bluuebunny/crossref_metadata_2025 huggingface dataset:
Umbilical Cord Haematoma: A Serious Pregnancy Complication
Authors: Gregora Michael G. , Lai Jerome
Published: February 2008

EDITORIAL COMMENT: We accepted this report for publication because it informs readers that umbilical cord haematoma is yet another cause of acute fetal hypoxia which may present as diminished fetal movements where cardiotocography can indicate the need for prompt delivery and save a life. We hope that further follow‐up of the infant in Case 1 will not reveal evidence of cerebral palsy. Diminished fetal movements is the indication for about 15% of antepartum cardiotocographs; evidence of critical fetal reserve as in Case I was found in 1% of such cases (24 of 2,601)A. The 2 cases reported here are very uncommon. There was no case of cord haematoma causing cardiotocographic evidence of fetal hypoxia in the large series referred to above.

A. Chew FTK; Beischer NA. Antepartum cardiotocographic surveillance of patients with diminished fetal movements. Aust NZ J Obstet Gynaecol 1992; 32: 107‐113.

Summary: The 2 cases presented show the potential morbidity and mortality which may be associated with umbilical cord haematoma. That timely diagnoses and delivery can save such an affected fetus is seen in Case 1. If fetal movements are absent, both a nonstress cardiotocograph and ultrasound scan may lead to the correct management.
Lupus Anticoagulant and HELLP Syndrome Complicated by Placental Abruption, Hepatic, Dermal and Adrenal Infarction
Authors: Ilbery M. , Jones A.R. , Sampson J.
Published: February 2008

Summary: : Pregnancy complicated by the HELLP syndrome and antiphospholipid antibodies has not previously been documented. The patient suffered a significant placental abruption, hepatic, adrenal and cutaneous infarctions, and ongoing adrenal insufficiency. Attention is drawn to the serious clinical potential of this association.
General Practitioner Obstetric Practice in Rural and Remote Western Australia
Authors: BSc Rosalind Welch , Sc Grad Dip Env , Power Ray
Published: February 2008

Summary: The objective of this study was to examine the practice of obstetrics by general practitioners in rural and remote areas of Western Australia (WA). A questionnaire was mailed to all rural and remote GPs in June, 1994. The response rate was 67%. Questionnaires asked GPs to self‐report how many deliveries they had performed in the previous year and how many of those deliveries were by Caesarean section or assisted by forceps or ventouse. Comparisons were made with perinatal statistics for the entire State of WA. GPs reported an average of 28 deliveries per year. The Caesarean section rate of 8% was lower than the rate of 21% for all WA in 1993. Ventouse was used more often than forceps to assist the delivery of a baby. Intervention rates for ventouse, forceps and Caesarean section were lower in rural and remote areas of WA than the State as a whole; there was also less use of epidural analgesia. More than half of these GPs currently practising obstetrics hold the Dip RACOG or DRCOG. Medical indemnity is an increasing issue for many GPs. For 6 of the 7 country health regions, close to 80% of women deliver within the health region in which they reside.
Using Glucose Tolerance Test Results to Predict Insulin Requirement in Women with Gestational Diabetes
Authors: Tan Y.Y. , Liauw P.C.Y. , Yeo G.S.H.
Published: February 2008

EDITORIAL COMMENT: This paper shows that the blood glucose values recorded in the glucose tolerance test which resulted in the diagnosis of gestational diabetes do not reliably predict which women will require insulin when dietary measures fail. It is not surprising that, in this study, the 2‐hour glucose value correlated best with the need for insulin therapy since gestational diabetes was diagnosed solely on the basis of a high 2‐hour glucose value (≥ 7.8 mmol/L). The data from the 596 women with gestational diabetes shown in the tables and figures should especially interest readers who manage women with gestational diabetes. In many centres women with gestational diabetes are managed without admission to hospital. Attendance at a day centre after initial diagnosis is helpful to arrange instruction from a diabetes educator and dietitian, including instruction regarding home monitoring of blood glucose levels in those where this seems necessary. In the clinics which the editorial subcommittee attend, insulin is commenced in women with gestational diabetes when the 2‐hour postprandial plasma glucose level exceeds 6.5 mmol/L on 2 or more occasions, in spite of dietary measures. In this clinic women with gestational diabetes seldom require hospitalization for stabilization of blood glucose levels. Figures 1–3 clearly show that although insulin therapy is more likely to be indicated when fasting, 1‐hour or 2‐hour plasma values are high, there are many women with high values at these points on the glucose tolerance test resulting in diagnosis of gestational diabetes, who did not require insulin. Patient compliance with dietary advice is the one explanation of this finding which the clinician is most likely to be able to influence.

Summary: This study was done to test the clinical impression that the result of the oral glucose tolerance test could be used to predict which patients with gestational diabetes did not need insulin therapy. If this was true, a full blood sugar profile assessment could be avoided in many of these women. The second analysis was to test the clinical impression that the fasting glucose level was the best predictor of insulin requirement in women with gestational diabetes. The results of the study showed that none of the 3 readings of the oral glucose tolerance test could be used to predict reliably which patients did not need insulin therapy. Hence, blood sugar profile assessment of all patients with gestational diabetes is still necessary. The receiver‐operator characteristic curves also showed that the 2‐hour postload glucose level during the 75 g load glucose tolerance test was a better predictor of insulin requirement than the fasting glucose level.
Quality of Life Assessment in Gynaecological Cancer Patients
Authors: Carter Jonathan , Saltzman Andrew , Chen Dwight , Carney Pamela , Johnson Peter , Hartenbach Ellen , Fowler Jeffrey , Carson Linda , Twiggs Leo
Published: February 2008

EDITORIAL COMMENT: Quality of life assessment is becoming more and more important in gynaecological oncology. At present, quality of life issues are not commonly considered when treatment is assessed. With new treatments costing more and more it is likely that quality of life assessment will be required in the future for all trials, and for the justification of various ongoing treatments in cancer patients Although the numbers in this paper are small and provide only limited information in the way of results, it is a step in the right direction and will serve to inform, remind or encourage readers to consider adopting or developing similar assessment tools relevant to Australia.

Summary: The feasibility of quality of life (QOL) assessment in a heterogeneous group of gynaecological cancer patients undergoing chemotherapy was determined.

All new patients being prescribed cytotoxic chemotherapy were asked to complete a modified QOL assessment tool. The elected assessment tool is the Functional Assessment Cancer Therapy‐General (FACT‐G) tool, comprising 33 questions under 5 broad categories: physical well‐being, social well‐being, relationship with doctor, emotional well‐being and functional well‐being. Raw scores were calculated and then transformed to a 0–100 scale.

Twenty eight patients received a total of 75 treatment cycles of chemotherapy. Four patients were not offered the assessment due to language difficulties. All patients offered the test satisfactorily completed the test to allow statistical analysis. The average number of chemotherapy courses received was 2.5 (range: 1–6). Of a total possible 2,475 study items (33 items × 75 cycles), 240 items were not answered (10%). Of these 240 unanswered items, 2 items (#14 and #15) comprised 38%. The mean transformed score for physical well‐being was 32 (SE 2.5), for social well‐being the mean transformed score was 50 (SE 1.7), relationship with doctor 86 (SE 2.4), emotional well‐being 41 (SE 2) and functional well‐being was 54 (SE 2.6). The assessment of QOL indices in gynaecological cancer patients undergoing chemotherapy is feasible. Further research needs to determine the optimal QOL tool for this patient population.
Amnion Rupture in the Second Trimester
Authors: Sc Beverley Hewitt BMed , Sampson Amanda , Renou Peter
Published: February 2008

Summary: Two cases of amnion rupture are presented in ‘low‐risk’ pregnancies. One case ended in fetal death in utero at 21 weeks. The other resulted in the preterm delivery of an otherwise normal male with mild amniotic band syndrome.
Successful Outcome with Serial Amniocenteses for Polyhydramnios Complicating Cystic Adenomatoid Malformation of the Lung
Authors: BSc S. E. Meagher , Simon D. R. , Hodges S. , Glasson M. J.
Published: February 2008

Summary: Hydrops fetalis secondary to congenital cystic adenomatoid malformation of the fetal lung is almost invariably a lethal condition. This poor prognosis may be attributed to the combined effects of tissue compression from the thoracic space occupying lesion and premature delivery of a hydropic baby following rupture of the membranes in the presence of polyhydramnios. We describe a successful outcome with serial amniocenteses. Partial in utero resolution of the lung lesion with complete return to normal of the aberrant liquor volume was documented, and a live infant was delivered at term.
Early Uterine Prolapse Following Colponeedle Suspension
Authors: Neuman Menachem , Lavie Ofer , Gdansky Efraim , Diamant Yoram Z. , Beller Uriel
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because of the warning it carries about the risk of prolapse occurring following vaginal surgery. Those gynaecologists who were in practice in the 1960s will remember that posterior colporrhaphy then had a bad reputation because of dyspareunia or apareunia following Manchester repair. The lesson should have been that posterior repair needs to be done with caution without excessive excision of vaginal epithelium or approximation of vaginal supports too high in the vagina rather than that posterior repair should be omitted from the Manchester operation. Nonetheless, for a time, posterior repair was often not performed in women with classical vaginal prolapse with the result that following anterior colporrhaphy with or without vaginal hysterectomy the woman re‐presented, often within a short time of surgery, with massive vaginal eversion. It seems to us that this case carries the same message, namely that provision of support for the anterior vaginal wall alone potentiates any tendency to prolapse of the posterior vaginal wall (enterocele or rectocele).

Summary: The association of retropubic colposuspension for the treatment of urinary stress incontinence with genital prolapse has been reported previously. Described here is a case of an 83‐year‐old patient who had a colponeedle suspension and was readmitted because of genital prolapse 3 weeks after surgery. This case emphasizes the need for proper evaluation of the whole pelvic floor prior to any surgical treatment for urinary incontinence, and addition of appropriate surgical measures aimed to avoid later genital prolapse, if necessary.
Transient Blindness Associated with Hypertensive Disorders in Pregnancy
Authors: To W. W. K. , Lau W.N.T.
Published: February 2008

EDITORIAL COMMENT": Readers will enjoy this paper, especially those who have had to care for a woman who suddenly became blind during pregnancy. The authors quote a wide range of reported incidences yet who could forget such a case or fail to code the history appropriately? The Editor can remember seeing only 3 such women in 38 years of obstetric practice. The first in 1963, at the Royal Women's Hospital, Melbourne, was in a woman already in hospital with severe preeclampsia. Ophtha‐Imological assessment showed only bilateral retinal pallor. Her vision returned within days of delivery after receiving magnesium sulphate, paraldehyde and sodium phenobarbitone prior to induction of labour and delivery. The second unforgettable case, at the Mercy Hospital for Women in 1975, was of a 20‐year‐old nullipara who presented to an ophthalmologist because of sudden blindness. This doctor fortunately measured her blood pressure (220/160), examined her urine (solid'on boiling i.e. proteinuria 24 g/L) and then diagnosed that she was about 16 weeks' pregnant. Examination of the fundi showed retinal haemorrhages and exudates. A misdiagnosis of hydatidiform mole with fetus was made, since this was the only condition that we believed could explain this presentation at 16–17 weeks' gestation. Hysterotomy was performed of a normal fetus and placenta after the severe preeclampsia was controlled with magnesium sulphate and heavy sedation. The vision improved after delivery and became normal over the course of the next 2 months. This woman subsequently was shown to have chronic renal disease and in her next pregnancy had a surviving infant, birth‐weight 1,745 g, delivered at 34 weeks'gestation because the cardiotocograph showed loss of beat to beat variation and late decelerations. The third case was seen in 1990 in Munster, West Germany, where the Editor was guest lecturer. This woman was at term but did not have the signs of severe preeclampsia. Her vision returned to normal within 24 hours after treatment with magnesium sulphate, sedation and delivery.

In both cases reported by the authors the patients had severe preeclampsia and in Case 2 the coagulation failure and abnormal hepatic function were indicative of the HELLP syndrome. The moral of this story and of these important cases is that sudden onset of blindness during pregnancy is usually a complication of preeclampsia, and requires control of the disease and delivery of the patient. This complication may be more likely when severe preeclampsia is treated conservatively i.e. without heavy sedation and prompt delivery. There have been 115,396 deliveries at the Mercy‐Hospital for Women from February. 1971 to April, 1995 and although the incidence of preeclampsia is 8.1% in this institution, we have seen only I case of blindness, transient or otherwise, associated with hypertensive disorders of pregnancy, in addition to the case summarized above.
Gestational Diabetes: Do All Women Need to be Tested?
Authors: Moses Robert , Griffiths Rhonda , Davis Warren
Published: February 2008

Summary: The results of glucose tolerance testing in 1,185 consecutive women were examined with respect to historical risk factors for gestational diabetes mellitus (GDM). GDM was present in 79 of 1,185 (6.7%) of the women. GDM was present in 8.5% of women aged ≥ 30 years, in 12.3% of women with a preconception BMI ≥30 and in 11.6% of women with a family history of diabetes in a first degree relation. A combination of one or all of these risk factors predicted GDM in only 48 of 79 (60.8%) cases. GDM was present in 4.8% of women without risk factors. Testing for GDM on the basis of these historical risk factors alone, and using the Australasian Diabetes in Pregnancy Society (ADIPS) criteria for diagnosis, would miss more than one‐third of all cases. This study supports the ADIPS recommendation that there should be universal testing.
A Study of Breast Feeding Rates at a Large Australian Obstetric Hospital
Authors: Nicholson Wendy , Yuen Hok Pan
Published: February 2008

Summary: A prospective breast feeding survey in a large obstetric hospital was carried out from 1988 to 1991. For each year, a sample of women were interviewed following delivery and data was collected which included the method of feeding, patient status (public or private patients), age, parity, (including previous breast feeding experience), marital status, country of birth and the number of babies. The mother's feeding method after delivery and on discharge from hospital were recorded. Women who were breast feeding on discharge were interviewed at 3 months. When putting the figures for the 4 years together, the breast feeding commencement rate was 88%, the breast feeding rate on discharge was 80% and the breast feeding rate at 3 months was between 51% and 57%. Factors found to be affecting die breast feeding rate at 3 months included patient status, age and parity. Problems experienced by the motiiers after discharge from hospital included nipple pain, nipple trauma and mastitis. Private patients reported a significantly higher rate of mastitis than public patients.
Management Guidelines for M. Tuberculosis in Pregnancy
Authors: Casper Gabrielle R. , Garland Suzanne M.
Published: February 2008

Summary: Unrecognized M. tuberculosis in pregnancy can have an adverse outcome for women and their babies. With world‐wide trends of increasing incidence of M. tuberculosis and increasing migration to Australia of women of childbearing age from countries with a high incidence of this disease, it is imperative that clinicians recognize and be aware of appropriate management of the disease. Management guidelines for M. tuberculosis occurring in pregnancy are outlined.
A Randomized Controlled Study of Prostaglandin 15‐Methyl F2 alpha Compared With Syntometrine for Prophylactic Use in the Third Stage of Labour
Authors: Chua S. , Chew S. L. , Yeoh C. L. , Roy A. C. , Ho L.M. , Selamat N. , Arulkumaran S. , Ratnam S. S.
Published: February 2008

Summary: A randomized controlled study of 112 women with singleton pregnancies at term, and no antenatal complications, admitted in spontaneous labour were randomized to receive either an intramuscular injection of 0.5 mg of Syntometrine or an intramuscular injection of 125 ug of prostaglandin 15‐methyl F2 alpha at delivery of the anterior shoulder of the baby. Blood lost in the first 2 hours, and subsequent 22 hours postdelivery were collected separately and measured by colourimetric measurement of haemoglobin content. Other parameters in the third stage were measured, including need for transfusion of blood or blood products, length of the third stage, and change in haemoglobin concentration before and 24 hours after delivery. The incidence of side‐effects with administration of either prostaglandin 15‐methyl F2 alpha or Syntometrine were documented. The prophylactic use of intramuscular prostaglandin 15‐methyl F2 alpha (Carboprost) in the active management of the third stage of labour gave similar results to prophylactic intramuscular Syntometrine in terms of length of the third stage of labour, incidence of postpartum haemorrhage and total blood loss in the first 2 hours and subsequent 22 hours after delivery. However it has the disadvantage of higher cost, as well as statistically significant increase in the incidence of profuse and frequent diarrhoea. Based on these results intramuscular injection of prostaglandin 15‐methyl F2 alpha offers no advantage over intramuscular Syntometrine for routine prophylactic use to reduce blood loss in the third stage of labour.
The Significance of Mild Squamous Atypia on Cytology
Authors: Dew J. E. , Athanasatos P. , Hacker N. F.
Published: February 2008

Summary: Between January, 1991 and February, 1993 inclusive, 396 Papanicolaou smears were reported to show Mild Squamous Atypia with or without Human Papilloma Virus (MSA ± HPV). All women with MSA ± HPV smears were routinely recalled for colposcopy. To determine the significance of MSA ± HPV on routine smear screening, the records of all patients were reviewed.

Three hundred and thirty‐seven women (85.1%) attended the colposcopy clinic and are the subjects analyzed for this report. The remaining 59 (14.9%) failed to attend. Intraepithelial neoplasia was found in 61 patients (18.1%), of whom 27 (8.0%) had a high grade lesion (CIN 2 or 3 or GIN 2). No patient had invasive cancer of the cervix. Only 1 of the 45 pregnant women had a significant lesion.

It is concluded that all asymptomatic women with MSA ± HPV on cervical smear may be managed in accordance with the current NH and MRC recommendations (1) and have a repeat smear in 6 months and colposcopy if the abnormality persists at 12 months.
Uterine Prolapse and Acute Renal Failure in a Chinese Patient
Authors: MacKenzie T. M. , Chan L. W. , Yuen P.M. , Ng C. F. , Chan P.S.F.
Published: February 2008

EDITORIAL COMMENT: A large prolapse of the uterus and vagina (often called a procidentia, although strictly speaking this term refers to any prolapse) may be associated with urgency, frequency, difficulty in passing urine, no urinary symptoms at all, or as in this patient with anuria and acute obstructive renal failure. Women with longstanding prolapses that have not been reduced and which rarely are irreducible, often have hydronephrosis and chronic renal failure. However it is exceedingly uncommon for a prolapse to be associated with anuria as occurred in this patient. The Editor has experience of an elderly patient admitted to the Austin Hospital, Melbourne, 32 years ago who was thought to be demented and who died shortly after admission. At autopsy she was found to have a large uterovaginal prolapse and hydronephrosis, the cause of death apparently being renal failure. A similar case was also reported in a letter in the BMJ approximately 30 years ago. These cases are rare but make the point that a patient who has a uterovaginal prolapse should have the mass replaced and her renal function assessed prior to the anticipated surgery. Usually it is possible to operate on such a patient within 4 or 5 days even when there has been gross ulceration of the cervix and posterior vagina which normally heals rapidly when the uterus and prolapsed vaginal walls (cystocele, enterocele ± rectocele) are reduced and the vagina packed with gauze soaked in oestrogen cream. When a prolapse is large, the bladder can be outside the body with kinking of the ureters, and passage of ureteric catheters may be impossible because of this. Reduction of the prolapse will relieve this obstruction of the ureters, and so lead to improvement in renal function. (See Illustrated Textbook of Gynaecology. Eric VMackay et al. Figures 23.10 and 23.11, pages 344 and 345).
First Trimester Aneuploidy Screening Using Nuchal Iranslucency, Free Beta Human Chorionic Gonadotrophin and Maternal Age
Authors: Scott Fergus , Wheeler Danielle , Sinosich Michael , Boogert Antheunis , Anderson John , Edelman David
Published: February 2008

Summary: Screening for aneuploidy using maternal age has a low detection rate and high false positive rate. Second trimester maternal serum screening increases trisomy 21 detection and decreases die false positive rate. First trimester screening would enable definitive diagnosis with chorionic villus sampling, and simple surgical termination of affected pregnancies would still be an option. Nuchal translucency (NT), free beta human chorionic gonadotrophin (fβHCG) and maternal age were assessed in 302 patients before chorionic villus sampling. NT positively and fβHCG negatively correlated with gestation, but neither correlated with maternal age nor with each other. Both NT and fβHCG were increased in trisomy 21. NT was increased and fβHCG was decreased in trisomy 18. Multivariate discriminant analysis enabled 87.5% detection of trisomy 21 in this high‐risk population, for a 14% false positive rate. In a simulated normal population, using a risk cut‐off of 1 in 250, 71% detection was achieved for a 7% false positive rate. The combination of NT, fβHCG and maternal age is a simple, readily available and viable first trimester screening strategy.
The Impact of Antenatal Screening for Down Syndrome in Western Australia: 1980–1994
Authors: O'Leary Peter , Bower Carol , Murch Ashleigh , Crowhurst June , Goldblatt Jack
Published: February 2008

Summary: Since the early 1970s, women in Western Australia have been screened for fetal Down syndrome risk on the basis of maternal age. Women 35 years of age or more at delivery, were offered fetal karyotyping with genetic diagnostic testing via amniocentesis or chorionic villus sampling. An increase in the prevalence of Down syndrome of 3.9% per year (95% confidence interval: 1.8‐6.0%) was observed between 1980 and 1994, almost all of which was accounted for by increased maternal age. In 1991, a maternal serum screening (MSS) programme for Down syndrome was first implemented in Western Australia and has since evolved with 6 separate laboratories providing Down risk assessment in 1994. The gradual introduction of MSS programmes had little discernible impact until 1994, when 38% of Down syndrome fetuses were ascertained as a result of increased‐risk MSS tests and the birth prevalence of Down syndrome decreased significantly. In this report, we review antenatal screening programmes and their impact on the birth prevalence of Down syndrome in Western Australia.
Booking Ultrasound Examinations Performed by Obstetric Senior House Officers ‐ Time to Reevaluate?
Authors: Bahmaie Arash , Edmonds D. Keith
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication to warn obstetrics hospital administrators that although it is commendable to train house officers to perform ultrasonography, these medical practitioners should not perform the duties of a trained ultrasonographer for the reasons presented. This series considered only the errors in assessment of gestational age. There is considerable literature to indicate that with the detailed 18–20 week scan the need for an expert is far greater.

Summary: We evaluated the proficiency of obstetrics senior house officers, not formally trained in ultrasonography, in assessing fetal viability, the number of fetuses and gestational age. Of 366 women who had an ultrasound examination at the first antenatal visit, 7 (2.1%) had nonviable pregnancies and 7 pairs of twins were correctly identified. Of these women, 329 had a detailed anomaly scan at 18–20 weeks. No anomalies were detected at either scan. Of the booking scans performed by the senior house officers, 89.4% correctly assessed the gestational age of the pregnancy when compared to the anomaly scan (±1 week). One in 10 of the scans performed by the senior house officers was inaccurate. This is important particularly when being used for risk assessment in serum screening for Down syndrome. At present the early ultrasound scan should be performed by more formally trained personnel.
Induction of Labour for Trial of Vaginal Birth After Caesarean Section in a Remote District Hospital
Authors: Kumar Sailesh , Maouris Panos
Published: February 2008

EDITORIAL COMMENT: We accepted this paper because it expresses an obstetric philosophy evolved in the circumstance of obstetrics practice in a hospital 1,800 km from a State capital city with patients whose homes may be hundreds of km from the ‘local’ hospital. In this setting induction of labour is more than a social convenience. This paper explores the hypothesis that it is reasonable to practise this finesse even when the woman has had a Caesarean section and wishes to achieve a vaginal delivery. This series is, as the authors indicate, very small ‐ absence of perinatal mortality or uterine rupture in 33 cases of trial of vaginal delivery after Caesarean section, with induction of labour in 26 of them, does not prove that the procedure is safe even if the obstetrician has the experience necessary to perform Caesarean hysterectomy should uterine rupture occur. Targett (A) reviewed a series of 1,577 patients having trial of vaginal delivery after Caesarean section and reported an incidence of uterine rupture of 0.8%. He concluded that to ensure the greatest chance of vaginal delivery with optimum safety, the onset of labour should be spontaneous. It is against this background that the excellent results in this small special series from Port Hedland should be viewed. Our statistician commented that with 33 cases and given a 0.8% chance of scar rupture, the study would have a 77% probability of finding no cases of uterine rupture just by chance. However, it does say with 80% certainty that the rupture rate is not more than 5%! The takeaway message from this report seems to be that induction of labour was favoured, not to increase the success rate of vaginal delivery after Caesarean section, but to satisfy the problems of planning the time of delivery within hours in women who had a previous Caesarean section and were living remote from a hospital with staff not routinely available to monitor labour and deal with any complications.

Summary: In a retrospective review of 79 women with 1 or more previous Caesarean section, 33 (41.8%) women agreed to a trial of vaginal birth. Twenty nine women had labour induced and 26 (89.7%) of them had a successful vaginal delivery.

Four women laboured spontaneously and 1 of them needed an emergency Caesarean section for failure to progress. The overall vaginal delivery rate for women selected to undergo a trial of vaginal birth after Caesarean was 87.9%. The overall emergency Caesarean section rate was 4 of 33 (12.1%). During the study period the Caesarean section rate for the hospital fell from 32.2% to 11%. This study suggests that induction of labour in women with a previous Caesarean section is very successful in achieving vaginal delivery and has a role to play in remote and rural hospitals.
Is ‘Herbal Health Tonic'Safe in Pregnancy; Fetal Alcohol Syndrome Revisited
Authors: Pradeepkumar V.K. , Tan K.W. , Ivy NG
Published: February 2008

EDITORIAL COMMENT: We accepted this case report for publication because of the warning it carries that herbal health tonics may have an alcohol content ranging from 14 to 40% and could cause the fetal alcohol syndrome even when the mother ‘denies exposure to alcohol or any other drugs’. These tonics wherever they are sold, should be labelled appropriately to indicate the alcohol content and warning of fetal hazard if consumed during pregnancy. Both Asian and non‐Asian members of our population should be informed of the possible dangers of herbal health tonics.

Summary: So called ‘Herbal Health Tonics' are freely available in the market. This has been promoted by the manufacturers for the following symptoms: poor appetite, gastroenteric weakness, poor blood circulation, chills, fatigue, weak constitution and weakness after disease.

We report a case of suspected fetal alcohol syndrome (FAS). A baby boy of 3,7(X) g born to a 29‐year‐old Chinese mother at 41 weeks' gestation was found to have features consistent with FAS. On follow up at 3 years of age. both motor and mental milestones as well as speech and language were delayed suggesting the possibility of FAS. There was a history of maternal ingestion of ‘Herbal Health Tonic’ (which contained 14% alcohol) daily for the first 2 months of the antenatal period. She denied exposure to alcohol or any other drugs.

The authors would like to highlight the risk of such ‘Herbal Health Tonics' in pregnancy and their probable deleterious effects on the growing fetus. We feel that it is extremely important to look into the traditional practices among pregnant women in Singapore and in other parts of the world where there are similar practices. otherwise more cases like these could occur in future.
Maternal Country of Origin and Infant Birthplace: Implications for Birth‐weight
Authors: Rundle Donna , Barclay Lesley , Nivison‐Smith Ian , Lloyd Beverly
Published: February 2008

Summary: This study investigated the effect of mother's country of origin and baby's birthplace on infant birth‐weight. The mean birth‐weights of full‐term babies born of well immigrant women from 5 countries were compared with diose of women of Anglo‐Australian origin confined at die same hospital. Data were collected from medical records at Canterbury hospital for 1,274 women confined between 1989 and 1992 and 2,524 of their babies. Multiple regression analysis showed that infants born in Australia to women from Vietnam and Korea were significantly heavier man infants born to these women in their country of origin. Babies born to women from Vietnam were significantly lighter than babies born to Anglo‐Australian controls.
Endometrial Resection ‐A Comparison of Techniques
Authors: Browne David S.
Published: February 2008

Summary: To assess the long‐term effectiveness and safety of endometrial resection, an ongoing prospective study of 927 patients, followed for 1 to 5 years, was carried out. The patients met criteria previously adopted, for vaginal hysterectomy. Three techniques were used, modified over time with experience gained and failures encountered: Technique 1: Resection alone; Technique 2: Resection, followed by roller‐ball cautery of the whole endometrium; Technique 3: Laparoscopic control, resection, roller‐ball cautery, further resection especially in the comua and fundus and finally laparoscopic cautery of the cornual region of the uterus. Various parameters were measured including preparation of the endometrium, pathology present, complications and outcomes. There was a marked improvement in the success of the procedure with changes from Technique I to 2 to 3. There was a fall in the failure rate from 22% to 5%. These results were statistically highly significant (p<0.0001). The best results obtained were in women with endometrial polyps and pure dysfunctional bleeding with good results in cases of intramural fibroids and adenomyosis. There were no deaths and no cases of long‐term adverse sequelae resulting from complications, but the following were encountered: perforation of the uterus, hyponatraemia, pregnancy, infection, unanticipated malignancy and cervical stenosis. It is concluded that in view of the high success rate and relative lack of serious complications, endometrial ablation should be considered the treatment of choice in cases of dysfunctional bleeding in women who have completed their families.
Placenta Praevia Accreta with Delayed Hysterectomy
Authors: Matthews N.M. , McCowan L.M.E. , Patten P.
Published: February 2008

EDITORIAL COMMENT: Placenta praevia accreta has an awesome fascination because of the horrendous haemorrhage that can occur; hence its contribution to maternal mortality is out of proportion to its incidence (A). This paper describes what can happen when the placenta is not disturbed at Caesarean section in such a case. We were interested that the authors did not consider the use of methotrexate which has been advocated in this testing circumstance and may be successful (B) or unsuccessful (C). The authors and their patient weathered the storm: readers can decide what they would have done. As stated previously, the editor would have called for the help of the most skilled gynaecological oncologist available before commencement of the hysterectomy (D). The antenatal findings in this woman are unusual, with features suggesting cervical pregnancy. The pathological diagnosis of placenta accreta 55 days postpartum may be more difficult to establish.

Authors'response to above comment:

In this case the surgery was performed by 2 senior gynaecologists one of whom was a gynaecological oncologist.

Summary: A case of placenta praevia accreta is described. Delivery was achieved by Caesarean section and the placenta was left in place because of the risk of haemorrhage. Successful internal iliac artery embolization was performed 9 days postpartum to control uterine bleeding. Hysterectomy was performed at 55 days postpartum because of bleeding and sepsis.
Acute Massive Haemoperitoneum Due to Mild Pelvic Endometriosis
Authors: Kumar Sailesh
Published: February 2008

EDITORIAL COMMENT: This is a strange case and informs us that bleeding from endometriosis can be life‐threatening. We are given no clue concerning the apparently erroneous ultrasonographic finding of a 9 times 5 x 4 cm adnexal mass, the presence of which was not confirmed at laparotomy. Our reviewer commented that a haemoperitoneum without adequate explanation requires careful exclusion of upper abdominal pathology such as ruptured spleen or haemorrhage from a splenic artery aneurysm which are well‐documented causes of morbidity and death in obstetrics and gynaecology.
Identification and Treatment of Women with Hyperglycaemia Diagnosed During Pregnancy Can Significantly Reduce Perinatal Mortality Rates*
Authors: Beischer Norman A. , Wein Peter , Sheedy Mary T. , Steffen Bettina
Published: February 2008

Summary: We wished to determine whether gestational diabetes was associated with an increased perinatal mortality rate, and to investigate the cause for the observed increase in the incidence of gestational diabetes. We therefore reviewed the results of glucose tolerance tests and pregnancy outcome in 116,303 pregnancies, 1971–1994, at the Mercy Hospital for Women. The main outcome measurements were the presence or absence of gestational diabetes, and perinatal mortality. Over the entire period of the study, gestational diabetes was associated with an increased risk of perinatal mortality (Mantel‐Haenszel adjusted odds ratio 1.53, 95% CI 1.13‐2.06, p=0.0069). Women with gestational diabetes that was only diagnosed retrospectively had a higher perinatal mortality rate than their contemporaries with normal glucose tolerance (OR 2.31,95% CI 1.37‐3.91, p=0.0025). Women in whom a glucose tolerance test was not performed continued to have a higher perinatal mortality rate than women who were tested (adjusted OR 2.21,95% CI 1.56‐3.12, p<0.00001). There has been an increase in the prevalence of gestational diabetes from 2.9% to 8.8%. Some of this is due to changes in population characteristics (increases in maternal age, obesity and proportion from South‐East Asia), but there was still an independent increase over time. We conclude that identification and treatment of women with gestational diabetes can reduce perinatal mortality rates. Similarly to diabetes mellitus in the total population, the prevalence of gestational diabetes has increased over time.
Actions of Magnesium, Nifedipine and Clonidine on the Fetal Vasculature of the Human Placenta
Authors: David Ronald , Leitch Ian M. , Read Mark A. , Boura Alan L.A. , Walters William A.W.
Published: February 2008

Summary: The anticonvulsant magnesium and the antihypertensives clonidine and nifedipine are extensively used for the clinical treatment of preeclampsia and eclampsia. Little, however, is known about the possible effects of these agents on human fetal‐placental vascular resistance. We therefore examined the actions of these agents on the human fetal placental vascular bed in vitro relating the concentrations causing any vasoactive effects to the maternal blood levels attained during treatment. Placentas (n=24) were obtained within 20 minutes of delivery from women (aged 30.2 ± 0.9 years). In each a placental lobule was bilaterally perfused with Krebs' solution (5 mL/minute, 37oC, 95% O2, 5% CO2,) and fetal arterial inflow pressure (FAP) monitored. Submaximal vasoconstriction of the fetal vascular bed was induced by continuous infusion of prostaglandin F2α (4.2 ± 0.5 μM) which increased FAP from 25.9 ± 3.9 to 95.1 ± 6.2 mm Hg. Using a group of placentas for each drug, the effects of MgCl2, nifedipine and clonidine, were examined. Magnesium (0.3–100 mM) (n=4) dilated the placental fetal circulation with an IC50 of 8.1 mM and a maximal response of 89.7 ± 3.6% (n=4). This effect of Mg2 was not changed during concomitant infusion of the cyclooxygenase inhibitor, indomethacin (3 μM). Nifedipine (3–10,000 nM) also produced vasodilatation (maximum response 42 ± 9%, n=5). Clonidine (3‐1,000 nM) caused no significant change (p<0.05 n=5) in vascular resistance (maximum response 11.2–5.7%) relaxation), when compared to controls. Thus in concentrations likely to be therapeutically present in maternal blood, magnesium causes a greater degree of placental fetal vasodilatation than does nifedipine, whereas clonidine is unlikely to have any effect on fetal placental vascular resistance.
Cervical Ripening Before Induction of Labour in Patients with an Unfavourable Cervix: A Comparative Randomized Study of the Atad Ripener Device, Prostaglandin E2 Vaginal Pessary, and Prostaglandin E2 Intracervical Gel
Authors: Yuen Pong Mo , Pang Hilda Y.Y. , Chung T. , Chang A.
Published: February 2008

Summary: One hundred and nineteen women with singleton pregnancy and cephalic presentation requiring induction of labour in the presence of an unfavourable cervix (Bishop score ≤ 4) were studied. Five patients were excluded because of failure to comply with the protocol. Cervical ripening was carried out using 3 different methods; 36 used the Atad Ripener Device, 39 received 0.5 mg PGE, intracervical gel and 39 received at least one 3 mg PGE2 intravaginal pessary. There were no differences in the demographic characteristics and the indications for induction. Five patients developed complications during the ripening period necessitating intervention; 3 required emergency Caesarean section and 2 delivered vaginally. Although statistically there were no differences among the 3 methods of cervical ripening, the power of the study is probably not large enough to show the differences. The PGE2 pessary appears to be more effective with 68% of patients either going into labour during cervical ripening or succeeding in the cervical ripening compared to around 50% in the Atad and PGE, gel groups. The vaginal delivery rate was 87.2% in the pessary group compared to 72.2% in the Atad group and 84.6% in the gel group. The duration of labour was also shorter in the pessary group with 73.5% delivered within 24 hours compared to 57.7% in the Atad group and 57.6% in the gel group. Although the results of the Atad device seem to be inferior, the risk of uterine hyperstimulation from the use of the device is probably lower than that of the PGE2 and may therefore be preferable in women with fetuses at high risk of fetal hypoxia.
Prolonged Induction to Delivery Time in Termination of Pregnancy Using 16,16‐dimethyl‐PGErmethyl ester (gemeprost) for Fetuses with a Neural Tube Defect or Hydrocephalus
Authors: Nesbitt Denise , Giles Warwick
Published: February 2008

Summary: A retrospective study is reported comparing the induction to delivery interval using gemeprost for termination of pregnancy, in the second trimester, in 3 groups of patients. It was observed that the mean induction to delivery interval was significantly longer in 75 pregnancies where there was a fetus with a neural tube defect and or hydrocephalus (31.7 hours) compared with 88 pregnancies with other fetal abnormalities (19.7 hours) and 84 pregnancies where there was an intrauterine death (113 hours). There was also an increase in the requirements for further intervention to obtain delivery in the group with a neural tube defect or hydrocephalus (n=33) compared with where there was an intrauterine fetal death (n=4) and other abnormality (n=14). We believe these results should be considered when counselling patients who have requested termination of pregnancy for fetal abnormalities.
Serum Progesterone and Human Chorionic Gonadotrophin Measurements in the Evaluation of Ectopic Pregnancy
Authors: O'Leary Peter , Nichols Christopher , Feddema Peter , Lam Tarry , Aitken Michael
Published: February 2008

Summary: We evaluated the clinical usefulness of measuring the serum concentrations of human chorionic gonadotrophin (HCG) and progesterone to distinguish between early viable and nonviable pregnancies. We investigated 110 women witfi clinical symptoms of abnormal pregnancy. A single HCG measurement did not clearly distinguish between ectopic and failing intrauterine pregnancies; an HCG value below 3,000 IU/L, together with a serum progesterone below 40 nmol/L, predicted abnormal pregnancy outcome in 97% of women (positive predictive value: 91%; negative predictive value: 95%). Serum HCG values above 3,000 IU/L or progesterones above 40 nmol/L, discriminated between an ongoing pregnancy and an abnormal pregnancy in 87% women (positive predictive value: 95%; negative predictive value: 91%) and provided reassurance of an ongoing pregnancy. Our results suggest that a combination of serum progesterone and HCG measurements provide clinically useful biochemical information which enhances the prediction of pregnancy outcome.
The Use of Large Loop Excision of the Transformation Zone (LLETZ) in an Outpatient Setting
Authors: Powell Beverley
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because it presents a detailed analysis of the results from one centre of treatment of women with cervical intraepithelial neoplasia by large loop excision of the transformation zone. Importantly it provides a very careful review of the reported literature on the subject: the conclusions warrant special scrutiny.

Summary: An audit of the results of 129 patients treated in the first 12 months of operation of an outpatient large loop excision of the transformation zone (LLETZ) clinic was performed. It confirmed the efficacy of the procedure in treatment of cervical intraepithelial neoplasia (CIN) with a cure rate of 93.8%. Major deficiencies identified were the lack of compliance with recommended follow‐up, a major discrepancy between predicted diagnosis on colposcopically directed punch biopsy and LLETZ specimen histology, and a large proportion of LLETZ specimens which had negative histology and may be regarded as overtreatment. Suggested strategies to address these include observation of low‐grade lesions and treatment with LLETZ at the first clinic appointment.
Severe Chronic Pelvic Pain in Women May Be Caused By Ligamentous Laxity in the Posterior Fornix of the Vagina
Authors: Petros Pe Papa
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because severe chronic pelvic pain, often with associated secondary dysmenorrhoea and dyspa‐reunia, is a difficult gynaecological problem to deal with, and is not uncommon. The women are usually premenopausal and bimanual palpation of the uterus reproduces the pain they complain of ‐ the uterus seems tender but the explanation could be that described in this paper. In these women the uterus is freely mobile and there is no palpable adnexal pathology, and as noted by the author, laparoscopic findings are normal. It is widely believed that it is the ovaries and not the uterus (or the contents of its supporting ligaments) that are the cause of this syndrome, and when hysterectomy is contemplated, the question of whether to perform bilateral oophorectomy arises. Hysterectomy alone is often curative of pain in these patients (A) but the lesser procedure described here warrants consideration in patients with chronic severe pelvic pain. To establish that the proposed operation is effective, it would be necessary to perform a properly designed blinded randomized controlled trial, with the control women having a ‘placebo’ operation (e.g. anaesthetic/sedation, local analgesia infiltration, incision of vagina without plicating the uterosacral ligaments). We believe that such a trial is feasible.

Summary: The aim was to prospectively study the relationship between pelvic pain of otherwise unknown origin and laxity in the posterior vaginal fornix. Twenty‐eight patients with negative laparoscopy findings, lower abdominal pain and laxity in the posterior ligamentous supports of the uterus underwent surgical approximation of their uterosacral ligaments. At 3‐month review, 85% of patients were cured, and at 12 months, 70%. Nonorganic pelvic pain has frequently been attributed to psychological factors. However, the results suggest that this may be a T12‐L1 parasympathetic pain referred to the lower abdomen, perhaps due to the force of gravity stimulating pain nerves unable to be supported by the lax uterosacral ligaments in which they are contained. It was concluded that laxity in the posterior ligaments of the vagina should first be excluded before referring patients with pelvic floor discomfort or pain for psychiatric care.