bluuebunny/crossref_metadata_2025 huggingface dataset:
Multiple Polypoid Endometriosis‐A Rare Complication Following Withdrawal of Gonadotrophin Releasing Hormone (GnRH) Agonist for Severe Endometriosis: A Case Report
Authors: Othman Nor H. , Othman M.S. , Ismail A.N. , Mohammad N.Z.N. , Ismail Z.
Published: February 2008

EDITORIAL COMMENT: We accepted this case report for publication because the condition of multiple pelvic polypoid lesions seems previously unreported, is an interesting clinical puzzle, and may be a rare complication of hormone therapy. Sections of these polyps have been reviewed by very senior pathologists one of whom confirmed that ‘they consist of an endometrial glandular component, a mesenchymal component and large numbers of blood vessels. One possibility is that simply these are very much altered foci of endometriosis‐though I find it difficult to believe that these lesions are due to hormonal therapy for if they were I am sure such lesions would have been recorded before now’. Can any reader provide further relevant information?

Summary: A 30‐year‐old female who initially had typical endometriosis treated according to a standard regimen later developed numerous highly vascular endometrial polyps on the vagina, cervix, ureter, serosal surfaces of the uterus, pouch of Douglas (POD) and other areas of pelvic peritoneum as well as the endometrium 8 months after withdrawal of treatment with Zoladex gonadotrophin releasing hormone (GnRH) agonist used for treatment of this disease. We postulate that these polyps developed as a rebound phenomenon upon withdrawal of Zoladex. We believe this is the first report of this complication following use of GnRH analogue.
Malignant Degeneration of Mature Cystic Teratomas*
Authors: Zorlu C. Gürkan , Kuscu Esra , Soysal Mehmet Emin , Caglar Turhan , Aydogdu Tugrul , Cobanoglu Omer , Alaybeyoglu Tuncay , Gökmen Oya
Published: February 2008

EDITORIAL COMMENT: We accepted this paper to remind readers that about 2% of cystic teratomas have undergone malignant transformation at the time of presentation. Frozen section study of the tumour may allow appropriate staging laparotomy and excisional surgery in these women. In the editor's experience frozen section of macroscopically benign ovarian tumours is being used increasingly. The false negative results of frozen section in 2 of 4 cases reported in this study is noteworthy but recent large series have shown that with the exception of tumours of borderline malignancy, the sensitivity and specificity of frozen‐section diagnosis of ovarian tumours are high (A).

A. Rose PG, Rubin RB, Nelson BE, Hunter RE, Reale FR. Accuracy of frozen‐section (intraoperative consultation) diagnosis of ovarian tumors. Am J Obstet Gynecol 1994; 171: 823–826.

Summary: Malignant transformation of benign cystic teratoma is rare and the most common malignancy is squamous cell carcinoma. The diagnosis is rarely made preoperatively and the prognosis is usually poor. We report 4 cases with dermoid cysts showing malignant transformation, 3 with squamous carcinoma and 1 with adenocarcinoma. The patients were within the reproductive age and underwent surgical intervention with intraoperative evaluation. Frozen section identified 2 cases with malignant transformation and staging laparotomy was performed at the initial laparotomy. One of the remaining underwent reoperation following a pregnancy termination and the other refused further surgery. None had metastases and/or capsule invasion. One had tumour rupture during excision and received combined chemotherapy following surgery. Three of the patients remain well and 1 is lost to follow‐up.
Association of Contraceptives and HTV‐1 Infection in Thai Female Commercial Sex Workers
Authors: Taneepanichskul Surasak , Phuapradit Winit , Chaturachinda Kamhaeng
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because it shows that condom usage is significantly associated with a lower incidence of HIV‐1 infection in commercial sex workers. This important message can more readily be obtained from a community with a high prevalence of HTV‐1 infection. This paper also provides a sad glimpse into the lives of these sex workers whose condom usage is at best described as modest.

Summary: We conducted a case‐control study to evaluate the association between contraceptive methods and HIV infection among Thai female commercial sex workers in Khon Kaen and Lumpang provinces, Thailand; 118 cases of HIV‐1 infected sex workers were eligible for inclusion and 258 HIV‐1 negative women were recruited as controls during the period of October 1, 1993 to December 31, 1994. Cases and controls were matched by age, education, parity, age at first exposure to commercial sex, number of clients per night, duration of work and sexual practice during menstruation. The ratio of case per control was 1:2. Both cases and controls were interviewed and underwent blood testing by a team of investigators. The study revealed no significant association between oral pill, injection, other contraceptives and HIV‐1 infection. However, condom usage showed a significant protective effect. It is suggested that these contraceptives in this high‐risk group of women do not increase the risk of HIV infection. In contrast, the use of condoms could reduce the risk of HIV infection.
Ovarian Response to Purified FSH in Infertile Women with Long‐standing Hypogonadotrophic Hypogonadism
Authors: Fox Robert , Ekeroma Alec , Wardle Peter
Published: February 2008

EDITORIAL COMMENT: We accepted this paper to illustrate an important point, namely that purified FSH preparations may not be appropriate for ovulation induction in ‐women lacking adequate levels of endogenous luteinizing hormone. Furthermore, if these preparations are used then reliance on oestradiol determinations alone may lead to inappropriate conclusions about the number of preovulatory follicles. However, there is probably a place for preparations of purified FSH in women with high circulating levels of endogenous luteinizing hormone.

Summary: It has previously been proposed that all anovulatory women requiring exogenous gonadotrophin therapy could be treated by purified FSH alone in the follicular phase. We have studied the ovarian response to purified FSH in 5 amenorrhoeic women with low endogenous LH production as a result of longstanding hypothalamic amenorrhoea. Follicles developed in all of the women but the rise in oestradiol was very slow. As a consequence of the HCG injection being delayed to allow the follicles to become functionally mature, too many follicles attained a preovulatory size. After the treatment was changed to more conventional preparations containing bom FSH and LH, the women had improved ovarian responses and 3 of them conceived. It is clear that FSH alone will promote follicular growth but that LH is needed to stimulate follicular function. We conclude that LH does play an important role in follicular maturation and that it is a critical component of exogenous gonadotrophin therapy for women with prolonged hypogonadotrophic hypogonadism.
Laparoscopic Surgical Treatment of Ectopic Pregnancy: Salpingectomy or Salpingostomy?
Authors: Parker Jim , Bisits Andrew
Published: February 2008

EDITORIAL COMMENT: We accepted this review for publication because it examines the important point of whether the classical operation of salpingectomy for tubal ectopic pregnancy provides superior results to salpingostomy in terms of subsequent fertility, and the possibility of short‐term complications due to incomplete removal of the ectopic pregnancy, or subsequent complications in terms of recurrence of a further ectopic pregnancy in the same tube. Of course there is seldom an indication for salpingectomy when the ectopic pregnancy is situated in the patient's only remaining Fallopian tube although it can be necessary if the tube is destroyed by rupture or salpingectomy is required to achieve haemostasis. In any case the woman can still become a mother with in vitro fertilization‐embryo transfer technology. This paper contains considerable information about the value of laparoscopy versus laparotomy in the surgical management of ectopic pregnancy but it seems to the Editorial Subcommittee that the important point being examined is whether or not salpingostomy should be attempted rather than salpingectomy in the majority of patients with ectopic tubal pregnancy

Summary: There is a widespread belief that salpingostomy is the treatment of choice for ectopic pregnancy. The ability to treat most ectopic pregnancies via a laparoscopic approach has been a major advance in gynaecological surgery. Despite die well publicized benefits of laparoscopy over laparotomy only 50% of patients with ectopic pregnancies in Australia presently benefit from this surgical advance. Although it is clear that laparoscopic treatments are preferable to laparotomy there is no consensus on whether salpingectomy or salpingostomy should be performed, despite over 40 years of research since the introduction of conservative tubal treatment. A systematic review of laparoscopic surgical treatments is needed and could be incorporated into die Cochrane Collaboration. A prospective clinical study, with long‐term follow‐up, needs to be performed to evaluate fertility prognosis and complications after laparoscopic salpingectomy versus salpingostomy.
Vulval Varicosities and Labial Reduction
Authors: Fliegner John R.H.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication since we agree with the author that it is rare for patients to request surgery for enlargement of the labia minora. Presumably patients would take such a problem to a gynaecologist, although as reference 3 shows, the editor would refer the unusual problem of vulval varicosities requiring surgery to a vascular surgeon, although the case concerned was complicated in other ways. Variation in size of the labia minora is quite remarkable as is the rarity of women seeking surgical correction of the condition. The editor has managed only one such patient, a woman with asymmetrical enlargement of the labia minora. Against his better judgement a simple reduction was performed on the left labium minus. Postoperatively the patient complained of intolerable pain although the wound appeared uncomplicated and healed uneventfully. The woman when last seen at follow‐up 3 months later remained unhappy with the operation and was concerned by the apparent enlargement of the right labium minus. Perhaps we should ask our plastic surgeon colleagues if they often perform plastic surgery for enlargement or asymmetry of the labia minora. Our senior gynaecologist reviewer stated that he has performed ligation of vulval varicosities in nonpregnant women in the way described by the author. He also stressed the need to mark the varicosities with the patient in the standing position prior to surgery. We reviewed the gynaecological surgical audit of one Melbourne hospital for 6 years to determine the prevalence of labial reduction. There were 3,896 cases of major abdominal or vaginal surgery, 2,126 laparoscopics and 14,054 of minor surgery, including 6 of labia minora reduction by excision of the excessive tissue; the operation was unilateral in 5 women and bilateral in 1.

Summary: Vulval varicosities and hypertrophic labia minora are 2 conditions that receive relatively little attention in the literature. However, they may cause especially bothersome discomfort in some women. Appropriate surgical treatment is eminently successful if certain guidelines and attention to detail are followed. The treatment of both conditions is described based on illustrative case reports, and a review made of the surgical anatomy.
Antenatal Patterns of Uterine Activity in Low‐Risk Women: A Longitudinal Study
Authors: Dickinson Jan E. , Godfrey Maryellen , Evans Sharon F.
Published: February 2008

Summary: There is a surprising lack of information on antenatal patterns of uterine activity in the normal obstetric population, with the majority of research having focussed on women at high‐risk for preterm birth. We conducted a prospective longitudinal study to investigate patterns of uterine activity in women with singleton gestations at low‐risk for preterm birth. Twenty pregnant women were recruited and their uterine activity was recorded using ambulatory tocodynamometry twice weekly throughout the latter half of pregnancy. The collected data were transmitted to a central receiving station for analysis. As gestation advanced there was a progressive increase in the median number of contractions detected per hour, peaking and stabilizing at 37–40 weeks (median of 0 contractions/hour at 20–24 weeks rising to 5.4 contractions/hour at 37–40 weeks). In those women with uterine activity, contraction duration and amplitude of deflection significantly increased as gestation advanced. There was a progressive increase in the number of higher amplitude contractions throughout the third trimester. Increasing parity was not associated with increasing antenatal uterine contraction frequency. No association between normal daily physical activity and uterine contraction frequency was evident throughout gestation. In normal human pregnancy there is a steady, progressive increase in the frequency, duration and amplitude of antenatal uterine activity throughout the latter half of gestation. The uterine contractile profile alters from one of a low amplitude, low frequency pattern in the second trimester to a higher amplitude, higher frequency pattern at term.
How Well Does Epidemiological Evidence Hold For The Relationship Between Smoking and Adverse Obstetric Outcomes in New South Wales?
Authors: P.L Patrick , Bauman Adrian
Published: February 2008

Summary: This study examines whether the established epidemiological relationships between cigarette‐smoking exposure in pregnancy and adverse obstetric outcomes are confirmed in Australian data from the NSW Midwives Data Collection (MDC). These data were analysed to compare the obstetric complications and pregnancy outcomes between smoking and nonsmoking women confined in 1994. Results showed that smoking mothers had higher rates of antepartum haemorrhage due to placental abruption and placenta praevia. They were also at higher risk of giving birth to low birth‐weight babies and preterm delivery. Infants born to smoking mothers were 17% more likely to be admitted to hospital special care nurseries or neonatal intensive care units. Moreover, the risk of reported perinatal death among babies of smoking mothers was 20% higher than babies of nonsmoking mothers. However, smoking during pregnancy was found to confer a protective effect against the development of pregnancy‐induced hypertension. These results were compared with existing evidence from the literature. Published research reports on the corresponding smoking effects were identified to assess the consistency of evidence and typical risk ratios. Findings from the literature search showed a near‐perfect concordance with the associations in the NSW MDC data. The paper documents the likely complications which might be prevented if smoking in pregnancy were eliminated. There remains a real need for effective programmes to reduce smoking prevalence in pregnancy.
The Metabolic Profile of Glucose Tolerant Women Who Have Had Large for Gestational Age Babies
Authors: Moses R. , Davis W. , Rodgers D. , Meyer B. , Calvert D.
Published: February 2008

Summary: The possibility has been raised that women who have had large for gestational age infants, while glucose tolerant during, pregnancy by conventional testing, may still have a subtle abnormality of carbohydrate metabolism. We have examined, some time after the completion of a pregnancy, the fasting levels of glucose, insulin and lipids in a group of women, glucose tolerant during pregnancy, who had a large for gestational age infant compared to a very carefully matched control group of women who had an appropriate for gestational age infant. No significant differences were found. These findings suggest that women who have a large for gestational age infant do so for a variety of reasons not related to maternal carbohydrate metabolism.
Twin‐Reversed Arterial Perfusion (TRAP) Sequence: Case Reports and Review of Literature
Authors: Hanafy Ash , Peterson C. Matthew
Published: February 2008

Summary: The twin reversed‐arterial‐perfusion (TRAP) sequence found in monozygotic twins is a consequence of primary or secondary cardiac development disruption and direct arterioarterial and venovenous placental anastomoses. Associated findings include the presence of a single umbilical artery (66%) and chromosomal abnormalities in the acardiac twin (33%). Morphological abnormalities in the acardiac twin are consistent with perfusion of tissues supplied by the common iliac and lower branches of the aorta with deoxygenated blood. The pump or donor twin may develop cardiac failure because of the anomalous perfusion circuit. Polyhydramnios is significantly associated with the presence of renal tissue in the acardiac twin. An acardiac pump twin weight ratio (>50%) is associated with the development of polyhydramnios and preterm labour. Identified high‐risk factors for poor obstetrical outcome include: acardiac anceps, polyhydramnios, acardiac twin with ears, and pump twin cardiac failure. Management options include elective termination, observation (serial cardiotocography (CTG), ultrasonography and echocardiography) and selective nonsurgical interventions (indomethacin, digitalis, tocolysis). Additionally, surgical interventions (hysterotomy with selective delivery of the acardiac twin or ligation of the acardiac twin's umbilical cord), and ultrasound‐guided embolization of the acardiac twin's umbilical artery with absolute alcohol, platinum coils, or thrombogenic coils have been reported. The most appropriate interventions for the varous clinical presentations of this disorder are as yet undetermined, and conservative nonintervention is often appropriate. Long‐term follow‐up data on surviving pump twins are lacking. It is anticipated that centres with active study protocols for these conditions will best serve patient care and clinical research needs.
Vault Haematoma Following Laparoscopic Hysterectomy
Authors: Rosen David M.B. , Cario Gregory M.
Published: February 2008

Summary: Thirty consecutive patients underwent transabdominal ultrasound scanning on day 2 postoperatively in order to provide data on the incidence of vaginal vault haematoma following laparoscopic hysterectomy. Details of postoperative morbidity, both inpatient and after discharge, were recorded. Results support the view that there is no significant association between the presence of vaginal vault haematoma (73%) and the incidence of posthysterectomy febrile morbidity (16.7%). Furthermore the incidence of vault haematoma after laparoscopic hysterectomy is comparable to literature figures for both abdominal and vaginal hysterectomy, whilst that of febrile morbidity is at least equivalent if not reduced for the laparoscopic approach. We believe this provides further evidence confirming the safety of the laparoscopic approach to hysterectomy.
A Case of Complete Iatrogenic Amnioreduction at 20 Weeks' Gestation
Authors: Griffin Christopher , Peek Michael John
Published: February 2008

EDITORIAL COMMENT": The editorial committee found this case report irresistible as an example of triumph over misfortune and disability. Iatrogenic, accidental, prolonged and complete amnioreduction is unique in the editor's clinical experience and knowledge of the literature. Importantly the case also illustrates that conservative management of ‘premature rupture of the membranes'can be successful. The favourable outcome may have been related to the abdominal rather than the usual cervical route of amnioreduction, and the restoration of normal liquor volume after the amnioreduction was discontinued. Moreover, in spontaneous rupture of the membranes the cause of the problem is likely to be persistent.

Summary: A successful outcome for an infant following complete iatrogenic amnioreduction at 20 weeks gestation is possible without any invasive medical treatment.
An Unusual Case of Acute Postpartum Broad Ligament Haematoma
Authors: Maxwell Chris , Gawler David , Green John
Published: February 2008

EDITORIAL COMMENT": We accepted this case for publication to remind readers that a broad ligament haematoma can occur after a normal vaginal delivery and can cause continued haemorrhage requiring radical and difficult surgery. The case also illustrates that conservative management of broad ligament haematoma may be contraindicated. As stated by the author, broad ligament haematomas most commonly are associated with a difficult delivery, usually mid‐forceps delivery, and usually can be treated conservatively although the patient requires resuscitation with blood transfusion and intravenous therapy for the paralytic ileus that is often associated. An indwelling urinary catheter is usually also necessary. A paravaginal haematoma when it occurs above the level of the levator ani muscle attachment to the lower one third of vagina will present into the upper vagina and broad ligament and not into the vulva. It is another cause of postpartum collapse without visible blood loss and may be overlooked if a vaginal examination is not performed.
Coital Tear: A Rare Cause of Secondary Peritonitis
Authors: Khosla Anju Huria , Singhal Savita
Published: February 2008

EDITORIAL COMMENT": We accepted this paper for publication to warn readers that coitus‐induced tears to the posterior fornix of the vagina can involve peritoneum and bowel. The authors claim this injury is common in India and at our request provided the information that in 1995 they treated a total number of 7 patients with coitus‐induced vaginal tears in their hospital which has some 4,000 deliveries per year. The authors noted that the incidence of this injury is much higher than these figures would indicate because ‘people do not like young girls being asked questions by male medical graduates and for this reason prefer to go to private hospitals for the problem of coital tears’. They stated that for Indians coital tears are relatively common and any obstetrician would see 4–5 cases every 1–2 years’. We have previously published information from Papua New Guinea describing 13 cases of laceration to the posterior fornix of the vagina from voluntary intercourse seen over a period of 3 years at the Port Moresby General Hospital (A), and 13 cases of women with coital injury admitted with haemorrhagic shock requiring resuscitation with blood transfusion seen over a period of 4 years from the Nehru Hospital (B). Anate (C) has reported the details of 36 cases of vaginal trauma due to intercourse seen over a 6‐year period in Nigeria. All of these papers stress the frequent involvement of the posterior fornix of the vagina in these coitus‐induced injuries.

Summary: A rare cause of secondary peritonitis due to coital tear is presented. The correct diagnosis can be made by a detailed history and gynaecological examination. Prompt surgical management is mandatory to prevent grave prognosis.
How Safe is Antenatal Transfer Between Level 3 Units?
Authors: Malpas J Timothy J. , Meates Jeremy , Horwood John , MD Brian A. DarlowJ
Published: February 2008

Summary: The effect of antenatal transport of women between level 3 units in New Zealand on maternal and infant well‐being was examined in a retrospective case‐controlled study. The outcomes of women transferred to other level 3 centres because of lack of neonatal unit space were compared with women who were able to be delivered at Christchurch Women's Hospital (CWH). Of 34 women transferred out of CWH from 1991–1994, 20 (59%) were delivered at the receiving centre, the remainder returning undelivered. Women transferred from Christchurch were more likely to be of lower parity (p<0.05), and were less likely to be in premature labour than those who remained in Christchurch (p<0.05). There was a trend for the initial risk of mortality as assessed by the Clinical Risk Index for Babies (CRIB) score to be lower for those infants born out of Christchurch but this was not statistically significant. Mortality, oxygen requirement at 36 weeks, periventricular haemorrhage, retinopathy of prematurity, and the time to regain birth‐weight were not statistically different between the 2 groups, despite significantly more outborn children being male (p<0.05). Antenatal transfer therefore seems to be a safe procedure, although this study did not consider the potentially serious effect of social factors on transferred families.
Fertility Awareness in Women Attending a Fertility Clinic
Authors: Blake D. , Smith D. , Bargiacchi A. , France M. , Gudex G.
Published: February 2008

EDITORIAL COMMENT: In this paper the authors have made an important point. Counselling concerning simple treatment options should be the first step in the management of infertility as for most other medical problems. Conversely it could be said, as stated by an Anglican priest to the editor about 10 years ago, that counselling the infertile couple, who were candidates for only the most complicated regimens of reproductive technology, should include acceptance of their infertility. Many years ago the editor, when doing a locum, met a couple whose longstanding infertility was the result of misunderstanding of the physiology of conception, with avoidance of coitus at the fertile time of the cycle ‐ conception occurred 2 months after a simple explanation of the physiology of the menstrual cycle as advocated in this paper.

Summary: Eighty women attending for consultation at a tertiary referral fertility unit over a 3‐month period were surveyed for their knowledge of fertility awareness and how they used this information to enhance their chances of conception. It was hypothesized that less than 50% of the subjects had an adequate understanding of when the fertile time occurred in their menstrual cycle. A questionnaire was completed anonymously by each subject and these were scored in 3 categories for fertility awareness by 2 independent Natural Family Planning teachers. Scores ranged from 0 for women who had no concept of fertility awareness, to 6 for women who were highly aware. The results showed that 26% (n=21) of subjects had a score of 4 or greater which was considered as having an adequate understanding. The hypothesis was accepted, giving reason for concern about the effectiveness of consumer education at all levels of fertility investigation.
Abnormal Umbilical Artery Flow Velocity Waveform ‐A Sign of Fetal Narcotic Withdrawal?
Authors: Wong Wai Ming , Lao Terence T.
Published: February 2008

Summary: We present a case of a heroin addict in whom Doppler flow study on the umbilical artery showed absent end diastolic flow at 29 weeks* gestation by ultrasound. Following methadone administration, the mother's withdrawal symptoms were controlled, the fetal diastolic flow returned, and there was a normal systolic/diastolic ratio. Delivery at 32 weeks' gestation by ultrasound resulted in a surviving infant who required treatment with phenobarbitone and morphine after birth to control withdrawal symptoms.
Urinary Cotinine Levels in Early Pregnancy
Authors: Foundas Maria , Hawkrigg Natalie C. , Smith Sarah M.S. , Devadason Sunalene G. , Souef Peter N. Le
Published: February 2008

Summary: We tested the hypotheses that in early pregnancy smokers have lower urinary cotinine levels than nonpregnant smokers, and that pregnant nonsmokers exposed to passive smoke have higher cotinine levels than nonsmokers not exposed to passive smoke. This was a prospective, quantitative, comparative study of the urinary cotinine levels and smoking characteristics of pregnant and nonpregnant females. A urine specimen was collected from each subject and the cotinine/creatinine level determined using radio‐immunoassay. A questionnaire regarding smoking status, health issues, and demographic variables was administered to each subject. There was no difference in cotinine level between pregnant smokers and control smokers. Pregnant nonsmokers with passive smoke exposure had higher cotinine levels than the same group not passively exposed. Confidence in ability to stop smoking was associated with lower numbers of cigarettes consumed, but was not reflected by lower cotinine levels. These data suggest that if the mother smokes, the fetus is exposed from conception to levels of nicotine which are as high as those in adult female smokers who are not pregnant. The level of fetal exposure to nicotine during early gestation is independent of intention to alter smoking behaviour. Women should be targeted for antismoking public health messages before conception.
Treatment of Cervical Incompetence by Transabdominal Cervicoisthmic Cerclage
Authors: MBBS Simon Craig , MD John R.H. Fliegner
Published: February 2008

Summary: Cervical incompetence is a condition traditionally treated by cervical cerclage which in most cases is inserted via the transvaginal route. However the insertion of a transabdominal cervicoisthmic suture is indicated in those patients with recurrent mid‐trimester losses due to an incompetent cervix where it is not technically possible to insert a transvaginal suture. Between 1987 and 1996, 12 women at the Royal Women's Hospital, Melbourne were treated with transabdominal cervicoisthmic cerclage (TCC). Eight patients had cerclage in the nonpregnant state, and 4 were pregnant at the time. The completed pregnancies thus far have resulted in 10 surviving infants, a successful pregnancy rate of 69.2%. This compares favourably with a corrected preTCC successful pregnancy rate of only 13%. There were minimal intraoperative complications in our series. Bleeding, chorioamnionitis and premature rupture of the membranes have been reported elsewhere and occurred in 2 of our patients. Our results and a review of the literature confirms that TCC has an important role in carefully‐selected patients.
Spontaneous Rupture of the Urinary Bladder in the Puerperium
Authors: Kekre Aruna N. , Kekre Nitin , Nath Vishwambhar , Seshadri Lakshmi
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because it is important for obstetricians to know that spontaneous rupture of the bladder can occur in the puerperium even when there is no predisposing cause such as obstructed labour or previous injury.

Summary: Spontaneous rapture of the urinary bladder in the puerperium is extremely rare. The patient usually presents with acute abdominal pain. Awareness on the part of the treating surgeon that bladder rupture is a possibility will lead to an early diagnosis. Immediate exploration, removing urine from the peritoneal cavity or retropubic space, closing the rupture and securing good vesical drainage, results in resumption of vesical function, and thereby decreases the mortality and morbidity.
Antenatal Indomethacin‐Adverse Fetal Effects Confirmed
Authors: Souter Dereck , Harding Jane , McCowan Lesley , O'Donnell Clare , McLeay Elisabeth , Baxendale Helen
Published: February 2008

Summary: We examined the association between antenatal indomethacin exposure and adverse neonatal outcome in a matched retrospective cohort study of infants born to 72 mothers at less than 31 weeks' gestation. Indomethacin‐exposed mothers were matched to controls by gestational age at delivery, antenatal corticosteroid exposure, prolonged spontaneous rupture of membranes, multiple pregnancy, thyrotrophin‐releasing hormone (TRH) exposure, and neonatal sex. Peri ventricular haemorrhage was significantly increased for infants delivered within 48 hours of maternal indomethacin exposure (Grade 1 and 2 19% versus 6%, and Grades 3 and 4 28% versus 3% (p<0.03)). Persistent patent ductus arteriosus was more common in those infants delivered within 48 hours of maternal indomethacin exposure (40% versus 20% (p<0.04)). More neonates exposed to antenatal indomethacin failed to respond to postnatal indomethacin to close a patent ductus arteriosus, 60% versus 0% (p<0.04). There were no adverse effects demonstrated of indomethacin administered greater than 48 hours from delivery. We have confirmed a probable association between antenatal indomethacin administration and an increased incidence of neonatal periventricular haemorrhage, patent ductus arteriosus, and impaired renal function. The adverse neonatal effects appear to be greatest when indomethacin is administered within 48 hours of delivery. We recommend that indomethacin should be used with caution as a tocolytic agent for the treatment of preterm labour at gestations less than 31 weeks.
Repeat Instrumental Delivery: How High is the Risk?
Authors: Lau T. K. , Leung T. N.
Published: February 2008

Summary: The objective of this study was to investigate whether a history of previous instrumental delivery imposes a higher risk of operative delivery in subsequent pregnancies. The outcome of labour in 108 women with 1 previous instrumental delivery was compared to that of 216 randomly‐selected controls delivered in the same period. There was no difference between these 2 groups of patients in maternal age, height, parity, gestational age, incidence of induction of labour, incidence of epidural analgesia, or birth‐weight of the babies. The incidence of instrumental delivery was found to be 8.3% among the study group, which was significantly higher than that of 2.3% among the control cases (relative risk = 3.6, 95% CI 1.24 to 10.5). This increase in risk of operative delivery was independent to the indications for or the type of instrumental delivery in previous pregnancies. We conclude that women with 1 previous instrumental delivery are at a higher risk of repeat operative delivery. This may have implication in assessing patients for home delivery.
Changes in Cotinine Levels During Pregnancy
Authors: Ford R. P. K. , Schuter P. J. , Tappin D. M.
Published: February 2008

Summary: We measured maternal cotinine levels on residual sera of antenatal blood samples to biochemically document changes in smoking between early and late pregnancy. It was a random sample of 404 mothers who had both an early and late sample. Cotinine levels were used to categorize maternal smoking into nonsmoker (<15 ng/mL) and smoker (≥15 ng/mL) groups. Designated smokers were further partitioned into lighter (15–100 ng/mL) and heavier (>100 ng/mL) semiquantitative groupings. There was a positive cotinine result in 113 (28%) mothers in early pregnancy; of these smoking women, 35 (31%) had quit smoking by the time of their late pregnancy blood test and 28 (25%) had reduced their cotinine level by at least 25%. Many more lighter smokers had quit (59%) compared to heavier smokers (17%) (X2= 20.9, df = 1, p<0.001). By late pregnancy, 86 (21%) mothers were still defined as smokers. Almost 30% of pregnant women in this sample were smoking during early pregnancy declining to 21% in late pregnancy.
Spontaneous Abortion: Short‐term Complications Following Either Conservative or Surgical Management
Authors: Chung T. K. H. , Cheung L. P. , Sahota D. S. , Haines C. J. , Chang A. M. Z.
Published: February 2008

Summary: Spontaneous abortion is a common gynaecological condition. It is a commonly held belief that medical morbidity associated with this condition is low and that routine treatment should be surgical evacuation of the uterus. This study was performed to study the short‐term complications of spontaneous abortion and its management. Transvaginal sonography (TVS) was used to determine whether retained products of conception (POCs) were visible inside the uterus in women presenting with spontaneous abortion. If tissue was present, surgical evacuation of retained products of conception (ERPC) was performed. If the uterus was empty, the patients were managed expectantly. Four hundred and seventy women were treated with ERPC and 297 were managed expectantly. The complication rate was 3.0% in those managed expectantly compared with 5.8% for those treated by ERPC. Subjects with no POCs on TVS can therefore be managed expectantly without increasing the risk of morbidity associated with this condition.
Vaginal Dinoprostone Versus Oral Misoprostol for Predilatation of the Cervix in First Trimester Surgical Abortion
Authors: Sparrow Margaret J. , Tail John D. , Stone Peter R.
Published: February 2008

Summary: Prostaglandins are effective in predilatation of the cervix prior to first trimester surgical termination of pregnancy under local analgesia. A randomized open comparative trial was devised to compare the effectiveness and acceptability of vaginal dinoprostone with oral misoprostol. Two groups were randomized to control for age, parity and ethnicity. The operation was easier and less painful in older, parous, and Polynesian women. Both methods were effective with respect to ease of dilatation. Both were acceptable and equal with respect to the level of pain experienced by the woman during the operation. Vaginal dinoprostone is more gradual in its action, but it is more expensive, has to be refrigerated and self‐insertion may sometimes cause problems. Oral misoprostol is considerably cheaper and does not require refrigeration, but it was associated with more preoperative nausea, cramping and occasional heavy bleeding.
Implications of Liver Cirrhosis in Pregnancy
Authors: Cerqui Anthony J. , Haran Mano , Brodribb Robert
Published: February 2008

Summary: We present the case of a pregnant woman with alcohol‐induced liver cirrhosis and a discussion of the clinically relevant issues of cirrhosis in pregnancy.
Urethral Diverticula in Pregnancy
Authors: Moran Paul A. , Carey Marcus P. , Dwyer Peter L.
Published: February 2008

Summary: In 4 cases, the clinical presentation of urethral diverticulum (UD) during pregnancy was a paraurethral mass (3), urinary incontinence (2), irritative symptoms (2), urinary tract infection (1), urethral pain and discharge (1) and voiding difficulty (1). The diagnosis of UD during pregnancy was made by trans vaginal ultrasonography (2), cystoscopy (1), and after pregnancy by a voiding cystourethrogram (1). Management during pregnancy involved antibiotics (2), diverticulum aspiration (2) and incision and drainage (1). Delivery was by the vaginal route in 2 women with diverticular aspiration being performed during the second stage to aid delivery in 1 woman. Caesarean section was performed in the other 2 women for reasons unrelated to the presence of the UD. Three women had diverticulectomy performed following pregnancy for persisting symptoms. Although uncommon, it is important to diagnose urethral diverticula given the associated morbidity and the potential for causing complications during pregnancy.
Endometrial Malignancy Missed by Office Sampling
Authors: van den Bosch Thierry , Cornelis Ann
Published: February 2008

EDITORIAL COMMENT: This article shows that in the presence of either continued postmenopausal bleeding or suspicious findings on ultrasonography, a negative result obtained by office endometrial sampling cannot be relied upon to exclude malignancy. This article emphasizes the importance of interpreting all information about a patient together rather than focussing on the result of a single investigation.
Genital Tract Fistula Repair on 116 Women
Authors: Goh Judith T.W.
Published: February 2008

Summary: A personal series of 130 genital tract fistula repairs in 116 women is presented. All fistulas were repaired vaginally. The majority of the fistulas were due to obstetric injuries, especially prolonged obstructed labour. Obstetric fistula continue to be a cause of personal and social morbidity to sufferers.
The Relationship Between Weight Gain in Pregnancy, Birth‐Weight and Postpartum Weight Retention
Authors: To W.W.K. , Cheung W.
Published: February 2008

Summary: A total of 292 middle class, nonsmoking Chinese patients with known prepregnant weight who subsequently had uncomplicated singleton pregnancies delivering after 36 weeks' gestation were recruited to assess their serial antenatal weight gain, weight at 6 weeks and 3 months postpartum. The average prepregnant body mass index in the whole group was 20.4 kg/m2 (SD 2.19), and the total pregnancy weight gain was 14 kg (SD 3.75). Those with weight gain over 17.83 kg (one SD above the mean) (n=58) had higher weight gain in all 3 trimesters taken separately, as well as higher weight retention at 6 weeks and 3 months postpartum (p <0.001). Similar differences were noted for those with total weight gain over 2 standard deviations above the mean. The average weight retained at 3 months postpartum was 3.64 kg (SD 2.75). Those with weight retention over 9.14 kg (2 SD above the mean) (n=8) had a significantly higher second and third trimester weight gain (p <0.01) compared to the rest. These data suggest that excessive weight gain during pregnancy for women with prepregnant BMI in the normal range occurred most significantly after the mid‐trimester, and was associated with higher postpartum weight retention without significant increase in birth‐weight.
Which Korotkoff Sound Should Be Used For the Diastolic Blood Pressure in Pregnancy?
Authors: Duggan P.M.
Published: February 2008

Summary: There is a gathering momentum favouring the adoption of the 5th Korotkoff sound to identify diastolic blood pressure in pregnancy. Our objective was to measure interobserver reliability for indirect blood pressure measurement in pregnancy for systolic and diastolic measurements and to calculate the difference in diastolic pressure measured by the 4th and 5th Korotkoff sounds. To minimize bias we used trained but previously inexperienced observers with proven, normal auditory acuity. The observers were paired in 4 teams and performed a series of 334 blinded, simultaneous observations of systolic and diastolic blood pressure measurements taken from pregnant women between 12–41 weeks' gestation. Reliability was measured by intraclass correlation coefficient for paired measures and kappa for the detection or nondetection of 4th (K4) and 5th (K5) Korotkoff sounds. K4 was undetected in 36% of observations and K5 was undetected in 2% of observations. Reliability for detection or nondetection of Korotkoff sounds was fair for K4 (kappa 0.36) and moderate for K5 (kappa 0.58). Reliability was good between observers for systolic, K4 and K5 diastolic measurements (intraclass correlation >0.80). The mean difference between the diastolic pressure measured by K4 and K5 was 15 mmHg for all measurements and 8 mmHg for the top quartile of measurements (p <0.001). We found K5 to be more often and more reliably detected than K4. If units adopt K5 in preference to K4, consideration will need to be given to lowering treatment thresholds for women with borderline or mild hypertension.
A Case of Transvaginal Evisceration
Authors: Cerqui Anthony J. , Haran Mano , Collier Sheree M.
Published: February 2008

EDITORIAL COMMENT: These spectacular cases are often entitled ‘vaginal evisceration’ (seeReferences). Chambers twentieth century dictionary defines eviscerate as ‘to tear out the viscera or bowels of: to gut’ which seems to imply protrusion of a great deal more than what is seen in these frightening (to both patient and physician) rare cases. With respect, the editor strongly disagrees from lack of such cases seen by him, and his reading of the literature, that ‘most cases are probably unreported, occurring in premenopausal women as a result of coital trauma, rape or obstetric trauma’.

Summary: We present a case of spontaneous evisceration of the small bowel through the vaginal vault in a 61‐year‐old woman. The predisposing factors and management are discussed.
Timing and Mechanism of Perinatal Human Immunodeficiency Virus‐1 Infection
Authors: Phuapradit Winit
Published: February 2008

Summary: There is sufficient evidence indicating a higher vertical HIV‐1 transmission rate in the last trimester and during labour compared with the first trimester. Antiretroviral therapy either single or in combination given to the mother during the last trimester and delivery can reduce the viral load in the maternal circulation. Vertical HIV‐1 transmission during delivery can be minimized by appropriate timing and route of delivery. Elective Caesarean section before the onset of labour with an intact bag of forewaters provides the least mother‐to‐fetus microtransfusion compared to other modes of delivery. Since an effective combination of HIV‐1 immunoglobulin and HIV‐1 vaccine given to the HIV‐1 exposed newborns to prevent HIV‐1 transmission similar to the viral hepatitis B model is not firmly established at present, postexposure antiretroviral prophylaxis and nonbreast‐feeding are advocated for infants born from the HIV‐1 infected mothers. In cases of advanced stage of maternal HIV‐1 infection, and in developing areas where malnutrition prevails, an adequate supply of essential micronutrients is proposed as an adjunctive measure to reduce HIV‐1 perinatal transmission.
Preterm Infants 30–36 Weeks' Gestation in Victoria — Where Should They Be Delivered?
Authors: Doyle Lex W. , Bowman Ellen , Davis Peter , Halliday Jane
Published: February 2008

Summary: There is little doubt that very preterm infants <30 weeks' gestation should be born in level‐3 perinatal centres. For preterm infants 30–36 weeks' gestation, however, the optimum place of birth is not so clear‐cut. The aims of this study of livebirths 30–36 weeks' gestational age born in Victoria were to determine: 1) the proportions delivered outside level‐3 centres, and 2) for infants born outside level‐3 centres, the proportions transferred after birth to a level‐3 nursery in the first days after birth. Data on the number of livebirths 30–36 weeks' gestational age in Victoria in the 3 years 1994–1996, inclusive, were supplied by the Victorian Perinatal Data Collection Unit. Data were obtained from the Newborn Emergency Transport Service (NETS) on all transfers within the first 3 days after birth to a level‐3 centre for infants born outside level‐3 centres. For the 3 years 1994–1996 there were 11,375 livebirths 30–36 weeks' gestational age in Victoria. The proportion born outside a level‐3 perinatal unit was 57.9% overall, and rose with increasing gestational age, from 10.9% at 30 weeks to 69.0% at 36 weeks. Of the 6,587 livebirths outside a level‐3 centre, 808 (12.3%) were transferred within the first 3 days after birth by NETS to a level‐3 centre, the proportions falling with increasing maturity, being 73.7%, 48.5%, 28.4%, 26.9%, 18.8%, 11.8%, and 7.0% at 30, 31, 32, 33, 34, 35, and 36 weeks, respectively. These data may help medical practitioners when determining the place of delivery for infants 30–36 weeks' gestation.
Is It Better To Avoid Urethral Catheterization at Hysterectomy and Caesarean Section?
Authors: Barnes John S.
Published: February 2008

Summary: This study involved 329 patients who had either a Caesarean section or a hysterectomy. A comparison has been made between 70 patients who were never catheterized and 251 who had a urethral catheter perioperatively. The absence of recognized urinary tract infections in those without a catheter was significant when compared with the 21 urinary infections identified in the catheterized group (p < 0.05). The absence of urinary tract infections in the uncatheterized group clearly demonstrates the benefit of avoiding catheterization when possible.