bluuebunny/crossref_metadata_2025 huggingface dataset:
Vulvar Dystrophies: An Evaluation
Authors: Ayhan Ali , Yuce Kunter , Urman Bulent , Ayhan Ayse , Gököz Aytac
Published: February 2008

EDITORIAL COMMENT: This paper provides readers with a logical plan of treatment for patients presenting with pruritus, vulvitis or visible vulvar disease who are found on directed biopsy to have vulvar dystrophy (hyperplasia, lichen sclerosus or mixed dystrophy). Excellent results were obtained using topical corticosteroid therapy for patients with hyperplasia, and topical testosterone for those with lichen sclerosus. In presenting the results in this series of 86 patients the authors do not explain the criteria for directed vulvar biopsy in women presenting with pruritus or vulvitis. These excellent results suggest that vulvar biopsy should be performed not only in all patients with clinical suspicion of carcinoma, but also in all those who fail to respond to initial therapy. The results presented here seem almost too good to believe because in this reviewer's experience vulvar biopsies in many patients with intractable pruritus and vulvitis show coexistence of hyperplasia and lichen sclerosus — in this series only 7 of 86 patients had mixed dystrophy. Readers should note that medical treatment was not used in patients with atypia on biopsy — these patients require a surgical approach to their treatment.

Summary: Of 86 patients diagnosed as having vulvar dystrophy in a 10‐year period 56 (65.1%) had hyperplastic dystrophy, 23 (26.7%) had lichen sclerosus and 7 (26.7%) had mixed vulvar dystrophy. The diagnoses were made by colposcopic or toluidine blue directed biopsies. Fluorinated corticosteroids were given to patients with hyperplastic dystrophy with a response rate of 90.1%. Patients with lichen sclerosus received topical testosterone propionate and the response rate was 87.7%. Topical fluorinated corticosteroids followed by testosterone propionate was given to patients with mixed dystrophy and 85.8% of the patients responded. Surgical therapy was reserved for patients with failed medical treatment.
Hysteroscopy: An Analysis of 523 Patients
Authors: Finikiotis George
Published: February 2008

EDITORIAL COMMENT: There is always the problem of when to perform curet‐tage in the premenopausal patient with irregular or heavy bleeding, when the clinical findings and cervical smear are normal, and the risk of significant endometrial pathology is low. Curettage is not without risk, inconvenience or expense and may be followed by irregular bleeding or infection. On the other hand oncologists remind us that about 20% of cases of endometrial cancer occur in premenopausal patients whose abnormal bleeding therefore warrants endometrial sampling. This paper makes a strong case for the more widespread use of hysteroscopy which does not enjoy the popularity it deserves. It may be used without anaesthesia, perhaps removing the need for hospitalization, and it can, as shown in this paper, select the patient with endometrial pathology that requires sampling by curettage. Hysteroscopy also has the added advantage, when used at the time of curettage, of ensuring that a macroscopic lesion has not been missed, or in the case of endometrial polyps, removed incompletely (figure 1).

Summary: An analysis is presented of the indications for, and findings on, hysteroscopy in 523 patients undergoing gynaecological investigation or treatment. Abnormal uterine bleeding or discharge was the indication for investigation in 202 patients. Based on hysteroscopic observation, dilatation and curettage (D & C) was adjudged unnecessary in 114 (56%) and a subsequent D & C on these patients revealed no histological abnormalities. In the remainder, more abnormalities were observed visually on hysteroscopy than were detected by D & C. The results suggest that D & C should be replaced by hysteroscopy and biopsy as a first‐line investigation of abnormal uterine bleeding or discharge.
Second Trimester Detection of Unilateral Hydrothorax: A Case Report of Successful Pregnancy Outcome with Passive Management
Authors: Weaver Edward , Costello Gerry , Innes Marty , Dye David , O'Brien Greg
Published: February 2008

EDITORIAL COMMENT: This case illustrates the important option of conservative management of abnormalities detected using ultrasound antenatally. The number of investigative and therapeutic techniques available for use on the fetus antenatally is increasing rapidly. All of these techniques however carry some degree of risk to the fetus. In some instances such as amniocentesis this risk is well defined but in others less well so. After the initial enthusiasm for operative intervention antenatally for treatment of such conditions as hydrocephalus and hydronephrosis most experts now recognize such procedures have a very limited role to play in the antenatal period. The natural history of many ultrasound detected abnormalities is poorly characterized. It is increasingly evident as more publications appear in the literature that many conditions such as that illustrated in this report will disappear spontaneously without any intervention being necessary.

There is still a place for masterly inactivity in obstetrics. With the sophistication of modern technology, observation of fetal condition can indeed be masterly, but the need for clinical judgement is probably greater now that spectacular beneficial intervention is technically possible in some conditions.

Our librarian traced for us the likely origin of the aphorism that ‘in obstetric practice an error of omission is better than an error of commission’—‘In medicine the sin of commission is mortal, the sin of omission venial.“1. Bulletin of the New York Academy of Medicine, 1929: 5.
Group B Streptococcal Colonization and Preterm Labour
Authors: McDonald Helen , Vigneswaran Rasiah , O'Loughlin John A.
Published: February 2008

Summary: Recent publications have highlighted the controversy regarding the significance of Lancefield Group B Streptococcal (GBS) colonization in pregnancy and preterm delivery. In this prospective study vaginal swabs from 692 women at approximately 24 weeks' gestation were cultured for GBS. GBS was detected in 91 (13.2%) women. The rate of preterm labour (PTL) (<37 weeks) was significantly higher in GBS positive women than in GBS negative women (18.7% versus 5.5%; p< 0.001). This association remained significant even when patients with other recognized factors predisposing to PTL were excluded (11.5% versus 3.9%; p< 0.001). The rate of premature rupture of membranes (PROM) was also significantly higher in GBS positive women (9.9% versus 2.7%; p < 0.005) and remained significantly higher when patients with other recognized risk factors were excluded (6.1% versus 1.8%; p < 0.025). These results unequivocably show that pregnant women who are vaginal carriers of GBS have a significantly increased risk of PROM and PTL.
Incidence of Prematurity and Low Birth‐weight in an Immigrant Chinese Population
Authors: Drew John H. , Chan Donald P.
Published: February 2008

Summary: This paper analyses the incidences of prematurity (gestation < 37 weeks) and low birth‐weight (birth‐weight between 500 and 2,500g) in liveborn singleton infants born in Australia to mothers of the Chinese race. The incidence of prematurity was lower in infants born to mothers from Hong Kong (4.6%), to those from an almost exclusive Chinese population (5.5%) and to those that comprised a predominantly Chinese population (6.1 %) when compared to that in a mainly non‐Chinese population (7.7%). The incidence of low birth‐weight was lower in infants born to mothers from Hong Kong (3.5%) and to those born to an almost exclusive Chinese population (4.1%) but not to those born to a predominantly Chinese population (5.9%) when compared to that in those born to a mainly non‐Chinese population (5.9%). The incidence of major fetal malformations was similar in these Chinese and non‐Chinese populations. This study confirms that Chinese have a significantly low incidence of prematurity and that this finding remains true when they live in Australia. Detailed prospective studies are required in immigrant Chinese to determine why they have such a low incidence of prematurity and to determine the incidence of fetal malformations which is said to be different than in Caucasian populations.
The Prediction of Intrauterine Growth Retardation in Remote Area Aboriginal Women Using Serial Fundal‐Symphysial Height Measurements
Authors: Norton R.
Published: February 2008

Summary: A well recognised, simple and effective method of charting uterine growth by measuring the fundal‐symphysial height serially was used in 3 tribal Aboriginal communities in East Arnhemland.

A total of 34 women were followed with serial measurements using a nomogram derived from Quaranta et al (1). There were 7 births with recorded birth‐weights of 2,500g or less (range 2,130g‐2,500g). Six of these had serial fundal height measurements consistently at or below the 10th percentile. These 6 babies were also found to be small for gestational age. There were 13 births with recorded birth‐weights between 2,500g‐3,000g. Four of these babies had serial fundal height measurements at or below the 10th percentile and 3 of the 4 were small for gestational age.

It is suggested that fundal‐symphysial height measurements may be useful in the detection of intrauterine growth retardation, particularly in remote areas where there is a shortage of experienced medical personnel. It can be used by trained Health Workers and provides an objective record of antenatal progress.
The Association of Anovulation and Endometriosis in the Infertile Female
Authors: Arumugam Kulenthran , Mahmood Tahir A , Kong Y F Sew‐Chine
Published: February 2008

Summary: Ninety‐six infertile patients with endometriosis were studied and their endometriosis staged according to the Revised American Fertility Society Classification. Anovulation was detected in 19% of the 32 patients with Stage 1 disease but in only 3% in the remaining 64 patients with Stage II, III and IV disease. These results show that contrary to traditional belief, anovulation does occur in a significant number of patients with endometriosis, especially in minimal or mild disease.
Sinusoidal‐like Fetal Heart Rate Tracing in a Case of Acute Fetomaternal Haemorrhage
Authors: Arulkumaran S. , Wong Y. C. , Anandakumar C. , Ratnarn S. S.
Published: February 2008

EDITORIAL COMMENT: This case indicates that when fetomaternal haemorrhage is the cause of critical fetal reserve as observed by cardiotocography the fetus may be doomed in spite of prompt delivery by emergency Caesarean section, although there are reports of successful fetal outcome with immediate delivery in such cases. The moral of this case report is that cardiotocographic evidence of reduced fetal reserve of any degree indicates delivery when the pregnancy is at term, especially when there are other complications, such as fetal growth retardation.
Obstructive Sleep Apnoea During Pregnancy Requiring Tracheostomy
Authors: Hastie Stewart J. , Prowse Keith , Perks Warren H. , Atkins John , Blunt V. Alan W.
Published: February 2008

Summary: The case is presented as an unusual example of the benefit of tracheostomy during pregnancy in a patient with obstructive sleep apnoea syndrome.
Trauma During Pregnancy — A Review of Management
Authors: Bowman Mark , Giles Warwick , Deane Stephen
Published: February 2008

Summary: The assessment and management of 22 pregnant patients who were admitted after trauma to Westmead Hospital between July, 1987 and October, 1988 was reviewed. Thirteen of the 22 patients were victims of motor vehicle accidents. Despite the fact that an injury research unit, responsible for the clerking and review of all trauma patients, is well established at our institution, only 6 patients in this series had been assessed in this fashion. Although a number of important obstetric investigations (albeit uncommon in the accident and emergency room situation) are well described in the literature, these were not performed in a number of patients. A protocol for the management of such patients is recommended so that more standardized and appropriate care might be given to the injured pregnant patient.
Secondary Postpartum Haemorrhage
Authors: King P.A. , Duthie S.J. , Ven Dip , Dong Z.G. , Ma H.K.
Published: February 2008

EDITORIAL COMMENT: This paper provides a useful review of the clinical features and management of secondary postpartum haemorrhage. Table 1A shows comparable statistics from an Australian hospital which the incidence was 2–3 times higher than the 0.5% reported by the authors from their hospital in Hong Kong. Since there are no predictive factors for secondary postpartum haemorrhage the important data concerns proper management. The high incidence of suction evacuation (87%) is noteworthy as was the authors' finding that the procedure stopped the bleeding in all 72 patients requiring this operation. The 1 case of uterine perforation serves as a reminder that the uterus may be soft and friable in these patients. Hysterectomy is seldom required in patients with secondary postpartum haemorrhage but when it is necessary, an experienced surgeon is required, since it is often difficult to secure haemostasis, and ligation of internal iliac arteries may be necessary. The 1 subtotal hysterectomy required in this series was performed before secondary postpartum haemorrhage occurred. The 3 other useful pieces of information provided in this Hong Kong series were that 24% of patients required blood transfusion, that bacteriology although useful on occasions was positive in only 12% of patients, and that histologically proven placental tissue was obtained at suction evacuation in 42% of patients — oedematous decidua is often macroscopically mistaken for placental tissue at the time of surgery in these patients.

Summary: Eighty‐three cases of secondary postpartum haemorrhage managed in this teaching unit over a 3‐year period are described. Bleeding occurred most frequently between the 8th and 14th day of the puerperium; 73% of the patients had already been discharged from hospital and required readmission. Suction evacuation was performed in 72 patients and was successful in arresting haemorrhage whether retained placental tissue could be demonstrated on histology or not. There was histological confirmation of retained gestational products in only 30 (42%) of the patients treated surgically. No predictive factors for secondary postpartum haemorrhage could be identified in the obstetric profiles or antenatal course of most of these patients. Patients with retained gestational products could not be distinguished from those without on the basis of history or examination alone apart from 4 patients noted to have incomplete membranes at delivery.
Is Elective Cerclage Justified in the Management of Triplet and Quadruplet Pregnancy?
Authors: Goldman Gil A. , Dicker Dov , Peleg Dan , Goldman Jack A.
Published: February 2008

Summary: The main complication in multiple gestation with more than two fetuses is prematurity, with its concomitant increase in perinatal mortality and morbidity. Clearcut indications as to management of these pregnancies are lacking, and the efficiency of elective cerclage is controversial.

Twelve triplets and three quadruplets out of 27 multiple pregnancies were electively sutured and compared to 10 triplets and two quadruplets without this procedure. Otherwise, both groups were managed uniformly regarding bed‐rest, beta‐mimetic drugs and dexamethazone for the enhancement of fetal lung maturity.

Mean duration of pregnancy in patients with cerclage was 35 weeks, significantly longer than those who did not undergo this procedure (30.7 weeks) (p<0.01).

Furthermore, in the former group, the mean neonatal weight was significantly higher (p<0.01), mean Apgar scores were better, significantly lower rates of respiratory distress syndrome occurred (p<0.05), perinatal mortality rate was significantly reduced (p<0.01) and the mean hospitalization period was shorter (p< 0.025).

It seems that elective cervical suture is a definite contribution to the successful management of multiple pregnancies with more than two fetuses.
The Inadequacies of Instruments Used for Cervical Screening
Authors: Spurred B. , Ayer B. , Pacey N.F.
Published: February 2008

EDITORIAL COMMENT: This paper illustrates the need for improved instruments for performing cytological screening of the cervix, especially the endacervix. Comparison of techniques is not easy because of the problems of variation of findings due to observer interpretation and the problem of the order in which the smears are taken — for example was the spatula inferior to the cytobrush in this study because it was used second or because it provided a less satisfactory specimen? Another problem with comparisons of different techniques is that there is an interobserver variation (cytological interpretation) of more than 30 per cent in the severity of cervical intraepithelial neoplasia lesions. In this study one gynaecologist took all of the smears and one cytologist interpreted them all.

Summary: Cervical cytology has a high false negative rate, especially for adeno‐carcinoma and its precursors. This study compares the traditional spatula with the cytobrush. Both the modified Ayre spatula and the cytobrush were found to be inadequate in a significant number of patients with known cytological atypia.

It is concluded that inadequate sampling instruments make a contribution to false negative rates and that brush cytology is superior to rigid instrument cytology in routine cervical screening.
Vaginal Dystocia in a Patient with a Double Uterus and a Longitudinal Vaginal Septum
Authors: Carey Marcus P. , Steinberg Lionel H.
Published: February 2008

EDITORIAL COMMENT: About 1 in every 500 women are born with a longitudinal vaginal septum. Presenting symptoms resulting in diagnosis of the malformation are usually dyspareunia or difficulty in insertion of a tampon. Septa may be thick and inelastic, or thin and readily displaced from the midline, such that the patient is unaware of the condition. Indeed the writer has the experience of diagnosis of such a septum at the time of Manchester repair in a postmenopausal multipara — the septum had been asymptomatic and unrecognized by herself or her obstetrician at her uneventful vaginal deliveries, and was displaced laterally such that the left sided uterus and vagina was unused — the diagnosis was made when the cervix was amputated! Management should be division and Hgation even if asymptomatic, because of the problems that can occur in labour. It is unnecessary to excise any of the flap since it takes up into the vagina with intercourse — even a large septum will disappear without a ridge remaining. The writer has 2 indelible memories of problems with such septa in labour. The first was being called, in 1961, to a case of delay in the second stage in a general practitioner unit in Coleraine, Northern Ireland. The mass projecting through the introitus was the longitudinal septum, seemingly transverse, pushed down by the head. Treatment was midforceps delivery of a healthy infant after pushing back the head so that the septum could be clamped, ligated and divided. The second, in 1965, was a 20‐year‐old primigravida with a known breech presentation (normal X‐ray pelvimetry), whose vaginal septum was not diagnosed until precipitate delivery occurred with the breech astride the septum which spontaneously avulsed from the posterior vaginal wall, after an episiotomy was made, and before the septum could be divided. The baby (birth‐weight 2,900 g) was alive and well. The vagina was packed after noting that the septum was a ‘huge necrotic fold the size of the placenta due to haematoma within it’, and the episiotomy was sutured. The septum was still noticeable anteriorly at the postnatal visit, but was no longer apparent I year later during the patient's second pregnancy.

In the case reported here, once the septum was recognized at the lime of curettage, the patient should have been counselled appropriately and the septum divided.

Summary: A case of a breech straddling a vaginal septum requiring urgent division is reported. This case demonstrates some of the obstetric complications asociated with congenital genital tract anomalies.
Ethics and Reproduction1
Authors: Pinker George
Published: February 2008

I am neither an expert on ethics nor a subspecialist in human reproduction, so that the experts amongst you in either or both fields will have to be a little patient and forebearing with me. Further, it must be appreciated that however carefully such a talk is prepared views will be expressed which are bound to inflame those who hold extreme views at one or other end of the scale. Further, I can of course only speak with any authority on the situation in the United Kingdom.
Uteroplacental Doppler Ultrasound in Routine Antenatal Care
Authors: Brown M.A. , North L. , Hargood J.
Published: February 2008

Summary: Three hundred and five pregnant women referred consecutively from a single antenatal clinic for imaging ultrasound after 26 weeks' gestation had doppler velocimetry of umbilical artery, uterine artery and umbilical vein. Results of doppler studies were not available to clinicians until after delivery and clinical case records were examined postpartum for the development of pregnancy‐induced hypertension (PIH) or gestational diabetes mellitus (DM) and for fetal outcome.

Accurate data were available for 272 women, of whom 167 had a normal pregnancy, 61 had or developed PIH and 44 had or developed DM. None of the various doppler velocimetry measurements differed significantly amongst these 3 groups at any gestational stage. Abnormal values for doppler systolic: diastolic (A/B) ratio were found in only 7% of umbilical artery measurements, 6% of uterine artery measurements and none of umbilical vein measurements. Specificity of abnormal results for PIH or DM was high (95–97%) but sensitivity low (16–17%) and positive and negative predictive values were generally low. Two perinatal deaths occurred and umbilical artery A/B ratio was abnormal in both cases. This study shows that there is a low yield of abnormal results for doppler velocimetry of umbilical artery, uterine artery or umbilical vein in routine antenatal screening.
Does Cord Drainage of Placental Blood Facilitate Delivery of the Placenta?
Authors: Thomas I. L. , Jeffers T. M. , Brazier J. M. , Burt C. L. , Barr K. E.
Published: February 2008

EDITORIAL COMMENT: Most busy practitioners hold strong opinions, based on clinical experience they will say, of the preferred regimen for management of common clinical problems. This study shows that strongly held beliefs may be falacious. The authors have shown that drainage of placental blood from the cord does not affect the rates of retained placenta and postpartum haemorrhage. The editor has always taught that releasing the cord clamp and allowing drainage of placental blood minimizes fetomatemal haemorrhage and assists placental delivery ‐ he stands corrected. However, draining the cord does no harm, and the reviewer of this paper commented that at least it minimizes the mess if the cord breaks during delivery of the placenta by controlled cord traction!

Our common clinical regimes should be scrutinized more often, especially when clinical results or community costs are involved. This study did not attempt to assess the value to the fetus of early versus late clamping of the cord. However, the volume of cord blood drained by release of the clamp (mean 54ml; range 0–185ml) suggests that the practice of early versus late clamping of the cord should be reevaluated to assess the volume of blood denied to the infant and the clinical implications of withholding this blood infusion.

Summary: A series of 1,908 women delivering vaginally, and actively managed in stage 3 of labour, were randomly assigned to 2 groups to study if cord drainage of placental blood facilitated delivery of the placenta. Prophylactic oxytocics were given with the birth of the anterior shoulder. In both groups, early cord clamping was practised, timing being at the midwives' discretion. In the control group the cord remained clamped; in the drainage group the cord was undamped and the volume of placental blood measured. Controlled cord traction completed active management at evidence of separation/descent of the placenta.

Rates for retained placenta, postpartum haemorrhage and transfusion were similar. It was concluded that when the third stage of labour is actively managed, placental drainage of cord blood confers no extra benefits.

Pre‐ and post‐delivery Kleihauer tests were performed on blood from 20 women in each group. All tests were negative. Contrary to previous work, this does not suggest that cord drainage reduces the fetomatemal transfusion rate.

The well known association of prolonged duration of stage 3 of labour and the risk of haemorrhage was strongly confirmed.
Macrosomic Babies
Authors: Cheung T. H. , Leung Ares , Chang Allan
Published: February 2008

EDITORIAL COMMENT:
This paper presents the useful information that shoulder dystocia associated with macrosomia is more likely to result in neonatal morbidity when instrumental delivery is necessary than when delivery is spontaneous; whether or not this important conclusion applies equally to nulliparas and multiparas cannot be evaluated from the data presented here where only 17 of the 93 patients delivered vaginally required forceps delivery. In the editor's opinion mid‐forceps delivery is likely to be followed by shoulder dystocia when macrosomia is associated with occipitoposterior position in either nulliparas or multiparas. One reviewer of this paper was uneasy that in the presence of suspected macrosomia, Caesarean section rather than forceps delivery should be performed. If the head is arrested in the mid‐pelvis the risk of shoulder dystocia is considerable. Trial of forceps in theatre does not provide an easy solution because the greater problem may prove to be the shoulders when, in spite of some articles to the contrary, one is committed to vaginal delivery once the head is born. Another consideration is the type of analgesia used for such forceps deliveries ‐ in the editor's opinion mid‐forceps delivery merits general anaesthesia when there is the possibility of macrosomia, to provide ideal conditions for assessment and forceps rotation and delivery, and dealing with impacted shoulders if this complication occurs. A final comment is to remember the advice we received in training to ‘beware of mid‐forceps delivery in a multipara’ and this is especially true if she has previously required mid‐forceps delivery and/or has delivered an infant with birth‐weight above 4,000–4,500g. (see previous comments on Shoulder Dystocia Aust NZ J Obstet Gynaecol 1988; 28: 107 and 1989; 29: 129).

Summary: A review on 3,241 delivery records was made to study the obstetrics and the neonatal outcomes of 129 macrosomic (>4,000g) babies. They were found to have a nearly 6‐fold increase in the neonatal morbidity rate compared with normosomic babies. The emergency Caesarean section rate for nulliparas and parous women with macrosomic babies was 41.3% and 8.4% respectively. Among macrosomic babies, shoulder dystocia was not associated with maternal stature, induction of labour, use of oxytocin or abnormal labour patterns, but was associated with instrumental delivery. Macrosomic babies with shoulder dystocia after instrumental delivery had a higher neonatal morbidity rate than those delivered spontaneously.
The Hyperaemic Endometrium at Hysteroscopy
Authors: Finikiotis George
Published: February 2008

Summary: Five hundred and thirty seven hysteroscopies were performed on 523 patients. In 37 cases, diffuse hyperaemia was the only abnormality found. Directed biopsy or dilatation and curettage (D&C) was performed on 28 of these, none of which revealed histological abnormalities. The hysteroscopically visualized hyperaemic endometrium was detected in all phases of the menstrual cycle, in the postmenopausa! state and in patients on hormonal therapy. In the absence of excessive thickness of the endometrium or other abnormalities, hyperaemia was not found in increased association with organic uterine pathology. The results suggest that hysteroscopy and directed biopsy of hyperaemic areas is adequate and may replace D&C as a first line of investigation.
CO2 Laser Laparoscopic Salpingotomy for Treatment of Tubal Ectopic Pregnancies: Potential Limitations
Authors: O'Shea Robert T. , Thompson Graeme R. St J.
Published: February 2008

EDITORIAL COMMENT: In appropriate selected cases (no shock, no active bleeding, no significant adhesions and no very high HCG levels) the treatment of choice of tubal ectopic pregnancy is by laparoscopic conservative surgery (salpingotomy). A laparoscopic approach compared to laparotomy, has proven economic advantages (shorter hospital stay and convalescence and earlier resumption of normal occupation) and suspected clinical advantages (less adhesion formation and better subsequent viable pregnancy rates) awaiting randomized prospective controlled studies for verification. Laparoscopic salpingectomy can also be performed with laser, as in this paper, or with cutting/coagulation diathermy (which is much, much cheaper) which yields comparative results. Salpingotomy can be performed laparoscopically with safety and could have been considered for one of the patients in this series who returned to theatre. The persistence of trophoblastic tissue requiring further treatment (usually methotrexate) occurs in about 10% of cases. Raphael Kuhn, Melbourne

Summary: Linear salpingotomy was performed on 16 patients using the CO2 laser laparoscopically directed. Median operating time was 60 minutes (range 40–100) and all patients were discharged on the first postoperative day. There were 4 patients in whom persistence of trophoblast activity was detected, 2 of whom were treated surgically and 2 by oral methotrexate therapy.
Immunology of Anogenital Human Papillomavirus (HPV) Infection
Authors: Tindle Robert W. , Frazer Ian H.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because it takes the human papillomavirus story further than the many other papers we have published on this increasingly common genital tract infection which has precancerous connotations. Many of the details may not excite the interest of general readers but the possibilities of vaccination against infection, nonsexual transmission and cocarcinogenesis are discussed. It seems to the editor that the main requirement is an accurate test to determine if women/men already harbour or have harboured the virus, because how else can we select candidates for vaccination when a vaccine becomes available ‐ unless one envisages a strategy of vaccinating the entire (? female) population, to preclude the need for selection of those already infected.

Summary: A subgroup of human papillomaviruses (HPVs) is implicated in the aetiology of neoplastic change in anogenital epithelium. Although abundant circumstantial evidence exists for the involvement of the immune system in the control of HPV infection, restriction of infection to epithelium and the lack of a viral productive phase pose problems for immune response induction, and for immunological effector mechanisms. In this article we discuss how HPV antigens may be presented to the immune system on the surface of keratinocytes as well as, or in addition to, presentation by ‘classical’ antigen presenting cells, and outline putative roles for non‐specific and specific (B‐ and T‐ cell) effector functions. We discuss the prospects for a vaccine and the use of anti‐HPV antibodies in immunodiagnosis.
The Gynaecological Problems of Neurofibromatosis
Authors: Blickstein I. , Lurie S.
Published: February 2008

Summary: The gynaecological problems of neurofibromatosis (NF) are not well documented. The present survey of the literature defines 3 main problems, namely: clitoral, vulvar and pelvic NF. The clinical suspicion of NF would in most cases improve patient care and prevent undue procedures. There remain some important unsettled questions to be answered.
Immediate Postpartum Complications
Authors: George Lourdes St , Crandon Alex J
Published: February 2008

Summary: Two hundred and sixty‐nine (5.4%) of the 4,998 patients who delivered in Westmead Hospital, New South Wales in 1985 had immediate postpartum complications. This analysis was compared with figures from a major institution in another state of Australia. Early detection and prompt management without procrastination was the key to a successful outcome in the fourth stage of labour (i.e. within 24 hours of delivery). Nearly three‐quarters of the complications were due to postpartum haemorrhage (PPH). The contributory factors are analysed and discussed. Reappraisal of the indications for induction of labour, epidural analgesia and forceps delivery is necessary to reduce the incidence of postpartum haemorrhage. The study reinforces the need for undiminished vigilance in the fourth stage of labour even if the first 3 stages are uncomplicated.
Inferior Vena Cava Ligation for Intractable Pelvic Haemorrhage
Authors: Bank S.S. , Dogra M. , Khunnu B. , Ghosh K. , Kalra M. , Dhall K.
Published: February 2008

Summary: Inferior vena cava ligation was performed as the last resort in a case of iatrogenic injury to the common iliac veins during pelvic surgery. The post‐operative recovery was satisfactory.
The Significance of Polyhydramnios Diagnosed During Labour or at Caesarean Section
Authors: Desmedt Els J. , Henry Olivia A. , Beischer Norman A.
Published: February 2008

EDITORIAL COMMENT: This paper reports a simple clinical message that may not surprise readers, but should interest them — polyhydramnios diagnosed for the first time during labour or at delivery is not a benign finding.

Summary: In the 38 cases of polyhydramnios reported here the diagnosis was made only at the time of artificial rupture of the membranes to induce or augment labour, or at Caesarean section. Usually this was a benign finding often associated with overweight in the mother (60%) or baby (39.4%). However there was an increased incidence of major congenital abnormality (13.1%) resulting in a high perinatal mortality rate (10.5%); the paediatrician should therefore be alerted prior to delivery of these patients.
Investigation of Spontaneously Aborted Concepti for Microbial DNA: Investigation for Cytomegalovirus DNA Using Polymerase Chain Reaction
Authors: Putland Rodney A. , Ford Judith , Korban George , Evdokiou Andreas , Tremaine Maureen
Published: February 2008

Summary: Karyotypic analysis of concepti spontaneously aborted in the first trimester shows approximately 50% of these concepti contain abnormal chromosomes. In order to determine whether cytomegalovirus (CMV) infection may play a role in the early loss of pregnancies with either normal or abnormal chromosomes, we have developed an assay to amplify CMV DNA in DNA extracts from spontaneously aborted concepti using the polymerase chain reaction (PCR). Using PCR, we were unable to detect CMV DNA in any of 350 spontaneously aborted concepti. Viral cultures were also negative when 36 of these were tested. Our results suggest that CMV infection is an unlikely cause of pregnancy loss in the first trimester of pregnancy.
Hormonal Changes Related to Impairment of Cervical Mucus in Cycles Stimulated by Clomiphene Citrate
Authors: Langer Rami , Golan Abraham , Ron‐El Raphael , Pansky Mordechai , Neuman Menachem , Caspi Eliahu
Published: February 2008

Summary: The levels of luteinizing hormone (LH), follicular stimulating hormone (FSH), 17‐oestradiol (E2), progesterone (P), and testosterone (T) were determined for the early, midfollicular and periovulatory phase of spontaneous and clomiphene citrate (CC) induced cycles in 5 patients who responded with appearance of hostile cervical mucus (Group A) and 5 patients whose cervical mucus remained unchanged during the same treatment (Group B). The patients with hostile mucus were further investigated during a third cycle stimulated by CC and ethinyloestradiol (EE). Patients treated with CC for induction of ovulation who developed hostile cervical mucus showed higher levels of LH and T in the midfollicular phase of the menstrual cycle and significantly higher levels of T in the periovulatory period compared to patients with unchanged mucus. EE treatment induced a drop in the elevated LH and T levels and improved the cervical score. No change in E2 levels was noted. A direct effect of EE on the cervical glands together with the centrally mediated lowering of serum T are suggested to be responsible for improving the cervical mucus.
Office Hysteroscopy and Curettage — A Safe Diagnostic Procedure
Authors: Itzkowic David J. , Laverty Colin R.
Published: February 2008

Summary: In a series of 50 patients investigated by office hysteroscopy and curettage, satisfactory direct inspection of the cervical canal and uterine cavity was possible in all patients. In addition satisfactory endometrial specimens suitable for reliable histological evaluation were obtained in 98% of patients. No endometrium was obtained in 1 postmenopausal patient.

Patients chosen for this form of investigation are those with an indication for diagnostic curettage who have no serious cardiovascular disease, are not bleeding or have light bleeding, and are willing to have an office procedure. Currently office curettage is done with a 5mm Karman catheter with an attached 10ml syringe for suction. Local analgesia is rarely used.
Hirsutism in a Gynaecological Context
Authors: McKenna K. Mark , Pepperell R.J. , Evans James
Published: February 2008

Summary: Investigation of patients presenting with hirsutism to a gynaecological endocrine clinic revealed a high incidence of anovulation, obesity and elevated androgen levels. The underlying abnormality was polycystic ovarian syndrome (PCOS) in the majority of patients. Low levels of sex hormone binding globulin were common; these increased with oestrogen treatment. Treatment with a combined oral contraceptive pill and low dose spironolactone was often effective in reducing symptoms.
The Influence of Paternal Height and Weight on Birth‐weight
Authors: Morrison J. , Williams G. M. , Najman J. M. , Andersen M. J.
Published: February 2008

Summary: : Analysis of 5,989 couples, for whom fathers' and mothers' heights and weights were recorded, showed that paternal height had a significant influence (p< 0.0007) on birth‐weight while paternal body mass index (Quetelets Index) had no significant effect (p>0.05).

Depending upon mother's height, the average effect of father's height (ranging from 165 cm to 184 cm) on birth‐weight was up to 152 g, with a greater effect where the mother was taller (up to 235 g) and a lesser effect where the mother was shorter (confirming the effect of maternal constraint).

The significance of these findings lies more with the need to consider this effect as an important variable in statistical analysis involving birth‐weight than in its immediate obstetrical implications.
Early Onset Neonatal Group B Streptococcus (GBS) Infection: Associated Obstetric Risk Factors
Authors: Garland Suzanne M.
Published: February 2008

Summary: : An analysis of all early onset neonatal Group B streptococcal (GBS) infections at the Royal Women's Hospital, Melbourne was made for the 10‐year period 1979–1988. There were 104 cases with 29 neonatal deaths (28%). One or more predisposing perinatal risk factors was evident in 82% of cases (premature labour 79%, prolonged membrane rupture (> 12 hours) 57%, premature rupture of the membranes 69%, maternal sepsis 29%). Overall, 88% of GBS infections were evident within 24 hours of birth, suggesting an intrapartum pathogenesis for infection.
A Comparative Treatment Trial of Endometriosis Using the Gonadotrophin‐releasing Hormone Agonist, Nafarelin, and the Synthetic Steroid, Danazol
Authors: Fraser Ian S. , Shearman Rodney P. , Jansen Robert P. S. , Sutherland Paul D.
Published: February 2008

Summary: : A randomized and double‐blind trial was carried out comparing intranasal nafarelin acetate (400 μg daily) and oral danazol (600 mg daily), given over 6 months, in the treatment of 49 patients with laparoscopically proven endometriosis. Both drugs produced a highly significant and similar reduction (of 60 to 70%) in objective American Fertility Society scoring, even in severe disease. No effect was seen on adhesions. Both drugs suppressed oestradiol levels to a similar extent, although nafarelin caused a substantial rise in the first 2 weeks after the initiation of therapy. Nafarelin suppressed LH substantially and FSH, testosterone and prolactin to a small degree, whereas FSH and LH increased slightly during danazol. Pregnancies occurred in 12 of 22 infertile women in the 12 months following nafarelin, and in 6 of 14 in the danazol group. Side‐effects were reported at a similar rate with both drugs, but the pattern was different. Hot flushes were the predominant side effect with nafarelin, although oestradiol levels were not suppressed to the extent expected. Small amounts of spotting or light bleeding were experienced with both drugs, but these tended to decrease with time with nafarelin and increase with danazol.
Nonlaser Videolaparoscopic Surgery for Ectopic Gestation*
Authors: Verco Christopher J.
Published: February 2008

EDITORIAL COMMENT: : Laparoscopic surgery for ectopic pregnancy has the important advantages of shorter stay in hospital and easier convalescence for the patient. The spate of articles on the subject also suggests that the treated tube is more likely to remain functional with high subsequent rates of intrauterine pregnancy; this could be due to the method of treatment or/and the fact that the technique is suitable only for early cases and ones where there are no extensive pelvic adhesions. Also the need for follow‐up serial beta HCG assay is important since residual trophoblast can result in tubal rupture. A recent case of near maternal death reported in conversation to the editor provokes us to warn readers that the patient with collapse from intraperitoneal haemorrhage due to a ruptured ectopic pregnancy requires resuscitation and laparotomy not laparoscopy. The new technology is impressive but follow‐up is also more sophisticated. Should all patients, after conservative surgery for ectopic pregnancy, undergo tubal patency investigation before embarking on further pregnancy?

Summary: : The potential of nonlaser videolaparoscopic surgery for ectopic gestation in a metropolitan public hospital was assessed by the review of the last 16 consecutive women presenting to the author with either a ruptured or an unruptured ectopic pregnancy. Ten of the 16 were treated by the videolaparoscopic techniques of either salpingotomy or aquaexpression, removal of the ectopic pregnancy and pelvic lavage; there were no intra or postoperative complications. HCG levels were monitored to extinction in all but one woman who had a coexistent intrauterine pregnancy. Three of the 10 women have subsequently had intrauterine conceptions and none have had further ectopic gestations. Those women unsuitable for videolaparoscopic therapy had substantial haemorrhage (4), an ovarian ectopic pregnancy (1) and extensive adhesions precluding laparoscopy (1). The techniques of nonlaser videolaparoscopic treatment for tubal ectopic gestation are simple and appropriate in a majority of women presenting with this condition.
Bradyarrhythmias and Laparoscopy: A Prospective Study of Heart Rate Changes with Laparoscopy
Authors: Myles Paul S.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication to remind readers that routine procedures performed by the laparoscopist often cause problems for the patient and her anaesthetist. The paper reminds us of the necessary team work between nursing staff, anaesthetist and surgeon which is equally important for other gynaecological operations and for obstetric anaesthesia. Brief operations are often performed for conditions of major significance to the patient; they can be dangerous and should not be referred to as ‘minor’.

Summary: : Cardiac arrhythmias are a common complication of laparoscopy. Brady‐arrhythmias (including asystole) may be life‐threatening. The recent introduction of new shorter‐acting muscle relaxants (atracurium and vecuronium), with their lack of vagolytic activity, may exacerbate this situation. At the Royal Women's Hospital there have been several episodes of severe bradyarrhythmias and/or asystole associated with these relaxants. This study evaluated heart rate changes in 49 women during laparoscopy: 47% of patients had arrhythmias, 30% of these being bradyarrhythmias. Nearly all the episodes occurred during carbon dioxide insufflation or with traction on pelvic structures. The life‐threatening nature of this phenomenon should be understood by all anaesthetists and gynaecologists engaged in laparoscopic procedures.
A Clinicopathological Study of Adenocarcinoma in Situ of the Cervix. The Influence of Cervical HPV Infection and Other Factors, and the Role of Conservative Surgery
Authors: Nicklin J. L. , Wright R. G. , Bell J. R. , Samaratunga H. , Cox N. C. , Ward B. G.
Published: February 2008

Summary: : Adenocarcinoma in situ (ACIS) of the uterine cervix is an increasingly recognized disease. Thirty‐seven cases were reviewed to determine the effect of HPV, marital status, parity, smoking habit and age on the topography and behaviour of this lesion. Using a commercial probe, 25% of 28 lesions tested were positive for HPV 16/18. The presence of HPV and a history of smoking appeared to exert no significant influence upon the topography and behaviour of ACIS. Nulliparity and a history of never being married was associated with a significant reduction in the incidence of coexisting CIN lesions. Age less than 36 years was associated with a significant reduction in the proximal linear extent of ACIS. While hysterectomy is probably the definitive treatment for ACIS of the cervix, there is an important place for conservative management by conization alone. Patients younger than 36 years are most likely to be desirous of retained fertility and appear to have the lesions most amenable to conservative surgery.
Ponderal Index: A Better Definition of the ‘At Risk’ Group With Intrauterine Growth Problems than Birth‐weight for Gestational Age in Term Infants
Authors: Fay Roger A. , Dey Philip L. , Saadie Christopher M.J. , Buhl Janice A. , Gebski Val J.
Published: February 2008

EDITORIAL COMMENT: This study provides persuasive evidence that estimation of ponderal index provides a worthwhile parameter for assessment of fetal condition in newborn infants. We agree with the authors' conclusions that ponderal index warrants documentation as well as fetal growth retardation using the accepted definition of equal to or less than the tenth percentile for birth‐weight for infants of similar gestational age born in the community concerned. The disadvantage of ponderal index is that it is less useful for the obstetrician making management decisions, since it cannot he calculated before delivery, when clinical and ultrasonographic estimations of fetal growth retardation are available. Ponderal index certainly should be calculated for paediatric follow‐up studies of high risk infants. Hopefully we will be offered further studies on ponderal index versus fetal growth retardation, symmetrical and asymmetrical, as a parameter for assessment of the condition of the newborn infant and the risk of subsequent physical and neurological impairment.

Summary: A study was undertaken at Nepean Hospital, Penrith to compare the outcome of pregnancies with growth retarded infants; 2,508 consecutive births were analyzed between August 1, 1989 and April 30, 1990. A comparison of outcome was made between infants whose birth‐weight for gestational age was below the tenth percentile and infants who had a low ponderal index from 37 weeks' gestation. The Caesarean section delivery and fetal distress rates were significantly higher for infants with a low ponderal index than for infants with a low birth‐weight. Ponderal index appears to be a better measure of infants with intrauterine growth problems than birth‐weight percentiles.