bluuebunny/crossref_metadata_2025 huggingface dataset:
The standard primipara as a basis for inter‐unit comparisons of maternity care
Authors: Cleary R. , Beard R. W. , Chapple J. , Coles J. , Griffin M. , Joffe M. , Welch A.
Published: August 2005

Objective
To assess the suitability of the standard primipara (a subset of the obstetric population that has relatively low risk or intervention and of adverse outcome) for making inter‐unit comparisons of indicators of the process and outcome of maternity care.

Design
Inter‐unit comparison of 10 indicators of obstetric intervention and adverse outcome derived from routinely collected computerised data held on the St Mary's Maternity Information System.

Setting
Fifteen maternity units in the former North West Thames Region.

Participants
15,463 primiparae who were delivered in 1992.

Main outcome measures
Proportion of primiparae within the standard definition; degree to which standard primiparae are associated with lower rates of intervention and adverse outcome, as compared to other primiparae.

Results
Within the database, 42.6% of all primiparae were found to be standard, with rates varying between units from 25.9% to 57.7%. As expected, the standard primiparous woman is at less risk of intervention or adverse outcome than other primiparae. All but one component variable of the standard definition is a significant risk factor for at least four of the 10 indicators. Statistically significant differences in indicator rates are seen between standard and nonstandard primiparae within units. Within the standard group, significant differences in rates of intervention and adverse outcome are seen between units. Units with relatively high levels of intervention within the higher risk nonstandard group also have relatively high levels of intervention within the standard group.

Conclusions
Use of the standard primipara, rather than the whole obstetric population, as the basis for inter‐unit comparisons of maternity care will control for the substantial difference in case mix seen in different units, thereby increasing the validity of those comparisons. The technique has the additional benefit of clarifying the relationship between everyday clinical decision making and a unit's performance in comparative indicator reports. The approach must be combined with a separate study of the other groups in the case mix, such as multiparae and high risk primiparae. Additional nonoverlapping groups, homogeneous in terms of risk factors, should be defined and used to extend the basis on which comparisons may be made.
Effects of hypoglycaemia on fetal heart activity and umbilical artery Doppler velocity waveforms in pregnant women with insulin‐dependent diabetes mellitus
Authors: Björklund A. O. , Adamson U. K. C. , Almström N. H. H. , Enocksson E. A. , Gennser G. M. , Lins P.‐E. S. , Westgren L. M. R.
Published: August 2005

Objective
To study the effect of induced hypoglycaemia on fetal wellbeing as indicated by fetal heart rate and umbilical artery flow velocity waveforms.

Design
A prospective experimental investigation.

Setting
High risk pregnancy unit and diabetes research unit at Karolinska Institutet, Danderyd Hospital, a university affiliated hospital.

Participants
Ten women with insulin‐dependent diabetes mellitus in the third trimester of pregnancy.

Interventions
The fetal heart rate, the blood flow velocity waveforms in the umbilical artery and the maternal catecholamine levels were investigated during a 150–minute hyperinsulinaemic hypoglycaemic clamp with induction and maintenance of an arterial blood glucose level of about 2.2 mmol/l.

Main outcome measures
1. Fetal: changes of fetal heart rate pattern and pulsatility index of the umbilical artery flow velocity waveforms. 2. Maternal: levels of plasma adrenaline and plasma noradrenaline.

Results
Maternal hypoglycaemia was associated with an increase in frequency and amplitude of fetal heart rate accelerations, a slight decrease in the pulsatility index of the umbilical artery and a rise in the maternal catecholamine levels.

Conclusions
We speculate that the increased number of fetal heart rate accelerations reflects an increased sympathico‐adrenal activity during the hypoglycaemic clamp. No potentially harmful effects on the fetus were observed in the fetal heart rate or in the umbilical artery Doppler waveform analysis during hypoglycaemia.
Ambulatory monitoring and conventional cystometry in asymptomatic female volunteers
Authors: Heslington K. , Hilton P.
Published: August 2005

Objective
Ambulatory monitoring continues to gain acceptance and increasing clinical application. There remains, however, a sparsity of published data from asymptomatic Volunteers, particulary women. Our aim was, by study of such a group, to establish normal ranges for cystometric variables on ambulatory monitoring.

Participants
We recruited 22 women from staff and gynaecological inpatients. A standard questionnaire of urinary complaints was administered and any woman with significant symptoms was excluded. Conventional cystometry and ambulatory monitoring were undertaken in all Volunteers in random order. Volunteers were asked to go about everyday activities and to keep a detailed event diary whilst undergoing ambulatory monitoring.

Results
Using standard International Continence Society terminology, detrusor instability was found in 18% of volunteers on conventional cystometry and in 68% on ambulatory monitoring. Significant differences were found between ambulatory monitoring and conventional cystometry with respect to the detrusor pressure rise on filling (P < 0.001) and voided volumes (P < 0.001). A significant difference was also present with respect to voiding pressures (P < 0.001), although the absence of simultaneous flow rate measurement makes absolute separation of voiding pressure from post‐voiding after contractions difficult.

Conclusions
Ambulatory monitoring detects a greater number of abnormalities based on conventional cystometric criteria of normality. Before we can usefully apply the method to symptomatic patients we must first define normal ranges for filling and voiding cystometry for the technique. This study moves towards this goal. (The addition of flow rate data will permit accurate identification and measurement of voiding pressures.)
Erythrocyte ion and water balance and membrane potential in the puerperium of normal pregnancy
Authors: Bolton L. M. , Thomas T. H. , Dunlop W.
Published: August 2005

Objective
To examine the balance of erythrocyte ions and water during the rapid changes in plasma osmolality in the early puerperium, and during the subsequent period of sustained readjustment.

Design
A serial study from the third trimester of pregnancy to 20 weeks after delivery.

Participants
Thirty‐five primiparous women who had experienced no antenatal complications.

Main Outcome Measures
Plasma osmolality, erythrocyte hydration, potassium, chloride and sodium were measured and nondiffusible ion content and erythrocyte membrane potential calculated. Plasma sodium, potassium and chloride were also measured.

Results
During the first week after delivery plasma osmolality increased (280 (SEM 0.52)–289 (SEM 064) mosmol/kg; P < 0.001) but erythrocyte hydration did not decrease (2.060 (SEM 0.018)–2.067 (SEM 0.021) l/kg dry cells) because of an increase in total cell osmole content (577 (SEM 5.31)–597 (SEM 6.15) mosmol/kg dry cells; P= 0.001). This increase included nondiffusible anions, chloride and potassium. These changes in ionic balance did not affect membrane potential. After the first week of the puerperium and up to the 20th week, plasma osmolality was stable but erythrocyte osmole content and hydration both decreased. This was due to a decrease in nondiffusible anions and potassium with a smaller increase in chloride leading to a decrease in membrane potential (–14.31 (SEM 0.34) mV to −12.66 (SEM 0.28) mV; P < 0.001).

Conclusions
A rapid increase in intracellular osmoles can occur in the mature erythrocyte and probably precedes the decrease in plasma osmolality in the puerperium. Changes in erythrocyte homeostasis in the first week of the puerperium can be accounted for by alterations in nondiffusible anions. After the first week of the puerperium it appears that the functional organisation of the membrane is changing.
A multicentre randomised controlled trial comparing elective and selective caesarean section for the delivery of the preterm breech infant
Authors: Penn Zoe J. , Steer Philip J. , Grant Adrian
Published: August 2005

Objective
To determine the optimum mode of delivery for women in preterm breech labour at a gestational age of 26 to 32 weeks.

Design
A multicentre randomised controlled trial. Setting Twenty‐six hospitals in England, UK.

Participants
Women with a singleton breech fetus in spontaneous preterm labour between 26 and 32 completed weeks of gestation, with no clear indication for a caesarean section or vaginal breech delivery.

Intervention
Random allocation to either ‘intention to delivery vaginally’ or ‘intention to deliver by caesarean section’.

Main outcome measures
Perinatal mortality, neonatal morbidity, maternal morbidity and gestation at delivery.

Results
The trial was closed after 17 months because of low recruitment, by which time substantial numbers of women had been in the eligible gestation period. Thirteen women from six hospitals were recruited. One infant, randomised to and delivered vaginally, was stillborn. Three fetal presentations were cephalic at delivery despite a diagnosis of breech presentation at trial entry. No formal statistical analysis was performed due to the small numbers.

Conclusions
No conclusions about the optimum mode of delivery for women in preterm labour with a fetus presenting by the breech can be drawn from this trial. The low accrual rate was due to clinicians' reluctance to randomise eligible women, reflecting the circumstances and nature of the trial.
Double‐blind evaluation of ritodrine sustained release for oral maintenance of tocolysis after active preterm labour
Authors: Holleboom C. A. G. , Merkus J. M. W. M. , van Elferen L. W. M. , Keirse M. J. N. C.
Published: August 2005

Objective
To evaluate the effect of ritodrine sustained release capsules for maintaining uterine quiescence after successful treatment of active preterm labour.

Design
Multicentre placebo‐controlled trial. Setting Five teaching hospitals in the Netherlands.

Participants
Women (n= 95) at less than 35 weeks of gestation in whom active preterm labour had been stopped with intravenous ritodrine.

Interventions
Women received either two 40 mg ritodrine sustained release capsules (n= 50) or identical placebo capsules (n= 45) three times a day for seven days.

Results
The proportion of women who received another course of active treatment was significantly smaller with the sustained release than with placebo (1 of 50 versus 11 of 45: P= 0.003) as was the number delivering because of preterm labour during treatment (0 of 50 versus 4 of 45: P= 0.04). There were no other significant differences between the two groups.

Conclusions
Maintenance treatment with ritodrine sustained release capsules after arrest of preterm labour reduces the risk of recurrences of preterm labour that necessitate treatment or precipitate delivery.
Smoking during pregnancy and preterm birth
Authors: Wisborg Kirsten , Henriksen Tine Brink , Hedegaard Morten , Jergen Niels
Published: August 2005

Objective
To evaluate the association between smoking during pregnancy and preterm birth.

Design
A follow up study.

Setting
Department of Gynaecology and Obstetrics, Aarhus University Hospital, Denmark.

Participants
Four thousand one hundred and eleven nulliparous women with singleton pregnancies who returned questionnaires about smoking habits at 16 weeks of gestation.

Results
The overall rate of preterm delivery was 4.3 %. Smokers had a 40 % higher risk of preterm birth compared with nonsmokers. A dose response relationship was found between smoking and risk of preterm birth. Adjustment for women's height, prepregnancy weight, age of the mother, marital status, education, occupational status, and alcohol intake did not change the results. Among women with an intake of less than 400 mg of caffeine per day no difference in the risk of preterm birth between smokers and nonsmokers was found. However, among women with an intake of more than 400 mg of caffeine per day, the risk of preterm birth was increased almost threefold among smokers compared with nonsmokers. Furthermore, among women with a high intake of caffeine a dose‐response relationship was found; women smoking one to five cigarettes per day had no increased risk of preterm birth compared with nonsmokers with the same intake of caffeine, women smoking six to ten cigarettes per day had almost three times higher risk of preterm birth, and women smoking more than 10 cigarettes per day had almost five times higher risk of preterm birth compared with nonsmokers with the same intake of caffeine.

Conclusions
Smoking increases the risk of preterm birth. The association between smoking and preterm birth was only present among women with a high intake of caffeine. However, whether smoking alone influences the risk of preterm birth among heavy consumers of caffeine needs further investigation.
Laparoscopic sterilisation: opinion and practice among gynaecologists in Scotland
Authors: Penney Gillian C. , Souter Vivienne , Glasier Anna , Templeton A. A.
Published: August 2005

Objectives
1. To produce a list of evidence‐based criteria for good quality care relating to female laparoscopic sterilisation. 2. To assess the level of agreement with each criterion among gynaecologists in Scotland. 3. To obtain an overview of current sterilisation practice for comparison with the agreed criteria.

Design
1. Agreement with criteria assessed by questionnaire survey; 2. Overview of current practice obtained by questionnaire survey and by casenote review.

Setting
Scotland.

Sample
1. Questionnaire survey: all 132 consultant gynaecologists in NHS practice. 2. casenote review: 988 consecutive women sterilised in 12 representative hospitals.

Results
The response rate to the questionnaire survey was 94%. A list of 15 evidence‐based criteria was produced, covering patient selection, information and counselling, techniques of tubal occlusion and timing of sterilisation. All 15 suggested criteria gained an overall balance of support among responding gynaecologists. Similar impressions of current practice were gained from the questionnaire survey and from the casenote review. Aspects of practice which measured up well to the agreed criteria included: only 6% of women sterilised were younger than 25 years of age; over 85% of casenotes included clear documentation that women had been counselled regarding failure rate and intended permanency; 88% of sterilisations were performed, or directly supervised by, a gynaecologist of consultant or senior registrar status; and only 2% of sterilisations were undertaken in combination with induced abortion. Aspects of practice which compared poorly with the agreed criteria, and for which recommendations for change have been made, included: only 22% of casenotes mentioned that the option of vasectomy had been discussed; only 30% of gynaecologists indicated that they provide locally produced information leaflets as an adjunct to counselling; four methods of tubal occlusion (including unipolar diathermy) were in use; and there were wide variations among hospitals in the use of day‐case care, ranging from 19% to 99%.

Conclusions
A list of criteria for good quality care in relation to sterilisation has been validated by agreement among Scottish gynaecologists. Current practice (as assessed by questionnaire survey and casenote review) has been compared with the criteria and some recommendations for change in practice have been made. Following dissemination of these results and recommendations, re‐audit will be undertaken in order to identify any changes.
Lipid peroxidation in cord blood: the effect of amniotic fluid volume
Authors: Wang Chi Chiu , Rogers Michael Scott
Published: August 2005

Objective
To assess the effect of amniotic fluid volume on umbilical cord arterial lipid peroxide levels in relation to intrapartum events.

Design
Prospective observational study.

Setting
Delivery suite of a teaching hospital, the Chinese University of Hong Kong.

Population
Women with singleton, term, cephalic presentation, and an initially normal fetal heart rate tracing.

Methods
All pregnancies had amniotic fluid index assessments before and after amniotomy and cord arterial lipid peroxide determination at delivery. Multiple regression analysis.

Main outcome measures
Cord arterial malondialdehyde and organic hydroperoxide levels.

Results
In 247 cases following amniotomy levels were inversely correlated with intrapartum amniotic fluid index. Amniotic fluid index during labour was an independent determinant of cord arterial lipid peroxide concentration, along with duration of second stage, absence of epidural, presence of tight nuchal cord entanglement and evidence of fetal distress.

Conclusions
Oligohydramnios during labour is associated with high levels of lipid peroxidation in the fetus, reflecting an increase in hypoxic cellular damage by free radicals.
Seizure prophylaxis in hypertensive pregnancies: a framework for making clinical decisions
Authors: Khan Khalid S. , Chien Patrick F. W.
Published: August 2005

Objective
To describe a framework for generating therapeutic recommendations using seizure prophylaxis in hypertensive pregnancies as an example.

Design
A decision‐making framework was built using: 1. evidence of therapeutic benefit, with number needed to treat as the effect measure; 2. baseline rates of the target disorder that the treatment was designed to prevent; and 3. a treatment threshold, determined by weighting the potential risks against the potential benefits of the treatment.

Methods
Evidence of therapeutic benefit (i.e. reduction in eclamptic seizures associated with magnesium sulphate therapy in hypertensive pregnancies) was determined by a systematic quantitative overview of controlled clinical trials. Baseline rates of seizures without magnesium sulphate therapy were derived from a recent cohort study. A treatment threshold was generated using estimates of treatment associated morbidities which were weighted against the potential reduction in seizures from magnesium sulphate therapy considering the relative values assigned to these outcomes by obstetricians practising in our hospital.

Results
The number of hypertensive women needed to be treated with magnesium sulphate to prevent a single case of eclamptic seizures varied in a curvilinear fashion dropping from 1000 to 14 as the baseline rate of seizures increased from 0.1% to 10%. The treatment threshold as measured by number needed to treat was 64 (range 57–77). The number needed to treat for nonproteinuric hypertension was 1000 (95% CI 180–40,000), whereas it was 32 (95% CI 20–57) for proteinuric hypertension. Considering the uncertainty in estimation of the numbers needed to treat and treatment threshold, magnesium sulphate therapy may be recommended for women at high risk of eclampsia (e.g. severe pre‐eclampsia) while it should be withheld in cases at low risk (e.g. nonproteinuric hypertension and mild pre‐eclampsia).

Conclusion
While awaiting further research obstetricians intuitively make decisions about seizure prophylaxis in hypertensive pregnancies. Our decision‐making framework generated therapeutic recommendations by explicit consideration of the available evidence.
Antenatal corticosteroid prescribing: setting standards of care
Authors: Wallace Euan M. , Chapman Janet , Stenson Ben , Wright Sherry
Published: August 2005

Objective
Despite widespread recognition that prenatal administration of corticosteroids dramatically reduces perinatal mortality and morbidity, clinical practice in this area remains less than ideal. We therefore reviewed our practice to identify reasons for this and to determine attainable standards of care.

Design
Retrospective case record review.

Setting
Level three maternity unit in Edinburgh, UK.

Population
All women admitted at gestations of 24 to 34 weeks and 6 days inclusive, and all women receiving corticosteroids in one institution, over a 10‐month period.

Main outcome measures
The number and clinical features of women delivering before and after 35 weeks of pregnancy who had received corticosteroids.

Results
Seven hundred and two women were admitted during the study period; case records were available for 688 of these. One hundred and ninety‐two women (28%) delivered before 35 weeks of gestation, of whom 123 (64%) had received dexamethasone. Of 69 women who received no steroids 30 (43%) were in hospital for more than 24 hours before delivery. Overall, 29% of women receiving dexamethasone delivered after 35 weeks of gestation and 42 (24%) women treated with dexamethasone received more than one course. While the grade of admitting doctor did not affect prescribing, there were other significant differences that may help guide future practice.

Conclusions
This study provides some guidance for optimising corticosteroid prescribing and for the development of clinical practice guidelines. Approximately 80% of women should be able to receive at least some corticosteroids prior to delivery before 35 completed weeks of pregnancy.
Port‐site recurrences following laparoscopic operations for gynaecological malignancies
Authors: Kadar Nicholas
Published: August 2005

Objective
To determine the frequency of port‐site recurrences following laparoscopic surgical treatment of gynaecological malignancies metastatic at the time of surgery.

Design
Retrospective review of metastatic primary and recurrent gynaecological malignancies.

Results
Twenty‐five women were studied. Twenty‐four had metastatic disease at the time of laparoscopic surgery, 22 in association with a primary malignancy (cervix: n= 12, ovary: n= 7, endometrium: n= 3), and two in association with recurrent ovarian cancer; all received pelvic or extended field radiation or chemotherapy after surgery. One woman with Stage IHC ovarian cancer, disease‐free at the completion of neoadjuvant chemotherapy following laparotomy by a general surgeon, was included; she developed scalene node metastases 18 months after definitive laparoscopic surgery. Seventy‐one 5 mm trocars and fifty 10 mm trocars (total n= 121) were used for surgery; thirty‐one 10 mm trocar sites and forty‐four 5 mm sites (total n= 75) received post‐operative treatment with chemotherapy (n= 49) or radiation (n= 26). Four women (16%) developed recurrences in association with endometrial (n= 2) and cervical (n= 2) cancer at six trocar sites. All recurrences were associated with abdominopelvic and/or distant metastases, and all occurred at untreated 5 mm trocar sites. The difference in recurrence rates between 5 mm and 10 mm trocar sites (χ2= 6; P < 0.025), and between treated and untreated trocars (χ2= 5; P < 0.05) were both statistically significant (McNemar's test), but the effects of treatment and trocar size on the port‐site recurrence rate were confounded.

Conclusions
Port‐site recurrences are local manifestations of disseminated disease that result from the enhancement of tumour growth characteristic of healing tissues and can be prevented by appropriate post‐operative therapy.
Antenatal serum screening for genital herpes: a study of knowledge and attitudes of women at a central London hospital
Authors: Vonau Barbara , Low‐Beer Naomi , Barton Simon E. , Smith J. Richard
Published: August 2005

Objective
To evaluate the knowledge and attitudes of women regarding genital herpes and specifically serum screening for prevention of vertical transmission.

Setting
Antenatal clinic at the Chelsea and Westminster Hospital, London.

Population
Randomly selected women at their first antenatal visit.

Methods
A questionnaire focussing on the women's knowledge of, and their attitudes about, genital herpes was completed. The results were analysed using the Statistical Package for Social Sciences (SPSS).

Results
One hundred women were surveyed over six weeks. The majority (80%) were aware that genital herpes was a sexually transmitted disease and 60% were aware that it can be transmitted to the baby in pregnancy. Only 34% thought that genital herpes is always symptomatic and 56% believed that they would know for certain if they had herpes. Sixty percent thought they would know whether their partners had ever been infected. Eighty percent of our sample population were prepared to be screened, and 76% would also encourage their sexual partner to have a blood test.

Conclusion
This study shows that the study population had a good knowledge about genital herpes and that there would be acceptance of antenatal testing. Whether serum screening is cost‐effective must still be evaluated. The impact of such a screening on a couple's relationship is potentially deleterious and needs to be assessed carefully before a screening programme for genital herpes is actually introduced. The next phase of our study will address this issue.
The effect of carotid sinus denervation on fetal heart rate variation in normoxia, hypoxia and post‐hypoxia in fetal sheep
Authors: Kozuma Shiro , Watanabe Takanori , Bennet Laura , Green Lucy R. , Hanson Mark A.
Published: August 2005

Objective
To investigate whether carotid sinus nerve reflexes are linked to the increase in heart rate variation in acute (one hour) hypoxia in late gestation fetal sheep

Design
Comparison of short term variation between intact and carotid sinus denervated fetuses in normoxia, hypoxia and post‐hypoxia.

Subjects
Sixteen chronically catheterised pregnant sheep in late gestation.

Results
There was no significant difference in short term variation between intact and denervated fetuses in normoxia. In intact fetuses short term variation increased significantly in hypoxia. In denervated fetuses it tended to increase in hypoxia, but this was not statistically significant. During the post‐hypoxia period, short term variation increased significantly in denervated fetuses, although at this time it was decreasing in intact fetuses. When the decrease in pH was small intact fetuses showed a significantly greater increase in short term variation than denervated fetuses in hypoxia. In contrast, short term variation increased similarly in both groups when the pH decrease was greater (> 0.03 in early hypoxia and > 0.05 in late hypoxia).

Conclusions
Carotid sinus nerve reflexes have an important influence on heart rate variation in hypoxia and post‐hypoxia. It appears that other mechanisms (e.g. a rise in circulating catecholamines) are linked to an increase in heart rate variation when mild acidemia occurs in hypoxia.
A single cervical fetal fibronectin screening test in; population at low risk for preterm delivery: an improvement on clinical indicators?
Authors: Faron Gilles , Boulvain Michel , Lescrainier Jean‐Pol , Vokaer Alain
Published: August 2005

Objective
To assess the accuracy of a single cervical fetal fibronectin test to predict spontaneous preterm delivery in an unselected antenatal population.

Design
A prospective blind cohort study.

Setting
Antenatal clinic of a teaching hospital in a Brussels semiurban area.

Participants
An unselected group of 170 women followed at the antenatal clinic.

Methods
A single cervical sample was obtained between 24 and 33 completed weeks of pregnancy. The fibronectin test was compared with clinical evaluation and their predictive properties were assessed.

Results
Fifteen women were excluded from the analysis because of elective preterm delivery for medical indications or loss to follow up. Of the 155 remaining women, nine (7%) had a spontaneous preterm delivery. For a single fetal fibronectin test, the sensitivity was 26.7%, the specificity 95.7%, and the positive and negative predictive values 40.0% and 92.4%, respectively. The likelihood ratio of a positive was similar to that of clinical predictors of preterm birth (LR = 6.2; 95% CI 2.0–19.6). Sensitivities were low for both clinical criteria and the fetal fibronectin test.

Conclusions
Because of low sensitivity in a low risk population, screening for preterm delivery should not be based on the result of a single fetal fibronectin test alone. However, due to its high specificity the test might be useful in avoiding unnecessary medical intervention.
Screening for Down's syndrome: changes in marker levels and detection rates between first and second trimesters
Authors: Berry Esther , Aitken David A. , Crossley Jennifer A. , Macri James N. , Connor J. Michael
Published: August 2005

Objective
To monitor changes with gestation in levels of alpha‐fetoprotein (AFP), free beta human chorionic gonadotrophin (FβhCG) and pregnancy associated plasma protein‐A (PAPP‐A) in Down's syndrome pregnancies and to compare risks estimated in the first trimester with those obtained by routine screening in the second trimester for the same pregnancies.

Design
In each of 47 Down's syndrome pregnancies two maternal serum samples were obtained, one in the first trimester and one in the second trimester. Comparison of marker levels with 10,600 first trimester controls and a smaller sample of second trimester controls allowed case identification criteria based on optimum marker combinations to be developed and compared directly between trimesters.

Setting
Biochemical genetics laboratory.

Results
FβhCG was an effective marker of Down's syndrome in both the first and second trimesters. PAPP‐A levels were significantly reduced in trisomy 21 pregnancies in the first trimester only. Using a population model, these two markers in combination with maternal age gave an overall detection rate of 55% for a 5% false positive rate in the first trimester. For the paired first and second trimester samples, three of six cases classified as low risk by routine second trimester screening were classified as high risk by the first trimester screening protocol of FβhCG/PAPP‐A/matemal age. However, fifteen cases identified as high risk by routine second trimester screening were classified as low risk in the first trimester, a net loss in detection of 12 cases by first trimester screening.

Conclusion
The data suggest that first trimester detection rates for Down's syndrome using a combination of FβhCG and PAPP‐A may vary with gestation and will be lower than those currently obtained by routine second trimester screening with AFP/hCG.
Maternal serum alpha‐fetoprotein in fetal neural tube and abdominal wall defects at 10 to 14 weeks of gestation
Authors: Sebire N. J. , Spencer K. , Noble P. L. , Hughes K. , Nicolaides K. H.
Published: August 2005

Maternal serum alpha‐fetoprotein concentration was determined in nine pregnancies with fetal anencephaly, seven with exomphalos containing liver, two with spina bifida and 100 normal controls at 10 to 14 weeks of gestation. The median alpha‐fetoprotein in the group with fetal anencephaly and exomphalos was significantly higher than in normal fetuses but the sensitivity of this test is likely to be only about 30% for a false positive rate of 5%.
Chlamydia trachomatis infection in prelabour amniorrhexis
Authors: Ville Y. , Carroll S. G , Watts P. , Ward M. , Nicolaides K. H.
Published: August 2005

The prevalence of Chlamydia trachomatis in the lower genital tract and amniotic fluid of women with preterm prelabour amniorrhexis was assessed by DNA amplification for C. trachomatis performed in cervical swabs and amniotic fluid obtained by amniocentesis. C. trachomatis was present in the cervix of 20 (23%) of the cases and in six (30%) of those the organism was also present in the amniotic fluid. There was no association with other pathogens in the lower genital tract or amniotic fluid. The presence of C. trachomatis was not associated with a significant decrease in the amniorrhexis to delivery interval or with an increase in perinatal mortality or morbidity.
Ampicillin‐metronidazole treatment in idiopathic preterm labour: a randomised controlled multicentre trial
Authors: Svare Jens , Langhoff‐Roos Jens , Andersen Lars Franch , Kryger‐Baggesen NieIs , Borch‐Christensen Hanne , Heisterberg Lars , Kristensen Jens
Published: August 2005

Objective
To determine whether treatment with ampicillin and metronidazole in women with threatened idiopathic preterm labour will prolong the gestation and reduce maternal and neonatal infectious morbidity.

Design
Randomised controlled double‐blind trial.

Setting
Six obstetric departments in the Copenhagen area.

Population
One hundred and twelve women with singleton pregnancies, with threatened idiopathic preterm labour and intact amniotic membranes at 26 to 34 weeks of gestation.

Methods
Random allocation to eight days intravenous and oral treatment with ampicillin and metronidazole, or placebo.

Main outcome measures
Number of days from admission to delivery, gestational age at delivery, rates of preterm delivery, low birthweight, maternal infections and neonatal infections.

Results
Treatment with ampicillin and metronidazole was associated with a significant prolongation of pregnancy (admission to delivery 47.5 days versus 27 days, P < 0.05), higher gestational age at delivery (37 weeks versus 34 weeks, P < 0.05), decreased incidence of preterm birth (42%versus 65%, P < 0.05), and lower rate of admission to neonatal intensive care unit (40%versus 63%, P < 0.05), when compared with placebo treatment. Antibiotic treatment had no significant effects on infectious morbidity.

Conclusions
Treatment with ampicillin and metronidazole in women with threatened idiopathic preterm labour significantly prolonged the gestation, but had no effects on maternal and neonatal infectious morbidity.
Effects of magnesium sulphate on the noradrenaline‐induced cerebral vasoconstrictor and pressor responses in the goat
Authors: Perales Alfredo J. , Torregrosa German , Salom Juan B. , Barbera Maria D. , Jover Teresa , Alborch Enrique
Published: August 2005

Objective
To examine the ability of magnesium sulphate to counteract the noradrenaline‐induced cerebral vasoconstrictor and pressor responses in goats by using both in vivo and in vitro techniques.

Design
Cerebral blood flow was measured in vivo by means of an electromagnetic flow probe around the internal maxillary artery. Isometric tension was recorded in vitro from rings of goat middle cerebral artery maintained in an organ bath.

Results
1. In vivo. Continuous infusion of noradrenaline (10 μg/min) directly into the cerebral arterial supply elicited sustained decrease in cerebral blood flow (61% [SEM 3] of control values) and increase in cerebral vascular resistance (178% [SEM 9] of control values). Magnesium sulphate, injected directly into the cerebral arterial supply (10–300 mg) or infused intravenously (0.3 g and 3 g during 15 min) at the noradrenaline‐induced steady state, increased cerebral blood flow by decreasing cerebral vascular resistance in a dose‐dependent manner. A similar result was obtained when intravenous magnesium sulphate (3 g/15 min) was tested against the cerebral vasoconstrictor and pressor responses induced by intravenous infusion of noradrenaline (30 ug/min). 2. In vitro. When compared with the response obtained in a control medium (1 mmol/L Mg2+), 10 mmol/L Mg2+significantly inhibited the maximum contraction elicited by noradrenaline (10−8 to 3 × 10−3 mol/L) from 45% [SEM 4] to 26% [SEM 4].

Conclusions
Magnesium sulphate reverses the noradrenaline‐induced cerebral vasoconstrictor and pressor responses by a direct inhibitory action of Mg2+ on the actions of noradrenaline in the cerebral and peripheral vascular beds, which leads to a decrease in vascular resistance. These results could explain, at least in part, the beneficial effects of magnesium sulphate in the management of pre‐eclampsia and eclampsia.
Magnetic resonance imaging of the uterus after endometrial resection
Authors: Turnbull L. W. , Jumaa A. , Bowsley S. J. , Dhawan S. , Horsman A. , Killick S. R.
Published: August 2005

Objective
Despite the increasing popularity of endometrial resection for the treatment of menstrual problems, the long term sequelae of this procedure are poorly recognised. As diagnostic hysteroscopy following endometrial resection is frequently unrewarding and transvaginal ultrasound is incapable of detecting subtle changes in endometrial morphology, magnetic resonance imaging was employed to evaluate the uterus.

Design
Retrospective study of unselected post‐operative women.

Methods
Fifty‐nine women, of whom 22 were amenorrhoeic, were studied a mean number of 34 months after endometrial resection, using a 1.5 Tesla magnetic resonance imaging system with a pelvic phased array coil for signal reception. T2‐weighted FSE images were acquired through the long and short uterine axis and volumetric assessment of each uterine layer performed using an ISG Allegro workstation.

Main outcome measures
The location and volume of residual endometrium, the volume of junctional zone and myometrial tissue, and the presence of additional intrauterine and pelvic pathology were recorded.

Results
Residual endometrium was demonstrated in all except three amenorrhoeic women, with a similar mean volume present in menstruating and amenorrhoeic groups. Additional findings included adenomyosis, haematometra, fallopian tube dilatation and free intraperitoneal fluid.

Conclusions
The majority of amenorrhoeic and all menstruating women have residual endometrium after endometrial resection. The lack of communication of islands of residual endometrium with the uterine cavity results in haematometra formation, fallopian tube dilatation and possibly free intraperitoneal fluid.
Zoonotic and viral infection in fetal loss after 12 weeks
Authors: Sanghi Anita , Morgan‐Capner Peter , Hesketh Louise , Elstein Max
Published: August 2005

One hundred and thirty‐six women from an urban, rural and farming community were recruited to a study of infectious causes of midtrimester miscarriage (n= 85), stillbirth (n= 32), or termination for developmental (n= 17) or chromosomal (n= 2) abnormalities. No woman had evidence of acute infection with toxoplasma, listeria, leptospira or Chlamydia psittaci (ovine enzootic abortion). One woman had midtrimester miscarriage associated with primary cytomegolovirus infection and five women had evidence of parvovirus B19 infection, although fetal infection was not proven. Zoonoses were not identified as a cause of fetal loss or malformation in this at‐risk population, but parvovirus B19 was a significant cause of midtrimester fetal loss.
A regional audit of perinatal and infant autopsies in Northern Ireland
Authors: Thornton C. M. , O'Hara M. D.
Published: August 2005

Objective
To investigate the rate and quality of perinatal/infant autopsies and their contribution to the final diagnosis.

Methods
The anonymised reports of autopsies performed on 174 of the 367 cases reported to the Northern Ireland Regional Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) coordinator in 1993 were reviewed. They were scored using a modification of the CESDI Pathology Audit Form 93 and, based on the score obtained, ascrined to one of three groups: good, adequate or inadequate. Based on the information obtained, they were also assessed as providing diagnostic, confirmatory, additional or no diagnostic data. The pre‐autopsy clinical extended Wigglesworth classification was compared with that based on autopsy findings.

Results
The autopsy rate was 47.4% and included 18 late fetal losses, 70 stillbirths, 57 neonatal deaths and 29 post neonatal deaths. The Regional Paediatric Pathology Centre performed 34.5% of the autopsies. Of the total number of autopsies, 46.6% failed to reach an adequate standard. Only 4.9% of the inadequate autopsies were performed in the Regional Centre. The Wigglesworth classification was altered in 20.7% of cases following autopsy. The autopsy findings of 49 cases were diagnostic, 75 confirmatory, 23 yielded additional information and 27 were useful in only a negative sense.

Conclusion
The autopsy rate for this region is well below the recommended level of 75%. With the exception of the Regional Centre, the quality of the perinatallinfant autopsy did not reach the standard suggested in the CESDI Pathology Audit form 93. Despite this the autopsy yielded valuable diagnostic, confirmatory or additional findings in 84.5% and resulted in alteration to the pre‐autopsy Wigglesworth classification in 20.7%.
Dysfunctional labour: a randomised trial
Authors: Blanch Geraldine , Lavender Tina , Walkinshaw Steve , Alfirevic Zarko
Published: August 2005

Sixty‐one women making slow progress in the active phase of spontaneous labour with intact membranes were randomised to oxytocin and amniotomy, amniotomy only or expectant management. The data show that oxytocin significantly increases the rate of cervical dilatation and shortens prolonged labour, when compared with amniotomy alone and expectant management (P= 0.144 and 0–0.06, respectively). The impact on the operative delivery rate and neonatal outcome is difficult to assess due to the small number of relevant adverse outcomes. Women reported higher satisfaction score in the two groups where intervention followed the diagnosis of dysfunctional labour.
A systematic review comparing continuity of midwifery care with standard maternity services
Authors: Waldenström Ulla , Turnbull Deborah
Published: August 2005

Objective
To review randomised controlled trials of alternative maternity services characterised by continuity of midwifery care.

Methods
A systematic review of randomised controlled trials, analysed on an intention to treat basis, in which the study intervention was characterised by a midwife or small group of midwives providing care from early pregnancy to the postnatal period (defined as that provided on the postnatal ward); and the controls by standard maternity care as practised in the place where the trial was conducted. The seven trials identified included 9148 women. Main outcome measures were interventions during labour, maternal outcomes and infant outcomes.

Results
The alternative models with continuity of midwifery care were associated with less use of obstetric interventions during labour (eg, induction, augmentation of labour, electronic fetal monitoring, obstetric analgesia, instrumental vaginal delivery and episiotomy). However, the caesarean section rate did not differ statistically between the trial groups (OR 0.91; 95% CI 0.78 to 1.05). The lower episiotomy rate in the alternative models of care (OR 0.69; 95% CI 0.61 to 0.77) was associated with a significantly higher rate of perineal tears in the pooled alternative groups (OR 1.15; 95% CI 1.05 to 1.26). The percentage of intact perineums was very similar for the two groups (OR 1.11; 95% CI 1.00 to 1.24). There was no maternal death, and rates of maternal complications based on unpooled estimates did not show any statistically significant differences. The proportion of babies with an Apgar score < 7 at five minutes after the birth was approximately the same in the pooled alternative groups as in the control groups (OR 1.13 95% CI 0.69 to 1.84). Admission to intensive care or special care baby unit was similar (OR 0.86; 95% CI 0.71 to 1.04). The difference in perinatal deaths was bordering on statistical significance (OR 1.60; 95% CI 0.99 to 2.59).

Conclusion
Continuity of midwifery care is associated with lower intervention rates than standard maternity care. No statistically significant differences were observed in maternal and infant outcomes. However, more research is necessary to make definite conclusions about safety, for the infant as well as for the mother. This review illustrates the variation in the different models of alternative and standard maternity care, and thus the problems associated with pooling data from different trials.
Potentially avoidable perinatal deaths in Denmark, Sweden and Lithuania as classified by the Nordic‐Baltic classification
Authors: Langhoff‐Roos Jens , Larsen Steen , Basys Vytautas , Lindmark Gunilla , Badokynote Migle
Published: August 2005

Objectives
To analyse which subgroups of perinatal deaths contribute most to the perinatal mortality rate in Lithuania compared with Denmar/Sweden.

Design
Comparison of all perinatal deaths in Denmark/Sweden 1991 and Lithuania 1993–1994 by the common Nordic‐Baltic perinatal death classification, based on information from the medical records.

Results
The doubled perinatal mortality in Lithuania compared with Denmark/sweden is mainly explained by a threefold increase of intrapartum and two‐ to fivefold increase in neonatal deaths of nonmalformed infants. The higher rate of malformed infants is partly explained by a four times higher mortality from neural tube defects.

Conclusions
The use of a common perinatal death classification has identified categories mainly responsible for the higher rate of perinatal mortality, but further investigation of potentially avoidable factors requires further study.
Liver function following pregnancy complicated by the HELLP syndrome
Authors: Knapen Maarten F. C. M. , van Altena Anne M. , Peters Wilbert H. M. , Merkus Hans M. W. M. , Jansen Jan B. M. J. , Steegers Eric A. P.
Published: August 2005

Serum levels of aminotransferases, lactate dehydrogenase, gammaglutamyl transferase, alkaline phosphatase, albumin and conjugated bilirubin, measured in 54 women at a median of 31 months (range 3–101) after pregnancies complicated by the HELLP syndrome, were not elevated. Total bilirubin levels, however, were elevated in 20′1/0 of these women; this represents a significant difference from the prevalence in 151 women with a previous normal pregnancy (χ2= 12.23, P < 0.001), or in the normal female population (χ2= 22.34, P < 0.00001). This raises the possibility that a dysfunction of the bilirubin‐conjugating mechanism represents a risk factor for the development of the HELLP syndrome.
Gender does not affect fetal heart rate variation
Authors: Ogueh Onome , Steer Philip
Published: August 2005

There is a widespread but erroneous view among the lay public that there is a difference in the baseline fetal heart rate between male and female fetuses. It has been suggested that this perception might reflect an actual difference in fetal heart rate variability. Therefore, we studied the fetal heart rate variation in 79 white European women using the Sonicaid System 8002 computer. Fourty‐four of the fetuses were male and 35 were female. There was no significant gender difference in any measured aspect of fetal heart rate variation.
A randomised trial of mode of delivery in women infected with the human immunodeficiency virus
Authors: Newell Marie‐Louise , Parazzini Fabio , Mandelbrot Laurent , Peckham Catherine , Semprini Augusto , Bazin Brigitte , Darbyshire Janet , Sanchez Emilia , Pardi Giorgio
Published: August 2005

Objective
During the pilot phase of a trial to evaluate the effectiveness of caesarean section delivery compared with vaginal delivery in reducing mother‐to‐child transmission of human immunodeficiency virus (HIV) infection, the feasibility of randomisation to mode of delivery was assessed.

Design
At 36 weeks of pregnancy, women infected with HIV were randomly allocated to either caesarean section delivery at 38 weeks or vaginal delivery. Information was also collected on the reasons why women were not enrolled, either because they refused or had a contraindication.

Setting
Fifty‐one centres in six European countries. Population Pregnant women with confirmed HIV1 infection Main outcome measures Randomisation.

Results
Three‐hundred and thirty‐nine women had been randomised by the end of 1996, the large majority from Italy (n= 250) and France (n= 54), with 22 from South Africa, three from Sweden, nine from Barcelona and one from London. A further 150 women were eligible but had not been randomised. Forty‐eight women (14%) were not delivered according to the arm to which they were randomised; the majority (n= 44) were changed from vaginal to caesarean section delivery. There is wide variation between European countries in the acceptability and adherence to the mode of delivery trial.

Conclusion
The pilot phase of this trial has shown that in some settings randomisation to mode of delivery is feasible and acceptable, but that in other setttings clinicians and pregnant women are more reluctant to be randomised. Pending further information on transmission rates and accrual, enrollment into the trial continues.