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EPIDURAL ANAESTHESIA AND AVOIDANCE OF POSTPARTUM STRESS URINARY INCONTINENCE
762 CLASSICAL VERSUS LOWER SEGMENT CAESAREAN SECTION IN VERY PRE-TERM DELIVERIES
SiR,—The incidence of classical caesarian section has increased lately largely because it is being used more often for the delivery of the very pre-term infant on the grounds that the outcome might improve thereby.1 In our hospital over 4200 infants were delivered in 1986, of whom 17 live singletons under 30 weeks’ gestation were delivered by caesarean section, in 6 classical and lower uterine segment in 11. The indications for operative interference, mean gestational age, mean birth weight and number of infants under 1000 were similar for both groups (table). However, the neonatal outcome of the two groups was very different, with only 2 survivors in the group delivered by classical caesarean section, and no losses among those delivered by lower segment caesarean section. CLINICAL DETAILS AND OUTCOME
Spontaneous rupture of membranes
SROM =
This evaluation of one method of delivery against another is retrospective but it would be very difficult, and probably not ethical, to
do
a
randomised trial. Differences in the indications for
one
operation rather than the other would be critical to the interpretation of our data: there will be situations in which a classical caesarean section is surgically inevitable, as when there is no formed lower uterine segment, or when there is a particular malpresentation; in addition some surgeons will choose classical section for fetal reasons. However, both groups were comparable in respect of the indication for operative interference. Our experience suggests that classical section should be undertaken only after full consideration has been given to the possibility of a lower segment procedure. Department of Obstetrics and Gynaecology, University of Edinburgh, Centre for Reproductive Biology, 37 Chalmers Street,
N. G. HADDAD D. S. IRVINE
Edinburgh EH3 9EW 1.
Keeping JD, Morrison J, Chang AMZ. Classical caesarean deliveries. Aust NZ J Obstet Gynaecol 1980; 20: 103-05.
section in
pre-term
Vaginal delivery can injure the pelvic floor, as demonstrated electrophysiologically by pudendal nerve damage,l,2 and this was reflected in postnatal SUI. Our fmdings suggest that the relaxation of the pelvic floor achieved by epidural anaesthesia may prevent the development of persistent postnatal SUI. Department of Obstetrics and Gynaecology, Klinikum Grosshadern, University of Munich, 8000 Munchen 70, West Germany
B. SCHUESSLER U. HESSE T. DIMPFL C. ANTHUBER
RE, Warell DW. The role of pregnancy and child birth in partial denervation of the pelvic floor Neurourology Urodynam 1987; 6: 183 2. Snooks ST, Stetchell M, Swash M, Henry MM. Injury to the innervation of the pelvic floor sphincter musculature in child birth. Lancet 1984, i: 546-50. 1. Allen
RECOMBINANT &agr;2-INTERFERON TREATMENT IN CHILDREN WITH CHRONIC HEPATITIS B
SIR,-In the two trials of recombinant oc2-interferon (rIFN) by Dr La Banda and colleagues in Spanish children (Jan 30, p 250), the number of children who became negative for hepatitis B virus (HBV) DNA and for hepatitis B e antigen (HBeAg) by 12 months and 15 months in the control groups was not significantly different from the treated groups-3 in the control groups and 4 in the treated groups in both trials. Like us (Oct 17, p 877), La Banda and colleagues also noted a decrease in HBV-DNA and HBV-DNA polymerase levels in all children during rIFN therapy. However, we did not report significance levels for the transient responders because we do not consider a non-sustained response as "useful". La Banda et al further noted a more prompt decrease in HBV-DNA and HBV-DNA polymerase in their treatment groups than in the control groups, a finding which we also reported. The decrease in alanine aminotransferase levels in La Banda and colleagues’ second trial was only observed in the rIFN responders. In our trial too, 2 of the 4 patients with sustained loss of HBV-DNA and HBeAg had high alanine and aspartate aminotransferase levels which became normal before the end of the trial. We fail to see what long-term beneficial effect rIFN alone has on children who carry hepatitis B surface antigen, irrespective of whether they are Chinese or Spanish. The only difference rIFN made in our trial and the trials of La Banda et al was to hasten the disappearance of HBV-DNA and HBeAg by a few months. Otherwise the loss of HBV-DNA and HBeAg occurred in the same proportion of children in both the treated and control groups in all three trials. However, we did suggest that further trials should be done, possibly with steroid as a "primer". Indeed we are midway through a new trial involving 90 children. Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
C. L. LAI H. J. LIN
P. C. WU
WARFARIN, SPONTANEOUS HYPHAEMAS, AND INTRAOCULAR LENSES
SIR,-Recurrent microscopic hyphaema is
EPIDURAL ANAESTHESIA AND AVOIDANCE OF POSTPARTUM STRESS URINARY INCONTINENCE
SIR,-Six months after delivery 424 primigravida were questioned about persisting stress urinary incontinence (SUI). Before the pregnancy no patient had experienced SUI. 334 women were delivered spontaneously, 32 needed instrumental assistance (12 forceps, 22 vacuum extraction), and 58 were delivered by caesarean
The
section.
frequency of SUI
was
0/58
for the
women
delivered
by
(6%) out of 366 in those delivered vaginally. Birthweight (>3500 g), large head circumference (>35 cm), prolonged second stage labour (> 30 min), instrumental vaginal delivery, and maternal age ( > 30 years) did not affect the frequency caesarean
and 22
of SUI significantly. SUI was found in 15 of 156 patients (9-6%) given a pudendal block but in only 7 of 210 patients (3-3%) given epidural anaesthesia
(p-001).
an occasional, late in eyes with iris-fixated intraocular lenses. In anticoagulated patients, however, the intraocular haemorrhage may be more serious. We report four such cases in patients with intraocular lens implants sutured to the iris at intracapsular cataract surgery. These implants have been widely used in the UK. Today posterior chamber implants have more or less replaced them but patients still have this type of implant, and physicians prescribing anticoagulants should be aware of the risk of serious intraocular haemorrhage since previous cases have appeared in journals for eye
complication
specialists. 1,2 Case1 (53, M with hyperlipidaemia and ischaemic heart disease; insertion of Binkhorst lens in 1983).-In 1985, after a cerebrovascular accident, he was anticoagulated with warfarin and 3 months later he presented with hazy vision and slit-lamp examination confirmed hyphaema. The prothrombin ratio was 15 and the eye settled with bed rest. In January, 1986, he presented with painless loss of vision and was found to have a large hyphaema, with a secondary rise in intraocular pressure. The prothrombin-
SiR,—The incidence of classical caesarian section has increased lately largely because it is being used more often for the delivery of the very pre-term infant on the grounds that the outcome might improve thereby.1 In our hospital over 4200 infants were delivered in 1986, of whom 17 live singletons under 30 weeks’ gestation were delivered by caesarean section, in 6 classical and lower uterine segment in 11. The indications for operative interference, mean gestational age, mean birth weight and number of infants under 1000 were similar for both groups (table). However, the neonatal outcome of the two groups was very different, with only 2 survivors in the group delivered by classical caesarean section, and no losses among those delivered by lower segment caesarean section. CLINICAL DETAILS AND OUTCOME
Spontaneous rupture of membranes
SROM =
This evaluation of one method of delivery against another is retrospective but it would be very difficult, and probably not ethical, to
do
a
randomised trial. Differences in the indications for
one
operation rather than the other would be critical to the interpretation of our data: there will be situations in which a classical caesarean section is surgically inevitable, as when there is no formed lower uterine segment, or when there is a particular malpresentation; in addition some surgeons will choose classical section for fetal reasons. However, both groups were comparable in respect of the indication for operative interference. Our experience suggests that classical section should be undertaken only after full consideration has been given to the possibility of a lower segment procedure. Department of Obstetrics and Gynaecology, University of Edinburgh, Centre for Reproductive Biology, 37 Chalmers Street,
N. G. HADDAD D. S. IRVINE
Edinburgh EH3 9EW 1.
Keeping JD, Morrison J, Chang AMZ. Classical caesarean deliveries. Aust NZ J Obstet Gynaecol 1980; 20: 103-05.
section in
pre-term
Vaginal delivery can injure the pelvic floor, as demonstrated electrophysiologically by pudendal nerve damage,l,2 and this was reflected in postnatal SUI. Our fmdings suggest that the relaxation of the pelvic floor achieved by epidural anaesthesia may prevent the development of persistent postnatal SUI. Department of Obstetrics and Gynaecology, Klinikum Grosshadern, University of Munich, 8000 Munchen 70, West Germany
B. SCHUESSLER U. HESSE T. DIMPFL C. ANTHUBER
RE, Warell DW. The role of pregnancy and child birth in partial denervation of the pelvic floor Neurourology Urodynam 1987; 6: 183 2. Snooks ST, Stetchell M, Swash M, Henry MM. Injury to the innervation of the pelvic floor sphincter musculature in child birth. Lancet 1984, i: 546-50. 1. Allen
RECOMBINANT &agr;2-INTERFERON TREATMENT IN CHILDREN WITH CHRONIC HEPATITIS B
SIR,-In the two trials of recombinant oc2-interferon (rIFN) by Dr La Banda and colleagues in Spanish children (Jan 30, p 250), the number of children who became negative for hepatitis B virus (HBV) DNA and for hepatitis B e antigen (HBeAg) by 12 months and 15 months in the control groups was not significantly different from the treated groups-3 in the control groups and 4 in the treated groups in both trials. Like us (Oct 17, p 877), La Banda and colleagues also noted a decrease in HBV-DNA and HBV-DNA polymerase levels in all children during rIFN therapy. However, we did not report significance levels for the transient responders because we do not consider a non-sustained response as "useful". La Banda et al further noted a more prompt decrease in HBV-DNA and HBV-DNA polymerase in their treatment groups than in the control groups, a finding which we also reported. The decrease in alanine aminotransferase levels in La Banda and colleagues’ second trial was only observed in the rIFN responders. In our trial too, 2 of the 4 patients with sustained loss of HBV-DNA and HBeAg had high alanine and aspartate aminotransferase levels which became normal before the end of the trial. We fail to see what long-term beneficial effect rIFN alone has on children who carry hepatitis B surface antigen, irrespective of whether they are Chinese or Spanish. The only difference rIFN made in our trial and the trials of La Banda et al was to hasten the disappearance of HBV-DNA and HBeAg by a few months. Otherwise the loss of HBV-DNA and HBeAg occurred in the same proportion of children in both the treated and control groups in all three trials. However, we did suggest that further trials should be done, possibly with steroid as a "primer". Indeed we are midway through a new trial involving 90 children. Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
C. L. LAI H. J. LIN
P. C. WU
WARFARIN, SPONTANEOUS HYPHAEMAS, AND INTRAOCULAR LENSES
SIR,-Recurrent microscopic hyphaema is
EPIDURAL ANAESTHESIA AND AVOIDANCE OF POSTPARTUM STRESS URINARY INCONTINENCE
SIR,-Six months after delivery 424 primigravida were questioned about persisting stress urinary incontinence (SUI). Before the pregnancy no patient had experienced SUI. 334 women were delivered spontaneously, 32 needed instrumental assistance (12 forceps, 22 vacuum extraction), and 58 were delivered by caesarean
The
section.
frequency of SUI
was
0/58
for the
women
delivered
by
(6%) out of 366 in those delivered vaginally. Birthweight (>3500 g), large head circumference (>35 cm), prolonged second stage labour (> 30 min), instrumental vaginal delivery, and maternal age ( > 30 years) did not affect the frequency caesarean
and 22
of SUI significantly. SUI was found in 15 of 156 patients (9-6%) given a pudendal block but in only 7 of 210 patients (3-3%) given epidural anaesthesia
(p-001).
an occasional, late in eyes with iris-fixated intraocular lenses. In anticoagulated patients, however, the intraocular haemorrhage may be more serious. We report four such cases in patients with intraocular lens implants sutured to the iris at intracapsular cataract surgery. These implants have been widely used in the UK. Today posterior chamber implants have more or less replaced them but patients still have this type of implant, and physicians prescribing anticoagulants should be aware of the risk of serious intraocular haemorrhage since previous cases have appeared in journals for eye
complication
specialists. 1,2 Case1 (53, M with hyperlipidaemia and ischaemic heart disease; insertion of Binkhorst lens in 1983).-In 1985, after a cerebrovascular accident, he was anticoagulated with warfarin and 3 months later he presented with hazy vision and slit-lamp examination confirmed hyphaema. The prothrombin ratio was 15 and the eye settled with bed rest. In January, 1986, he presented with painless loss of vision and was found to have a large hyphaema, with a secondary rise in intraocular pressure. The prothrombin-