bluuebunny/crossref_metadata_2025 huggingface dataset:
Leptin and pre‐eclampsia in Black African parturients
Authors: Kafulafula G.E. , Moodley J. , Ojwang P.J. , Kagoro H.
Published: December 2003

Objective
To measure serum concentrations of the hormone leptin during late pregnancy in Black African women with pre‐eclampsia, healthy normotensive pregnant women as controls and healthy normotensive non‐pregnant women; secondly, to explore the relationship between leptin and obesity.

Design
Observational, cross sectional study.

Setting
Antenatal clinics, antenatal wards, gynaecology out patient and family planning clinics of a tertiary hospital, Durban, South Africa.

Population
Pregnant and non‐pregnant Black African women.

Method
Serum leptin was measured by a homologous radio‐immunoassay technique. Simple anthropometric parameters were used to explore the relationship between leptin and obesity. In each group, leptin levels were compared between obese (body mass index, BMI ≥ 30 kg m−2) and lean women.

Main outcome measures
Serum leptin concentrations, anthropometric parameters, mean blood pressures and proteinuria.

Results
There were 68 women with pre‐eclampsia, 92 healthy normotensive pregnant women (controls) and 32 healthy normotensive non‐pregnant women. Serum leptin levels were higher in pregnant compared with non‐pregnant women [26.66 (1.96) and 25.89 (1.65) vs 17.97 (2.11) ng/mL, P= 0.02]. Weight and BMI showed the greatest correlation with leptin both in pregnant (r= 0.61 and r= 0.58, respectively) and non‐pregnant women (r= 0.74 and 0.79, respectively). There was no significant difference in the mean concentrations of leptin between women with and those without pre‐eclampsia [26.66 (1.96) vs 25.89 (1.65) ng/mL, respectively, P= 0.95].

Conclusion
Pregnancy is a hyperleptinaemic state. There is no difference in serum leptin levels between Black African women with pre‐eclampsia and healthy normotensive pregnant women. Serum leptin concentration is largely determined by the degree of adiposity.
Lay perceptions of a ‘natural’ menopause. Cross sectional study of the British Women's Heart and Health Study
Authors: Lawlor Debbie A. , Adamson Joy , Ebrahim Shah
Published: December 2003

Health practitioners and researchers define a natural menopause as one not due to a hysterectomy or oophorectomy. In a large cross sectional study of postmenopausal women, we found that the majority of women who report that their menopause was not natural gave a gynaecologic reason. However, 3% gave a major life event, such as divorce or bereavement. Age at menopause for women who had had a hysterectomy/oophorectomy was the same as that of women who reported that their periods has stopped because of a major life event—on average six years younger than that of women who described their menopause as natural. We suggest that women whose periods stop ‘naturally’ (from a medical perspective) but at a relatively young age perceive this as unnatural and search for an explanation for the early cessation of their menses.
Prenatal diagnosis of bilateral isolated fetal hyperechogenic kidneys. Is it possible to predict long term outcome?
Authors: Tsatsaris V. , Gagnadoux M.F. , Aubry M.C. , Gubler M.C. , Dumez Y. , Dommergues M.
Published: December 2003

Objective
To study perinatal and long term outcome following prenatal diagnosis of hyperechogenic kidneys.

Design
Prospective observational cohort study.

Setting
The Maternité Port‐Royal Hôpital Cochin and at the Departments of Obstetrics and Paediatric Nephrology, Necker Enfants Malades in Paris, France.

Population
Forty‐three fetuses with isolated bilateral hyperechogenic kidneys.

Methods
All patients referred with isolated bilateral hyperechogenic fetal kidneys were followed up prospectively up to 34–132 months. The following prenatal items were analysed: fetal kidney size, amniotic fluid volume, gestational age at diagnosis, family history and renal ultrasound in parents. Postmortem examination was carried out in cases with perinatal death. Postnatal follow up of survivors included postnatal ultrasound, blood pressure, serum creatinine, proteinuria, need for restricted diet, weight and height and renal biopsy when available.

Main outcome measures
Aetiology of hyperechogenicity, perinatal mortality and renal function in survivors.

Results
The aetiology could be established by family history, postmortem or postnatal data, but not by prenatal ultrasound. There were 20 autosomal recessive, 8 autosomal dominant polycystic kidney diseases, 9 other renal disorders and 6 symptom‐free survivors without aetiological diagnosis. There were 19 terminations of pregnancy, 5 neonatal deaths and 19 survivors, of whom 14 had normal renal function three had mild and two had end stage renal failure. None of those with severe oligohydramnios and fetal kidneys > 4 SD survived (n= 14, 10 terminations and 4 neonatal deaths), whereas of the 17 with normal amniotic fluid volume and kidneys < 4 SD, 14 survived, of whom 9 were symptom‐free.

Conclusion
Aetiology could not be established prenatally in the absence of familial data. Kidney size and amniotic fluid volume were the best prenatal predictors of outcome.
Prenatal diagnosis for risk of spinal muscular atrophy
Authors: Cuscó I. , Barceló M.J. , Soler C. , Parra J. , Baiget M. , Tizzano E.
Published: December 2003

Objectives
Prenatal diagnosis of spinal muscular atrophy is usually performed in high risk couples by detection of a homozygous deletion in the survival motor neurone gene (SMN1). However, other relatives at risk of being carriers very often request genetic counselling and the possibility of prenatal diagnosis. The aim of this study was to validate a SMN1 gene quantitative test to help the couples formed by one spinal muscular atrophy carrier and a partner of the general population (1/200 potential risk) to achieve a less ambiguous risk result for the pregnancy.

Design
Spinal muscular atrophy carrier studies in at‐risk individuals.

Setting
Department of Genetics and Gynaecology and Obstetrics in a large university hospital.

Population
Seventy‐nine obligate carriers (more than one affected child with deletion in the offspring) and 58 non‐carriers (relatives of spinal muscular atrophy families defined by marker studies) were tested to set up a quantitative analysis. The method was applied in different situations in 126 members from 34 families with spinal muscular atrophy patients.

Methods
DNA studies of the SMN1 gene by marker analysis and quantitative assay.

Main outcome measures
To determine double (non‐carrier) or single dose (carrier) of exon 7 of the SMN1 gene in relatives of spinal muscular atrophy patients. Bayesian calculation of risk.

Results
The sensitivity and specificity of the method were 96% and 100%, respectively. Studies on different couples with an a priori risk of 1/200 allowed us to reduce the final risk to 1/5000 or to increase it to 1/4.

Conclusions
The quantitative method can be used to achieve a less ambiguous risk in pregnancies with a 1/200 risk and in families where no sample is available to study the index case. Screening of gamete donors when the recipient is a known carrier should also be considered.
Neurodevelopmental outcome after intrauterine red cell transfusion for Parvovirus B19‐induced fetal hydrops
Authors: Dembinski J. , Haverkamp F. , Maara H. , Hansmann M. , Eis‐Hübinger A.M. , Bartmann P.
Published: December 2003

Objective
To assess long term neurodevelopmental outcome of children after intrauterine intravascular red cell transfusion (IUT) for Parvovirus B19‐induced fetal hydrops.

Design
Data of study children were investigated retrospectively. Neurodevelopmental evaluation was performed by appropriate standard tests (Griffiths, Snijders–Oomen, Kaufmann Assessment Battery for Children tests).

Setting
Tertiary care university teaching hospital.

Sample
Twenty children who had Parvovirus‐induced fetal hydrops and intrauterine transfusion of packed red blood cells (IUT).

Methods
Retrospective chart analysis and standard neurodevelopmental testing.

Main outcome measures
Developmental quotient (DQ) and intelligence quotient (IQ) according to the age at testing.

Results
Twenty survivors of Parvovirus B19‐induced fetal hydrops successfully treated by IUT were followed until 13 months to nine years of age. On clinical follow up, no neurologic sequelae were evident. Neurodevelopmental scores of all children ranged within two standard deviations of a normal population (median 101, range 86–116) and exceeded one standard deviation in three children. There was no significant neurodevelopmental delay.

Conclusion
Children having survived successful IUT for Parvovirus B19‐induced fetal anaemia and hydrops have a good neurodevelopmental prognosis. Our results support the use of IUT for correction of Parvovirus B19‐induced fetal anaemia and subsequent hydrops.
Factors affecting the outcome of early medical abortion: a review of 4132 consecutive cases
Authors: Ashok Premila W. , Templeton Allan , Wagaarachchi Prabhath T. , Flett Gillian M.M.
Published: December 2003

Objective
To assess the outcome of a regimen of a reduced dose of mifepristone followed by one or two doses of vaginal misoprostol as a non‐surgical method for termination of pregnancy.

Design
Prospective observational study.

Setting
Aberdeen Royal Infirmary, Aberdeen, Scotland.

Population
Women seeking abortion under the 1967 Abortion Act.

Methods
Factors influencing the outcome in a consecutive series of 4132 women undergoing early medical abortion in one Scottish teaching hospital since 1994.

Main outcome measures
Complete abortion rates following one or two doses of misoprostol. The effect of age, gestation, previous pregnancy and previous termination on complete abortion rates following the medical regimen.

Results
Of the 4132 women, 95 (2.3%) aborted within 48 hours of mifepristone and a further 3942 (95.4%) achieved complete abortion following administration of one or two doses of misoprostol. Thus, the overall complete abortion rate was 97.7% (4037/4131). A total of 94 (2.3%) women required surgical intervention of whom 13 (0.3%) had a continuing pregnancy. Following change of the regimen to include the possibility of two doses of misoprostol the continuing pregnancy rates were significantly reduced (OR = 5.88) and gestation ceased to have an effect on overall efficacy. Women who had a previous abortion were more likely to have a failed medical abortion (OR = 2.09), while women with no previous termination, but a previous live birth were more likely to have a failed abortion (OR = 2.03).

Conclusion
Mifepristone in combination with one to two doses of vaginal misoprostol is an effective regimen for early medical abortion. The option of administering two doses of misoprostol significantly reduced the ongoing pregnancy rates and abolished the effect of gestation on overall efficacy. Previous termination was the strongest predictor of failed medical abortion.
Mid‐trimester severe intrauterine growth restriction is associated with a high prevalence of thrombophilia
Authors: Kupferminc Michael J. , Many Ariel , Bar‐Am Amiram , Lessing Joseph B. , Ascher‐Landsberg Jessica
Published: December 2003

Objective
To investigate the association between severe mid‐trimester IUGR, whose causes are unknown in most cases, and maternal thrombophilias.

Design
Case–control study.

Setting
Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, The Sackler Faculty of Medicine, Tel Aviv University.

Population
Twenty‐six women with severe mid‐trimester (22–26 weeks of gestation) IUGR (birthweight <3rd centile) and 52 matched multiparous women with normal pregnancies (controls).

Methods
After excluding pregnancies with vascular maternal disease, chromosomal and structural aberrations and cytomegalovirus infection, 26 women out of 35 with severe mid‐trimester IUGR remained and composed the study group. Each was matched for age, ethnicity and smoking status with two healthy women who had normal pregnancies. All the women were tested for genetic and acquired thrombophilias at least eight weeks after delivery.

Main outcome measures
Prevalence of maternal thrombophilias.

Results
The frequency of thrombophilias was 69% in the study group compared with 14% in the control group [odds ratio (OR) 4.5; 95% confidence interval (CI) 2.3–9, P< 0.001]. The frequencies of factor V Leiden mutation, prothrombin gene mutation and protein S deficiency were significantly increased in the study group compared with the control group. The frequency of multiple thrombophilias was 33% in the study group versus none among the controls. Of the 26 pregnancies with severe mid‐trimester IUGR, 13 ended in intrauterine fetal death before 25 weeks of gestation: 10 of these women had thrombophilia.

Conclusion
Women with mid‐trimester severe IUGR have an increased prevalence of inherited and acquired thrombophilias.
Defining the problem: the epidemiology of preterm birth
Authors: Lumley Judith
Published: December 2003

Preterm birth is the major clinical problem associated with perinatal mortality, serious neonatal morbidity and moderate to severe childhood disability in prosperous countries. Its prevalence is affected by the way in which gestational age is assessed, by national differences in the registration of births, associated practices, such as burial costs, or maternity benefits, which encourage or discourage registration, and by the perceived viability of extremely preterm infants. Despite these uncertainties, there is reliable evidence that preterm births are increasing, especially births before 28 weeks gestation. Contributing factors include births following assisted reproductive therapy and ovulation induction, especially multiple births, and the increasing proportion of births among women >34 years. On the other hand, improvements in neonatal care have substantially increased the survival of preterm infants during the last 15 years. There is wider acceptance of the importance of infection as a factor in preterm birth, and increasing recognition that processes leading to preterm birth may be initiated in very early pregnancy (the initiation of pre‐eclampsia, major birth defects, premature placental separation), or even prior to pregnancy (prior pregnancy losses). It is unclear whether the familiar clinical presentations of preterm labour and birth reflect different pathophysiological processes. The pathways which link those processes to the consistent pattern of social differences in the probability of preterm birth have prompted new research approaches but in 2002 ‘the stubborn challenge of preterm birth’ remains just that.
Gender aspects of preterm birth
Authors: Ingemarsson Ingemar
Published: December 2003

It was previously believed that sex differentiation took place when the undifferentiated gonads formed either testes or ovaries. Studies in recent years indicate that sex differentiation begins at conception. The SRY gene on the Y‐chromosome is already transcribed at the 2‐cell stage and triggers growth acceleration in the XY embryos. This accelerated growth is believed to be important for the male embryo as it allows complete testicular differentiation before the levels of oestrogenic hormones become too high as pregnancy progresses. It is well known that the death rate is higher for male than for female fetuses and that the increase is about 30% in chromosomally normal spontaneous abortions (i.e. significantly higher than at birth). National figures from Sweden show that boys are more likely to be delivered prematurely, accounting for 55–60% of all newborns between 23 and 32 gestational weeks. Neonatal deaths in these gestational weeks are also more common among boys. In 1993, the overall 1‐year mortality rate (including all gestational weeks) in Sweden was 5.4% for boys and 4.1% for girls. The difference in infant mortality (within 1 year) is most pronounced at extremely early birth (23–24 gestational weeks) being 60% for boys compared with 38% for girls. The release of catecholamines during labour is an important defence mechanism by a hypoxic fetus. Preterm females have significantly higher catecholamine levels than males, which may explain the better outcome in females after a hypoxic event. Deaths occurring secondary to respiratory distress syndrome are greater for males and their cognitive recovery from perinatal intracranial haemorrhage is worse. Pulmonary hypoplasia after preterm rupture of the membranes is significantly more common among male newborns.Gender differences in mode of delivery, fetal heart rate in labour, acidaemia at birth, and age degenerative changes will also be discussed.
Mechanisms of labour—biochemical aspects
Authors: Bernal Andrés López
Published: December 2003

The mechanism of labour is not fully understood and further research into this important physiological process is needed. In some species, notably sheep, parturition is due to activation of the fetal hypothalamic–pituitary–adrenal axis. However, in primates, this axis appears to have a supportive, rather than essential role. Successful parturition requires an increase in coordinated uterine contractility together with changes in connective tissue that allow cervical ripening and dilatation. In most mammals, however, these changes are synchronised by a fall in maternal progesterone levels and a rise in oestrogens. This is not the case in women in whom the onset of labour occurs without apparent changes in circulating steroid levels. The basis of uterine contractility is the interaction between actin and myosin in myometrial smooth muscle cells. This is driven by calcium through Ca2+–calmodulin‐dependent myosin light chain kinase (MLCK) activity. Moreover, calcium sensitisation occurs via activation of Rho kinase, a calcium‐independent pathway that promotes contractility by inhibiting myosin phosphatase and probably by phosphorylating myosin on the same site as MLCK. Uterine activity can be modulated by many G‐protein coupled receptors (GPCRs). For example, receptors coupled to Gαq (oxytocin‐, prostanoid FP and TP, endothelin‐receptors) stimulate contractility by activating the phospholipase C/Ca2+ pathway; receptors coupled to Gαs (β2‐adrenoceptors, prostanoid EP2 and IP, some 5‐hydroxytryptamine receptors e.g. 5‐HT7) relax the uterus by increasing myometrial cyclic AMP levels; and receptors coupled to Gαi (α2‐adrenoceptors, muscarinic, 5‐HT1) potentiate contractility, probably by inhibiting cAMP production. Because of its relative abundance in pregnant uterine tissue, the oxytocin receptor is an obvious target for tocolytic therapy. Oxytocin antagonists have been introduced into clinical practice for the management of preterm labour and offer the advantage of uterine selectivity and fewer side effects than conventional beta‐agonist therapy.
Antenatal corticosteroids—current thinking
Authors: Crowley Patricia
Published: December 2003

Numerous investigations have indicated that antenatal corticosteroid administration reduces neonatal morbidity in preterm infants. Despite this, antenatal corticosteroid usage continued to be low on both sides of the Atlantic up to the late 1980s and early 1990s. Antenatal corticosteroid therapy finally came of age in 1995 with the publication of the National Institutes of Health Consensus Statement on effects of corticosteroids for fetal maturation on perinatal outcomes. The randomised trials of antenatal corticosteroid therapy have been based on the use of dexamethasone or betamethasone. However, observational evidence indicates differences in outcome, which may relate to the preparations themselves or to the preservatives included.
What are the realistic expectations of tocolytics?
Authors: Smith Graeme N.
Published: December 2003

Preterm birth, the leading cause of neonatal morbidity and mortality worldwide, is a major public health problem in terms of loss of life, long term disability (e.g. cerebral palsy, chronic lung disease), and health‐care costs. The outcome of preterm infants is directly related to the gestational age at delivery. The goal of tocolytic therapy is to reduce neonatal morbidity and mortality by delaying delivery, to allow for the administration of corticosteroids and/or the safe transfer to a tertiary‐care centre. However, currently available tocolytics in Canada (ritodrine, indomethacin, calcium antagonists, magnesium sulphate) have poor efficacy, have not been shown to increase the completion of a course of corticosteroids, are potentially associated with significant maternal/fetal side effects, and most importantly, have not been shown to improve neonatal outcomes. At the Canadian Tocolysis Consensus Conference, there was general agreement that recommendations should be based on good quality research evidence, particularly that of randomised clinical trials when available. It was concluded that there is little evidence to support the use of any of the currently available tocolytics; tocolytic use has not been associated with improved perinatal outcomes and often have detrimental effects on the mother. Therefore, questionable efficacy and potentially serious side effects may outweigh their use. Any new tocolytic demonstrated to improve neonatal outcome will have an immediate impact on societal and long term public health‐care costs.
Exploring the role of Tractocile in everyday clinical practice
Authors: Helmer Hanns , Brunbauer M. , Rohrmeister K.
Published: December 2003

The purpose of this retrospective study is to evaluate the effects of atosiban (Tractocile available in Austria since February 2000) for routine treatment of women with threatened preterm delivery. The advantage of this drug compared to other tocolytic agents is its specific action on reproductive tissues without the accompanying severe side effects. Women (n= 208) were retrospectively evaluated. Diagnoses at admission were preterm labour (n= 117), preterm rupture of membranes (n= 65), incompetent cervix (n= 19) and vaginal bleeding (n= 7). Gestational age was between weeks 21 and 33 of pregnancy. Preterm labour was defined as ≥4 uterine contractions/30 min and cervical length <30 mm examined by vaginal ultrasound and/or detection of vaginal fetal fibronectin. Tocolytic effectiveness was determined as the number of women having a diagnosis of preterm labour who were still pregnant after 48 hours and after 7 days. The influence on the frequency of contractions before and 3–12 hours after the start of treatment was assessed. Maternal side effects, perinatal and neonatal morbidity and transfers to the NICU were also evaluated. The proportion of women who remained undelivered was 78.7% after 48 hours, and 64.3% after 7 days. Atosiban decreased the frequency of contractions from 5.4/30 min before treatment to 1.6 contractions/30 min after the start of treatment. At the initial bolus application, 20.2% of women presented drug‐related side effects, such as nausea, vertigo and flush over a short period of 1–2 minutes. During infusion, side effects possibly related to atosiban could be detected in 6% of women. Mean length of stay was 11.8 days in the NICU and 30.9 days in intermediate care. Twenty‐three children developed intraventricular haemorrhage (I–IV). In conclusion, atosiban is an effective tocolytic drug in the treatment of preterm labour and preterm rupture of the membranes. It has significantly less side effects due to its lack of cardiovascular activity.
The critical role of perinatal pathology
Authors: Jeffrey Iona J.M.
Published: December 2003

In spite of great advances in imaging and biochemistry, histological examination of tissues remains a vital part of the multidisciplinary approach to the prevention of the onset, morbidity and mortality of preterm birth. There has been increasing interest in the role of infection and inflammatory cytokines in causation both of early labour and the white matter damage in the brain of preterm infants. However, labour itself is associated with the build up of increased numbers of inflammatory cells in the uterine cervix and increased concentrations of inflammatory cytokines and positive microbiological cultures may reflect carriage or contamination. Confirmation of an infective aetiology in an individual case is best achieved by demonstration of a pathological inflammatory response in tissues, for example, by showing the presence of chorioamnionitis in the placenta. A proper understanding of the poor response to neonatal intensive care of some preterm babies often requires histological examination of the lungs after death, where unsuspected pneumonia, interstitial emphysema and/or pulmonary hypoplasia may help provide an explanation for the adverse outcome in individual cases. The pathophysiological mechanism of brain injury in preterm infants is undergoing re‐evaluation, and the systemic study of brain tissue using the latest histological techniques may elucidate the importance of apoptosis in this situation and could point the way towards an effective preventative strategy. Paediatric pathology is also essential to explain many cases of sudden unexpected death in preterm infants, as demonstrated by the recent realisation that death may be caused by total parenteral nutrition fluid‐associated myocardial necrosis, and acute cardiac tamponade.
Clinical manifestations and abnormal laboratory findings in pregnant women with primary cytomegalovirus infection
Authors: Nigro Giovanni , Anceschi Maurizio M. , Cosmi Ermelando V. ,   The Congenital Cytomegalic Disease Collaborating Group,   The names of collaborators may be found on page 576
Published: December 2003

Objective
To compare the clinical manifestations and laboratory abnormalities associated with primary cytomegalovirus (CMV) infection in pregnancy with recurrent and non‐active CMV infection (controls).

Design
A prospective cohort study.

Setting
Rome, Latium and other Italian regions.

Population
Three hundred and sixteen pregnant women with CMV infection: 102 had primary infection, 105 had recurrent infection and 109 with non‐active infection were followed up as controls.

Methods
CMV diagnosis was based on serological examinations (CMV IgG, IgM and IgG avidity) and detection of CMV DNA by polymerase chain reaction in maternal serum, urine and cervical samples. The clinical history and laboratory evaluations were carried out at enrolment and at each subsequent visit, every one to three months.

Main outcome measures
Identification of clinical and laboratory indicators of primary CMV infection in pregnancy.

Results
Compared with women with recurrent or non‐active infection, women with primary infection had a statistically significant higher prevalence of fever, asthenia, myalgia and flu‐like syndrome (P < 0.001). In particular, relevant symptomatology was observed in 32 women (31.4%), of whom 25 had flu‐like syndrome and 7 persistent fever as a single manifestation. Moreover, women with primary infection showed a significantly increased rate of lymphocytes ≥40% (39.2% vs 5.7% or 3.7%, respectively, P < 0.001) and elevated aspartate aminotransferase and/or alanine aminotransferase levels (35.3% vs 3.9% or 0.9%, respectively, P < 0.001): lymphocytosis and/or increased aminotransferases occurred in 53 patients (52%). In total, clinical manifestations and/or laboratory abnormalities occurred in 61 women with primary infection (59.8%) compared with 20 with recurrent infection (19%) and 13 controls (11.9%) (P < 0.001).

Conclusion
Clinical manifestations (i.e. flu‐like syndrome, fever) and abnormal laboratory findings (i.e. lymphocytes ≥40%, elevated aminotransferases) may suggest the presence of primary CMV infection and should prompt subsequent virological investigations.
Gestational trophoblastic disease in the Asian population of Northern England and North Wales
Authors: Tham B.W.L. , Everard J.E. , Tidy J.A. , Drew D. , Hancock B.W.
Published: December 2003

Objective
To determine the incidence and trends of gestational trophoblastic disease in the Asian population of Northern England and North Wales.

Design
A prospective observational study.

Setting
Trophoblastic Screening and Treatment Centre, Weston Park Hospital.

Population
A total of 3660 women registered with gestational trophoblastic disease between 1991 and 1999.

Main outcome measures
1. The incidence of gestational trophoblastic disease in Asian and non‐Asian population. 2. Trend in incidence over study period.

Results
Three hundred and twenty‐two Asian patients were registered. The incidence of gestational trophoblastic disease in the northern part of England and Wales averaged 1 per 714 live births. The incidence of gestational trophoblastic disease in the Asian population was 1.95 times higher than in the non‐Asian population (1 per 387 live births vs 1 per 752 live births). There was an excess of molar pregnancies in the extreme maternal age groups; the incidence in these women was twice as high as in the whole reproductive cohort. The ratio of partial to complete hydatidiform mole increased from 0.9 in the lower age to 2.6 in the older age group. There appeared to be a slowly rising trend in the incidence of gestational trophoblastic disease; the increase was higher in the Asian than in the non‐Asian population. The ratio of partial to complete moles increased with age in both populations.

Conclusions
Asian women are at increased risk of having molar pregnancies. Molar pregnancies are more common at the extremes of reproductive age. The setting up of regional or national registration centres has helped to provide more accurate estimates of the true incidence of the disease.
Assessing urinary albumin excretion in pre‐eclamptic women: which sample to use?
Authors: Kieler Helle , Zettergren Tuttan , Svensson Hanna , Dickman Paul W. , Larsson Anders
Published: December 2003

Objective
To evaluate whether the gold standard of 24‐hour urine collection for measuring albumin excretion in pre‐eclamptic women could be substituted by shorter collection periods.

Design
Prospective study.

Setting
Fetal maternity ward, university hospital.

Participants
Thirty women with pre‐eclampsia and a positive urinary test strip for protein of at least 2+.

Methods
From each woman, within a 25‐hour period, three spot, two 12‐hour (day and night) and one 24‐hour urine sample were collected. Urine albumin concentrations in milligrammes per litre were analysed by rate nephelometry on a Beckman Array protein system. The urinary albumin concentrations in the spot and the 12‐hour samples were compared with the concentration in the 24‐hour urine collection.

Main outcome measures
Urinary albumin concentrations in spot and 12‐hour samples measured against the standard 24‐hour albumin excretion.

Results
Albumin concentrations in the day and night collection fitted closely with the concentrations of the 24‐hour collection. The median difference between the 24‐hour and the day collection was −3 mg/L (interquartile range −264 to 116 mg/L). The median difference between the 24‐hour and the night collection was 17 mg/L (interquartile range −186 to 210 mg/L). The association of urinary albumin concentration in the 24‐hour collection and the spot samples was much weaker. Of the spot urine samples, the albumin concentration in the sample taken on the morning after admission to hospital was closest to the 24‐hour urinary albumin excretion, with a median difference of −62 mg/L (interquartile range −1131 to 285 mg/L).

Conclusion
The gold standard of 24‐hour urinary excretion for assessment of albuminuria in pre‐eclamptic women can be substituted with a 12‐hour collection. Spot urine samples were inaccurate and are therefore not recommended for quantification of albumin excretion.
Term breech presentation in The Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33,824 infants
Authors: Rietberg Christine C.Th. , Elferink‐Stinkens Patty M. , Brand Ronald , van Loon Aren J. , Van Hemel Oscar J.S. , Visser Gerard H.A.
Published: December 2003

Objective
To analyse neonatal mortality and morbidity in term infants born in breech presentation in relation to the mode of delivery (planned caesarean section, emergency caesarean section or vaginal delivery) and to compare these findings with those of the Term Breech Trial Collaborative Group [Hannah et al. Lancet 2000; October].

Design
Retrospective observational study.

Setting
The Netherlands.

Population
Infants (n= 33,824) born at term in breech presentation in the Netherlands between 1995 and 1999. Multiple pregnancies, antenatal death and major congenital malformations were excluded.

Methods
Data derived from the Dutch Perinatal Database were used to compare neonatal outcome of infants born in breech presentation in relation to the different modes of delivery (i.e. planned caesarean section, emergency caesarean section and vaginal delivery). Correction was made for differences in parity, duration of gestation and birthweight, using logistic regression.

Main outcome measures
Intrapartum and first‐week neonatal death, 5 minute Apgar score and birth trauma.

Results
Vaginal delivery and emergency caesarean section resulted in a sevenfold increase in low Apgar score, a threefold increase in birth trauma and a twofold increase in perinatal mortality when compared with the results of planned caesarean section.

Conclusions
This study confirms the data found by Hannah et al. on an increase in early neonatal morbidity and mortality, following a trial of labour in cases of term breech presentation. These data require carefully weighed consideration against increased maternal (long term) risks due to a rise in caesarean sections.
High caesarean rates in Madras (India): a population‐based cross sectional study
Authors: Sreevidya S. , Sathiyasekaran B.W.C.
Published: December 2003

Objective
To estimate the population caesarean section rate in urban India.

Design
Population‐based cross sectional study.

Setting
Madras City (Chennai), India.

Sample
Seven hundred and eighty resident women who delivered in Madras between June 1997 and May 1999.

Methods
Cluster sampling was done using streets as cluster units. Thirty clusters were selected from 1255 clusters by the probability proportion to size method and 26 women were selected randomly from each cluster.

Main outcome measures
Total and primary caesarean rates.

Results
Total population caesarean section rate was 32.6% (95% CI 27–38) and primary caesarean section rate was 25% (95% CI 20–30). Total caesarean section rates in the public, charitable and private sectors were 20%, 38% and 47%, respectively. Private sector deliveries had an odds ratio of 2.4 (95% CI 1.5, 3.8) of a primary caesarean section delivery in comparison with the public sector after adjustment for parity, age at delivery of mother and educational status.

Conclusions
Forty‐seven percent of births by caesarean section in the private sector is alarming and could implicate private sector care as the main contributing factor behind the high population caesarean section rates. Policymakers should urgently institute systems for accountability and ethical practice and regularly monitor all medical interventions, before large scale exploitation of the rural markets begins.
Birth outcomes: utility values that postnatal women, midwives and medical staff express
Authors: Pham C.T. , Crowther C.A.
Published: December 2003

Objective
To determine if and to what extent postnatal women's preferences for birth outcomes differ from those of midwives and medical staff, and whether any variations in utility scores are associated with demographic variables.

Design
Cross sectional cohort study.

Setting
The Women's and Children's Hospital, Adelaide.

Population
A total of 180 participants which included 90 postnatal women, 59 midwives and 31 medical staff.

Methods
Preferences (utility scores) for eight birth outcomes were measured by direct interviews using two utility techniques: the visual analogue scale and the standard gamble.

Main outcome measures
Preferences (utility scores) for eight birth outcomes.

Results
Women assigned higher utility scores for the five birth outcomes of jaundice requiring phototherapy, admission to neonatal nursery, shoulder dystocia, nerve palsy and transient neurological symptoms than midwives, which suggested that women regarded these outcomes as less severe (P < 0.01). Utility scores for the women and medical staff were similar. The majority of postnatal women, midwives and medical staff preferred permanent neurological sequelae to perinatal death. Eighty‐nine percent of postnatal women preferred permanent neurological sequelae to perinatal death compared with 71% of midwives (P < 0.01), and 68% of medical staff (P < 0.01).

Conclusion
Utility values for important birth outcomes varied between women who had recently given birth and health professionals. Clinical practice should recognise and respect the preferences of women, with appropriate balance between their preferences, those of health professionals and the known benefits of care.
Maternal serum activin, inhibin, human chorionic gonadotrophin and α‐fetoprotein as second trimester predictors of pre‐eclampsia
Authors: Davidson Emma J. , Riley Simon C. , Roberts Stephen A. , Shearing Catherine H. , Groome Nigel P. , Martin Cameron W.
Published: December 2003

Objective
To compare the serum levels of human chorionic gonadotrophin (hCG), α‐fetoprotein, activin A, inhibin A and inhibin isoforms containing pro and αC in the second trimester serum of women who subsequently developed hypertensive disorders of pregnancy with those who remained normotensive throughout pregnancy.

Design
Retrospective case–control study of 15–20 week serum samples matched for duration of storage at −20°C.

Setting
Antenatal clinics at a teaching hospital in Scotland.

Sample
Second trimester serum samples of 39 women who subsequently developed pre‐eclampsia, 31 who subsequently developed pregnancy‐induced hypertension and 155 women who remained normotensive throughout pregnancy.

Main outcome measures
hCG, α‐fetoprotein, activin A, inhibin A and inhibin pro–αC serum levels.

Results
Activin A levels in serum were significantly elevated in women who later developed pregnancy‐induced hypertension (26% increase compared with controls) and hCG levels were significantly elevated in women who later developed pre‐eclampsia (24% increase compared with controls). α‐Fetoprotein, inhibin A and inhibin pro–αC levels were not significantly elevated in the patient groups compared with their controls.

Conclusions
A combination of analyses including second trimester serum activin A and hCG may yet prove to be helpful predictors of women at risk of hypertensive disorders of pregnancy. While the results proved significant, the effects reported in this study are too modest compared with natural variability to be useful as screening tools on their own.
Differences in perinatal mortality and suboptimal care between 10 European regions: results of an international audit
Authors: Richardus Jan H. , Graafmans Wilco C. , Verloove‐Vanhorick S. Pauline , Mackenbach Johan P. ,   The EuroNatal International Audit Panel,   The EuroNatal Working Group,   A list of the members of the EuroNatal International Audit Panel and the EuroNatal Working Group may be found on page 104
Published: December 2003

Objective
A European concerted action (the EuroNatal study) investigated the background of differences in perinatal mortality between countries of Europe. The study aimed to determine the contribution of differences in quality of care, by looking at differences in the presence of suboptimal factors in individual cases of perinatal death.

Design
Retrospective audit study.

Setting
Regions of 10 European countries.

Population
1619 cases of perinatal death.

Methods
Perinatal deaths between 1993 and 1998 in regions of 10 European countries were identified. Reviewed were singleton fetal deaths (28 or more weeks of gestational age), intrapartum deaths (28 or more weeks) and neonatal deaths (34 or more weeks). Deaths with (major) congenital anomalies were excluded. Cases were blinded for region and an international audit panel reviewed them using explicit audit criteria.

Main outcome measures
Presence of suboptimal factors.

Results
The audit covered 1619 cases of perinatal death, representing 90% of eligible cases in the regions. Consensus was reached on 1543 (95%) cases. In 715 (46%) of these cases, suboptimal factors, which possibly or probably had contributed to the fatal outcome, were identified. The percentage of cases with such suboptimal care factors was significantly lower in the Finnish and Swedish regions compared with the remaining regions of Spain, the Netherlands, Scotland, Belgium, Denmark, Norway, Greece and England. Failure to detect severe IUGR (10% of all cases) and smoking in combination with severe IUGR and/or placental abruption (12%) was the most frequent suboptimal factor. There was a positive association between the proportion of cases with suboptimal factors and the overall perinatal mortality rate in the regions.

Conclusions
The findings of this international audit suggest that differences exist between the regions of the 10 European countries in the quality of antenatal, intrapartum and neonatal care, and that these differences contribute to the explanation of differences in perinatal mortality between these countries. The background to these differences in quality of care needs further investigation.
The Doppler Assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy
Authors: Giles Warwick , Bisits Andrew , O'Callaghan Stephen , Gill Andrew ,   DAMP Study Group,   Names of group collaborators may me found on page 596
Published: December 2003

Objective
To assess the addition value of umbilical artery Doppler ultrasound added to standard ultrasound biometry measurements in the management of twin pregnancies.

Design
A prospective randomised controlled multicentre trial of women with twin pregnancies.

Setting
Tertiary level referral hospitals in Australia, New Zealand and Southeast Asia.

Population
Pregnant women with twin pregnancies.

Methods
Women were randomised at 25 weeks of gestation to receive either standard ultrasound biometric assessment or standard assessment plus Doppler ultrasound umbilical artery flow velocity waveform analysis. The studies were repeated at 30 and 35 weeks unless otherwise indicated. Physicians were advised to institute close fetal surveillance in the presence of an abnormal umbilical artery Doppler study or with biometry indicators of fetal compromise.

Main outcome measures
Standard obstetric (mode of delivery, perinatal mortality, hypertension, antenatal admissions and gestation at delivery) and neonatal (5 minute Apgar scores <5, admissions to neonatal nursery and requirements for ventilation) outcomes and statistical analysis was on intention‐to‐treat.

Results
There were no significant differences between the two groups with respect to demography, antenatal, peripartum and neonatal outcomes. There was no difference in the perinatal mortality rate in the no Doppler group (n= 264), which was 11/1000 live births, and the Doppler group (n= 262), which was 9/1000 live births. There were three unexplained intrauterine deaths in the no Doppler group and none in the Doppler group (OR 0.14, 95% CI 0.01–1.31). Two intrauterine deaths in the Doppler group were due to cord prolapse in labour and a fetomaternal haemorrhage, both very unlikely to be influenced by Doppler surveillance.

Conclusions
In this study, close surveillance in twin pregnancy resulted in a lower than expected fetal mortality from 25 weeks of gestation in both the no Doppler and Doppler groups. The lower rate of unexplained fetal death in the no Doppler group was not significantly different from the Doppler group.
Pregnancy outcome in severe placental abruption
Authors: Kayani Salma Imran , Walkinshaw Stephen A. , Preston Carrol
Published: December 2003

Objective
To determine the relationship between decision to delivery interval and perinatal outcome in severe placental abruption.

Design
A case–control study.

Setting
Large inner city teaching hospital.

Methods
Retrospective case note review of pregnancies terminated following severe placental aburption and fetal bradycardia. One year paediatric follow up by case note review or postal questionnaire. The differences in outcome (death or cerebral palsy) were examined using non‐parametric and univariate analysis for the following time periods — times from onset of symptoms to delivery, onset of symptoms to admission, admission to delivery, onset bradycardia to delivery and decision to delivery interval.

Main outcome measures
Prenatal death or survival with cerebral palsy.

Results
Thirty‐three women with singleton pregnancies over 28 weeks of gestation, admitted with clinically overt placental abruption, where delivery was effected for fetal bradycardia. Eleven of the pregnancies had a poor outcome (cases), eight infants died and three surviving infants have cerebral palsy. Twenty‐two pregnancies had a good outcome (controls): survival with no developmental delay. No statistically significant relationship was found between maternal age, parity, gestation, or birthweight and a poor outcome. A statistically significant relationship between time from decision to delivery was identified (P= 0.02, Mann–Whitney U test). The results of a univariate logistic regression for this variable suggest that the odds ratio of a poor outcome for delivery at 20 minutes compared with 30 minutes is 0.44 (95% CI 0.22–0.86). Fifty‐five percent of infants were delivered within 20 minutes of the decision to deliver. Serious maternal morbidity was rare.

Conclusion
In this small study of severe placental abruption complicated by fetal bradycardia, a decision to delivery interval of 20 minutes or less was associated with substantially reduced neonatal morbidity and mortality.
Cerebral palsy and clinical negligence litigation: a cohort study
Authors: Greenwood Catherine , Newman Sally , Impey Lawrence , Johnson Ann
Published: December 2003

Objective
To compare the prevalence of criteria suggesting acute intrapartum hypoxia in children with cerebral palsy who have and have not been the subjects of clinical negligence legal claims.

Design
Nested cohort study within a geographically defined cohort.

Setting
The former Oxfordshire Health Authority.

Population
Singleton children with cerebral palsy born between 1984 and 1993, excluding cases with a recognised postnatal cause for cerebral palsy.

Methods
Retrospective review of medical records by blinded observer.

Main outcome measures
Three ‘essential’ criteria defined by the International Cerebral Palsy Task Force which identify acute intrapartum hypoxia.

Results
One‐fifth (27/138) of all singleton cerebral palsy children were the subject of a legal claim. The presence of all three criteria was significantly more likely to lead to a legal claim (P < 0.01), but in 74% (20/27) of claims, all three were not fulfilled and 36% (4/11) of those satisfying all three criteria did not claim. At least one of the three criteria was met in 82% (91/111) of the cases where there was no claim. Data on fetal or neonatal arterial blood gases were available in only 57% (78/138). Of the 27 claims, 12 were discontinued, 8 were settled and in 7 the legal process is still pending. The presence of the three essential criteria for acute intrapartum hypoxia did not increase the likelihood of a legal claim being settled.

Conclusion
The prevalence of the ‘template essential’ criteria is high in all cases of cerebral palsy. Although the presence of all three essential criteria was more likely in the claims group, this did not appear to influence the outcome of a claim. It remains to be seen whether the existence of the template leads to change in the pattern of decisions made by the courts.