bluuebunny/crossref_metadata_2025 huggingface dataset:
Association of reduced selenium status in the aetiology of recurrent miscarriage
Authors: Nicoll A. E. , Norman J. , Macpherson A. , Acharya U.
Published: August 2005

Objective
To determine whether recurrent miscarriage is associated with reduced selenium status.

Design
Case–control study.

Setting
Department of Obstetrics and Gynaecology, Glasgow Royal Infirmary and Glasgow Royal Maternity Hospital.

Population
Twenty nonpregnant women with a history of unexplained recurrent miscarriage, and 47 nonpregnant parous women with a history of at least one successful pregnancy and no more than one miscarriage.

Methods
A 7 mL blood sample from each woman was collected into lithium heparin ‘vacutainer’ tubes. Samples were centrifuged at 3000 g for 15 minutes, and plasma was extracted and stored at −20°C. Selenium concentrations were measured using a fluorescence spectrophotometer. The selenium concentrations in the two groups were compared and the differences examined using the Student's t test.

Main outcome measures
Plasma selenium concentration (μg/L).

Results
The mean selenium concentration for women with a history of unexplained recurrent miscarriage was 67.7 μg/L (SD 16.4). The selenium level for the women with no history of recurrent miscarriage was 70.3 μg/L (SD 12.7). There was no difference in selenium concentrations between the two groups (P= 0.53).

Conclusions
In this study there is no association between unexplained recurrent miscarriage and reduced selenium status, implying that reduced selenium status is not a factor in the pathogenesis of recurrent miscarriage. We can find no rationale for a trial of selenium therapy in women with a history of recurrent miscarriage.
Expression of low density lipoprotein receptor messenger ribonuclein acid in placentas from pregnancies with preterm delivery and pregnancies with intrauterine growth retardation
Authors: Stepan Holger , Faber Renaldo , Walther Thomas
Published: August 2005

The low density lipoprotein receptor plays an important role in the uptake of maternal plasma lipoproteins for placental steroid metabolism. Using an RNase protection assay, the expression of low density lipoprotein receptor mRNA was measured in human placentas from pregnancies in the second and third trimester and from pregnancies with intrauterine growth retardation. Pregnancies complicated by intrauterine growth retardation showed a significantly higher expression (1–28), compared with the term and preterm pregnancies (P < 0.05). The increased low density lipoprotein receptor expression in placentas from pregnancies with intrauterine growth retardation could be a compensatory mechanism for the lower circulating low density lipoprotein concentrations in women with intrauterine growth retardation.
A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage
Authors: Tahir M. M. , Bigrigg M. A. , Browning J. J. , Brookes T. , Smith Phillip A.
Published: August 2005

Objective
To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding.

Design
A randomised controlled trial.

Setting
Two university teaching hospitals.

Participants
Four hundred women with abnormal uterine bleeding (postmenopausal bleeding, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular periods) above the age of 35 years, between June 1993 and January 1995.

Main outcome measures
1. Incidence of detection of abnormal pathology by vaginal ultrasound, outpatient hysteroscopy and endometrial biopsy compared with inpatient hysteroscopy and curettage; 2. Number of ‘lesions’ (e.g. fibroids, polyps, endometrial hyperplasia or malignancy) found by hysteroscopy that would have been missed by the combination of endometrial sampling and ultrasound; 3. Comparison of the quality of tissue obtained for histology by outpatient endometrial sampling and inpatient curettage; and 4. An evaluation of patient acceptability of outpatient and inpatient procedures.

Results
1. A combination of transvaginal sonography, Pipelle endometrial biopsy and outpatient hysteroscopy has similar efficacy to inpatient hysteroscopy and curettage for the investigation of abnormal uterine bleeding; 2. Hysteroscopy will detect some fibroids and polyps missed by a combination of transvaginal ultrasound and Pipelle endometrial sampling; 3. The quality of histological samples obtained by outpatient Pipelle were comparable to those obtained by formal inpatient curettage; and 4. Outpatient procedures were well tolerated, with good patient acceptability.

Conclusion
Transvaginal sonography and endometrial biopsy can safely be used as the initial investigations in the management of abnormal uterine bleeding. Hysteroscopy can be used as a second line investigation. Outpatient hysteroscopy with local anaesthesia is well tolerated although general anesthesia may occasionally be necessary.
Cumulative probability of clinical pregnancy and live birth after a multiple cycle IVF package: a more realistic assessment of overall and age‐specific success rates?
Authors: Engmann Lawrence , Maconochie Noreen , Bekir Jinan S. , Jacobs Howard S. , Tan Seang Lin
Published: August 2005

Objective
To provide an assessment of pregnancy and live birth probabilities for women presenting for in vitro fertilisation treatment for the first time, when committed in advance to have up to three cycles of treatment in one year.

Design
Up to three cycles of in vitro fertilisation within one year, committed in advance.

Setting
A tertiary referral centre for assisted reproduction.

Participants
Two hundred and thirty‐two women, undergoing a total of 536 cycles of in vitro fertilisation.

Methods
Analysis of cumulative clinical pregnancy and live birth rates for women having IVF treatment for the first time and undertaking a three‐cycle package, using the life‐table approach.

Main outcome measures
Cumulative clinical pregnancy and live birth rates.

Results
The cumulative probabilities of clinical pregnancy and live birth after two cycles of treatment were 38.2% and 33.2%. respectively, compared with 54.2% and 48.2%, respectively, after three cycles of treatment. Cumulative clinical pregnancy and live birth rates after three cycles of treatment for women up to the age of 40 years were 57.8% and 51.3%, respectively. Cumulative clinical pregnancy and live birth rates declined with increasing age (P= 0.02 and P= 0.01, respectively).

Conclusion
The three‐cycle package encourages couples to have multiple treatment cycles, thereby improving their ultimate chances of a live birth. The cumulative clinical pregnancy and live birth rates after such a package provide a more realistic assessment of overall and age‐specific success rates after multiple treatment cycles.
A six year study of the antenatal detection of fetal abnormality in six Scottish health boards
Authors: Smith Norman C. , Hau Cathy
Published: August 2005

Objective
To assess the sensitivity of prenatal diagnosis by ultrasound and biochemical methods, to evaluate the reasons for non‐detection and to make appropriate recommendations.

Design
Six year observational study, during which biochemical screening for trisomy 21 was introduced and there was an increase in routine ultrasound scanning at 18–22 weeks.

Setting
Six health boards in Scotland.

Population
264, 481 pregnancies, of which 862 were terminated because of fetal abnormality, and 2123 delivered with prenatally detectable major fetal abnormalities.

Main outcome measures
The prenatal detection of trisomies 13, 18 and 21, and 12 major structural abnormalities, which the average ultrasonographer with average skills using average equipment would be expected to detect.

Results
Serum biochemical screening improved detection of trisomy 21 from 33% to 57%. The detection rate for the major abnormalities was 62% (815/1320) and 73% (598/818) when the trisomies were excluded. 18–22 weeks scanning yielded a 92% detection rate. Of the 505 undetected cases, 15% declined prenatal screening, 46% were unscreened because they were ineligible for testing, unbooked, booked too late or scanned too early for a diagnosis to be made, 2% had findings suspicious of a chromosomal abnormality but testing was not undertaken and 37% had a negative scan at a gestation when the abnormality was potentially detectable.

Conclusions
A policy of first trimester scanning followed by serum alpha‐fetoprotein screening and additional scanning as clinically indicated is effective in detecting major structural abnormalities, but scanning at 18–22 weeks and serum biochemical screening for trisomy 21 improved the detection rates. Supervised training and adequate equipment are essential. Present prenatal diagnostic tests will not detect all abnormalities and patients must be made aware of this.
Subsequent obstetric performance related to primary mode of delivery
Authors: Jolly John , Walker James , Bhabra Kalvinder
Published: August 2005

Objective
To relate subsequent obstetric performance with primary mode of delivery.

Design
Postal questionnaire survey of women who delivered their first child five years ago.

Setting
Huddersfield Royal Infirmary.

Population
Women who were delivered of their first baby in 1991: 250 by normal vaginal delivery; 250 by instrumental vaginal delivery; and 250 by caesarean section.

Main outcome measures
Answers to fixed choice questions on fear of future childbirth, number of subsequent children and reasons for no further children.

Results
The response rate was 64%. Overall, 222 (4606%) women were initially frightened about future childbirth. According to mode of delivery: 93 (57.1%) after instrumental vaginal; 79 (47.9%) after caesarean section; and 50 (33.8%) after normal vaginal delivery. Five years after the primary delivery, 99 women (20.8%) were still frightened about future childbirth: instrumental vaginal group 41 (25.2%); caesarean section group 43 (26.1%); and normal vaginal group 15 (10.1%). In the group of women who were delivered by caesarean section 13% more women had not had a second child after five years compared with the normal vaginal delivery group ((P < 0.03, relative risk 1.46 (1.07–1.99)). In the group of women who had a vaginal instrumental delivery 6% more had not had a second child after five years compared with normal vaginal delivery group. Of the women who had no further children, 30% who had caesarean section and 28% vaginal instrumental delivery had involuntary infertility.

Conclusions
Caesarean section or vaginal instrumental delivery leaves many mothers frightened about future childbirth. Primary caesarean section and to some extent vaginal instrumental delivery is associated with an increased risk of voluntary and involuntary infertility.
A prospective placebo controlled double blind randomised study to investigate the use of indoramin to prevent post‐operative voiding disorders after surgical treatment for genuine stress incontinence
Authors: Watson A. J. S. , Currie I. , Jarvis G. J.
Published: August 2005

A prospective placebo controlled double blind randomised study was undertaken to investigate the use of indoramin an alpha blocker to prevent post‐operative voiding disorders after surgical treatment for genuine stress incontinence. Fifty‐six patients were randomised to receive indoramin 20 mg orally twice a day or identical placebo from the first post‐operative day until discharge from hospital. After seven exclusions, 49 patients were included in the study. There was no significant differcnce between the treatment (indoramin) group and placebo group for any of the outcomes measured. The routine use of indoramin to prevent post‐operative voiding problems cannot be justified on the basis of these data.
A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years
Authors:   Aberdeen Endometrial Ablation Trials Group
Published: August 2005

Objective
To assess the long term impact of initial management by endometrial ablation for women with dysfunctional uterine bleeding who would otherwise have had a hysterectomy.

Design
Long term follow up of randomised cohorts of women.

Setting
Gynaecology department of a large teaching hospital.

Sample
Two hundred and four women who had joined a randomised comparison of endornetrial ablation with hysterectomy, 4 to 5.6 years previously.

Methods
Postal questionnaire and casenote review.

Main outcome measures
Women's satisfaction with treatment, gynaecological symptoms and psychological outcomes at four years; further surgical treatment and differential resource use at a minimum of four years' follow up.

Results
Further surgical treatment was received by 39 (38%) women randomised to endometrial ablation, including six women who each had two additional treatments. At four years, the probability of receiving further surgical treatment by any method was 36% and by hysterectomy was 24% (compared with 29% and 14% respectively at one year). Satisfaction rates were high (80% ablation group vs 89% hysterectomy group), the difference reflecting re‐treatment. Premenstrual symptoms improved over time but more so in the hysterectomy group, who also rated their improvements in general health higher. The estimated overall mean cost of the endometrial ablation group is 93% of that of the hysterectomy group (£1231 vs£1332).

Conclusions
While about two out of every five women allocated to endometrial ablation eventually received further surgical treatment, hysterectomy with its associated morbidity was still avoided by 76% of women with dysfunctional uterine bleeding who would otherwise have had a hysterectomy. At four years, the difference in the costs of endometrial ablation and hysterectomy policies had narrowed.
Changes in trabecular bone architecture in women during pregnancy
Authors: Shahtaheri Seyed Mohsen , Aaron Jean E. , Johnson David R. , Purdie David W.
Published: August 2005

Objective
To examine the effect of early and late pregnancy on the microarchitecture of maternal cancellous bone.

Sample
Transilial bone biopsies were obtained from two groups of pregnant women one group (n= 15) in the first trimester and the other (n= 13) at term. Comparison was made with biopsy and autopsy samples from a group (n= 25) of normal premenopausal nonpregnant women.

Methods
Undecalcified sections were analysed under a low power optical microscope using an automated trabecular analysis system which measures a comprehensive range of structural variables including the bone volume, trabecular number, width, separation and connectivity.

Results
In early pregnancy the quantity of cancellous bone fell from a mean relative bone volume of 23.07% (SD 5.49) in nonpregnant controls to 16.72% (SD 3.91) (P < 0.001). This was primarily due to a decline in trabecular thickness from 122.9 pm (SD 10.5) to 97.2 pm (SD 21.8) (P < 0.01) and was accompanied by a loss of trabecular connectivity expressed as a reduction in the trabecular node: terminus ratio from 0.90 (SD 0.71) to 0.38 (SD 0.26) (P < 0.001). By late pregnancy the bone volume had been entirely restored to 23.41% (SD 9.76). This was primarily due to an increase in the number of trabeculae from 73.2 (SD 35.5) /field to 100.3 (SD 33.3) /field to (P < 0.05)with an associated reduction in trabecular separation from 431 pm (SD 150) to 315.8 pm (SD 78.5) (P < 0.01).

Conclusions
Pregnancy affects the maternal skeleton by producing a fluctuation in the cancellous bone volume in which early temporary bone loss through trabecular thinning is restored in entirety through the addition of new trabeculae to produce a modestly more complex system of thinner more numerous bars by term.
Vaginal delivery compared with caesarean section in early preterm breech delivery: a comparison of long term outcome
Authors: Wolf Hans , Schaap Arty H. P. , Bruinse Hein W. , Smolders‐de Haas Hetty , van Ertbruggen Ingrid , Treffers Pieter E.
Published: August 2005

Objective
To determine the optimum mode of delivery of the early preterm fetus in breech presentation.

Design
Retrospective comparison of two cohorts of preterm breech fetus.

Setting
Two tertiary care centres: at one centre the preferred management for preterm breech presentation was vaginal delivery; at the other centre, the preferred method was caesarean section.

Population
All singleton infants delivered after breech presentation from 1984 through 1989, at a gestational age of 26 to 31 weeks. Those with lethal congenital abnormalities, placenta praevia, placental abruption, fetal death or fetal distress before the onset of labour were excluded.

Main outcome measures
Survival without disability or handicap documented at two years corrected age. The influence of a number of relevant variables on this outcome was assessed by logistic regression analysis.

Results
There was no difference in survival without disability or handicap between the centres (odds ratio 1.5, 95% CI 0.6–3.9 vaginal delivery compared with caesarean section). Survival without disability or handicap was positively influenced by increasing birthweight and corticosteroids > 24 h before birth, and negatively influenced by footling presentation.

Conclusion
A policy of caesarean section for early preterm (26–31 weeks) breech delivery is not associated with increased survival without disability or handicap.
Newborn shoulder width: a prospective study of 2222 consecutive measurements
Authors: Verspyck Eric , Goffinet François , Hellot Marie F. , Milliez Jacques , Marpeau Loïc
Published: August 2005

Objectives
To relate maternal and infant characteristics to newborn shoulder width and to evaluate the predictive value of newborn shoulder width measurement in cases of shoulder dystocia.

Design
Newborn shoulder width was systematically measured at birth during a period of 18 months.

Setting
Department of Obstetrics and Gynaecology of Saint‐Antoine University Hospital, Paris, France.

Population
A total of 2222 newborn shoulder width measurements were performed and 22 cases of true shoulder dystocia occurred during the study period.

Methods
Newborn shoulder width measurements were reviewed and correlated with maternal age, parity, nonpregnant weight, weight gain during pregnancy, height, race, fasting glucose and one hour glucose levels, gestational age, birthweight and sex of the neonate. A receiver‐operating characteristics curve was constructed to evaluate newborn shoulder width as a test for predicting shoulder dystocia.

ResultS
The mean newborn shoulder width was 122.06 mm (10.50 SD). Stepwise multiple regression showed that newborn shoulder width was significantly associated with birthweight (P < 0.001), parity (P= 0.04), and nonpregnant weight (P= 0.04). We estimated that the best cut off for shoulder dystocia prediction was a newborn shoulder width measurement with a low false positive rate (< 10%) in association with a high sensitivity rate. Therefore, newborn shoulder width measurement ≥ 140 mm was selected. This measurement should have a low sensitivity of 27.27%, a specificity of 91.82%, a positive predictive value of 4.02%. and a negative predictive value of 99.01% for shoulder dystocia prediction. Nevertheless, birthweight ≥ 4000 g should have a better predictive value retrospectively for shoulder dystocia.

Conclusions
Newborn shoulder width measurement, which is strongly correlated with birthweight, still remains a poor predictor for shoulder dystocia, even when this evaluation is correct antenatally.
Labour pain treated with cutaneous injections of sterile water: a randomised controlled trial
Authors: Måtensson Lena , Wallin Gunnar
Published: August 2005

Objective
To evaluate the relief of pain in labour with subcutaneous and intracutaneous injections of sterile water, compared with placebo.

Design
Randomised controlled trial.

Setting
Labour ward with approximately 3000 deliveries annually in a suburban area near Gothenburg, Sweden.

Participants
Ninety‐nine pregnant women at term, requiring pain relief for severe lower back pain during the first stage of labour. The women were randomised to receive four injections of 0.1 mL sterile water (without salt) intracutaneously (n= 33), four injections of 0.5 mL sterile water subcutaneously (n= 33) or placebo treatment (n= 33).

Main outcome measures
Reduction of labour pain measured by visual analogue scale.

Results
The median visual analogue scale pain score for labour pain was significantly lower compared with initial values in the two study groups and compared with placebo at 10 and 45 minutes after treatment. The median reductions in visual analogue scores after 10 minutes were 5.0 cm and 4.5 cm in the intracutaneous and subcutaneous injection groups, respectively; women in the placebo group scored a median reduction of 1.7 cm. After 45 minutes the median reductions in the visual analogue scores were 4.9 cm and 4.0 cm in the intracutaneous and subcutaneous injection groups, respectively, compared with 1.0 cm for women in the placebo group. No significant differences in analgesic effect or pain experienced during administration were found between the two study groups.

Conclusion
The new subcutaneous method of administering sterile water, as well as the earlier described intracutaneous injection method, were effective for the relief of pain in labour.
The utility of clinical tests of eligibility for a trial of labour following a caesarean section: a decision analysis
Authors: Macones George A.
Published: August 2005

Objective
There is evidence to suggest that women who have a failed trial of labour following caesarean section are at the highest risk of major morbid events, compared with those who have a successful trial of labour or elective repeat caesarean section. Attempts are being made to predict, either by radiological or ultrasonic measurements or clinical factors, who should attempt a trial of labour after a prior caesarean section and who should not, in the hopes of reducing the number of failed trials of labour with their associated morbidity. The goal of this study was to determine the necessary sensitivity and specificity for such a test to be clinically useful in this setting.

Methods
A decision analytic approach was used which compared two strategies for treating women with a prior caesarean section: trial of labour for all or application of a hypothetical test, the results of which would determine whether a woman would be offered a trial of labour. It was assumed that the goal of the strategies was to minimise the number of major maternal morbid events (hysterectomy, uterine rupture, operative injury) with an acceptable caesarean section rate. Probability estimates for these outcomes were obtained from the existing literature. We evaluated several combinations of sensitivity and specificity to determine the impact of these characteristics on the number of major complications and the number of caesarean sections, compared with the strategy of trial of labour for all women. The results are reported per 1000 women with a previous caesarean section.

Results
Under baseline assumptions, a clinical test for determining eligibility for a trial of labour must have both a sensitivity and specificity in excess of 75% to obtain a reasonable trade‐off between reduction in morbidity and the total rate of caesarean sections. In women with a low empiric likelihood of a successful trial of labour, tests with lesser degrees of both sensitivity and specificity are reasonable. In women with a high empiric likelihood of a successful trial of labour, much higher sensitivities and specificities are required.

Conclusions
In developing tests to determine to whom to offer a trial of labour, investigators and clinicians must realise that in most cases, a highly sensitive and specific test is needed, although this is dependent on the empiric likelihood of the success of a trial of labour.
A gonadotrophin‐releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis
Authors: Vercellini Paolo , Crosignani Pier Giorgio , Fadini Ruben , Radici Enrico , Belloni Carlo , Sismondi Piero
Published: August 2005

Objective
To ascertain whether the frequency of pelvic pain recurrence is reduced and time to symptoms recurrence is prolonged in women with symptomatic endometriosis undergoing conservative surgery and post‐operative hormonal therapy compared with women treated with surgery only. Pregnancy rates and time to conception in women wanting children were also evaluated.

Design
A multicentre, prospective, randomised controlled study.

Setting
Nineteen Italian academic departments and teaching hospitals specialising in reparative and reconstructive surgery.

Population
A total of 269 women undergoing conservative surgery for mild to severe symptomatic endometriosis.

Methods
After surgery the women were assigned to treatment with subcutaneous goserelin depot injections for six months or to expectant management. Dysmenorrhoea, deep dyspareunia, nonmenstrual pain and general discomfort were graded according to a verbal rating scale from 0 (absent) to 3 (severe) and the scores summed to give a total symptoms score. Only patients with at least one preoperative moderate or severe symptom were enrolled. The women were evaluated regularly for two years.

Main outcome measures
Post‐operative pain recurrences (total symptoms scores ≥ 5), time to recurrence, pregnancy rates and time to conception in the two study groups.

Results
At oneand two‐year follow up visits, 14/107 (13.1%) and 19/81 (23.5%) patients had moderate or severe symptoms recurrence in the goserelin group compared with, respectively, 22/103 (21.4%) and 27/74 (36.5%) in the expectant management group (P= 0.143 at 1 year and 0.082 at 2 years). Time to symptoms recurrence was significantly longer in the goserelin group according to survival analysis (Wilcoxon test, P= 0.041). Among women wanting children, few conceptions occurred in both the goserelin (8/69, 11.6%) and the expectant management group (14/76, 18.4%). There was no significant difference at survival analysis (Wilcoxon test, P= 0.427).

Conclusion
Post‐operative treatment with goserelin significantly prolonged the pain‐free interval after conservative surgery for symptomatic endometriosis and did not influence reproductive prognosis.
Long term follow up of hysteroscopic myomectomy assessed by survival analysis
Authors: Hart Roger , Molnár Béla G. , Magos Adam
Published: August 2005

Objective
To identify patient characteristics which affect outcome after hysteroscopic myomectomy for submucous fibroids.

Design
Prospective observational study.

Setting
A university teaching hospital.

Sample
One hundred and twenty‐two consecutive patients treated by hysteroscopic myomectomy for submucous leiomyoma over a period of almost eight years.

Methods
Hysteroscopic electroresection of the leiomyoama using a continuous flow resectoscope.

Main outcome measures
The avoidance of further surgery and patient satisfaction.

Results
The average age of the patients at the time of their surgery was 424 years. A total of 194 fibroids were removed. The mean follow up period was 2.3 years (range 1–7.6). Of those asked, 71.4% were satisfied with the results of surgery. Sixteen women required further surgery for fibroids, and six ultimately underwent hysterectomy. Survival analysis showed that the risk of further surgery was 21% at four years after the myomectomy, and 0% thereafter. Univariate regression analysis suggested that outcome was significantly better in older women, and in cases where the uterus was equivalent in size to I 6 weeks of gestation, the fibroid was I 3 cm in diameter and mainly intracavitary, and the proce‐ dure time was I 20 minutes. The influence of hormonal pre‐treatment and the number of fibroids excised was not statistically significant. After multivariate regression analysis, only overall uterine size and the position of the fibroid being removed were found to significantly influence the success of surgery.

Conclusions
Hysteroscopic myomectomy is an effective way to manage patients with symptomatic submucous leiomyomata, particularly when the uterus is not grossly enlarged and the fibroid(s) are mainly inside the uterine cavity.
Antecedents of neonatal encephalopathy with fetal acidaemia at term
Authors: Westgate Jenny A. , Gunn Alistair J. , Gunn Tania R.
Published: August 2005

Objective
To identify the relative contribution of antenatal hypoxia, obstetric catastrophe during labour and fetal monitoring practice to the occurrence of neonatal encephalopathy associated with acidaemia at term.

Design
Prospective study

Setting
Tertiary referral hospital in Auckland, New Zealand

Sample
Twenty‐two term babies born between January 1996 and October 1997 with umbilical artery pH ≤ 7.09 (median 6.88) or 5 minute Apgar score c 7 (median 5.0), and moderate to severe encephalopathy within five hours of birth

Methods
Antenatal and intrapartum events and fetal heart rate monitoring practice were reviewed by an experienced obstetrician

Results
More than half the cases were associated with events beyond the control of the clinician: 5 of 22 (23%) had evidence of antenatal hypoxia and 5 of 22 (23%) experienced an obstetric catastrophe during labour. Use of continuous fetal monitoring techniques or the interpretation of fetal heart rate changes was suboptimal in 8 of 12 cases. Continuous monitoring was not performed at all in three cases. All pregnancies were of either low or medium risk; none had proteinuric hypertension and no case was breech, small for gestational age or had a gestational age ≥ 42 weeks.

Conclusions
A significant proportion of babies with encephalopathy associated with acidaemia at term experienced either antenatal hypoxia or catastrophic events beyond the control of the clinician. Further improvements in obstetric care will require greater vigilance in low to medium risk pregnancies and improved fetal monitoring practice during both induction and labour.
Intrapartum umbilical artery Doppler velocimetry as a predictor of adverse perinatal outcome: a systematic review
Authors: Farrell Tom , Chien Patrick F. W. , Gordon Adam
Published: August 2005

Objective
To evaluate the diagnostic prediction of intrapartum umbilical artery Doppler velocimetry for adverse perinatal outcomes using systematic quantitative overview of the available literature.

Design
Online searching of MEDLINE database (January 1966–September 1997), scanning of bibliography of known primary and review articles, review of recent journal issues and that from personal files. Study selection, assessment of study quality and data extraction were all performed in duplicate under masked conditions.

Participants
2700 women (unselected, low, high, and combined low and high obstetric risk populations) included in eight studies selected for meta‐analyses.

Main outcome measures
Likelihood ratios (LRs) for positive and negative test results were generated for the following outcome measures: Apgar scores < 7 at 1 and 5 minute following delivery, small for gestational age fetus; intrapartum fetal heart rate abnormality, umbilical arterial acidosis at delivery; and caesarean section for fetal distress.

Results
For Apgar score < 7 at 1 minute following delivery, the pooled LR was 2.5 (95% CI1.7–3.7) for a positive test and 1.0 (95% CI 0.9–1.1) for a negative test result. A positive test predicted an Apgar score < 7 at 5 minute following delivery with a pooled LR of 1.3 (95% CI 0.4–4.1) while a negative test had a pooled LR of 1 0 (95% CI 0.8–1.2). For the prediction of a small for gestational age fetus, the pooled LR was 3.4 (95% CI 2.3–5.1) for a positive test and 0.9 (95% CI 0.8–1.0) for a negative test. The prediction for fetal heart rate abnormality during labour was similarly disappointing: the pooled LR for a positive test result was 1.4 (95% CI 0.9–1.2) whereas a negative test result generated a pooled LR of 0.9 (95% CI 0.9–1 e0). With umbilical acidosis at delivery, the pooled LR was 1.6 (95% CI 1.1–2.5) for a positive test and 1.1 (95% CI 1.0–1.2) for a negative test. The LRs for the prediction of caesarean section for fetal distress were 4.1 (95% CI 2.7–6.2) for a positive test result and 0.9 (95% CI 0.8–1.0) for a negative test result.

Conclusion
Intrapartum umbilical artery Doppler velocimetry is a poor predictor of adverse perinatal outcomes.
Psychosocial predictors of low birthweight: a prospective study
Authors: Paarlberg K. Marieke , Vingerhoets J. J. M. , Passchier Jan , Dekker Gustaaf A. , Heinen Antonius G. J. J. , van Geijn Herman P.
Published: August 2005

Objective
To examine the role of psychosocial risk factors for low birthweight.

Design
A prospective study.

Setting
Obstetric outpatient clinics of the University Hospital Vrije Universiteit, Amsterdam.

Participants
Three hundred and ninety‐six nulliparous women.

Methods
Questionnaires on background variables, daily stressors, psychological and mental wellbeing, social support and work factors were completed by the women in the first, second and third trimester of pregnancy. Low birthweight for gestational age was defined at different cut off points: 1. ≤ 10th customised birthweight centile (n= 69); 2 ≤ 5th customised birthweight centile (n= 54); 3. ≤ 3rd customised birthweight centile (n= 35); and 4. ≤ the 10th Dutch birthweight centile (n= 40). Multivariate logistic regression was applied and the results were expressed in odds ratios and their 95% confidence intervals.

Results
When the cut off level was defined ≤ 5th and ≤ 3rd customised centile, the number of daily stressors in the first trimester was a statistically significant risk factor (OR 1.04, 95% CI 1.01–1.07 and OR 1.04,95% CI 1.01–1.08). No significant psychosocial risk factors could be identified when low birthweight for gestational age was defined ≤ the 10th customised birthweight centile. When low birthweight for gestational age was defined I the 10th Dutch birthweight centile, number of hours housekeeping per week in the first trimester (OR 1.59, 95% CI 1.03–2.46), low subjective severity rating of daily stressors in the first trimester (OR 0.41,95% CI 0.17497) and depressive mood in the first trimester (OR 1.12, 95% CI 1.01–1.24) were statistically significant psychosocial risk factors after controlling for maternal weight and height, number of cigarettes smoked per day and educational level.

Conclusions
In the fist trimester of pregnancy maternal psychosocial factors are associated with an increased risk of low birthweight. The specific psychosocial risk factors found were different when the definition of low birthweight was changed. Therefore, in this field of research, we suggest use of the most valid outcome measure for low birthweight, being the customised birthweight centiles.
Urinary incontinence: prevalence and risk factors at 16 weeks of gestation
Authors: Højberg Karen‐Elise , Salvig Jannie Dalby , Winsløw Nitnoi Albertsen , Lose Gunnar , Secher Niels Jø;rgen
Published: August 2005

Objective
To evaluate the prevalence of urinary incontinence at 16 weeks of gestation and to identify possible maternal and obstetric risk factors.

Design
Cross‐sectional study and cohort study.

Setting
Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark.

Population
Cross‐sectional study: 7795 women attending antenatal care. Cohort study: a sub‐group of 1781 pregnant women with one previous delivery at our department.

Results
Prevalence and maternal risk factors: the prevalence of urinary incontinence within the preceding year was 8.9% among women at 16 weeks of gestation (nulliparae, 3.9%. para 1, 13.8%, para 2+, 16.2%). Stress or mixed incontinence occurred at least weekly in 3% of all the women. After adjusting for age, parity, body mass index, smoking, previous abortions, and previous lower abdominal or urological surgery in a logistic regression model, primiparous women who had delivered vaginally had higher risk of stress or mixed urinary incontinence than nulliparous women (OR 5.7; 95% CI 3.9–8.3). Subsequent vaginal deliveries did not increase the risk significantly. Young age, body mass index > 30, and smoking were possible risk factors for developing urinary incontinence. Obstetric factors: weight of the newborn > 4000 g (OR 1.9; 95% CI 14–3.6) increased the risk of urinary incontinence; mediolateral episiotomy in combination with birthweight > 4000 g also increased the risk (OR 3–5; 95% CI 1.2–10.2); a number of other intrapartum factors did not increase the risk of urinary incontinence.

Conclusions
The first vaginal delivery was a major risk factor for developing urinary incontinence; subsequent vaginal deliveries did not increase the risk significantly. Birthweight > 4000 g increased the risk; episiotomy in combination with birthweight > 4000 g also increased the risk.
Use of oral contraceptives and uterine fibroids: results from a case‐control study
Authors: Chiaffarino Francesca , Parazzini Fabio , La Vecchia Carlo , Marsico Silvia , Surace Matteo , Ricci Elena
Published: August 2005

Objective
To analyse the association between oral contraceptive use and the risk of uterine fibroids.

Design
Participants We considered data collected in a case‐control study on risk factors for uterine fibroids.

Participants
We studied 843 women with uterine fibroids, whose clinical diagnosis dated back no more than two years. Controls were 1557 non‐hysterectomised patients younger than 55 years admitted for acute, non‐gynecological, non‐hormonal, non‐neoplastic conditions.

Results
A total of 254 cases (30.1 %) and 360 controls (23.1 %) reported ever using oral contraceptives: the odds ratio (OR) for ever vs never users was 1–1 (95% CI 0‐8–1.3). The risk in current users was below unity when compared with never users (OR 0.3,95% CI 0.2–0.6), while ex‐users had a risk of fibroids comparable with never users (OR 1. I, 95% CI 0.9–1.4). The risk of uterine fibroids decreased with duration of oral contraceptive use: compared with never users, the estimated OR was 0.8 (95% CI 0.5–1.2) in ever users for four to six years and 0.5 (95% CI 0.349) for seven years or more (trend = 4.6, P= 0.03).

Conclusions
Although the role of selection bias should be carefully evaluated, the present data suggest that uterine fibroids should not be considered a contra‐indication for oral contraceptive use.
Two dosing regimens for preinduction cervical priming with intravaginal dinoprostone pessary: a randomised clinical trial
Authors: Tan Lay‐Kok , Tay Sun‐Kuie
Published: August 2005

Objective
To compare the efficacy within 24 hours of a three‐times‐a‐day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming.

Design
Randomised controlled trial.

Setting
Department of Obstetrics and Gynaecology, Singapore General Hospital.

Participants
One hundred singleton term primigravidae with cephalic presentation with unfavourable cervical scores (Bishop score ≤ 15) requiring induction of labour.

Methods
Eligible women were randomly assigned the standard regimen (3000 pg dinoprostone [Prostin, Upjohn, Crawley, UK] once daily) or an intensive regimen (3000 pg dinoprostone given sequentially three times daily four hours apart) for cervical priming until successful priming (Bishop score of ≤ 6) or the onset of active labour occurred.

Main outcome measures
Number of women whose cervices were ripened successfully or who entered active labour within 24 hours of starting cervical priming, priming to induction interval, and priming to delivery interval.

Results
Forty‐nine women were assigned to the standard regimen and 51 to the intensive regimen. The median number (range) of dinoprostone pessaries used was two (one to seven) in the standard regimen and three (one to nine) in the intensive regimen. Forty‐two women (82.4%) who underwent the intensive regimen achieved successful cervical ripening or active labour within 24 hours, compared with 21 assigned to standard regimen (OR 6.2, 95% CI 2.3–17.4). This difference was statistically significant. The median intervals from priming to induction, and from priming to delivery, were also statistically significantly shorter in women treated with the intensive regimen. Thirty‐five women (68.63%) assigned the intensive regimen experienced pain, compared with 21 (42.86%) in the standard regimen (OR 2.92, 95% CI 1.19–7.21), with two and one women in the respective regimens requiring opiate analgesics. Five women with oligohydramnios had transient cardiotocographic abnormalities during priming with the intensive regimen, none of which required immediate intervention, and the babies were born in good condition. There were no cases of uterine hypertonus and the outcomes of labour were similar for women from both regimens.

Conclusions
Preinduction cervical priming with the intensive dosing regimen improves the chances of successful ripening within 24 hours for primigravidae with unfavourable cervical scores at full term singleton pregnancies, and shortens the interval from priming to induction, and priming to delivery. This regimen may be more cost effective by shortening the period of hospital stay. The overall incidence of adverse reactions to the mother and fetus during priming was low. However, close fetal surveillance must be maintained, particularly in pregnancies complicated with oligohydramnios.
The relation of breech presentation at term tocerebral palsy
Authors: Krebs Lone , Topp Monica , Langhoff‐Roos Jens
Published: August 2005

ObjectiveTo examine the relation between breech delivery and cerebral palsy, considering the influence of intrauterine growth, low Apgar score at birth, and mode of delivery.

DesignRegister‐based, case‐control study.

PopulationA cohort of infants with cerebral palsy born between 1979 and 1986 in east Denmark, identified by linkage of the cerebral palsy register with the national birth register. Discharge letters from births of breech infants with cerebral palsy were reviewed.

Main outcome measuresPresentation, mode of delivery, gestational age, birthweight, Apgar score, type of cerebral palsy, severity of handicap.

ResultsBreech presentation at term was associated with a borderline significantly higher risk of cerebral palsy than vertex presentation (OR 1.56; 95% CI 0.9–2.4). Breech presentation infants more often had a lower Apgar score (< 7 at 5 minutes) and were smaller for gestational age (SGA < 2 SD) than were those with vertex presentation; infants with a low Apgar score, or who were small for gestational age, had a higher risk of cerebral palsy. After stratification by being small for gestational age the risk of cerebral palsy was not related to presentation. There were no differences between breech and vertex infants with cerebral palsy in terms of low Apgar score, being small for gestational age, mode of delivery, and severity of the handicap. Breech presentation infants were more often classified as diplegic (77.8% versus 42.3% in cephalic infants).

ConclusionThe risk of cerebral palsy among term breech presentation infants does not seem to be related to mode of delivery, but is more likely linked to a higher rate of being small for gestational age in breech infants.
Lack of consistency in research papers over the definition of pre‐eclampsia
Authors: Chappell Lucy , Poulton Lena , Halligan Aiden , Shennan Andrew H.
Published: August 2005

The most common definition of pre‐eclampsia involves hypertension and proteinuria. This has changed little in over a hundred years despite advances in understanding the underlying pathological process. However, a number of variations in definition exist, and this paper demonstrates a lack of consistency in research articles in defining pre‐eclampsia. A quarter of papers omit description, and many authors choose their own interpretation of the standard classification. Editors and reviewers should ensure that papers include a clear description of the definition used and an adequate description of the population studied to allow meaningful interpretation of research findings.
Computerized Physician Order Entry with Clinical Decision Support in the Long‐Term Care Setting: Insights from the Baycrest Centre for Geriatric Care
Authors: Rochon Paula A. , Field Terry S. , Bates David W. , Lee Monica , Gavendo Linda , Erramuspe‐Mainard Janet , Judge James , Gurwitz Jerry H.
Published: August 2005

Although computerized physician order entry (CPOE) has been successfully implemented in many acute care hospitals, few descriptions of its use in the long‐term care (LTC) setting are available. This report describes the experiences of one LTC facility in developing and implementing a CPOE system with clinical decision support (CDS). Even when a facility has the necessary resources and “institutional will,” many challenges are associated with the implementation of this application. The system was designed to meet the needs of healthcare providers in the LTC setting, in particular by informing prescribing decisions, reducing the frequency of prescribing and monitoring errors, and reducing adverse drug event rates. Based on experience adopting this technology early, 10 insights are offered that it is hoped will assist others who are considering the implementation of CPOE systems with CDS in the LTC setting.
Disparities Between Black and White Patients in Functional Improvement After Hospitalization for an Acute Illness
Authors: Sands Laura P. , Landefeld C. Seth , Ayers Sandra Moody , Yaffe Kristine , Palmer Robert , Fortinsky Richard , Counsell Steven R. , Covinsky Kenneth E.
Published: August 2005

The aim of this study was to determine whether older black and white patients experience different rates of improvement in functioning after being acutely hospitalized. Of the 2,364 community‐living patients in this prospective cohort study, 25% self‐reported their race/ethnicity to be black. The outcomes were improvement in basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) from admission to discharge and 90 days postdischarge. Multivariable models that included statistical adjustment for age, illness severity, in‐hospital social service referral, dementia, admission level of functioning, and change in functioning from 2 weeks before admission were computed to determine whether black and white patients experienced significantly different rates of recovery at discharge and 90 days after discharge in ADL and IADL functioning. Black patients were as likely as white patients to improve in ADL functioning by discharge (odds ratio (OR)=0.97, 95% confidence interval (CI)=0.76–1.24) or by 90 days after discharge (OR=0.95, 95% CI=0.73–1.24) but significantly less likely to improve IADL functioning by discharge (OR=0.72, 95% CI=0.56–0.93) or by 90 days after discharge (OR=0.68, 95% CI=0.51–0.90). The findings suggest that differential rates of recovery in functioning after an acute hospitalization may contribute to racial/ethnic disparities in IADL functioning, which has implications for the setting of future interventions oriented toward reducing these disparities.
Factors Affecting Outpatient Rehabilitation Outcomes in Elders
Authors: Yu Fang , Richmond Therese
Published: August 2005

Purpose:

To identify factors affecting outpatient rehabilitation outcomes in elders.

Design:

A retrospective cohort design was used to explore factors affecting outpatient rehabilitation outcomes in elders.

Methods:

Analyses of health records from a nurse‐managed comprehensive outpatient rehabilitation facility were conducted. Data pertinent to the study were abstracted from 201 health records, including scores from three standard instruments: the Functional Independence Measure, the Mini‐Mental State Examination, and the Geriatric Depression Scale, to construct study variables. Multivariate and stepwise regression analyses were performed.

Findings:

Cognitive impairment was associated with lower admission and discharge function, but not with rehabilitation outcomes (functional gain, rehabilitation efficiency, days of service, and discharge location). Age ≥80 years, admission function, and the interaction of age ≥80 years and admission function affected functional gain and rehabilitation efficiency. Older age, being Black, and having more medical comorbidities were associated with days of service. None of these factors contributed to discharge location.

Conclusions:

Cognitive impairment was not associated with outpatient rehabilitation outcomes. Rather, age ≥80 years and function when admitted affected functional gain and rehabilitation efficiency in elders who participated in outpatient rehabilitation services.