and seven of these have permanent complications of prematurity. Thirty-two of the 40 patients who had the Shirodkar type of operation performed during pregnancy have been delivered of normal infants, including two sets of twins. Twenty-two were delivered by Crosarean section and 10 vaginally, after removal of the cervical suture. Two of the failures were considered due to deep lacerations of the cervix not amenable to this type of operation. The authors conclude that careful selection of patients for operation and performance of the operation during pregnancy between the fourteenth and twenty'seventh weeks result in successful pregnancies in at least 80% of patients. Breech Presentation and Delivery. D. HAY (J. Obstet, Gynooc. Brit. Emp., August, 1959) discusses a study of 218 single breech deliveries over a four-year period. The teaching and procedure of the Liverpool school have been broadly followed. Emphasis has been placed on careful prenatal assessment of cases and experienced obstetrical supervision at delivery. There were 84 cases of assisted breech delivery, 25 full breech extractions, 29 spontaneous breech deliveries, and 27 lower segment Crosarean sections in a total of 165 breech deliveries of babies weighing 3 lb. 10 oz. and over. The corrected fcetal mortality rate in this series was 1·2% after exclusion of 49 foetal deaths from other causes such as premature labour, foetal abnormalities, accidental heemorrhage, etc. The Cresarean section rate of 16% in the corrected series was largely determined by the age of the patient (over 36 years), previous obstetric history and large babies. During the six years prior to this study the corrected fcetal mortality rate was 5'6% and the Cresarean section rate 17'5%. A trial of labour was carried out on 10 patients, of whom four came to Cresarean section on account of incoordinated uterine action. Post-maturity was exceptional among these patients. The author stresses the importance of the position of the fcetal limbs in the prognosis of breech cases. The legs were extended in 141 cases and flexed in 42 cases. The breech with flexed legs is considered a potentially dangerous presentation on account of the increased risks of prolapsed cord, prolonged first stage and difficult second stage. The author advocates Cresarean section in otherwise doubtful cases when the legs are flexed. The practice of pulling down a leg to encourage better pains in breech presentations with flexed legs is condemned. Cord presentation or prolapse occurred in eight of 42 breech presentations with flexed legs, while no case of prolapse of the cord was noted in cases with extended legs. The incidence of manual removal of the placenta in breech presentations with vaginal delivery was 13%, and delayed involution of the uterus occurred in 35%. The author considers that the chief danger to the fcetus in breech presentations lies in the soft tissue resistance of an undilated cervix and the muscles of the pelvic floor and perineum. For this reason the Liverpool technique of "assisted breech delivery" is preferred to the "hands off the breech" method. Trial labour in breech deliveries where there is doubt concerning disproportion is considered a safe procedure providing the obstetrician has excluded outlet contraction. Incoordinate uterine action is a dangerous complication in breech delivery, and, if persistent, is considered by the author to be an indication for Cresarean section. He presents evidence that primary breech presentation is due to uterine abnormalities and that the practice of external cephalic version has no influence on the steady incidence of breech deliveries of about 3%. He considers it safer nowadays for the baby to be delivered either vaginally by the breech, or by Cresarean section in selected cases, than to run the increased risk of external version, and therefore he condemns the practice ofantenatal external cephalic version. The increased use of lower segment section for selected breech deliveries is considered responsible for the low fcetal death rate in this series. The relative safety of Oeesareen section for these patients is discussed and the author concludes with the dictum: "When the outcome of the festus is in doubt (in breech presentation) it is safer to carry out Crosarean section." Protoveratrine in the Prevention and Management of Eclampsia. P. M. ELLIOTT (J. Obstet, Gynooc. Brit. Emp., August, 1959) discusses recent methods employed in the prevention and management of eclampsia and reports a study of 25 patients treated at King George V Memorial Hospital, Sydney, with intravenously administered protoveratrine. This drug exerts a hypotensive response through generalized arteriolar dilatation, causes bradycardia through vagal stimulation, and has a digitalis-Iike effect on the failing heart. Initial intravenous medication was given to four patients with eclampsia, 16 with preeclampsia, four with essential hypertension and superimposed preeclampsia, and one with chronic pyelonephritis. In many of the cases it was used after magnesium sulphate and paraldehyde had been unsuocessful. The preparation used was "Puroverine" in a dosage of 0·1 mg. in 10 Jul. of distilled water, given at the rate of 1 Jul. per minute until a fall of about 30 mm, of mercury in the systolio pressure and 25 mm. in the diastolio pressure was recorded. Maximum response was usually obtained within 20 to 60 minutes of injection and if no response occurred the intravenous injection was repeated. After an initial satisfactory response the blood pressure levels were maintained around 120-140/70-90 mm. of mercury by intramuscular injections of the drug. An effective initial hypo. tensive response was obtained in 24 cases, being immediate in 16 and delayed in eight. Four patients who had an eclamptic fit or fits before treatment had no further convulsions after the intravenous administration of protoveratrine. No patient with preeclamptic toxeemia had a convulsion after initial protoveratrine treat· ment. Five preeclamptic patients with headache and one with blurred vision were promptly relieved by this treatment. One patient developed anuria after treatment and six patients with known oliguria had improved urinary output after treatment. In all of the 24 patients diuresis was established within 36 hours of intravenous injection. The rate of diminution of eedema paralleled the diuretic response. With one exception there was an appreciable diminution of the degree of proteinuria in all cases. There was one maternal death in the series. Among 16 patients who received intravenous injections of protoveratrine ante partum but after gestation had reached 28 weeks, there were 12 living children (one case of twins), two stillbirths and three neonatal deaths. Side effects JULY 30. 1960 THE MEDICAL JOURNAL OF AUSTRALIA 189 due to the drug occurred in eight patients, and included nausea and vomiting, excessive hypotension, cardiac arrhythmias, retrosternal burning, swelling of the salivary glands, periorbital oedema, excessive salivation and rhinorrhoea. All such side effects were rapidly controlled. The author discusses seven cases in which there was a delayed response to protoveratrine and the single case of failed response. He concludes that, in the absence of exact knowledge concerning the ootiology of eclampsia, the most profitable line of treatment would appear to be that directed towar