Long-term exogenous oestrogen therapy has resulted in the suggestion that conditions such as osteoporosis and myocardial infarction may be prevented. But as yet there is no evidence that progesterone plays any significant role in the physiology of the menopause.
Original Description:
Original Title
1.4 Management of Constriction Ring of the Uterus Using Isoxuprine m. Barker and j.v. Laursen_2
Long-term exogenous oestrogen therapy has resulted in the suggestion that conditions such as osteoporosis and myocardial infarction may be prevented. But as yet there is no evidence that progesterone plays any significant role in the physiology of the menopause.
Long-term exogenous oestrogen therapy has resulted in the suggestion that conditions such as osteoporosis and myocardial infarction may be prevented. But as yet there is no evidence that progesterone plays any significant role in the physiology of the menopause.
TYDSKRIF VIR OBSTETRIE EN GINEKOLOGIE 1 Junie 1968
symptoms such as hot flushes and atrophic vaginitis, but their prophylactic use in the prevention of ageing has as yet to be established. Early enthusiasm for long-term exogenous oestrogen therapy has resulted in the suggestion that conditions such as osteoporosis and myocardial in- farction may be prevented. It has, however, not yet been shown that these changes are the direct result of with- drawal of endogenous oestrogens and are preventable by appropriate oestrogen therapy. With regard to progesterone administration. Kistner' states that as yet there is no evidence that progesterone plays any significant role in the physiology of the meno- pause. Several questions urgently require answers. I. Is the climacteric a normal physiological stage in the life of the human female, or is it a simple result of ovarian failure and oestrogen deficiency? 2. Are the manifestations of ageing directly related to diminution of circulating sex hormones? 3. Can the administration of exogenous oestrogen or other sex hormones prevent the manifestations of ageing? 4. Are the oestrogens at present available for adminis- tration equivalent in effect to circulating endogenous oestrogens? 5. Does long-term oestrogen administration result in an increased incidence of breast or uterine carcinoma? 6. Do oestrogens have a direct effect on the psychologi- cal state and sense of well-being in the postmenopausal patient? To these ends the development of more precise diagnos- tic techniques and methods of evaluation is vital. Wilson's' description of the probable fate of the non- treated elderly female as being one of hypertension, athe- rosclerosis, flabby breasts, dowager's hump, atrophic geni- tals and a vapid cow-like feeling called a 'negative state' would appear to be an overstatement of the case. How- ever, there is some reason to believe that the administra- tion of oestrogens or other sex hormones may not only alleviate menopausal symptoms, but will have some real effects on ageing processes in the postmenopausal woman. SUMMARY Evidence for the current concept that the climacteric is a result of hormone deficiency is critically appraised. There is as yet no proof that long-term oestrogen therapy to the post- menopausal female is of any major benefit in the prevention of coronary occlusive disease or osteoporosis. Further con- trolled investigation into the use of natural oestrogens, particu- larly their effect on ageing, is an urgent necessity. I wish to thank Prof. D. A. Davey, head of the Department of Obstetrics and Gynaecology of the University of Cape Town, for his constructive criticism during the preparation of this review. REFERENCES 1. JefIcoate, T. N. A. (1967): Principles of Gynaecology, 3rd ed.. p. 112. London; Butterworths. 2. Lewis, T. L. T. (1964): Progress in Clinical Obstetrics and Gynae- cology, 2nd ed.. p. 460. London: J. & A. Churchill. 3. Kistner, R. W. (1968): s. Afr. J. Obstet. Gynaec.. 6. 1. 4. Wilson. R. A. and Wilson, T. A. (1963): J. Arner. Geriat. Soc .. le 347. 5. Davis, M. E. ill Marcus. S. L. and Marcus, C. C.. eds. (1967): Ad- vances in Obstetrics and Gynaecology, vo!. 1, p. 419. Baltimore: \Villiams & Wilkins. 6. GreenhiH, J. P., ed. (1967): Yearbook of Obs!ecrics and G)'"aecolog)", 1967 - 1968. p. 472. Chicago: Year Book Medical Publishers. 7. Pick, R.. Stamler, J., Rodbard, S. and Katz, L. N. (1952): Circula- tion. 6, 276. 8. Oliver, M. F. and Boyd. G. S. (1959): Lancet. 1, 690. 9. Snajderrnan. M. and Oliver. M. F. (1963): Ibid., 1, 962. 10. Leading Article (1966): Ibid., 2, 96. 11. Veterans Administration Cooperative Study of Atherosclerosis (1966): Circulation. 33, suppl. 2. 12. Parrish. H. M., Carr, C. A., Hall, D. G. and King, M. T. (!967): Arner. J. ObSlet. Gynec.. 99, 155. 13. Symposium on Estrogen and the Menopausal Woman (1966): Bull. Sloane Hosp. Worn. N.Y., 12. 99. 14. WaHach. S. and Hennernan. P. H. (1959): J. Arner. Med. Assoc., 171, 1637. 15. Albright, F., Smith, P. H. and Richardson. A. M. (1941): Ibid.. 116, 2465. 16. Kretzschrnar. W. A. and SlOddard, F. J. (1964): Chn. ObSlet. Gynec .. 7, 451. 17. Young. C. M.. Blondin. J.. Tensuan, R. and Fryer. J. H. (1963): Ann. N. Y. Acad. Sci., HO, 589. MANAGEMENT OF CONSTRICTION RING OF THE UTERUS USING ISOXUPRINE* M. BARKER. M.B., CH.B. (BIRMINGHAM) AND J. V. LARSEN, M.B., CH.B. (CAPE TOWN), Charles John.son Memorial Hospital, Nqutu, Zululand, Natal A constriction ring of the uterus 'represents an area of intense local activity" in an organ in which the normal polarity of contractions is disturbed. The usual site of such a ring is at the junction of the upper and lower segments. Because the Bantu patient tends to go into labour with the presenting part well above the brim of the pelvis, such a constriction ring, even in vertex presentations, usually forms below the presenting part, thus confining the foetus to the upper segment of the uterus. When this occurs, it gives rise to a distinct clinical picture, generally first recognized because of the failure of the presenting part to engage with the brim of the pelvis, in spite of good contractions. Indeed, palpation during a contraction will often reveal that the presenting part moves up, away from the pelvic 'brim, and the examiner's hand can always be comfortably pressed against the abdominal wall be- *Date received: 28 Sepremben 1967. tween the vertex and the symphysis pubis, the vertex making no attempt to push past it to engage with the brim. Vaginal examination is necessary to confirm the diagnosis, and usually reveals a more or less dilated cervix, an empty lower segment, and a constriction ring holding the presenting part out of the lower segment. There is no relationship between this condition and Bandl's ring. In this unit, where the incidence of constriction ring of the uterus in vertex presentations during a I-year period (1966 - 1967) was 8 cases in 1,509 deliveries (0'53%), special interest in treatment was aroused by the failure of more conventional methods to relax the ring before foetal distress supervened. The caesarean sections thus necessitated were technically difficult, and resulted in poor scars because the upper segment had so often to be encroached upon in order to deliver the foetus through a tight ring. For these. reasons it was decided to study the TABLE 11. STATUS AT TIME OF DIAGNOSIS S.A. JOURNAL OF OBSTETRICS AND Gv 'AECOLOGV The following cases seem to us to be worth describing in detail. Results of the treatment are tabulated in Tables I, Il and Ill. The constriction rings were relieved completely I I I I I I I I I I I I I I I I I I I I I I I I I 11 1V 3* hrs. later Summary of treatment Isoxuprine } IM Pethilorfan Isoxuprine 5 mg. IM Isoxuprine 10 mg. IM Isoxuprine 5 mg. Pethilorfan 100 mg. lsoxuprine 5 mg. IM Pethilorfan lOO rng. Isoxuprine 10 mg. IM 6 hrs. later Pethilorfan 100 mg. IM Isoxuprine 10 mg. IM + IV fl 'd Pethilorfan 100 mg. UI s Both repeated 12 hrs. later Isoxuprine 10 mg. } IM Pethilorfan 100 mg. Pethilorfan lOO mg. } IM Chlorpromazine 25 mg. Isoxuprine 10 mg. IM 7 hrs. later Yes No Probably Yes Yes Yes Yes Yes TABLE I. SUMMARY OF ANTE 'ATAL FINDINGS Esrimared period Obstetrical Age in of geslQlion conjugate Shape of brim Patient years Parity (weeks) (estimated) (CIIl.) oj"pehis I 23 I 38 10 Android 2 26 2 40 9'5 Gynaecoid J 26 5 40 12 Gynaecoid 4 34 3 38-40 105 Platypelloid 5 28 4 40 10 Android 6 16 0 38 11 Gynaecoid 7 26 4 40 10 Android 8 30 I (LSCS) 40 10'5 Android Each case was then handled on its merits. If the constriction ring wa relieved. the vertex descended into the lower segment within an hour of giving isoxuprine, and gross disproportion did not then become apparent. the patient was allowed to proceed with labour in the normal way, and vaginal delivery was awaited. If the constriction ring appeared to have been improved, but the vertex remained high. it was sometimes considered wise to rupture the membranes if these were intact, either half an hour after the first injection of isoxuprine or shortly after the drug was repeated. The mother was then instructed to bear down briefly between two con- tractions while the ring was relaxed, the observer's hand being kept in the vagina to assess the result of this manoeuvre, and to make sure the cord did not prolapse. In more recent cases, not included in this series, in whom the cervix was sufficiently dilated to admit one of the smaller cups of the vacuum extractor, and in whom the ring disappeared completely between but was still evident during contractions, we have used this instrument to bring the vertex down against the cervix, where it was held during one or two contractions before the vacuum wa, released. in 6 out of 8 cases. In one further case it was probably relieved, but this was not confirmed vaginally. There was only I failure. Constriction ring relieved? Ruptured Intact Ruptured Ruptured Ruptured Intact Intact Intact StaTe of membranes At The time of diagnosis I June 1968 Patiell1 Duration oflabour Dilation ofcervix (hours) (cm.) 10 45 2 15 5 3 6 45 4 4 1 5 5 5i 3 6 19 3 7 8 45 8 6 3 effect of i oxuprine (Duvadilan-Philips-Duphar, Amster- dam) in these cases. MATERIALS AND METHODS Our unit is situated in a rural area, where methods of communication are poor. Because of this, the majority of our patients spend the final "2 or 3 weeks in the antenatal ward in the hospital grounds. thus usually reaching the labour ward fairly early in the course of the first stage. The standard of care is reasonably high, as evidenced by a maternal mortality rate of 0'66/1,000 (spontaneous rupture of a left cardiac ventricle in early puerperium), and a perinatal mortality rate of 43'3/1,000, during the period under discussion. All patients. with only one exception, were Zulus or Basutos. Each patient had the usual investigations during the antenatal period, including estimation of haemoglobin, the Wassermann reaction and a clinical pelvic assess- ment. Facilities for radiological assessment were not available. Inpatients, unless ill, were seen twice weekly for routine antenatal examinations by a medical officer. Only cases with vertex presentation were included in this series, because the prognosis for vaginal delivery if the ring could be relieved was so much better. Limiting the discussion in this way also removes other factors which would interfere in the assessment of the assistance this treatment gave to the surgeon in such caesarean sections as became necessary. All caesarean sections were performed under local anaesthesia. As soon as a constriction ring of the uterus was sus- pected on abdominal examination, the diagnosis was confirmed by vaginal examination by one of us. The treatment then instituted consisted of isoxuprine, 5 mg. or 10 mg. given by the intramuscular or intravenous route, with or without Pethilorfan 100 mg., generally given intramuscularly. One patient (case 5), was given Pethilor- fan only, with the intention of administering isoxuprine later if this proved necessary. Another (case 8) was given Pethilorfan, 100 mg., and chlorpromazine, 25 mg., both intramuscularly, followed later by isoxuprine when there was no improvement in the condition. 12 S.A. TYDSKRIF VIR OBSTETRIE E r GINEKOLOGIE TAilLE Ill. SUMMARY OF RESULTS OF TREATMENf 1 Junie 1968 MaTernal side-effects possibly Weight ofbaby Puerperium atTribuTable 10 isoxuprine 6 lb. 6 oz. Normal None 6 lb. 11 oz. Normal Urinary retention 12 hrs. postpartum Trealmem- IndicaTions PaTient delivery imerral Type ofdelhery for LSCS Blood loss 1 13 hrs. 10 min. Spontaneous 60 ml. 2 2 hrs. 30 min. LSCS Disproportion. 450 ml. Foetal distress 3 18 hrs. 45 min. Spontaneous 300 ml. 4 10 hrs. 45 min. LSCS Unrelieved 450 ml. constriction ring 5 7 hrs. 30 min. Spontaneous 10 record 6 12 hrs. Spontaneous 450 ml. 7 5 hrs. LSCS Foetal distress 900 ml. 8 9 hrs. LSCS Disproportion 400 ml. 8 lb. 3 oz. 6 lb. 12 oz. 71b. 13 oz. 7 lb. 4!- oz. 7 lb. 11 oz. 5 lb. 151 oz. ormal lormal Normal ormal Moderate sepsis ormal Twitching (transitory) Urinary retention 24 hrs. postpartum 'one Records incomplete 'one None CASE REPORTS Case I C.M., aged 23 years, para. 1, gravida 2, with a negative Wassermann reaction, and a haemoglobin concentration of 115 G /100 ml., presented in the labour ward soon after sunrise, having been in labour since about midnight. Her general condition was good, with a blood pressure of 100/70 mm.Hg. Abdominal palpation revealed a high mobile vertex as the presenting part. Uterine contractions were poor and incoordinate in type. Foetal heart rate was 140/min. Vaginal examination confirmed a constriction ring about the junction of the upper and lower segments, well above a 4-5-cm. dilated cervix. The vertex was resting on this ring. Membranes were intact. Pethilorfan, lOO mg., and isoxuprine, 5 mg., were given by the intra- muscular route. Contractions became weaker, but the vertex descended into the lower segment, and vaginal examination carried out 6 hours later confirmed that the constriction ring had disappeared. She gave birth to a male infant with an Apgar rating of 9, weighing 6 lb. 6 oz., 13 hours after the isoxuprine injection. The puerpe- rium was normal. Case 3 A.B., aged 26 was a para. 5, gravida 6, and had had one abortion at 16 weeks. Her last baby had weighed 9 lb. 5 oz., and had been delivered by vacuum extraction. She was ad- mitted to the labour ward in good condition, having been in labour for about 6 hours. Her blood pressure was 110/70 mm.Hg. Abdominal palpation revealed a high mo- bile vertex presentation. The foetal heart was within normal range. Vaginal examination revealed a 4-5-cm. dilated cervix with a sausage of membranes protruding through this from a constriction ring 2 inches higher up, which admitted 2 fingers only. Isoxuprine, 10 mg., was adminis- tered by the intramuscular route. Three hours later the cervix had progressed to almost full dilation, but the constriction ring remained unchanged. Isoxuprine, 5 mg., and Pethilorfan, 100 mg., were administered intravenously, and the membranes were ruptured. The patient subse- quently had some mild twitchings. with a blood pressure of 110/70 mm.Hg. Two hours after the second dose of isoxuprine, the constriction ring had disappeared, and contractions were very weak. The cervix had closed down to 3 cm. dilation and was now only partially effaced. but was well applied to the presenting part. Within a few hours contractions became established again, and 12 hours later she delivered an 8 lb. 3 oz. infant with an Apgar rating of 10. Blood loss was 300 ml. The puerperium was uneventful. Case 4 M.S., aged 34 years, was a para 3, gravida 4, with a negative Wassermann reaction, and a haemoglobin con- centration of 115 G /100 mI. She was first seen when she had been in labour for 4 hours. Her general condition was good, and her blood pressure was within the normal range. On abdominal palpation, the vertex was presenting and was high and mobile. Contractions were irregular and fairly strong. Vaginal examination confirmed a constric- tion ring of the uterus well above a 15-cm. dilated cervix and seemingly at the junction of the upper and lower segments. The membranes were intact. The patient was given a simple enema. Isoxuprine, 5 mg., and Pethilorfan, 100 mg., were administered intramuscularly. Seven hours later the uterus had become even more abnormal in action, an additional constriction ring having formed at the level of the neck of the foetus. Findings on vaginal examination were unchanged. Isoxuprine, 10 mg., was given intra- muscularly, and Pethilorfan, 100 mg., by slow intravenous injection, with no improvement in the first constriction ring, although the second ring disappeared. Lower-segment caesarean section was decided upon 12 hours after the diagnosis had been made, before foetal distress super- vened. Operation, performed under local anaesthesia, re- vealed sufficient lower segment to make the procedure feasible, but the upper segment had to be entered in the left-hand corner of the incision in order to deliver the baby. The Apgar rating was 9, and the weight 6 lb. 12 oz. Blood loss was about 450 mI. The puerperium was compli- cated in the first 24 hours by urinary retention necessitat- ing catheterization and drainage for 12 hours. In retrospect, it seems likely that if intravenous isox- uprine had been used when the condition was first diag- nosed, and membranes had been ruptured when relaxation had occurred, better results might have been obtained. However, the second dose of isoxuprine did relax the ring around the neck of the foetus, making delivery of the baby relatively easy once the primary ring had been cut. ISOX PRINE Isoxuprine (Duvadilan) has the following structural for- mula: > CH) C1H) > Ho\. ) CHOH- tH-NH-cH-CHP <. HCl It is postulated that the drug depresses uterine activity by activating the beta-adrenergic receptors of the muscle cells,' and the effect in laboratory animals was found to be independent of hormonal status. However, it is sug- S.A. JOURNAL OF OBSTETRICS A D GYNAECOLOGY 1 June 1968 gested that the effect in humans may be regulated to some degree by oxytocin levels! The effect on the human parturient uterus was investi- gated by Karim: and may be summarized as follows: (a) Reduction in the tone of the uterus. (b) Reduction in the frequency of contractions. (c) Reduction in the amplitude of contractions. This effect was of shorter duration than the effect on the tone of the uterus, thus giving 'greater effi- ciency of the uterus for delivery'. This in turn led to more rapid dilation of the cervix in 25 % of his cases. In patients in premature labour, isoxuprine has been found capable of stopping contractions; but in the par- turient uterus at term, when low oxytocinase levels are present, the chief effect appears to be on the tone of the uterus, correcting abnormal patterns of contraction, but not stopping the labour. Karim was able to show that isoxuprine does not cause postpartum haemorrhage: Given intravenously, in undiluted form, the drug acts almost immediately, but 10 mg. given in this way will produce a certain incidence of side-effects. By the intra- muscular route, the drug acts within 5 minutes, and maintains its action for one hour; side-effects are rare. Subsequent to this series, it has become our practice to give 5 mg. intravenously and 5 mg. intramuscularly at the same time, in an effort to minimize side-effects, while getting the benefit of a rapid onset of action. In all the cases in this series, the reduction in tone of the uterus and in the frequency and duration of con- tractions was a very noticeable result of the injection. It was during this period of uterine tranquillity that the vertex passed through the constriction ring and applied itself to the cervix. The moment this had occurred, the pattern of labour became more normal, contractions be- coming stronger and more frequent, and the cervix dilated in the normal way. The side-effects encountered by Karim included a tran- sient, and usually unimportant, drop in maternal blood pressure, and a rise in maternal and foetal heart rates. More important effects included occasional cases of diplopia, tremors and urinary retention. All these effe:t:; were transitory: Table III illustrates the side-effects we encountered. One patient had transient twitching an hour after her second dose of isoxuprine; her blood pressure and urine were normal at the time. Two patients developed urinary reten- tion after caesarean section, but the significance of this, in the presence of postoperative pain, is difficult to assess. Postpartum blood loss was normal in all cases except one in whom a branch of both uterine arteries was cut during caesarean section, resulting in a total loss of about 900 m!. DISCUSSION From this series of cases, several interesting facts emerge. This is a condition found chiefly in multiparous patients. The single primiparous patient in this series is the only case we have had in this unit, and so we suspect that the incidence in first pregnancies is, in fact, lower than this series suggests. The condition usually seemed to be present 13 from an early stage during the labour. Cases 1, 2 and 6 were seen initially by junior members of staff who were misled by fairly weak contractions and failure of descent of the vertex, into thinking that the patients were not in established labour, and the diagnosis was therefore de- layed. Ruptured membranes were not by any means a con- stant feature, 50% of these patients having intact mem- branes at the time of diagnosis. This is in contrast to the experience of others in obstetrics dealing only with Whites.' The success of treatment does not seem to depend greatly upon the state of the cervix or the duration of labour at the time it is instituted, but rather upon the degree of disruption of normal uterine polarity, as the single failure in this series seems to suggest. Insurmountable cephalopelvic disproportion was present in 2 of the cases, a much higher incidence than in the general obstetrical population in this area (about 10%). Of the cases requiring caesarean section, well-formed lower segments were present in cases 2 and 8, the opera- tions were technically easy and the surgeon expected the scars to be good. In case 7, labour had to be interrupted before enough time had elapsed for a good lower seg- ment to be formed, but it was still possible to obtain a good lower-segment scar. Only in case 6, in whom the ring persisted, was it necessary to cut into the upper segment at the left-hand end of the incision in order to deliver the baby. These findings are in marked contrast to those of Bourne, who states that 'it is essential to make a vertical incision through the ring' in order to deliver the baby safely. Only in one case (case 6) was maternal distress a feature. CONCLUSIONS While we accept that rupture of the uterus due to a constriction ring is a very unlikely event, and the con- dition is 'reversible with heavy sedation and the lapse of time',' it was all too often our experience with other methods of treatment that, after many anxious hours, a difficult caesarean section was the only safe means of delivering a distressed foetus. Frequently it was necessary to extend the incision into the upper segment in order to deliver the head through a tight constriction ring, and sometimes one had the unpleasant experience of the vertex floating away out of reach, necessitating internal version and breech extraction in an already dangerously tight uterus. With its ability to relax a constriction ring and allow the vertex to descend into the lower segment, isoxuprine seems to be a useful drug in the management of this difficult condition. At best it ensures a spontaneous vaginal delivery, and at worst a technically eas;er, and therefore safer, caesarean section. Best results are obtained when active measures are employed to prevent the recurrence of the constriction ring as the effect of the isoxuprine wears off. There was no foetal loss or morbidity in this series, and only one case of significant maternal distress. SUMMARY A suggested method of m a n a ~ e m e n t of a con triction ring of the uterus in vertex presentations, incorporating the use of I I I I I I I I I I I I I I I I I I I I I I I I I THE INVESTIGAnON OF BACTERIURIA IN PREGNANCY* HERMAN A. VAN COEVERDEN DE GROOT, M.B., CH.B. (CAPE TOWN), M.R.C.O.G., DENNIS A. DAVEY, M.B., B.S. (LOND.), PH.D., M.R.C.O.G., ARDERNE A. FORDER, M.B., CH.B. (CAPE TOWN), M.MED. (PATH.) AND S. T. TREZISE. M.B., CH.B. (CAPE TOWN), M.R.C.O.G., From the Departments of Obstetrics and Gynaecology and Bacteriology, Groote Schllllr Hospital, and University of Cape Town S.A. TVDSKRIF VIR OBSTETRIE EN GlNEKOLOOm 14 isoxuprine, is discussed with reference to a small series in Bantu patients. Treatment was successful in 6 out of 8 cases, with a further probable success and only one failure. There was no serious maternal or foetal morbidity. We wish to thank Dr. E. A. Barker, Medical Superintendent of the Charles Johnson Memorial Hospital, for permission to use hospital records, and Mrs. A. Reynoldson and Sister J. Conway for their valuable assistance. Since the studies of Kass,'" routine screening for asympto- matic bacteriuria by means of bacterial counts has become an accepted part of antenatal care. Dixon and Brant' stated that the value of bacterial counts in the detection of pyelonephritis of pregnancy had been overemphasized. Most writers, however, agree with Williams et at.' that the relationship between bacteriuria and acute and chronic pye- lonephritis seems beyond doubt and that the prevention of these conditions is sufficient reason to make routine screening for bacteriuria essential. In practically all the published work the specimens of urine used for bacterial counts and for cultural examina- tion have been midstream urine collections. Sleigh et al.' and Williams et al.' stressed the importance of the tech- nique of midstream urine collection and of the careful handling of the specimens, but this has received little mention in other articles. Before embarking on a programme of routine screening for bacteriuria, it was decided to investigate the importance of the technique of midstream collection on bacterial counts in the urine. Two series of patients were investigated. In the first series, no special instructions were given regard- ing the method of midstream urine collection, or of handling of the urine specimens. which were delivered to the laboratory by the usual hospital service. In the second series, strict criteria were laid down for the method of collection and for the transport of the specimens to the laboratory, with particular attention to the technique of vulval cleansing, and the efficiency of two cleansing agents. MATERIALS At..... '!) METHODS All the patients were healthy, pregnant females with no evidence of urinary tract infection. No postpartum cases were included. In the first series, 78 midstream specimens of urine were collected from patients attending the Antenatal Clinic at the Peninsula Maternity Hospital, and sent to the Bacte- riology Laboratory in Groote Schuur Hospital by the usual hospital service. In the second series, 87 midstream specimens of urine were collected during the morning from ward patients in the Groote Schuur Maternity Block. The method of collec- tion was as follows: The patient stood astride the toilet and held her labia
'Paper presented at the 46th South African Medical Congress (M.A.S.A.),
Durban. July 1967. I Junie 1968 REFERENCES 1. Donald. 1. ((959): Practical Obstetrical Problems, 2nd ed., p. 375. London: L1oydLuke. 2. Lish. P. N.. Dungan. K. W. and Peters. E. L. ((960): J. Pharmacal. 3. Ciblis, L. A. ((961): Amer. J. Obste!. Gynec., 82. 5. . 4. Karim. M. (1963): J. Obsre!. Gynaec. Brit. Cwlth. 70, 6. 5. Bishop. H. and Wontery, B. (1961): J. Amer. Med. Assoc.. 178. 812. 6. Bourne. A. W. (959): A Synopsis 0/ Obsretrics and GynaecologL 12th ed., p. 231. Bristol: John Wright & Sons. apart. The nurse collecting the specimen, then swabbed the vulva with 3 separate sterile cottonwool swabs, soaked in either 0'5% aqueous chlorhexidine or sterile normal saline. Half the patients were swabbed with the first and the other half with the second solution. The patient then commenced to pass urine and the nurse collected not less than 10 ml. from the middle of the stream into a clean plastic container with a clip-on lid. The container was then labelled and delivered immediately by the house surgeon to the laboratory in the hospital. Care was taken that the patient had not passed urine for at least 4 hours before the collection of the specimen. In the laboratory each urine specimen from both series was treated as follows: (a) A semi-quantitative count was carried out as described by Leigh and Williams: In principle, a measured area of blotting paper is used as a vehicle for transferring a constant aliquot of urine to the surface of a culture medium. From the number of colonies on the inoculated area the number of organisms in the urine may be calcu- lated. (b) Wet preparations and Gram-stained smears were examined microscopically, and if pus cells or organisms were noted in the 2 preparations, the urine was cultured by plating onto a MacConkey agar plate and Hartley agar or blood-agar plate. RESULTS First Series Of the 78 specimens, only 5 failed to show any bacterial growth on culture. Sixty-eight (87%) were ob- viously contaminated as shown by either a heavy vaginal flora on microscopic examination of Gram-stained smears or by a quantitative bacterial count of more than 100,000 organisms per m!. with a mixed growth of microorganisms on the culture plates. The remaining 5 specimens (65{,) had a count of more than 100,000 organisms per m\. with a pure growth on culture, but the findings on microscopy showed that these too were probably contaminated. Nine- teen of the urines were a day old when received at the laboratory and all were heavily contaminated. Second Series Of the 87 urines. 44 (51 showed no growth on culture. Thirty-five (40%) were contaminated as shown by either a scanty vaginal flora on examination of Gram-stained smears and no growth using the semi-quantitative tech-