bluuebunny/crossref_metadata_2025 huggingface dataset:
A Novel Approach to the Management of Pregnancies Complicated by Uteroplacental Insufficiency and Previous Stillbirth
Authors: Oyelese K. O. , Black R. S. , Lees C. C. , Campbell S.
Published: February 2008

EDITORIAL COMMENT: These interesting case reports present apparently favourable results of an uncontrolled experiment in the treatment of suspected fetal compromise. Women with a history of severe fetal growth retardation leading to fetal death in utero in whom no underlying cause (diabetes, renal disease, antiphospholipid syndrome) is found present a difficult management problem in future pregnancies. There is a clear risk of recurrence but there is no clearly proven effective method of prevention or treatment. In the past 40 years there have been many other methods of treating fetal growth retardation andplacental insufficiency, ranging from the introduction of intraamniotic amino acids and maternal intravenous dextrose infusions, to abdominal decompression, beta‐sympathomimetics, supplemental oxygen, dipyridamole, heparin and aspirin. Some of these methods carry risks and in the absence of a specific aetiology for the problem none of them has been shown effective in appropriately conducted trials. The use of trans dermal glyceryl trinitrate (GTN) for suspected fetal compromise has the advantages of ease of use and apparent safety, given the long experience with this drug. As the authors point out there is also theoretical and experimental justification of its use to improve Uteroplacental perfusion. However, these 2 cases cannot be considered reliable evidence of the use of GTN in clinical practice but may point the way for further research.

Summary: To our knowledge, this is the first time that a combination of aspirin and glyceryl trinitrate (GTN) has been used in the prophylaxis of preeclampsia and fetal growth retardation, and their use associated with not only Doppler screening of the uterine arteries but also regular Doppler follow‐up of the fetal arterial and venous circulation. Whilst future trials are needed to prove whether screening, prophylaxis and Doppler management are individually beneficial, we propose that this combination of management strategies contributed to a good outcome in the cases described. Furthermore, randomized trials are required to determine the safety and efficacy of prophylactic low‐dose aspirin combined with GTN treatment in pregnancies affected by an impaired Uteroplacental circulation.
Group B Streptococcal Septicaemia/Meningitis in Neonates in a Singapore Teaching Hospital
Authors: Tan Keng Wee , Tay Leng , Lin Raymond , Daniel Mary , Bhavani S. , Lim Siok Hong
Published: February 2008

Summary: Our aims were to establish the incidence and clinical characteristics of early and late onset Group B Streptococcal (GBS) septicaemia in neonates in our hospital over a period of 1 year. Routine screening for maternal GBS was not standard practice in the hospital. GBS was isolated from high vaginal swabs (HVS) obtained antenatally or postnatally for risk factors as determined by the obstetrician or neonatologist in charge. Data obtained were analyzed separately and these did not form part of the study. By a system of clinical case review and follow‐up, mail, telephone and home visits, the outcome of all 15,062 livebirths in the hospital over a 1‐year period were verified and reported. Our results show a low incidence of GBS infection in neonates in the hospital: early onset disease was 0.265 per 1,000 livebirths and late onset a quarter of that. The majority of our cases of early onset GBS disease were in premature infants. Because of our low incidence, prophylaxis schedules would have to ensure an acceptably smaller number of mothers exposed to antibiotics over and above the current level and the cooperation of our obstetricians. We have devised a schedule incorporating a current PROM (prelabour premature rupture of membranes) protocol which would result in only an additional 2.2% of mothers requiring prophylactic antibiotics.
An Audit of Oestrogen Implant Hormone Replacement Therapy
Authors: Templeman Claire , Quinn David , Hansen Ross , Moreton Terry , Baber Rodney
Published: February 2008

Summary: The aim of this review was to determine the factors that impact upon oestradiol levels in patients receiving oestradiol implants and to assess the relationship between symptom scores and oestradiol levels. In addition we sought to determine the incidence of tachyphylaxis (menopausal symptoms in spite of high oestradiol levels) among our patients, and to assess the degree of menstrual cycle control in the nonhysterectomized women receiving implant treatment. We undertook an audit of the medical records of 118 women who received 673 oestradiol implants (50 or 100 mg) over an 8‐year period in the menopause clinics at Royal North Shore Hospital. Data on patient age, clinical diagnosis, symptom score, previous or subsequent hysterectomy, oestradiol implant dosage (50 mg or 100 mg), number of doses, oestradiol levels and concurrent testosterone implant insertion were recorded. We found that implant dosage (p < 0.001) and implant number (p < 0.001) were the factors that significantly impact upon oestradiol levels. Concomitant testosterone implant usage (p = 0.74), patient age (p = 0.14) and hysterectomy (p = 0.57) did not have a statistically significant effect upon oestradiol levels. The incidence of tachyphylaxis was 1.7% (2 patients). There was no relationship between oestradiol levels and symptom scores (p = 0.69). Oestradiol implant treatment, when administered on the basis of return of symptoms, without a strict target oestradiol level, results in a steady increase in baseline oestradiol levels. The dosage used and the number of implants received are important factors influencing oestradiol levels. The incidence of tachyphylaxis is low when patients are counselled regarding the lack of agreement between symptom scores and oestradiol levels.
The Retained Twin/Triplet Following a Preterm Delivery‐An Analysis of the Literature
Authors: Trivedi Amarendra Nath , Gillett Wayne R.
Published: February 2008

Summary: We summarized the overall experience of the management and outcome of the retained twin/triplet and statistically analyzed the effects of the different variables such as cervical cerclage, tocolysis, use of antibiotics etc. on the retained fetal survival; 45 case reports in English were analyzed. The survival rate of the first born was very poor in contrast to the second and third‐born infants. Spontaneous rupture of the membranes was the most common cause of the loss of the first born, whereas for the second born, premature labour was the commonest cause. Despite substantial obstetric events leading to delivery of the first‐born infant, interval problems were uncommon. The mean period of retention of the surviving retained twin/triplet was 48.9 ± 37.9 days compared to 25.7 ± 31.6 days for the dead retained twins/triplets (p = 0.08). The female retained twins/triplets were retained much longer than the males (p = 0.008). The pregnancies lasted 45.9 days in the tocolytic group and 37 days in the nontocolytic group (p = 0.51). The delivery interval of the second born in the cerclage group was 52 ± 42 days compared to 34 ± 30 days in the noncerclage group (p = 0.1). The longer the twins/triplets were retained the better was their survival. Tocolysis, cervical cerclage and prophylactic use of antibiotics failed to make a statistically significant difference in the fetal outcome. The birth‐weights, gestations and sex of the retained twins/triplets affected their survival significantly.
Spontaneous Uterine Venous Rupture During Labour: A Case Report With Postoperative Ultrasonographic Findings
Authors: Nakai Yuichiro , Maeda Takeshi , Nishio Junko , Tachibana Daisuke , Imanaka Motoharu , Ogita Sachio
Published: February 2008

EDITORIAL COMMENT: We accepted this case for publication to remind readers that although uterine rupture during labour in a primigravida is extremely uncommon it does occur, or at any rate nulliparas can develop abdominal pain and shock in labour with a haemoperitoneum resulting from a tear in a vein in the lower posterior uterine wall. When one sees the hugely dilated uterine and ovarian venous plexuses at Caesarean section it is easy to believe that bleeding from such a vessel during labour could be prodigious. This case suggests that a dilated vein with blood flow derangements may be the cause. Nonetheless, as the authors warn us, the necessary response is not a precise diagnosis, but rapid laparotomy. See also Editorial Comment to Chin MMS, Harvey JA, Duffy BL. Uterine rupture during labour in a primigravida. Aust NZ J Obstet Gynaecol 1996; 36: 210.
Symptoms During Normal Pregnancy: A Prospective Controlled Study
Authors: Martina Zib BMed Sc(Hons)  , Lynette Lim BSc (Hons)MSc, PhD and  , William A. W. Walters PhD FRCOG, FRANZCOG, FACSHP
Published: February 2008

EDITORIAL COMMENT: This is an important study which attempts to evaluate the effect of pregnancy on numerous symptoms. The point of this comment is to direct readers to table 3 because it contains much information of interest and importance that has not been dealt with in the text because of space considerations. For example, there is confirmation of the wide‐held belief that epistaxis is much more common in pregnancy and the same can be said for fainting, flushing and shortness of breath. The increased incidence of nausea, heartburn and bleeding gums also fits with traditional teaching and beliefs, at least of the editor, but the finding that headache is less common in pregnant women was a surprise. There is confirmation that leg cramps and abdominal pain are common in pregnancy. The increased frequency of nail changes was news to the editor, although the urogenital symptoms preponderance in the pregnant group was expected. The huge increase in dyspnoea during at rest and exertion in the pregnancy group also warrants emphasis. N.B.

Summary: Symptoms of normal pregnancy have received scant attention in the literature and what is reported is largely unsubstantiated. Yet this is an important aspect of antenatal counselling and care which deserves further investigation if symptoms are to be interpreted correctly. Accordingly, we conducted a prospective controlled study of symptoms during normal pregnancy in both primigravidas and multigravidas. A total of 38 symptoms occurred with a significantly different frequency (mainly increased) in the pregnant subjects in the third trimester compared with the controls. Of these a mean of 24.2 symptoms was experienced by each pregnant woman, double that (mean, 11.2) experienced by healthy nonpregnant controls. The 5 symptoms reported most frequently by the pregnant subjects were frequency of micturition, fatigue, pelvic pressure, insomnia and lower backache. However, a wide range of symptoms involving most body systems were reported. This study has established that symptoms of pregnancy are more numerous than mentioned in current obstetric texts and that they can be attributed to the effects of pregnancy. The third trimester is associated with the greatest number of symptoms and there is a marked decline in their number after delivery.
A Laparoscopic Surgical Training and Accreditation Program Up and Running
Authors: Munday D. , Kerin J.
Published: February 2008

EDITORIAL COMMENT: In the words of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, ‘Because there are special risks and hazards relating to laparoscopic surgery there is a need to provide guidelines for minimum standards relating to training, practice and equipment used for gynaecological laparoscopic surgery’.

The Australian Gynaecological Endoscopy Society (AGES) has been recognised by RANZCOG as the appropriate body to share with the College and hospital authorities the responsibility for implementation of supervised tuition for gynaecologists.

The implementation of the AGES guidelines has provoked much debate amongst gynaecologists. The majority of them feel that they are under threat from the guidelines and that such regulation is unnecessary as they have already been credentialled as specialist gynaecologists. The rising cost of medical indemnity could also result in medical insurance companies demanding evidence of credentialling before gynaecologists are covered for surgical mishaps which may occur during advanced laparoscopic surgery. Patient advocate groups similarly may demand evidence of extra training in this new surgical specially.

This paper reports the first successful attempt at implementing the AGES recommended College guidelines for advanced laparoscopic surgery. It addresses the problems that have confronted all institutions which have accreditation committees for laparoscopic procedures in place. We can all take heart that the oft quoted ‘draconian guidelines' have been tried and accepted in this teaching institution.

Peter Maher, Past President, Australian Gynaecological Endoscopy Society

Summary: Beginning in March 1997, a training and accreditation program in laparoscopic surgery was established at our hospital according to the training guidelines provided by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) (1, 2). Registrars were accredited upon satisfactory completion of supervised surgery at each training level. Consultants seeking clinical privileges in advanced laparoscopic surgery were asked to submit a formal application. By August 1998, 143 minor laparoscopic procedures had been formally assessed resulting in 8 of 9 registrars successfully completing training to level 2 laparoscopy. Thirty‐three of 83 (39.8%) advanced laparoscopic procedures were directly supervised and an experienced laparoscopic surgeon was available, if required, for a further 15 procedures. Two consultants undertook additional supervised training before being granted full accreditation for level 3 laparoscopic procedures. Another 2 consultants have been given provisional accreditation for level 3 procedures. Although challenging, implementation of the RANZCOG guidelines on training and accreditation in laparoscopic surgery is quite possible. Greater efforts should be undertaken to establish these guidelines as the ‘gold standard’ for hospital accreditation committees.
Threatened Abortion: Prediction of Viability Based on Signs and Symptoms
Authors: Chung T.K.H. , Sahota D.S. , Lau T.K. , Mongelli J.M. , Spencer J.A.D. , Haines C.J.
Published: February 2008

Objective: To examine the relationship between signs and symptoms associated with threatened abortion and viability of the pregnancy.

Design: A prospective observational study

Setting: A university teaching hospital

Participants: One thousand consecutive women presenting with a threatened abortion.

Intervention: A structured history and an examination were performed as initial clinical assessment. These were followed by transvaginal sonography to determine the status of the pregnancy.

Main outcomes: The relationship between individual signs and symptoms and the status of the pregnancy was determined. Logistic regression was performed to determine which signs or symptoms were independent predictors of spontaneous abortion.

Results: A history of having passed a tissue mass, the presence of products of conception in the vagina and an open cervix were the only sign or symptom associated with a greater than 90% chance that the pregnancy was non‐viable.

Logistic regression of signs and symptoms at presentation indicated that maternal age greater than 35 years, a history of passing clots vaginally, vaginal bleeding similar to normal menstruation, increasing vaginal bleeding and discrepancy of 4 or more weeks between the uterine size on examination and that which would have been expected by menstrual dates were significant predictors of nonviable pregnancy.

A history of vomiting was predictive of a viable pregnancy.

Conclusion: The clinical assessment of threatened abortion is unreliable in most cases and should be superseded by ready access to sonographic assessment.
Glucose Intolerance and Other Cardiovascular Risk Factors in Chinese Women with a History of Gestational Diabetes Mellitus
Authors: T.C. Ko Gary , C.N. Chan Juliana , Tsang Lynn W.W. , Yin Li Chi‐ , S Cockram Clive
Published: February 2008

Summary: Women with a history of gestational diabetes (GDM) are at increased risk of developing diabetes compared with other women. There are few data on associations between GDM and cardiovascular risk factors. Between 1988 and 1995, 801 Chinese women with a history of GDM were recruited for a 75g oral glucose tolerance test (OGTT) and assessment of various cardiovascular risk factors, namely obesity, hypertension and dyslipidaemia, 6 weeks after delivery at the Diabetes Centre of the Prince of Wales Hospital. Another 431 women with no past history of diabetes or GDM recruited in a diabetes prevalence study were used as control subjects. After adjustment for age, body mass index and smoking, the prevalence of glucose intolerance remained higher in women with a history of GDM when compared to normal controls. The relative risks of obesity, hypertension, dyslipidaemia, diabetes and impaired glucose tolerance in women with a history of GDM comparing to normal subjects were, respectively, 2.4, 7.5, 2.4, 8.1 and 5.0. After excluding those with abnormal glucose tolerance, subjects with a history of GDM still had more adverse cardiovascular risk factors, including higher blood pressure, glycaemic and lipid parameters, than control subjects (after adjustment for age, body mass index and smoking). In conclusion, compared with normal subjects, Chinese women with a history of GDM had an 8‐fold increased risk of having diabetes based on their OGTTs performed 6 weeks postdelivery. These women also have increased rates of other cardiovascular risk factors including obesity, high blood pressure and dyslipidaemia.
Transvaginal Chorionic Villus Sampling—an Alternative Approach
Authors: George Korula , S. George Susan , James Christina , Fernandes Herman A. , Shaji R. V. , Srivastava Alok , Chandy Mammen
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because it seems so sensible to use a transvaginal approach for a posteriorly situated placenta for chorionic villus sampling especially when the uterus is retroverted and the patient is obese. Consultation with the leading practitioners of chorionic villus sampling in Melbourne showed that all were aware of this approach, as mentioned in the literature, although they had not used it. The authors mention that a smaller needle may be appropriate such as the 20 gauge needle usually used for abdominal chorionic villus sampling. One reviewer stressed the importance of not performing this investigation before 10 weeks' gestation because of the recorded association with reduction defects of the limbs in the fetus, presumably due to interruption with vascular supply by trauma to the chorion. Future reports of a larger series of patients is required to reinforce the authors' message that this technique does not carry significant risk of infection. N.B.

Summary: Conventional transabdominal approach for chorionic villus sampling (CVS) is difficult in obese women, retroverted uteri and when the placenta is posteriorly placed, while the transcervical method is technically demanding. We investigated the use of an alternative approach‐transvaginal‐in 38 consecutive women undergoing CVS for prenatal diagnosis of haematological conditions. This is an effective method with regard to access and visualization of the placenta, patient tolerance and tissue yield. No major complications were encountered. We recommend that the transvaginal approach be considered for CVS, especially in difficult cases.
Choriocarcinoma Developing After Prolonged Molar Surveillance
Authors: Nada Wagdy , Parke Jim , Carter Jonathan
Published: February 2008

EDITORIAL COMMENT: This case, as the authors point out, illustrates yet again the unpredictability of the development of malignant trophoblastic disease especially after a hydatidiform mole. The editor is not an oncologist but has been interested in hydatidiform moles and their sequelae for more than 40 years. It would seem that the method of treatment of an evacuated or unevacuated hydatidiform mole in a multipara aged 44 years should consider ‘primary prophylactic hysterectomy’ as advocated by Professor Tow as a result of his analysis of a large series of patients in Singapore and analyzed in detail in his MD thesis. Had hysterectomy been performed in this patient following the diagnosis of a hydatidiform mole she would almost certainly have avoided the need for chemotherapy and the risks of metastatic choriocarcinoma. Readers are referred to the fourth paragraph of the summary of a study of 328 consecutive molar pregnancies in the State of Victoria during the 30 years 1940 to 1970, that ‘it is concluded that Tow's recommendation for primary prophylactic hysterectomy in patients over 40 is valid for this community’ (A). N.B.

(A) Beischer NA, Bettinger HF, Fortune DW, Pepperell R. Hydatidiform mole and its complications in the State of Victoria. J Obstet Gynaecol Br Commonw 1970; 77: 263–276
Prenatal Diagnosis and Management of Sacrococcygeal Teratoma
Authors: Ní Chuileannain Fiona , Woodrow Nicole , de Crespigny Lachlan
Published: February 2008

Summary: Five fetuses, each with a sacrococcygeal teratoma (SCT) were delivered at the Royal Women's Hospital while 2 fetuses, each with a SCT were delivered at Monash Medical Centre in 1998. The number of cases reported in this series is higher than expected but it most likely occurred due to chance. The diagnosis was made prenatally in all cases. Three of the SCT were entirely external while the remaining 4 were external with intrapelvic extension. Rapid growth of the SCT occurred in 3 fetuses. This was associated with polyhydramnios in 2 fetuses. No fetus developed nonimmune hydrops. Six infants were liveborn (perinatal mortality rate of 14%), 3 of whom were delivered prior to 37 weeks' gestation. Two infants were delivered by classical Caesarean section. The remaining 4 infants were delivered by lower uterine segment Caesarean ection. There was 1 perinatal death. This stillborn infant was delivered vaginally. The 6 surgical resections were performed between the 4th and 10th postnatal days. Histological examination confirmed the diagnosis of benign SCT in each. One infant developed a recurrence at 2 months of age and required chemotherapy.
Twin Pregnancy in a Uterus Didelphys, with Unilateral Placental Abruption and Onset of Labour
Authors: Browns Oliver
Published: February 2008

Summary: A dizygotic twin pregnancy with a fetus in each side of a uterus didelphys is described. An antepartum haemorrhage at 26 weeks' gestation, with subsequent onset of contractions in the right‐sided uterus, precipitated delivery by Caesarean section.
Factor V Leiden as a risk factor for miscarriage and reduced fertility
Authors: Baré S N , Póka R , Balogh I , Ajzner É
Published: February 2008

Summary: The Leiden mutation is a recent discovery. It is the main cause of inherited thrombophilia and has been found in 20–60% of deep vein thrombosis cases. More recently it has been found in a significant number of cases of obstetric complications attributable to placental thrombosis. Current patient management practice for dealing with the Leiden mutation is based mainly on information about deep vein thrombosis because there is little information on pregnancy complications. There are no prospective studies examining the risk of developing pregnancy complications for Leiden mutation carriers. The aim of this study is to do that by comparing the frequency of unfavourable pregnancy outcomes among carriers with those among controls. The number of women developing miscarriages, intrauterine deaths, or infertility problems among 128 Leiden mutation carriers was compared with the number among 461 controls. The risk of having at least one miscarriage or infertility problems was 1.5 times greater for Leiden mutation carriers than controls. This result was statistically significant (95% CI 1.2, 2.7). The risk of having at least two miscarriages or infertility problems was 2.5 times greater for Leiden mutation carriers than controls. This was also statistically significant (95% CI 1.2, 5.13).
A randomised controlled trial of dietary energy restriction in the management of obese women with gestational diabetes
Authors: Rae Anne , Bond Dianne , Evans Sharon , North Felicity , Roberman Brian , Walters Barry
Published: February 2008

Summary: A randomised controlled trial was designed to determine the effect of moderate 30% maternal dietary energy restriction on the requirement for maternal insulin therapy and the incidence of macrosomia in gestational diabetes. Although the control group restricted their intake to a level similar to that of the intervention group (6845 kiloJoules (kJ) versus 6579 kJ), the resulting cohort could not identify any adverse effect of energy restriction in pregnancy. Energy restriction did not alter the frequency of insulin therapy (17.5% in the intervention group and 16.9% in the control group). Mean birth weight (3461 g in the intervention group and 3267 g in the control group) was not affected. There was a trend in the intervention group towards later gestational age at commencement of insulin therapy (33 weeks versus 31 weeks) and lower maximum daily insulin dose (23 units versus 60 units) which did not reach statistical significance. Energy restriction did not cause an increase in ketonemia.
Body image and psychological well‐being in pregnancy. A comparison of exercisers and non‐exercisers
Authors: Goodwin Ann , Astbury Jill , McMeeken Joan
Published: February 2008

Summary: This study compared the perceptions of body image and psychological well‐being between exercising and non‐exercising pregnant women. A prospective longitudinal study was conducted with 65 nulliparous women (mean age years = 30.3, range = 23–39) who were allocated to 2 groups based on level of recreational exercise participation; 25 exercisers were compared with 18 non‐exercisers. A self‐report exercise history questionnaire and a 10 item Body Cathexis Scale were completed on two occasions during the pregnancy, at approximately 17 weeks and 30 weeks of gestation. The General Health Questionnaire (GHQ‐28) was administered in late pregnancy. There was a significant difference between the exercise group and the non‐exercise group in late pregnancy for some items on the Body Cathexis Scale. The exercise group had a lower level of probable caseness on the GHQ‐28 with reduced frequency of somatic symptoms, anxiety and insomnia, and a higher level of psychological well‐being.
Successful vaginal delivery in a woman with amyoplasia
Authors: Hackett Anna , Giles Warwick , James Sue
Published: February 2008

Summary: We report on the pregnancy management of a 22‐year‐old woman with amyoplasia, the commonest type of arthrogryposis multiplex congenita (AMC). Extrapolating from childhood and adult studies, the majority of cases are likely to be ambulatory and live independent lives as adults. Many females, therefore, would be expected to achieve a pregnancy.

There have been several case reports on anaesthetic management for Caesarean section delivery in women with arthrogryposis, but no medical literature exists regarding the likelihood or management of vaginal delivery. This is the first reported case of conservative management of a woman with amyoplasia. A multi‐disciplinary team was involved in her care. This involved careful assessment of her suitability for vaginal delivery, possible anaesthetic complications and potential difficulties in caring for an infant at home. Induction of labour at 37 weeks gestation resulted in the successful vaginal delivery of a liveborn healthy male.
Term breech birth in New South Wales, 1990–1997.
Authors: Roberts Christine L. , Peat Brian , Algert Charles S. , Henderson‐Smart David
Published: February 2008

Data on 636,708 women delivering a singleton infant of gestational age >37 weeks in NSW from 1 January 1990 to 31 December 1997 were used to examine trends in breech births at term and the mode of delivery. From 1990 to 1997, although the crude rate of breech births at term remained stable at 3,4%, the adjusted odds ratio for breech birth compared with cephalic birth decreased over time. Among live breech births, the crude rate of vaginal breech birth declined from 29.4% to 19.7%, with an attendant increase in elective Caesarean sections from 49.1 % to 58.4%. Most of this increase was at 38 and 39 weeks gestation. There was no change in the perinatal mortality rate among breech births during the study period. Despite increasing maternal age, the adjusted odds of a breech birth at term decreased over time. This could be due to offsetting factors, such as increased use of external cephalic version. If the decrease in vaginal breech birth continues, it may lead to the skills for this procedure being lost.
Risk factors related to premature rupture of membranes in term pregnant women: a case‐control study
Authors: Kovavisarach Ekachai , Sermsak Patipan
Published: February 2008

A case‐control study of premature rupture of membranes (PROM) of full term pregnant women was undertaken between 1 November 1996 and 30 July 1997 at Rajavithi Hospital to determine the risk factors related to PROM.

Two hundred and twenty pregnant women with PROM and 220 pregnant women without PROM were recruited by a simple random sampling. The diagnosis of rupture of membranes was made from history and from positive microscopic ferning and pH tests performed during a speculum examination. The demographic data was not significantly different between the two groups. The risk factors, such as a history of PROM in a previous pregnancy, a history of abortion in a previous pregnancy, and body mass index (BMI) <20 were significantly different between the PROM group and the control group. However, on using multiple logistic regression analysis, we found that the residual significant risk factors were a history of PROM in a previous pregnancy and BMI < 20.
Surgery and post‐operative radiotherapy for early stage cervical cancer
Authors: Vinod S K. , MacLeod C A. , Dalrymple C , Elliott P , Atkinson K , Carter J , Firth I
Published: February 2008

The use of post‐operative radiotherapy in the treatment of cervical cancer is controversial. The aim of this study was to document the results and toxicity of adjuvant irradiation in patients with Stage 1B and 2A cervical cancer.

We performed a retrospective review of all patients treated with post‐operative radiotherapy at Royal Prince Alfred Hospital between 1986 and 1993. Patient, tumour and treatment factors and late toxicity were recorded. Relapse‐free and overall survival were calculated.

Eighty‐one patients form the study population. The median follow‐up was 6.1 years. Fifty‐eight patients (72%) had stage 1B cervical cancer and 23 (28%) stage 2A. The 5 year relapse‐free and overall survival were 78% and 80% respectively. Six patients (7%) had late toxicity requiring inpatient medical treatment and 6 patients (7%) required surgery.

The survival was comparable to other series reported in the literature. There was an incidence of 14% late toxicity requiring medical or surgical intervention which is greater than with hysterectomy or pelvic irradiation alone. Clinical prognostic factors should be used to select patients for either surgery or radiotherapy alone to minimise the increased toxicities associated with a combination of surgery and radiotherapy.
Sickle cell disease in pregnancy
Authors: Ladwig Petra , Murray Henry
Published: February 2008

Homozygous sickle cell anaemia (Hb S) is the most common major haemoglobinopathy in the United States, occurring in approximately 1 in 626 African Americans. While haemoglobinopathies involving Hb S occur commonly in blacks of African descent, they are also found in people of Middle Eastern, East Indian and Mediterranean origin. It is an uncommon disease, especially in homozygous form, in Australia. We present the case of a woman in her third pregnancy, originally from Ghana, with HB F, and discuss the current issues in the management of sickle cell disease in pregnancy.
Operative vaginal delivery: clinical appraisal of a new vacuum extraction device
Authors: Vacca Aldo
Published: February 2008

Summary: The efficacy of a new vacuum extraction device, the Kiwi OmniCup, and its effects on mothers and infants were tested in a study of 18 non‐rotational and 32 rotational vacuum assisted deliveries. Forty‐nine (98%) of the extractions resulted in successful vaginal births. Autorotation of the fetal head when the occiput was transverse or posterior was achieved in 31 (97%) of the 32 vacuum procedures. The high success rates recorded for both vaginal delivery and autorotation of the fetal head were largely attributable to the fact that flexing cup applications were achieved in 90% of the vacuum attempts.

There were no cases of serious maternal trauma or clinically significant neonatal injuries. Two infants had cephalohaematomas and one infant developed a small subgaleal haemorrhage following a difficult delivery, which resolved rapidly without complications.

It was concluded that the Kiwi OmniCup is an efficient and safe vacuum device for assisted vaginal delivery, provided it is used correctly and appropriately.
The fetal inflammatory response syndrome and cerebral palsy: yet another challenge and dilemma for the obstetrician
Authors: Svigos John M
Published: February 2008

Summary: There is increasing evidence demonstrating a relationship between intrauterine infection and the development of neonatal intraventricular haemorrhage and periventricular leukomalacia with the subsequent occurrence of cerebral palsy, which is thought to be mediated through the generation of pro‐inflammatory cytokines by the fetus.

In the light of this relationship, a review of the current management of intrapartum infection and the associated complications of intrauterine infection such as preterm labour and preterm premature rupture of the membranes would seem timely, along with the development of potential strategies which might prevent or ameliorate the effects of the fetal inflammatory response syndrome.

The suggested changes in the understanding and management of the fetal inflammatory response syndrome provide a challenge and pose a dilemma for the practising obstetrician.
Effects of ethnicity on glucose tolerance, insulin resistance and beta cell function in 223 women with an abnormal glucose challenge test during pregnancy
Authors: Gunton Jenny E , Hitchman Rosemary , McElduff Aldan
Published: February 2008

Summary: This study was conducted to investigate body‐mass‐index (BMI), insulin resistance and beta cell function in a group of pregnant women. Two hundred and twenty‐three consecutive women with an abnormal 50 g glucose challenge test in the third trimester were studied. All underwent oral glucose tolerance testing; 97 had a 100 g test and 126 a 75 g test. Fasting insulin was measured. Insulin resistance and beta cell function were calculated using the homeostasis model.

Among the 136 Caucasian, 60 Asian, 11 Indian and 16 Arabic women studied, there were no age differences. Arabic women had higher parity (p < 0.05). Asian women had lower BMI than Caucasian (p < 0.001), Indian (p < 0.01), and Arabic women (p < 0.01).

Women with gestational diabetes had higher insulin resistance than women with normal glucose tolerance (2.9 ± 4.0 vs 2.3 ± 2.5 p = 0.025). Women with gestational diabetes tended to have lower beta cell function 199 ± 203 vs 247 ± 380 p = 0.08). Asian women had higher glucose levels than Caucasian women after 50 g challenge (8.9 + 2.1 mmol/1 vs 8.6 ± 1.6; p = 0.034). Asian women were more likely to have gestational diabetes than Caucasian women (31.7% vs 14%; p = 0.02). Fasting glucose and insulin were comparable in Asian and Caucasian women. Mean insulin resistance and beta cell function in Asian and Caucasian women were not significantly different.

We concluded that Asian women had lower BMI than Caucasian women. Women with gestational diabetes were more insulin resistant. Insulin resistance and beta cell function in Asian and Caucasian women are similar. Gestational diabetes in Asian women is of similar aetiology to that seen in Caucasian women, but occurs at a lower BMI.
The impact of ethnicity on the presentation of polycystic ovarian syndrome
Authors: Williamson Karen , Gunn Alistair J , Johnson Neil , Milsom Stella R
Published: February 2008

Summary: The effect of etnnicity on me prevalence ana presentation of polycystic ovarian syndrome (PCOS) was examined in a cross‐sectional study of women with clinical ‐ and ultrasound ‐ diagnosed PCOS. European, Maori and Pacific Island women were seen in proportion to the general population, whereas Indian women were over‐represented and Chinese women under‐represented. European and Maori women were more likely to present with hirsutism than other ethnic groups (43% versus 25%, p < 0.05), while European women were less likely to present with infertility (46% versus 68%, p < 0.01). The Pacific Island women had little or no acne but other signs of PCOS were similar among ethnic groups. Although less than 10% of patients were referred with obesity, the majority of PCOS women were overweight on examination. Maori and Pacific Island women were more obese and had the highest rates of insulin resistance and lipid abnormalities. The adverse metabolic profile of many of these women, particularly the Maori and Pacific Islanders, is very likely to predispose them to early cardiovascular disease.
Follicular flushing at oocyte retrieval: a reappraisal
Authors: Knight David C , Tyler John PP , Driscoll Geoffrey L
Published: February 2008

Summary: A survey of Australian assisted reproduction technique (ART) units revealed many (> 50%) use flushing of the follicle in addition to direct aspiration of the fluid during oocyte retrieval. The rationale is that flushing offers an advantage to the patient, with a larger number of oocytes being collected and thus a higher potential for pregnancy.

Following a complication in a patient, the medical staff determined that flushing might have been implicated. While this was later shown to be unfounded, the unit changed the method of oocyte collection, thus providing an opportunity historically to evaluate the differences between aspiration of follicular fluid alone or with additional flushing of each follicle.

Thus the aim of this analysis was to test the hypothesis that aspiration alone does not effect the outcomes of ART with respect to oocyte numbers collected, their quality and subsequent fertilisation, or ultimate pregnancy rate in a large patient group (n = 2378).

During the review period (1991–1993) the manufacturer of the aspiration needles; the pump and pressure used for aspiration; the staff involved in all procedures; and the premises, equipment and media used for oocyte collection and culture remained constant. Similarly the two patient groups did not differ in their demographics and physical characteristics.

There was no difference (p > 0.5) in the number of oocytes collected, the number of embryos created or the pregnancy rate for that treatment cycle. There was also no significant difference between the two groups in fertilisation rates, irrespective of the type of treatment being used in vitro fertilisation (IVF), gamete intrafallopian transfer (GIFT) or intracytoplasmic sperm injection (ICSI)).

The data presented in this paper are not prospective. They use historical comparison and are confounded by minor changes in ovarian stimulation protocols, but the conclusions are still valid. These data suggest there is no difference in the outcome of ART (from oocyte collection through to pregnancy rate) whether or not aspiration of follicles is accompanied by flushing. First principles of surgery advocate the shortest possible operating time, the simplest procedure and minimum amount of tissue handling as maxims for reducing complication. Therefore, as a routine, flushing would seem superfluous in ART.
Antenatal counselling, resuscitation practices and attitudes among Australian neonatologists towards life support in extreme prematurity
Authors: Munro Michael , Yu Victor YH , Partridge J Colin , Martinez Alma M
Published: February 2008

Summary: A questionnaire survey of Australian neonatologists was conducted to ascertain their antenatal counselling and resuscitation practices, and attitudes towards life support in the extremely preterm infant. This study showed that in antenatal parental counselling, whether a paediatrician was given the opportunity to participate depends on the gestation at the time of the threatened preterm delivery. The counselling employed almost invariably covered mortality and morbidity. The obstetrician's opinion was considered to be of utmost importance. Both financial and moral obligations were found to be of little importance in counselling and resuscitation. Only one‐third of institutions had guidelines for limiting resuscitation. The onus remained on the neonatologists concerning which infant to resuscitate, and the level of the resuscitation to be conducted.

In Australia, resuscitation at birth was restricted to infants of 23 weeks' gestation or above, and neonatologists did not believe the legal system has a role to play in limiting or mandating resuscitation of extremely preterm infants. Neither were they concerned with the threat of litigation when they decide to limit resuscitation. The majority of neonatologists agreed with their institution's approach to life support in extremely preterm infants. One grey area was the question of withholding assisted feeding in an infant for which the decision to withdraw life support has been made. Australia lacked a current consensus policy on selective non‐treatment. The establishment of national guidelines would be helpful to aid Australian obstetricians and neonatologists in their clinical practice.
Ten‐year review of hysterectomy morbidity and mortality: can we change direction?
Authors: Varol Nesrin , Healey Martin , Tang Peter , Sheehan Penny , Maher Peter , Hill David
Published: February 2008

Summary: The medical records of all women who underwent hysterectomy for benign disease performed between 1986 and 1995 were reviewed to ascertain the incidence of morbidity and mortality of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy at a university teaching hospital. A total of 1940 hysterectomies were performed during this period; 74% of hysterectomies were performed abdominally, 24% vaginally and 2% were laparoscopically assisted. In 80% of the patients uterine leiomyomas, adenomyosis, dysfunctional uterine bleeding or uterine prolapse were the indications for hysterectomy. The overall complication rate was 44% for abdominal hysterectomy (AH) and 27.3% for vaginal hysterectomy (VH). An unintended major surgical procedure was required in 3% and 1% of women undergoing AH and VH respectively. The rate of return to the operating room for haemostasis was 0.6% for AH and 0.2% for VH. The AH group was four times more likely than the VH group to require surgical intervention (36% versus 9%) at readmission. Vaginal hysterectomy was associated with a lower febrile morbidity and minor complication rate. Prophylactic antibiotics reduced the febrile morbidity for VH and AH by 50% (Student's t‐test, p = 0.02) and 40% (Student's t‐test, p < 0.001) respectively The overall mortality rate was 1.5 per 1000.
Oestrogen, glycogen and vaginal candidiasis
Authors: Dennerstein Graeme J , Ellis David H
Published: February 2008

Summary: Our aim was to relate vaginal candidiasis to vaginal oestrogenisation. First, the incidence was determined (subjected to chi‐square analysis) of vaginal Candida albicans infection in 339 consecutive dermogynaecology clinic patients aged 55 years and over, of whom 142 were using and 197 were not using oestrogen. Second, the ability of Candida species to utilise glycogen as a sole nutrient source was studied by performing assimilation tests using yeast nitrogen broth as a basal medium.

Of the women using oestrogen, 26% had C. albicans infection on initial presentation compared with 4oo in the cohort not using oestrogen (p < 0.001). All 34 isolates of C. albicans assimilated glycogen. Twenty‐six non‐albicans species of Candida tested did not assimilate glycogen.

In this study of postmenopausal women, there was a highly significant relationship between the usage of oestrogen and the occurrence of C. albicans infection. The production of glycogen by oestrogen stimulated epithelial maturation provides an attractive substrate for C. albicans.
Subsequent birth outcomes after an unexplained stillbirth: preliminary population‐based retrospective cohort study
Authors: Robson Stephen , Chan Annabelle , Keane Rosemary J , Luke Colin G
Published: February 2008

The objective of this study was to determine whether women who have experienced an unexplained stillbirth have a higher risk of adverse perinatal outcomes in subsequent births. We compared 316 subsequent births to women with a previous unexplained stillbirth, with 3160 births to women with no previous history of stillbirth, matched by year of birth, in the period 1987–1997, from the South Australian perinatal database, using logistic regression analysis. There was no increase in the rate of stillbirth and no statistically significant increase in the rate of perinatal death (OR 1.62 [95% CI 0.63^4.20]) or neonatal death, although larger studies are needed to confirm this. However, after adjusting for age, parity, and hospital category of birth, women who had a previous stillbirth had increased incidences in subsequent births of abnormal glucose tolerance or gestational diabetes (a fourfold increase); induction of labour and elective Caesarean section; fetal distress and postpartum haemorrhage; and forceps and emergency Caesarean delivery and preterm birth, which were independent of Induction of labour. Gestational age at birth and birthweight were also significantly reduced, suggesting a need for close monitoring of their future pregnancies.
Manual removal of the placenta ‐ a case control study
Authors: Titiz Hasan , Wallace Allan , Voaklander Donald C
Published: February 2008

The aim of this study was to determine the incidence and complications related to manual removal of the placenta in a regional hospital in Australia. The study was carried out at the Goulburn Valley Base Hospital in Shepparton. The hospital medical records were reviewed from 1992 to 1999. A total of 3734 singleton live vaginal deliveries took place during the 7‐year study period. The placenta was removed manually in 114 women (3%). For a control group, a series of 113 women who had singleton live vaginal deliveries from the same period were chosen at random. The case and control groups were similar in age, parity, and gravidity.

A previous history of retained placenta and a history of preterm delivery in the current pregnancy were significantly related to retained placenta (OR 9.8 [95% CI 1.1–85.5] and OR 5.6 [95% CI 1.1–26.8], respectively). The cases received significantly more blood transfusions than the control group (13% versus 0%). Decreased maternal age was also significantly related to retained placenta. There were also more post‐delivery dilatation and curettage (D&C) operations and diagnosis of endomyometritis in the case group. However, these differences were not statistically significant. One woman, in the case group, had to have a hysterectomy due to placenta accreta.