bluuebunny/crossref_metadata_2025 huggingface dataset:
A multicentre evaluation of a new surgical technique for urethral bulking in the treatment of genuine stress incontinence
Authors: Henalla S. M. , Hall V. , Duckett J. R. A. , Link C. , Usman F. , Tromans P. M. , van Veggel L.
Published: August 2005

This prospective study assesses the surgeon and patient acceptability of a new implantation device for transurethral Macroplastique injection, as well as the safety and effectiveness of the technique. Ten women with genuine stress incontinence were recruited at each of four participating urogynaecological centres. Treatment was performed in an outpatient or day case setting and follow up took place at six weeks and three months after treatment. Those in whom treatment had failed were offered re‐treatment. The operator acceptance of the device was rated as excellent or acceptable in 95% after the first treatment and 100% after re‐treatment. Urethral insertions were rated acceptable in 92.5%. Pain was scored as mild to moderate in 89% of all insertions. The overall success rate was 74.3% at three months with an implantation rate of 1.35 which appears to be comparable to published endoscopic data. We have concluded from this study that the Macroplastique implantation device is safe to use and provides simplified, yet effective alternative to the endoscopic implantation of urethral bulking agents.
An in vivo comparative study of the pregnant and nonpregnant cervix using electrical impedance measurements
Authors: O'Connell M. P. , Tidy J. , Wisher S. J. , Avis N. J. , Brown B. H. , Lindow S. W.
Published: August 2005

Electrical impedance may be measured using electrodes on the surface of the cervix and recording the potential that results when an electrical current is passed. Increased hydration of the cervix has been described throughout pregnancy and occurs most dramatically before labour. This study compared tissue impedance measurements of the pregnant and non‐pregnant cervix and found a statistically significant lower value (P < 0.001) in pregnancy. Further work may show that such measurements alter in relation to labour onset.
p53 and WAF1 polymorphisms in Jewish‐Israeli women with epithelial ovarian cancer and its association with BRCA mutations
Authors: Yair Daniel , Ben Baruch Gilad , Chetrit Angela , Friedman Tal , Yechezkel Galit Hirsh , Gotlieb Walter H. , Fishman Amiram , Belter Uzi , Bar‐Am Amiram , Friedman Eitan
Published: August 2005

Objective
To investigate whether polymorphic p53 and WAF1 alleles are associated with clinical, demographic and histopathological features and BRCA mutation in women with ovarian cancer.

Design
A cross‐sectional study.

Population
Two hundred and twenty‐one nonselected Israeli women with epithelial ovarian cancer.

Methods
DNA was analysed for known polymorphisms in intron 3 (a 16 nucleotide single repeat) and intron 6 (a G to A change at nucleotide 13,494) of the p53 gene, the S31R polymorphism in the WAF1 gene, and for three predominant Jewish mutations in the BRCA genes (185delAG and 5382insC in BRCA1, and 6174delT in BRCA2).

Main outcome measure
The rate of polymorphic p53 and WAF1 alleles and their association with BRCA mutation, ethnic origin, age and stage at diagnosis, and family history of cancer.

Results
Of the tested women, 72 (32.6%) were either BRCA1 (n= 57) or BRCA2 (n= 15) mutation carriers. Sixty‐eight of 213 (31.9%) were heterozygous for intron 3 polymorphism, 67/193 (34.7%) for intron 6 polymorphism, and 22/154 (14.3%) for S31R of the WAF1 gene. The p53 and WAF1 polymorphism rate did not differ between BRCA mutation carriers and noncarriers. No significant association between specific p53 or WAF1 genotypes, and clinical, histopathological or demographic variables was observed.

Conclusion
In Jewish‐Israeli women with sporadic and familial ovarian cancer, p53 or WAF1 polymorphisms do not seem to affect the phenotype.
The relationships between antenatal management, the cause of delivery and neonatal outcome in a large cohort of very preterm singleton infants
Authors: Baud O. , Zupan V. , Lacaze‐Masmonteil T. , Audibert F. , Shojaei T. , Thebaud B. , Ville Y. , Frydman R. , Dehan M.
Published: August 2005

Objective
To determine whether the cause of very preterm delivery influences neonatal outcome.

Design
A cohort study of 685 consecutive singletons born before 33 weeks of gestation.

Methods
Causes of birth and perinatal outcome variables were correlated for statistical significance by uni‐ and multi‐variate analyses.

Results
Intrauterine growth retardation or pre‐eclampsia were associated with a higher rate of respiratory distress syndrome compared with prolonged rupture of membranes, after controlling for gestational age, antenatal corticosteroid therapy, antenatal antibiotic administration, mode of delivery and origin (inborn or outborn) (adjusted OR 3.12; 95% CI 1.55–6.28). The prevalence of grade 3–4 intraventricular haemorrhage or cystic periventricular leukomalacia was 25% in newborn babies born after intrauterine infection or prolonged rupture of membranes. Among infants born after intrauterine growth retardation/pre‐eclampsia, the rate of severe intraventricular haemorrhage was 3.2% and the rate of periventricular leukomalacia was 0.9%. Compared with intrauterine infection and after controlling for potential confounding covariates, intrauterine growth retardation/pre‐eclampsia was associated with a lower rate of periventricular leukomalacia (adjusted OR 0.08; 95% CI 0.02–0.41). In the same multiple logistic regression model, antenatal corticosteroid administration was associated with a lower incidence of periventricular leukomalacia (adjusted OR 0.36; 95% CI 0.16–0.79).

Conclusions
The cause of very preterm delivery has an important influence on neonatal outcome.
Dietary folate and the prevalence of neural tube defects in the British Isles: the past two decades
Authors: Murphy Michael , Whiteman David , Stone David , Botting Beverly , Schorah Chris , Wild Jenny
Published: August 2005

ObjectivesTo measure the changes in folate consumption and the prevalence of neural tube defects in the British and Irish populations during the past two decades.

DesignEcological study.

Main outcome measuresAverage daily dietary folate consumption for Britain for the period 1980–1996 was estimated from the National Food Survey. Annual neural tube defect prevalences for the same period were obtained from the Oxford Record Linkage Study Neural Tube Defect register, the Glasgow EUROCAT register, and the three Irish EUROCAT registers (Belfast, Dublin and Galway).

ResultsDietary folate consumption increased on average by 1.6% per annum in Scotland and 1.4% in England during the study period. The annual rate of decline of neural tube defect prevalence averaged 10.4% in the Irish population, 8.2% in Glasgow, and 5.2% in Oxfordshire and West Berkshire.

ConclusionsThe decline in neural tube defect prevalence observed in all British and Irish populations since the early 1970s continued with the introduction of folate fortification of cereals, which produced measurable increases in average daily folate consumption. Further declines in neural tube defect prevalence may be achieved by targeted folate supplementation during the periconceptual period.
Diet in late pregnancy and glucose‐insulin metabolism of the offspring 40 years later
Authors: Shiell A. W. , Campbell D. M. , Hall M. H. , Barker D. J. P.
Published: August 2005

Objective
To determine how diets of women in pregnancy influence the glucose‐insulin metabolism of their offspring in adult life.

Design
A follow up study of men and women born during 1948–1954 whose mothers had taken part in a survey of diet in late pregnancy.

Setting
Aberdeen, Scotland.

Population
One hundred and sixty‐eight men and women born in the Aberdeen Maternity Hospital.

Main outcome measure
Plasma glucose and insulin concentrations, fasting and after a standard oral glucose challenge.

Results
The offspring of women who had high intakes of fat and protein in late pregnancy had a reduced plasma insulin increment between fasting and 30 min with a 7.0% decrease in increment (P= 0.007) per 10 g increase in protein intake and a 4.9% decrease (P= 0.002) per 10 g increase in fat intake. This was independent of the mother's body mass index or weight gain in pregnancy. A low maternal body mass index in early or late pregnancy was associated with a raised fasting plasma insulin concentration with a decrease of 2.4% (P= 0.05) per 1 kg/m2 increase of maternal body mass.

Conclusion
High intakes of protein and fat during pregnancy may impair development of the fetal pancreatic beta cells and lead to insulin deficiency in the offspring. The offspring of thin mothers tend to be insulin resistant.
Umbilical artery Doppler studies in small for gestational age babies reflect disease severity
Authors: McCowan Lesley M. E. , Harding Jane E. , Stewart Alistair W.
Published: August 2005

Objectives
To determine: 1. whether abnormal umbilical artery Doppler studies were independently associated with newborn morbidity; and 2. whether small for gestational age babies with normal umbilical artery Doppler studies had small mothers and a low rate of newborn malnutrition and morbidity.

Design
Prospective observational study.

Setting
National Women's Hospital, a tertiary referral centre, Auckland, New Zealand.

Population
One hundred eighty‐six women and their small for gestational age babies (birthweight < 10th%) who had been participants in one of two randomised controlled trials of small for gestational age pregnancies between 1993 and 1997.

Methods
Newborn morbidity and morphometry were compared between small for gestational age babies with normal and abnormal umbilical artery Doppler studies (resistance index > 95th%). Maternal demographic characteristics and morbidity were also compared.

Results
Compared with small for gestational age babies with normal umbilical artery Doppler studies (n= 109), small for gestational age babies with abnormal umbilical artery Doppler studies (n= 77) were diagnosed earlier in pregnancy as being small for gestational age (30.3 vs 32.9 weeks, P < 0.001), were smaller in all body proportions at birth (median Z score birthweight −1.82 vs−1.70, P= 0.004, Z score length −1.86 vs−1.36, P < 0.0001, Z score head circumference −1.31 vs−0.89, P < 0.0001) and were more likely to experience newborn morbidity. When birthweight and gestation were entered into a logistic regression model, an abnormal umbilical artery Doppler study was not an independent predictor of prolonged newborn nursery admission or hypoglycaemia. Of small for gestational age babies with normal umbilical artery Doppler studies, 53 (49%) had low ponderal indices, 26/98 (26%) were hypoglycaemic and 38 (35%) required admission to the newborn nursery. There was no difference in maternal height, weight and ethnicity between the abnormal and normal umbilical artery Doppler groups.

Conclusions
Abnormal umbilical artery Doppler studies reflect earlier onset and more severe growth restriction and are not independently associated with newborn morbidity. Small for gestational age babies with normal Doppler studies have a high rate of newborn nursery admission and malnutrition at birth and are not all just normal small babies.
Elevated circulating homocyst(e)ine levels in placental vascular disease and associated pre‐eclampsia
Authors: Wang Jian , Trudinger Brian J. , Duarte Natalia , Wilcken David E. , Li Wang Xing
Published: August 2005

We examined the hypothesis that hyperhomocyst(e)inaemia in the maternal or fetal circulation is associated with placental vascular disease with either the maternal syndrome of pre‐eclampsia and/or fetal syndrome of growth restriction. Maternal plasma homocyst(e)ine levels were significantly higher in pregnancies complicated by pre‐eclampsia, pregnancies with evidence of umbilical placental vascular disease, and pregnancies with both complications compared with the normal pregnancy group. In the fetal circulation mean plasma homocyst(e)ine concentration was significantly higher in the pre‐eclampsia group compared with the normal group. The results suggest that hyperhomocyst(e)inaemia may be a risk marker for placental vascular disease and maternal pre‐eclampsia. The elevated fetal plasma homocyst(e)ine concentrations, found only in the group of pregnancies with pre‐eclampsia in the absence of umbilical placental vascular disease, may be due to an effect of placental vascular disease on homocyst(e)ine transfer from the maternal to fetal circulation.
Serum inhibin, activin and follistatin in postmenopausal women with epithelial ovarian carcinoma
Authors: Menon Usha , Riley Simon C. , Thomas Janice , Bose Chinmoy , Dawnay Anne , Evans Lee W. , Groome Nigel P. , Jacobs Ian J.
Published: August 2005

Objective
To investigate the role of serum inhibin A, inhibin pro‐αC immunoreactivity, activin A, and follistatin in postmenopausal women with epithelial ovarian cancer.

Design
Case‐control study.

Sample
Serum samples from 27 postmenopausal women with epithelial ovarian cancer and 54 controls from the general population participating in an ovarian cancer screening trial.

Results
Women with epithelial ovarian cancer had significantly higher serum levels of pro‐αC immunoreactivity (P= 0.03), activin A (P= 0.004) and follistatin (P= 0.04), but not inhibin A (P= 0.13). Using the 90th centile in the control group as the cut off, pro‐αC levels were elevated in 41% of women with epithelial ovarian cancer, while inhibin A was elevated in only 15%. Using the 95th centile as the cut off, serum pro‐αC was elevated in only 11% of women with epithelial ovarian cancer (3/27), while activin A was elevated in 48% (11/23). Follicle stimulating hormone levels were significantly lower in women with epithelial ovarian cancer (P= 0.01). Although, inhibin‐related peptides can modulate follicle stimulating hormone levels, there was no correlation between inhibin A, pro‐αC immunoreactivity, activin A or follistatin and follicle stimulating hormone.

Conclusion
These data demonstrate that though there is preferential secretion of precursor forms of the α subunit rather than dimeric inhibin A by epithelial ovarian cancer, pro‐αC is unlikely to be a useful tumour marker. Activin A is more commonly elevated in postmenopausal women with epithelial ovarian cancer and its role as a tumour marker in the diagnosis and screening of epithelial ovarian cancer warrants further evaluation.
Ultrasonographic measurement of endometrial changes following discontinuation of tamoxifen treatment in postmenopausal breast cancer patients
Authors: Cohen Ilan , Beyth Yoram , Azaria Ron , Flex Dov , Figer Arie , Tepper Ron
Published: August 2005

Objective
To assess whether there is a decrease in endometrial thickness following discontinuation of tamoxifen treatment as measured by ultrasound.

Design
Prospective study.

Setting
Department of Obstetrics and Gynaecology, Sapir Medical Centre, Kfar‐Saba, Israel.

Population
Fifty‐eight postmenopausal women with breast cancer who were treated with tamoxifen.

Methods
Transvaginal ultrasonographic measurements of endometrial thickness.

Main outcome measures
Evaluation of the changes of endometrial thickness and the frequency the endometrium reached a thickness of ≤ 5 mm at different time intervals after stopping tamoxifen treatment.

Results
There was a significant decrease in median thickness of the endometrium, within six months after stopping tamoxifen, from 7.75 mm measured at the last ultrasonographic study performed before tamoxifen discontinuation down to 5.2 mm (P= 0.002). There were no further reductions in endometrial thickness, and it remained constantly low in subsequent ultrasonographic studies which were performed at various times up to 30 months following the discontinuation of tamoxifen treatment. While taking tamoxifen, only 25.9% of the women had an endometrial thickness of ≤ 5 mm. This proportion doubled in their first six months after stopping.

Conclusions
Median thickness of endometrial thickness significantly reduced within six months following tamoxifen discontinuation, and remained constantly low thereafter. This finding may support use of ultrasonographic imaging for the measurement of tamoxifen's effect on the endometrium of postmenopausal breast cancer patients.
The misoprostol third stage of labour study: a randomised controlled comparison between orally administered misoprostol and standard management
Authors: El‐Refaey Hazem , Nooh Randa , O'Brien Pat , Abdalla Mona , Geary Michael , Walder Jane , Rodeck Charles
Published: August 2005

Objective
To compare misoprostol with standard oxytocic regimens in the prevention of postpartum haemorrhage.

Design
Randomised controlled trial.

Setting
Obstetric unit in a large teaching hospital.

Methods
One thousand women randomised to 500 μg misoprostol given orally or to standard oxytocic regimens of oxytocin, oxytocin with ergometrine, or ergometrine.

Main outcome measures
Incidence of postpartum haemorrhage and the incidence and severity of side effects.

Results
Postpartum haemorrhage occurred in 12% of women given misoprostol and in 11% of women given standard oxytocic drugs (relative risk (RR) 1.10, 95% confidence interval (CI) 0.79, 1.55). Blood loss of 1000 mL or more occurred in 2% of women in each group. Nausea, headache, dizziness and tiredness were less frequent with misoprostol (RR (95% CI) 0.71 (0.59, 0.84); 0.53 (0.38, 0.74); 0.73 (0.61, 0.87) and 0.88 (0.83, 0.94) respectively). The main side effects of misoprostol were shivering (RR 1.95, 95% CI 1.69, 2.25) and a rise in temperature (difference in mean rise 0.34°C, 95% CI 0.26, 0.42).

Conclusion
Oral misoprostol for the prevention of postpartum haemorrhage was comparable to standard oxytocics. Many side effects were less common with misoprostol but shivering and pyrexia were more common. Larger randomised trials are needed before establishing the equivalence between misoprostol and standard oxytocic drugs in the prevention of postpartum haemorrhage.
Antenatal use of enoxaparin for prevention and treatment of thromboembolism in pregnancy
Authors: Ellison Joanne , Walker Isobel D. , Greer Ian A.
Published: August 2005

Objective
To assess the safety and efficacy of enoxaparin use for thromboprophylaxis or treatment of venous thromboembolism during pregnancy.

Design
Retrospective review of casenotes of women who received enoxaparin during pregnancy.

Setting
Obstetric Medicine Unit at Glasgow Royal Maternity Hospital.

Sample
Data were obtained on 57 pregnancies in 50 women over six years.

Methods
Information was obtained from case records in relation to outcome measures, the presence of underlying thrombophilia and indication for anticoagulation.

Main outcome measures
Incidences of venous thromboembolism, haemorrhage, thrombocytopenia, peak plasma anti‐factor Xa levels and symptomatic osteoporosis.

Results
There were no thromboembolic events in the thromboprophylaxis group. There were no incidences of heparin‐induced thrombocytopenia. Twenty‐two women had spinal or epidural anaesthesia and no complications were encountered. There was one instance of antepartum haemorrhage following attempted amniotomy in a woman with previously unknown vasa praevia. Two women sustained postpartum haemorrhage, both secondary to vaginal lacerations, resulting in blood loss > 1000 mL. Blood loss following caesarean section was not excessive. No instances of vertebral or hip fracture were encountered. The median peak plasma anti‐factor Xa level on a dose of 40 mg once daily was 0.235 U/mL; peak plasma anti‐factor Xa levels were not affected by gestational age.

Conclusions
The use of enoxaparin in pregnancy is associated with a low incidence of complications and a dose of 40 mg once daily throughout pregnancy provides satisfactory anti‐factor Xa levels and appears effective in preventing venous thromboembolism.
The development and validation of an algorithm for real‐time computerised fetal heart rate monitoring in labour
Authors: Taylor Graham M. , Mires Gary J. , Abel Eric W. , Tsantis Stavros , Farrell Tom , Chien Patrick F. W. , Liu Ying
Published: August 2005

Objective
To develop and validate a computerised algorithm for the interpretation of the characteristics of fetal heart rate monitoring in labour.

Design
Prospective observational study.

Setting
Labour ward in a tertiary hospital.

Sample
Intrapartum cardiotocograms from 24 pregnancies.

Methods
A computerised algorithm was developed to assess the fetal heart baseline rate, variability, the number of accelerations and the number of decelerations. Twenty five minute segments of cardiotocograms were interpreted by the algorithm and also by seven expert reviewers independently. The reviewers were unaware of the outcome of labour. The reliability of the characteristics of car‐diotocography and the validity of the computerised algorithm were assessed using the intraclass correlation coefficient and weighted kappa statistic for continuous and ordinal variables respectively.

Results
The inter rater reliability of the baseline fetal heart rate and the number and type of decelerations was good (intraclass correlation coefficient 0.93, 0.93 and 0.79, respectively). The reliability of baseline variability (kappa = 0.27) and accelerations (intraclass correlation coefficient = 0.27) was poor. The computerised algorithm had good agreement with the reviewers for the baseline fetal heart rate (intraclass correlation coefficient 0.91 to 0.98) and the number of decelerations (intraclass correlation coefficient 0.82 to 0.91), but was less valid as regards the number of late decelerations (intraclass correlation coefficient 0.68 to 0.85) and the number of accelerations (intraclass correlation coefficient 0.06 to 0.80), and was invalid as regards baseline variability (kappa 0.00 to 0.34).

Conclusions
The high level of validity of the computerised algorithm for the estimation of the baseline fetal heart rate and the number of decelerations justifies its further technical development.
The relationship between increased folate catabolism and the increased requirement for folate in pregnancy
Authors: Higgins John R. , Quinlivan Eoin P. , McPartlin Joseph , Scott John M. , Weir Donald G. , Darling Michael R. N.
Published: August 2005

Objectives
To estimate the rate of folate catabolism in pregnant and nonpregnant women and to derive the recommended dietary allowance for folate.

Design
Prospective, observational study.

Setting
Rotunda Hospital, Dublin.

Women
Twenty‐four healthy gravid women were studied once during each trimester and postpartum. Twenty‐five nonpregnant controls were assessed before and after folic acid supplementation.

Interventions
Women provided 24‐hour urine collections while adhering to a strict dietary regimen containing no exogenous folate catabolites.

Main outcome measures
Urinary levels of p‐acetamidobenzoylglutamate and p‐aminobenzoylglutamate were measured by high pressure liquid chromatography.

Results
The 24‐hour excretion of folate catabolites, expressed as mean [95% CI] folate equivalents in μg) progressively increased during pregnancy. A peak was reached in the third trimester (349.1 μg [308.1 to 390.1]) where the rate was more than twice the rate in the nonpregnant control group (136.4 μg [112.4 to 160.4]) (P < 0.001). Based on our results the recommended dietary allowance for folate in nonpregnant women should be 250 μg and this should rise during pregnancy to 430 μg in the second trimester and 540 μg in the third trimester.

Conclusions
The rate of folate catabolism progressively increases during pregnancy reaching a peak in the third trimester at the time of maximal fetal growth. The increased demand for folate during pregnancy appears to be due to the accelerated breakdown of the vitamin because of its participation in cellular biosynthesis. These results provide a quantitative basis for the current debate on the appropriate recommended dietary allowance for folate in both pregnant and nonpregnant women.
Site of origin of epithelial ovarian cancer: the endometriosis connection
Authors: Vercellini Paolo , Scarfone Giovanna , Bolis Giorgio , Stellato Giovanna , Carinelli Silvestro , Crosignani Pier Giorgio
Published: August 2005

To investigate the left‐ and right‐sided distribution of ovarian malignant surface epithelial tumours, data were collected on 209 women undergoing first‐line surgery for Stage I and II disease. Considering the unilateral cancers, the observed proportion of left‐sided lesions was 35/54 (65%) in the endometrioid, 20/45 (44%) in the serous, 19/35 (54%) in the clear cell, 13/29 (45%) in the mucinous, 2/8 (25%) in the mixed, and 2/5 (40%) in the undifferentiated histological type group. The proportion of left‐sided unilateral endometrioid cancers was significantly different from the expected 50% (χ21, 4.74, P= 0.03) and very similar to that previously observed for benign endometriotic cysts, constituting further evidence in favour of a possible development of endometrioid cancers from the latter lesions.
A comparative analysis of cross sectional imaging techniques in minimal deviation adenocarcinoma of the uterine cervix
Authors: Itoh Kazuko , Toki Toshihiko , Shiohara Shigeki , Oguchi Osamu , Konishi Ikuo , Fujii Shingo
Published: August 2005

A pre‐operative diagnosis of minimal deviation adenocarcinoma of the cervix is often difficult. We assessed transvaginal sonography, computed tomography and magnetic resonance imaging in 16 women with histologically confirmed minimal deviation adenocarcinoma. Increased fluid accumulation was frequently observed within the endometrial cavity and/or vagina by all three techniques. A multicystic cervical lesion was occasionally detected by transvaginal sonography or by computed tomography. On T2‐weighted magnetic resonance images, a noncystic fine villous or multicystic lesion was noted in most cases. Among the three imaging techniques used, T2‐weighted magnetic resonance images showed the most detailed features and the best correlation with the histology.
Fibroid embolisation: a technique not without significant complications
Authors: Vashisht A. , Studd J. W. W. , Carey A. H. , McCall J. , Burn P. R. , Healy J. C. , Smith J. R.
Published: August 2005

Uterine artery embolisation is a new minimally invasive technique used for the treatment of fibroids. Twenty‐one women underwent bilateral uterine artery embolisation at our unit, and we assessed the efficacy, morbidity and patient satisfaction with the procedure. Mixed outcomes were found. Reduction in fibroid volume measured by magnetic resonance imaging was impressive, and the majority of women felt their symptoms had improved. One woman achieved a full term pregnancy following the procedure. However, the procedure involved a significant inpatient stay, analgesia requirement, and a slower recovery time than anticipated. One woman died following overwhelming sepsis occurring 10 days after the procedure. Further studies are required to assess the role this technique may play in the management of uterine fibroids.
Angiographic embolisation in the management of pelvic haemorrhage
Authors: Lingam K. , Hood V. , Carty M. J.
Published: August 2005

Haemorrhage from pelvic veins during obstetric and gynaecological surgery is a major cause of morbidity and mortality. In a recent commentary entitled The Seven Surgeons of King's: a fable by Aesop1, surgeons from different specialties used techniques peculiar to their own practice to treat a woman with intractable haemorrhage. Could transcatheter arterial embolisation be the ‘eighth surgeon’? We describe two cases where embolisation was used to control bleeding when local surgical measures had failed and discuss the use of embolisation in obstetrics and gynaecology.
The long learning curve of gynaecological cancer surgery: an argument for centralisation
Authors: Trimbos J. Baptist , Hellebrekers Bart W. J. , Kenter Gemma G. , Peters Lex A. W. , Zwinderman Koos H.
Published: August 2005

ObjectiveTo study the development of surgical performance of an unchanging surgical team over 13 years.

DesignProspective, observational study.

SettingA university hospital, The Netherlands.

ParticipantsThree hundred and eight women who underwent surgical treatment for early cervical cancer.

InterventionsRadical hysterectomy and pelvic lymphadenectomy between 1 January 1984 and 31 December 1996.

ResultsThe surgical procedure and indication for treatment remained unchanged during the study period. This applied also to the surgical team. The women's age increased significantly during the study years, as was the case with the number of nodes removed. The depth of infiltration by the tumour increased steadily throughout the study, but this failed to reach statistical significance. The distribution of FIGO stages, percentage of positive lymph nodes, radicality of the surgical margins and post‐operative morbidity remained the same. Overall, the five year survival rate was 83%; for women with negative nodes 91%, and for women with positive nodes 53%. Survival tended to improve during the course of the study, but this was not statistically significant. Blood loss during surgery decreased consistently during the whole study period, from a mean of 1515 mL at the beginning of the study to a mean of 1071 mL at the end (P< 0.0001). The operating time also diminished significantly by 8 minutes per year (P< 0.0001). In 1985 the average operating time was 270 minutes, compared with 187 minutes in 1996.

ConclusionsThese findings indicate that it takes a long time to acquire skill in the surgical treatment of early cervical cancer. Centralisation of relatively infrequent operations for cancer should be encouraged.
The role of laparoscopic surgery in the management of endometrial cancer
Authors: Lim B. K. , Lavie Ofer , Bolger B. , Lopes Tito , Monaghan J. M.
Published: August 2005

Objective
To assess the place of laparoscopically assisted vaginal hysterectomy in the treatment of endometrial cancer.

Design
A retrospective uncontrolled case series.

Setting
Gynaecological Oncology Department, Queen Elizabeth Hospital, Gateshead.

Population
Women with endometrial cancer referred to this centre from August 1992 to August 1997.

Main outcome measures
Success of laparoscopically assisted vaginal hysterectomy, operative morbidity, and the length of hospital stay.

Results
Laparoscopically assisted vaginal hysterectomy was successful in 35 of 40 women (88%). Five women required laparotomy. Two women sustained injury to the inferior epigastric vessels. One sustained injury to the small intestine requiring later laparotomy and three women required a blood transfusion. The mean hospital stay was 3.3 days (SD 1.5). Three women died of the disease within one year of their operation.

Conclusion
Laparoscopically assisted vaginal hysterectomy is a feasible treatment for endometrial cancer. It can be performed successfully in high risk population who are medically unfit and overweight. However, a larger randomised study is required to assess the morbidity compared with the traditional open approach.
Risk factors for pre‐eclampsia in a large cohort of Latin American and Caribbean women
Authors: Conde‐Agudelo Agustin , Belizán José M.
Published: August 2005

Objective
To study risk factors for pre‐eclampsia in a large cohort of Latin American and Caribbean women.

Design
Retrospective cross‐sectional study from the Perinatal Information System, the database of the Latin American Center for Perinatology and Human Development, Montevideo, Uruguay.

Setting
Latin America and the Caribbean, 1985–1997.

Population
878,680 pregnancies at 700 hospitals; of these 42,530 were complicated by pre‐eclampsia and 1872 by eclampsia.

Main outcome measures
Crude and adjusted relative risks (RR) of risk factors for pre‐eclampsia. Adjusted relative risks were obtained after adjustment for potential confounding factors through multiple logistic regression models based on the method of generalised estimating equations.

Results
The following risk factors were significantly associated with increased risk of pre‐eclampsia: nulliparity (RR 2.38; 95% CI 2.28–2.49); multiple pregnancy (RR 2.10; 95% CI 1.90–2.32); history of chronic hypertension (RR 1.99; 95% CI 1.78–2.22); gestational diabetes mellitus (RR 1.93; 95% CI 1.66–2.25); maternal age ≥ 35 years (RR 1.67; 95% CI 1.58–1.77); fetal malformation (RR 1.26; 95% CI 1.16–1.37); and mother not living with infant's father (RR 1.21; 95% CI 1.15–1.26). Pre‐eclampsia risk increased according to pre‐pregnancy body mass index (BMI). In comparison with women with a normal pre‐pregnancy BMI (19.8 to 26.0), the RR estimates were 1.57 (95% CI 1.49–1.64) and 2.81 95% CI 2.69–2.94), respectively, for overweight women (pre‐pregnancy BMI = 26.1 to 29.0) and obese women (pre‐pregnancy BMI > 29.0). Cigarette smoking during pregnancy and a pre‐pregnancy BMI < 19.8 were significant protective factors against the development of pre‐eclampsia. The pattern of risk factors among nulliparous and multiparous women was quite similar.

Conclusions
Risk factors for pre‐eclampsia observed among Latin American and Caribbean women are similar to those found among North American and European women.
Prenatal diagnosis of fetal primary cytomegalovirus infection
Authors: Antsaklis Aris J. , Daskalakis George J. , Mesogitis Spyros A. , Koutra Panagiota T. , Michalas Stylianos S.
Published: August 2005

Objective
To determine the reliability of prenatal diagnosis for congenital cytomegalovirus in women with primary infection.

Design
Retrospective analysis of case records between 1992 and 1997.

Setting
Fetal medicine unit of a large teaching hospital.

Population
Forty‐two pregnant women with primary cytomegalovirus infection.

Methods
Fetal diagnosis was made by amniocentesis for viral culture and amplification of cytomegalovirus DNA by polymerase chain reaction (n= 37), or by cordocentesis for the detection of cytomegalovirus ‐specific IgM antibodies (n= 13). All patients had serial ultrasonographic scans in order to detect those fetuses with abnormalities that could be associated with cytomegalovirus infection.

Results
Fourteen pregnancies (33.3%) had evidence of vertical transmission. Nine out of 14 (64.3%) had positive amniotic fluid culture, while 11 (78.6%) had positive polymerase chain reaction results. The combination of both tests allowed antenatal diagnosis in 12 of the 14 infected fetuses (sensitivity 85.7%). All women who underwent cordocentesis for the detection of cytomegalovirus‐specific IgM antibodies had negative results, but in two cases cytomegalovirus infection was detected by amniotic fluid studies. In five of the infected fetuses there were abnormal ultrasonographic findings. All pregnancies with evidence of vertical transmission were terminated and the remainder proceeded normally to term.

Conclusions
Our data showed that amniotic fluid studies, preferably polymerase chain reaction amplification of viral DNA, are the best diagnostic tools for the detection of vertical transmission in pregnancies with primary cytomegalovirus infection. For women with positive amniotic fluid studies who elect to continue their pregnancies, cordocentesis and serial ultrasound scans may be useful for assessment of fetal status.
Association of a lack of psychosocial resources and the risk of giving birth to small for gestational age infants: a stress hypothesis
Authors: Dejin‐Karlsson Elisabeth , Hanson Bertil S. , Östergren Per‐Olof , Lindgren Anna , Sjöberg Nils‐Otto , Marsal Karel
Published: August 2005

Objective
To test the stress hypothesis that women who give birth to small for gestational age infants lack important psychosocial coping resources, such as a sufficient social network, social support and control in daily life.

Design
A prospective cohort study of nulliparous pregnant women.

Setting
Antenatal care units in the city of Malmö, Sweden.

Population
All women (n= 994) during a one year period (1991–1992) were invited, and 872 (87.7%) participated. This study was restricted to pregnancies resulting in singleton live birth (n= 826); 6.7% of infants were classified as small for their gestational age.

Methods
Self‐administered questionnaires were given to all women at the time of their first antenatal visit.

Main outcome measures
The classification of small for gestational age was based on a gender‐specific intrauterine growth reference curve. Newborn babies were classified as being small for gestational age if their birthweight was > 2 SD below the mean weight for gestational age.

Results
Lack of psychosocial resources, such as social stability, social participation, emotional and instrumental support, all increased the likelihood of delivering an infant that was small for gestational age. The odds ratios when controlled for demographic background factors, lifestyle factors and anthropomorphic measures were: OR 1.7 (95% CI0.9–3.3) for women with poor social stability; OR 2.2 (95% CI 1.1–4.4) for women with poor social participation; OR 2.6 (95% CI 1.2–5.7) for women with poor instrumental support; and OR 1.5 (95% CI 0.8–2.8) for women with poor emotional support. Simultaneous exposure to a poor total network index, as well as a poor total support index showed a significantly increased odds ratio for having a small for gestational age baby: OR 3.3 (95% CI 1.6–6.7) and OR 2.7 (95% CI 1.3–5.6), respectively. A synergy index of 9.0 and 6.8 supported the assumption of an interaction between immigrant status and poor total network or poor total support, in a synergistic direction.

Conclusions
The findings support the stress‐hypothesis that a lack of psychosocial resources might increase the risk of giving birth to a baby that is small for gestational age.
Attitudes toward clinical guidelines among obstetricians in Northern Ireland
Authors: Dye Timothy D. , Alderdice Fiona , Roberge Eric , Jamison James Q.
Published: August 2005

Objectives
To evaluate the attitudes of, and the influences on decisions made by, obstetricians in Northern Ireland in order to understand the feasibility of applying guidelines to obstetric practice.

Design
Cross‐sectional postal survey.

Setting
Northern Ireland.

Population
Consultants, senior registrars, registrars, and senior house officers in obstetrics in Northern Ireland (n= 170). Responses were received from 68.8% (n= 117), with complete data available for 67.1% (n= 114).

Main outcome measures
An attitudes score was constructed by consolidating responses to a variety of statements about guidelines. Individual responses to guidelines statements and the standardised attitudes T‐score were analysed by demographic and practice characteristics.

Results
Attitudes toward guidelines were generally positive, with women practitioners more likely to have positive attitudes toward guidelines than did their male counterparts. Younger obstetricians were more likely to report that practitioners should incorporate guidelines into their practices. Doctors who responded that their decisions were influenced by specific tools related to guidelines, such as computerised databases, during the previous three months had more positive attitudes toward guidelines than doctors who did not use such tools. Furthermore, doctors based in teaching hospitals were more likely than others to have been influenced by the guidelines of professional societies.

Conclusions
Generally guidelines appear to be quite well received, with doctors reporting that their practice often is influenced by them. Doctors who reported that their decisions were influenced by guidelines had an especially positive attitude toward them. However, some tools which target the application of evidence‐based methods (e.g. computerised databases) are used infrequently by obstetricians. The challenge remains to encourage the further development of guidelines and tools that are useful and appropriate for practitioners.
Evidence of dysfunctional β2‐adrenoceptor signal system in pre‐eclampsia
Authors: Aune B. , Vårtun Å. , Øian P. , Sager G.
Published: August 2005

Objectives
To determine how β2‐adrenoceptor binding and function differ between healthy women and those with pre‐eclampsia.

Design
Case‐control study.

Setting
Faculty of Medicine, University of Tromsø, Norway.

Participants
Two groups of pregnant women: eight cases with pre‐eclampsia, matched with eight healthy controls.

Methods
Venous blood was drawn from women in both groups after an overnight rest. The two groups were matched for gestational age which was (mean (SD)) 36.4 (3.8) and 36.5 (4.4) weeks for the pre‐eclamptic and control groups, respectively. Six weeks after delivery a second blood sample was obtained. The binding and function of β2‐adrenoceptors were determined in isolated human mononu‐clear leukocytes. The levels of adrenaline and noradrenaline were determined in plasma from venous blood.

Results
An elevated density of functional β2‐adrenoceptors was observed in normal pregnancy [mean (SD) 390 (90) vs 270 (60) sites/cell postpartum], due to an increased fraction of receptors in high affinity state, with unaltered total receptor density. The number of functional β2‐adrenoceptors was reduced in pre‐eclampsia [mean (SD) 80 (40) vs 240 (30) sites/cell postpartum], due to a reduction in the total receptor number with an unaltered fraction of high affinity receptors. In pregnancy, both unstimulated and isoprenaline‐stimulated cAMP levels were reduced in the women with pre‐eclampsia (0.5 (0.2) and 1.7 (0.9) pmol/106 cells, respectively) compared with the normal pregnant controls (mean (SD) 1.2 (0.3) and 4.7 (1.8) pmol/106 cells, respectively). Plasma catecholamine levels were not elevated in the women with pre‐eclampsia.

Conclusions
The increased number of functional β2‐adrenoceptors may contribute to the vasodilatation seen in normal pregnancy, while the reduced overall number of receptors may be one of several factors that account for increased peripheral vascular resistance in pre‐eclampsia.
A randomised controlled trial of flexibility in routine antenatal care
Authors: Jewell David , Sharp Debbie , Sanders Julia , Peters Tim J.
Published: August 2005

Objective
To assess changes in satisfaction associated with a flexible approach to antenatal care schedules offered to women at low obstetric risk.

Design
Randomised controlled trial.

Setting
Eleven primary care centres providing midwifery care in Avon.

Participants
Six hundred and nine women at low risk of obstetric complications presenting for antenatal care.

Methods
A standard antenatal care schedule (‘traditional care’) was compared with a schedule based on a minimum number of visits and additional visits with timing agreed between women and midwives (‘flexible care’).

Main outcome measures
Women's attitudes to pregnancy and motherhood using a subscale of the Maternal Adjustment and Maternal Attitudes scale, satisfaction with antenatal care, and perception of the speed of recognition of antenatal complications.

Results
There was no difference between the two groups in terms of attitudes to pregnancy and motherhood (mean difference on Maternal Adjustment and Maternal Attitudes scale −0.64, 95% CI −1.39 to 0.11, P= 0.068) and no difference in the proportions of women reporting antenatal problems as soon as possible (traditional group 74.5%, flexible group 76.4%, difference −2%, 95% CI −12.1 to 8.2, P= 0.70). Women receiving traditional care reported higher levels of satisfaction for the care provided by community midwives (P < 0.01). Women receiving flexible care were more likely to report having a choice over the number and timing of their antenatal visits (P < 0.001), but were also more likely to report that they would like to have been seen more often (P < 0.01). There was no difference between the groups in rates of obstetric complications.

Conclusions
An imposed reduction in antenatal visits has been reported to increase dissatisfaction in other studies. In this study, encouraging women to adopt a flexible approach to antenatal care resulted in a similar finding. Successful implementation of such approaches may depend on more careful selection of women who welcome such an approach, more encouragement to pregnant women to express their own needs and greater feelings of commitment on the part of the care providers.
Expectant management of early onset, severe pre‐eclampsia: maternal outcome
Authors: Hall D. R. , Odendaal H. J. , Steyn D. W. , Grové D.
Published: August 2005

Objective
To evaluate the safety and outcome of women undergoing expectant management of early onset, severe pre‐eclampsia.

Design
Prospective case series extending over a five‐year period.

Setting
Tygerberg Hospital, a tertiary referral centre.

Population
All women (n= 340) presenting with early onset, severe pre‐eclampsia, where both the mother and the fetus were otherwise stable.

Methods
Frequent clinical and biochemical monitoring of maternal status, together with careful blood pressure control, in a high care obstetric ward.

Main outcome measures
Major maternal complications and prolongation of gestation.

Results
Multigravid women constituted 67% of the group. Antenatal biochemistry was reassuring with some expected, but not severe, deteriorations. Twenty‐seven percent of women experienced a major complication, but few had poor outcomes. No maternal deaths occurred. Most major complications resolved quickly, necessitating only three admissions (0.8%) to the intensive care unit. One woman required dialysis. Pregnancies were prolonged by a mean (median) number of 11 days (9) before delivery, with more time being gained at earlier gestations. The postpartum inpatient stay (89%≤ 7 days, bearing in mind that 82% of women were delivered by caesarean section) was not extended.

Conclusion
Careful noninvasive management of early onset, severe pre‐eclampsia in a tertiary centre can diminish and limit the impact of serious maternal complications. Valuable time to prolong the pregnancy and improve neonatal outcome is thereby gained.
First trimester maternal serum free β human chorionic gonadotrophin and pregnancy associated plasma protein A as predictors of pregnancy complications
Authors: Ong Charas Y. T. , Liao Adolfo W. , Spencer Kevin , Munim Shama , Nicolaides Kypros H.
Published: August 2005

Objective
To examine the value of first trimester maternal serum free β human chorionic gonadotrophin (β hCG) and pregnancy associated plasma protein A (PAPP‐A) as predictors of pregnancy complications.

Design
Screening study.

Setting
Antenatal clinics.

Population
Singleton pregnancies at 10–14 weeks of gestation.

Methods
Maternal serum free β hCG and PAPP‐A were measured at 10–14 weeks of gestation in 5584 singleton pregnancies. In the 5297 (94.9%) pregnancies with complete follow up free β hCG and PAPP‐A were compared between those with normal outcome and those resulting in miscarriage, spontaneous preterm delivery, pregnancy induced hypertension or fetal growth restriction and in those with pre‐existing or gestational diabetes.

Results
Maternal serum PAPP‐A increased and β hCG decreased with gestation. The multiple of median maternal serum PAPP‐A was significantly lower in those pregnancies resulting in miscarriage, pregnancy induced hypertension, growth restriction and in those with pre‐existing or gestational diabetes mellitus, but not in those complicated by spontaneous preterm delivery. The level was < 10th centile of the reference range in about 20% of the pregnancies that subsequently resulted in miscarriage or developed pregnancy induced hypertension or growth restriction, and in 27% of those that developed gestational diabetes. Maternal serum free β hCG was < 10th centile of the reference range in about 15% of the pregnancies that subsequently resulted in miscarriage or developed pregnancy induced hypertension or growth restriction, and in 20% of those that developed gestational diabetes.

Conclusion
Low maternal serum PAPP‐A or β hCG at 10–14 weeks of gestation are associated with subsequent development of pregnancy complications.