bluuebunny/crossref_metadata_2025 huggingface dataset:
Screening for Down's syndrome: experience in an inner city health district
Authors: Saridogan E. , Djahanbakhch O. , Naftalin A. A.
Published: August 2005

Objective
To review the experience of Down's syndrome screening in an inner city health district.

Design
In this retrospective study the names of the women were obtained from the Regional Cytogenetic Laboratory and District Down's Syndrome Register. Antenatal notes of the mothers were studied. Maternal age during the affected pregnancy, screening test performed if any, gestational age at booking and at screening, screening test results, and pregnancy outcome were reviewed.

Setting
An inner city health district.

Population
Down's syndrome cases diagnosed prenatally and postnatally.

Interventions
None.

Results
Antenatal diagnosis of Down's syndrome was made in 15/45 women (33.3%); Edwards' syndrome was diagnosed antenatally in 2/5 women. Screening was not performed in eight women (17.8%) whose infants were affected by Down's Syndrome; it was also not performed in one woman whose baby was affected by Edwards' syndrome due to late presentation to the antenatal clinic or loss of the blood sample. Nineteen women (42.2%) with a Down's syndrome pregnancy and two women with a Edwards' syndrome pregnancy had had a negative screening test. Three women had had a positive screening test but declined amniocentesis. Among those who had a screening test, the overall detection rate of screening was 48.6% (18/37) for Down's syndrome and 50% (2/4) for Edwards' syndrome. The detection rates in different ethnic groups did not show significant difference. Four women chose not to have termination following diagnosis of Down's syndrome, giving a total reduction rate of 21 %.

Conclusion
Screening programmes for Down's syndrome have not yet resulted in a substantial reduction in the number of affected babies. In addition to trials at developing screening programmes with better detection rates, efforts should be made to improve the provision of the screening service and the quality of antenatal care in general with emphasis on early presentation and optimal understanding of the implications of the tests.
A clinical analysis of 500 medico‐legal claims evaluating the causes and assessing the potential benefit of alternative dispute resolution
Authors: B‐Lynch Christopher , Coker Adeyemi , Dua John A.
Published: August 2005

Objective
1. To evaluate the common causes of medico‐legal dispute in obstetrics and gynaecology. 2. To assess the potential benefit of early alternative dispute resolution.

Design
A prospective analysis of over 500 cases submitted from over 100 solicitors between 1984 and 1994 for medical expert opinion on potential medico‐legal claims.

Cases
Five hundred consecutive cases that met the inclusion criteria: 488 from the United Kingdom and 12 from abroad (Hong Kong, Republic of Ireland).

Main outcome measures
The main principles underlining medico‐legal disputes and causes of such claims

Results
Analysis of 500 claims show 46% were misguided allegations, 19% incompetent care, 12% error of judgement, 9% lack of expertise, 7% failure of communication, 6% poor supervision and 1% inadequate staffing. Of the misguided allegations 119/225 cases (59%) were obstetric and 111/275 (40%) cases were gynaecological. The most common cause of obstetric dispute was ‘cerebral palsy’ (22%), while the commonest cause of gynaecological dispute was failed sterilisation (19%). Settled claims were under‐reported by solicitors.

Conclusion
Because of the high percentage (46%) of misguided allegations, an alternative course of dispute resolution must be a realistic way forward. This course of action, combined with improved communication, could result in a major reduction in the costs of potential medical litigation. Early alternative dispute resolution should be considered in an attempt to reduce the escalating quantum of damages and costs. We recommend recruiting independent, experienced and unbiased consultants in active practice within the appropriate speciality to review such cases at the level of hospital complaints management as an in house review procedure, particularly for small and moderate‐sized claims, as a means whereby doctors can retain control of medico‐legal disputes, in contrast to control by the legal profession.
Non‐invasive prenatal diagnosis by isolation of both trophoblasts and fetal nucleated red blood cells from the peripheral blood of pregnant women
Authors: Durrant Lindy , McDowall Katherine , Holmes Rachel , Liu David
Published: August 2005

Objective
To isolate fetal trophoblasts and nucleated red blood cells from the peripheral blood of pregnant women.

Design
Trophoblasts were isolated from whole blood of women in the first trimester of pregnancy by a specific monoclonal antibody, 340. Nucleated red blood cells were isolated by separating whole blood on a triple gradient, staining with ferromagnetic particles coated with an antitransferrin monoclonal antibody and separated on a mini magnetic activated cell sorting (MACS) column. Sorted cells were sexed using a nested polymerase chain reaction for a specific sequence on the Y chromosome and the sex was confirmed by karyotyping of chorionic villus samples.

Participants
Patients between 10 and 14 weeks of pregnancy who were undergoing elective chorionic villus sampling for the detection of fetal aneuploidies.

Main outcome measure
Fetal sex determined by polymerase chain reaction on fetal cells sorted from maternal blood.

Results
When both trophoblasts and nucleated red blood cells were sorted, fetal sex was correctly predicted in 12/13 cases (92%), which included correct diagnosis of five of six male pregnancies. More importantly the two techniques were complementary, with only one male pregnancy being diagnosed on both trophoblasts and nucleated red blood cells, two being detected only with trophoblasts and two on nucleated red blood cells alone. No false positives (male signal from a female pregnancy) were diagnosed with either trophoblasts or nucleated red blood cells even with the highly sensitive nested polymerase chain reaction technique, which is very prone to contamination. This study also shows that it is possible to isolate both trophoblasts and nucleated red blood cells from the same sample of maternal blood.

Conclusion
Fetal cells can be isolated from maternal blood at around 10 weeks of pregnancy.
Induction of labour: a randomised clinical trial of amniotomy versus amniotomy with oxytocin infusion
Authors: Moldin Per G. , Sundell Gunilla
Published: August 2005

Objective
To compare two methods of induction of labour—amniotomy with oxytocin infusion versus amniotomy alone.

Design
Prospective randomised clinical trial.

Setting
The department of obstetrics in a Swedish central hospital.

Participants
One hundred and ninety‐six pregnant women with indication for induction of labour at term and a favourable cervix (modified Bishop score ≥ 6).

Interventions
The women were randomised to amniotomy followed by oxytocin infusion after 1 h (group A, n= 98) or amniotomy alone (group B, n= 98). If labour had not ensued on the following morning, after approximately 24 h, the women in group B were given an oxytocin infusion.

Main outcome measures
Induction‐delivery interval, duration of labour, time spent in delivery ward, oxytocin use, maternal and neonatal clinical outcome.

Results
Amniotomy combined with early oxytocin infusion resulted in shorter induction‐delivery interval (median 6.0 h; 95% confidence interval (CI) 5.0 to 6.5 h) than amniotomy alone (median 9.0 h; 95% CI 7.5 to 10.0 h). This was due to a shorter latent period in the former group (median 2.3 h; 95% CI 2.0 to 3.0 h) compared to the latter (median 4.3 h; 95% CI 3.0 to 5.5 h). The duration of labour stages 1 and 2 were similar in both groups. The time spent in the delivery ward was slightly reduced for women managed by amniotomy alone (median 5.0 h; 95% CI 4.5 to 6.0 h) compared with those managed by the combination of amniotomy and oxytocin infusion (median 6.0 h; 95% CI 5.0 to 6.5 h). Eighty‐seven percent in group A and 95% in group B were given oxytocin, and the total oxytocin infusion time was nearly five times longer in group A. No other important effect on maternal or fetal outcomes was demonstrated.

Conclusion
With regard to safety the results do not warrant recommending either type of labour induction. The minor differences observed between the induction groups justify an individual management policy, with attention paid to both the indication for induction of labour and the woman's choice.
Hepatitis C virus infection in pregnancy
Authors: Floreani A. , Paternoster D. , Zappalà F. , Cusinato R. , Bombi G. , Grella P. , Chiaramonte M.
Published: August 2005

Objective
To evaluate the clinical aspects of hepatitis C virus (HCV) liver disease in anti‐HCV + ve mothers, both during pregnancy and six months after delivery, and to assess the outcome of pregnancy.

Setting
Obstetric department for high risk pregnancies of the University of Padova, Italy.

Participants
Seventeen hundred consecutive pregnant women were studied.

Methods
Each woman underwent the following: 1. serological screening for hepatitis surface antigen (HBsAg), antibodies to HCV (anti‐HCV), antibodies to human immunodeficiency virus type 1 (HIVI) within the first trimester of pregnancy; and 2. clinico‐biochemical assessment in order to ascertain previous or active liver disease and risk factors for viral infections.

Results
Twenty‐nine (1.7%) of the 1700 women were found anti‐HCV positive. Eight of them had an associated positivity for HIV infection. HCV‐RNA was positive in 64.2% of anti‐HCV positive women. Liver function tests (included transaminases) were within the normal range in 27 mothers (both during and six months after delivery). Only 2/29 women had a slight increase in AST/ALT; liver biopsy in these cases was compatible with mild chronic active hepatitis. In all women the outcome of pregnancy was favourable (12/29 anti‐HCV positive mothers underwent caesarean delivery for causes independent from HCV infection).

Conclusions
A substantial proportion of anti‐HCV positive pregnant mothers, even if asymptomatic, have circulating HCV‐RNA. The pregnancy does not induce a deterioration of liver disease, and vice versa, HCV infection does not increase the risk of obstetric complications.
A comparative study of safety and efficacy of continuous low dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy
Authors: Ayton Rosemary A. , Darting Giselle M. , Murkies Atice L. , Farrell Elizabeth A. , Weisberg Edith , Statistician Ingemar Selinus , Fraser Ian S.
Published: August 2005

Objective
To compare the safety, efficacy and acceptability of a continuous low dose oestradiol releasing vaginal ring with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy.

Design
An open, parallel, comparative multicentre trial.

Setting
Sydney and Melbourne, Australia.

Participants and Interventions
One hundred and ninety‐four postmenopausal women with symptoms and signs of urogenital atrophy were randomised on a 2:1 basis to 12 weeks of treatment with an oestrogen vaginal ring versus an oestrogen cream.

Main outcome measures and results
Equivalence (95% CI) was demonstrated between the two treatments for relief of vaginal dryness and dyspareunia, resolution of atrophic signs, improvement in vaginal mucosal maturation indices and reduction in vaginal pH. No significant difference was demonstrated in endometrial response to a progestogen challenge test and equivalence was demonstrated in the incidence of intercurrent bleeding episodes. The vaginal ring was significantly more acceptable than the cream (P < 0.0001), and was preferred to the cream (P < 0.001).

Conclusion
With equivalent efficacy and safety and superior acceptability to vaginal cream, the low dose oestradiol vaginal ring is an advance in vaginal delivery systems for the treatment of urogenital atrophy.
Vulvar intraepithelial neoplasia: long term follow up of treated and untreated women
Authors: Herod J. J. O. , Shafi M. I. , Rollason T. P. , Jordan J. A. , Luesley D. M.
Published: August 2005

Objective
To investigate the long term outcome of patients with vulvar intraepithelial neoplasia.

Design
A retrospective study using information obtained from patient casenotes.

Sample
One hundred and thirty‐three women with a primary diagnosis of vulvar intraepithelial neoplasia (VIN), identified during a 15‐year period.

Results
The diagnosis of vulvar intraepithelial neoplasia increased throughout the study period. Human papilloma virus changes were noted in 104 patients (78%); these women were significantly younger than those without (P≤ 0.001). Nineteen (14%) were managed by observation or medical treatment and the remainder by surgical methods. Histological or symptomatic recurrence after surgical treatment occurred in 55 (48%). When disease recurred, it usually did so within four years of treatment. Recurrence was more common following laser vapourisation than after local excision (75%vs 40%; P≤ 001). Progression to invasive disease occurred in nine patients (7%), none of whom were in the group being observed. Four deaths occurred in this group, three from gynaecological malignancies of the lower genital tract.

Conclusions
Patients with vulvar intraepithelial neoplasia require long term follow up, and the risk of invasion may be higher than previously thought. Surgical treatment when required should be by excisional rather than ablative methods in most instances. In selected cases it is also possible to safely manage patients by more conservative methods.
Irrigating fluid absorption from the intact uterus
Authors: Olsson J. , Berglund L. , Hahn R. G.
Published: August 2005

Objective
Absorption of irrigating fluid may occur through severed blood vessels during endometrial resection. We studied whether irrigating fluid can also be absorbed through the undamaged uterus.

Participants
We studied 25 women, aged 28–46 years (mean 38 years), who underwent elective laparoscopic sterilisation under general anaesthesia.

Interventions
In 15 women blue‐stained irrigating fluid containing glycine 1.5% and ethanol 1% was applied to the uterine cavity under increasing pressure. Laparoscopy was employed to see when fluid emerged from the Fallopian tubes. Another 10 women had their Fallopian tubes clamped before the fluid pressure was raised, and systemic absorption was detected by measuring the serum glycine concentration.

Results
Passage of fluid through the Fallopian tubes occurred in 14 of the 15 patients at a utero‐abdominal pressure gradient of 40 mmHg (n= 4), 80 mmHg (n= 4), 120 mmHg (n= 3), and 160mmHg (n= 3), respectively. The fluid passage rate ranged between 0.5 and 13 (mean 6.4) ml min−1. Of the women with clamped Fallopian tubes, 8 of 10 showed an increase in the serum glycine level of 60% at a pressure gradient of 160 mmHg, and of 120% at 200 mmHg.

Conclusions
Uterotubal and transendometrial passage of small to moderate amounts of irrigating solution occurred frequently at the intrauterine fluid pressures normally used during endometrial resection.
Prediction of pre‐eclampsia by abnormal uterine Doppler ultrasound and modification by aspirin
Authors: Bower Sarah J. , Harrington Kevin F. , Schuchter Katharina , McGirr Cathy , Campbell Stuart
Published: August 2005

Objective
To assess the effect of low dose aspirin on severe pre‐eclampsia when given to women identified as high risk by abnormal uterine artery Doppler ultrasound.

Design
Women with abnormal uterine artery flow velocity waveforms were recruited to the CLASP trial at 24 weeks. Abnormal uterine artery waveforms, with a high resistance index or an early diastolic notch, were identified at the 18–22 week anomaly scan and confirmed at 24 weeks. Of those women with persistently abnormal waveforms, 63 agreed to enter the CLASP trial. Three women were lost to follow up and five did not comply. Thus, 60 were randomised: 29 to placebo and 31 to low dose aspirin (60 mg daily) and analysis by intention to treat is reported.

Results
There were nine cases (29%) of pre‐eclampsia in the aspirin group and twelve (41%) in the placebo group (odds ratio (OR) 0.58, confidence interval (CI) 0.2–1.69, P = 0.32). Severe pre‐eclampsia developed in four women in the aspirin group and eleven women in the placebo group (OR 0.24, CI 0.07–0.88, P = 0.03) and intrauterine growth retardation occurred in eight cases in the aspirin group and twelve in the placebo group (OR 0.49, CI 0.17–1.47). The mean birthweight and gestation at delivery were 2.69 kg and 38.5 weeks in the aspirin group and 2.38 kg and 37.4 weeks in the placebo group, neither of which were statistically significant using the unpaired t test; P = 0.09 and P = 0.23, respectively.

Conclusions
In high risk pregnancy low dose aspirin commenced at 24 weeks may reduce the incidence of severe pre‐eclampsia.
The effects of the antihormones RU486 and tamoxifen on fetoplacental development and placental bed vascularisation in the rat: a model for intrauterine fetal growth retardation
Authors: Sadek Saher , Bell Stephen C.
Published: August 2005

Objective
To examine the effect of administration of the antihormones RU486 and tamoxifen in early pregnancy during the period of maximal decidual development in the rat upon fetoplacental and placental bed development.

Design
Case‐control study in an experimental animal model.

Setting
Academic department of obstetrics and gynaecology in a UK medical school.

Animals
Small laboratory animal—the rat—exhibiting haemochorial placentation.

Intervention
Administration of antiprogesterone or antioestrogen (RU486 and tamoxifen respectively) during early pregnancy.

Main outcome measures
Weight of the whole pregnancy implant, fetus, mesometrial decidua and placenta; incidence of intrauterine fetal death; and histological changes in the placental bed.

Results
RU486 produced resorption of all implants when administered above a threshold dose, below which it had no effect upon subsequent fetoplacental development. Tamoxifen treatment on days 9 to 11 resulted in significant reduction of decidual weight (35.1% on day 12 of pregnancy, P < 0.001). This was associated with a higher rate of implants or fetuses weighing below the 10th centile (59.6% and 5.7% on day 12, P < 0.001; 42.9% and 7% on day 16, P < 0.001; 25.4% and 7.6% on day 20, P < 0.001 in treated and control animals, respectively). This was also associated with a higher rate of intrauterine fetal death (30.7% on day 16 compared with 4.5% in controls, P < 0001; 47.8% on day 20 compared to 0.83% in controls, P < 0.001). Histologically, the placental bed of treated animals failed to develop a dilated uteroplacental artery although trophoblast cells migrated endovascularly to a level equivalent to untreated animals.

Conclusions
RU486 had an all or none dose‐dependent effect on fetoplacental development, resulting in either abortion or normal development of pregnancy. Tamoxifen produced significant impairment of decidual development, which was associated with altered blood vessel transformation in the placental bed, impaired fetoplacental development and higher incidence of growth retarded fetuses and fetal death.
The effect of maternal epidural analgesia on fetal oxygen saturation
Authors: Johnson Nick , van Oudgaarden Elisabeth , Montague Imogen A. , McNamara Helen
Published: August 2005

Objective
To observe fetal arteriolar oxygen saturation during maternal epidural analgesia. Design An observation study of 27 epidural top‐ups.

Setting
Labour ward, St James's University Hospital and Leeds General Infirmary, Leeds University, UK.

Sample
Seventeen fetuses in uncomplicated labour monitored with a N400 fetal pulse oximeter. Outcome measure A change in fetal pulse oximetry reading following epidural analgesia.

Results
There is no change in fetal oxygen saturation following an uncomplicated epidural top‐up (F = 0.93; df 35 and 784).

Conclusion
An uneventful maternal epidural has no measurable effect on fetal oxygen saturation measured with a N400 pulse oximeter.
Obstetric outcome of pregnancies resulting from embryos biopsied for pre‐implantation diagnosis of inherited disease
Authors: Soussis Iakovos , Harper Joyce C. , Handyside Alan H. , Winston Robert M. L.
Published: August 2005

Objective
Pre‐implantation diagnosis of inherited disease is now a viable option for some couples at risk of transmitting inherited disorders to their children. Since the pregnancy begins knowing that the embryo is not at risk, the need for repeated terminations is eliminated. Up to 25 % of the embryo is removed during the procedure, and so it is important to study the resulting pregnancies. Here we report on the obstetric outcome of our first 16 pregnancies resulting from embryo biopsy and preimplantation diagnosis of inherited disease.

Setting
Teaching hospital.

Sample
The first 16 pregnancies (12 singletons and 4 twins) following pre‐implantation diagnosis.

Results
Three singleton pregnancies were lost in the first trimester. Of the remaining pregnancies, two had no prenatal diagnosis, six cases of X‐linked disease had the sex confirmed by ultrasound and chorionic villus sampling was performed in the remaining five. All the singleton pregnancies had an uneventful antenatal course and the birthweights and Apgar scores of the babies were normal. The twin pregnancies presented obstetric complications but these were not unusual.

Conclusions
Fifteen healthy infants were born, but for the foreseeable future pre‐implantation diagnosis pregnancies should be closely followed up.
Childhood growth and age at menarche
Authors: Cooper Cyrus , Kuh Diana , Egger Peter , Wadsworth Michael , Barker David
Published: August 2005

Objective
To study the influence of birthweight, and weight and height at age seven years, on menarcheal age in a national sample of 1471 girls in England, Scotland and Wales.

Methods
We studied 1471 girls included in the MRC National Survey of Health and Development. During medical examinations carried out by school doctors in this cohort, born in the first week of March 1946, the mothers of girls were asked whether their daughters had started to menstruate, and if so, the month and year when this happened. Anthropometric measurements at birth and at age seven years were also obtained.

Results
Girls who were heavier at age seven years had menarche at an earlier age. The average age at menarche of those in the highest fifth of the distribution of weight at seven years was 7.3 months less than that of those in the lowest fifth of the distribution. In contrast, girls who were heavier at birth had menarche at a later age. The average age at menarche of those in the highest fifth of the birthweight distribution was 2.2 months more than those in the lowest fifth. These opposing trends of birthweight and weight at seven years on age at menarche were observed across the distribution of each variable, and exerted statistically significant (P < 0.001) independent effects in a multivariate model.

Conclusions
These observations are consistent with the hypothesis that menarcheal age is linked to programmed patterns of gonadotrophin release established in utero, when the fetal hypothalamus is imprinted, and is subsequently modified by weight gain in childhood.
Pregnancies complicated by placenta praevia: what is appropriate management?
Authors: Love Corinne D. B. , Wallace Euan M.
Published: August 2005

Objective
To review the outcome of pregnancies complicated by placenta praevia over a three‐year period (1991–1993) and to describe in detail the antenatal course and the events leading to delivery, assessing retrospectively whether there are clinical features predictive of outcome and whether outpatient management would be reasonable.

Design
A retrospective review of the case records of women with a pregnancy complicated by placenta praevia.

Setting
A tertiary referral teaching hospital in Edinburgh.

Results
There were 15,930 deliveries in the study period. Fifty‐eight women (0.4%) had a placenta praevia in the third trimester, 42 of whom (72%) had at least one episode of bleeding. Overall, 62% of the women had a major praevia with no differences in the grade of praevia between those women who did or did not have bleeding. Both diagnosis and delivery occurred significantly earlier in women with antepartum bleeding than in those without (median gestation at diagnosis 28.6 weeks versus 33.3 weeks (P < 0.01) and at delivery 36.0 weeks versus 37.1 weeks (P= 0.04), respectively). Delivery by emergency caesarean section was more common in women with bleeding (62%versus 38%). An increasing number of bleeding episodes experienced by individuals was not associated with significant differences in outcomes. Rapid emergency delivery for bleeding was necessary for three women, in none of whom could the bleeding have been predicted.

Conclusions
The clinical outcomes of placenta praevia are highly variable and cannot be predicted confidently from antenatal events. Nonetheless, in the majority of cases with or without bleeding and irrespective of the degree of praevia, outpatient management would appear safe and appropriate.
Reliability of the recording of hysterectomy in the Saskatchewan health care system
Authors: Edouard Lindsay , Rawson Nigel S. B.
Published: August 2005

Objective
To determine the validity of data pertaining to hysterectomy in the Saskatchewan health care utilisation datafiles.

Design
Retrospective analysis of routinely collected data covering hospital discharge records and practitioner claims for reimbursement of services, together with a review of clinical charts.

Setting
Province of Saskatchewan, Canada.

Sample
All 1905 cases of hysterectomy in one calendar year for analysis of datafiles and a random sample of 227 clinical charts for review.

Method
Information in the hospitalisation datafile was validated through an external comparison with data extracted from a review of clinical charts, as well as an internal comparison with independent data from the practitioner claims file. Corresponding context data on drug use and performance of related procedures were also analysed.

Results
Concordance between hospital data and clinical charts was greater than 95% for those items of an administrative nature as well as type of hysterectomy and was around 85% for the diagnoses. When hospitalisation and practitioner claims data were compared, the concordance was 98% for type of hysterectomy but only 56% for diagnoses.

Conclusions
The agreement between hospital data and clinical charts was excellent. The concordance between hospitalisation and practitioner claims data was almost exact for type of hysterectomy, while discrepancies in diagnoses between these files were mostly explainable on the basis of accepted clinical practice. Saskatchewan health care utilisation datafiles provide a source of valid data for research and evaluation studies.
Protective effect of depot‐medroxyprogesterone acetate on surgically treated uterine leiomyomas: a multicentre case‐control study
Authors: Lumbiganon Pisake , Rugpao Sungwal , Phandhu‐fung Surang , Laopaiboon Malinee , Vudhikamraksa Nara , Werawatakul Yuthapong
Published: August 2005

Objective
To assess the protective effect of depot‐medroxyprogesterone acetate (DMPA) on uterine leiomyomas. DMPA has been widely used in Thailand for many years; uterine leiomyomas is the most common female tumour.

Design
A multicentre hospital‐based case‐control study.

Setting
University and regional hospitals.

Patients
Cases were all newly diagnosed patients with pathologically proven diagnosis of uterine leiomyomas, who were admitted to eight hospitals in three regions of Thailand from January 1991; to June 1993;. Three controls matched with cases by sex, age within five years and date of admission within three months were recruited.

Main outcome measures
Information on socio‐demographic factors, personal and family history, current disease, reproductive and contraceptive history was collected from cases and controls by interview.

Results
There were 910 cases and 2709; controls. After univariate and unconditional multiple logistic regression analysis, risk factors associated positively with uterine leiomyomas are tubal ligation, family history of uterine leiomyomas, higher education, obesity and abortion. In contrast, DMPA, use of oral contraceptives, higher parity and smoking are associated with a lower relative risk suggesting that they have a protective effect against uterine leiomyomas. This causative relation is further strengthened by the strong duration‐response relation between DMPA and uterine leiomyomas. This protection may persist for more than 10 years after the last dose.

Conclusion
We have demonstrated a strong, duration dependent protective effect of DMPA against uterine leiomyomas.
Counselling implications of chromosomal abnormalities other than trisomy 21 detected through a maternal serum screening programme
Authors: Sheridan E. , Williams J. , Caine A. , Morgan R. , Mason G. , Mueller R. F.
Published: August 2005

Objective
To identify counselling requirements, we reviewed the frequency and type of non‐trisomy 21 chromosome abnormalities found at amniocentesis after maternal serum screening for Down's syndrome.

Design
The study involved a review of the cytogenetic results of amniocenteses performed because of a raised maternal serum screening risk.

Setting
The maternal serum screening and amniocenteses were performed at hospitals in the Yorkshire region.

Sample
1715 amniocenteses were performed as a result of a raised maternal serum screening risk for the period 1990 to 1993.

Methods
The cytogenetic results were classified into the main categories of numerical and structural chromosomal abnormalities.

Main outcome measures
The nature and frequency of abnormal cytogenetic results were identified in which parental samples were required in order to determine if the abnormal finding was de novo or familial and/or for which specialist genetic counselling was required.

Results
Sixty‐nine pregnancies of 1715 amniocenteses were identified with a chromosomal abnormality (4.0%): 35 (2.0%) with trisomy 21 and 34 (2.0%) with another chromosomal abnormality. For 20 of these 34 abnormalities, parental karyotypes were required and in 29 of the 34 specialist genetic counselling was required.

Conclusions
Women undergoing maternal serum screening and, in particular, those proceeding to amniocentesis, should be informed that there is an equal chance that a chromosomal abnormality other than trisomy 21 will be found at amniocentesis, the nature of which usually requires parental samples and specialist counselling.
A double‐blind randomised controlled trial of the effects of medroxyprogesterone acetate on bone density of women taking oestrogen replacement therapy
Authors: Adachi Jonathan D. , Sargeant Everett J. , Sagle Margaret A. , Lament David , Fawcett Paul D. , Bensen William G. , McQueen Matthew , Nazir Darius J. , Goldsmith Charles H.
Published: August 2005

Objective
To assess the effects of medroxyprogesterone acetate on bone density in women who have had a hysterectomy

Design
Randomised, double‐blind, placebo‐controlled trial of medroxyprogesterone acetate 10 mg, 20 mg or placebo as an adjunct to oestrogen therapy.

Participants
One hundred and twenty‐three women, aged 18 to 45 years and currently receiving daily oestrogen, who presented at a university‐based rheumatology practice.

Interventions
The women were randomly assigned to receive either medroxyprogesterone acetate 10 mg, 20 mg or placebo daily beginning on day 15 of each month for one year. Forty‐one women were randomised into each group.

Main outcome measure
The primary outcome measurement was the percentage of change from baseline in bone mineral density of the lumbar spine (L2–L4). Secondary outcome measures included differences in femoral neck bone density, cholesterol and triglyceride levels between groups.

Results
At one year, change in bone mineral density did not differ between either the treatment or placebo groups. Medroxyprogesterone acetate 20 mg and 10 mg led to statistically significant reductions in very low density lipoprotein cholesterol, total triglycerides, and very low density lipoprotein triglycerides when compared with placebo. Medroxyprogesterone acetate 20 mg also led to a statistically significant reduction in high density lipoprotein cholesterol, high density lipo‐protein‐2 cholesterol, and high density lipoprotein‐2 triglycerides.

Conclusions
Medroxyprogesterone acetate at either dose as an adjunct to oestrogen did not improve bone mineral density at one year when compared with placebo. Medroxyprogesterone acetate 10 mg may not adversely affect lipids. Medroxyprogesterone acetate 20 mg, however, did reduce high density lipoprotein cholestrol and therefore may increase cardiovascular risk.
Computerised estimation of the baseline fetal heart rate in labour: the low frequency line
Authors: Mongelli Max , Dawkins Robert , Chung Tony , Sahota Daljit , Spencer John A. D. , Chang Allan M. Z.
Published: August 2005

Short Headline: Computerised FHR baseline estimation

Objective
To develop and evaluate a computerised algorithm for the estimation of the fetal heart rate baseline (low frequency line) during labour.

Design
Retrospective observational study.

Methods
Fetal heart rate signals were obtained from women in labour using the Nottingham fetal ECG monitor. The computerised algorithm for the baseline estimation was developed for intrapartum applications and is based on averaging modal fetal heart rate values. Evaluation was carried out on sixty cardiotocographic recordings by 12 experts and by the computer. These estimates were compared with those obtained from the computerised system using paired differences and intraclass correlation.

Results
The study showed that it is possible to produce a low frequency line from data obtained from intrapartum records. The system could not estimate the low frequency line in four records, whereas experts were also unable to estimate between one and seven tracings. The 95% CI for the paired differences between computer and experts was ‐12 to 15 bpm, whereas between the experts this was ‐10 to 10. With the exception of one expert, there was a high concordance between experts and between computer and experts (intraclass correlation > 0.9).

Conclusions
The performance of this computerised algorithm cannot be distinguished from that of experienced clinicians. There were no significant differences between baseline values obtained by the computerised algorithm and those by the clinicians.
Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma
Authors: Smith J. R. , Boyle D. C. M. , Corless D. J. , Ungar L. , Lawson A. D. , Priore G. Del , McCall J. M. , Lindsay I. , Bridges J. E.
Published: August 2005

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility‐sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re‐anastomosed.
Incidence of ovarian cancer after hysterectomy: a nationwide controlled follow up
Authors: Loft Anne , Lidegaard Øjvind , Tabor Ann
Published: August 2005

Objective
To estimate the risk of developing ovarian cancer after abdominal (total or subtotal) hysterectomy on benign indication.

Design
Prospective historical cohort study with 12.5 years of follow up. Setting Denmark, nationwide.

Population
All Danish women (aged 0 to 99 years) having undergone hysterectomy with conservation of at least one ovary for a benign indication from 1977 to 1981 (n= 22,135). Follow up was conducted from 1977 to 1991. The reference group included all Danish women who had not undergone hysterectomy, age‐standardised according to the hysterectomy group (n= 2,554,872).

Methods
Registry data derived from the Danish National Register of Patients (diagnoses and operation codes) and the Civil Registration System (information about general population, including time of death).

Main outcome measures
Incidence rate of ovarian cancer, lifetime risk of ovarian cancer, relative risk of ovarian cancer.

Results
Seventy‐one women developed ovarian cancer on average 7.0 years after hysterectomy and 10,659 women in the reference group had ovarian cancer diagnosed after on average 6.4 years. The incidence rate of ovarian cancer was 0.27 per 1000 person‐years in the group that had undergone hysterectomy and 0.34 per 1000 person‐years in the general population (age‐standardised). The extrapolated lifetime risk of developing ovarian cancer was 2.1% after hysterectomy and 2.7% in the general population (RR 0.78; 95% CI0.60–0.96).

Conclusions
The risk of ovarian cancer is lower among women who have undergone hysterectomy compared with those who have not. The protection seems to decrease with time.
A national survey of the complications of endometrial destruction for menstrual disorders: the MISTLETOE study
Authors: Overton Christopher , Hargreaves Janet , Maresh Michael
Published: August 2005

Objectives To study the frequency of complications of endometrial resection and ablation for menstrual disturbances and the influence of the experience of the operators.

Design Prospective survey with additional retrospective reporting by theatre staff.

Setting 300 National Health Service and independent hospitals in the United Kingdom (excluding Scotland).

Population 10,686 women registered by 690 doctors (1–222 cases/doctor) from April 1993 to October 1994.

Methods Mailings were sent to relevant medical and non medical staff at every hospital to ascertain who performed the operations. These doctors were asked to complete a questionnaire detailing their previous experience. Completed patient registration forms were returned each month. Theatre contacts returned lists of cases reported in theatre registers.

Main outcome measures Perioperative, post‐operative and delayed complications by method of surgery and experience of operator.

Results Two directly related deaths were reported. Laser and rollerball ablations were associated with least operative and post‐operative complications. Combined loop and rollerball diathermy was associated with a higher rate, but with fewer immediate operative complications than loop resection alone. Endometrial thinning agents were not associated with decreased complications. Fibroids were associated with increased operative haemorrhage. Early post‐operative complication rates ranged from 0.77% to 1.51%. Six‐week follow up in 82.5% of the women revealed few complications (1.25% to 4.58%). Increasing operative experience was associated with fewer uterine perforations in the loop resection alone group χ2 for trend, P < 0.001), but had no effect on operative haemorrhage in any group.

Conclusions These procedures were used widely in 1993 to 1994 with low morbidity and mortality. The techniques may be relatively easily learned in the apprenticeship system without compromising safety. Combined diathermy resection appears safer than loop resection alone, but laser and rollerball ablation were safest.
Impact of metronidazole therapy on preterm birth in women with bacterial vaginosis flora (Gardnerella vaginalis): a randomised, placebo controlled trial
Authors: McDonald H. M. , O'Loughlin J. A. , Vigneswaran R. , Jolley P. T. , Harvey J. A. , Bof A. , McDonald P. J.
Published: August 2005

Objective To ascertain whether metronidazole treatment of women with a heavy growth of Gardnerella vaginalis during mid‐pregnancy would reduce the risk of spontaneous preterm birth.

Design A multicentre, randomised, placebo‐controlled trial

Setting Four metropolitan hospitals.

Participants Eight hundred and seventy‐nine singleton women with a heavy growth of G. vaginalis or Gram stain indicative of bacterial vaginosis at 19 weeks of gestation.

Interventions Oral metronidazole (400 mg) or placebo twice daily for two days at 24 weeks of gestation, and at 29 weeks if G. vaginalis found in test‐of‐cure swab four weeks after treatment.

Main outcome measures Spontaneous preterm birth less than 37 weeks.

Results Intention‐to‐treat analysis showed no difference between metronidazole and placebo groups in overall preterm birth (31/429 [7.2%] vs 32/428 [7.5%]) or spontaneous preterm birth (20/429 [4.7%] vs 24/428 [5.6%]). Among the 480 women with bacterial vaginosis, treatment had no effect on spontaneous preterm birth (11/242 [4.5%] vs 15/238 [6.3%]). In the subset of 46 women with a previous preterm birth, women in the metronidazole group showed a significant reduction in spontaneous preterm birth (2/22 [9.1%] vs 10/24 [41.7%], OR 0.14, 95%CI 0.01–0.84). A treatment effect was also found in compliant women with a previous preterm birth and bacterial vaginosis (0/14 [0%] vs 6/17 [35.3%], OR 0.0,95%CI 0.0–0.94).

Conclusion Metronidazole treatment of women with a heavy growth of G. vaginalis or bacterial vaginosis did not reduce the preterm birth rate. Among women with a previous preterm birth, treatment reduced the risk of spontaneous preterm birth. Further studies are required to confirm these findings.
Is there an irritable bladder in the irritable bowel syndrome?
Authors: Monga Ash K. , Marrero Jose M. , Stanton Stuart L. , Lemieux Marie‐Claude , Maxwell J. Douglas
Published: August 2005

In this prospective case controlled study 16 premenopausal women with documented irritable bowel syndrome were recruited from the gastroenterology clinic and 16 premenopausal controls without symptoms of irritable bowel syndrome were recruited from the gynaecology clinic. All women answered a standardised bowel and urinary symptom questionnaire and underwent twin channel subtracted cystometry. Women with irritable bowel syndrome also underwent oesophageal balloon distension studies for perception and pain. Oesophageal and bladder sensory thresholds were compared. Urinary frequency and urgency and the urodynamic finding of detrusor instability were significantly more common in women with irritable bowel syndrome (P < 0.05). We were unable to demonstrate a relationship between first sensation of bladder fullness and oesophageal perception or between maximum bladder capacity and oesophageal pain thresholds. These findings suggest that there is an irritable bladder in the irritable bowel syndrome and support the concept that irritable bowel syndrome is part of a generalised disorder of smooth muscle.
A randomised controlled trial evaluating a novel cytotoxic drug delivery system for the treatment of cervical intraepithelial neoplasia
Authors: Sidhu Harmini Kaur , Price John H. , McCarron Paul A. , McCafferty Dermot F. , Woolfson A. David , Biggart Denis , Thompson William
Published: August 2005

Objective
To investigate the efficacy of a novel method for the treatment of cervical intraepithelial neoplasia. A cytotoxic drug delivery system using a bilaminar bioadhesive polymeric film was applied directly to the cervix. This cytotoxic drug delivery system allowed the dose, the site and the duration of application of the cytotoxic drug (5‐fluorouracil) to be controlled.

Design
A prospective, double‐blind randomised controlled trial.

Setting
The Departments of Obstetrics and Gynaecology and Pathology of Belfast City Hospital and The Queen's University of Belfast, and the Department of Pharmacy of The Queen's University of Belfast.

Participants
One hundred and four patients who had been referred to the colposcopy outpatient clinic because of abnormal cervical cytology were recruited into the trial. They were assessed colposcopically and biopsies for histopathology were obtained. Only patients with cervical intraepithelial neoplasia lesions Grades 1 and 2 were recruited.

Interventions
All patients were re‐assessed one, three, and six months after application of the cytotoxic drug delivery system by colposcopy. Clinical endpoints were noted.

Main outcome measures
Pre‐treatment histopathological biopsy results were compared with those obtained after treatment.

Results
The cytotoxic drug delivery system fulfilled the requirements for treatment of cervical intraepithelial neoplasia without causing any architechtural damage, but the chemotherapeutic agent, 5‐fluorouracil, did not provide effective treatment of disease.

Conclusions
This study showed that the delivery system was effective, and further studies using this mechanism are now possible.
Incontinence in elderly women: is periurethral collagen an advance?
Authors: Stanton Stuart L. , Monga Ash K.
Published: August 2005

Objective
To determine whether periurethral collagen is an effective, safe and practical day‐case procedure to control genuine stress incontinence (urethral sphincter incompetence) in the elderly female.

Design
Prospective longitudinal study using subjective and objective outcome measures with long term follow up.

Setting
A teaching hospital tertiary referral centre.

Sample
Thirty‐two women over 65 years of age with a urodynamic diagnosis of genuine stress incontinence.

Results
At one year, 22 women (79%) were subjectively cured or improved, and 14 (50%) were objectively cured; at two years, 18 (69%) and 14 (54%), respectively. Symptoms of urgency, urge incontinence, frequency and nocturia improved, while voiding difficulty remained unchanged. Brief urinary retention was encountered in seven women. No long term side effects or complications were encountered. Urodynamic studies suggest that collagen works by preventing premature bladder neck opening through physical stress, rather than by obstruction. This would account for the slight increase in functional urethral length.

Conclusion
Contigen collagen is a simple and effective day case procedure as an alternative to major surgery and is without significant morbidity or complication. It is ideal for the elderly.
Transcutaneous electrical nerve stimulation in labour pain: a systematic review
Authors: Carroll Dawn , Tramèr Martin , McQuay Henry , Nye Bethany , Moore Andrew
Published: August 2005

Objective
To review the effectiveness and safety of transcutaneous electrical nerve stimulation (TENS) for labour pain.

Design
A systematic review of randomised controlled trials of TENS in pain during labour.

Sample
Eight reports involving 712 women were included; 352 women received active TENS and 360 acted as controls.

Methods
Reports were sought by searching MEDLINE and the Oxford Pain Relief Database.

Main outcome measures
Analgesic and adverse effect outcomes.

Results
Evidence for reduced pain using TENS in labour was weak. Additional analgesic interventions may be less likely with TENS (odds ratio 0.57; 95% CI 0.34–0.96), number‐needed‐to‐treat 14 (95% CI 7.3–119).

Conclusions
Randomised controlled trials provide no compelling evidence for TENS having any analgesic effect during labour. Weak positive effects in secondary (analgesic sparing) and tertiary (choosing TENS for future labours) outcomes may be due to inadequate blinding causing overestimation of treatment effects.