bluuebunny/crossref_metadata_2025 huggingface dataset:
Litigation and the cardiotocogram
Authors: Symonds E. M.
Published: August 2005

The extent of the liability in obstetric litigation is discussed. Arguments between experts reveal the lack of agreed standards in cardiotocography. This paper discusses the problems which need to be addressed when defning what constitutes an abnormal cardiotocogram (CTG), how long it needs to abnormal before it is significant, the contribution made by inadequate equipment and the question of whether it is defensible to decide positively not to monitor. Records need to be archived for a minimum of 25 years.
Signal processing and display—cardiotocographs
Authors: Carter Michael C.
Published: August 2005

The technology used in cardiotocographs limits the basic resolution of the recorded data. The limitations and errors generated by the data collection, signal processing (autocorrelation) and printing the fetal heart rate (FHR) are discussed. Although adequate for displaying baseline variability, present‐day cardiotocographs are incapable of displaying beat‐to‐beat changes in FHR.
The loss of a baby at birth: the role of the bereavement officer
Authors: Appleton Richard , Gibson Brenda , Hey Edmund
Published: August 2005

Objective
To illustrate and emphasise the role of the Bereavement Officer in the management of perinatal death, as recommended and envisaged by a report of the Royal College of Obstetricians and Gynaecologists in 1985.

Design
A description of the training and responsibilities of the officer and an account of her involvement with all perinatal deaths within a given period.

Setting
Perinatal deaths in the 12 months, 1 October 1989 to 30 September 1990 from a regional neonatal intensive care unit within a maternity hospital.

Subjects
A total of 59 registerable deaths, three late terminations (severe fetal abnormality) and 12 late mid‐trimester miscarriages were dealt with by the Bereavement Officer in this 12 month period.

Results
The introduction of this service to our unit has led to an improvement in our management of both perinatal and fetal deaths.

Conclusion
The service has justified fully the recommendations made by the Royal College of Obstetricians and Gynaecologists. Reducing parents’ distress will facilitate their grieving and any subsequent bereavement counselling.
Screening for fetal distress in labour using the umbilical artery blood velocity waveform
Authors: Somerset D. A. , Murrills A. J. , Wheeler T.
Published: August 2005

Objective
To investigate the potential value of umbilical artery blood velocity waveform measurement as a screening test for intrapartum fetal distress on admission to the labour ward.

Design
Prospective study drawn from the local population of pregnant women.

Setting
The labour ward of the Princess Anne Hospital, Southampton, UK.

Subjects
334 women with singleton pregnancies of at least 37 weeks gestation.

Main outcome measure
Emergency caesarean section for fetal distress.

Results
There was a twelvefold increase in the rate of emergency caesarean section for fetal distress (95% Confidence Interval (CI), 4.9‐29) among women with a systolic/diastolic (S/D) ratio 3.0, when compared to those with an S/D ratio of <3.0 (P < 0.00001). Measurement of the umbilical artery blood velocity waveform compared favourably with admission cardiotocography.

Conclusions
Umbilical artery blood velocity waveform analysis may be used to screen for fetal distress in labour and appears to be particularly sensitive to problems of placental origin. However, it is not likely to confer benefit in labour wards whose fetal heart rate monitoring policy is determined by pregnancy risk factors and admission cardiotocography.
Low maternal serum levels of pregnancy associated plasma protein A (PAPP‐A) in the first trimester in association with abnormal fetal karyotype
Authors: Brambati B. , Macintosh M. C. M. , Teisner B. , Maguiness S. , Shrimanker K. , Lanzani A. , Bonacchi I. , Tului L. , Chard T. , Grudzinskas J. G.
Published: August 2005

Objective
To assess the relation between maternal serum pregnancy associated plasma protein A (PAPP‐A) in the first trimester and the outcome of pregnancy by karyotype.

Design
A retrospective study of PAPP‐A levels in blood samples collected prior to chorionic villus sampling.

Setting
Milan, Italy.

Subjects
Five hundred twenty‐two women, aged 20 to 47, at 7 to 11 weeks gestation, prior to undergoing chorionic villus sampling. Four hundred forty‐five women had a pregnancy with a normal karyotype; in 30 pregnancies the karyotype was abnormal (including 14 cases of Down's syndrome and 7 of trisomy 18).

Main outcome measures
Normal or abnormal fetal karyotype. Serum PAPP‐A at 6 to 11 weeks gestation measured by radioimmunoassay.

Results
The median value of PAPP‐A in the abnormal group was 0.27 multiples of the normal median (MoM). This is significantly lower than the median value in the normal group (1.01 MoM) (95% CI for the difference 0.46–0.84 MoM; P<0.00001 Mann‐Whitney test).

Conclusions
There is an association between low levels of PAPP‐A in the first trimester with chromosome anomalies. Screening by measurement of PAPP‐A might detect 60% of cases of Down's syndrome in the first trimester with a false positive rate of 5%.
The individualised birthweight ratio: a more logical outcome measure of pregnancy than birthweight alone
Authors: Wilcox Mark A. , Johnson Ian R. , Maynard Paul V. , Smith Sarah J. , Chilvers Clair E. D.
Published: August 2005

Objective
To provide a new outcome measure for pregnancy specifically related to the individual.

Design
Computer analysis of physiological factors affecting birthweight.

Setting
Two provincial teaching hospitals (University and City Hospitals, Nottingham) and an associated district general hospital (Derby City Hospital) serving a defined catchment area in the East Midlands.

Subjects
All women delivering in the above hospitals since the start of computerised obstetric records: 31 561 women with gestational age verified by early pregnancy ultrasound scan data.

Main Outcome Measures
Calculation of the predicted birthweight taking into account maternal and fetal physiological factors. Derivation of the individualised birthweight ratio (actual birthweight divided by predicted birthweight expressed as a percentage) for each individual baby.

Results
The individualised birthweight ratio redefines as normally grown 41% of babies below the 10th centile of crude birthweight for gestation. Other babies previously regarded as normal are redefined as growth retarded. At the upper end of the distribution 46% of those above the 90th centile of birthweight for gestation are redefined as normally grown.

Conclusions
The predicted birthweight can be calculated for an individual pregnancy at a given gestation. The standardised comparison between this predicted birthweight and the actual birthweight is a more logical reflection of the normality of intrauterine growth and therefore more logical as an outcome measure for pregnancy than crude birthweight for gestation.
Intravaginal misoprostol as a cervical ripening agent
Authors: Fletcher H. M. , Mitchell S. , Simeon D. , Frederick J. , Brown D.
Published: August 2005

Objective
To determine if misoprostol (exogenous prostaglandin E1 PGE1) used vaginally was of value in improving the Bishop score, leading to an early safe vaginal delivery in women in whom the cervix is unripe and delivery is indicated.

Design
A double‐blind clinical trial.

Setting
Antenatal and labour wards of the University Hospital of the West Indies, Jamaica.

Subjects
Forty‐five women in the third trimester with various obstetric indications for induction of labour and with no contra‐indications to prostaglandins.

Interventions
The women were randomly assigned to receive treatment or a placebo. The treated group had 100 μg misoprostol inserted vaginally while the placebo was similarly inserted.

Main outcome measures
Efficacy of the misoprostol was measured by the increase in the Bishop score 12 h after giving the treatment, the time between insertion and delivery, the need for oxytocin, and the out‐come of the pregnancy.

Results
The prostaglandin was superior to the placebo in ripening the cervix and inducing labour. The change in Bishop score was 5·3 in the misoprostol group compared with 1·5 in the placebo group (P < 0·001). The mean time from insertion to delivery was 15·6 h in the former while it was 43·2 h in the placebo group (P≤ 0·001). The need for oxytocin was also significantly less in the women receiving the prostaglandin compared with those who received the placebo (29%vs 62%, P < 0·02). There was no difference in the two groups in the delivery outcome in terms of complications, Apgar scores and mode of delivery.

Conclusions
Intravaginal misoprostol is an effective and cheap method of inducing labour in the third trimester.
The design, effectiveness and acceptability of the arm sleeve for the prevention of body fluid contamination during obstetric procedures
Authors: Kabukoba Josaphat J. , Pearce J. Malcolm
Published: August 2005

Objective
1. To design a device that would reduce contamination of staff during obstetric procedures. 2. To undertake clinical trials to assess the effectiveness and acceptability of such a device.

Design
A prospective study. The arm sleeve is made of a nonwoven material laminated on polyethylene film making it waterproof. It has an elastomeric cuff with adhesive that ensures a watertight seal between it and the glove.

Setting
Delivery suite in a teaching hospital.

Methods
Doctors and midwives were requested to wear the sleeve on top of the standard gown and gloves. Each user was assessed for blood contamination at the end of the procedure and a questionnaire detailing the extent of contamination and the views of the user was completed.

Results
Eighty questionnaires were completed. The contamination of arms and hands was 3.8% and 5%, respectively. Eighty‐nine percent thought the sleeve had served its purpose and 76% said they would use it regularly.

Conclusions
The sleeve is an effective protective device which complements the glove and gown. We recommend that it should be used during all obstetric procedures.
Endometrial fibrinolytic enzymes in women with normal menstruation and dysfunctional uterine bleeding
Authors: Gleeson N. , Devitt M. , Sheppard B. L. , Bonnar J.
Published: August 2005

Objective
To study fibrinolysis in the endometrium in women with normal menstruation and dysfunctional uterine bleeding (DUB).

Design
Tissue plasminogen activator activity (t‐PA) and antigen (t‐PAAg) and plasminogen activator inhibitor Type 1 antigen (PAI‐1) were measured in homogenates of endometrium sampled between 24 and 36 h after the onset of menstruation.

Subjects
Women complaining of menorrhagia who had negative findings at clinical examination and curettage had their menstrual blood loss (MBL) measured from the third cycle after D&C. Those with MBL greater than 80 ml per cycle formed the DUB group.

Measurements
Fibrinolytic enzyme antigen levels were measured with ELISAs. Tissue plasminogen activator activity was assayed by measuring the rate of conversion of Glu‐plasminogen to plasmin, using a chromogenic plasmin substrate.

Conclusions
There is a strong positive correlation between endometrial t‐PA activity on the second day of menstruation and measured menstrual loss (P<0.05). Concentrations of endometrial t‐PAAg and PAI‐1 antigen are higher in women with DUB compared with normal women during menstruation.
Increased risk of aneuploidy in women having unsuccessful chorionic villus sampling procedures
Authors: Donnenfeld Lan E. , Librizzi Ronald J. , Weiner Stuart , Bolognese Ronald J.
Published: August 2005

Objective
To determine the incidence of fetal aneuploidy in women who had unsuccessful chorionic villus sampling (CVS) procedures.

Design
Retrospective study.

Setting
Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.

Subjects
Two thousand six hundred and sixty‐eight women who underwent chorionic villus sampling, in 78 (2.9%) of whom villi could not be obtained.

Interventions
Sixty‐nine of 78 (88%) women who had an unsuccessful CVS procedure underwent a subsequent amniocentesis later in the same pregnancy.

Main outcome measures
The incidence of aneuploidy identified from amniotic fluid chromosome analysis in the 69 women who had an unsuccessful CVS procedure compared to the frequency of aneuploidy in women having a successful CVS procedure.

Results
Of the 69 women who underwent a post‐CVS amniocentesis because of failure to obtain chorionic villi, six aneuploid pregnancies were identified (8.7%). The frequency of aneuploidy in the 2590 successfully sampled CVS patients was 2.5%. This difference was statistically significant (P= 0.009) by Fisher's exact test (two‐tailed).

Conclusions
Women having an unsuccessful CVS procedure should be informed that they may be at increased risk for carrying an aneuploid fetus.
The adnexal mass: benign or malignant? Evaluation of a risk of malignancy index
Authors: Davies Ann Prys , Jacobs Ian , Woolas Robert , Fish Andrew , Oram David
Published: August 2005

Objective
To validate a risk of malignancy index incorporating menopausal status, serum CA 125 level and pelvic ultrasound features in the pre‐operative diagnosis of ovarian cancer.

Design
A retrospective observational study.

Setting
Department of Obstetrics and Gynaecology, The Royal London Hospital.

Subjects
One hundred and twenty‐four women admitted consecutively to the gynaecology department for surgical exploration of an adnexal mass.

Main outcome measures
The sensitivities and specificities of menopausal status, serum CA 125 level and ultrasound features, in isolation and combined (the risk of malignancy index (RMI)), for diagnosing ovarian cancer.

Results
Tested on a new population of women, the RMI retained the high sensitivity for diagnosing ovarian cancer seen in the original report describing its derivation. The specificity, however, was lower. The study confirmed that the RMI is more accurate than the individual criteria in diagnosing ovarian cancer, and was comparable with other scoring systems.

Conclusions
The risk of malignancy index is a simple scoring system for ovarian cancer. Application of the risk of malignancy index in clinical practice may provide a rational basis for specialist referral of patients with ovarian cancer before diagnostic surgery.
Electroencephalogram and computerised cerebral tomography findings in eclampsia
Authors: Moodley J. , Bobat S. M. , Hoffman M. , Bill P. L. A.
Published: August 2005

Objective
To define more clearly the neuropathophysiology of eclampsia.

Design
A prospective study relating to computerised cerebral tomography (CAT) scan and electroencephalogram (EEG) findings in eclampsia.

Setting
A large referral centre in a developing society.

Subjects
Thirty‐two women with eclampsia.

Main outcome measures
Abnormalities in EEG and CAT scan findings.

Results
Approximately 45% of the women studied had CAT scan abnormalities, while 90% had EEG abnormalities. A burst suppression pattern on EEG examination was found in four women suggesting a temporary dissolution of cerebral function to the midbrain level as the cause of seizures.

Conclusions
EEGs are probably more sensitive than CAT scans in detecting the extent of the pathology in the brain in women with eclampsia.
Fetal intracranial haemorrhage: clinical significance of in utero ultrasonographic diagnosis
Authors: Achiron R. , Pinchas O. Hamiel , Reichman B. , Heyman Z. , Schimmel M. , Eidelman A. , Mashiach S.
Published: August 2005

Objective
To review in utero detection of fetal intracranial haemorrhage.

Design
Retrospective survey of pregnant women presenting to the ultrasonographic unit in whom the diagnosis of fetal intracranial haemorrhage was reached.

Setting
The Chaim Sheba Medical Center in Ramat Gan, and Shaare Zedek Medical Center in Jerusalem; two large district general hospitals, each with 6000 maternity patients per year.

Subjects
Five fetuses with gestational ages ranging from 26 to 36 weeks.

Main outcome measures
Maternal complications, fetal monitoring, prenatal Doppler ultrasound studies, postnatal imaging studies, neonatal morbidity and mortality.

Results
Transabdominal sonography showed hyperechoic lesions in the brain parenchyma, and the lateral ventricle in three of five fetuses. In the remaining two fetuses, transvaginal sonography enhanced the visualisation of ventriculomegaly with intraventricular haemorrhage in one and periventricular leukomalacia was identified in the second. Three fetuses were appropriate for gestational age, and two were severely growth retarded. In one woman severe pre‐eclamptic toxaemia may explain intracranial haemorrhage. Abnormal nonstress test and abnormal flow velocity waveforms in the umbilical and cerebral arteries were present in the two growth retarded fetuses, and in one who was appropriate for gestational age. The two growth retarded fetuses died shortly after birth. Of the three surviving infants, two had normal long term development, and one developed hydrocephalus with subsequent severe neurodevelopmental retardation, dying at the age of seven months.

Conclusions
This small series shows that intracranial haemorrhage has a broad spectrum of manifestations with diverse prognosis. Following an antenatal diagnosis of intracranial haemorrhage, the obstetrician must give special consideration to electronic fetal heart monitoring and Doppler velocity waveforms. The prenatal diagnosis of intracranial haemorrhage has medico‐legal implications suggesting that neurological outcome may not necessarily be due solely to intrapartum events and management.
The coagulation system in placental insufficiency: a study in the fetal circulation
Authors: Wilcox Gavin R. , Trudinger Brian J. , Exner Thomas
Published: August 2005

Objective
To examine the hypothesis that Doppler‐defined umbilical placental insufficiency is associated with intravascular coagulation in the fetal circulation.

Design
A prospective, descriptive, single centre study.

Setting
The University of Sydney, Department of Obstetrics at Westmead Hospital.

Subjects
Ninety‐one infants were classified on the basis of the systolic: diastolic (SD) ratio of the umbilical artery flow velocity waveforms into severe (SD > 99.9th centile), moderate (SD >95th centile) or control groups.

Intervention
Blood was collected from the umbilical vein at delivery.

Main outcome measures
The coagulation variables measured were the plasma concentrations of thrombin‐antithrombin, fibrinopeptide A and fibrinogen, the antithrombin III activity, the prothrombin time and the activated partial thromboplastin time.

Results
There were no differences in activated partial thromboplastin time, antithrombin III activity, fibrinopeptide A or thrombin‐antithrombin complex concentrations between fetuses with placental insufficiency and those with no placental disease. Fetuses with severe and moderate placental insufficiency had a statistically significant prolongation of their mean prothrombin time compared to controls (23.7 ± 0.8, 23.6 ± 1.6, and 19.9 ± 0.6 s, respectively). Infants in the severe group had a lower plasma fibrinogen concentration than control fetuses (1.66 ± 0.09 and 1.94 ± 0.09 g/l, respectively). The activated partial thromboplastin time and antithrombin III activity were both highly dependent on gestational age.

Conclusions
These results do not support the hypothesis that Doppler‐defined umbilical placental insufficiency is associated with activation of coagulation in the fetal circulation.
An audit of general practitioner requests for pelvic ultrasound: analysis of referral patterns and outcome
Authors: Skillern L. H. , Pearce J. M.
Published: August 2005

Objectives
1. To assess the information supplied by general practitioners on the gynaecological ultrasound request form and to determine how this information influences the interpretation of scans; and 2. To examine the influence of scans on the subsequent management of patients both by general practitioners and, where relevant, by hospital gynaecologists.

Design
Retrospective analysis of gynaecological ultrasound requests made by general practitioners. Postal questionnaire and assessment of outcome according to general practitioners' records and, where appropriate, the hospital notes.

Setting
A London teaching hospital gynaecological ultrasound department and associated general practices.

Subjects
Four hundred ninety‐eight women referred by general practitioners for a gynaecological ultrasound scan over a one year period (1990).

Results
The 498 requests for gynaecological ultrasound scans included 472 primary diagnostic referrals. Seventy‐one percent of general practitioners replied to the questionnaires. Overall, 46% of the scans were normal, but the proportion of normal scans fell to 21% if the date of the last menstrual period and a pregnancy test result were included on the form. Forty per cent of women scanned subsequently were referred for hospital care.

Conclusions
General practitioners would appear to use the ultrasound service in a rational way and therefore there can be no justification for not allowing them open access. The positive diagnostic yield can be further improved if time is taken to supply simple relevant information which may be facilitated by a specific request form.
A randomised trial of 45 minutes and 15 minutes incremental oxytocin infusion regimes for the induction of labour in women of high parity
Authors: Orhue A. A. E.
Published: August 2005

Objective
To investigate whether in women of high parity induction of labour using a regimen of intravenous oxytocin, increasing incrementally at 45 min intervals, is safer than one increasing at 15 min intervals.

Setting
University of Benin Teaching Hospital, Department of Obstetrics and Gynaecology, Benin City, Nigeria.

Design
Randomised controlled trial.

Subjects
Ninety women of parity 5 or more requiring induction of labour by infusion of oxytocin were randomly allocated to incremental increases at either 45 min intervals (experimental group) or 15 min intervals (control group).

Main outcome measures
Mode of delivery; complications of labour and delivery (uterine rupture, precipitate labour, hyperstimulation, postpartum haemorrhage, perineal tears, puerperal pyrexia); number of days spent in hospital.

Results
The 45 min incremental regimen resulted in longer induction–delivery intervals (estimate of difference in population medians 2 h, 95% confidence interval (CI) 1‐4 h); less precipitate labour (odds ratio (OR) 0.09,95% CI 0.03–0.30); less uterine hyperstimulation (OR 0.23, 95% CI 0.09–0.59); and a reduced length of hospital stay (estimate of difference in population medians 3 days, 95% CI 2–5 days). With the 45 min interval regimen there was a reduction in the occurrence of uterine rupture, postpartum haemorrhage, perineal tears and puerperal pyrexia, but these differences did not reach statistical significance.

Conclusion
For the induction of labour in women of high parity the infusion rate of oxytocin should be increased every 45 min rather than every 15 min until contractions occur three times in 10 min and this infusion rate of oxytocin is maintained until delivery.
Is HIV infection associated with an increase in the prevalence of cervical neoplasia?
Authors: Smith J. R. , Kitchen V. S. , Botcherby M. , Hepburn M. , Wells C. , Gor D. , Forster S. M. , Harris J. R. W. , Steer P. , Mason P.
Published: August 2005

Objective
To test the hypotheses:

that HIV infection predisposes to cervical intraepithelial neoplasia (CIN);

that this CIN is a result of HIV related immunosuppression; and

that this CIN is a result of immunosuppression causing increased expression of the potentially oncogenic viruses, human papilloma virus (HPV), Epstein Barr virus (EBV) and herpes simplex virus (HSV).

Design
A matched cross sectional study.

Setting
The Department of Gynaecological Oncology, The Samaritan Hospital, London; the Department of Genitourinary Medicine, St Mary's Hospital, London; and the Family Planning Clinic, Claremont Terrace, Glasgow.

Subjects
Fifty HIV seropositive women enrolled from the Genitourinary Medicine Department and the Drug Dependency Unit at St Mary's Hospital, London, and the Unit of Infectious Diseases at Ruchill Hospital, Glasgow. Forty‐three HIV seronegative controls enrolled from the Department of Genitourinary Medicine at St Mary's Hospital, matched against 43 of the seropositive women for age, age at first intercourse, lifetime number of sexual partners, and smoking habit.

Main outcome measures
Associations between CIN, as detected by cytology and histology, and HIV infection. Association was also sought between CIN and immunosuppression, as measured clinically by T4 cell number, β‐2‐microglobulin and p24 antigen. Associations of these with: (1) HPV, as detected by Southern blot testing and the polymerase chain reaction; (2) EBV, as detected by Southern blot testing; and (3) HSV, as detected by tissue culture of endocervical swabs, was also studied.

Results
There was no significant difference in the prevalence of CIN or oncogenic viruses between HIV seropositive and seronegative women in the absence of immunosuppression. If the HIV infected women showed signs of immunosuppression, the prevalence of CIN was increased. No association was shown between detection of HPV, EBV and HSV and immunosuppression or CIN.

Conclusion
HIV infection may only be associated with an increased risk of CIN when immunosuppression is present.
Correlation between clinical staging (FIGO) and prognostic groups with gestational trophoblastic disease
Authors: Smith David B. , Holden Lydia , Newlands Edward S. , Bagshawe Kenneth D.
Published: August 2005

Objective
To compare the Charing Cross Hospital scoring system with FIGO staging for gestational trophoblastic disease.

Design
A retrospective analysis of patients referred to Charing Cross during the period 1979–1989.

Setting
National referral centre.

Subjects
Two hundred and seven women with gestational trophoblastic disease presenting between 1979–1989.

Main outcome measures
The women were classified according to the Charing Cross Hospital scoring system and FIGO clinical staging and the results of treatment compared.

Results
Of the 207 women studied, there were 102 low risk, 39 medium risk and 66 high risk according to the Charing Cross system and 26 stage 0,83 stage 1,23 stage 2,51 stage 3 and 24 stage 4 according to the FIGO system. If the FIGO system had been used to determine therapy, 17 women would have been at risk of under‐treatment and nine of overtreatment. The main prognostic factors contributing to a higher Charing Cross score and thus more intensive chemotherapy from the outset were: HCG > 105, interval from antecedent pregnancy >12 months and term delivery.

Conclusions
The Charing Cross scoring system incorporates factors predictive of the presence of drug resistant tumour and thus allows more appropriate use of chemotherapy from the start of treatment than is possible with the anatomically based FIGO staging. Moreover, the system is easy to apply relying only on history and clinical examination in addition to a reliable quantitative HCG assay.
Transdermally administered oestradiol combined with oral medroxyprogesterone acetate: the effects on lipoprotein metabolism in postmenopausal women
Authors: Mattsson Lars‐Åke , Samsioe Göran , von Schoultz Bo , Uvebrant Margareta , Wiklund Ingela
Published: August 2005

Objective
To investigate the effects of two doses of transdermally applied oestradiol on lipid and lipoprotein metabolism in climacteric women.

Design
A randomised double blind cross‐over comparison.

Setting
Departments of Obstetrics and Gynaecology, Östra and Sahlgren's Hospital, Göteborg and Karolinska Hospital, Stockholm, Sweden.

Subjects
Fifty‐two women with climacteric symptoms were treated with oestradiol transdermally applied (50 μg and 100 μg/24 h). A daily dose of 5 mg oral medroxyprogesterone acetate was added 14 days each treatment cycle of four weeks.

Interventions
Blood samples were drawn after an overnight fast before and after four and eight months of treatment.

Main outcome measures
Assays for serum triglycerides and cholesterol as well as low density lipoprotein (LDL) and high density lipoprotein (HDL) cholesterol including the subfractions HDL2 and HDL3 were performed.

Results
Significant decrements were found in triglycerides and serum and LDL cholesterol during treatment with both doses. A modest rise in HDL2 cholesterol was observed after treatment with the 100 μg/24 h dose.

Conclusions
The serum lipid and lipoprotein profile encountered in these women was similar to that reported with oral formulations except for a decrease in triglycerides. The metabolic differences between the two doses of transdermal oestradiol is probably of minor clinical significance in normal postmenopausal women.
Concentration of endometrial protein PP14 in uterine flushings throughout the menstrual cycle in normal, fertile women
Authors: Li T. C. , Ling E. , Dalton C. , Bolton A. E. , Cooke I. D.
Published: August 2005

Objective
To determine the variation in concentration of endometrial protein PP14 in uterine flushings throughout the menstrual cycle comparing this to concentrations in plasma samples.

Design
Precise timing of all samples by the luteinising hormone surge.

Setting
Jessop Hospital for Women, Sheffield.

Subjects
Twenty‐three regularly cycling, previously fertile volunteer women.

Interventions
Observational study; 10 ml of physiological saline was used to flush the uterine cavity once or serially in the cycle of the study.

Main outcome measures
The measurement of PP14 levels by radioimmunoassay in uterine flushings and plasma samples.

Results
In uterine flushing, PP14 levels were not detectable in significant amounts in the proliferative phase and the early luteal phase; after day LH+6, the concentration rises rapidly with a doubling time of only 6.6 to 14.6 h in the midluteal phase. In the late luteal phase, the concentrations in uterine flushing were over a hundred times higher than the corresponding plasma samples.

Conclusions
The measurement of PP14 in uterine flushings is likely to be of greater value than the measurement in plasma samples; it may provide a valuable alternative to the evaluation of endometrial function.
Noninvasive test of microvascular endothelial function in normal and hypertensive pregnancies
Authors: Eneroth‐Grimfors E. , Lindblad L. E. , Westgren M. , Ihrman‐Sandahl C. , Bevegárd S.
Published: August 2005

Objective
To examine microvascular endothelial cell function in vivo in pre‐eclampsia.

Design
Iontophoresis of acetylcholine (Ach), which gives rise to endothelial cell dependent vasodilatation, and of sodium nitroprusside (SNP), which elicits vasodilatation independently of functioning vascular endothelium.

Setting
Södersjukhuset, Stockholm, Sweden.

Subjects
Ten pre‐eclamptic patients, ten healthy pregnant women and ten healthy nonpregnant women were examined.

Main outcome measures
The degree of vasodilatation following iontophoretic administration of Ach compared with SNP was recorded with a laser Doppler technique, the data being analysed on a personal computer.

Results
Both Ach and SNP administration resulted in marked vasodilatation; the magnitude of the vasodilatation was similar in the three groups of women.

Conclusion
Following iontophoretic administration of endothelial cell dependent or independent vasodilatators, laser Doppler measurement of blood flow demonstrated no microvascular endothelial cell dysfunction in pre‐eclamptic women.
Fetal angiotensin II levels and vascular (type I) angiotensin receptors in pregnancies complicated by intrauterine growth retardation
Authors: Kingdom John C. P. , McQueen James , Connell John M. C. , Whittle Martin J.
Published: August 2005

Objective
To investigate the status of the fetal renin‐angiotensin system (RAS) in pregnancies complicated by severe intrauterine growth retardation (IUGR), and its possible relationship to elevated fetoplacental vascular resistance as indicated by abnormal umbilical artery Doppler flow velocity waveforms (FVW).

Design
Prospective survey of pregnancies falling into predefined categories and presenting at the Queen Mothers Hospital, Glasgow, over the study period.

Subjects
Effects of mode of delivery and gestational age were investigated using uncomplicated term pregnancies delivered vaginally (SVD group, n= 15) or by elective caesarean section (ECS group, n= 9), and normal pregnancies with spontaneous preterm onset of labour (PREM group, n= 6; normal birthweight for gestational age (31 weeks)). These groups were used as controls for the 13 IUGR cases delivered preterm (31 weeks) by caesarean section in the fetal interest.

Main outcomes measures
Umbilical artery FVW, birthweight, cord venous angiotensin II concentration ([cv ANG II]), fetoplacental vascular ANG II receptor concentration.

Results
Cord venous angiotensin II concentration was similar to maternal values in the ECS group (31–101 pmol/1, 95% CI), but was elevated (81–288 pmol/l, P= 0.03) after vaginal delivery. The concentration of ANG II receptors (type AT1, dissociation equilibrium constant, 1.27 nmol/l) in placental primary/secondary stem vascular tissue was lower in the SVD group (18–44 fmol/mg membrane protein, 95% CI), compared with the ECS group (29–122 fmol/mg, P= 0.03) consistent with acute receptor down‐regulation by the elevated ANG II levels. No effect of gestational age on receptor number was demonstrable (P= 0.13, PREM (premature delivery) vs ECS group). In the IUGR group, [cv ANG II] (94–378 pmol/l) was markedly elevated compared with the ECS controls (P= 0.001) but receptor concentration (28–84 fmol/mg) was not significantly altered (P= 0.13). No relationships between [cv ANG II] or receptor number and umbilical artery FVW could be identified. No changes in receptor affinity were observed.

Conclusion
These results indicate activation of the fetal RAS in IUGR and suggest that responsiveness of the fetoplacental vasculature to the peptide is not diminished as would be expected from the elevated plasma ANG II levels. ANG II may contribute to the increased fetoplacental vascular resistance observed in this disorder, but does not apparently account for the abnormal umbilical artery FVW that is observed in a proportion of IUGR cases.
Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists Multicentre Randomised Trial of Cervical Cerclage
Authors:   MRC/RCOG Working Party on Cervical Cerclage, Macnaughton M. C. , Chalmers I. G. , Dubowitz V. , Dunn P. M. , Grant A. M. , McPherson K. , Pearson J. F. , Peto R. , Turnbull A. C.
Published: August 2005

Objective
To assess whether cervical cerclage in women deemed to be at increased risk of cervical incompetence prolongs pregnancy and thereby improves fetal and neonatal outcome.

Design
Multicentre randomised controlled trial.

Setting
Hospitals in the United Kingdom, France, Hungary, Norway, Italy, Belgium, Zimbabwe, South Africa, Iceland, Ireland, the Netherlands and Canada.

Subjects
One thousand two hundred and ninety‐two pregnant women whose obstetricians were uncertain whether to recommend cervical cerclage, most of whom had a history of early delivery or cervical surgery.

Interventions
Cervical cerclage was compared with a policy of withholding the operation unless it was considered to be clearly indicated.

Main outcome measures
Delivery before 33 completed weeks, preterm delivery (<37 weeks), and vital status of the baby after completion of the pregnancy.

Results
The overall preterm delivery rate was 28%. There were fewer deliveries before 33 weeks in the cerclage group (83 (13%) compared with 110 (17%), P=0.03) and this difference reflected deliveries characterised by features of cervical incompetence (painless cervical dilatation and prelabour rupture of the membranes). There was a corresponding difference in very low birthweight deliveries (63 (10%) compared with 86 (13%), P=0.05). The difference in the overall rate of miscarriage, stillbirth or neonatal death (55 (9%) compared with 68 (11%)) was less marked and was not statistically significant. The use of cervical cerclage was associated with increased medical intervention and a doubling of the risk of puerperal pyrexia.

Conclusions
These results suggest that the operation had an important beneficial effect in 1 in 25 cases in the trial (95% confidence interval (CI) 1 in 12 to 1 in 300 sutures). Its use is associated with increased medical intervention and puerperal pyrexia. Nevertheless, this trial suggests that, on balance, cervical cerclage should be offered to women at high risk, such as those with a history of three or more pregnancies ending before 37 weeks gestation.
Previous pregnancy outcomes and subsequent risk of preterm rupture of amniotic sac membranes
Authors: Ekwo Edem E. , Gosselink Carol A. , Moawad Atef
Published: August 2005

Objective
To test the hypothesis that previous unfavourable pregnancy outcomes increase the risk for premature birth, with (PP) or without (PTB) premature rupture of the amniotic sac (PROM) at the index pregnancy and that multiple undesirable outcomes increase risk.

Design
Case control study.

Setting
Two university hospitals.

Subjects
Four hundred sixty‐three women aged 15 to 45 years who were delivered preterm PROM, full term PROM and preterm without PROM matched with 463 women who delivered full term. All women included in the study had at least one previous pregnancy.

Outcome measures
Odds ratio of previous adverse pregnancy outcome among index cases.

Results
Compared with controls, PP cases had odds ratios of 95 for previous preterm birth, 186 for abortion and prematurity and 158 for fetal loss, abortion/prematurity after controlling for confounding variables. Compared with controls, PTB cases had an odds ratio of 96.5 for previous preterm delivery, 84 for abortion and prematurity, and 320 for fetal loss/abortion and prematurity after controlling for confounding variables.

Conclusions
Previous preterm delivery, abortion and prematurity and fetal loss/abortion and prematurity all increase risk for subsequent preterm birth with or without PROM.
Changes in platelet reactivity following aspirin treatment for pre‐eclampsia
Authors: Sullivan M. H. F. , Elder M. G.
Published: August 2005

Objective
To determine whether aspirin therapy in women at risk of pre‐eclampsia alters in vitro platelet aggregation.

Design
Longitudinal observational study.

Setting
RPMS Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London.

Subjects
Six pregnant women at‐risk or with pre‐eclampsia.

Methods Women considered to be at risk of pre‐eclampsia or with the disorder were treated with aspirin. In vitro platelet aggregation in response to platelet‐activating factor (PAF) and adenosine diphosphate (ADP) before and after aspirin therapy were analysed.

Results
Prior to aspirin therapy platelet aggregation was decreased compared with normal pregnant women. After aspirin therapy platelet aggregation in response to PAF and ADP was greater, but did not return to levels associated with normal pregnancy.

Conclusions
In women with pre‐existing decreased platelet aggregation suggestive of platelet exhaustion, aspirin increased aggregation. This suggests that aspirin decreases in vivo platelet activation and thereby decreases the platelet exhaustion revealed by the in vitro studies.
The intravascular mass of albumin during human pregnancy: a serial study in normal and diabetic women
Authors: Whittaker Paul G. , Lind Tom
Published: August 2005

Objective
To quantify the changes in serum albumin during human pregnancy.

Design
Longitudinal prospective study.

Setting
Before conception and antenatal clinic.

Subjects
Sixty‐nine normal women and 23 women with Type 1 diabetes.

Interventions
Administration of Evans' blue dye and collection of serum samples.

Main outcome measures
Albumin concentration, plasma volume and intravascular mass of albumin

Results
In normal subjects serum albumin concentration showed a significant decrease of 1.9 (95% CI 1.0 to 2.9) g/l by 7 weeks gestation with a further 8.2 (95% CI 7.5 to 8.9) g/l decrease by 36 weeks gestation, an overall change of 22%. Plasma volume first increased significantly by 190 (95% CI 105 to 275) ml between 7 and 12 weeks, with a further increase of 1003 (95% CI 871 to 1135) ml between 12 and 36 weeks of pregnancy, a change of 53%. The intravascular mass of albumin showed no change between non‐pregnant, 7 and 12 week values but there was a significant rise of 19.5 (95% CI 15.1 to 23.9) g between 12 and 28 weeks of gestation, an overall increase of 19%. Diabetic subjects showed similar changes.

Conclusions
Rather than simply reflecting plasma volume dilution, the changes in serum albumin imply alterations in albumin metabolism during pregnancy.
Hydralazine boluses for the treatment of severe hypertension in pre‐eclampsia
Authors: Paterson‐Brown S. , Robson S. C. , Redfern N. , Walkinshaw S. A. , de Swiet M.
Published: August 2005

Objective
To audit the use of bolus hydralazine for control of severe hypertension within a protocol for the management of severe pre‐eclampsia.

Design
A retrospective review.

Setting
Three UK teaching hospitals.

Subjects
Seventy consecutive women who received hydralazine for the treatment of sustained severe hypertension. Twenty‐five women had more than one episode of hypertension amounting to a total of 109 treatment episodes.

Intervention
Intravenous bolus hydralazine 5 mg, repeated every 15min to reduce the mean arterial pressure to < 125 mmHg.

Main outcome measures
Change in mean arterial pressure in response to bolus hydralazine, fetal condition, as assessed by heart rate changes and umbilical arterial pH at delivery, and protocol violations were analysed.

Results
Mean arterial pressure fell by 12 mmHg (95% CI 10–14) after the first bolus, 9 mmHg (95% CI 6.5–12) after the second bolus and 5 mmHg (95% CI 1–10) after the third bolus. Eighty‐two (75 %) episodes were managed strictly according to the protocol; of these, blood pressure was controlled by bolus therapy alone in 89%. Of the 27 instances in which the protocol was not adhered to, blood pressure was not controlled in four. There were no significant differences in the incidence of cardiotocographic abnormalities or umbilical acidaemia in the women treated before delivery (n= 36) compared with those in whom treatment was first initiated afterwards (n= 34).

Conclusions
Hydralazine given in 5 mg boluses is a safe and effective method of treating severe hypertension in pre‐eclampsia. Despite clear management guidelines, protocol violations were common, and in 4% of treatment episodes these were potentially serious resulting in failure to control blood pressure.
Fetal nuchal translucency: ultrasound screening for fetal trisomy in the first trimester of pregnancy
Authors: Nicolaides K. H. , Brizot M. L. , Snijders R. J. M.
Published: August 2005

Objective
To investigate a new method of screening for fetal trisomies on the basis of maternal age and fetal nuchal translucency thickness at 10 to 13 weeks of gestation.

Design
A prospective screening study.

Setting
Tertiary referral centre.

Subjects
One thousand two hundred and seventy‐three women with singleton pregnancies undergoing first trimester fetal karyotyping because of advanced maternal age, parental anxiety, or family history of a chromosomal abnormality in the absence of balanced parental translocation.

Methods
Estimates of maternal age‐related risks for fetal trisomies 21, 18 and 13 at this gestation were used to derive the expected incidence of these trisomies in fetuses with nuchal translucency < 3 mm, 3 mm and > 3 mm, respectively, and the ratio of observed to expected number of cases was calculated.

Results
The nuchal translucency was ≥ 3 mm in 86% of the trisomic and in 4.5% of the chromosomally normal fetuses. The observed number of trisomies in the 1185 cases with nuchal translucency < 3 mm was approximately five times less than the number expected on the basis of maternal age. In the groups with translucency of 3 mm (n= 52) and > 3 mm (n= 36), the observed numbers of trisomies were approximately five times and 24 times higher than the respective numbers expected on the basis of maternal age.

Conclusion
The risk of fetal trisomy can be derived by combining maternal age and fetal nuchal translucency thickness at 10 to 13 weeks of gestation. It is predicted that for a false positive rate of 5%, the sensitivity of the new method of screening would be at least 85%, which compares favourably with the respective 20 to 30% and 50 to 60% of screening based on maternal age alone or the combination of maternal age with maternal serum biochemistry.
Cervical carcinoma in the Grampian region (1980–1991): a population‐based study of survival and cervical cytology history
Authors: Macleod A. , Kitchener H. C. , Parkin D. E. , Sarkar T. , Miller I. D. , Mann E. , Gordon N. , Campbell M.
Published: August 2005

Objectives
To study survival in women treated for cervical carcinoma in Grampian region, to identify clinical and pathological prognostic factors, and to correlate survival with cytology history.

Design
A retrospective study of all cases of cervical carcinoma using a prospectively gathered database. Data validated by 1 in 10 randomised retrospective case note sampling.

Setting
Aberdeen Royal Infirmary.

Subjects
Three hundred and sixty‐three women resident within Grampian diagnosed as having cervical carcinoma between 1980 and 1991, with five‐year survival data on the 206 diagnosed by the end of 1986.

Main outcome measure
Five‐year survival rates.

Results
The mean annual incidence of cervical carcinoma in our population was 11.2 per 100 000 women, with an overall five‐year survival of 67% in those under 40 years of age and 60% in those aged 40 years and over. On univariate analysis, survival was significantly adversely affected by tumour stage, grade and absence of previous smears. On multivariate analysis, the effect of previous smear history was lost, but stage and grade remained strong independent risk factors for survival. There was no significant difference in five‐year survival by age or tumour type.

Conclusions
The prognosis of cervical carcinoma in Grampian region was independently affected only by stage of disease and tumour grading and cervical smear history.
Effect of the prostaglandin E1 analogue gemeprost on the blood flow velocity waveforms of uterine arteries during the first trimester of pregnancy
Authors: Jouppila Penhi , Suomalainen‐König Sanna
Published: August 2005

Objective
To investigate the effect of the vaginal application of the prostaglandin (PGE1) analogue gemeprost on the vascular resistance of the main uterine arteries in early pregnancy.

Design
A prospective observational study.

Subject
Twenty‐one patients seeking legal termination of pregnancy at 7–12 weeks gestation.

Methods
Pulsatility indices for the main uterine arteries were measured by vaginal colour Doppler ultrasound before and 3 to 4 h after vaginal application of the PGE1 analogue gemeprost.

Results
A significant increase of pulsatility indices was observed (P < 0001) which was not affected by parity or gestational age. The change was similar in both uterine arteries, and placental lateralisation did not affect the results. All fetuses were still alive at the second examination.

Conclusions
Vaginal application of prostaglandin analogue gemeprost in early pregnancy increases the vascular resistance of uterine arteries. This may be caused by a direct vasoconstrictory effect or be secondary to uterine contractions.