bluuebunny/crossref_metadata_2025 huggingface dataset:
Undiagnosed breech
Authors: Nwosu Ezechi Cally , Walkinshaw Steve , Chia Philip , Manasse Paul R. , Atlay Robert D.
Published: August 2005

Objectives
To assess the proportion of breech presentations diagnosed in labour and to compare their outcomes with those diagnosed prior to the onset of labour.

Design
Retrospective casenote review.

Setting
Mill Road Maternity Hospital, a teaching hospital in central Liverpool.

Subjects
Three hundred and five singleton breech presentations delivered in the hospital between January 1988 and July 1991; 226 cases prior to the onset of labour and 79 cases diagnosed for the first time in labour.

Main outcome measures
Rates of vaginal delivery and caesarean section, birthweight, short term morbidity as assessed by trauma, signs of cerebral irritation and admission to the newborn intensive care unit (NBICU), and Apgar scores.

Results
Breech presentations diagnosed for the first time in labour were more likely to deliver vaginally than those assessed and allowed to go into labour (odds ratio 1:68 95% CI 1.0–3.0). This difference was not due to demographic variables or differences in birthweight. There was no short term morbidity attributable to vaginal breech delivery.

Conclusion
A significant number of breech presentations are not detected until labour despite rigorous antenatal surveillance. Our results show that undiagnosed breeches may not be important as they are more likely to deliver vaginally, with no excess morbidity or mortality, compared to diagnosed breeches in labour, carefully assessed for vaginal delivery. There are, therefore, no grounds for delivering all undiagnosed breeches by caesarean section.
Experience of autologous blood transfusion in an obstetrics and gynaecology department
Authors: O'Dwyer Gearoid , Mylotte Michael , Sweeney Maura , Egan Ernest L.
Published: August 2005

Objective
To demonstrate the potential and effectiveness of autologous blood transfusion in an obstetric and gynaecological practice.

Setting
The Department of Obstetrics and Gynaecology and the department of Haematology, University College Hospital, Galway, Ireland.

Subjects
One hundred and sixty‐eight women undergoing abdominal hysterectomy, 42 women undergoing repair procedures, and 56 women undergoing elective caesarian sections participated in this programme.

Results
In the abdominal hysterectomy group 329 units of blood were collected of which 48% were transfused to the donors. In the repair group 82 units of blood were collected of which 21.9% were transfused to the donors. In the elective caesarian section group 105 units of blood were collected of which 64.7% were transfused to the donors. Overall the donation procedure was well tolerated with infrequent donor reactions.

Conclusion
Our experience demonstrates that autologous blood transfusion is a safe and reasonable transfusion practice in the setting of obstetrics and gynaecology.
Prediction of perinatal morbidity at term in small fetuses: comparison of fetal growth and Doppler ultrasound
Authors: Chang Tou C. , Robson Stephen C. , Spencer John A. D. , Gallivan Steven
Published: August 2005

Objective
To compare fetal growth assessed by ultrasound (change in standard deviation score of abdominal circumference and estimated fetal weight) during the third trimester with predelivery ultrasound measurements of fetal size and Doppler measurements from the umbilical and fetal arteries in order to predict suboptimal perinatal outcome in small babies at term.

Design
Prospective observational study.

Setting
Day assessment unit in a university hospital.

Subjects
One hundred and four consecutive women with a clinical suspicion of a small fetus during the third trimester confirmed by ultrasound (abdominal circumference below the 10th centile) and ultimately delivered at term.

Main outcome measures
Acidaemia at birth, fetal distress requiring emergency caesarean section in labour, admission to the neonatal intensive care unit.

Results
Ninety‐four babies (90%) weighed less than the 10th centile and the incidence of suboptimal perinatal outcome was 27%. The largest areas under the receiver operating characteristic curves for suboptimal perinatal outcome were obtained with the change in standard deviation score of abdominal circumference and estimated fetal weight, and the ratios of aortic/middle cerebral and renal/middle cerebral pulsatility index. Although low, the odds ratios of the change in estimated fetal weight standard deviation score and the Doppler ratios were significantly different from zero.

Conclusion
Ultrasound assessment of fetal growth and predelivery fetal Doppler pulsatility index ratios were superior to predelivery estimates of fetal size and umbilical artery pulsatility index in predicting suboptimal perinatal outcome in small fetuses delivering at term, although the clinical value of such a prediction may be limited.
Reduction of pain after laparoscopic sterilisation with local bupivacaine: a randomised, parallel, double‐blind trial
Authors: Wheatley S. A. , Millar J. M. , Jadad *A. R.
Published: August 2005

Objective
To investigate the efficacy of applying 10 ml bupivacaine 0.5%versus normal saline to the fallopian tubes under direct vision during day case laparoscopic sterilisation under general anaesthesia.

Design
Randomised, parallel, double‐blind controlled trial.

Setting
Day Surgery Unit.

Subjects
Sixty women presenting for day case laparoscopic sterilisation.

Main outcome measures
Time to first post‐operative analgesia, and pain levels at 1 h, at discharge, and at time of first analgesia.

Results
In the group receiving bupivacaine, time to first analgesia was significantly longer (P= 0.03) and significantly fewer patients requested escape analgesia before the 1 h assessment (P= 0.01). This group also had significantly less pain on visual analogue scale (P= 0.04) and significantly lower categorical verbal pain scores (P= 0.01) at the 1 h assessment. By the time of discharge, there were no significant differences between the groups. Eight women in the saline group and 15 in the bupivacaine group required no escape analgesia. This difference was not significant. One woman who received saline required to be admitted overnight for severe pain.

Conclusion
Topical application of bupivacaine to the fallopian tubes during laparoscopic sterilisation is an easy and effective contribution to the management of pain in the immediate post‐operative period after day case laparoscopic sterilisation under general anaesthesia.
Charts of fetal size: 1. Methodology
Authors: Altman Douglas G. , Chitty Lyn S.
Published: August 2005

Objectives To discuss the features of study design and analysis which are necessary to derive valid reference centiles for fetal size. To describe a study which meets the stated criteria.

Design
Prospective study of 663 fetuses.

Results
The selection of the sample and adequate sample size are of great importance. Prospective collection of data specifically for the purpose of deriving centiles is recommended. It is essential to use statistical methods that take proper account of the increasing variation among fetuses as pregnancy proceeds; such methods are described and illustrated. A study is described which meets the stated criteria for design and analysis, and from which new fetal size centile charts have been derived and are presented in subsequent papers.

Conclusions
Many published studies containing charts (standards) of fetal size are methodologically flawed. Research design and statistical analysis must adhere to sound principles for fitted centiles of size to be valid and so clinically relevant.
Charts of fetal size: 4. Femur length
Authors: Chitty Lyn S. , Altman Douglas G. , Henderson Annabel , Campbell Stuart
Published: August 2005

Objective
To construct a new size chart for fetal femur length.

Design
A prospective, cross sectional study of fetuses scanned once only for the purpose of the study at gestations between 12 and 42 weeks.

Setting
The routine ultrasound department of a London teaching hospital.

Subject
The fetuses of 663 women seen in the routine antenatal booking clinic whose ultrasound and menstrual dates agreed within 10 days.

Results
Femur length was measured on 649 of the 663 fetuses. A linear‐cubic regression model was fitted to estimate the mean and a separate linear regression to estimate the standard deviation. Gentiles were derived by combining these two regression models, assuming that the measurements have a normal distribution at each gestational age. A new chart for femur size is presented and compared with previously published data.

Conclusions
We have constructed a new size chart for fetal femur length taking into consideration the increasing variability with increasing gestational age. We have compared our chart with other published data, and believe that the differences seen may be largely due to methodological differences.
The effects of dihydralazine, labetalol and magnesium sulphate on the isolated, perfused human placental cotyledon
Authors: Petersen Olav B. , Skajaa Kristjar , Svane Danny , Gregersen Hans , Forman Axel
Published: August 2005

Objective
To assess the effects of dihydralazine, labetalol and magnesium sulphate on the vascular tone in the isolated, perfused human placental cotyledon.

Methods
In vitro perfusion of the fetal compartment of isolated, human placental cotyledons.

Results
None of the drugs affected basal vascular tone. The thromboxane A2‐mimic U46619 and endothelin‐1 induced a concentration‐dependent increment in perfusion pressure, while 5‐ hydroxytryptamine induced a variable increase, and norepinephrine induced a small, transient increase in perfusion pressure. After preconstriction with U46619, magnesium sulphate (1.5×10−3 to 6.10−3 mol/1) induced a decrease in perfusion pressure, while dihydralazine (10−6to 10−4 mol/1) or labetalol (10−7 to 10−4 mol/1) enhanced the perfusion pressure. These effects of dihydralazine and labetalol were unaffected by treatment with indomethacin 10−6 mol/1, but could be reversed by addition of magnesium sulphate 6.10−3 mol/1. Labetalol 10−6 to 10−4 mol/1 also caused an increase in the perfusion pressure induced by endothelin‐1, but showed no effects after preconstriction with 5‐hydroxytryptamine. Pretreatment with labetalol 10−4 mol/1 inhibited the transient increase in perfusion pressure induced by norepinephrine 3.10−5 mol/1.

Conclusions
The present data demonstrated that the commonly used vasodilating agents labetalol and dihydralazine do not produce vasodilatation in the human perfused cotyledon after vasoconstriction induced by agents of suggested importance for maintenance of fetal placental vascular tone, and that high concentrations of these drugs may even enhance vasoconstriction induced by thromboxane and endothelin‐1 in this area. Magnesium sulphate may show the potential to reverse such unwanted effects of dihydralazine and labetalol.
Roles of prostaglandins and intracellular free calcium mobilisation in epidermal growth factor‐induced proliferation of human amnion cells
Authors: Tahara Masahiro , Masumoto Nobuyuki , Mizuki Jirou , Kasahara Kanji , Tasaka Keiichi , Kurachi Hirohisa , Miyake Akira
Published: August 2005

Objective
To investigate the mechanisms which regulate the growth of human amnion cells.

Design
A prospective descriptive study.

Subject
Women undergoing caesarean section at term before the onset of labour.

Interventions
Amnion cells were cultured in monolayer.

Main outcome measures
Cell cycle analysis, intracellular calcium levels, prostaglandin (PG) production rates.

Results
Epidermal growth factor (EGF) stimulated intracellular Ca2+ mobilisation and PGE2 production in cultured amnion cells. The addition of a Ca2+ channel blocker (cobalt) or a Ca2+ chelator (EGTA) into the culture medium inhibited intracellular Ca2+ mobilisation and PGE2 production induced by EGF. The analysis of cell cycles showed that EGF induced the initiation of DNA synthesis and that the addition of cobalt or EGTA into the culture medium inhibited EGF‐induced DNA synthesis. The addition of a cyclo‐oxygenase inhibitor (indomethacin) inhibited PGE2 production and DNA synthesis induced by EGF without the effect on intracellular Ca2+ mobilisation. Moreover, the inhibitory effect of indomethacin on EGF‐induced DNA synthesis was attenuated by the addition of exogenous PGE2 or PGF2n.

Conclusions
These data suggest that EGF induces an increase in intracellular Ca2+ levels and the rate of prostaglandin production which leads to proliferation of human amnion cells.
Episiotomies and the occurrence of severe perineal lacerations
Authors: Anthony S. , Buitendijk S. E. , Zondervan K. T. , van Rijssel E. J. C. , Verkerk P. H.
Published: August 2005

Objective
To investigate the relation between the use of mediolateral episiotomy and the occurrence of severe (third degree) perineal tears in hospital deliveries in the Netherlands.

Design
An observational study.

Subject
Data were derived from the Dutch National Obstetric Database (LVR) of 1990, from which 43 309 spontaneous, occipito‐anterior, vaginal deliveries of live, singleton infants were investigated.

Intervention
Medio‐lateral episiotomy.

Main outcome measure
The occurrence of severe perineal tears.

Results
The severe tear rate was 1.4% in the total study group. Using multiple logistic regression to control for possible confounding variables, the use of mediolateral episiotomy was found to be associated with a more than fourfold decrease in risk of severe lacerations (odds ratio 0.22, 95% CI 0.17 to 0.29). Further, in a logistic model deliveries in hospitals with restrictive use of episiotomy (< 11%) were compared with those in hospitals with liberal use of episiotomy (≥ 50%). Liberal use of episiotomy was not associated with a lower frequency of severe perineal tears.

Conclusion
Although a protective effect of mediolateral episiotomy on the occurrence of severe lacerations was found, liberal use of mediolateral episiotomy should be discouraged on the basis of our findings.
The individualised birth weight ratio: a new method of identifying intrauterine growth retardation
Authors: Sanderson David A. , Wilcox Mark A. , Johnson Ian R.
Published: August 2005

Objective
To assess the effectiveness of the newly developed individualised birthweight ratio in identifying growth retarded infants.

Design
Prospective observational study.

Setting
Obstetric unit, City Hospital Nottingham.

Subjects
Two thousand eight hundred and thirty‐five women delivered between December 1991 and July 1992 and the infants of 616 of these selected by virtue of their birthweight for gestation and individualised birthweight ratio centile positions.

Main outcome measures
Skinfold thickness and ponderal index measurements, occurrence of abnormal fetal heart rate patterns, operative delivery due to fetal distress and the need for neonatal resuscitation.

Results
Using an individualised birthweight ratio less than the 10th centile as a cut‐off results in 25% of those less than the 10th centile of birthweight for gestation being reclassified as normally grown. A slightly larger group are reclassified as small; significantly more of these infants have abnormal ponderal indices and skinfold thicknesses, suffer abnormal fetal heart rate patterns, operative delivery for fetal distress and need neonatal resuscitation than do those who are reclassified as normally grown.

Conclusion
The individualised birthweight ratio combines the simplicity of birthweight measurement with the accuracy of clinical measurements in the identification of the growth retarded baby.
Five year survival rate in endometrial carcinoma stages I‐II: influence of degree of tumour differentiation, age, myometrial invasion and DNA content
Authors: Lindahl Bengt , Ranstam Jonas , Willén Roger
Published: August 2005

Objective
To compare the prognostic capability of clinical stage, tumour differentiation, myometrial invasion, age and DNA content in endometrial carcinoma. Then to use the results to identify a small, high risk group suitable for more intensive adjuvant therapy.

Design
A prospective five year follow up between June 1980 and June 1987.

Setting
Department of Oncology, gynaecological section, University Hospital, Lund, Sweden. Endometrial tissue was obtained immediately prior to treatment for flow cytometric DNA analysis.

Subjects
Two hundred and fifty‐one patients referred for treatment.

Interventions
None.

Results
Age, myometrial invasion of greater than 50%, and number of DNA populations (ploidy) were the only significant parameters related to survival. By combining myometrial invasion and number of DNA populations, we divided the patients into four groups. A very small high risk group was identified (7%) with a low survival rate (61%). Two intermediate groups with either myometrial invasion exceeding 50% or with more than one DNA population present constituted 34% of the patients and these had an overall survival rate of 75% and a relatively large low risk group of 59% of the patients (with a survival rate of 95%) was constructed out of those without deep myometrial invasion and demonstrating only one DNA population.

Conclusions
These data suggest that number of DNA populations and depth of myometrial invasion could be combined to identify a small high risk group (7%) with a low survival rate (61%) suitable for adjuvant therapy.
First trimester maternal serum alpha‐fetoprotein in fetal trisomies
Authors: Brizot M. L. , Kuhn P. , Bersinger N. A. , Snijders R. J. M. , Nicolaides K. H.
Published: August 2005

Objective To evaluate the potential value of maternal serum alpha‐fetoprotein concentration in the detection of fetal trisomy at 10 to 13 weeks gestation and to examine the possible association between maternal serum alpha‐fetoprotein and fetal nuchal translucency thickness.

Design Cross‐sectional study.

Setting Harris Birthright Research Centre for Fetal Medicine, King's College Hospital Medical School, London.

Subjects and methods Maternal serum alpha‐fetoprotein concentration was measured at 10 to 13 weeks gestation in samples from 57 pregnancies with fetal trisomies (trisomy 21 (n= 35), trisomy 18 (n= 16), and trisomy 13 (n= 6)) in 228 matched controls in whom the fetal nuchal translucency was < 3 mm and in 114 chromosomally normal fetuses with translucency ≥3 mm.

Results In the control group maternal serum alpha‐fetoprotein increased significantly with fetal crown‐rump length (r= 0.451). In this group, the median maternal serum alpha‐fetoprotein was not significantly different from that in the groups with trisomy 21 (median = 0.84 MOM), trisomy 18 (median = 0.86 MOM), or trisomy 13 (median = 0.94 MOM), respectively. Neither in the control group nor in the group with trisomic fetuses was maternal serum alpha‐fetoprotein significantly associated with fetal nuchal translucency thickness (r= 0.01 and r= 0.03).

Conclusion Measurement of maternal serum alpha‐fetoprotein concentration in the first trimester of pregnancy is not likely to be useful in the prediction of fetal trisomies.
The effects of maternal betamethasone administration on the fetus
Authors: Derks Jan B. , Mulder Eduard J. H. , Visser Gerard H. A.
Published: August 2005

Objective To examine prospectively the effects of maternal betamethasone administration on fetal heart rate variation, body, breathing and eye movements and the rest‐activity cycle.

Design Thirty‐one women on 38 occasions were at risk of premature delivery and received two doses of betamethasone 24 h apart. Gestational age ranged between 26 and 32 weeks. Fetal heart rate was monitored on each of five successive days (0–4) and fetal body, breathing and eye movements were recorded on days 0, 2 and 4.

Results Compared with the control day before steroid administration (day 0), both long term and short term fetal heart rate variation were reduced on days 2 and 3 (P < 0.01). In one‐third of the cases, fetal heart rate variation fell transiently below the lower normal range for gestational age. Body movements were reduced on day 2 by 50% (P 0.01) due to prolonged periods of inactivity (P < 0.01). Breathing movements were largely absent on day 2 (P < 0.01), but the occurrence of eye movements remained unchanged after betamethasone administration. All values returned to baseline on day 4, indicating that no fetal deterioration had occurred during the course of the study period. Similar responses to betamethasone were observed in five fetuses when studied at re‐presentation two weeks later.

Conclusions Maternal betamethasone administration causes a considerable but transient reduction in fetal body movements and activity periods, breathing and heart rate variation, without affecting fetal eye movements. Knowledge of this phenomenon is important when assessing the fetal condition. The effect may be due to a glucocorticoid receptor mediated process in the fetal brain.
Mortality after gynaecologic operations in Finland, 1986–1991
Authors: Virtanen H. S. , Mäkinen J. I.
Published: August 2005

Objective To study the current in‐hospital, 30–day and 42–day mortality after conventional gynaecologic procedures in Finland, with special reference to hysterectomy.

Design Nationwide six‐year annual study.

Setting Data were from the Finnish Population Register Centre, the Finnish Cause‐of‐Death and Hospital Discharge Register, and the Register for Legal Abortions and Sterilisations.

Subjects Gynaecologic operations (n= 299257) performed between January 1986 and December 1991.

Main outcome measures The overall and age‐adjusted mortality rates during the initial hospitalisation, as well as 30 and 42 days after the operations. Age‐adjusted probability of dying withn 42 days after hysterectomy compared with the overall probability of age‐matched Finnish female control population.

Results Overall mortality rates per 10000 hysterectomies increased gradually from 6.0 during initial hospitalisation to 9.1 and 12.9 when calculated 30 and 42 days post‐operatively. The overall 42–day mortality rates of radical hysterectomy, curettage and laparoscopy (other than sterilisation) exceeded the post‐hysterectomy mortality rate, while the rates after caesarean section, legal abortion and laparoscopic sterilisation did not. No deaths occurred after laparoscopic sterilisation (n= 40346). The patients who died after radical hysterectomy, curettage and for other laparoscopy than sterilisation were old, and the great majority of them died of cancer.

Conclusions The mortality rates after gynaecologic procedures in Finland are currently very low and have clearly decreased in recent decades. Patients may be reassured that conventional gynaecologic operations are safe.
Obstetricians' views on prenatal diagnosis and termination of pregnancy: 1980 compared with 1993
Authors: Green Josephine M.
Published: August 2005

Objective To examine the attitudes of obstetricians in England and Wales concerning prenatal diagnosis and termination of pregnancy and to compare these with a similar survey carried out in 1980.

Methods Postal questionnaires, based on those used in 1980, were sent to a random sample of 555 nonacademic consultant obstetricians, 71% of whom replied.

Results The proportion of consultant obstetricians with a conscientious objection to termination of pregnancy was the same in both surveys, although virtually all conscientious objectors said that they made an exception for serious fetal abnormality. A major change was in the proportion saying that they generally required an undertaking to terminate an affected pregnancy before proceeding with amniocentesis: 75% in 1980 compared with 34% in 1993. As in 1980, lower priority is given to telling women of negative test results than of positive. More obstetricians in 1993 are prepared to consider terminations later in pregnancy, both for fetal abnormality and for social reasons, than was the case in 1980, but many are not prepared to recommend termination as late in pregnancy as the law allows. In some cases this is due to misapprehensions about what is legal. There are particular problems concerning terminations for fetal anomalies that not all would consider serious. One in seven of the 1993 sample would not recommend termination for cystic fibrosis at any gestation. Only 13 % would recommend termination for Down's syndrome beyond 24 weeks. There is a need not only for clarification of the law, but also of obstetrician's willingness to implement it.
The chronically symptomatic vulva: aetiology and management
Authors: Fischer Gayle , Spurrett Brian , Fischer Arthur
Published: August 2005

Objective
To determine the causes and management of chronic vulval symptoms and to compare the findings in patients first presenting to a gynaecologist with those in patients first presenting to a dermatologist.

Design
A prospective study of 144 patients, approximately half each being referred to a gynaecologist and a dermatologist. Diagnosis was based on clinical history, vulvoscopy, vulval biopsy and bacteriology. Biopsies were examined by a histopathologist experienced in dermatopathology and gynaecological pathology.

Results
The two patient groups were similar in both range and frequency of conditions. The commonest cause of chronic vulval symptoms was dermatitis, which was found in 64% of our patients. Dermatitis occurred alone in 55% and was found in association with histological evidence of human papilloma virus (HPV) in a further 9%. These patients responded to simple dermatological methods, mainly topical corticosteroids. Histopathological evidence of HPV was encountered in only 23% of our patients, and of these 36% also demonstrated dermatitis on biopsy. Most responded to topical corticosteroids. Another 7% had lichen sclerosus, and all responded to potent topical corticosteroid. The remaining 15% demonstrated a range of diagnoses, including psoriasis, dysaesthetic vulvodynia, vulval intraepithelial neoplasia (VIN) and chronic candidiasis. The majority of patients had a corticosteroid responsive dermatosis rather than a gynaecological condition.

Conclusions
The majority of patients with a chronically symptomatic vulva who present to either a gynaecologist or a dermatologist have a dermatological condition that responds to simple dermatological treatments. We believe that the presence or absence of the human papilloma virus is not relevant to most patients with a chronically symptomatic vulva and treatments should not be aimed at eradicating this virus. Histopathologists and gynaecologists who have focused on gynaecological disorders have often missed simple dermatological conditions that are easily treatable.
The prediction of fetal acidosis at birth by computerised analysis of intrapartum cardiotocography
Authors: Chung T. K. H. , Mohajer M. P. , Yang Z. J. , Chang A. M. Z. , Sahota D. S.
Published: August 2005

Objective
To assess the capability of a computer software interpretation program, using intrapartum fetal heart rate and intrauterine pressure as recorded in a cardiotocogram to predict fetal acidosis at birth.

Design and subjects
A retrospective analysis of digitised fetal heart rate and uterine activity values obtained from 73 high risk women in labour.

Setting
Two university teaching hospitals.

Methods
A computer software program was constructed to analyse the digitised data and predict acidosis. The results of the analysis were compared with actual umbilical arterial blood pH and base excess at delivery.

Results
The software cardiotocogram interpreter was able to predict a pH of less than 7.15 with an accuracy of 77%, a sensitivity of 88% and specificity of 75% in this set of data. It was able to predict a base excess of less than –8 mmol/1 with an accuracy of 81%, a sensitivity of 76% and specificity of 82%.

Conclusions
A computerised method of analysing fetal heart rate and uterine activity using a simple algorithm has demonstrated a capability to predict fetal acidosis at the time of delivery. Further research in this area is warranted.
Reducing the induction to abortion interval in termination of second trimester pregnancies: a comparison of mifepristone with laminaria tent
Authors: Ho P. C. , Tsang S. S. K. , Ma H. K.
Published: August 2005

Objective
To determine whether mifepristone (RU486) is more effective than laminaria tent in shortening the induction‐abortion interval in termination of second trimester pregnancies with gemeprost.

Design
Prospective randomised comparative trial.

Setting
Department of Obstetrics and Gynaecology in a University teachng hospital.

Subjects
Sixty‐two women undergoing termination of pregnancy in the second trimester.

Interventions
The women were allocated at random to one of the two treatment groups. The first group received 600 mg of mifepristone 36 h before administration of gemeprost. In the second group, a medium‐sized laminaria tent was inserted 12 h before gemeprost. The pregnancies in both groups were terminated with vaginal gemeprost, 1 mg every 3 h up to a maximum of 5 mg/day.

Main outcome measures
Induction‐abortion intervals, amount of gemeprost required, and incidence of side effects.

Results
The median induction‐abortion interval in the mifepristone group (75 h) was significantly shorter than that in the laminaria tent group (11 h) and significantly fewer gemeprost pessaries were required. There was no significant difference in the amount of narcotic analgesics required or the incidence of side effects between the two groups.

Conclusions
Mifepristone is more effective than laminaria tent in shortening the induction‐abortion interval in termination of second trimester pregnancies.
A multicentre comparative study of 17 experts and an intelligent computer system for managing labour using the cardiotocogram
Authors: Keith Robert D. F. , Beckley Sarah , Garibaldi Jonathan M. , Westgate Jenny A. , Ifeachor Emmanuel C. , Greene Keith R.
Published: August 2005

Objectives
To investigate 1. whether an intelligent computer system could obtain a performance in labour management comparable with experts when using cardiotocograms (CTGs), patient information, and fetal blood sampling and 2. whether experts could be consistent and agree in their management of labour.

Subjects
An intelligent computer system and 17 clinicians experienced in fetal monitoring from 16 centres in the UK.

Design
Fifty cases with complete intrapartum CTGs and clinical data were reviewed by each expert and the system independently on two occasions, at least one month apart. Each CTG was scored in 15 min segments according to a protocol and estimates of the cervical dilatation and fetal scalp blood pH were given when requested.

Main outcome measures
Consistency and agreement in the recorded scores, agreement and timing of cases recommended for caesarean sections, fetal blood sampling rates, intervention in cases with poor outcome and intervention in cases with good clinical outcome.

Results
The system:

Agreed with experts well and significantly better than chance (67.33%, kappa = 0.31, P 0.001).

Was highly consistent (99.16%, kappa = 0.98, P 4.0001) when used by two operators independently.

Recommended no unnecessary intervention in cases with normal delivery and good condition (cord artery pH > 7.15, vein pH > 7.20, 5 min Apgar ≥ 9 and no resuscitation). This was better than all but two of the experts.

Recommended delivery by caesarean section in 11 cases; at least 15 of the 17 experts in each review also recommended caesarean section delivery in these cases. The majority did so within 15 min of the system and two‐thirds did so within 30 min.

Identified as many of the birth asphyxiated cases (cord arterial pH < 7.05 and BDecf ≥ 12, and Apgar score at 5 min ≤ 7 with neonatal morbidity) as the majority of experts and one more than was acted upon clinically.

The experts were found to be consistent and to agree. There was good agreement in the cases and the timing of caesarean section recommendations. The majority of experts did not recommend operative intervention in cases which had a normal delivery and good outcome, but did recommend operative interventions in 10 of 12 cases delivered with cord arterial pH c 7.05. However, in one of the cases delivered with birth asphyxia, 14 of the 17 experts and the system failed to recommend intervention.

Conclusions
The system's performance was found to be indistinguishable from the experts' in the 50 cases examined, but it was more consistent. This demonstrates the potential for an intelligent computer system to improve the interpretation of the CTG and decrease intervention. Furthermore, the good performance of most experts in this study demonstrates the potential effectiveness of the CTG and raises important questions regarding why the CTG has fallen short of expectations in current practice.
Hormone replacement therapy, sleep quality and psychological wellbeing
Authors: Purdie David W. , Empson Jacob A. C. , Crichton Caroline , Macdonald Linda
Published: August 2005

Objective
To examine the effect of hormone replacement therapy upon sleep quality and duration in postmenopausal women.

Design
Randomised, single‐blind, placebo‐controlled trial.

Setting
Sleep research laboratory.

Subjects
Thirty‐three healthy postmenopausal women.

Interventions
Continuous 0–625 mg conjugated equine oestrogens with 0.15 mg cyclic norgestrel taken for 12 days per 28 day cycle.

Main outcome measures
Occurrence of vasomotor symptoms, polysomnographic sleep stage measures, Stanford sleepiness questionnaire, Crown‐Crisp experiential index and the cognitive failures questionnaire.

Results
Hormone replacement therapy results in an improvement in menopausal symptoms but not in parameters of sleep quality. Despite this, certain measures of psychological wellbeing showed significant improvement in the hormone replacement therapy group.

Conclusion
Hormone replacement therapy results in a measurable improvement in physical and psychological welfare, the latter being independent of improvement in sleep quality.
A comparison of the inactive urinary kallikrein:creatinine ratio and the angiotensin sensitivity test for the prediction of pre‐eclampsia
Authors: Kyle Phillips M. , Campbell Sarah , Buckley Davina , Kissane Jennifer , de Swiet Michael , Albano Janet , Millar J. Gavin , Redman Christopher W. G.
Published: August 2005

Objective
To determine the relation between the inactive urinary kallikreimcreatinine ratio (IUK:Cr) and the angiotensin sensitivity test (AST) at 28 weeks of gestation and to assess each as a screening test for pre‐eclampsia.

Design
Prospective interventional study.

Subjects
Four hundred and fifty‐nine normotensive nulliparous women recruited from hospital antenatal clinics.

Setting
John Radcliffe Maternity Hospital, Oxford, and Queen Charlotte's and Chelsea Hospital, London.

Interventions
A urine sample for IUK:Cr measurement was provided before performing the AST at 28 weeks of gestation. Those women who demonstrated increased sensitivity to angiotensin II were entered into a randomised placebo controlled trial of low dose aspirin for the prevention of pre‐eclampsia (CLASP).

Main outcome measures
The development of pre‐eclampsia.

Results
The IUK:Cr ratio was significantly lower in those women who showed increased sensitivity to angiotensin II (P < 0.0001 Student's t test). The sensitivity and specificity for detecting pre‐eclampsia were, respectively, 22% and 85% for the AST and 67% and 75% for the IUK:Cr. Low‐dose aspirin (60 mg) had no effect on the pregnancy outcome.

Conclusion
There appears to be some relation between the IUK:Cr and AST tests in pregnancy. However, in this population, the IUK:Cr ratio was a better screening test for pre‐eclampsia than the AST, but overall neither test was a powerful predictor for the syndrome.
Perinatal morbidity in chronic hypertension
Authors: McCowan Lesley M. E. , Buist Robert G. , North Robyn A. , Gamble Gregory
Published: August 2005

Objective
To investigate if chronic hypertension in the absence of superimposed pre‐eclampsia is associated with increased perinatal morbidity (especially small for gestational age babies and preterm deliveries) when compared to the general obstetric population.

Design
A retrospective cohort study.

Setting
A tertiary referral obstetric hospital.

Participants
One hundred and fifty‐five pregnant women with chronic hypertension who had a diastolic blood pressure of greater than 90 mmHg before 20 weeks or had pre‐existing essential hypertension were studied. The study period was January 1 1991 to June 30 1993.

Main outcome measures
Perinatal related loss rate, birthweight less than the fifth centile (small for gestational age) preterm delivery, placental abruption and development of superimposed pre‐eclampsia.

Results
Women with chronic hypertension without superimposed pre‐eclampsia had an increased rate of small for gestational age babies (10.1%) compared with the general population (4.1%) (odds ratio 2.9 [confidence interval 1.6 to 5.01). Women with chronic hypertension without superimposed pre‐eclampsia did not have a significant increase in preterm delivery or perinatal loss. Severe hypertension (diastolic blood pressure ≥ 110) at less than 20 weeks was associated with a trend to an increased risk of small for gestational age babies (odds ratio 3.8 [confidence interval 1.0 to 13.7]), increased rate of delivery at less than 32 weeks (odds ratio 7.4 [confidence interval 1.9 to 29.51) and increased rate of superimposed pre‐eclampsia (odds ratio 5.2 [confidence interval 1.5 to 17.21). Women with superimposed pre‐eclampsia had the greatest perinatal morbidity.

Conclusions
Women with chronic hypertension without pre‐eclampsia have an increased risk of delivering a small for gestational age baby. Perinatal morbidity and pre‐eclampsia is greatest in women with severe hypertension at less than 20 weeks. Preterm delivery is more common in women with superimposed pre‐eclampsia.
The haemodynamic and respiratory effects of intravenous nimodipine used in the treatment of eclampsia
Authors: Anthony J. , Mantel G. , Johanson R. , Dommisse J.
Published: August 2005

Objective
To establish the antihypertensive properties of intravenous nimodipine used to treat eclamptic patients. To assess the effects of intravenous nimodipine on oxygen delivery and consumption.

Design
A prospective observational study.

Setting
The Maternity Centre Obstetric Intensive Care Unit, Groote Schuur Hospital.

Participants
Four unselected patients presenting with proteinuric hypertension and seizures.

Methods
Haemodynamic observations were obtained by a radial artery catheter and right heart catheterisation with a pulmonary artery flow directed thermodilution catheter. Observations were obtained prior to and after the administration of nimodipine.

Resuts
A significant reduction in mean arterial pressure occurred in all patients after administration of nimodipine. This was due to a significant reduction in systemic vascular resistance. Neither oxygen delivery to the tissues nor peripheral oxygen consumption changed significantly during nimodipine infusion. No adverse effects related to the use of nimodipine were documented.

Conclusions
Nimodipine is an effective vasodilator. There may be a role for nimodipine as a single agent for the management of eclampsia.
Common iliac artery flow velocity waveforms in fetuses with a single umbilical artery: a longitudinal study
Authors: Sepulveda Waldo , Nicolaidis Peter , Bower Sarah , Ridout Deborah A. , Fisk Nicholas M.
Published: August 2005

Objective
In fetuses with a single umbilical artery the entire blood flow to the placenta is transported through the common and internal iliac arteries from the side of the single artery, whereas the pelvic vessels from the side of the missing artery do not participate in the fetoplacental circulation. The aim of this study was to investigate the effect of gestational age on pelvic arterial blood flow in fetuses with single umbilical artery.

Design
In 15 fetuses with a single umbilical artery (SUA), common iliac artery flow velocity waveforms were studied longitudinally using high resolution colour Doppler ultrasonography at three gestational ages: 18 to 20 weeks, 28 to 30 weeks, and 35 to 37 weeks. The pulsatility index was measured in each common iliac artery and mixed model analysis of variance was used to examine the effect of gestational age and side.

Results
There was a highly significant difference in pulsatility index between common iliac arteries at all gestational ages, the values always being higher on the side that did not participate in the fetoplacental circulation (P < 0.001). For increasing gestation, the pulsatility index fell significantly in the SUA side but remained high in the non‐SUA side (P < 0.001).

Conclusions
This study shows that the asymmetry in the pelvic arterial blood flow in fetuses with SUA increases as pregnancy progresses, consistent with decreasing vascular resistance in the placenta and increasing resistance in the lower extremities.
Head‐to‐cervix force: an important physiological variable in labour. 1. The temporal relation between head‐to‐cervix force and intrauterine pressure during labour
Authors: Allman Andrew C. J. , Genevier Eric S. G. , Johnson Mark R. , Steer Philip J.
Published: August 2005

Objective
To investigate the relation between the rise in intrauterine pressure and rise in fetal head to cervix force in normal, slow and induced labour.

Design
Prospective observational study.

Setting
The labour ward of a London teaching hospital.

Participants
Forty patients were recruited from the antenatal clinic and labour ward of a West London Hospital. Five had normal onset and progression of labour, 14 had slow progression of labour and 21 had induced onset of labour.

Method
Intrauterine pressure and head‐to‐cervix force was measured simultaneously using an intrauterine pressure catheter and a specially designed four sensor head‐to‐cervix force probe.

Results
For each contraction of each labour, scattergrams of force by pressure were plotted. Three patterns were observed. When the rise in pressure preceded the rise in force, a positive ‘loop’ was generated. When the rise in pressure and force occurred simultaneously a linear pattern was generated (a neutral ‘loop’). When the rise in pressure lags the rise in force, a negative ‘loop’ was generated. In normally progressive labour the distribution of loops was 291%, 22.6% and 48‐3 %, respectively, in slow labour the distribution was 26.1 %, 14.1 % and 59.8 % and in induced labour the distribution was 33.8 %, 14.4% and 51.8 %. These distributions were not statistically different. However, a higher proportion of negative loops was observed in labours augmented with oxytocin compared to those receiving no oxytocin (MW‐U = 87, P= 0.036). No differences were observed comparing parity, use of PGE2, epidural analgesia, or mode of delivery. Contraction frequency (number/10 minutes) was inversely correlated to the percentage of negative loops (r8= 0.34, P= 0.033) and positively correlated with percentage of positive loops (r8= 0.36, P= 0.027).

Conclusions
This is the first report of the temporal relation between intrauterine pressure and head‐to‐cervix force in labour. The most common pattern is that the rise in pressure lags the rise in force, suggesting that a seal has to be created between the fetal head and cervix before a rise in pressure can occur. When oxytocin is given in labour, a higher proportion of loops are negative indicating that there is poor application of the fetal head and cervix in a greater proportion of contractions.
Antenatal screening for cystic fibrosis
Authors: Cuckle Howard , Quirke Philip , Sehmi Indera , Lewis Fraser , Murray Jennifer , Cross Debra , Cuckle Patricia , Ozols Barbara
Published: August 2005

Objective
To assess the practicality of implementing antenatal screening for cystic fibrosis in Yorkshire.

Design
Prospective study in which all pregnant women were offered testing for the AF508 mutation which accounts for about 85 % of carriers in Yorkshire. The reproductive partners of those found to be cystic fibrosis carriers were then tested and any carrier referred for genetic counselling.

Setting
Antenatal clinics in two hospitals and eight general practices.

Population
Six thousand and seventy‐one pregnant women.

Results
A total of 3773 women (62 %) accepted the screening offer. This was a lower uptake rate than in other published UK studies: Aberdeen (85–91%), Manchester (85%), Edinburgh (76–84%) and Oxford (67%). Nonetheless there were large and statistically significant differences in the uptake rate between centres within the study: 78% and 60% for the two hospitals and 67% for the general practices. One hundred and thirty women (3.4%) were found to be carriers and three carrier couples were identified. The median time interval for the laboratory to produce a result was five days and the cost was £16 on average.

Conclusions
Antenatal screening for cystic fibrosis does not pose any special practical difficulties. It would be feasible to introduce it into routine practice in Yorkshire.
Ultrasound: a noninvasive screening test for detrusor instability
Authors: Khullar V. , Cardozo L. D. , Salvatore S. , Hill S.
Published: August 2005

Objective
To determine whether transvaginal ultrasound measurement of bladder wall thickness can be used as a screening test for detrusor instability in women with urinary symptoms.

Design
A blinded prospective study.

Setting
A London teaching hospital.

Participants
One hundred and eighty‐four symptomatic women presenting to a urodynamic clinic.

Main outcome measure
The detection of detrusor instability by means of videocystourethrography (VCU) and ambulatory urodynamics in women with a mean bladder wall thickness of greater than 5 mm measured by transvaginal ultrasound.

Results
One hundred and eight women had a mean bladder wall thickness of greater than 5 mm. Ninety‐four percent (102) of these women had detrusor instability either when undergoing VCU or ambulatory urodynamics. Seventeen women had a bladder wall thickness of less than 3.5 mm of whom three were found to have detrusor instability on VCU.

Conclusion
The measurement of a mean bladder wall thickness greater than 5 mm with transvaginal ultrasound is a sensitive screening method for diagnosing detrusor instability in symptomatic women without outflow obstruction.
A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy
Authors: Davies Anthony , O'Connor Hugh , Magos Adam L.
Published: August 2005

Objective
To assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy.

Design
Prospective study.

Setting
London teaching hospital.

Population
Between March 1993 and March 1995, 40 women were admitted under the care of one consultant for vaginal hysterectomy and bilateral oophorectomy.

Methods
The success rate of removing the ovaries vaginally was calculated and the operative time, blood loss, intra‐ and post‐operative complications and patient recovery were analysed and compared with 48 patients who had a vaginal hysterectomy but retained their ovaries during the same time period.

Results
Thirty‐nine (97.5%) of the 40 women due to undergo removal of the ovaries were managed successfully via the vaginal route; one woman required laparoscopic removal of one of her ovaries containing an ovarian cyst which was not diagnosed pre‐operatively. A variety of techniques were used for vaginal oophorectomy which included salpingo‐oophorectomy, oophorectomy without salpingectomy, and transvaginal endoscopic oophorectomy utilising endoloop sutures or bipolar electrosurgery. Oophorectomy added a mean of 23.4 min (88.3 vs 64.9 min, 95% CI 10.2–36.7, P < 0.001) to the total operating time compared with vaginal hysterectomy alone. No laparotomies were required, and both the complication rate and post‐operative inpatient stay were similar for the two groups.

Conclusion
The need to perform oophorectomy should not be considered a contraindication to vaginal hysterectomy.