bluuebunny/crossref_metadata_2025 huggingface dataset:
A comparison of isosorbide mononitrate, misoprostol and combination therapy for first trimester pre‐operative cervical ripening: a randomised controlled trial
Authors: Ledingham Marie‐Anne , Thomson Andrew J. , Lunan C. Burnett , Greer Ian A. , Norman Jane E.
Published: December 2003

Objective
To determine whether a combined therapy with isosorbide mononitrate (40mg) and misoprostol (400μg) for pre‐operative cervical ripening in the first trimester would result in improved clinical effectiveness, and fewer side effects compared with each agent used alone.

Design
Randomised controlled trial.

Setting
Glasgow Royal Infirmary.

Population
Sixty‐six primigravid women scheduled for suction termination of pregnancy.

Methods
Women were randomly assigned to receive before surgery, per vaginam, isosorbide mononitrate 40 mg (n=22), misoprostol 400 μg (n=22) or both agents together [isosorbide mononitrate 40 mg and misoprostol 400 μg] (n=22).

Main outcome measures
1. To assess the cumulative force required to dilate the cervix to 8 mm; 2. the onset of new symptoms before termination of pregnancy.

Results
The cervical resistance following combination therapy with isosorbide mononitrate and misoprostol was not significantly different than following misoprostol alone [24.5N vs 18.5N; median difference (95% CI) 19N (‐22 to 49)]. Pre‐treatment with misoprostol used alone resulted in a lower cervical resistance than isosorbide mononitrate alone (18.5Nvs 39N, P=0.04, Mann‐Whitney U test). There was no difference in the number of women remaining asymptomatic following either isosorbide mononitrate or misoprostol or combination therapy [14/22 (64%) vs 11/21 (52%) vs 11/22 (50%), Fisher's exact test].

Conclusions
We have not shown any advantage of combining misoprostol with the nitric oxide donor isosorbide mononitrate compared with misoprostol alone for pre‐operative cervical ripening in the first trimester.
A randomised controlled trial of antibiotic prophylaxis in elective caesarean delivery
Authors: Bagratee J.S. , Moodley J. , Kleinschmidt I. , Zawilski W.
Published: December 2003

Objective To determine whether prophylactic antibiotic administration using cefoxitin at the time of elective caesarean section significantly reduces infectious morbidity.

Setting A tertiary teaching hospital in a large urban city in South Africa.

Participants Women undergoing elective caesarean section.

Design A prospective, double‐blind randomised placebo‐controlled trial.

Methods Four hundred and eighty women undergoing elective caesarean section had cefoxitin or placebo administration after umbilical cord clamping. Postpartum complications including febrile morbidity, wound infection, endometritis, urinary tract infection, pneumonia and transient postpartum fever were recorded, as were the duration of hospital stay and the need for therapeutic antibiotics.

Results Wound infection was the most common complication occurring in 13.3% and 12.5% of women in the placebo and cefoxitin groups, respectively. Prophylactic antibiotics did not decrease febrile morbidity, wound infection, endometritis, urinary tract infection and pneumonia. Women who received cefoxitin stayed on average a day less in hospital than those who received placebo (6.9 vs 7.8 days, risk difference −0.94 CI 1.57 –−0.31 days). Eleven women (4.6%) in the placebo group and eight (3.4%) in the cefoxitin group had microbiological evidence of wound infection. Staphylococcus aureus was the most common pathogen (43%) isolated. Similar proportions in both groups (6.3% placebo and 5.1% cefoxitin) required a course of therapeutic antibiotics.

Conclusion Antibiotic prophylaxis with cefoxitin in elective caesarean section did not reduce post‐operative infectious morbidity in this double‐blind randomised placebo controlled trial.
Systematic review of economic aspects of alternative modes of delivery
Authors: Henderson Jane , McCandlish Rona , Kumiega Lesley , Petrou Stavros
Published: December 2003

Objective To carry out a systematic review of the literature relating to economic aspects of alternative modes of delivery.

Methods A comprehensive literature search of the years 1990–1999 was conducted of electronic and non‐electronic sources using a tested search strategy. Papers considered to contain useful cost or resource use data were read in full and classified according to their relevance to the review and their methodological quality. Relevant cost and resource use data were converted to £ sterling and inflated to 1998‐1999 price levels.

Results The literature search resulted in 975 papers, 49 of which met criteria for the review. Thirty‐two papers were from the USA where the organisation, structure and costs of health care are significantly different from that of other industrialised countries. The aggregate costs of different modes of delivery reported in these American studies were between four and five times higher than costs reported in other studies. The majority of included studies were of poor quality. Data from the better quality studies demonstrated that caesarean section costs a health service substantially more than other modes of delivery. The range of costs of an uncomplicated vaginal delivery were £629‐£1298 compared with £1238‐£3551 for a caesarean section. However, papers have so far only considered short term health service costs.

Conclusions Research is required to estimate the cost and resource use attributable to alternative modes of delivery. Future research should investigate the long term health service costs and the costs that arise outside the health service which are likely to vary according to mode of delivery.
Aneuploidy screening in direct chorionic villus samples by fluorescence in situ hybridisation: the use of commercial probes in a clinical setting
Authors: Quilter Claire R. , Holman Samantha , AL‐ Hammadi Raiham M. Y. A. , Theodorides Danae , Hastings Rosalind J. , Delhanty Joy D.A.
Published: December 2003

The results of screening for the common aneuploidies involving chromosomes 13, 18, 21, X and Y by florescent in‐situ hybridisation (FISH) in direct preparations from 100 chorionic villus samples from pregnancies between 10 and 20 weeks’ gestation are reported. Samples prepared using routine methods and analysed with commercially available probes, accurately detected 12 cases of fetal aneuploidy, all referred because of developmental abnormality. Three of the four cases where chromosome abnormality was detected in cultured villi but not by the direct fluorescence in situ hybridisation (FISH) assay, were due to confined placental mosaicism. No chromosomal anomalies were found in the 20 low risk cases where the referral reason was a familial single gene disorder. We conclude that the FISH assay with commercial probes may act as an accurate and less labour intensive alternative to direct chromosome analysis of chorionic villus samples. In cytogenetically low risk cases its use can obtain a result within the time needed for DNA analysis and avoid the need to set up cultures.
The development of high venous velocity at the fetal umbilical ring during gestational weeks 11–19
Authors: Skulstad Svein M. , Rasmussen Svein , Iversen Ole‐Erik , Kiserud Torvid
Published: December 2003

Objective
To determine the occurrence of high venous velocities at the umbilical ring in the normal early second trimester, based on the assumption that a narrow umbilical ring may cause obstruction and increased venous blood velocity at the abdominal wall.

Design
sectional study.

Setting
Hospital antenatal clinic.

Population
One hundred and one low risk singleton pregnancies specifically recruited for the study.

Methods
Ultrasound was used at 11–19 weeks to determine the diameter and velocity in the umbilical vein at the fetal end of the cord and at the inlet through the abdominal wall.

Outcome
measures 10th, 50th and 90th centiles were estimated for the time‐averaged maximum velocity in the cord and at the abdominal inlet. The increase of velocity as the blood entered the abdominal wall was calculated in percent of the velocity in the cord.

Results
During weeks 11‐12 there was hardly any difference between blood velocity in the umbilical vein at the umbilical ring and that in the cord. From week 13 onwards it was increasingly common to find blood acceleration at the umbilical ring of 50–500%. Velocity increment >50% was found in 0/12 fetuses (0%) at 11–12 weeks, 5/20 (25%) at 13–14 weeks, and in 21/28 (75%) at 17–19 weeks.

Conclusions
Blood velocity is higher in the umbilical vein at the abdominal wall than the cord, particularly after 13 weeks of gestation. If acceleration of blood velocity at the umbilical ring is a sign of a narrow inlet, it seems that a progressive tightening occurs during the second trimester.
Differences in hormone replacement therapy use by social class, region and psychological symptoms
Authors: Shah Sunil , Harris Tess J. , Cook Derek G.
Published: December 2003

Objective
To describe the relationship between socio‐demographic factors, heart disease risk factors, psychological symptoms and the use of hormone replacement therapy by English women.

Design
sectional analysis of a population‐based survey.

Setting
England.

Population
13,214 women aged 40–69 years who participated in the nurse‐administered schedule of the Health Survey for England between 1993 and 1996.

Outcome
Current hormone replacement therapy use.

Results
Women from social classes II and I and women who live in the south of England were more likely to use hormone replacement therapy independently of a range of socio‐demographic factors including education. The adjusted odds ratio for social classes II and I compared with social classes IV and V was 1.51 (95% CI 1.20 to 1.91) and for women in the South of England was 1.38 (95% CI 1.18 to 1.62). Women with a history of heart disease and those with high cholesterol levels were less likely to use hormone replacement therapy. Women with psychological symptoms were more likely to be prescribed hormone replacement therapy, as were those who had recently seen a doctor.

Conclusion
There is marked socio‐demographic inequity in use of hormone replacement therapy. This may accentuate existing inequalities in health and reduce any potential benefits of Hormone Replacement Therapy for public health. The relationship between psychological symptoms, use of medical services and use of hormone replacement therapy suggests that hormone replacement therapy is prescribed for the management of psychological symptoms.
Hepatitis C virus among high and low risk pregnant women in Dundee: unlinked anonymous testing
Authors: Goldberg D. , McIntyre P.G. , Smith R. , Appleyard K. , Dunlop J. , Taylor A. , Hutchinson S.
Published: December 2003

Objective
To determine the prevalence of the hepatitis C virus among pregnant women, to gauge the non‐injecting, particularly sexual, risk of them being hepatitis C virus infected and to assess the potential impact of selective antenatal screening.

Population
Antenatal clinic attenders and women undergoing termination of pregnancy in 1997.

Setting
Ninewells Hospital, Dundee.

Design
Unlinked anonymous hepatitis C virus antibody testing of residual sera from specimens sent to the virus laboratory for routine serological testing. The results were linked to non‐identifying risk information.

Results
Overall anti‐hepatitis C virus prevalence was 0.6% (23/3548). Prevalences among injecting drug users, non‐injectors who had a sexual partner who injected, and those with neither risk respectively were 41% (7/17), 15% (5/33) and 0.3% (11/3498). Relative risks for being an injector and a sexual partner of an injector respectively were 131 (95% CI 58‐297) and 48 (95% CI 5‐32). It is estimated that one of the 18 antenatal clinic attenders gave birth to an infected child.

Conclusion
Findings suggest that non‐injecting partners of injectors may be at considerable risk of acquiring hepatitis C virus sexually. Efforts to promote the use of condoms among injectors and their sexual partners should be increased. Selective anti‐hepatitis C virus screening of women who reported high risk behaviour would have failed to detect half the cases. Research to gauge the views of women of childbearing age on anti‐hepatitis C virus testing is required.
The tension‐free vaginal tape procedure is successful in the majority of women with indications for surgical treatment of urinary stress incontinence
Authors: Nilsson Carl Gustaf , Kuuva Nina
Published: December 2003

Objectives
To evaluate the effectiveness and safety of the ambulatory, minimally invasive tension‐free vaginal tape procedure in women scheduled for incontinence surgery.

Design
A prospective open study with a standardised protocol for pre‐ and post‐operative evaluation.

Participants
One hundred and sixty‐one consecutive women with urodynamically proven stress incontinence. The mean age was 56 years; 45 women (28%) had recurrent incontinence, 59 women (37%) had mixed incontinence and 18 women (11%) had a low pressure urethra.

Main outcome measures
Subjective and objective cure rates, complications and length of hospital stay.

Results
The average follow up time was 16 months. Ninety‐four percent of the treated women were completely cured or significantly improved. Eighty percent of the women were released from hospital on the afternoon of the day of surgery. There were no major complications and 80.2% of the women had no complication at all. Seven women (4.3%) had no more than four days of urinary retention problems, five women (3.1%) developed de novo urge symptoms, ten women (6.1%) had urinary tract infection, six cases (3.7%) of intraoperative bladder perforation occurred and less than 3% had bleeding or infection problems. There was no difference in the cure rate between women suffering from primary, recurrent or mixed incontinence.

Conclusions
The tension‐free vaginal tape operation is an effective and safe procedure for treatment of most cases of female urinary stress incontinence. The operation can be performed as an ambulatory procedure because of the low risk of post‐operative morbidity.
A comparison of the objective and subjective outcomes of colposuspension for stress incontinence in women
Authors: Bidmead John , Cardozo Linda , McLellan Anne , Khullar Vik , Kelleher Cornelius
Published: December 2003

Objectives
To investigate the impact of colposuspension for stress incontinence on the symptoms and quality of life of women undergoing both primary and repeat surgery for genuine stress incontinence and in addition to assess the use of a condition specific quality of life questionnaire as an outcome measure following surgery.

Design
Prospective case series: videocystourethrography performed before and between six and twelve months after surgery. Validated condition specific quality of life (QoL) questionnaires completed by women before and six to twelve months after surgery.

Setting
A tertiary referral Urogynaecology Unit in a teaching hospital.

Participants
A consecutive series of 83 women undergoing colposuspension between March 1995 and December 1997. Pre‐operative assessment and surgery was performed by, or was under the direct supervision of, the unit director.

Intervention
Modified Burch colposuspension.

Main outcome measures
Objective results of surgery assessed with videocystourethrography. Subjective results evaluated using a condition specific QoL tool, the Kings Health Questionnaire (KHQ). Symptom severity was evaluated as a component of the condition specific QoL questionnaire.

Results
Objective cure was demonstrated in 92% of women undergoing primary surgery with an 8% incidence of de‐novo detrusor instability and a 10% incidence of voiding difficulties. In the group of women having repeat surgery the objective cure rate was 81% with no de‐novo detrusor instability and a 6% incidence of post‐operative voiding difficulties. QoL scores improved in 95% of women. Improvements of over 25% were seen in 70% of women and of over 50% in 28%. However, 2.4% of women recorded a deterioration in QoL scores.

Conclusions
Colposuspension performed in this setting, assessed using both objective and standardised subjective measures, completed by women themselves, appears to produce good objective and subjective results and leads to enhanced quality of life in the great majority of women.
Assessment of cerebral hemodynamics during roll over test in healthy pregnant women and those with pre‐eclampsia
Authors: Zatik János , Major Tamás , Aranyosi János , Molnár Csilla , Limburg Martien , Fülesdi Béla
Published: December 2003

Objective
To compare cerebral autoregulatory responses obtained during roll over tests in healthy pregnant women and those with pre‐eclampsia in order to assess the middle cerebral artery velocity changes in relation to the roll over test in normotensive and pre‐eclamptic women.

Participants
Twenty‐two healthy pregnant women and 26 with pre‐eclampsia underwent transcranial Doppler measurements of the middle cerebral artery.

Methods
Systolic, mean and diastolic blood flow velocities and mean arterial blood pressures were recorded in the left lateral position and five minutes after turning to the supine position. Absolute values of mean blood flow velocities, mean arterial blood pressure values and calculated cerebral blood flow indices as well as cerebrovascular resistance area products were compared at different positions among the groups.

Results
Mean arterial blood pressure increased in both groups while turning from the left lateral to the supine position. In women with pre‐eclampsia both mean arterial blood pressure and absolute values of mean blood flow velocity values were higher in both positions, compared with healthy pregnant women. In both groups, changing the position resulted in a decrease of absolute values of mean blood flow velocities. Calculated cerebral blood flow indices did not change, while cerebrovascular resistance area products increased significantly in the groups during roll over testing. In women with pre‐eclampsia, the increase of cerebrovascular resistance area products was more pronounced as compared with healthy pregnant women.

Conclusions
In women with pre‐eclampsia roll over test results in an increase of the mean arterial blood pressure, which is accompanied by a decreased mean blood flow velocity in the middle cerebral artery. Further studies are needed to clarify the pathophysiological background of cerebral haemodynamic changes in pre‐eclampsia.
Cardiovascular function in pregnancy: effects of posture
Authors: Del Bene Riccarda , Barletta Giuseppe , Mello Giorgio , Lazzeri Chiara , Mecacci Federico , Parretti Elena , Martini Elisabetta , Vecchiarino Sabrina , Franchi Franco , La Villa Giorgio
Published: December 2003

Objective
To evaluate the cardiovascular response to active postural changes in pregnancy.

Design
Prospective study.

Setting
Outpatient Clinic, Fetal Maternity Unit.

Participants
Sixteen healthy women referred prior to pregnancy.

Methods
Heart rate, arterial pressure, echocardiographic end–diastolic and end–systolic left ventricular volumes (Teichholz's formula) were measured in the three months before pregnancy, at the end of the first and second trimester, at mid third trimester, and six months after delivery in the supine and standing position, in thirteen women (mean age 33, range 25–38 years).

Results
Cardiac output (supine position) significantly increased (28%): it reached its maximum at the second trimester, remained steadily elevated in the mid third trimester, and returned to baseline after delivery. Cardiac output increased during pregnancy also in the active orthostatic position, the percentage increase being greater (70%) since the standing pre–conception value was lower. The postural stress induced similar changes in heart rate, arterial pressure and left ventricular ejection fraction before, during and after pregnancy. However, the reduction in cardiac output associated with early standing attenuated significantly at the second trimester and it was absent at mid third trimester (F = 3.13, P= 0.021). This was due to the interplay between the significantly lesser increase in systemic vascular resistance, occurring since the first trimester, and the significantly lesser decrease in left ventricular end–diastolic volume which was observed in the mid third trimester.

Conclusion
These data indicate that the elevated cardiac output is adequately maintained in pregnancy during the postural challenge, due to optimisation of the responses of preload and afterload.
Use of a portable bladder scanner to reduce the incidence of bladder catheterisation prior to laparoscopy
Authors: Moselhi Marsham , Morgan Margery
Published: December 2003

The aim of this study was to evaluate the usefulness of estimating bladder volume with a dedicated portable ultrasound device immediately prior to gynaecological laparoscopy. Catheterisation was performed if the estimated volume was greater than 100 ml. Forty consecutive women were studied prospectively. Twenty‐six women did not require catheterisation. The procedure was quick and effective in safely reducing the frequency of pre‐operative catheterisation.
Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy
Authors: Johanson Richard , Kumar M. , Obhrai Manjit , Young Peter
Published: December 2003

Postpartum haemorrhage remains a significant complication of childbirth in the UK and worldwide. The most common cause of postpartum haemorrhage is uterine atony, but placent accreta is becoming more frequent. In these situations tamponade may be required. The successful use of the inflated stomach balloon (300ml) of a Sengstaken–Blakemore tube has been reported previously. We describe an innovative method of ‘tamponade’ which is simple and effective, using the Rüsch urological hydrostatic balloon catheter. In two cases of failed medical therapy for PPH, where the catheter has been tried, further surgical interventions have been avoided.
Vulvar vestibulitis: a multi‐factorial condition
Authors: Danielsson Ingela , Eisemann Martin , Sjöberg Inga , Wikman Marianne
Published: December 2003

Objective
To study differences in somatic symptoms and personality dimensions between women with vulvar vestibulitis and a non‐symptomatic control group.

Design
A case–control study conducted in 1998.

Setting
Two clinics in northern Sweden.

Sample
Thirty‐eight women, 18–25 years of age, suffering from vulvar vestibulitis, and 70 healthy controls.

Methods
The women completed two questionnaires: the temperament and character inventory to study personality aspects, and the Giessen subjective complaints list, which is a checklist of subjective bodily complaints.

Results
Regarding personality aspects the women with vulvar vestibulitis scored significantly higher than the control group, on exclusively one out of seven subscales of the temperament and character inventory (i.e. harm avoidance). This trait is considered to be partly inherited and stable throughout life, and to give the person a tendency to react to problems with pessimistic thoughts, increased anxiety and fatigue. On the Giessen subjective complaints list the women with vestibulitis reported a significantly higher number of somatic complaints in several areas.

Conclusions
The findings that women suffering from vulvar vestibulitis have more bodily complaints than the controls is interpreted as an indication of a psychosomatic element in their illness, which could be primary or secondary. Furthermore, these women are characterised by a particular personality trait, and it is suggested that this trait might influence their experience and management of pain and stress. A multi‐factorial origin of vulvar vestibulitis is advocated and a multimodal interdisciplinary treatment approach is suggested. To elucidate further the mechanisms behind this health problem, prospective controlled studies are urgently needed.
Ultrafast magnetic resonance imaging of central nervous system abnormalities in utero in the second and third trimester of pregnancy: comparison with ultrasound
Authors: Whitby Elspeth , Paley Martyn N. , Davies Norman , Sprigg Alan , Griffiths Paul D.
Published: December 2003

Objective
To assess the ability of ultrafast magnetic resonance imaging to visualise abnormalities in the central nervous system of third trimester fetuses in utero and to compare the results with the current ‘reference standard’ of ultrasound and postnatal imaging or post‐mortem data.

Design
A prospective, observational study comparing the diagnostic accuracy of two imaging methods: antenatal ultrasound and antenatal magnetic resonance with each other and postnatal or post mortem data.

Population
Twenty‐one pregnant women of 19–36 weeks of gestation whose fetus were thought to have a central nervous system abnormality on the basis of antenatal ultrasound. The women had either not been offered or had refused a termination and were willing to have a magnetic resonance scan.

Methods
A 1.5T magnetic resonance scanner used a single shot fast spin echo sequence, in three image planes. The results were compared with the ultrasound results obtained by an experienced investigator independently. A series of 21 patients, with a range of pathologies of central nervous system, were imaged. Postnatal ultrasound and/or magnetic resonance imaging, or post‐mortem data were used for additional confirmation of the pathology in all cases.

Results
The magnetic resonance report was different to the ultrasound in 10/21 (47.6%), magnetic resonance provided information additional to the ultrasound in 5/21 (23.8%), ultrasound and magnetic resonance results agreed in 6/21 cases (28.6%).

Conclusion
Magnetic resonance in the third trimester provides a useful adjuvant to ultrasound imaging of the fetus when assessing abnormalities of the central nervous system after 19 weeks of gestation particularly if the abnormality involves the posterior fossa.
Declining trend in major gynaecological surgery in The Netherlands during 1991–1998. Is there an impact on surgical skills and innovative ability?
Authors: Brölmann Hans A.M. , Vervest Harry A.M. , Heineman Maas J.
Published: December 2003

Objectives
To assess the number of major surgical procedures in gynaecology over a period of eight years in The Netherlands and to detect possible trends. Relevance of the trends and the possible impact on surgical skills and on innovative ability are discussed.

Design
Observational study.

Setting
Hospital care in The Netherlands.

Sample
Data from a national hospital discharge database, from all 119 hospitals in The Netherlands.

Methods
When a patient is discharged from the hospital, data on the diagnosis and treatment are registered by local medical officers and administrators. Registration of surgical procedures is based on the International Classification of Procedures in Medicine (ICPM, WHO 1978), the so‐called WCC‐standard. All hospitals but one (a cancer centre) in The Netherlands participate in this registration, resulting in 99.3 % of all admissions. Data on gynaecological manpower were obtained from the Dutch College of Obstetricians and Gynaecologists. In order to standardise the frequency numbers per 1000 women, yearly data of the female population according to age were obtained from the Central Office for Population Statistics.

Results
The female population aged 20 years of age and older increased 3% between 1991 and 1998, from 5.8 million to 6.0 million. In the same period the number of gynaecologists grew from 604 to 625, also an increase of 3%. The total number of hysterectomies dropped from 21,433 in 1991 to 16,320 (‐24 %) in 1998 (χ2 for trend 1245.1, P< 0.001) Surgery of the uterine cavity, either performed hysteroscopically or blind, increased from 311 to 1,958 (+ 625 %) cases per year (χ2 for trend 2459.2, P<0.001). No trend has been detected in the numbers of adnexal operations, including surgical treatment of tubal pregnancy (tubotomy or tubectomy). In 1998, 12% of all ovarian surgery and 28% of all surgery for ectopic pregnancies was performed laparoscopically. Surgery for female urinary incontinence experienced a strong decline of 46% in the studied period. The frequency of vaginal repair decreased with 1354 (‐16 %) cases. The abdominal prolapse surgery (abdominal sacral colpopexy, obliteration of the Douglas pouch) is steadily increasing, although the absolute numbers are small. In 1998 seven hundred and forty‐three women underwent an abdominal approach of their prolapse repair, compared with 7239 that had the vaginal repair.

Conclusions
The declining trend of major gynaecological surgery in combination with the increasing number of gynaecologists will result in more difficulty for gynaecologists to acquire and maintain surgical skills and may therefore affect their ability to innovate within the surgical profession.
Anatomical and functional changes in the lower urinary tract during pregnancy
Authors: Wijma Jacobus , Potters Annemarie E. Weis , de Wolf Ben T.H.M. , Tinga Dick J. , Aarnoudse Jan G.
Published: December 2003

Objective
To assess the prevalence and the development of urinary incontinence in nulliparous pregnant women, both subjectively and objectively, and to investigate the relation of incontinence with the mobility of the urethro‐vesical junction measured by perineal ultrasound.

Design
A prospective longitudinal study.

Setting
University Hospital and Martini Hospital Groningen, the Netherlands.

Population
A cohort of 117 nulliparous pregnant women and 27 nulliparous non‐pregnant controls.

Methods
Urinary incontinence was measured by a questionnaire and by a 24‐hour pad test. The position of the urethro‐vesical junction and its mobility were measured by perineal ultrasound.

Main outcome measure
Prevalence of urinary incontinence; mobility of the urethro‐vesical junction, indicated by the displacement/pressure coefficient.

Results
Up to 35% of the women reported urinary incontinence in pregnancy, and 20% of the women had a positive pad test. The angle of the urethro‐vesical junction angle at rest and the displacement/pressure coefficient during coughing showed a significant increasing trend during pregnancy, but no changes were seen during the Valsalva manoeuvre. No relationship was found between subjective and objective incontinence data and the position and mobility of the urethro‐vesical junction.

Conclusion
The prevalence of incontinence in nulliparous women as found by the pad test was significantly higher in pregnancy (20%) than in the non‐pregnant control group (4%). Perineal ultrasound of the urethro‐vesical junction showed lowering of the pelvic floor occurring as early as 12‐16 weeks of pregnancy. Serial measurements of the displacement/pressure coefficient suggest that the dynamic characteristics of the connective tissues of the pelvic floor remain unaltered, whereas a significant decrease in pelvic floor muscle contraction occurs. Since no relation was found between measurements of the urethro‐vesical junction and incontinence, urinary incontinence in pregnancy is most likely explained by other factors.
Leucocyte intracellular pH and Na+/H+ exchanger isoform‐1 activity in postpartum women with pre‐eclampsia
Authors: Lee Virginia M. , Halligan Aidan W.F. , Ng Leong L.
Published: December 2003

Objective
To investigate leucocyte Na+/H+ exchanger isoform 1 activity in postpartum pre‐eclamptics.

Design
Exchanger isoform‐1 activity and intracellular resting pH were established in leucocytes isolated from two study groups.

Sample
Leucocytes isolated from 10 women who had had pre‐eclamptic pregnancies more than five months postpartum, and from 10 age‐matched normotensive women who were more than five months postpartum.

Setting
Hypertension Clinic, Antenatal Assessment Area, Leicester Royal Infirmary.

Methods
A well validated technique involving flurometry using a pH sensitive dye (BCECF‐AM) was performed to determine exchanger isoform‐1 activity and intracellular pH. Determination of exchanger isoform‐1 protein abundance was performed by western blotting. Exchanger isoform‐3 protein abundance was examined to rule out the possibility of activity due to this particular isoform.

Results
Intracellular pH was significantly lower in the postpartum pre‐eclamptic group (7.11 +/‐ 0.02), compared with the postpartum normotensive controls (7.33 +/‐ 0.04; P<0.001). Exchanger isoform‐1 efflux rate (in mmol/L/minute) was significantly higher in the postpartum pre‐eclamptic group (35.91 +/‐ 3.1), compared with the postpartum normotensives (23.94 +/‐ 2.0; P= 0.005). Exchanger isoform‐1 protein density was established to be similar among the two subject groups. No exchanger isoform‐3 protein was identified by western blotting.

Conclusion
Our results suggest that elevated exchanger isoform‐1 activity is an important finding in women who have suffered from pre‐eclampsia. This increased activity is not due to an increase in exchanger isoform‐1 protein abundance or the presence of exchanger isoform‐3.
Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse
Authors: Leron Elad , Stanton Stuart L.
Published: December 2003

Objective
To study the ongoing results of sacrohysteropexy with Teflon mesh for treatment of uterovaginal prolapse in women who desire to preserve their uterus.

Design
Prospective observational study.

Setting
Tertiary referral urogynaecology unit.

Participants
Thirteen consecutive women with uterovaginal prolapse wishing to retain their uterus operated on by one surgeon.

Surgical
method Sacrohysteropexy with Teflon mesh attached to the uterine isthmus and to the anterior longitudinal ligament of the first or second sacral vertebra in a tension‐free fashion.

Main
outcome measures Subjective and objective cure of uterine prolapse and operative and post‐operative complications.

Results
The mean age of the women was 38 years (range 27–60). Eight women were multiparous. Twelve women had second degree uterine prolapse and one woman had third degree of uterine prolapse. Mesh was extended to correct a cystocele in one woman and a rectocele in three women. In four women colposuspension was performed at the same time. There were no intra‐ and post‐operative complications. The mean follow up time was 16 months (range 4–49). At follow up only one woman had a first degree uterine prolapse. A total of seven women (53.8%) reported constipation which had been experienced pre‐operatively by four women (30.8%).

Conclusions
We consider the sacrohysteropexy with Teflon mesh a safe, effective and durable surgical procedure for the management of uterovaginal prolapse in young women and those who desire to retain their uterus.
Are there common triggers of preterm deliveries?
Authors: Petridou E. , Salvanos H. , Skalkidou A. , Dessypris N. , Moustaki M. , Trichopoulos D.
Published: December 2003

Objective
To assess the effect(s) of transient events which are perceived as stressful on the inseption of preterm delivery.

Design
A case–control study, with immature infants as cases and borderline term babies as controls.

Setting
A teaching maternity hospital in Athens.

Population
All infants born at less than 37 weeks of gestation, during a twelve‐month period.

Methods
Information was collected about maternal socio‐demographic and lifestyle characteristics, clinical variables and stressful events occurring within two weeks prior to delivery.

Main
outcome measures Factors affecting the risk of preterm delivery.

Results
Extreme prematurity (<33 weeks) is more common among younger (<25 years of age) and older (>29 years of age) women and is positively associated with parity, body mass index and smoking, whereas it is inversely associated with educational level, regular physical exercise and serious nausea/vomiting. After controlling for these factors, however, only coitus during the last weeks of pregnancy had a significant triggering effect on prematurity (P= 0.004, odds ratio 3.21, 95% CI 1.45 to 7.09 for very immature babies, and P= 0.04, OR=2.20, 95% CI 1.03 to 4.70 for immature babies). On the contrary, several events perceived as stressful, such as illness of relatives or friends, husband's departure, loss of employment, were unrelated to the onset of premature labour.

Conclusions
Coitus during the last few weeks of pregnancy appears to increase the risk of preterm delivery, while a possible detrimental effect of physical exertion seems more limited. Stressful events should not receive undue attention as possible causes of preterm delivery.
Factors associated with nucleic acids related to human immunodeficiency virus type 1 in cervico‐vaginal secretions
Authors: Spinillo Arsenio , Debiaggi Maurizia , Zara Francesca , Maserati Renato , Polatti Franco , De Santolo Antonella
Published: December 2003

Objective
To assess HIV‐related nucleic acids in cervico‐vaginal secretions and the factors associated with them.

Design
Observational study.

Setting
Department of Obstetrics and Gynaecology, University of Pavia, Italy.

Population
HIV‐positive patients attending a cytology service.

Methods
Paired blood and cervico‐vaginal lavage samples were obtained from 122 known HIV‐seropositive patients during periodic visits for cytologic screening for lower genital tract neoplasia. Vaginal specimens for the diagnosis of bacterial vaginosis, trichomonas vaginalis and candida infection were also obtained. HIV‐1‐RNA in plasma, proviral HIV‐1‐DNA, cell associated and cell‐free HIV‐1 RNA in cervico‐vaginal secretions were quantitatively evaluated by competitive polymerase chain reaction (c‐PCR) and reverse transcriptase PCR (cRT‐PCR).

Main
outcome measure Prevalences of HIV related nucleic acids in cervico‐vaginal secretions and their univariate and multivariate associations with clinical variables.

Results
Proviral HIV‐1 DNA, cell‐associated and cell‐free HIV‐1 RNA were detected in 50% (61/122), 37.7% (46/122) and 32.8% (40/122) of the patients, respectively. In logistic regression analysis, the presence of HIV‐1 RNA in blood was the factor which correlated best with the detection of HIV‐1 DNA (OR = 5.48, 95% CI=2.28‐13.20), cell‐associated (OR = 4.85; 95% CI = 1.89–12.45) and cell‐free HIV‐1 RNA (OR = 4.63, 95% CI = 1.74–12.33) in cervico‐vaginal samples. However, between 20% and to 35% of patients who tested negative for blood HIV‐1 RNA were positive for either HIV‐1 DNA or HIV‐1 RNA detection in cervico‐vaginal lavages. Bacterial vaginosis was associated with an increased prevalence of cell‐associated (OR=3.58, 95% CI = 1.22–10.54) and cell‐free HIV‐1 RNA (OR = 2.94, 95% CI = 1.0–8.7) detection in cervico‐vaginal secretions. Additional factors associated with increased prevalence of HIV‐1 RNA detection were advanced stage of HIV disease and vulvovaginal candidiasis.

Conclusions
Although the presence of HIV‐1 RNA in blood is the factor which correlates best with the detection of HIV‐related nucleic acids in cervico‐vaginal secretions, the shedding of HIV in the genital tract can occur in 20‐30% of non‐viremic subjects. Bacterial vaginosis and candida infection could have a facilitating role in local HIV viral replication and shedding.
Microvascular vasodilator response to acetylcholine is increased in women with pre‐eclampsia
Authors: Davis Karl R. , Ponnampalam Janani , Hayman Richard , Baker Philip N. , Arulkumaran Sabaratnam , Donnelly Richard
Published: December 2003

Objectives
To evaluate in vivo microvascular responses to incremental doses of the endothelial‐dependent vasodilator, acetylcholine, and the endothelial‐independent vasodilator, sodium nitroprusside, in women with pre‐eclampsia and gestation‐matched normotensive pregnant controls.

Design
Prospective clinical study.

Setting
Southern Derbyshire Acute Hospitals Trust, and University of Nottingham Division of Vascular Medicine.

Population
Thirteen women with pre‐eclampsia and 16 normotensive pregnant controls.

Methods
Cutaneous microvascular vasodilator responses to iontophoretic administration of incremental doses of acetylcholine and sodium nitroprusside (25‐100μC) were evaluated under temperature‐controlled conditions using laser Doppler fluximetry.

Results
Resting skin temperature and blood flow were similar among 13 women with pre‐eclampsia [mean blood pressure 151/93 mmHg (4/3); mean gestation 35.6 weeks (1.0); and mean proteinuria 1.1 g/24h (0.2)] and 16 normotensive pregnant controls [mean blood pressure 111/63 mmHg (2/2); mean gestation 34.3 weeks (0.9)]. Peak vasodilator responses to acetylcholine were increased in women with pre‐eclampsia (median flux ratio 15.1 [IQR 12.3‐17.6] vs 11.7 [IQR 8.4‐12.6], P<0.05), whereas sodium nitroprusside responses were not different between the two groups: 11.4 [IQR 8.6‐13.4] vs 9.5 [IQR 8.0‐12.3].

Conclusion
In vivo microvascular vasodilator responses to acetylcholine are increased in women with pre‐eclampsia, while endothelial‐independent vasodilation is unchanged. Although the mechanism of acetylcholine induced vasodilation in small vessels is unclear, this study confirms previous animal data and provides in vivo evidence of altered microvascular endothelial cell function in pre‐eclampsia.
Screening for HIV, hepatitis B and C infection in a population seeking assisted reproduction in an inner London hospital
Authors: Hart R. , Khalaf Y. , Lawson R. , Bickerstaff H. , Taylor A. , Braude P.
Published: December 2003

The Human Fertilisation and Embryology Authority requires all sperm donors to be screened for human immunodeficiency virus (HIV), hepatitis B and C and their semen quarantined for six months. No guidelines exist for screening prior to in vitro fertilisation or intracytoplasmic sperm injection. We prospectively analysed the prevalence of these viruses in our patients. Screening detected one case of HIV (0.13%), four of hepatitis C (0.5%) and 14 new cases of hepatitis B (1.7%). The prevalence of hepatitis B and HIV in our antenatal population at this time was 1.4% and 0.8%, respectively. Knowledge allows measures to be taken to reduce the risk of transmission to partner, fetus, new born baby, or by cross‐contamination during embryo cryostorage and enables couples to make an informed decision regarding proceeding with treatment. Detection of infection in one partner should no longer preclude fertility treatment.
Spontaneous opening of the Filshie clip as a cause of sterilisation failure
Authors: Lammes Frits B.
Published: December 2003

An open Filshie clip is sometimes detected during the evaluation of a case of sterilisation failure. This spontaneous opening of the clip does not need to have been caused by material failure, but may be produced by jamming of the clip what can occur by incorrect squeezing during closure. On superficial observation, the clip will appear to be closed, but it may easily open itself by its spring mechanism when the clip is moved or merely touched. Especially in the teaching situation one should be careful for this lapse.
Accuracy of frozen section for the operative management of endometrial cancer
Authors: Quinlivan Julie A. , Petersen Rodney W. , Nicklin James L.
Published: December 2003

Objective
To assess the accuracy of intra‐operative frozen section reports at identifying the features of high risk uterine disease compared with final histopathology.

Design
Retrospective study.

Methods
The records of 460 patients with uterine cancer registered with the Queensland Centre for Gynaecological Cancer between January 1, 1996 and December 31, 1998 were reviewed. Intra‐operative frozen section was undertaken in 260 patients with endometrial adenocarcinoma. Frozen section pathology was compared with the final histopathology reports. Inter‐observer reliability was assessed using percentage agreement and kappa statistics. Clinical notes were also reviewed to determine if errors resulted in sub‐optimal patient care.

Results
Respectively, tumour grade and depth of myometrial invasion were accurately reported in 88.6% of cases (expected 61.5%, Kappa 0.70) and 94.7% (expected 53.8%, Kappa 0.89). Errors were predominantly attributable to difficulties with respect to the interpretation of tumour grade. The error resulted in the patient receiving sub‐optimal surgical management in only 11 cases (5.3%)

Conclusion
Frozen section is accurate at identifying the features of high risk uterine disease in the setting of endometrial cancer and can play an important role in directing primary operative management.
Influence of peritoneal factors on port‐site metastases in a xenograft ovarian cancer model
Authors: Agostini Aubert , Robin François , Aggerbeck Martine , Jaïs Jean‐Philippe , Blanc Bernard , Lécuru Fabrice
Published: December 2003

Objective
We determine the main physical effects of pneumoperitoneum on tumour dissemination and port‐site metastases occurrence.

Design
A prospective randomised study in rats.

Methods
A human ovarian cancer cell line (IGR‐OV1) was xenografted in nude rats. Seven days after cancer inoculation, surgery was performed. Rats were randomised in two main groups and underwent either: gasless laparoscopy (n= 20) CO2 laparoscopy with pneumoperitoneum pressure at 4 mmHg (n= 20), or 8 mmHg (n= 20) with in each case, increasing operative duration: 30,60,90 or 120 minutes (five rats for each time). Animals were killed seven days after the intervention.

Main outcome measures
Tumour dissemination and frequency of port‐site metastases.

Results
Tumour dissemination was not influenced by gas pressures or duration of procedure. The rate of rats with at least one port‐site metastasis (one or two) was similar in all groups: gasless: n= 10/20; 4 mmHg CO2: 5/20; 8 mmHg CO2: 7/20,(P= 0.26). The number of port‐site metastases were significantly higher in the gasless group compared with the 4 mmHg CO2 group (15/40 (37.5%) vs 5/40 (12.5%), P= 0.01). Difference was not significant between the 8mmHg group and the gasless group (9/40(22.5%) vs 15/40(37.5%), P= 0.14) or the 4mmHg group (9/40(37.5%) vs 5/40 (12.5%), P= 0.24). Duration of procedures had no significant influence on port‐site metastases rate (P>0.05).

Conclusions
Unlike previous animal studies, port‐site metastases were more frequent with gasless laparoscopy than with CO2 pneumoperitoneum. Local peritoneal factors could play an important role in port‐site metastases mechanism.
A randomised double‐blind placebo controlled trial of low molecular weight heparin as prophylaxis in preventing venous thrombolic events after caesarean section: a pilot study
Authors: Burrows Robert F. , Gan Eng T. , Gallus Alexander S. , Wallace Euan M. , Burrows Elizabeth A.
Published: December 2003

Objective
To pilot a protocol for a national multicentre randomised trial in which a low molecular weight heparin will be compared with placebo for prevention of venous thrombotic events occurring within six weeks after caesarean section.

Design
Double‐blind randomised controlled trial.

Setting
Tertiary care centre.

Participants
Seventy‐six women having had a caesarean section, 37 in the control group and 39 in the Dalteparin group.

Methods
Consenting patients having had an emergency or elective caesarean section were commenced on study medication 6–24 hours post‐operatively. The study medication, dalteparin 2500iu or saline, was given subcutaneously once daily for four or five days post‐operatively depending on the patient's length of stay. Patients were reviewed in hospital for operative outcomes and contacted at two and six weeks post‐operatively.

Results
Of the 141 women given information about the trial, 76 (54%) consented to participate. Follow up to six weeks was achieved in all women who were recruited. More women in the placebo arm had general anaesthesia, but otherwise the two groups had similar characteristics at randomisation. There was only one occurrence of a deep vein thrombosis during the study. This patient was in the treatment arm and the thrombosis occurred between two and six weeks post‐operatively. All other outcomes were similar in the two groups.

Conclusion
Our experience of a 26% recruitment rate, the thrombosis rate of 1.3% (95% CI 0.03‐7.1%) and the contactability of all participants two and six weeks post‐operatively, indicates that this study is feasible.