bluuebunny/crossref_metadata_2025 huggingface dataset:
Does the increased risk of preterm delivery in teenagers persist in pregnancies after the teenage period?
Authors: Olausson Petra Otterblad , Cnattingius Sven , Haglund Bengt
Published: December 2003

Objective To study the associations between low maternal age at first birth and the risks of very and moderately preterm birth, in first birth and in second successive birth in adulthood.

Design Population‐based cohort study.

Setting Sweden.

Population Women aged less than 25 years at first birth (n=275,933), having two successive live single births from 1973 through 1993.

Methods Odds ratios with 95 percent confidence intervals were calculated to estimate the effect of low maternal age at first birth. Analyses of first births were adjusted for year of first birth and maternal education and in second births also for previous pregnancy outcomes and interpregnancy interval.

Main outcome measures Very preterm birth (less than 33 completed weeks) and moderately preterm birth (33‐36 completed weeks).

Results Compared with women aged 20 to 24 years at first birth, mothers aged 13 to 15 years were at increased risk of very preterm birth (odds ratio=4.8). The corresponding risks among women aged 16 to 17 years at first birth were doubled (odds ratio=2.3). The influence of maternal age on risks of moderately preterm birth was similar, although the age‐related risks were lower. At second birth, risks of preterm birth were reduced in all age groups. However, mothers who were 17 years or less at first birth, faced, compared with mothers aged 20‐24 years, significantly larger reduction in risks of very and moderately preterm birth.

Conclusions Our results suggest that there may be a biological effect of very young maternal age, affecting foremost very preterm birth.
Obstetric practice and faecal incontinence three months after delivery
Authors: MacArthur C. , Glazener C.M.A. , Wilson P.D. , Herbison G.P. , Gee H. , Lang G.D. , Lancashire R.
Published: December 2003

Objective To determine whether obstetric and maternal factors relate to faecal incontinence at three months postpartum.

Setting Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand).

Population All women who delivered during one year in the three maternity units.

Methods Postal questionnaire at three months postpartum, to obtain information on faecal incontinence, linked to obstetric casenote data.

Main outcome measures Prevalence of faecal incontinence.

Results 7879 questionnaires were returned, a 71.7% response rate. The prevalence of faecal incontinence was 9.6%, with 4.2% reporting this more often than rarely. Logistic regression, confined to primiparae, showed that forceps delivery was a predictor of an increased risk of symptoms (OR=1.94, 95% CI 1.30 to 2.89) while vacuum extraction was not associated. Caesarean section was marginally associated with a reduced risk (OR=0.58, 95% CI 0.35 to 0.97). Older maternal age, Indian sub‐continent ethnic origin and body mass index ‘not known’ also showed significant associations. No associations were found for induced labour, duration of second stage labour, episiotomy, laceration or birthweight.

Conclusions Women delivered by forceps had almost twice the risk of developing faecal incontinence, whereas vacuum extraction was not associated with faecal incontinence at three months postpartum. Caesarean section appears to offer some protection.
Fetal lung volume measurement by magnetic resonance imaging in congenital diaphragmatic hernia
Authors: Mahieu‐Caputo D. , Sonigo P. , Dommergues M. , Fournet J.C. , Thalabard J.C. , Abarca C. , Benachi A. , Brunelle F. , Dumez Y.
Published: December 2003

Objective
To study the potential for prenatal magnetic resonance imaging to predict pulmonary hypoplasia in congenital diaphragmatic hernia.

Design
Prospective observational study.

Setting
Tertiary care centre.

Participants
Thirteen cases of congenital diaphragmatic hernia (11 left, 2 right) without associated anomalies and 74 controls.

Methods
Measurements by magnetic resonance imaging of fetal lung volume were achieved. In the control fetuses, a regression analysis was performed to associate fetal lung volume with gestational age. This yielded a formula allowing calculation of the expected fetal lung volume as a function of gestational age. In the cases with congenital diaphragmatic hernia, the observed/expected fetal lung volume ratio was compared with perinatal outcome.

Main
outcome measures Neonatal mortality and pulmonary hypoplasia, which was defined as lung/body weight ratios less than 0.012.

Results
The expected fetal lung volume was derived from the following formula: Fetal lung volume (mL) = exp (1.24722 + 0.08939 × gestational age in weeks). The observed/expected fetal lung volume ratio was significantly lower in congenital diaphragmatic hernia (median: 0.31, range: 0.06–0.63), than in controls (median: 0.99, range: 0.42–1.94). This ratio was significantly less in the infants with congenital diaphragmatic hernia who died (median: 0.26, range: 0.06–0.63) compared with those who survived (median: 0.46, range: 0.35–0.56). The observed: expected fetal lung volume ratio was significantly correlated with the post mortem lung: body weight ratio.

Conclusion
In isolated congenital diaphragmatic hernia, fetal lung volume measurement by magnetic resonance imaging is a potential predictor of pulmonary hypoplasia and postnatal outcome. Further studies are required to establish the clinical value of magnetic resonance imaging for the prenatal assessment of fetal lungs.
Chronological aspects of ultrasonic, hormonal, and other indirect indices of ovulation
Authors: Ecochard René , Boehringer Hans , Rabilloud Muriel , Marret Henri
Published: December 2003

Objective
To improve prediction of ovulation in normal cycles.

Design
Collection of women's characteristics and their menstrual cycles. Monitoring and analysis of time relationships between several indicators of ovulation: transvaginal ultrasonography, cervical mucus, basal body temperature, urinary luteinising hormone, and ratio of urinary oestrogen to progesterone metabolites.

Setting
Each of eight natural family planning clinics was to study 12 women for at least three cycles.

Population
One hundred and seven normally fertile and cycling women aged 18 to 45.

Methods
Daily measurements of urinary luteinising hormone, follicle stimulating hormone, oestrone‐3‐glucuronide and pregnanediol‐3α‐glucuronide. Basal body temperature recording and cervical mucus checking. Transvaginal ultrasound examination of the ovaries.

Main
outcome measures Delays between the expected day of ovulation according to the luteinising hormone peak or to ultrasound evidence and the expected days according to the other indices of ovulation.

Results
Ultrasonography was able to show evidence of ovulation in 283 out of 326 cycles. The average time lag between luteinising hormone peak and ultrasound evidence was less than one day (+0.46) but premature and late luteinising hormone‐expected date of ovulation were observed in nearly 10% and 23% of cycles, respectively. Basal body temperature rise was observed in 98% of cycles. Cervical mucus peak symptom, rapid drop in the ratio of urinary metabolites, and luteinising hormone initial rise were all close to ultrasonographic evidence in more than 72% of cycles.

Conclusions
For accuracy and practical reasons, the cervical mucus peak symptom, the ratio of urinary metabolites and luteinising hormone initial rise might be better indices of ovulation than the luteinising hormone peak.
Computerised analysis of the fetal heart rate and relation to acidaemia at delivery
Authors: Strachan Bryony K. , Sahota Daljit S. , van Wijngaarden Willem J. , James David K. , Chang Allan M.Z.
Published: December 2003

Objective
To identify the individual features of the computerised analysis of the cardiotocograph that relate to arterial pH and base deficit at delivery.

Design
Retrospective observational study.

Setting
Teaching hospital labour wards.

Participants
679 women requiring continuous intrapartum fetal monitoring.

Methods
Fetal heart and uterine contraction data were obtained using the Nottingham Fetal ECG monitor. Fetal heart rate patterns for the last half‐hour preceding delivery were analysed using a computer algorithm developed for intrapartum application. The significance of the areas under receiver operator characteristic curves were calculated.

Main
outcome measures Umbilical arterial pH and base deficit at delivery.

Results
Three parameters, fetal bradycardia, total deceleration area and the deceleration area after a contraction had receiver operator characteristic curves that significantly predict a low umbilical arterial pH and base deficit at delivery (areas under receiver‐operator characteristic curves =0.53, SD 0.01 P= 0.03; 0.60, SD 0.03 P= 0.002; 0.62 SD 0.04 P<0.001, respectively). Tachycardia, accelerations and variability did not.

Conclusions
The individual components of the computerised analysis of the fetal heart rate that predict acidaemia at delivery are identified.
Computerised antenatal fetal heart rate recordings between 24 and 28 weeks of gestation
Authors: Roberts Devender , Kumar Bidyut , Tincello Douglas G. , Walkinshaw Stephen A.
Published: December 2003

Objective
To assess computerised fetal heart rate recordings between 24 and 28 weeks of gestation for gestation related differences.

Design
Prospective, cross sectional observational study.

Setting
Liverpool Women's Hospital.

Population
112 women: 28 at 27 weeks, 30 at 26 weeks, 27 at 25 weeks and 27 at 24 weeks of gestation, respectively.

Methods
Fetal heart recordings of 60 minutes duration were performed once in each pregnancy using the System 8000 fetal heart rate programme (System 8000, Oxford Sonicaid Ltd, Chichester, UK). For each gestational age, records were analysed for short term variation, basal heart rate, accelerations and time spent in high episodes.

Results
The mean short term variation increased with gestation (P=0.05). No record had a short term variation <4 msecs. There was no relationship between heart rate and increasing gestation. The mean number of accelerations per record increased with increasing gestation (P<0.01). 20% of recordings showed no accelerations >15 bpm. The mean duration spent in episodes of high variation increased with gestation (P=0.05). 13% of recordings showed no time spent in high episodes. All fetuses had normal outcomes at delivery.

Conclusions
Absence of episodes of high variation or absence of accelerations is not an abnormal finding at lower gestations. The standard threshold of 4 msecs for short term variation appears to remain valid at lower gestations. These differences should be considered when using computerised CTG analysis at early gestations.
Is the intrauterine device appropriate contraception for HIV‐1‐infected women?
Authors: Morrison Charles S. , Sekadde‐Kigondu Christine , Sinei Samuel K. , Weiner Debra H. , Kwok Cynthia , Kokonya Donald
Published: December 2003

Objective
To assess whether the risk of complications is higher in HIV‐1‐infected women compared with non‐infected women in the two years following insertion of the intrauterine contraceptive device.

Design
Prospective cohort study.

Population
Six hundred and forty‐nine women (156 HIV‐1‐infected, 493 non‐infected) in Nairobi, Kenya who requested an intrauterine contraceptive device and met local eligibility criteria.

Methods
We gathered information on complications related to the use of the intrauterine contraceptive device, including pelvic inflammatory disease, removals due to infection, pain or bleeding, expulsions, and pregnancies at one, four, and 24 months after insertion by study physicians masked to participants’ HIV‐1 status. Cox regression was used to estimate hazard ratios.

Results
Complications were identified in 94 of 636 women returning for follow up (14.7% of HIV‐1‐infected, 14.8% of non‐infected). The incidence of pelvic inflammatory disease was rare in both infected (2.0%) and non‐infected (0.4%) groups. Multivariate analyses suggested no association between HIV‐1 infection and increased risk of overall complications (hazard ratio=1.0; 95% CI 0.6‐1.6). Infection‐related complications (e.g. any pelvic tenderness, removal for infection or pain) were also similar between groups (10.7% of HIV‐1‐infected, 8.8% of non‐infected; P=0.50), although there was a non‐significant increase in infection‐related complications among HIV‐1‐infected women with use of the intrauterine contraceptive device longer than five months (hazard ratio=1.8; 95% CI 0.8‐4.4). Neither overall nor infection‐related complications differed by CD4 (immune) status.

Conclusions
HIV‐1‐infected women often have a critical need for safe and effective contraception. The intrauterine contraceptive device may be an appropriate contraceptive method for HIV‐1‐infected women with ongoing access to medical services.
Perinatal outcome in SGA births defined by customised versus population‐based birthweight standards
Authors: Clausson Britt , Gardosi Jason , Francis Andre , Cnattingius Sven
Published: December 2003

Objective
To determine whether customised birthweight standard improves the definition of small for gestational age and its association with adverse pregnancy outcomes such as stillbirth, neonatal death, or low Apgar score.

Design
Population based cohort study.

Population
Births in Sweden between 1992‐95 (n=326,377).

Methods
Risks of stillbirth, neonatal death, and Apgar score under four at five minutes were calculated for the lowest 10% birthweights according to population‐based and customised standards, and were compared with the data from the group with birthweights over this limit. Population attributable risks for stillbirth using various birthweight centile cutoffs were calculated for the two standards.

Outcome
measures Odds ratios and 95% confidence intervals for stillbirth, neonatal death and Apgar score under four at five minutes, and population attributable risks for stillbirth at different birthweight centiles.

Results
Risks of stillbirth, neonatal death, and Apgar score under four at five minutes and population attributable risks of stillbirth were consistently higher if ‘small for gestational age’ was classified by a customised rather than by the population‐based birthweight standard. Compared with infants who were not small for gestational age by both standards, the odds ratio for stillbirth was 6.1 (95% CI 5.0‐7.5) for small for gestational age by customised standard only, whereas it was 1.2 (95 % CI 0.8‐1.9) for small for gestational age by population standard only.

Conclusions
Compared with the population‐based birthweight standard, a customised birthweight standard increases identification of fetuses at risk of stillbirth, neonatal death and Apgar score under 4 at 5 minutes, probably due to improved identification of fetal growth restriction.
Radical trachelectomy in early stage carcinoma of the cervix: outcome as judged by recurrence and fertility rates
Authors: Shepherd John H. , Mould Tim , Oram David H.
Published: December 2003

The recurrence and fertility rates in 30 women undergoing radical trachelectomy for early stage invasive cervical cancer at St Bartholomew's and Royal Marsden Hospital were reviewed. There were no recurrences, and the mean follow up was 23 months (range 1–64 months). Of 13 women trying to have a baby, eight had conceived with a total of 14 pregnancies and nine live births. Two were still trying and three were experiencing sub‐fertility. There were seven premature deliveries and one late miscarriage. Six of the preterm births and the late miscarriage were associated with prelabour spontaneous rupture of membranes. This conservative yet locally radical procedure for a highly selected group of women who wished to preserve their fertility appears to offer a safe alternative to radical hysterectomy in early invasive cervical cancer.
Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? A retrospective analysis of routinely collected data
Authors: Bell Jacqueline S. , Campbell Doris M. , Graham Wendy J. , Penney Gillian C. , Ryan Mandy , Hall Marion H.
Published: December 2003

Objective
To determine whether the higher levels of obstetric intervention and maternity service use among older women can be explained by obstetric complications.

Design
A retrospective analysis of routinely collected data from the Aberdeen Maternity and Neonatal Databank.

Participants
All residents of Aberdeen city district delivering singleton infants at the Maternity Hospital 1988‐1997 (28,484 deliveries).

Main outcome measures
Odds ratios for each intervention in older maternal age groups compared with women aged 20‐29. Interventions considered include obstetric interventions (induction of labour, augmentation, epidural use, assisted delivery, caesarean section) and raised maternity service use (more than two prenatal scans, amniocentesis, antenatal admission to hospital, admission at delivery of more than five days, infant resuscitation, and admission to the neonatal unit).

Methods
Logistic regression was used to investigate the association between maternal age and the incidence of interventions. The odds ratios for each intervention were then adjusted for relevant obstetric complications and maternal socio‐demographic characteristics.

Results
Levels of amniocentesis, caesarean section, assisted delivery, induction, and augmentation (in primiparae) are all higher among older women. Maternity service use also increases significantly with age: older women are more likely to have an antenatal admission, more than two scans, a hospital stay at delivery of more than five days, and have their baby admitted to a neonatal unit. Controlling for relevant obstetric complications reveals several examples of effect modification, but does not eliminate the age effect for most interventions in most groups of women.

Conclusions
Higher levels of intervention among older women are not explained by the obstetric complications we considered.
Management of monoamniotic twin pregnancies: a case series and systematic review of the literature
Authors: Allen Victoria M. , Windrim Rory , Barrett Jon , Ohlsson Arne
Published: December 2003

Objectives
To review the experience of the University of Toronto Perinatal Complex, Ontario, Canada concerning antenatally diagnosed monoamniotic twin pregnancies; and to compare our results with cases reported in the literature with respect to antenatal surveillance and perinatal outcome.

Methods
A retrospective chart review of all twin gestations from 1993 to April 2000 was performed. A systematic review of the literature, 1966 to April 2000, of perinatal outcome in monoamniotic twin pregnancies was undertaken.

Setting
All monoamniotic twin gestations at the University of Toronto.

Results
Case‐series: 25 prenatally diagnosed monoamniotic twin pregnancies were identified. Seven pregnancies were affected by fetal anomalies. One fetus died at 29 weeks. Neonatal complications occurred below 33 weeks of gestational age and were related to immaturity. Systematic review of the literature: 49 studies met our selection criteria and reported 88 cases diagnosed antenatally. Fourteen pregnancies were affected by major congenital anomalies. Twenty fetuses died after 24 weeks of gestation. Neonatal complications varied widely in severity and depended on gestational age at birth. The risk of intrauterine fetal death was 10% at the University of Toronto and 12% in the review of the literature.

Discussion
Our experience, the largest so far, suggests that regular fetal surveillance and appropriate steroid administration leads to a good perinatal outcome. The risk of fetal death (10%–12%) is lower than the previously quoted risk of 30%–70%. A careful review of obstetric interventions and further work examining outpatient surveillance of monoamniotic twin pregnancies are needed. The best treatment of monoamniotic twin pregnancies can only be determined by randomised trials.
Quantitative and qualitative assessment of women's experience of a one‐stop menstrual clinic in comparison with traditional gynaecology clinics
Authors: Abu Jafaru I. , Habiba Marwan A. , Baker Richard , Halligan Aidan W. F. , Naftalin Nicholas J. , Hsu Ronald , Taub Nicholas
Published: December 2003

Objective
A quantitative and qualitative evaluation of the views of patients attending two types of clinics for menstrual disorders.

Methods
Semi‐structured qualitative interview and quantitative questionnaire.

Setting
Five traditional general gynaecology clinics and a one‐stop menstrual clinic, where investigations are performed and results given to patients on the same day.

Participants
Two hundred and thirty‐nine women (126 from the gynaecology clinic and 113 from the menstrual clinic) were recruited into the quantitative study; 18 and 26 patients from the gynaecology and the menstrual clinic, respectively, were interviewed for the qualitative study.

Main
outcome measures Women's views about their care and progress towards resolution of their problem.

Results
Following the initial consultation, 106 (84%) of the gynaecology clinic, and 98 (87%) of the menstrual clinic patients completed the first part of the questionnaire. Of those, 75 (71%) and 79 (81%) patients from the two types of clinic, respectively, completed a follow up questionnaire one year later. There were statistically significant differences in all the components of the first part of the questionnaire (information, continuity, waiting, organisation, and limbo) in favour of the one‐stop menstrual clinic. After one year, there was a statistically significant difference in one of the components, patient centeredness, but not in overall process co‐ordination. The interviews showed that patients attending the menstrual clinic appreciated getting the results of their investigations on the same day. They also found the organisation of the one‐stop menstrual clinic more closely suited to their needs and as a result were more likely to feel they were making progress.

Conclusion
Women were consistently more positive about their experience in the one‐stop clinic. One‐stop clinics organised to meet the needs of patients might be appropriate for other clinical conditions. The combination of quantitative and qualitative methods is an effective method of assessing patients’ views of health services.
Endothelial function in myometrial resistance arteries of normal pregnant women perfused with syncytiotrophoblast microvillous membranes
Authors: Van Wijk Marja J. , Boer Kees , Nisell Henry , Smarason Alexander K. , Van Bavel Ed , Kublickiene Karolina R.
Published: December 2003

Objective
To investigate the effects of syncytiotrophoblast microvillous membranes (STBM) in concentrations, found in vivo in women with pre‐eclampsia, on endothelial function in isolated resistance arteries.

Setting
Department of Obstetrics and Gynaecology, Huddinge University Hospital, Stockholm.

Sample
Twenty‐nine myometrial resistance arteries isolated from biopsies of healthy term pregnant women, obtained during caesarean section.

Methods
The myometrial arteries were mounted in a pressure arteriograph and perfused intraluminally for three hours with STBM (20 to 2000ng/mL) or with erythrocyte membranes or physiological salt solution as controls, all substituted with 0.5% bovine serum albumin. Bradykinin concentration‐response curves were performed before and after perfusion.

Main outcome measures
The bradykinin concentrationresponse curves were fitted to the Hill equation and maximal dilation and the pEC50 values were determined from these fits. Differences within groups were analysed with a paired Student's t test. Electron microscopic evaluation of the endothelium was performed.

Results
Neither STBM nor erythrocyte membrane perfusion affected maximal dilation or the pEC50 values of the bradykinin concentration‐response curves at any concentration. Examination by electron microscopy showed no obvious damage to the endothelium after perfusion with STBM or erythrocyte membranes.

Conclusion
Perfusion with STBM in concentrations up to 100 times those reported in pre‐eclampsia has no significant effect on bradykinin‐mediated dilation in isolated myometrial arteries.
Secondary postpartum haemorrhage: incidence, morbidity and current management
Authors: Hoveyda Fatemeh , MacKenzie I.Z.
Published: December 2003

Objective
To determine the incidence, risk factors, presentation, treatment and morbidity associated with secondary postpartum haemorrhage.

Design
Analysis of 132 consecutive women presenting with secondary postpartum haemorrhage occurring over a three‐year period.

Setting
The maternity unit in a district general teaching hospital serving an annual delivery rate of around 6500 women.

Main
outcome
measures Factors associated with the cause of the haemorrhage and the resulting morbidity.

Results
Most women presented during the second week after delivery. A history of primary postpartum haemorrhage (OR 9.3; 95% CI 6.2‐14.0) and manual removal of placenta (OR 3.5; 95% CI 1.6‐7.5) were the only significant risk factors identified. There was a high associated morbidity, with 84% requiring hospital admission, 63% surgical evacuation, 17% blood transfusion, with three women suffering a uterine perforation, one managed by hysterectomy. In women undergoing evacuation only, 37% had retained placental tissue confirmed after surgery; pre‐operative ultrasound examination did not provide a better discrimination over clinical assessment for this finding.

Conclusions
Secondary postpartum haemorrhage occurs in just under 1% of women, is associated with primary postpartum haemorrhage and retained placenta, and may result in significant maternal morbidity. This problem deserves more attention than it has received in recent years.
Titrated oral misoprostol solution for induction of labour: a multi‐centre, randomised trial
Authors: Hofmeyr G.J. , Alfirevic Z. , Matonhodze B. , Brocklehurst P. , Campbell E. , Nikodem V.C.
Published: December 2003

Objectives
To determine the effects of titrated oral misoprostol solution, compared with vaginal dinoprostone.

Study design
Open, randomised clinical trial.

Setting
Academic hospitals in South Africa and Liverpool, UK.

Methods
Women undergoing induction of labour after 34 weeks of pregnancy were allocated by randomised, sealed opaque envelopes, to induction of labour with titrated oral misoprostol solution, or two doses of vaginal dinoprostone (2mg) administered six hours apart. Failure to deliver within 24 hours of randomisation was the primary outcome on which the sample size was based. The data were analysed by intention‐to‐treat.

Results
Six hundred and ninety‐five women were randomly allocated: 346 to oral misoprostol and 349 to vaginal dinoprostone. There were no significant differences in substantive outcomes. Vaginal delivery within 24 hours was not achieved in 38% of women in the oral misoprostol group and 36% in the vaginal dinoprostone group (RR 1.08; 95% CI 0.89‐1.31). The caesarean section rates were 16% and 20%, respectively (RR 0.80; 95% CI 0.58‐1.11). Hyperstimulation with fetal heart rate changes occurred in 4% of women in the oral misoprostol group and 3% after vaginal dinoprostone (RR 1.32, 95% CI 0.59–2.98). The response to induction of labour in women with unfavourable cervices was somewhat slower with misoprostol when membranes were intact, and with dinoprostone when membranes were ruptured. There were no differences in neonatal outcome between the two groups.

Conclusions
This new approach to oral misoprostol administration was successful in minimising the risk of uterine hyperstimulation, which has been a feature of misoprostol use for induction of labour, at the expense of a somewhat slower response in women with intact membranes and unfavourable cervices. Misoprostol is not registered for use in pregnant women, and further research is needed to confirm optimal and safe dosages.
Monopolar thermocoagulation in acardiac twinning
Authors: Holmes Anna , Jauniaux Eric , Rodeck Charles
Published: December 2003

The paper describes the use of monopolar thermocoagulation in the treatment of acardiac twinning. The technique and outcomes of a series of 12 pregnancies which have presented for treatment at the Fetal Medicine Unit of University College London are presented.
The use of nuchal translucency measurement and second trimester biochemical markers in screening for Down's Syndrome
Authors: Michailidis G.D. , Spencer K. , Economides D.L.
Published: December 2003

Objective
To assess the effectiveness of antenatal screening for trisomy 21 by first trimester sonography followed by second trimester biochemical screening.

Design
Retrospective five‐year review.

Setting
Maternity unit of a university hospital.

Population
An unselected group of 7447 pregnant women who had a first trimester scan and nuchal translucency measurement in our unit after January 1995 and had an estimated date of delivery before 1 January 2000. 11.9% were ≥ 37 years old. A subgroup (n=4864) also had second trimester biochemical testing by alpha‐fetoprotein and free β‐human chorionic gonadotrophin.

Main
outcome measures Prenatal and postnatal diagnosis of trisomy 21.

Results
There were 23 fetuses affected with trisomy 21. The overall prenatal detection rate was 87% (20/23; 95% CI 66% to 97%) and we performed invasive procedures in 8.5% of our population. First trimester sonography identified 74% (95% CI 51.6% to 89.8%) of affected fetuses. Second trimester biochemical screening detected half of the fetuses with trisomy 21 which were missed by first trimester screening, increasing the sensitivity to 90.5% (19/21; 95% CI 69.6% to 98.8%) for an invasive procedure rate of 4.2% performed in screened positive women. However, the positive predictive value of the biochemical test was very low (0.5%). In screen negative women, karyotyping for advanced maternal age did not detect any affected fetuses.

Conclusion
First trimester nuchal translucency measurement is an effective screening test for the prenatal detection of fetuses with Down's Syndrome. Although the measurement of biochemical markers in the second trimester can detect additional affected fetuses this may be outweighed by the delay in diagnosis, the extra visits and cost so that the right time for biochemical screening is most likely to be in the first trimester.
Operative intervention in delivery is associated with compromised early mother‐infant interaction
Authors: Rowe‐Murray Heather J. , Fisher Jane R.W.
Published: December 2003

Objective
To investigate the effects of mode and place of delivery on first mother–infant contact and maternal emotional wellbeing.

Design
A prospective, longitudinal study.

Participants
A sociodemographically representative sample of 203 consecutive primiparous women was recruited, of whom 81% (n=164) were followed up.

Setting
Four metropolitan hospitals, including one accredited baby friendly hospital, in Melbourne, Australia, 1997.

Methods
During the postnatal hospital stay women were interviewed and medical records were inspected. Participants completed two self‐report psychometric measures: the Edinburgh Postnatal Depression Scale (EPDS) and the Profile of Moods States (POMS). Follow up at eight months postpartum comprised completion of a postal questionnaire and repeat administration of the standardised self‐report psychometric mood questionnaires.

Results
The First Contact Index provides a measure of the first contact between a mother and her baby after the birth. Two‐way analysis of variance revealed significant differences in First Contact Index between three modes of delivery groups: spontaneous, instrumentally‐assisted, and caesarean section (P<0.001) and four hospital of delivery groups (P<0.001), but there was no significant interaction effect (P=0.55). Significant negative correlations existed between the First Contact Index and both the POMS and EPDS scores at two days postpartum (POMS, r = ‐0.339, 95% CI ‐0.46 to ‐0.22; EPDS, r = ‐0.279, 95% CI ‐0.41 to ‐0.16), even within delivery groups, and these were still present at eight months postpartum (POMS, r = ‐0.298, 95% CI ‐0.44 to ‐0.14, EPDS, r = ‐0.206, 95% CI ‐0.36 to ‐0.03).

Conclusion
Instrumental and surgical delivery exert a negative impact on first postnatal contact between a mother and her baby which has persistent adverse maternal emotional correlates. Hospital practices associated with obstetric intervention in delivery also varied and are amenable to change, enabling optimal first mother–baby interaction regardless of mode of delivery.
Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal survey
Authors: Henriet Laurence , Kaminski Monique
Published: December 2003

Objective
To study the impact of previous induced abortions on preterm delivery, small for gestational age and low birthweight in subsequent pregnancies.

Design
Survey of a national sample of births in France in 1995.

Setting
All public and private maternity hospitals in France.

Population
12,432 women who had a singleton live birth during one week.

Methods
Data were collected during the women's postpartum stay in hospital, partly obtained by interview and partly abstracted from hospital medical records. Rates of preterm delivery, small for gestational age and low birthweight were compared according to existence and number of previous induced abortions. Maternal age, parity, history of previous adverse pregnancy outcome, maternal weight before pregnancy, marital status, educational level, maternal employment status during pregnancy, nationality, smoking during the third trimester of pregnancy and antenatal care were controlled for using multiple logistic regression and polytomous logistic regression.

Results
Twelve percent of women reported one previous induced abortion, and 3% two or more. Previous induced abortion was associated with an increased risk of preterm birth (OR 1.4; 95% CI 1.1–1.8); the risk of preterm delivery increased with the number of previous induced abortions (OR 1.3; 95% CI 1.0–1.7 for one previous abortion and OR 1.9; 95% CI 1.2–2.8 for two or more). The relationship was the same for very preterm and moderately preterm deliveries and for spontaneous and indicated preterm deliveries. After controlling for potential confounders, the association between previous induced abortions and small for gestational age and low birthweight infants was no longer significant.

Conclusion
This study suggests that a history of induced abortion increases the risk of preterm delivery, particularly for women who have had repeated abortions. The respective role of the surgical and medical techniques used for induced abortions needs to be explored.
Age related detection and false positive rates when screening for Down's Syndrome in the first trimester using fetal nuchal translucency and maternal serum free βhCG and PAPP‐A
Authors: Spencer Kevin
Published: December 2003

Objective
To determine how first trimester detection rates for Down's Syndrome vary with maternal age and to calculate the predictive value of an increased risk report at various maternal ages.

Design
Mathematical modelling of first trimester screening performance using fetal nuchal translucency and maternal serum free βhCG and pregnancy associated plasma protein‐A (PAPP‐A).

Methods
From within the Gaussian distributions of each marker in normal pregnancies and those affected by Down's Syndrome a series of 15,000 marker multiple of the medians were obtained for each group. These markers were then used to calculate the risks of Down's Syndrome using maternal ages ranging from 15 to 49 and the background risk of Down's Syndrome at each age. Using a 1 in 300 risk cutoff (at time of sampling) the false positive rate and detection rate was assessed at each year of maternal age. The predictive value of a positive result was calculated using Baye's theorem.

Outcome
measures False positive rates and detection rates at each year of maternal age between 15 and 49; the predictive value of a positive result for each maternal age between 15 and 49.

Results
At 15 years of age the detection rate was 77% at a 1.9% false positive rate, 84% at a 4% false positive rate at age 30, rising to 100% at a 67% false positive rate at age 49. The probability of Down's Syndrome once identified with an increased risk was 1:34 at 15 years, 1:29 at 30 years and 1:6 at 49 years.

Conclusions
As with second trimester biochemical screening, the detection rate and false positive rate vary considerably with age. However, detection rates across all ages are significantly higher than with second trimester screening. The risk of a positive screening result being a Down's pregnancy is considerably greater than with second trimester screening with an average probability of 1:29, compared with 1:55 in the second trimester. This information may be useful in counselling women with an increased risk result in first trimester screening.
Dyslipidemia in early second trimester is mainly a feature of women with early onset pre‐eclampsia
Authors: Clausen Torun , Djurovic Srdjan , Henriksen Tore
Published: December 2003

Objective
To investigate whether hypertriglyceridemic dyslipidemia is a risk factor for either early or late onset pre‐eclampsia.

Design
Prospective cohort study and nested case–control study.

Setting
Aker Hospital: a university hospital with all levels of obstetric care.

Participants
2157 Caucasian pregnant women.

Methods
Blood samples were obtained from non‐fasting subjects at 18 weeks of gestation. All samples were analysed for triglycerides, total‐cholesterol, high density lipoproteins cholesterol and non‐high density lipoproteins cholesterol. ApoB‐100 were analysed in pre‐eclamptic women and in 3:1 matched controls. The cohort data were analysed by multiple logistic regression and the case–control data by conditional logistic regression.

Main
outcome measures Adjusted odds ratios of early and late onset pre‐eclampsia according to early second trimester serum concentration levels of lipids and ApoB‐100.

Results
Eighteen women developed early onset pre‐eclampsia and 53 women developed late onset pre‐eclampsia. In the cohort model, women with triglycerides above 2.4mmol/L had increased risk (OR 5.1; 95% CI 1.1–23.1) of early onset pre‐eclampsia compared with those with triglycerides levels ≤ 1.5mmol/L. For women with high triglycerides: non‐high density lipoproteins cholesterol ratios (>90 centile) the OR (95% CI) for early onset pre‐eclampsia was 7.1 (2.3–22.0) compared with those with low ratios (≤ 50 centile). Similar associations were found in the case control model. We found no associations between plasma lipids and risk of late onset pre‐eclampsia.

Conclusions
Hypertriglyceridemic dyslipidemia before 20 weeks of gestation is associated with the risk of developing early but not late onset pre‐eclampsia, giving support to the contention that these two variants of the disease are at least partly pathogenically different.
Influence of training on reliability of surgical knots
Authors: Ind Thomas E. J. , Shelton Julia C. , Shepherd John H.
Published: December 2003

Objectives
To determine whether trainees in obstetrics and gynaecology tie adequate surgical knots and to assess whether formal training improves knot tying skills.

Design
A comparative study assessing surgical knots before and after tuition.

Population
Fourteen trainees in a single obstetrics and gynaecology department.

Setting
A basic surgical skills workshop based in a London teaching hospital.

Methods
Trainees tied surgical knots around a 120mm jig using 2/0 glycan polymer. Each trainee tied 11 knots before and after a two and a half hour teaching session. Knots were tested using a mechanical testing machine.

Outcome
measures Knot strength (N); proportion of knots that were ‘secure’ (defined as those that eventually failed on the testing device by breakage rather than slippage); proportion of knots that were ‘dangerous’ (defined as those with a tensile strength of < 5 N).

Results
After tuition, the median knot strength of the whole group was 5.7 N stronger than before instruction (95% CI 4.6–12.3 N). Prior to tuition 13.5% (20/148) knots tied had a tensile strength of < 5 N. This was compared with 3.4% (5/148) after tuition (OR = 0.2, 95% CI 0.1–0.6). Before instruction 55.4% (82/148) of the knots were secure compared with 66.9% (99/148) after tuition (OR = 1.6, 95% CI 1.0–2.7).

Conclusion
Knot tying workshops can improve the ability of trainees in obstetrics and gynaecology to tie reef knots.
Maternal carriership of factor V Leiden associated with pathological uterine artery Doppler measurements during pregnancy
Authors: Lindqvist Pelle G. , Gudmundsson Saemundur
Published: December 2003

To determine whether increased vascular resistance in the uterine artery is associated with carriership of factor V Leiden, a retrospective study was undertaken of 231 pregnant women who were monitored with Doppler velocimetry of the uterine arteries. These women had been part of a prospective study of 2480 pregnant women in whom factor V Leiden had been analysed. When compared with non‐carriers of factor V Leiden, carriers had a tendency towards an increased proportion of pathological Doppler measurements, including a significant increase in bilateral uterine artery notches (7/33 vs 16/198, relative risk 3.1; 95% CI 1.2–8.1). This suggests an increased vascular resistance in the uteroplacental circulation among carriers of factor V Leiden.
Insulin‐mediated vasorelaxation in pregnancy
Authors: Ang Christine , Hillier Chris , MacDonald Alisdair , Cameron Alan , Greer Ian , Lumsden Mary Ann
Published: December 2003

Objective
To investigate insulin‐mediated vasorelaxation in pregnancy, and the role of nitric oxide in this response.

Design
In vitro study of isolated subcutaneous resistance arteries from pregnant and non‐pregnant women.

Methods
Small arteries (mean vessel diameter <300μm) were isolated from biopsies of subcutaneous fat from 14 pregnant and seven non‐pregnant women. Insulin‐mediated attenuation of the vasoconstriction response to noradrenaline, before and after nitric oxide synthase inhibition, was studied in isolated arteries using wire myography. Vessel responses to noradrenaline following incubation with insulin were also tested after endothelial denudation. Maximum responses were compared using one‐way ANOVA and Bonferroni's post hoc test for multiple comparisons.

Results
In pregnancy, the maximum vasoconstriction produced by noradrenaline was increased (P<0.01). Insulin significantly reduced this response in pregnant women (P<0.01), while inhibition of nitric oxide synthase with Nω‐nitro‐L‐arginine methyl ester (L‐NAME) resulted in potentiation (P<0.05). Following inhibition of nitric oxide synthase with L‐NAME, addition of the insulin was still able to produce a significant attenuation in maximum vasoconstriction to noradrenaline in pregnant women (P<0.01). Furthermore, the absence of functioning endothelium did not abolish the attenuating effect of the insulin on noradrenaline‐induced vasoconstriction in pregnant women (P<0.01).

Conclusions
The vasodilatory effect of insulin is not diminished in pregnancy, despite the development of insulin resistance. Furthermore, the attenuation of vasoconstrictor tone is via an endothelium‐independent mechanism. This suggests that the vascular dysfunction associated with diabetes mellitus does not occur with physiological insulin resistance.
Maternal endothelial soluble cell adhesion molecules with isolated small for gestational age fetuses: comparison with pre‐eclampsia
Authors: Bretelle Florence , Sabatier Florence , Blann Andrew , D'Ercole Claude , Boutière Brigitte , Mutin Muriel , Boubli Léon , Sampol José , Dignat‐George Franc¸oise
Published: December 2003

Objective
1.To evaluate the activation profile of the endothelium in pregnancies complicated by small for gestational age fetuses compared with pre‐eclampsia and normal pregnancy, by measuring the plasma levels of soluble adhesion molecules soluble E‐selectin, intercellular cell adhesion molecule‐1 and vascular cell adhesion molecule‐1. 2. To determine whether soluble adhesion molecules were related to the severity of small for gestational age fetuses and pre‐eclampsia.

Design
Observational study.

Participants
Sixteen women with small for gestational age fetuses; 15 women with pre‐eclampsia and 15 healthy primigravidae were recruited as controls.

Methods
Plasma levels of soluble E‐selectin, intercellular cell adhesion molecule‐1 and vascular cell adhesion molecule‐1 were measured by ELISA.

Results
Compared with the healthy controls, soluble E‐selectin was significantly increased in both small for gestational age fetuses and pre‐eclampsia, whereas intercellular cell adhesion molecule‐1 and vascular cell adhesion molecule‐1 were increased only in pre‐eclampsia. In the small for gestational age fetuses group, soluble E‐selectin correlated inversely with the ratio between birthweight and the expected normal birthweight (r=‐0.4, P=0.007). In the pre‐eclampsia group, a significant correlation was observed between vascular cell adhesion molecule‐1 and blood pressure (r=0.54, P=0.039).

Conclusions
Endothelial activation, reflected by raised levels of soluble E‐selectin, is a feature of small for gestational age fetuses and is correlated with the severity of the disease. Differences in the profile of soluble cell adhesion molecules suggest variations in the degrees of endothelial activation between pre‐eclampsia and small for gestational age fetuses.
Five‐year follow up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes
Authors: Cooper Kevin G. , Jack Stuart A. , Parkin David E. , Grant Adrian M.
Published: December 2003

Objective
To assess clinical status, changes in health related quality of life, and subsequent management five years after medical management or transcervical resection of the endometrium for treatment of heavy menstrual loss.

Design
Five year follow up using postal questionnaires and operative databank review.

Setting
Gynaecology department of a large UK teaching hospital.

Population
Women referred to the gynaecologist for treatment of heavy menstrual loss.

Methods
Eligible women, without a treatment preference, were randomised equally to either medical treatment or transcervical resection of the endometrium.

Main Outcome Measures
Women's satisfaction with treatment, menstrual status, changes in health related quality of life, and additional treatments received at five years.

Results
One hundred and forty‐four patients completed questionnaires, achieving 77% follow up (medical n=71/94; transcervical resection of the endometrium n=73/93). At five‐year follow up, 7/71 (10%) of those randomised to the medical arm still used medical treatment, while 72/94 (77%) had undergone surgical treatment and 17/94 (18%) a hysterectomy. Twenty‐five (27%) women allocated to transcervical resection of the endometrium had undergone further surgery, 18/93 (19%) a hysterectomy. At five years women initially randomised to medical treatment were significantly less likely to be totally satisfied (P<0.01, difference 21%, 95% CI –37% to –4%), or to recommend their allocated treatment to a friend (P<0.001, difference 59%, 95% CI –73% to –45%). Bleeding and pain scores were similar in both groups and highly significantly reduced. Significantly more women in the transcervical resection of the endometrium arm had no bleeding or very light bleeding (P<0.02, difference ‐22%, CI –31% to –4%), and they had significantly less days heavy bleeding (P<0.02). Short Form 36 health survey scores were significantly improved from baseline for all eight health scales in the transcervical resection of the endometrium arm, and four in the medical arm.

Conclusions
A policy of immediate transcervical resection of the endometrium for women referred to a gynaecologist for treatment of heavy menstrual loss achieves higher levels of satisfaction, better menstrual status, and greater improvements in health related quality of life than medical treatment. In addition, transcervical resection of the endometrium is safe and does not lead to an increase in the number of hysterectomies. An effective endometrial ablative technique should be offered to all eligible women seeking treatment of their heavy menses from a gynaecologist.