Section of Obstetrics & Gynwcology
9
827
or occurred spontaneously by then. There was a significant difference in the time to delivery. The effect of maternal intramuscular steroid by Ian Craft FRCS MRCOG, John Day, administration was studied in a double-blind Vim Brummer, David Horwell FRCSEdmanner, injecting either saline or the same dose of and Heulwen Morgan MB Bch (Institute ofObstetrics & Gynaecology, betamethazone in women near, at, or beyond term, but in this instance with induction planned Queen Charlotte's Hospital, after 96 hours if labour had not occurred before. London W6) Numbered, coded, identical ampoules were The experiments of Liggins et al. (1967) have injected before a Bishop score was evaluated. An clearly demonstrated the importance of an assessment was made of the incidence of sponintact fetal hypothalamic-pituitary-adrenal axis taneous labour and whether the results related for spontaneous labour. In several animal to length of gestation. There was no significant species labour may be provoked by either infusing difference between the number of patients going into labour in the two groups of 20 patients of or injecting glucocorticoids into the fetus or even comparable mean Bishop score and gestation. by administering the agent to the mother. Two studies have described the effects of Labour occurred spontaneously in 9 receiving administering steroids to women for the same saline and in 13 receiving the steroid. However, the latter appeared to be more likely to provoke purpose. Mati et al. (1973) reported a significant reduction in time to delivery in a small group of labour if the patient was postmature (Table 2). postmature women receiving an intra-amniotic injection of betamethazone 20 mg when compared with normal saline. Delivery occurred in a Table 2 Occurrence of spontaneous labour in patients receiving mean time of 79 hours (n=6) as opposed to 323 intramuscular saline or betamethazone 20 mg hours (n=5). More recently Nwosu et al. (1976) Gestation (weeks) injected either cortisol (hydrocortisone hemisuccinate) 500 mg or saline intra-amniotically in 38-39 39-40 40-41 41 +
Betamethazone Induction of Labour
postmature women; the rationale behind this study being the reported finding that plasma cortisol values in postmature neonates are lower than in term infants (Nwosu etal. 1975). The mean instillation-labour time was 86 hours (n = 10) compared with 228 hours (n=9) in the control group.
We have investigated the effects of administering betamethazone in women near, at, or beyond term by three routes: intra-amniotic, intramuscular, intravenous. The intra-amniotic study was undertaken to confirm or refute the findings of Mati et al. (1973) and was performed in a similar manner except that all intra-amniotic injections were undertaken under ultrasound control. The details and results of the patients receiving either betamethazone or saline are seen in Table 1. The patients who were between 39 and 41 weeks gestation had labour induced six days after the injection if this had not been provoked
Saline Steroid
1/2 1/2
0/4 3/6
6/9 4/6
2/5 5/6
The intravenous route was studied to assess the endocrinological sequele of using a constant infusion of betamethazone by performing sex steroid, prostaglandin, and betamethazone assays. In 3 postmature patients a dose of I mg/h was infused for 4 hours (1 patient) or 8 hours (2 patients). Labour was provoked in one of the latter subjects but induction was required in the others. One further patient received 2 mg/h for 8 hours and delivered 72 hours later. Radioimmunoassay determinations showed a marked suppressive effect on plasma cortisol values as betamethazone levels rose, a steady fall in aestradiol, but no effect on peripheral progesterone concentrations. Comment
Table I Details and results in patients receiving intra-amniotic saline or betamethazone 20 mg No. of patients Mean gestation Mean Bishop score Spontaneous labour
Saline 5 Term 6.8 (range 4-8) 1
Betamethazone 5 Term + 3 weeks 6.4 (range 5-9) 5
prior to planned induction Mean injection/ delivery interval
153 hours
79 hours
(range 131-168) (range 65-93)
Intra-amniotic glucocorticoid administration will provoke labour in women at or beyond term but the effects of the same dose given intramuscularly appear to be related to the duration of gestation. It is possible that a larger intramuscular dose would be more effective because a greater amount of steroid would reach the fetoplacental unit. It is not known whether a critical circulating concentration or duration of exposure to steroid is required for labour to ensue but the results of the
828 Proc. roy. Soc. Med. Volume 69 November 1976
10
limited intravenous studies indicate there are The following papers were also read: variations in individual responsiveness which may be related to the status of steroid inter- Recent Advances in Ultrasound relationships within the fetoplacental unit. It has Professor S Campbell been suggested that steroid induced CNS (Institute of Obstetrics & Gynwecology, sequelk may occur in experimental animals and .Queen Charlotte's Maternity Hospital, in preterm infants but there is no evidence that Goldhawk Road, London W6 OXG) exposure at term has adverse effects. Antiandrogen Treatment of Hirsutism Dr Rosemary Underhill Acknowledgments: We thank the Ethical Com- (Institute of Obstetrics & Gynacology, mittee and Consultant Staff of Queen Charlotte's Queen Charlotte's Maternity Hospital, Hospital for permission to undertake this study, Goldhawk Road, London W6 OXG) and Glaxo Laboratories Limited for providing supplies of betamethazone and for financial support. Meeting 23 January 1976 REFERENCES Liggins G C, Kennedy P C & Holm L W (1967) American Journal ofObstetrics and Gynecology 98, 1080-1086 Mati J K G, Horrobin D F & Bramley P S (1973) British Medical Journal ii, 149-151 Nwosu U, Wallach E E, Boggs T R, Nemiroff R L & Bongiovanni A M (1975) American Journal of Obstetrics and Gynecology 121, 366-370 Nwosu U C, Wallach E E & Bolognese R J (1976) Obstetrics and Gynecology 47, 137-142
Correction The reference to Palmer (1962) quoted by Mr Patrick Steptoe in his paper on 'Retrospective and prospective studies in laparoscopy' (February 1976 Proceedings, p 143) should read as follows: Palmer R (1962) Bulletin de la Federation des Socic'tids de gynecologie et d'obstetrique de languefranfaise 14, 298
A debate was held on Obstetrics and Gynacology is a Postgraduate Subject. The speakers were: Dr
James Cameron (Wallington, Surrey), Professor Hugh McLaren (University of Birmingham), Mr David B Brown (Postgraduate Institute of Obstetrics and Gynaxcology, St John's Hospital, Chelmsford) and Dr R W Shaw (Birmingham Maternity Hospital)
9
827
or occurred spontaneously by then. There was a significant difference in the time to delivery. The effect of maternal intramuscular steroid by Ian Craft FRCS MRCOG, John Day, administration was studied in a double-blind Vim Brummer, David Horwell FRCSEdmanner, injecting either saline or the same dose of and Heulwen Morgan MB Bch (Institute ofObstetrics & Gynaecology, betamethazone in women near, at, or beyond term, but in this instance with induction planned Queen Charlotte's Hospital, after 96 hours if labour had not occurred before. London W6) Numbered, coded, identical ampoules were The experiments of Liggins et al. (1967) have injected before a Bishop score was evaluated. An clearly demonstrated the importance of an assessment was made of the incidence of sponintact fetal hypothalamic-pituitary-adrenal axis taneous labour and whether the results related for spontaneous labour. In several animal to length of gestation. There was no significant species labour may be provoked by either infusing difference between the number of patients going into labour in the two groups of 20 patients of or injecting glucocorticoids into the fetus or even comparable mean Bishop score and gestation. by administering the agent to the mother. Two studies have described the effects of Labour occurred spontaneously in 9 receiving administering steroids to women for the same saline and in 13 receiving the steroid. However, the latter appeared to be more likely to provoke purpose. Mati et al. (1973) reported a significant reduction in time to delivery in a small group of labour if the patient was postmature (Table 2). postmature women receiving an intra-amniotic injection of betamethazone 20 mg when compared with normal saline. Delivery occurred in a Table 2 Occurrence of spontaneous labour in patients receiving mean time of 79 hours (n=6) as opposed to 323 intramuscular saline or betamethazone 20 mg hours (n=5). More recently Nwosu et al. (1976) Gestation (weeks) injected either cortisol (hydrocortisone hemisuccinate) 500 mg or saline intra-amniotically in 38-39 39-40 40-41 41 +
Betamethazone Induction of Labour
postmature women; the rationale behind this study being the reported finding that plasma cortisol values in postmature neonates are lower than in term infants (Nwosu etal. 1975). The mean instillation-labour time was 86 hours (n = 10) compared with 228 hours (n=9) in the control group.
We have investigated the effects of administering betamethazone in women near, at, or beyond term by three routes: intra-amniotic, intramuscular, intravenous. The intra-amniotic study was undertaken to confirm or refute the findings of Mati et al. (1973) and was performed in a similar manner except that all intra-amniotic injections were undertaken under ultrasound control. The details and results of the patients receiving either betamethazone or saline are seen in Table 1. The patients who were between 39 and 41 weeks gestation had labour induced six days after the injection if this had not been provoked
Saline Steroid
1/2 1/2
0/4 3/6
6/9 4/6
2/5 5/6
The intravenous route was studied to assess the endocrinological sequele of using a constant infusion of betamethazone by performing sex steroid, prostaglandin, and betamethazone assays. In 3 postmature patients a dose of I mg/h was infused for 4 hours (1 patient) or 8 hours (2 patients). Labour was provoked in one of the latter subjects but induction was required in the others. One further patient received 2 mg/h for 8 hours and delivered 72 hours later. Radioimmunoassay determinations showed a marked suppressive effect on plasma cortisol values as betamethazone levels rose, a steady fall in aestradiol, but no effect on peripheral progesterone concentrations. Comment
Table I Details and results in patients receiving intra-amniotic saline or betamethazone 20 mg No. of patients Mean gestation Mean Bishop score Spontaneous labour
Saline 5 Term 6.8 (range 4-8) 1
Betamethazone 5 Term + 3 weeks 6.4 (range 5-9) 5
prior to planned induction Mean injection/ delivery interval
153 hours
79 hours
(range 131-168) (range 65-93)
Intra-amniotic glucocorticoid administration will provoke labour in women at or beyond term but the effects of the same dose given intramuscularly appear to be related to the duration of gestation. It is possible that a larger intramuscular dose would be more effective because a greater amount of steroid would reach the fetoplacental unit. It is not known whether a critical circulating concentration or duration of exposure to steroid is required for labour to ensue but the results of the
828 Proc. roy. Soc. Med. Volume 69 November 1976
10
limited intravenous studies indicate there are The following papers were also read: variations in individual responsiveness which may be related to the status of steroid inter- Recent Advances in Ultrasound relationships within the fetoplacental unit. It has Professor S Campbell been suggested that steroid induced CNS (Institute of Obstetrics & Gynwecology, sequelk may occur in experimental animals and .Queen Charlotte's Maternity Hospital, in preterm infants but there is no evidence that Goldhawk Road, London W6 OXG) exposure at term has adverse effects. Antiandrogen Treatment of Hirsutism Dr Rosemary Underhill Acknowledgments: We thank the Ethical Com- (Institute of Obstetrics & Gynacology, mittee and Consultant Staff of Queen Charlotte's Queen Charlotte's Maternity Hospital, Hospital for permission to undertake this study, Goldhawk Road, London W6 OXG) and Glaxo Laboratories Limited for providing supplies of betamethazone and for financial support. Meeting 23 January 1976 REFERENCES Liggins G C, Kennedy P C & Holm L W (1967) American Journal ofObstetrics and Gynecology 98, 1080-1086 Mati J K G, Horrobin D F & Bramley P S (1973) British Medical Journal ii, 149-151 Nwosu U, Wallach E E, Boggs T R, Nemiroff R L & Bongiovanni A M (1975) American Journal of Obstetrics and Gynecology 121, 366-370 Nwosu U C, Wallach E E & Bolognese R J (1976) Obstetrics and Gynecology 47, 137-142
Correction The reference to Palmer (1962) quoted by Mr Patrick Steptoe in his paper on 'Retrospective and prospective studies in laparoscopy' (February 1976 Proceedings, p 143) should read as follows: Palmer R (1962) Bulletin de la Federation des Socic'tids de gynecologie et d'obstetrique de languefranfaise 14, 298
A debate was held on Obstetrics and Gynacology is a Postgraduate Subject. The speakers were: Dr
James Cameron (Wallington, Surrey), Professor Hugh McLaren (University of Birmingham), Mr David B Brown (Postgraduate Institute of Obstetrics and Gynaxcology, St John's Hospital, Chelmsford) and Dr R W Shaw (Birmingham Maternity Hospital)
