Background Retained placenta is associated with post-partum haemorrhage. Meta-analysis has suggested that umbilical injection of oxytocin could increase placental expulsion without the need for a surgeon or anaesthetic. We assessed the effect of high-dose umbilical vein oxytocin as a treatment for retained placenta.Methods In this double-blind, placebo-controlled trial, haemodynamically stable women with a retained placenta for more than 30 min were recruited from 13 sites in the UK, Uganda, and Pakistan. 577 women were randomly assigned by a computer-generated randomisation list stratified by Centre to 30 mL saline containing either 50 IU oxytocin (n=292) or 5 mL water (n=285), which was injected into the placenta through an umbilical vein catheter. All trial participants, study workers, and data handlers were masked to individual allocations. The primary outcome was the need for manual removal of the placenta. Analysis was by intention to treat. This study is registered, number ISRCTN 13204258.Findings The primary outcome was recorded for all participants. We detected no difference between the groups in the need for manual removal of placenta (oxytocin 179/292 [61.3%] vs placebo 177/285 [62.1%]; relative risk 0.98, 95% CI 0.87-1.12; p=0.84). The need for manual removal was higher in the UK (overall 250/361 [69%]) than in Uganda (90/190 [47%]) or Pakistan (16/26 [62%]). Adverse events did not differ between the two groups.Interpretation Umbilical oxytocin has no clinically significant effect on the need for manual removal for women with retained placenta.Funding WHO, WellBeing of Women, Pakistan Higher Education Commission.

There are very few reports in the literature of successful pregnancy following allogeneic transplantation for Fanconi anaemia (FA). Despite attenuation of conditioning, transplantation causes significant germ cell injury and is generally considered to induce secondary infertility. Goi et al (2006) recently reported a patient presenting with menorrhagia aged 19 years, subsequently found to be pancytopenic due to FA. She received an allogeneic transplantation from her human leukocyte antigen (HLA)-matched sister and re-started regular menstruation at 6 months post-transplant. She went on to conceive naturally 48 months post-transplant and delivered a healthy child. The one other case described is of a patient with FA transplanted from her HLA-matched sibling at aged 17 years (Dalle et al, 2004). The patient had experienced spontaneous menarche aged 11 years, followed by regular periods. Secondary amenorrhoea was evident by 18 months post-transplant, although it is unclear what replacement therapy was instigated. She subsequently carried two natural pregnancies and delivered two healthy children. We report a female patient initially diagnosed with FA aged 8 years. She underwent HLA-matched allogeneic bone marrow transplantation from her sibling aged 10 years, conditioned with Cyclophosphamide 20 mg/kg total dose, total body irradiation (TBI) over 4 d (4 Gy total dose) and antithymocyte globulin (60 mg/kg total dose). The procedure was tolerated extremely well and she did not develop graft-versus-host disease. She entered puberty spontaneously aged 12 years with normal menstrual cycles. She became pregnant naturally 13 years and 16 years post-transplant and delivered two healthy children after uncomplicated pregnancies monitored in collaboration with the Late Effects and Obstetric clinics at our institution. Clearly, despite the significant doubts that transplant and reproductive specialists may harbour, successful natural pregnancy is realistic in patients with FA following allogeneic haemopoietic transplantation, even when myeloablative (TBI-containing) conditioning is used. Significantly, this is the first report of successful pregnancies in a patient with FA transplanted in the pre-pubertal period with preservation of fertility. We recommend patients transplanted for FA should be appropriately counselled in relation to family planning and contraception, and ideally managed within a multidisciplinary Late Effects clinic.

A case of monozygotic twins in a 19-year-old primigravida is presented. Ultrasound examination at 15 weeks' gestation showed one twin to have a cystic hygroma and hydrops fetalis. The other twin appeared normal. The twins appeared to occupy the same amniotic cavity. Fluid was taken from the cystic hygroma under ultrasound guidance for karyotyping and this showed 45,XO chromosomes. Conservative management was adopted. Serial ultrasound examination showed deteriorating hydrops and at 26 weeks the first twin died. Intensive monitoring of the remaining twin was undertaken with weekly ultrasound, cardiotocography (CTG), and clotting screens. At 29 weeks' gestation the CTG and clotting were normal, but ultrasound revealed that multicystic encephalomalacia had developed in the second twin. A very thin dividing membrane was seen for the first time between the twins. The parents decided to terminate the pregnancy. Prior to an intracardiac potassium chloride injection, a fetal blood sample was taken which revealed 46,XX chromosomes and a normal clotting screen including natural anticoagulant levels. Labour was then induced. Delivery took place 5 h later and the woman made an uneventful recovery. The mechanism for genetic differences between monozygotic twins is discussed and the literature reviewed. A non-disjunction event around the time of splitting of the twins is proposed as the cause. The prognosis for the remaining twin is also discussed, as is the pathogenesis of the cerebral damage.