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Faecal incontinence presents with a female to male ratio of 8:1 suggesting childbirth as the principal causative factor, although most women do not become symptomatic until after menopause. Obstetric injury may arise as a result of direct muscular damage to the anal sphincter, as occurs during a third-degree tear, and/or may be the result of cumulative damage to the pudendal nerves. Symptomatic women should be assessed in a dedicated clinic where time is available for comprehensive evaluation. Clinical examination alone may fail to detect specific abnormalities. The performance of anal manometry, endoanal ultrasound and neurophysiology studies of the pelvic floor will increase the diagnostic yield. Treatment may include dietary manipulation and physiotherapy. In severe cases surgery may be warranted with secondary repair of the anal sphincter muscle. Adequate primary management of third-degree tears requires careful appraisal so as to reduce the incidence of later incontinence.

C CLARKE, CG BRENNAN, K RODGERS, RM DWYER, PPA SMYTH ENDOCRINE LABORATORY, DEPARTMENT OF MEDICINE AND THERAPEUTICS, UNIVERSITY COLLEGE DUBLIN, IRELAND he demonstration in extrathyroidal human tissues of the sodium iodide symporter (NIS) has raised the possibility that 1311, commonly used as a systemic therapeutic ablative agent in hyperthyroidism and thyroid cancer, might be applied in the treatment of tumours in other NISexpressing tissues such as human breast cancer. Thyroidal transport of 1311 is known to be proportional to circulating stable I and the aim of this study was to determine how stable I (KI) would effect such transport in human breast cancer cell lines MDA-MB-231, MCF-7 and in FRTL-5 thyroid cells. All cells were incubated with KI (01 00mM) for 72 hours after which 1Th I was added . Incubation and uptake of 'l by cells was counted every four hours. Timed efflux of '^I was measured every five minutes. KI in the incubation medium blocked 1251 uptake in a dose-dependent manner in the E receptor positive MCF7 cell line. The effect was less marked in the E receptor negative MDA-MB-231 with significant uptake being maintained even at an I concentration of 50mM. A similar blockade was seen in the FRTL-5 cells with maximum uptake blockade of 25mM I. The rate of efflux of 15I was similar in both MCF-7 and MDA-MB-231 cell lines with a tin of 35 and 40 minutes respectively. In contrast, efflux from the FRTL-5 cells was faster (tire=15 mins). As the human breast has a much lower avidity for I than the thyroid, control of dietary intake would assume even greater importance in radioactive iodine treatment of breast tumours or their metastases.

In contrast to the long tradition of audit in Obstetrics in Dublin audit in Gynaecology is a new concept. Analysis of data collected during the years 1991-1993 is presented. This has addressed the number and type of patients seen in the Gynaecology Unit, procedures performed and complications ensuing. The figures presented are similar to Gynaecology Units in Britain. Deficiencies, such as auditing for outpatient and inpatient waiting lists have been highlighted. These issues are currently being addressed.

SummaryThe relationship between clinical data and the subsequent occurrence of striae gravidarum was studied in a consecutive series of 261 primiparae, using a stepwise logistic regression analysis. The incidence of striae was 42-9 per cent. Variables which demonstrated an independent relationship with the occurrence of striae were maternal age (P

Background Anal sphincter hypertonia is commonly thought to underlie development of anal fissure, yet anal fissure is particularly common after childbirth, a time when anal canal pressure may be reduced. This paradox was investigated by a prospective study of the effect of parturition on the pelvic floor. Methods Anal manometry was performed 6 weeks before and after delivery in 209 primigravid women with no pre-existing history of anorectal disease. Postpartum studies only were performed on a further 104 primiparae. Anal fissure was diagnosed by history and direct examination. Results Some 29 women (9 per cent) developed postpartum anal fissure. Antepartum anal canal resting and squeeze pressures were similar in women who did and those who did not develop fissure. Resting and squeeze anal canal pressures decreased post partum in both groups. Postpartum constipation was more common in those with fissure (62 per cent) than in those without (29 per cent) ( X 2 = 10.6, 1 d.f., P

We wished to establish whether delivery by Caesarean section influenced the incidence of developmental dysplasia of the hip in term breech infants compared with those delivered vaginally. We used maternal charts, singleton term breech presentation, mode of delivery and incidence of developmental dysplasia of the hip for births between January 1997 and October 2002. During the study period 46 089 infants were born. We analysed a total of 941 breech infants of whom 756 were delivered by Caesarean section (515 pre-labour, 241 intrapartum) and 185 vaginally. The incidence of developmental dysplasia of the hip according to the mode of delivery was 19 of 515 (3.69%) following pre-labour Caesarean section, 16 of 241 (6.64%) for intrapartum Caesarean section and 15 of 185 (8.11%) after vaginal delivery. There was a lower incidence of developmental dysplasia of the hip among those infants delivered by elective Caesarean section compared with those delivered vaginally (p < 0.02). These results demonstrate a significantly lower incidence of developmental dysplasia of the hip in term singleton breech births delivered by elective, pre-labour Caesarean section and suggest that labour and delivery influence hip stability in predisposed infants.

Increasing public and professional attention has recently been focused on the issue of both faecal and urinary incontinence following childbirth and these symptoms are sometimes being cited as indications for elective caesarean section. Faecal incontinence has a female-to-male preponderance of 8:1, consistent with childbirth as the principal causative factor, although most symptomatic women do not seek medical advice until after the menopause. Similarly, urinary stress incontinence is almost an exclusively female phenomenon. Obstetric injury may take the form of direct muscular damage to the anal sphincter, as occurs during a third-degree tear, and/or may be the result of cumulative damage to the pudendal nerves. Mechanical, neural and endocrine factors may all play a causative role in faecal incontinence. Symptoms are rarely volunteered by the patient, and may be present for many years after the index pregnancy, and clinical examination alone may fail to detect specific abnormalities. The performance of anal manometry, endoanal ultrasound, urodynamics and neurophysiology studies of the pelvic floor may help to increase the diagnostic yield. Treatment for both urinary and faecal incontinence is available in the form of physiotherapy, fluid and dietary manipulation and in more severe cases, surgery. Adequate primary management of third-degree tears requires careful appraisal as this injury, in particular, is the most important risk factor for subsequent faecal incontinence symptoms. In this chapter we aim to outline the mechanism of damage to the pelvic floor during childbirth, concentrating primarily on anal sphincter damage. We describe the necessary investigations, follow-up and treatment which women with significant pelvic floor damage should receive following delivery, and we finally discuss the issue of further deliveries and, specifically, the current place of caesarean section.

Objectives: To assess factors influencing the prevalence of hysterectomy in Ireland. Methods: Analysis of results of a questionnaire completed by a population-based cohort of 17 735 women aged 50–65 years attending for breast screening. Results: Prevalence of hysterectomy was 22.2%, was increased in proportion to parity and was higher in younger women, those who had previously used oral contraception and those who had private health insurance; peak age at operation was 45–49 years. Conclusion: The relatively high prevalence parity reflects contraceptive practices and utilization of health service resources.

Background A PubMed search (2004-2011) yielded 115 abstracts on induction of labor of which 27(23.5%) specifically stated that the study was confined to nulliparas or multiparas, 23(20%) mentioned parity as a variable and 65 (56.5%) did not mention parity. The objective was to clarify the major differences between nulliparas and multiparas so that in future, labour outcomes would be reported separately for nulliparas and multiparas. Methods Obstetric data were collated on a computer database on all patients at the time of delivery for the year 2009. Results Among 9161 women (nulliparas, n=4407, multiparas, n=4754) there were 3882 nulliparas and 3563 multiparas (without scar) at term (> 37 weeks gestation). The caesarean section rate was significantly higher amongst nulliparas compared with multiparas for both spontaneous labor (195/2502; 7.8% vs. 25/2678; 0.9%) and induced labor (389/1311;29.7.%v.s.51/811; 6.3%, P Conclusion The results confirm the major differences between nulliparas and multiparas and provide unequivocal evidence that obstetric outcome should be reported separately by parity.

Summary Ovarian follicular growth during the periovulatory period was measured using real-time ultrasound in 33 patients during 53 spontaneous ovulatory cycles. The mean follicular diameter increased from 14·1 mm four days before ovulation to a maximum of 20·1 mm on the day of presumptive ovulation. The results correspond with previous static ultrasound studies of follicular development and in nine cycles in which both methods were employed the correlation between measurements on the same day was highly significant (r = 0·944; p

High serum follicle stimulating hormone (FSH) values are consistent with ovarian failure. We studied the progress of 67 women aged under 35 years with oligomenorrhoea or secondary amenorrhoea in whom the serum FSH value was greater than 20 U/1. Twenty-four patients remained amenorrhoeic, but 17 ovulated and six conceived, two on two occasions. Coincident mean serum luteinising hormone (LH) concentrations were significantly lower and mean total urinary oestrogen concentrations were significantly higher in patients who subsequently ovulated, but the degree of increase in FSH did not correlate well with later ovarian function. Treatment with oestrogens, clomiphene citrate, human pituitary gonadotrophin, and bromocriptine was of no benefit in inducing an ovarian response while FSH concentrations remained raised. Our results suggest that a considerable proportion of younger women with ovulatory disorders associated with FSH values in the menopausal range will spontaneously resume ovulation and some will conceive.

Asphyxial seizures occurred in 89 of 101,829 infants born alive at term (0.87/1000) in three large maternity hospitals from January 1980 to December 1984. These seizures were significantly associated with antenatal complications, primiparity, and prolonged pregnancy. Meconium staining of the amniotic fluid was also associated with asphyxial seizures, but there were high false positive (11%) and false negative (50%) rates. Fifteen of the infants who had seizures died (18%) and 21 (25%) were handicapped at 1 year. Outcome was most successfully predicted by the way the infant was feeding at 1-2 weeks. All infants taking more than half their estimated requirements by mouth at 1 week were normal, and those still being fed by tube at 2 weeks were handicapped.

Summary The urinary oestrogen :creatinine (O/C) ratio was measured in first morning specimens of 261 women at 34 weeks gestation to assess prospectively its potential in predicting fetal complications. Forty-two patients (16.1 per cent) had low O/C ratios. All three stillbirths in the series occurred in this group and the incidences of fetal growth retardation and fetal distress in labour were also significantly increased. These complications were unusual when the O/C ratio was high. The O/C ratio at 34 weeks reflected fetal well-being more accurately than clinical examination or blood pressure measurement. The mean O/C ratios of cigarette smokers and non-smokers were similar, although smokers were delivered of lighter babies. Measurement of the urinary O/C ratio is simple and inexpensive. Used as a screening test at 34 weeks it appears to provide an early and fairly reliable indication of reduced placental function.

Intravaginal prostaglandin (PG) E 2 has been shown to ripen the cervix before induction and to shorten labor when the fetal presentation is cephalic. This study reports the influence of PGE 2 gel on induction and labor in 13 primigravid patients with unfavorable cervixes and breech presentation. The results were compared with 25 similarly treated primigravidae with cephalic presentations. Comparable cervical ripening was achieved in the breech and cephalic groups; labors were of similar duration and the incidence of cesarean section was not significantly different in the breech patients. There were no unwanted fetal or maternal effects associated with the gel. PGE 2 gel is an effective aid to induction of labor when the cervix is unfavorable and the breech presents in otherwise uncomplicated pregnancies.

Thirty anovulatory patients, previously unresponsive to clomiphene citrate in standard dosage, were treated with a new incremental method of clomiphene therapy. Clomiphene was given continuously with dosage increments every 5 days, up to a maximum dose of 3750 mg, and ovarian response was monitored with urinary estrogen estimation and with ultrasound. Twenty-one patients (70%) ovulated on this regimen and 8 (27%) conceived; 6 patients who ovulated but did not conceive had other infertility factors. Clomiphene response was associated with a progressive rise in follicle-stimulating hormone, luteinizing hormone, and estrogen excretion; these parameters were unchanged in nonresponders. Side effects of treatment were minimal and only 1 case of hyperstimulation occurred. Preliminary testing with estrogen-amplified gonadotropin-releasing hormone did not differentiate responders from nonresponders. Incremental clomiphene treatment appears to be a less complicated alternative for patients who would otherwise require exogenous gonadotropin therapy.

Cord IgM values were determined in small-for-gestational-age infants born at Hammersmith Hospital during a 5 1/2-year period. 121 (12.5%) infants had levels more than 0.2 g/l; in 92 these were between 0.21 and 0.3 g/l. In only 18 (14.8%) was a level of 0.4 g/l exceeded, and 5 proved cases of intrauterine infection--rubella (2), syphilis (2), and toxoplasmosis (1)--were in this group. The factor most often associated with cord IgM more than 0.4 g/l was prolonged rupture of the membranes. There was an increased incidence of blood group B among the mothers, probably reflecting the greater number of nonCaucasian women giving birth to small-for-gestational-age infants. Determination of cord IgM did not help significantly indiagnosis.

Nine subjects were studied by means of ultrasound to determine the precise time of ovulation and to document follicular changes immediately prior to, during, and after rupture. There were no demonstrable changes in the size of appearance of the follicle over a period of up to 7 hours prior to its rupture. In one of the four subjects in whom follicular collapse was witnessed, the follicle emptied completely within less than 1 minute. In two of the other three subjects, there was an initial rapid loss of fluid followed by a flower release of the remaining contents. This latter process took 7 minutes in the first patient and 35 minutes in the second patient. The slow phase of follicular collapse may well be an important aspect in the release of the ovum. The corpus hemorrhagicum was seen to develop within 1 hour of ovulation.High-resolution ultrasound equipment was used to document the events occurring immediately before, during, and after human ovulation. 9 subjects were studied. No demonstrable changes in size or appearance of the follicle over a 7-hour period before rupture were seen. In 1 of 4 subjects with follicular collapse, the follicle emptied completely within less than 1 minute. In 2 of the other 3 subjects, an initial rapid loss of fluid occurred followed by a flower-like release of the remaining contents. The release took 7 minutes in Patient 1 and 35 minutes in Patient 2. The slow phase of follicular collapse may be an important aspect in ovum release. The corpus hemorrhagicum was seen to develop within an hour of ovulation completion.

In a review of 108 cases of consecutively selected women undergoing hysterectomy for nonmalignant disease, it was found that one third of the patients or their husbands had previously been sterilized. In many instances, the gynecologic problem necessitating hysterectomy antedated the sterilizing procedure. It is postulated that, when couples request sterilization, two operations might be avoided if routine consideration were given to any condition that might lead to hysterectomy.