bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparability of published perinatal mortality rates in Western Europe: the quantitative impact of differences in gestational age and birthweight criteria
Authors: Graafmans Wilco C. , Richardus Jan‐Hendrik , Macfarlane Alison , Rebagliato Marisa , Blondel Beatrice , Verloove‐Vanhorick S. Pauline , Mackenbach Johan P.
Published: December 2003

Objective
To quantify the impact of publication criteria on differences in published national perinatal mortality rates among Western European countries.

Design
Descriptive study of perinatal mortality rates in Western European countries with adjustments for international differences in publication data.

Population
All live births and perinatal deaths in 1994 in Western European countries.

Methods
The 1994 perinatal mortality rates were obtained from national and Eurostat publications for Belgium, Denmark, Finland, France, Germany, Greece, The Netherlands, Norway, Portugal, Spain, Sweden, United Kingdom (England, Wales, Scotland, Northern Ireland). Two methods, one direct and one indirect, were used for adjusting these officially published rates for differences in registration laws or publication practices. For the indirect method adjustment factors were derived from an analysis of a large Finnish database using different cutoff points for gestational age and birthweight. For the direct method a common cutoff point was imposed for birthweight (1000g) and gestational age (28 completed weeks) on national perinatal mortality data, obtained from civil registration or hospital/obstetrics databases in each country.

Results
The published perinatal mortality rates ranged from 5.4 per 1000 total births in Sweden and Finland to 9.7 in Greece and Northern Ireland. The indirect adjustment method showed that some countries apply cutoff points for registration or publication of perinatal mortality which may raise the perinatal mortality rate by up to 17% above the most commonly used threshold for including live and stillbirths. The direct adjustment method showed that a common lower limit of 1000g for birthweight or 28 weeks for gestational age would reduce the perinatal mortality rate, but by a differing extent ranging from 14% to 40%. Both adjustment methods reduced the contrast between the countries’ perinatal mortality rates, and changed their rank order.

Conclusion
These quantitative results confirm that international differences in countries’ published perinatal mortality rates partly reflect differences between countries’ criteria for registration and publication of perinatal deaths.
Fetal magnetoencephalography: a non‐invasive method for the assessment of fetal neuronal maturation
Authors: Schleussner Ekkehard , Schneider Uwe , Kausch Sylvia , Kähler Christiane , Haueisen Jens , Seewald Hans‐Joachim
Published: December 2003

Objective
To assess the maturation of auditory evoked cortical responses in the human fetus using fetal magnetoencephalography.

Design
Prospective case series over a three‐year period.

Setting
Antenatal clinics, university hospital.

Population
Singleton pregnancies at 29–40 weeks of gestation.

Methods
We used a 31‐channel‐SQUID‐biomagnetometer in a magnetically‐shielded room to perform fetal magnetoencephalography. To record auditory evoked fields from the fetal brain we applied 500 monotonal bursts generated by a computerised sound generator directly to the maternal abdominal wall near the fetal head. The continuously recorded data sets were analysed stepwise using a specially developed heart artefact rejection software, Fourier filtering, principle component analysis and half split analysis of the averaged data.

Results
In 36 of 64 examinations we detected signals of auditory evoked fields comparable to the P2m component in adults. The earliest recording succeeded in the 29th gestational week. The latencies of the auditory evoked responses declined during the third trimester from 300ms to nearly 150ms at term. The maturation of different components of the auditory evoked field could be demonstrated from the 31st gestational week onwards.

Conclusion
The maturation of a fetal auditory cortical function using fetal magnetoencephalography could be assessed directly for the first time. We believe that this method will add information to current indirect methods of assessing the normal maturation of the human fetal brain.
Mass closure: a new technique for closure of the vaginal vault at vaginal hysterectomy
Authors: Miskry Tariq , Magos Adam
Published: December 2003

A variety of methods of management of the vaginal vault have been described, all of which maintain certain principles. In techniques that advocate closure of the vault, the peritoneum and vaginal epithelium are treated with separate sutures. This leaves a potential space above the vaginal closure. We describe a simple technique of mass closure which obliterates this space and incorporates the pedicles to provide support for the vault. This method may hold potential advantages in terms of haemostasis, risk of vault haematoma, and post‐operative vaginal cuff infections.
Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula
Authors: Murray Christine , Goh Judith T. , Fynes Michelle , Carey Marcus P.
Published: December 2003

Objective
To evaluate: (1) the factors associated with the development of obstetric genitourinary fistula, (2) the incidence of urinary and faecal incontinence following closure of the fistula and (3) the urodynamic findings in women with persistent urinary incontinence.

Design
An observational clinical study.

Setting
A specialised fistula unit in a developing country.

Population
Women following successful anatomical closure of obstetric genitourinary fistula.

Methods
Fifty‐five women were enrolled from the Fistula Hospital in Ethiopia, following obstetric fistula repair. Their case records were reviewed and details regarding (1) antecedent obstetric factors, (2) the site, size and type of fistula and (3) pre‐operative bladder neck mobility and vaginal scarring were recorded. All women were questioned regarding symptoms of faecal and urinary incontinence. Women reporting urinary incontinence following fistula repair underwent urodynamic investigations.

Main outcome measures
Clinical and urodynamic assessment.

Results
The mean age of the women was 23 years (range 16–45 years). The fistula in 38 women (69%) followed the first delivery and in 17 women (31%) following a subsequent delivery. The mean duration of labour was four days (range 1–9 days). Forty‐four women (80%) had an isolated vesico‐vaginal fistula and 11 (20%) had a combined vesico‐vaginal and recto‐vaginal fistula. The mean diameter of the fistula was 2.9 cm (0.5–6 cm). Successful repair occurred in all women. Thirty women (55%) reported persistent urinary incontinence and 21 (38%) altered faecal continence at follow up. In the former group, urodynamic investigations identified genuine stress incontinence in 17 women (31%), detrusor instability in two (4%) and mixed incontinence in 11 (20%).

Conclusion
This study demonstrates the high rate of successful closure of the fistula in a specialised fistula unit, but highlights the problem of persistent urinary incontinence following closure.
Antenatal ultrasound screening for fetal abnormalities: a systematic review of studies of cost and cost effectiveness
Authors: Roberts Tracy , Henderson Jane , Mugford Miranda , Bricker Leanne , Neilson James , Garcia Jo
Published: December 2003

Objective
To review systematically and critically evidence to derive estimates of costs and cost effectiveness of routine ultrasound screening for fetal abnormalities.

Design
A systematic review of the literature using explicit criteria for inclusion of primary research studies, a stated electronic strategy to identify relevant material, and an explanation of why apparently relevant studies have not been included.

Setting
All countries of origin were included. The results of this review are important to obstetricians and to health service managers in the allocation of resources, and others who are considering conducting further research in this area.

Main outcome measure
Formal economic evaluations and cost studies of routine ultrasound screening. Costs of routine anomaly scans and costs of other procedures carried out as part of antenatal screening by ultrasound.

Results
One hundred and ninety‐nine studies were identified in total, 24 reaching the final stage of the review. Nine studies were formal economic evaluations and 15 reported costs studies or clinical effectiveness studies with some assessment of cost. The studies were carried out mainly in Europe and in the United States. After quality criteria were applied, data were extracted from six of the economic evaluations and six of the costs studies. One economic evaluation conducted alongside a randomised trial concluded that screening for fetal abnormalities by ultrasound in the second trimester was cost effective, compared with routine antenatal care. The costs of routine scans ranged from £18 to £204 and for non‐routine ranged from £32 to £113.

Conclusions
There is a lack of good quality primary studies of the costs of ultrasound screening in pregnancy. Typically, economic evaluations of ultrasound screening have been based on poor quality evidence of clinical effectiveness. There is a need for more published data on the costs and cost effectiveness of routine ultrasound screening for fetal anomalies, and of the longer term consequences of screening for anomalies.
Alteration of anal sphincter morphology following vaginal delivery revealed by multiplanar anal endosonography
Authors: Williams A.B. , Bartram C.I. , Halligan S. , Marshall M.M. , Spencer J.A.D. , Nicholls R.J. , Kmiot W.A.
Published: December 2003

Objective
To assess morphologic change in the anal sphincters in the absence of endosonographic evidence of trauma after vaginal delivery.

Design
Prospective observational study.

Setting
District general hospital.

Population
Consecutively booked nulliparous pregnant women attending antenatal clinic.

Methods
All women were examined using three‐dimensional anal endosonography, simple manometry and had questionnaire assessment of incontinence before and after delivery.

Main outcome measures
Components of the anal canal were measured in the axial, sagittal and coronal planes and paired pre‐ and post‐delivery examinations were compared. Any changes were related to changes in continence and anal canal manometry.

Results
Twenty‐two women had a vaginal delivery and no endosonographic evidence of perineal trauma after delivery. After delivery, there was significant shortening of the length of the anterior external anal sphincter [EAS] (mean 21.7 vs 20.5 mm, P= 0.02) when measured in the sagittal plane, which increased in anterior angulation with respect to the axis of the anal canal (10°vs 13.8°, P= 0.03). In the axial plane, no change was seen in the thickness of any of the sphincter components after delivery. None of these morphologic changes correlated with changes in manometry or continence score.

Conclusions
Anal sphincter morphology changes after an otherwise atraumatic vaginal delivery. This change does not correlate with any functional symptoms.
A longitudinal study of biochemical markers of bone turnover during normal pregnancy and pregnancies complicated by pre‐eclampsia
Authors: Anim‐Nyame N. , Sooranna S.R. , Jones J. , Alaghband‐Zadeh J. , Steer P.J. , Johnson M.R.
Published: December 2003

Objectives
To test the hypothesis that the increased bone turnover observed in established pre‐eclampsia is present earlier in pregnancy prior to the diagnosis of pre‐eclampsia.

Design
A prospective longitudinal study.

Setting
Obstetric Unit at Chelsea and Westminster Hospital, London.

Population
Nine women who subsequently developed pre‐eclampsia and 17 normal pregnant controls.

Methods
Maternal plasma levels of the cross‐linked carboxyl terminal telopeptide of the type I collagen (ICTP), a marker of bone resorption, and of the carboxy‐terminal propeptide of type I collagen (PICP), a marker of bone formation, were measured longitudinally in nine women who developed pre‐eclampsia and 17 women with normal pregnancy. Serial blood samples were obtained at 16, 20, 24, 28, 32 and 36 weeks of gestation and the levels of ICTP and PICP were measured by radio‐immunoassay.

Results
ICTP and PICP increased progressively in the normal pregnant and pre‐eclampsia groups, but the rate of increase was significantly greater in the latter (P= 0.00002 and 0.0008, unpaired t test, for ICTP and PICP summary measures, respectively). In the pre‐eclampsia group, positive correlation were observed between ICTP levels at 36 weeks of gestation and plasma uric acid (r= 0.9, P= 0.001) and degree of proteinuria (r= 0.78, P= 0.04). No correlation was observed between the two bone markers and other variables during normal pregnant group.

Conclusion
These data show that biochemical markers of bone turnover are greater in pregnancies complicated by pre‐eclampsia compared with normal pregnancy but only when the disease is clinically evident.
Thrombophilia and immunological disorders in pregnancies as risk factors for small for gestational age infants
Authors: Verspyck Eric , Le Cam‐Duchez Véronique , Goffinet François , Tron François , Marpeau Loïc , Borg Jeanne Yvonne
Published: December 2003

Objectives
To determine if inherited thrombophilia and immunological disorders represent risk factors for small for gestational age infants, and to assess their relationship with neonatal status.

Design
Case–control study.

Population
Ninety‐seven consecutive women who had pregnancies complicated by unexplained small for gestational age infants, defined as a birthweight below the third centile and 97 women as controls who delivered infants with a birthweight ≥10th centile.

Methods
Patients were included in the immediate postpartum period and tested for antithrombin III, protein C, protein S, anticardiolipin and antinuclear antibodies, lupus anticoagulant, Factor V Leiden mutation, prothrombin 20210A mutation, and methylenetetrahydrofolate reductase (MTHFR) polymorphism. Women with small for gestational age infants were then divided into subgroups depending on haemostatic and immunologic status in order to compare neonatal events.

Results
Frequencies for anticardiolipin and antinuclear antibodies were higher in women with small for gestational age infants compared with controls (P= 0.02 and P= 0.004, respectively), and overall prevalence of inherited thrombophilia were comparable in cases and controls (19.6% and 18.6%, respectively). The subgroups of patients with small for gestational age infants were women with only one inherited thrombophilia (n= 10), only one imunological disorder (n= 14), combined disorders (n= 9), and no detected abnormality (n= 64). Admission to paediatric ward significantly increased in the group with combined disorders (P= 0.002) compared with the other groups. Also one‐third of the babies from this group had a poor neonatal outcome. However, most of the neonatal deaths (6/7 = 85.7%) occurred in the group with no detected abnormality.

Conclusion
The prevalence of inherited thrombophilia was considered to be similar between the case and the control groups even when immunological disorders were significantly elevated in pregnancies complicated by the baby being small for gestational age. Combined disorders may represent a potential risk factor for severe small for gestational age infants. However, the aetiology of small for gestational age infants with poor neonatal outcomes remains unknown in most cases.
Comparative levels of psychological distress, stress symptoms, depression and anxiety after childbirth—a prospective population‐based study of mothers and fathers
Authors: Skari Hans , Skreden Marianne , Malt Ulrik Fredrik , Dalholt Merethe , Ostensen Anniken Bjornstad , Egeland Thore , Emblem Ragnhild
Published: December 2003

Objective
To compare maternal and paternal psychological responses following birth of a healthy baby; and to explore predictors of parental psychological distress.

Design
A prospective, longitudinal, population‐based cohort study.

Setting
A Norwegian district general hospital.

Population
One hundred and twenty‐seven mothers and 122 fathers were included.

Methods
Eligible consenting parents were enrolled. The assessments, which were performed zero to four days after birth, at six weeks and at six months, included General Health Questionnaire‐28 (GHQ‐28), State Anxiety Inventory and Impact of Event Scale. The response rates at the three occasions were 97%, 85% and 71%.

Main outcome measures
Symptoms of intrusion, avoidance, arousal and psychological distress including anxiety, depression, social dysfunction and somatisation.

Results
Clinically important psychological distress was reported by 37% of the mothers and 13% of the fathers a few days after childbirth (P < 0.001). Severe intrusive stress symptoms were reported by 9% and 2% of mothers and fathers, respectively (P= 0.002). Level of intrusive stress was the outcome that differed most clearly between mothers and fathers at all three points of time. Being a single parent, multiparity and a previous traumatic birth were significant independent predictors of acute maternal psychological distress. After six weeks and six months, the level of psychological distress including symptoms of depression fell to levels found in the general population.

Conclusions
Childbirth does not seem to trigger long term psychological distress in most parents. Clinically important psychological distress occurred more frequently in mothers than in fathers. Acute maternal psychological distress was predicted by being a single parent, being multiparous, and having a previous traumatic birth.
Warfarin dosage in postpartum women: a case–control study
Authors: Brooks Cath , Rutherford Jane M. , Gould Jane , Ramsay Margaret M. , James David K.
Published: December 2003

Objective
To investigate the clinical suspicion that postpartum women are more difficult to anticoagulate with warfarin than non‐pregnant women due to the physiological changes in coagulation proteins that persist into the postpartum period.

Design
A retrospective case–control study.

Setting
University Hospital, Nottingham, UK.

Sample
Twenty‐three postpartum women discharged from the obstetric wards on warfarin and 23 age‐matched control women discharged from the medical wards on warfarin were identified using hospital databases.

Methods
Warfarin doses and international normalised ratio values were recorded from day one to 35. The number of days and total warfarin dose to achieve therapeutic international normalised ratio were recorded. Doses were compared with those recommended by a dosing nomogram.

Results
The postpartum group took significantly longer and significantly larger doses of warfarin to reach therapeutic international normalised ratio (P < 0.05). The postpartum group required a persistently higher maintenance dose of warfarin. Comparing the warfarin dose given on day three with a standardised nomogram, 79% of women in the postpartum group compared with 57% in the control group were under‐dosed.

Conclusion
Postpartum women require larger doses of warfarin to reach therapeutic international normalised ratio than non‐pregnant women. We would recommend the use of a dosing nomogram.
The decision‐to‐delivery interval for emergency caesarean section: is 30 minutes a realistic target?
Authors: Helmy W.H. , Jolaoso A.S. , Ifaturoti O.O. , Afify S.A. , Jones M.H.
Published: December 2003

Objective
To evaluate whether a 30‐minute decision‐to‐delivery interval is a realistic target for emergency caesarean section.

Design
An audit of all emergency caesarean sections over five separate periods.

Setting
A district general hospital.

Participants
Five groups of women (343 women) with an indication for emergency caesarean section.

Methods
Following an initial survey, a structured time sheet was introduced, followed by four other surveys to complete the audit cycle.

Main outcome measure
The proportion of caesarean sections where the decision‐to‐delivery interval measures was achieved within 30 minutes. The reasons for delay.

Results
In the first survey of 73 emergency caesarean sections, the time to deliver the infant exceeded 30 minutes in 47 women (64%). The main sources of delay were transferring the women to the operating theatre and starting the anaesthetic. After the introduction of a structured time sheet, there was an improvement with each survey, but the target of 30 minutes was reached in only 71% of caesarean sections in the final survey.

Conclusions
The introduction of a time sheet can improve the decision‐to‐delivery interval for emergency caesarean section; however, a universal standard of 100% in 30 minutes is unrealistic.
A comparison of urethral pressure profilometry using microtip and double‐lumen perfusion catheters in women with genuine stress incontinence
Authors: Wang Alex C. , Chen Min‐Chi
Published: December 2003

Objective
To compare urethral pressure profilometry measurements using microtip transducer and double‐lumen perfusion catheters.

Design
Prospective study.

Setting
Tertiary referral urogynaecology unit.

Sample
Three hundred and ninety two non‐pregnant women with various lower urinary tract symptoms.

Methods
Multichannel urodynamic investigations were performed using double‐lumen perfusion catheters with external pressure transducers in 392 women. For those 301 (76.8%) diagnosed as having genuine stress incontinence, an investigation with microtip transducers followed. For data analysis, a mixed‐effects model was used to evaluate changes in the urethral profilometry and an approach proposed by Bland and Altman was applied to access agreement between the two techniques.

Results
Of the 301 women with genuine stress incontinence, 272 were eligible for this study. In resting status, the differences between the two techniques were statistically significant (48.9cm H2O vs 73.4cm H2O, P= 0.0001) after adjusting for age. Moreover, the agreement study also confirmed that these two techniques do not agree sufficiently.

Conclusion
Maximum urethral closure pressure obtained from the double‐lumen catheter was significantly higher than that obtained from the microtip catheter. Use of the double‐lumen catheter for the measurement of maximum urethral closure pressure can be considered a reliable technique since its reproducibility is as good as that of the microtip catheter. Therefore, the diagnosis of ‘low pressure urethra’ will be different between the two techniques.
Effects of vitamin A deficiency during pregnancy on maternal and child health
Authors: Radhika M.S. , Bhaskaram P. , Balakrishna N. , Ramalakshmi B.A. , Devi Savitha , Kumar B. Siva
Published: December 2003

Objective
To examine the association between biochemical vitamin A deficiency in pregnancy and maternal and fetal health.

Design
A cross sectional clinical study.

Setting
Antenatal clinic of nutrition unit of Niloufer Hospital catering for a low socio‐economic population, and a private nursing home (Swapna nursing home) catering for a high socio‐economic population.

Population
736 pregnant women in their third trimester of pregnancy belonging to low (n= 522) and high socio‐economic groups (n= 214).

Methods
All the women were subjected to a detailed clinical, anthropometric and obstetric examination. Night blindness was assessed by administering the standard WHO questionnaire. Birthweight and gestational age of the infants, maternal anaemia and development of pregnancy‐induced hypertension in the mother were recorded. Haemoglobin and serum retinol were estimated at the time of recruitment to the study.

Main outcome measures
Serum retinol levels, anaemia, pregnancy‐induced hypertension, birthweight and gestational age of the infant.

Results
Night blindness was observed in 2.9% of the women and subclincal vitamin A deficiency (serum retinol <20 μg/dL with no clinical signs) in 27% of the women. Moderate to severe anaemia was observed in 41.2% of the women, and 15.8% of the women developed pregnancy‐induced hypertension. Sixty‐one (9.4%) women delivered preterm. Univariate analysis identified a significant association between serum retinol <20 μg/dL and preterm delivery (OR = 1.74, 95% CI 1.03–2.96), maternal anaemia (OR = 1.82, 95% CI 1.28–2.60) and pregnancy‐induced hypertension (OR = 1.56, 95% CI 1.02–2.83). After adjusting for the confounding variables (body mass index, parity, age and socio‐economic status) in a multivariate analysis, the significant associations between serum retinol <20 μg/dL and preterm delivery (P= 0.02) and anaemia (P= 0.003) persisted, while that for pregnancy‐induced hypertension disappeared (P= 0.71).

Conclusion
The study suggests that subclinical vitamin A deficiency is a problem during the third trimester of pregnancy. Serum concentration of retinol <20 μg/dL appears to indicate a deficient status, and is associated with an increased risk of preterm delivery and maternal anaemia.
Substandard care in immigrant versus indigenous maternal deaths in The Netherlands
Authors: Van Roosmalen J. , Schuitemaker N.W.E. , Brand R. , Van Dongen P.W.J. , Gravenhorst J. Bennebroek
Published: December 2003

As part of the Confidential Enquiry into the Causes of Maternal Deaths in The Netherlands, substandard care was assessed in immigrant versus indigenous maternal deaths. Except for substandard care related to the women's and relatives' decisions, substandard care factors were hypothesised to occur in similar frequency among both groups of women. The results, however, indicate that substandard care factors related to all aspects of care were disproportionately more frequent in immigrant women. More research into the interpretation of these worrying data is needed.
The economic costs of alternative modes of delivery during the first two months postpartum: results from a Scottish observational study
Authors: Petrou Stavros , Glazener Cathryn
Published: December 2003

A study was conducted to estimate the economic costs of alternative modes of delivery during the first two months postpartum. Hospital and community health service utilisation data for 1242 women were extracted from self‐completed questionnaires, medical case notes and computerised hospital discharge records. Unit costs (1999–2000 prices) were collected for each item of resource use and combined with resource volumes to obtain a net cost per woman. There were significant differences in initial hospitalisation costs between the three mode of delivery groups (spontaneous vaginal delivery £1431, instrumental vaginal delivery £1970, caesarean section £2924, P < 0.001). There were also significant differences in the cost of hospital readmissions, community midwifery care and general practitioner care between the three mode of delivery groups. However, total post‐discharge health care costs did not vary significantly by mode of delivery. Total health care costs were estimated at £1698 for a spontaneous vaginal delivery, £2262 for an instrumental vaginal delivery and £3200 for a caesarean section (P < 0.001). It is imperative that hospital and community health service providers recognise the economic impact of alternative modes of delivery in their service planning.
Inter‐assay variation in antiphospholipid antibody testing
Authors: Roberts Judith M. , Macara Lena M. , Chalmers Elizabeth A. , Smith Gordon C.S.
Published: December 2003

We evaluated inter‐assay variation in anticardiolipin antibody status, comparing three centres, and using different assays among 36 women with recurrent miscarriage and 26 controls. There was no more agreement between the laboratories than would be predicted on the basis of chance for IgM and only fair agreement among the laboratories for IgG. None of the tests were significantly more likely to be positive in the cases compared with the controls.
Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. A Canadian multicentre study
Authors:   The names of collaborators may be found on page 744, Effer Sidney B. , Moutquin Jean‐Marie , Farine Dan , Saigal Saroj , Nimrod Carl , Kelly Edmond , Niyonsenga Theophile
Published: December 2003

Objective
To determine the current survival rate of singleton living newborns born at gestational age of 24 and 25 weeks, using obstetric factors available to the physician before birth.

Design
Retrospective study of all live births in 13 of 17 Canadian tertiary centres.

Population
All singleton live births without congenital abnormalities.

Methods
During the years 1991–1996, data were abstracted from clinical databases and charts of 860 live births, in 13 of the 17 tertiary centres in Canada, all with major neonatal intensive care units. Newborn survival was defined as alive at discharge from neonatal intensive care unit. Abstracted elements included gestational age, maternal antenatal corticosteroid treatment, birthweight, gender, fetal presentation and mode of delivery.

Results
Average survival rates increased from 56.1% at 24 weeks (n= 406) to 68.0% at 25 weeks (n= 454). Survival rates ranged from 53.1% at day 168 to 81.6% at day 181 (r = 0.802, P < 0.05). Steroid administration improved the survival rates at 24 and 25 weeks compared with that of unexposed fetuses, respectively (58.9%vs 41.8%; OR 1.70; 95% CI 1.03–2.08 and 74.2%vs 56.8%; OR 2.19; 95% CI 1.41–3.38). Caesarean delivery for breech presentation improved survival compared with vaginal delivery, both at 24 and 25 weeks (56.1%vs 36.0%; OR 2.19; 95% CI 1.10–4.34, and 68.7%vs 55.2% OR 1.78; 95% CI 0.093–3.43). Female neonates displayed better survival rates (59.6%vs 52.1% OR 1.36; 95% CI 0.92–2.01, and 72.6%vs 63.1% OR 1.51; 95% CI 1.02–2.25) at 24 and 25 weeks, respectively. Explanatory regression model confirmed these factors as prognostic variables associated with survival.

Conclusions
This extensive collaborative study confirms that several prognostic factors, known before birth, including gestational age in days, steroid treatment, mode of presentation and fetal sex may help obstetricians, neonatologists and parents in their decision‐making process at 24 and 25 weeks of pregnancy.
Algorithms for combining menstrual and ultrasound estimates of gestational age: consequences for rates of preterm and postterm birth
Authors: Blondel Béatrice , Morin Isabelle , Platt Robert W. , Kramer Michael S. , Usher Robert , Bréart Gérard
Published: December 2003

We compared rates of preterm and postterm birth according to six algorithms for gestational age (GA) estimates based on last menstrual period (LMP) and early ultrasound (EUS): LMP alone, LMP if the discrepancy between the two estimates was within 14 days and otherwise EUS (14‐day rule), a 10‐day rule, a seven‐day rule, a three‐day rule and EUS alone. In a sample of 44,623 births in a Canadian tertiary hospital, the choice of algorithms makes a substantial impact on both preterm and postterm birth rates, even when EUS was used for discrepancies over two weeks.
Long term follow up of the cruciate fascial sling for women with genuine stress incontinence
Authors: Hawkins Emma , Taylor Debbie , Hughes‐Nurse Jennifer
Published: December 2003

Objective
To determine the long term success of the cruciate fascial sling procedure for the treatment of genuine stress incontinence in women.

Design
In 1998, a pre‐validated questionnaire was sent to all women who had a cruciate fascial sling between 1979 and 1996 under the care of the senior author at a District General Hospital and in private practice.

Participants
Questionnaires were sent to 246 women; 198 (80%) were returned.

Results
Overall, 142 women felt that they were much improved or cured. The success rate was 74% (95% CI 70%–81%) in women having the sling as a primary procedure and 67% (95% CI 54%–81%) in women having the sling as a secondary procedure. There was no relationship between symptom severity score and age at time surgery, duration of follow up, current weight or body mass index, previous surgery for stress incontinence or concomitant surgery. Of the 103 women with six or more years of follow up, 29 felt that their operation had failed, 16 of whom thought that it lasted between five and 10 years. Urgency was experienced by 29% of women, three needed to perform intermittent self‐catheterisation, and 9% found it difficult to empty their bladder. Thirty‐seven women (19%) experienced problems that they attributed to the abdominal wound.

Conclusion
Although inevitably there are some failures over time, the cruciate fascial sling has good long term success rates. Direct comparison with the literature is impossible, as few studies have relied on properly validated questionnaires.
Cord blood sampling at delivery: do we need to always collect from both vessels?
Authors: Tong Stephen , Egan Val , Griffin Julie , Wallace Euan M.
Published: December 2003

The literature suggests that up to 19% of umbilical cord blood samples are invalid. Accordingly, it has been proposed that blood should be universally collected from both vessels. We prospectively collected paired arterial and venous blood to examine whether our centre, where staff were experienced in single vessel collection, was more accurate. Of 289 paired samples, 53 (18.3%) were considered invalid. Despite this significant error rate, we propose that routinely, only arterial sampling is needed and that an additional venous sample need only be taken to validate samples in cases of pH < 7.15, a difficult delivery or a non‐vigorous baby.
Urinary symptoms in pregnancy: are they useful for diagnosis?
Authors: Chaliha Charlotte , Khullar Vik , Stanton Stuart L. , Monga Ash , Sultan Abdul H.
Published: December 2003

This is the second part of a study assessing 161 women 12 weeks after their first delivery. The urodynamic data have previously been published [Br J Obstet Gynaecol 2000; 107:1354]. The symptoms have been assessed using a (non‐validated) urinary symptom questionnaire. There was no correlation between symptoms and urodynamic findings and most importantly between the symptom of stress incontinence, a diagnosis of urodynamic stress incontinence (USI) and vaginal delivery. Symptoms of incontinence and abnormal urodynamic findings were also found in women who underwent caesarean section. These data explain why caesarean section does not appear to be wholly protective in preventing postpartum incontinence. This suggests that the aetiology of postpartum incontinence is multifactorial and urinary symptoms are misleading in determining the underlying causes.
Effect of inhibiting the sarcoplasmic reticulum on spontaneous and oxytocin‐induced contractions of human myometrium
Authors: Kupittayanant S. , Luckas M.J.M. , Wray S.
Published: December 2003

Objective
1. To assess the contribution of the sarcoplasmic reticulum calcium store in the generation of uterine smooth muscle contractions; 2. to evaluate the contribution of calcium induced calcium release or ryanodine gated calcium channels to myometrial force production.

Design
Laboratory scientific study.

Methods
Myometrial strips were obtained from women undergoing elective prelabour caesarean section at term. These were loaded with the calcium sensitive indicator Indo‐1 allowing simultaneous assessment of intracellular calcium concentrations and force production. The effect of exposing the strips to ryanodine (which abolishes calcium induced calcium release), caffeine (which activates calcium induced calcium release) and cyclopiazonic acid (which abolishes the sarcoplasmic *reticulum calcium store) was examined.

Results
Exposure to ryanodine had no appreciable effect on either the amplitude or the duration of the myometrial calcium and force transients but did increase the frequency of contractions (139 ± 5%). Caffeine did not potentiate force. Cyclopiazonic acid increased frequency, duration and amplitude of both calcium and force transients. The ability of oxytocin to provoke calcium and force transients in the absence of extracellular calcium was abolished by cyclopiazonic acid but not by ryanodine.

Conclusions
These results demonstrate that calcium induced calcium release does not play a significant role in human myometrium and that no functioning role for the ryanodine receptors in human myometrial tissue could be shown. These data suggest that the sarcoplasmic reticulum may act to limit contractions and act as a calcium sink, rather than to amplify contractions.
A randomised comparison of early versus late amniotomy following cervical ripening with a Foley catheter
Authors: Levy Roni , Ferber Asaf , Ben‐Arie Alon , Paz Beatrice , Hazan Ynon , Blickstein Isaac , Hagay Zion J.
Published: December 2003

Objectives
Ripening of the cervix with a Foley catheter commonly results in cervical dilatation without contractions. We examined the outcome of labour in women who underwent induction of labour using a Foley catheter, followed by either 1. early amniotomy, or 2. augmentation of labour by oxytocin and late amniotomy

Design
Prospective randomised clinical trial

Setting
Labour and delivery ward of a university teaching hospital

Participants
Pregnant women ≥38 weeks of a singleton gestation, who had had no prior caesarean section

Methods
All women underwent cervical ripening using a Foley catheter. Following removal of the catheter, women were randomly assigned to either early (n= 80) or late amniotomy (n= 88).

Main outcome measures
Comparison of mode of delivery and duration of labour between the two groups

Results
The rate of caesarean section was significantly higher in the early amniotomy group compared with the late amniotomy group (25%vs 7.9%; relative risk 1.74; 95% CI 1.3 – 2.34). The increase in caesarean section rate was due primarily to dystocia (15%vs 3.3%; relative risk 1.8; 95% CI 1.32 – 2.45). When excluding caesarean deliveries, no significant difference was found in duration of labour between the groups (8.3 hours (3.8) vs 7.7 hours (2.9))

Conclusions
In women who undergo cervical ripening with a Foley catheter, augmentation of labour by oxytocin followed by amniotomy during active labour results in a lower rate of caesarean delivery for dystocia
Randomised trial of amnioinfusion during labour with meconium stained amniotic fluid
Authors: Rathorea Asmita Muthal , Singh Ruchira , Ramji S. , Tripathi Reva
Published: December 2003

Objective
To assess the effect of amnioinfusion during labour with meconium stained amniotic fluid on caesarean section rate and perinatal outcome.

Design
Prospective randomised controlled study.

Setting
A tertiary care teaching hospital in India.

Population
Women in labour at term with meconium stained amniotic fluid.

Methods
Two hundred women in labour with ≥37 weeks gestation, single cephalic presentation with moderate or thick meconium were randomised to control and amnioinfusion groups at a 1:1 ratio. Amnioinfusion was performed using 500mL of normal saline over a period of 30 minutes in a study group. The control group received routine care. Both groups had intermittent auscultation of fetal heart rate during labour.

Main outcome measures
The primary outcome measure was caesarean section rate. Secondary outcome measures were meconium aspiration syndrome, 1 minute and 5 minute apgar <7, hypoxic ischaemic encephalopathy, neonatal intensive care unit admission, meconium at the level of vocal cords.

Results
The caesarean section rate in the amnioinfusion group was less than the control group (RR 0.47; 95% CI 0.24–0.93). Amnioinfusion was associated with a significant decrease in the incidence of meconium at the vocal cords (P= 0.001); improvement in 1 minute apgar scores (P <0.05), respiratory distress (P= 0.002) and fewer admissions to nursery compared with the controls. This sample size was inadequate to study the impact on meconium aspiration syndrome.

Conclusion
Amnioinfusion in an under resourced labour ward decreases caesarean section rates and fetal morbidity.
Development and validation of a questionnaire for the assessment of bowel and lower urinary tract symptoms in women
Authors: Hiller L. , Radley S. , Mann C.H. , Radley S.C. , Begum G. , Pretlove S.J. , Salaman J.H.
Published: December 2003

Objective
To develop a simple but sensitive instrument to evaluate and document symptoms of both bowel and urinary dysfunction in women.

Design
A 22‐item questionnaire covering a range of bowel and urinary symptoms was developed and underwent rigorous psychometric testing.

Setting
The gynaecology departments of three hospitals, a urogynaecology clinic, a functional bowel clinic and a general practice.

Population
Six hundred and thirty women, comprising four groups: 1. women awaiting hysterectomy (n= 379), 2. women following hysterectomy (n= 45), 3. women referred with functional bowel and/or urinary symptoms (n= 65), 4. asymptomatic controls (n= 141).

Main outcome measures
The content, construct and criterion validity, internal consistency, reliability and responsiveness of the questionnaire were measured.

Results
Peer and patient reports and missing data patterns supported face and content validity. Factor analysis showed a clinically relevant four‐factor structure with low content replication able to distinguish between patient groups, indicating good internal structure. Comparison with clinical, anorectal physiological, videoproctographic, transit time and urodynamic test results provide provisional indication of criterion validity. Key domain question analysis and Cronbach's alphas showed internal consistency. Kappa values demonstrated good test–retest reliability and key question correlation over time proved responsiveness.

Conclusions
Our findings support the suitability, clinical validity, reliability and responsiveness of a simple questionnaire, which is sensitive to the constraints of clinical practice. The authors recommend its use in health care evaluation research assessing the effects of pelvic surgery and as a useful tool in comparing treatment efficacy.
Adhesion molecules expression in the placental bed of pregnancies with pre‐eclampsia
Authors: Tziotis John , Malamitsi‐Puchner Ariadne , Vlachos George , Creatsas George , Michalas Stylianos
Published: December 2003

ObjectiveTo compare the expression of intercellular adhesion molecule‐1 (ICAM‐1), vascular cell adhesion molecule‐1 (VCAM‐1), platelet endothelial cell adhesion molecule‐1 (PECAM‐1) and E‐selectin in placental bed biopsies (endothelium of spiral arteries as well as trophoblastic cells) from normal and pre‐eclamptic pregnancies

DesignA prospective study.

Setting1. First Department of Obstetrics and Gynaecology, Alexandra Hospital, University of Athens, Greece. 2. Laboratory of Pathophysiology, Laikon Hospital, University of Athens

PopulationSixteen placental bed biopsies from women with pre‐eclampsia were compared with 20 placental bed biopsies from uncomplicated normotensive women

Main outcome measuresImmunocytochemical staining of the placental bed biopsies for ICAM‐1, VCAM‐1, PECAM‐1 and E‐selectin

ResultsNo statistically significant differences were found in the expression of the adhesion molecules ICAM‐1, VCAM‐1, PECAM‐1 and E‐selectin in the endothelium of the spiral arteries and the trophoblastic cells of the placental bed of the two studied groups

ConclusionsAdhesion molecules ICAM‐1, VCAM‐1, PECAM‐1, but not E‐selectin, are expressed in the placental bed of normal and pre‐eclamptic pregnancies, but there are no differences between the two groups of women. It seems that the above molecules are not likely to be implicated in the aetiology of pre‐eclampsia
Effect of twin‐to‐twin delivery interval on umbilical cord blood gas in the second twins
Authors: Leung Tak‐Yeung , Tam Wing‐Hung , Leung Tse‐Ngong , Lok Ingrid Hung , Lau Tze‐Kin
Published: December 2003

Objective
To examine the effect of twin‐to‐twin delivery interval on the umbilical cord blood gas status of the second twin following vaginal delivery.

Design
A retrospective study.

Setting
The department of obstetrics and gynaecology in a university teaching hospital.

Population
Twin deliveries at or beyond 34 weeks of gestation over a period of five years, with the first twin delivered vaginally. Twins with any antepartum complications including discordant growth, intrauterine growth restriction, intrauterine death, fetal malformations and pre‐eclampsia were excluded.

Methods
The correlation between the twin‐to‐twin delivery interval, and both the umbilical arterial and venous blood gas parameters of the second twin, including pH, partial pressure of CO2 and base excess, were studied.

Results
A total of 118 cases were reviewed. The mean gestation at delivery was 37.1 weeks. The median twin‐to‐twin delivery interval was 16.5 minutes. There were significant negative correlations between twin‐to‐twin delivery interval and both the umbilical cord arterial and venous pH and base excess of the second twin (P <0.05). There were also significant positive correlations between both arterial and venous partial pressure of CO2 and the delivery interval (P <0.05). Similar changes were found even if the analyses were limited to those who had normal vaginal deliveries. The umbilical arterial pH of Twin 2 was <7.00 in none of the cases delivered within 15 minutes of the birth of Twin 1, 5.9% if within 16–30 minutes, and 27% if more than 30 minutes. Among those with an inter‐twin delivery interval of more than 30 minutes, 73% had cardiotocographic evidence of fetal distress which required operative delivery.

Conclusions
Umbilical cord arterial and venous values of pH, partial pressure of CO2 and base excess of the second twin deteriorate with increasing twin‐to‐twin delivery interval. Risks of fetal distress and acidosis in the second twin are high when the twin‐to‐twin delivery interval is beyond 30 minutes.
Flow‐mediated dilatation of the brachial artery in pregnancy at high altitude
Authors: Kametas Nikos A. , Savvidou Makrina D. , Donald Ann E. , McAuliffe Fionnuala , Nicolaides Kypros H.
Published: December 2003

Objective
Pregnancy at high altitude has been associated with increased prevalence of pre‐eclampsia and reduced maternal oestrogen levels, factors that have been associated with endothelial dysfunction. The aim of this study was to examine the effect of high altitude (4370 m above sea level) on endothelial function during pregnancy as assessed by a non‐invasive method.

Design
Cross‐sectional study.

Setting
Two maternity units providing routine antenatal care: one at high altitude (District General Hospital ‐ IPSS in Cerro de Pasco, Peru) and one at sea level (Instituto Materno‐Perinatal in Lima, Peru).

Population
Sixty pregnant women at 6–42 weeks of gestation resident at high altitude (Cerro de Pasco, Peru, 4370 m above sea level) and 54 at sea level (Lima, Peru). Comparisons were performed also in 11 and 14 non‐pregnant women at each altitude, respectively.

Methods
Endothelial function was assessed by flow‐mediated dilatation of the brachial artery using high‐resolution ultrasound.

Main outcome measures
Differences in flow mediated dilatation of the brachial artery in two groups of pregnant women, one at high altitude and one at sea level.

Results
Both at high altitude and sea level flow‐mediated dilatation of the brachial artery increased in the first two trimesters to levels 32% higher than non‐pregnant controls. However, in the third trimester, flow‐mediated dilatation of the brachial artery was lower than non‐pregnant levels. Resting vessel size increased during pregnancy by 15% compared with non‐pregnant controls at term, with no difference between the two populations at high and low altitude. Pregnancy at high altitude, compared with sea level, was associated with 59% lower baseline blood flow and 76% higher reactive hyperaemia. Similarly, non‐pregnant controls at high altitude compared with sea level demonstrated similar flow‐mediated dilatation of the brachial artery and 40% lower resting blood flow of the brachial artery. However, the difference in reactive hyperaemia did not reach statistical significance.

Conclusion
These data suggest that, during pregnancy at high altitude, endothelial function, as assessed by flow‐mediated dilatation of the brachial artery, is not impaired.