Search

The syndrome of amenorrhoea-galactorrhoea has been known for years, but new diagnostic methods opened up a new approach to the treatment of patients with this syndrome. Whether the increasing awareness of hyperprolactinaemia is due only to the impact of these newer diagnostic methods, or whether there is an increasing incidence due to modern civilization, is unsettled. The clinical picture is variable and therefore a high-risk group should be delineated, namely those patients with amenorrhoea-galactorrhoea and hyperprolactinaemia. Since this condition responds very well to treatment with bromergocriptine, and since there is a 5% (micro-adenomas) - 35% incidence of tumour extension during pregnancy, this high-risk group should be scrutinzed for a possible pituitary adenoma. The treatment of pituitary adenomas is at the present stage best labelled as an emotional matter, more particularly for micro-adenomas. This is certainly so for the patient not interested in pregnancy. The long-term outcome in patients with hyperprolactinaemia effectively treated with bromergocriptine is not known. The group with macro-odenomas interested in pregnancy should be treated by some form of destructive procedure. For the rest, the future will tell.

Eighty nine cases of rupture of the gravid uterus occurring over a period of 15 years with 77,133 deliveries, were analysed. The overall incidence of ruptured uteri was 1 per 866 deliveries. The patients were divided into two groups, those with a scarred uterus (47) and those with an unscarred uterus (42). Distinct differences in terms of parity, age, aetiology and pathogenesis, the clinical picture, pathology, type of surgery and outcome were seen between the two groups. Most pronounced was the difference in symptoms and signs. Lower abdominal tenderness (38.2%), and vaginal exploration after delivery (44.6%) were the clinical hallmarks in the scarred uterus group, compared to shock (33.3%), uterine bleeding (30.9%) and severe abdominal pain (23.8%) in the unscarred group. Moreover, conservative surgery was possible in 72.3% of the scarred group against 14.3% in the other group. A maternal mortality of 5.6% and fetal mortality of 52.8% was seen. All maternal deaths and 71.4% of fetal losses occurred in the unscarred group. Fortunately, the number of ruptures clearly decreased over the study period, and furthermore the ratio between spontaneous and traumatic ruptures of an unscarred uterus and ruptures of a scarred uterus increased.

The rapidly changing scene as regards anatomical physiology and neurosecretory systems of the hypothalamic-pituitary-ovarian axis is discussed. New neural polypeptide-like substances are daily added to a long list of known brain hormones. However, many areas in this particular system remain a mystery and present a firm stimulus for further research.

The fine structure of rejected human in vitro fertilized embryos was studied by light and transmission electron microscopy. Apart from normal cytoplasmic features, changes suggestive of degeneration are discussed. Cytoplasmic blebs and cellular debris as well as primitive interblastomeric junctions are also described.

A case of hydrops fetalis with intra-uterine death after premature closure of the ductus arteriosus because of inhibition of premature labour by the administration of indomethacin is presented. The physiology of acute and chronic intra-uterine constriction of the ductus arteriosus and the effects of indomethacin on the fetal circulation are discussed. Mention is also made of the moral conflict confronting the doctor in the management of an affected fetus during the third trimester.

A rare case of transverse myelitis caused by schistosomiasis of the spinal cord during pregnancy is presented. The diagnosis and treatment are discussed.

Fifty patients with premature gonadal failure were subdivided into primary and secondary failure groups. Karyotyping in the primary and ovarian histological examination in the secondary group are preferred diagnostic procedures. Several rare clinical syndromes are mentioned. Possible aetiological factors are identified, and a plea is made for the accurate diagnosis of this condition. Diagnostic pitfalls are also presented.

Human amniotic fluid was compared with Ham's F-10 culture medium as a possible alternative for use in in vitro fertilisation. The cleavage success of mouse embryos in human amniotic fluid (experimental group) was 92% compared with 86% in Ham's F-10 medium. It is concluded that human amniotic fluid is a viable alternative culture medium for mouse embryos.

There are conflicting reports in the literature about the effect of the water source for growth and insemination media in an in vitro fertilisation (IVF) programme. A controlled trial was carried out in which two-cell mouse embryos were cultured in Ham F10 medium containing either grade 1 water (test group) or grade 2 water (control group). Of the two-cell embryos, 92.0% (69 of 75) in the test group and 91.8% (67 of 73) in the control group cleaved to the blastocyst stage (no statistically significant difference). On the basis of this experiment grade 2 water was used in the Tygerberg Hospital human IVF programme with good results. A continuing pregnancy rate of 23% per embryo transfer over a 1-year period is reported.

the ultimate goal of any clinical programme treating infertility by means of in vitro fertilisation and embryo replacement is to maximise the number of patients who become pregnant in a treatment cycle. A 12% pregnancy rate was previously reported from this unit. Following the instigation of changes and further modifications, an overall success rate of 27% per patient was obtained in phase II. The reasons for this improved success are hard to pinpoint, but experience and changes in methodology probably play a role. These changes are described and the results discussed.

Cardiotocograms of 6044 patients in labour were examined for evidence of an abrupt fall in the fetal heart 50 beats within 3 minutes, without a demonstration of signs of recovery in the following 2 minutes. Only 9 instances could be found -- an incidence of 0,15%. Umbilical cord entanglement possibly played a role in 6 of these instances, and 2 of the infants concerned were stillborn. Intra-uterine growth retardation was associated with deceleration in 3 infants, 1 of whom was stillborn.

Serum sodium, potassium, chloride, magnesium, calcium, phosphate, urea, urate, creatinine, carbon dioxide, total alkaline phosphatase, total protein and albumin levels during pregnancy were studied in groups of subjects at less than 14 weeks' gestation, at 14-20 weeks, at 20-28 weeks and at 36-40 weeks. These were compared with levels in a nonpregnant control group matched for age and sex. Serum potassium, sodium and chloride levels remained within the normal range, while calcium, phosphate, total protein and albumin levels decreased progressively after the first trimester. Magnesium levels decreased progressively from early pregnancy to term, and urea, creatinine and carbon dioxide levels all decreased markedly throughout pregnancy. Urate levels were markedly decreased in early pregnancy but returned to normal at term, and the alkaline phosphatase values demonstrated the expected marked increase to term. The fact that all these values were not equally affected suggests that haemodilution cannot be held responsible for all serum changes during pregnancy. Individual results are discussed and a biochemical profile is suggested.

Hypergonadotrophic amenorrhoea implies permanent gonadal failure, This has intense psychological, sociological and practical implications for the patient, and an accurate diagnosis is therefore important. Moreover, it is a heterogeneous group including on the one hand some treatable entities and on the other some conditions which could be deleterious to the patient's general health. Although in the majority of patients a precise aetiological factor for the premature disappearance of the oöcytes cannot be identified, future research will most probably implicate immunological mechanisms.

The protocol for in vitro fertilisation (IVF) at Tygerberg Hospital is presented and the results are analysed. Indications for ovulation induction for IVF included the following: (a) irreversible tubal damage; (b) infertility due to immunological factors; (c) male factor-infertility; and (d) endometriosis. A combination of human menopausal gonadotrophin (HMG) and clomiphene citrate (Clomid; Mer-National) and human chorionic gonadotrophin was used. Clomid is given in dosages of 100 mg for 5 days depending on the cycle length. Three doses of HMG (150 IU) are given on alternate days, starting on the second day of clomiphene treatment. If the leading follicle has not reached a mean diameter of 14 mm the day after the last HMG dose, another dose is given. This dosage is continued until the leading follicle reaches a diameter of 14 mm. A total of 109 cycles in 100 patients was analysed. Ova were considered to be mature as soon as the dominant follicle had reached a sonographic average diameter of 18 mm, another two follicles of 16 mm average diameter being present. Serum luteinising hormone levels were determined 4-hourly from the stage when the leading follicles exceeded an average diameter of 14 mm. In this study the pregnancy rate was 21,3% per laparoscopy and 24,4% per embryo transfer. The oestradiol levels on the 5th day of treatment have a predictive value of the length of stimulation.

Patients with leiomyoma and leiomyosarcoma of the vulva are described. The clinical features of these conditions are summarized and the diagnostic criteria for differentiating leiomyomas from leiomyosarcomas are mentioned. The treatment and follow-up of patients with vulval leiomyosarcomas is discussed briefly.

The effect of serum supplementation was evaluated on 108 oocytes obtained from 29 patients. The oocytes were all mature and randomly distributed in two groups. Each ovum was paired with another ovum within the same patient. The experimental group contained no serum in the insemination and growth medium, but in the control group 10% serum was added to the insemination and growth medium. In the experimental group the cleavage rate was 66.7%, compared to 83.3% in the control group. The embryos from each patient were individually evaluated. The sign test was used for statistical analysis. A significant difference between the two groups (P = 0.01) indicated that in this study the addition of serum to the medium gives better cleavage results. The effect of serum on embryos is discussed, as well as the practical implications of this finding.