bluuebunny/crossref_metadata_2025 huggingface dataset:
Velamentous umbilical cord insertion may be suspected from maternal serum α‐fetoprotein and hCG
Authors: Heinonen Seppo , Ryynänen Markku , Kirkinen Pertti , Saarikoski Seppo
Published: August 2005

Objective
Patients with unexplained elevations in second trimester maternal serum α‐fetoprotein or human chorionic gonadotrophin (hCG) concentrations are at increased risk as regards a variety of pregnancy complications and adverse perinatal outcomes. Evidence suggests that elevated α‐fetoprotein and hCG concentrations may, in some case, be sensitive indicators of underlying placental pathology, either vascular or inflammatory in nature. The present study was carried out to compare these biochemical markers in pregnancies complicated by velamentous umbilical cord insertion (VCI) with normal pregnancies.

Design
An observational study.

Participants
Maternal serum hCG and α‐fetoprotein concentrations were measured in samples from 76 singleton pregnancies complicated by VCI and from 5200 chromosomally normal controls at 15 weeks of gestation.

Results
Maternal serum hCG concentrations were elevated (mean 1·47 multiples of median (MOM)) in affected pregnancies, whereas α‐fetoprotein levels were lower (mean 0·88 MOM) in the subjects than in the controls. In relation to Down's syndrome risk assessment, the pattern of the two markers indicated high risk more often in VCI than in pregnancies with normal umbilical insertion. Accordingly, the increased false positive rate (26·3% compared with 6·6%) resulted in a higher rate of invasive techniques for fetal karyotyping in these pregnancies.

Conclusions
In obstetric practice, elevated maternal serum hCG concentrations may in some cases be explained as being solely the result of abnormal insertion, which provides a link between unexplained hCG elevation and adverse pregnancy outcome. We suggest colour flow Doppler imaging of cord insertion in pregnancies followed because of unexplained hCG elevation or a false positive result in Down's syndrome screening.
Very preterm birth–a regional study. Part 2: The very preterm infant
Authors: Hagan R. , Benninger H. , Chiffings D. , Evans S. , French N.
Published: August 2005

Objective
To ascertain the growth characteristics, delivery room management and hospital mortality of very preterm live born infants (< 33 weeks of gestation) and to identify differences between infants associated with the aetiological factor related to their very preterm delivery.

Design
Cohort analytical study.

Setting
King Edward Memorial Hospital for Women, Western Australia.

Main variables examined
Gestational age, birthweight, birthweight ratio, condition at birth and mortality.

Results
Six hundred and ninety‐three live born very preterm infants were born to 608 mothers between 1.1.90 and 31.12.91. This was 1.37% of all live borns in Western Australia. Three hundred and eighty‐five (55.6%) were male. Growth characteristics (birthweight, birthweight ratio and proportion small for gestational age) differed between infants depending on the primary obstetric complication associated with the very preterm delivery. Overall 217 (31%) infants were small for gestational age, 34 (4.9%) had a congenital anomaly, and 102 (14.7%) died. Corrected mortality, excluding major fatal congenital anomaly, was 86 (12.7%). The majority of infants died on the first day (n= 59 (57.8%). The only factors associated with an increased or decreased mortality were decreasing gestation (adjusted odds ratio (AOR) 1.7, 95% CI 1.50–1.93), decreasing birthweight ratio (small for gestational age) (AOR 1.3, 95% CI 1.08–1.53), antepartum haemorrhage as primary complication (AOR 3.1, 95% CI 1.25–7.69) and any antenatal steroids (AOR 0.26, 95% CI 0.14–0.51). In comparison with other studies, survival in the extremely preterm group, defined as a gestational age of less than 28 weeks, is improving.

Conclusions
Very preterm infants account for a large proportion of perinatal mortality. Further studies are required to explore the differences between infants on the basis of the primary obstetric complication and to ensure that increased survival is not associated with an increase in disabilities.
Vaginal hysterectomy for the large uterus
Authors: Magos Adam , Bournas Nikolaos , Sinha Rakesh , Richardson Robert E. , O'Connor Hugh
Published: August 2005

Objective
To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size.

Design
A prospective observational study.

Setting
The Royal Free Hospital, London.

Participants
Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size.

Interventions
Vaginal hysterectomy with or without bilateral salpingo‐oophorectomy or oophorectomy.

Main outcome measures
Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra‐and post‐operative complications, duration of hospitalisation.

Results
The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n= 6) and superficial vaginal grazes (n= 5). One of the women required a blood transfusion. The mean post‐operative hospital stay was 3.7 days (range 2 to 9 days).

Conclusion
Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.
The Burch colposuspension for women with and without detrusor overactivity
Authors: Colombo Mario , Zanetta Gerardo , Vitobello Domenico , Milani Rodolfo
Published: August 2005

Objective
To compare the results of the Burch colposuspension in women with stress urinary incontinence and detrusor overactivity with those obtained in women with stress incontinence and stable bladders. Additionally, to analyse the value of two detrusor instability indexes and of standard cystometric parameters in predicting the surgical outcome.

Design
Retrospective cohort study.

Setting
Secondary referral centre Urodynamics Unit, San Gerardo Hospital, Monza.

Sample
Forty‐four women with detrusor overactivity (21 with low compliance bladder and 23 with detrusor instability) and 44 with stable bladders. They were matched for age, parity, dystocia, menopause, body mass index, previous vaginal surgery, heavy work, urethral functional length and maximum urethral closure pressure.

Results
At two years follow up, the cure rate of stress incontinence was 95% in the control group (patients with stable bladders) and 75% in detrusor overactivity group (odds ratio 0.1, 95% confidence interval 0.01–0.9, P= 0.02). No significant differences were observed between cured and failed patients according to both detrusor instability indexes. Likewise, mean pre‐operative standard cystometric values of cured and failed patients showed no differences.

Conclusions
Although results were better in women with stable bladders, we believe that the success of the Burch colposuspension in cases with mixed incontinence should be considered satisfactory. No pre‐operative cystometric parameter consistently predicting the surgical outcome on stress incontinence was identified.
Umbilical artery pulsatility index in early pregnancies with chromosome anomalies
Authors: M. Martinez J. , Comas C. , Ojuel J. , Puerto B. , Borrell A. , Fortuny A.
Published: August 2005

Objective
The aim of our study was to obtain measurements of the umbilical artery pulsatility index in pregnancies before invasive procedures for prenatal diagnosis, to investigate its potential prognostic value in predicting chromosomal abnormalities.

Design
A prospective study.

Participants
Nine hundred and twenty‐four consecutive women with singleton pregnancies between 10 and 18 weeks of gestation who underwent chorionic villus sampling (n= 385) or genetic amniocentesis (n= 539). All Doppler measurements were obtained by a single investigator before the invasive procedure. Pregnancies where structural malformations were detected by ultrasound were excluded.

Results
Twenty‐six fetuses with chromosomal anomaly, including 12 with trisomy 21, were diagnosed. Using the 90th centile in umbilical artery pulsatility index values as a cut‐off for trisomy 21 the detection rate was 66.6%, with a specificity of 90.4% and a positive predictive value (defined as the proportion of unaffected individuals with positive results, 1‐specificity) of 8.8%. However, with this cut‐off the false positive rate was 9.6%. All 19 chromosomally normal pregnancies in which a fetal loss occurred after the procedure had a normal umbilical artery pulsatility index before it was carried out.

Conclusions
These preliminary data suggest that trisomic fetuses have an abnormally increased umbilical artery pulsatility index in early pregnancy. Because the number of cases is too small to draw any firm conclusions, the use of a single measurement for screening purposes needs to be confirmed by further investigation and the clinical significance of reference curves of normal values in the detection of pathological conditions has still to be determined. The potential of umbilical artery pulsatility index as an additional parameter along with others previously established for Down's syndrome screening, such as nuchal oedema, needs to be explored further.
A comparison of goserelin and danazol as endometrial thinning agents prior to endometrial laser ablation
Authors: Garry Ray , Khair Anu , Mooney Paul , Stuart Mary
Published: August 2005

Objective
To compare the effectiveness of goserelin and danazol prior to endometrial laser ablation and assess different dosage regimens.

Design
A prospective open randomised trial.

Setting
Specialist unit in minimal access gynaecological surgery in a district general hospital.

Participants
One hundred and sixty premenopausal women with dysfunctional uterine bleeding.

Interventions
Randomisation into four groups receiving either one or two injections of goserelin acetate (3.6 mg subcutaneously) or 28 or 56 days of danazol (four 200 mg tablets daily), followed by endometrial laser ablation.

Main outcome measures
Endometrial thickness pretreatment and, immediately prior to endometrial laser ablation, assessed by vaginal ultrasound and full thickness endometrial biopsy; appearance of the endometrium at surgery; duration of the operation; the amount of fluid absorbed during surgery; and the clinical outcome at 24 weeks after surgery.

Results
The two drugs were equally effective in thinning the endometrium. Compared with danazol, goserelin was better tolerated and resulted in a more satisfactory endometrial appearance at hysteroscopy, a greater reduction in cavity length (0.5 cm compared with 0.3 cm, P < 0.002), a shorter operation (16.4 min compared with 21.6 min, P < 0.00l), less fluid absorption (0 ml compared with 200 ml, P= 0.001), and a higher rate of amenorrhoea or oligoamenorrhoea (77% compared with 54%, P < 0.001) at the six month check. The administration of goserelin for 8 weeks compared with 4 weeks produced greater thinning of the endometrium on ultrasound and on histological examination, a greater reduction in cavity length on ultrasound and an increase in reported vasomotor symptoms. In both treatment regimens, 95 % of women reported a satisfactory reduction in menstrual flow at the six month check.

Conclusions
Goserelin appears to be more effective and better tolerated than danazol for treatment prior to endometrial laser ablation. Eight weeks treatment with goserelin resulted in better operating conditions and more vasomotor side effect, compared with four weeks treatment, although there was no difference in clinical outcome.
The effect of directed biopsy on the atypical cervical transformation zone: assessed by digital imaging colposcopy
Authors: Chenoy R. , Billingham L. , Irani S. , Rollason T. P. , Luesley D. M. , Jordan J. A.
Published: August 2005

Objective
To determine the effect of directed punch biopsy trauma on the natural history of atypical cervical transformation zones.

Design
A prospective randomised clinical trial.

Setting
Academic Unit colposcopy clinics in Birmingham.

Participants
One hundred and eighty women attending the colposcopy clinics were recruited over an 18 month period, of which 161 were eligible for analysis.

Methods
Three‐way randomisation of patients into 1. no biopsy, 2. central biopsy and 3. peripheral biopsy groups. Quantitative assessment of the change in surface area and severity of cervical intra‐epithelial neoplasia (CIN) lesions in each group measured six weeks apart using digital imaging colposcopy.

Results
No significant difference in change in lesion size (P= 0.40) was noted in the three treatment groups. Results suggest that the severity of the lesion was underestimated by the peripheral biopsy.

Conclusions
The results of this study suggest that directed punch biopsy trauma does not have a significant effect on the immediate natural history of CIN. No statistically significant differences were found in lesion size whether biopsy was employed or not. In addition, the site of biopsy had no influence on the outcome. It appears, therefore, that tissue trauma from punch biopsy and the subsequent inflammatory and wound healing processes do not modify the course of CIN. The regressive changes observed after punch biopsy in previous natural history studies are probably not a result of the initial inflammatory response to biopsy trauma and subsequent re‐epithelialisation with normal cells, but may result from processes that continue long after tissue repair is completed.
Prenatal genetic services for Down's syndrome: access and provision in 1990–1991
Authors: Williamson P. , Harris R. , Church S. , Fiddler M. , Rhind J. ,   on behalf of the Steering Committee of the National Confidential Enquiry into Counselling for Genetic Disorders
Published: August 2005

Objective
To examine access to and provision of prenatal genetic services relating to Down's syndrome.

Design
Retrospective review of obstetric casenotes.

Sample
Pregnancies involving Down's syndrome in England and Wales in 1990–1991 in women aged 38 or over. Information was obtained in 430 cases from a questionnaire completed by the obstetric team who were asked to provide details based only on documentation in the antenatal casenotes. The outcome of pregnancy was a termination in 268 (62%) cases, a liveborn child with Down's syndrome in 144(34%), a stillbirth in 9(2%), a miscarriage in 8(2%) and in one case was not known.

Results
Overall, prenatal diagnosis was not offered in 7% pregnancies (95% CI: 4.4–9.2%) with late booking given as the main reason. Of women offered prenatal diagnosis, 76% accepted (95% CI: 72.3–80.6%). Counselling was documented before prenatal diagnosis in 89% of cases (95% CI: 86.0–92.3%) and after the procedure, to discuss the results, in 73% (95% CI: 67.5–77.7%). In 10% of pregnancies terminated for Down's syndrome, fetal products were not sent to the laboratory. There was no report of a normal fetus having been terminated as a consequence of incorrect prenatal diagnosis. However, in 10% (95% CI: 5.9 to 14.0%) of cases examined in the laboratory, the diagnosis of Down's syndrome could not be confirmed. Details of prenatal diagnosis were not provided in five cases where a child with Down's syndrome was born. Of the remaining 139 livebirths, prenatal diagnosis was not offered in 27 (19%) cases, offered and declined in 92 (66%) and accepted in 20 (14%). In two cases a normal fetal karyotype was reported following prenatal diagnosis.

Conclusions
The study has demonstrated that in 1990–1991: 1. There were certain shortcomings in the documentation of antenatal care; 2. Late booking was the main factor precluding the offer of prenatal diagnosis to women aged 38 or over, and 3. The rate of confirmation of Down's syndrome in terminated fetuses was incomplete.
Head‐to‐cervix force: an important physiological variable in labour. 2. Peak active force, peak active pressure and mode of delivery
Authors: Allman Andrew C. J. , Genevier Eric S. G. , Johnson Mark R. , Steer Philip J.
Published: August 2005

Objective
To assess the relation between peak active (above baseline) head‐to‐cervix force (paHCF) and peak active (above baseline) intrauterine pressure (paIUP) in labour, and to compare the relation between labours progressing well and ending in vaginal delivery and those labours progressing slowly and ending in caesarean section.

Design
Prospective observational study.

Setting
The labour ward of a London teaching hospital.

Participants
Forty women in labour who agreed to have an experimental head‐to‐cervix force probe and an intrauterine pressure catheter inserted.

Results
The relation was linear, with a correlation coefficient which ranged from 0.012 to 0.885 (mean value 0.438). The closeness of the relation did not correlate with the rate of cervical dilatation (r = 00192, P= 0.574) or the mode of delivery (r = 0.215, P= 0.183). However, in women who progressed well to a vaginal delivery, the mean slope of the paHCF to paIUP regression line was 0.72, significantly steeper than in women who progressed slowly and required delivery by caesarean section (mean slope = 0.45, t = 2.31, P= 0.02). Mean paIUPs were significantly higher in women progressing well and achieving a vaginal delivery than in those progressing slowly and requiring caesarean section (45.3 mmHg SD 7.5 vs 38.4 mmHg SD11.4, t = 2.31, P= 0.02), but the overlap between the two groups was considerable. However, in keeping with their steeper paHCF/paIUP slope, women progressing well to a vaginal delivery had substantially higher head‐to‐cervix forces (46.4 gWt SD 11.8 vs 28.3 gWt SD 8.2, t = 5.22, P < 0.00001) than those progressing slowly and requiring caesarean section, and there was much less overlap between paHCF than paIUP. This resulted in paHCF being a much better discriminating variable than paIUP for mode of delivery.

Conclusions
The relation between paHCF and paIUP is linear, but there is a wide variation in the degree of correlation between one woman and another. Women with a steep slope of paHCF relative to paIUP are more likely to achieve a high mean paHCF, progress rapidly in labour and achieve a vaginal delivery than women with a flap slope, although mean paIUPs do not differ substantially between the two groups. The level of paHCF was substantially better than cervical dilatation rate at predicting mode of delivery. These results suggest that head‐to‐cervix force is sensitive to factors determining mode of delivery which are not reflected in either the level of uterine activity as measured by intrauterine pressure, or cervical compliance as measured by cervical dilatation rates.
Risk factors and fetal outcome in cases of shoulder dystocia compared with normal deliveries of a similar birthweight
Authors: Bahar Ahmed Mohammed
Published: August 2005

Objective
To compare risk factors and fetal morbidity in deliveries complicated by shoulder dystocia with deliveries of similar infant birthweights but not complicated by shoulder dystocia.

Design
A retrospective case‐controlled study.

Setting
Kuwait Maternity Hospital.

Participants
Sixty‐nine cases of true shoulder dystocia and 138 controls matched for exact infant's birth‐weight.

Methods
Demographic data and data regarding history of previous shoulder dystocia, diabetes mellitus, labour course, method of delivery and newborns' condition were collected from patients and case notes following delivery. The mothers' height and weight were measured. Oral glucose tolerance test were performed on patients who were not known as diabetics. The infants' head and chest circumferences and bisacromial diameter were measured.

Results
There were no significant differences between cases and controls when mean age, parity, height, weight and gestational ages were compared. The cases demonstrated a higher incidence of previous shoulder dystocia (P < 0.01), diabetes mellitus (P < 0.001), use of oxytocin for acceleration of labour (P < 0.01) and operative vaginal deliveries (P < 0.01). Differences between cases and controls in their newborn infants' head and chest circumferences were not significant, but the newborns of cases have a longer mean bisacromial diameter and a shorter head circumference: bisacromial diameter ratio (P < 0.001 and P < 0.001, respectively). Thirty‐seven infants (53.6%) from cases and two from controls (1.4%) sustained birth injuries. There were two stillbirths among the cases.

Conclusions
Although fetal macrosomia is the principal risk factor for shoulder dystocia, other important risk factors include diabetes mellitus, previous history of shoulder dystocia, prolonged labour, delay in the second stage of labour and fetal shoulder width which appear to be independent of fetal weight.
Combining nuchal translucency with umbilical Doppler velocimetry for detecting fetal trisomies in the first trimester of pregnancy
Authors: Martinez J. M. , Borrell A. , Antolin E. , Puerto B. , Casals E. , Ojuel J. , Fortuny A.
Published: August 2005

Objective
The aim of our study was to evaluate whether the combined use of umbilical artery pulsatility index (UAPI) and nuchal translucency (NT) measurements would be useful in the prediction of fetal chromosomal abnormalities at 10 to 13 weeks of gestation.

Design
A prospective study.

Population and methods
Five hundred and fifty‐three consecutive women with singleton pregnancies between 10 and 13 weeks of gestation, who underwent chorionic villus sampling at our institution. UAPI and fetal NT thickness were measured immediately before the invasive procedure. Pregnancies in which structural malformations had been detected by ultrasound were excluded.

Results
Using the 95th centile and 3 mm as the cutoffs for UAPI and NT, respectively, the detection rate for all chromosomal anomalies was 84.2%, with a false positive rate (1‐specificity) of 6.6%, a positive predictive value of 31.3%, and a negative predictive value of 99.4%. Out of the 553 tested pregnancies 502 had both parameters within the normal range and only three of them (0.6%) were chromosomally abnormal; in six of the eight cases (75%) in which both parameters were abnormal a chromosome anomaly was present. Of the 43 cases in which only one parameter was abnormal, 10 were chromosomally abnormal (23.2%).

Conclusions
Our results suggest that the presence of chromosomal anomalies may be strongly suspected when an increased NT thickness (NT 3 mm) is associated with an abnormally high UAPI at 10 to 13 weeks of gestation. The number of cases studied is small, however, and these conclusions are tentative and preliminary. The value of a single measurement of NT and UAPI for screening purposes needs to be substantiated by further investigation.
Fetal Rhesus D genotyping on amniocytes in alloimmunised pregnancies using fluorescence duplex polymerase chain reaction
Authors: Crombach †Gerd , Picard Frauke , Beckmann Matthias , Resident Boris Tutschek , Bald Reiner , Niederacher Dieter
Published: August 2005

Objective
1. To establish the reliability of fetal amniocyte Rhesus D (RhD) genotyping using fluorescence duplex polymerase chain reaction (PCR) and 2. to assess the potential clinical impact on management of alloimmunised pregnancies.

Design
Multicentre observational study.

Setting
Four departments of obstetrics and gynaecology in Germany.

Methods
Fourty‐four amniotic fluid samples were obtained by amniocentesis from a retrospective group of 27 RhD alloimmunised pregnancies and 15 samples from 14 women treated prospectively. Two RhD gene specific fragments (exon 7 and 10) were amplified using two separate fluorescence duplex PCR assays, and laser detected in an automated DNA sequence analyser.

Results
Amplification of the Rh gene sequences was successful in all samples. PCR at the two RhD gene regions resulted in complete concordance. Genotyping correctly predicted the RhD status of all fetuses serotyped (n= 41). After intrauterine transfusions, PCR identified the RhD type of two fetuses more accurately than serotyping. Earlier knowledge of a negative RhD status would have rendered unneccessary 12 amniocenteses in four fetuses of the retrospective study group, and pre‐ vented further invasive testing in one fetus treated prospectively. In the latter group, women with a positive fetal RhD genotype underwent intensive prenatal care including serial invasive monitoring and intrauterine treatment.

Conclusions
Fetal RhD genotyping of amniocytes is a reliable technique with the potential to improve routine management of alloimmunised pregnant women.
Ripening and dilatation of the unfavourable cervix for induction of labour by a double balloon device: experience with 250 cases
Authors: Atad Jack , Hallak Mordechai , Ben‐David Yehuda , Auslender Ron , Abramovici Haim
Published: August 2005

Objective
To determine the efficacy of the double balloon device (the Atad Ripener Device) in ripening and dilatation of the unfavourable cervix for induction of labour.

Methods
Two hundred and fifty women with unfavourable cervices (Bishop score 4) underwent induction of labour with the Atad Ripener Device. Indications were pregnancy induced hypertension (n= 118), post‐dates (n= 69), elective inductions (n= 23), other reasons including nonreassuring nonstress test, intrauterine growth retardation, previous caesarean section and diabetes mellitus (n= 40). The Atad Ripener Device was inserted into the cervix, the uterine balloon inflated in the internal os, and the cervico‐vaginal balloon in the external os of the cervix (100 mL of normal saline to each balloon). Pressure produced by the inflated balloons caused gradual dilatation and effacement of the cervix. The Atad Ripener Device was removed 12 h after insertion, the cervix assessed again, and labour managed according to obstetrical criteria.

Results
The Atad Ripener Device caused an increase in the Bishop score in all subgroups with a mean change of 4.6 (from 2.0 prior to induction to 6.6 upon removal of the Atad Ripener Device; P < 0.05). The mean time interval from insertion of the Atad Ripener Device to delivery was 18.9 h, and from removal to delivery was 6.9 h. Caesarean section was performed in 39/250 patients (16%), and the others had a normal vaginal delivery.

Conclusions
1. The double balloon device induces significant ripening and dilatation of the unfavourable cervix. 2. Induction of labour was successfully achieved following removal of the Atad Ripener Device. 3. Our caesarean section rate was low compared with rates reported for women with an unfavourable cervix induced by other methods.
Reversal of sterilisation by the railroad technique
Authors: Edozien L. C. , Anastassopulos D. , Mander A. M.
Published: August 2005

Objective
To show that a simple, easily learned and relatively inexpensive method of reversal of sterilisation provides good results.

Design
Retrospective observational study.

Setting
An NHS Trust Hospital.

Sample
Sixty‐seven women aged 19 to 39 years who underwent reversal of sterilisation between January 1984 and December 1993.

Main outcome measures
Pregnancy rate following reversal; rate of ectopic pregnancy.

Results
Thirty‐four women (51%) had intrauterine pregnancies after reversal of sterilisation; intrauterine pregnancy rate in women who had been sterilised with rings or clips was 64%. Five women (7.5%) had ectopic pregnancies.

Conclusion
This technique provides results that compare favourably with those of microsurgery. It offers hope to couples who do not meet the restrictive criteria for microsurgery and in vitro fertilisation and should appeal to purchasing authorities.
Loss of endothelium‐dependent relaxation in myometrial resistance arteries in pre‐eclampsia
Authors: Ashworth Janet R. , Warren Averil Y. , Baker Philip N. , Johnson Ian R.
Published: August 2005

Objective
To measure endothelium‐dependent relaxation in myometrial resistance arteries and to compare this parameter in nonpregnant and normotensive pregnant women and those with pregnancies complicated by pre‐eclampsia.

Design
A prospective study.

Setting
Nottingham City Hospital.

Sample
Thirty‐seven nonpregnant women undergoing hysterectomy and 51 pregnant women undergoing caesarean section, of whom there were 39 normotensive and 12 with pre‐eclampsia.

Methods
Resistance arteries, dissected from myometrial biopsies, were mounted on a wire myograph and preconstricted with vasopressin then subjected to incremental doses of bradykinin.

Results
Endothelium‐dependent relaxation to bradykinin was seen in the vessels of nonpregnant and normotensive pregnant women. Markedly reduced endothelium‐dependent relaxation was found in the myometrial arteries from women with pre‐eclampsia when compared with both nonpregnant (P < O.000l) and normotensive pregnant (P < 0.0001) women.

Conclusion
A significant loss of endothelium‐dependent relaxation in myometrial resistance arteries in pre‐eclampsia may contribute to the altered vasoreactivity seen in pre‐eclampsia, and particularly to the decreased placental perfusion and fetal growth retardation commonly associated with this condition.
Continuous transdermal oestrogen and interrupted progestogen as a novel bleed‐free regimen of hormone replacement therapy for postmenopausal women
Authors: Cameron Sharon T. , Critchley Hilary O. D. , Glasier Anna F. , Williams Alistair R. , Baird David T.
Published: August 2005

Objective
To investigate the effects of a hormone replacement therapy regime of continuous oestrogen and interrupted progestogen, administered transdermally, on the endometrium of postmenopausal women, the pattern of bleeding and relief of menopausal symptoms.

Design
Volunteer pilot study of up to six months duration involving weekly application of an oestrogen‐only skin patch releasing 50 μg oestradiol per day interspersed with a combined oestrogen and progestogen patch releasing 50 μg oestradiol and 250 μg norethisterone acetate per day for three days. Transvaginal ultrasound measurements of endometrial thickness and endometrial biopsies were performed in the third month of treatment at the end of both an oestrogen‐only phase of treatment and a combined oestrogen‐progestogen phase.

Setting
Specialist community menopause clinic, Dean Terrace Centre, Edinburgh.

Participants
Fifteen healthy postmenopausal women.

Main outcome measures
Effect of treatment on endometrial histology, the immunolocalisation of oestrogen and progesterone receptors and the cell proliferation marker Ki 67 after three months of treatment and the proportion of women without bleeding at six months.

Results
Treatment provided relief of hot flushes and by the sixth month of study 10 of the 14 women who completed treatment had no vaginal bleeding (71 %). No endometrial hyperplasia or atypical changes were observed in biopsies and ultrasound measurements of endometrial thickness demonstrated a thin endometrium. Reduced immunostaining for Ki 67 was observed in endometrium from the combined phase of treatment compared with the oestrogen‐only phase, consistent with a progestogenic‐antagonism of proliferation. Exposure to progestogen did not suppress steroid receptors as similar immunostaining was observed in both treatment phases.

Conclusions
Continuous oestrogen and interrupted progestogen administered transdermally offers promise as a novel bleed‐free hormone replacement therapy for postmenopausal women.
Detection of glove puncture and skin contamination during caesarean section
Authors: Eckford S. D. , James M. , Jackson S. R. , Hamer A. J. , Browning J. J.
Published: August 2005

Measures that can be taken to reduce exposure to potentially infected body fluids are of particular relevance in obstetric and gynaecological surgery due to high rates of glove puncture and relatively higher prevalence of human immunodeficiency virus seropositivity in the obstetric age group. We describe the use of a simple electronic device that alarms following puncture of surgical gloves or the creation of a fluid bridge between surgeon and patient. Further exposure to potentially infected body fluids is thus prevented. This present study was performed in the context of caesarean section, but the application of the technique to gynaecological procedures is appropriate.
HLA‐G polymorphism in Finnish couples with recurrent spontaneous miscarriage
Authors: Karhukorpi Jari , Laitinen Tarja , Tiilikainen Anja S.
Published: August 2005

HLA‐G is a class 1 major histocompatibility complex gene that is expressed in cytotrophoblasts at the materno‐fetal interface. It has been suggested that HLA‐G could play a key role in materno‐fetal immunological interactions during pregnancy. To investigate whether there is an association between HLA‐G locus and recurrent spontaneous miscarriage, HLA‐G alleles were determined by a PCR‐RFLP method in 38 couples with recurrent spontaneous miscarriage and in 26 random control couples. In this series parental HLA‐G sharing, extended HLA‐G/A haplotypes and the frequencies of the HLA‐G alleles were similar in the two groups. Thus, our data suggest that there is no detectable relation between susceptibility to recurrent spontaneous miscarriage and HLA‐G locus.
The fetal aortic pressure pulse waveform in normal and compromised pregnancy
Authors: Mori Akira , Trudinger Brian , Mori Ranko , Reed Vivienne , Takeda Yoshihiko
Published: August 2005

Objective
To study the arterial pressure waveform in the descending thoracic aorta during pregnancy in both normal and compromised fetuses.

Design
The pressure pulsation waveform propagated along the vascular tree, and acting laterally on the arterial wall, produces a corresponding change in the vessel diameter. The distance between diametrically opposite points of the aortic lumen was followed using a phase locked loop echo tracking system coupled to a B‐mode ultrasonic imager (central frequency 3.5 MHz).

Setting
Tertiary referral unit, teaching hospital.

Participants
A cross‐sectional study of 80 normal fetuses between 20 and 40 weeks yielded normal data. We studied 58 women with evidence of potential fetal compromise (high umbilical artery systolic: diastolic ratio).

Main outcome measures
From the aortic diameter waveform we measured the maximum systolic and minimum diastolic dimension and calculated pulse amplitude. The first derivative of the aortic diameter waveform identified the incisura of aortic and pulmonary valve closure and was used to time the end of ventricular ejection and systole.

Results
In normal pregnancy there was an increase in systolic and diastolic diameter and pulse amplitude with advancing gestation. Ventricular ejection time was constant. In the fetal compromised group the absolute systolic and diastolic diameters were within the normal range, but diastolic diameter per unit fetal weight was increased. There was a decrease in pulse amplitude as a percentage of diastolic diameter and an increase in the diastolic systolic diameter ratio. Fetal outcome was examined in relation to the diastolic systolic diameter ratio. Those with a high ratio (above 90th centile of normal group) exhibited significantly more adverse indices of fetal outcome.

Conclusions
The fetal aortic pressure pulse waveform was represented by the vessel diameter waveform. In fetal compromise reduced pulse amplitude and increased diastolic to systolic diameter ratio suggest corresponding changes in arterial pressure pulse. We suggest these are the response of the cardiac pump to increased afterload imposed by the high umbilical placental vascular resistance.
The effect on the likelihood of further pregnancy of placental abruption and the rate of its recurrence
Authors: Rasmussen Svein , Irgens Lorentz M. , Dalaker Knut
Published: August 2005

Objective
To assess the effect of having a placental abruption on 1. the probability of having further pregnancies, and 2. the rate of recurrence in such pregnancies.

Design
A cohort study based on the Medical Birth Registry of Norway.

Results
From 1967 to 1989, placental abruption occurred in 218/4951 subsequent deliveries after a placental abruption index case. After placental abruption with perinatal survival in the first delivery 59% of women had a further delivery, compared with 71% who did not have placental abruption at delivery. After a perinatal loss corresponding rates were 83% and 85%, respectively. Odds ratios of recurrence of abruption, crude and adjusted for maternal age, birth order and time period were 7.1 and 6.4, respectively. No secular trends were found. Caesarean section rates increased and were higher in pregnancies with recurrent placental abruption and in subsequent pregnancies without placental abruption than in the total birth population.

Conclusions
Women who have placental abruption are less likely than other women to have another pregnancy. For women who do have subsequent pregnancies placental abruption occurs significantly more frequently.
The impact of using a partially randomised patient preference design when evaluating alternative managements for heavy menstrual bleeding
Authors: Cooper Kevin G. , Grant Adrian M. , Garratt Andrew M.
Published: August 2005

Objective To identify the advantages and disadvantages of using a partially randomised patient preference design rather than a conventional randomised controlled design when evaluating alternative managements for heavy menstrual bleeding.

Design Randomised controlled comparison of two clinical trial designs with subsequent follow up of the cohorts of women generated.

Participants Women attending a general gynaecology clinic for the first time because of heavy menstrual bleeding.

Interventions Partially randomised patient preference clinical trial design and conventional randomised controlled design.

Main outcome measures Overall participation; participation in randomised clinical trial of medical management compared with transcervical surgical resection of the endometrium; prognostic characteristics (socio–demographic and Short Form 36) of clinical trial groups; outcomes (clinical and Short Form 36) of clinical trial groups.

Results Overall, more women participated in the partially randomised patient preference design (130/135 vs97/138; difference 27%, 95% CI 18% to 34%) but there was no difference in the numbers who agreed to be randomised (90/135 vs97/138; difference −3%, 95% CI −15% to 7%). Women who chose medical management tended to have better general health, to be less restricted by their menstrual problems, with fewer having been previously treated by their general practitioner. Those who chose transcervical resection of the endometrium had all tried medical management and had higher bleeding scores. Follow up satisfactions and acceptability rates, and Short Form 36 scores were highest after transcervical resection of the endometrium, whether chosen or randomised. Acceptability and a desire to continue the same treatment was greater among those who chose medical management than those randomly allocated it.

Conclusions Use of the partially randomised patient preference design did not affect recruitment to the randomised controlled trial suggesting that a conventionally designed trial would not be biased by motivational factors in this context. Data from the preference groups informed the generalisability of the results but did tend to confirm conclusions that anyway reasonably followed from the randomised controlled trial. The extra resource implications of using the partially randomised patient preference design were significant reflecting the additional 40% who participated and the extra analyses entailed.
Elevation of serum interleukin‐1 receptor antagonist levels in women with gynaecological cancers
Authors: Fujiwaki Ritsuto , Hata Toshiyuki , Miyazaki Kohji , Kawamura Takae , Inada Katsuya
Published: August 2005

This study included 15 patients with gynaecological cancers (7 with cervical cancer, 6 with endometrial cancer, and 12 with ovarian cancer); 7 with benign gynaecological disorders (5 with benign ovarian tumour and 2 with uterine myoma); and 10 healthy women as a control group. Serum interleukin‐1 receptor antagonist (IL‐1 ra) levels in patients with gynaecological cancer were significantly higher than those in patients with benign gynaecological disorders (P= 0.04) and in healthy controls (P= 0.0009). IL‐1 ra may play an important role in host immune responses in local and general environments against gynaecological cancers.
Increased fetal nuchal translucency thickness at 10–14 weeks: is screening for maternal–fetal infection necessary?
Authors: Sebire N. J. , Bianco D. , Snijders R. J. M. , Zuckerman M. , Nicolaides K. H.
Published: August 2005

Objective
To investigate the relation between increased fetal nuchal translucency thickness at 10–14 weeks of gestation and maternal–fetal infection.

Design
Prospective study.

Setting
Harris Birthright Research Centre for Fetal Medicine.

Population
Four hundred and twenty‐six chromosomally normal pregnancies with increased fetal nuchal translucency thickness at 10–14 weeks of gestation and 63 with ‘unexplained’ second or third trimester fetal nuchal oedema or hydrops.

Methods
Maternal serum infection screening and investigations for fetal infection in those with evidence of recent maternal infection.

Main outcome measures
Maternal and fetal infection.

Results
Evidence of recent maternal infection was present in six of the 426 pregnancies (1.4%) with increased fetal nuchal translucency thickness at 10–14 weeks, but in all cases a healthy infant was born with no evidence of infection. In contrast,‘unexplained’ second or third‐trimester fetal hydrops was associated with maternal infection in six of the pregnancies (9.5%) and in all cases there was evidence of fetal infection.

Conclusions
Maternal–fetal infection is one of the causes of second or third trimester nuchal oedema or fetal hydrops. In contrast, the presence of increased nuchal translucency in the first trimester is not a marker of either maternal or fetal infection.
Management of twin pregnancies with fetal trisomies
Authors: Sebire Neil J. , Snijders Rosalinde J. M. , Santiago Carlos , Papapanagiotou George , Nicolaides Kypros H.
Published: August 2005

Objective
To examine options of management and outcome of twin pregnancies affected by fetal trisomies.

Design
Retrospective study.

Setting
Research Centre for Fetal Medicine.

Population
Twenty‐seven twin pregnancies affected by fetal trisomy.

Methods
A computer search was made of our database for twin pregnancies concordant or discordant for trisomies. The data were reviewed for gestation at diagnosis of the chromosomal abnormality, management and pregnancy outcome.

Main outcome measures
Pregnancy management and outcome in relation to type and gestation at diagnosis of the trisomies.

Results
There were seven cases where both fetuses were trisomies and in these the parents opted for termination of pregnancy; termination was also performed in another pregnancy where one fetus had trisomy 18 and the chromosomally normal co‐twin had a major facial cleft. In 19 cases one fetus had either trisomy 21 (n= 14) or trisomy 18 (n= 5) and the other was normal. Selective fetocide was carried out in 13 of 14 pregnancies discordant for trisomy 21 and in one of the five with trisomy 18. In the four cases discordant for trisomy 18 that were managed expectantly, the trisomic baby died in utero or in the neonatal period, whereas the normal co‐twin was liveborn at 33 to 40 weeks (median 37). In the 14 cases of selective fetocide, the chromosomally normal co‐twin was live born at 24 to 41 weeks of gestation (median 38), and there was a nonsignificant inverse correlation between the gestation at fetocide and gestation at delivery.

Conclusions
In twin pregnancies discordant for fetal trisomies the main determinant in deciding whether to perform selective fetocide or adopt expectant management is the degree of lethality of the chromosomal defect.
Is HTLV‐1 status another antenatal screening test that we need?
Authors: Otigbah C. , Kelly A. , Aitken C. , Norman J. , Jeffries D. , Erskine K. J.
Published: August 2005

Human T‐lymphocytic virus type 1 (HTLV‐1) carriage is associated with a 2% to 5% lifetime risk of developing a severe, if not fatal, disease. In our Inner London antenatal population, we found that the carrier rate was 0.3%. The antenatal transmission rate is known to be very low, but if the infant is breastfed the transmission rate is up to 25%. It is therefore possible to interrupt the transmission cycle by advising against breastfeeding. The ethical and fiscal issues surrounding antenatal testing are addressed.
Randomised trial comparing a policy of early with selective amniotomy in uncomplicated labour at term
Authors: Johnson Nicholas , Lilford Richard , Guthrie Kate , Thornton James , Barker Margaret , Kelly Mike
Published: August 2005

Objective
To compare two management policies: rupture of the fetal membranes when women are in normal labour or leave them intact as long as feasible.

Setting
The labour ward of a city university hospital.

Design
Automated randomised clinical trial.

Participants
1540 women in uncomplicated term labour. Data on labour duration, blood loss, oxytocin use and fetal condition were collected from 1132 women. Some data from nulliparous women has been presented earlier by the UK Amniotomy Group.

Main outcome measures
Duration of labour, Apgar score, fetal morbidity and maternal morbidity including perineal injury, mode of delivery, epidural rates and the total number of vaginal examinations in the first stage of labour after amniotomy.

Interventions Amniotomy at the next vaginal examination or amniotomy only if indicated. The median cervical dilatation at membrane rupture was 2 cm greater in the first group.

Results
A policy of routine amniotomy in labour had no measurable advantage over selective amniotomy for parous women (difference = 4 min) but shortened labour in nulliparous women by 1 h (Mann‐Whitney U test: P < 0.05). There was a suggestion of a higher caesarean section rate (OR 1.9; 95% CI 0.9–3.5), and there were more vaginal examinations after membrane rupture in the group allocated routine amniotomy. There were no measurable differences in oxytocin use, fetal condition at birth, retained placenta rates, blood loss, pain or analgesia requirements.

Conclusion
Routine amniotomy may shorten the first labour but not subsequent ones. There is a suggestion that routine surgical interference may be harmful by increasing the risk of caesarean section, and this agrees with data from other trials (common odds ratio 1.2; 95% CI 0.92–1.6).