bluuebunny/crossref_metadata_2025 huggingface dataset:
Routine obstetric ultrasound examinations in South Africa: cost and effect on perinatal outcome–a prospective randomised controlled trial
Authors: Geerts Lut T. G. M. , Brand Esther J. , Theron Gerhard B.
Published: August 2005

Objective
To compare routine midtrimester with selective obstetric ultrasonography concerning the Health Service cost and the effect on perinatal outcome.

Design
A randomised controlled trial.

Setting
Urban area served by Tygerberg Hospital, a tertiary referral centre in South Africa.

Participants
Pregnant patients without risk factors for congenital anomalies referred for ultrasonography between 18 and 24 weeks of gestation.

Intervention
Between 18 and 24 weeks, a level one ultrasound examination was performed on study patients only. Except for the routine scan, both groups received the same antenatal care and could be referred later for additional scans as judged by their clinicians.

Main outcome measures
Overall adverse perinatal outcome and use of antenatal and neonatal services.

Results
The groups did not differ significantly in their use of antenatal and neonatal services except for a greater number of ultrasound scans in the study group. More suspected postdate pregnancies occurred in control patients, as well as more amniocenteses for confirmation of lung maturity. More babies of low birthweight were born in the study group. The incidence of overall or major adverse perinatal outcome was comparable. Routine ultrasonography was accompanied by a considerable increase in costs.

Conclusion
Selective use of obstetric ultrasonography did not increase the use of antenatal and neonatal services. Not routinely performing ultrasonography has led to considerable Health Service savings without increasing the risk for adverse perinatal outcome. It saved 75% of selected patients a referral to an ultrasound unit. Specific problems related to inaccurate gestational age determination need to be addressed.
Antenatal diagnosis of congenital toxoplasmosis: evaluation of the biological parameters in a cohort of 286 patients
Authors: Pratlong F. , Boulot P. , Villena I. , Issert E. , Tamby I. , Cazenave J. , Dedet J.‐P.
Published: August 2005

Objective
To evaluate the biological parameters obtained by cordocentesis and amniocentesis in the antenatal diagnosis of congenital toxoplasmosis.

Design
Nine‐year retrospective study.

Setting
Parasitology Laboratory, Department of Obstetrics and Gynaecology and Department of Paediatrics, Centre Hospitalo‐Universitaire, Montpellier, France.

Participants
Two hundred and eighty‐six pregnant women infected with toxoplasmosis between 7 and 34 weeks of gestation.

Methods
Detection of abnormalities by ultrasound examination. Detection in fetal blood of Toxoplasma, of specific IgM and IgA and of nonspecific biological markers. Detection in amniotic fluid of Toxoplasma.

Results
Out of 286 antenatal diagnoses, 211 were negative (1st group), 40 were positive (2nd group) and led to 8 medical abortions, and 35 were uncertain (3rd group). In the 1st and 3rd groups respectively, 7 (3.3 %) and 5 (14.3 %) cases of congenital toxoplasmosis were observed. Overall, 52 cases of congenital toxoplasmosis were detected: 12 were clinically apparent, 36 subclinical (of which 12 were in groups 1 and 3) and 4 were lost to follow up.

Conclusion
There is substantial importance in making the diagnosis of toxoplasmosis antenatally in order to limit the number of medical abortions. In our series, the most accurate predictor was the detection of the fetal antibody response (specific IgM and IgA) to Toxoplasma.
Treatment with a gonadotrophin releasing hormone agonist before endometrial resection: a multicentre, randomised controlled trial
Authors: Vercellini Paolo , Perino Antonio , Consonni Roberto , Trespidi Laura , Parazzini Fabio , Giorgio Pier
Published: August 2005

Objective
To ascertain whether treatment with a gonadotrophin releasing hormone agonist before endometrial resection reduces absorption of distension fluid and operating time and facilitates the procedure.

Design
A multicentre, prospective, randomised controlled study.

Participants
Seventy‐one premenopausal women with established menorrhagia.

Interventions
Eight weeks of goserelin depot treatment before endometrial resection of immediate surgery in the early proliferative phase of the cycle.

Main outcome measures
Irrigation fluid deficit, operating time and degree or difficulty of the procedure.

Results
After randomisation eight women withdrew from the study, leaving 33 women in the goserelin arm and 30 in the immediate surgery arm. Mean (SD) operating time was 15.1 (9.0) min in the goserelin group versus 16.9 (9.5) min in the controls; mean difference † 1.8 min, 95% CI, −2.9 to + 64. Mean (SD) distension medium deficit was, respectively, 422 (287) ml versus 564 (291 ml); mean difference + 142 ml, 95 % CI‐4 to + 288. The goserelin effect was restricted to the 29 women with adenomyosis as the mean (SD) fluid deficit was considerably less in the 19 treated women than in the 10 controls (299 (206) ml versus 597 (135) ml; mean difference + 298 ml, 95YO CI +149 to + 447). The surgeons classified the intraoperative difficulties as none in 6, minimal in 20, moderate in 7, and severe in no cases in the goserelin group; corresponding figures in the group without pretreatment were 2, 14, 13, and 1.

Conclusions
Goserelin administration before endometrial resection may reduce absorption of fluid at surgery in women with adenomyosis and may facilitate intrauterine operating conditions.
Differentiation of growth retarded from normally grown fetuses and prediction of intrauterine growth retardation using Doppler ultrasound
Authors: Bates Jane A. , Evans J. Anthony , Mason Gerald
Published: August 2005

Objective
To assess the hypothesis that infants exhibiting catch‐up growth as an indicator of intrauterine growth retardation (IUGR) have a higher incidence of predelivery abnormal Doppler results.

Setting
Obstetric unit, St James's University Hospital, Leeds.

Participants
One hundred and ninety‐six women with singleton pregnancies at high risk of IUGR, delivered between October 1992 and August 1993.

Main outcome measures
Postnatal catch‐up growth during the first seven months.

Results
Forty‐six of the 196 infants demonstrated catch‐up growth and were therefore classified as growth retarded; 85% of this group had had abnormal Doppler results prior to delivery, compared with 14% of the normally grown group. However, there is considerable overlap in birthweight ratio distribution between the two groups.

Conclusion
This study confirms the existence of a population of IUGR infants of average birthweight ratio. Doppler appears to distinguish IUGR (as defined by catch‐up growth) from normal growth more successfully in infants with an average birthweight ratio than in infants with a low birthweight ratio and is a better predictor of IUGR than SGA.
Multiparity and bone mass
Authors: Bererhi Haddia , Kolhoff Niels , Constable Anthony , Nielsen Stig Pors
Published: August 2005

Objective
To investigate the influence of multiparity on bone mass of the axial skeleton in a population of women of high parity.

Design
Open study of Omani women.

Setting
Medical physics department and clinical physiology department of a third degree referral (university) hospital.

Participants
A consecutive series of 159 normal women referred with low back pain over a period of six months.

Results
The bone mineral density was measured with dual‐photon absorptiometry and the mean was found to be 0.984 (± 0.166) (± SD) g cm−2. The age ranged from 20 to 70 years with a mean age of 43.4 (± 12.5) years. The number of children per woman ranged from 0 to 14 with a mean of 5.1 (53.5). There was no statistically significant influence of the number of children per woman on bone mineral density but there was a strong correlation with age and body size variables.

Conclusion
Multiparity does not influence lumbar spine bone mineral density in normal women.
Evaluation of a risk of malignancy index based on serum CA125, ultrasound findings and menopausal status in the pre‐operative diagnosis of pelvic masses
Authors: Tingulstad Solveig , Hagen Bjørn , Skjeldestad Finn Egil , Onsrud Mathias , Kiserud Torvid , Halvorsen Tore , Nustad Kjell
Published: August 2005

Objective
To evaluate the ability of a risk of malignancy index (RMI), based on a serum CA125 level, ultrasound findings and menopausal status, to discriminate a benign from a malignant pelvic mass and to discriminate early stage (Figo Stage I) from Stages II, III and IV of ovarian cancer.

Design
A prospective study.

Setting
Department of Gynaecology, Trondheim University Hospital, Trondheim, Norway.

Participants
One hundred and seventy‐three women, 30 years or older, consecutively admitted between February 1992 and February 1994 for primary laparotomy of a pelvic mass.

Main outcome measures
The sensitivity, specificity and positive predictive value of serum CA125 level, ultrasound findings and menopausal status, separately and combined into the RMI, to diagnose ovarian cancer.

Results
The RMI was more accurate than any individual criterion in diagnosing cancer. Using a RMI cut‐off level of 200 to indicate malignancy, the RMI derived from this dataset gave a sensitivity of 80%, specificity of 92% and positive predictive value of 83%. Applying RMI criteria developed by others, the following test performance was found: sensitivity 71%, specificity 96% and positive predictive value 89%. For the Stages II, III and IV of ovarian cancer the sensitivity increased to approximately 90% without any substantial loss in specificity.

Conclusions
The risk of malignancy index is able to correctly discriminate between malignant and benign pelvic masses. It is a scoring system which can be introduced easily into clinical practice to facilitate the selection of patients for primary surgery at an oncological unit.
Fetal karyotyping in twin pregnancies: selection of technique by measurement of fetal nuchal translucency
Authors: Sebire N. J. , Noble P. L. , Psarra A. , Papapanagiotou G. , Nicolaides K. H.
Published: August 2005

Objective
To examine the usefulness of selecting the appropriate techque for fetal karyotyping in twin pregnancies by using maternal age and fetal nuchal translucency thickness to determine risk for chromosomal defects in each fetus.

Setting
Fetal Medicine Centre, London, United Kingdom.

Subjects
Sixty‐seven twin pregnancies identified at the time of an ultrasound scan for determination of fetal nuchal translucency thickness, where the parents requested karyotyping.

Intervention
The risk for chromosomal defects in each fetus was calculated from the maternal age and fetal nuchal translucency thickness at 10 to 14 weeks of gestation. If the estimated risk for either fetus was 1 in 50 or greater, chorion villus sampling was the method of choice, whereas if the risk was less than 1 in 50 second trimester amniocentesis was performed.

Results
The estimated risk for trisomies was more than 1 in 50 in 34 pregnancies and 23.5% of these fetuses were found to be chromosomally abnormal. In contrast, in the 33 low risk pregnancies chromosomal abnormalities were found in only 1.5% of the fetuses.

Conclusions
In twin pregnancies the technique for fetal karyotyping may be selected by calculating the risk for chromosomal abnormality based on maternal age and fetal nuchal translucency thickness.
Stepwise compared with rapid application of vacuum in ventouse extraction procedures
Authors: Lim F. T. H. , Holm J. P. , Schuitemaker N. W. E. , Jansen F. H. M. , Hermans J.
Published: August 2005

Objective
To compare a one‐step (rapid) application of negative pressure (vacuum) with conventional stepwise application for ventouse extraction following a prolonged second stage of labour.

Design
Randomised controlled study.

Setting
Teaching Hospital.

Participants
Forty‐seven women were randomised to the rapid vacuum group and 47 to the stepwise group.

Main outcome measures
Duration of ventouse procedure, effectiveness of methods of application, morbidity of mother and infant.

Results
There was no significant difference in frequency of detachment of the cup after rapid or stepwise application of vacuum. A reduction in mean duration of the ventouse procedure of 6 min was realised without significant difference in maternal or neonatal morbidity.

Conclusion
Rapid application of vacuum significantly reduces the duration of a ventouse extraction procedure without compromise to efficiency and safety.
Are sociodemographic factors predictive of preterm birth? A reappraisal of the 1958 British Perinatal Mortality Survey
Authors: Wildschut Hajo I. J. , Nas T. , Golding J.
Published: August 2005

Objective
Reassessment of the predictive value of sociodemographic factors on preterm birth.

Design
Population‐based case—control study.

Setting
England, Wales and Scotland.

Sample
The study sample consisted of 5630 primiparous and 9538 multiparous women who were delivered during the first week of March 1958 in Britain. Multiple births were excluded.

Method
Factors potentially predictive of preterm birth were assessed for primiparous and multiparous women separately, using the split‐sample cross‐validation technique.

Main outcome measure
Preterm birth, defined as birth occurring before 259 days of gestation.

Results
Preterm birth rates for primiparous and multiparous women were 54 and 53 per 1000 births, respectively. In primiparous women low maternal age (under 20 years) was the only sociodemographic variable that was predictive of preterm birth (P= 0.01). However, only 10.7% of preterm birth among primiparous women was associated with low maternal age. In multiparous women, using univariable analysis, employment status was statistically significantly associated with preterm birth. This association disappeared when employment status was adjusted for by other variables in the model. Social class was not predictive of preterm birth in either primiparous or multiparous women.

Conclusion
From the results of this study it is concluded that sociodemographic factors do not have a substantial impact on the risk of preterm birth. It seems unlikely that preventative measures aimed at social‐demographic adversity will reduce preterm birth rates.
The impact of hormone replacement therapy on quality of life and willingness to pay
Authors: Zethraeus Niklas , Johannesson Magnus , Henriksson Peter , Strand Roland T.
Published: August 2005

Objective
To measure the gain in quality of life due to hormone replacement therapy for women with mild and severe menopausal symptoms.

Design
Prospective study where data on quality of life and willingness to pay were collected by interview.

Setting
Department of Gynaecology at Sodertalje Hospital near Stockholm.

Participants
One hundred and four women aged 45 to 65 years treated for menopausal symptoms for at least one month.

Methods
Quality oflife was measured by the time tradeoff and rating scale methods. The willingness to pay for hormone replacement therapy was investigated using the contingent valuation method.

Main outcome measures
The quality adjusted life year weight measured with the rating scale and time tradeoff methods, and willingness to pay.

Results
The increase in the quality adjusted life year weight due to hormone replacement therapy for women with mild symptoms was 0.26 according to the rating scale method and 0.18 according to the time tradeoff method. For women with severe symptoms the quality adjusted life year weight increased by 0.50 according to the rating scale method and by 0.42 according to the time tradeoff method. The mean willingness to pay for hormone replacement therapy per month was 2300 Swedish krone for women with mild symptoms and 4800 Swedish krone for women with severe symptoms (£1 = 10.3 Swedish krone).

Conclusions
Hormone replacement therapy leads to a major improvement in quality of life for women with menopausal symptoms. Both for women with mild and severe menopausal symptoms the willingness to pay for the treatment also greatly exceeds the costs, indicating that hormone replacement therapy is economically beneficial for women with menopausal symptoms.
Routine ultrasound screening in pregnancy and the children's subsequent growth, vision and hearing
Authors: Kieler Helle , Haglund Bengt , Waldenström Urban , Axelsson Ove
Published: August 2005

Objective
To test a hypothesis of no association between ultrasound exposure in early fetal life and growth or impaired vision or hearing during childhood.

Design
Follow up of eight to nine year old children born to women who participated in a randomised controlled trial on ultrasound screening during pregnancy.

Setting
Nineteen antenatal care clinics run by three central hospitals in Sweden from 1985 to 1987.

Population and methods
Of 4637 eligible singleton pregnancies, 3265 (71%) were followed up through a questionnaire sent to their mothers. Analyses were performed both according to randomised groups and to ultrasound exposure.

Main outcome measures
Parents’ report of vision and hearing tests as recorded on child's record card. Parents’ report of their child's weight and height at 1, 4 and 7 years of age.

Results
Reduced hearing was reported by 3.4% in the screening group compared with 3.5% in the nonscreening group (odds ratio [OR] 1.0; 95% confidence interval [CI] 0.67–1.41). The same prevalences were found when analysed according to ultrasound exposure (OR 1.0; 95% CI 0.67–1.42). Reduced vision was reported by 6.3% in the screening group compared with 7.8% in the nonscreening group (OR 0.8; 95% CI 0.60–1.03). Corresponding figures for ultrasound exposed and unexposed were 6.2% and 8.0%, respectively (OR 0.8; 95% CI 0.58–1.00). No statistically significant differences in body weight or height at 1, 4 or 7 years of age between screened and not screened children or between exposed and unexposed were found.

Conclusion
This study found no association between ultrasound exposure in early fetal life and growth or impaired vision or hearing during childhood.
A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss
Authors: Cooper Kevin G. , Parkin David E. , Garratt Andrew M. , Grant Adrian M.
Published: August 2005

Objectives To compare medical with hysteroscopic management in women referred to a gynaecologist complaining of heavy menstrual loss.

Design Single‐centre randomised trial.

Setting A teaching hospital in the United Kingdom.

Participants One hundred and ninety‐seven women seeking specialist treatment of heavy menstrual loss for the first time and willing to accept either treatment.

Interventions 1. Medical treatments not previously used by the women prescribed by experienced gynaecologists in standard doses and timings for a minimum of three cycles (n= 94), and 2. transcervical resection of the endometrium performed under general anaesthesia five weeks after goserelin preparation (n= 93).

Main outcome measures Treatment satisfaction and acceptability, relief of symptoms, change in haemoglobin, and improvement in health related quality of life, all after four months.

Results Women allocated transcervical resection were more likely to be totally or generally satisfied (76%versus 27%, P < 0.001), to find the treatment acceptable (93%versus 36%, P < 0.001), and willing to have the treatment again (93%versus 31%, P < 0.001). Although pain and bleeding were significantly reduced by medical treatment this was modest in comparison with transcervical resection (P < 0.001). Haemoglobin levels were significantly increased only following transcervical resection. Short form 36 scores were also improved in both arms, although only transcervical resection returned them to normal values.

Conclusions Medical treatment was less effective than transcervical resection of the endometrium, irrespective of previous treatment or type of medical management. Early hysteroscopic endometrial surgery should be considered by such woman with the choice made by the woman after a full discussion of the advantages and disadvantages of all the options.
A new questionnaire to assess the quality of life of urinary incontinent women
Authors: Kelleher C. J. , Cardozo L. D. , Khullar V. , Salvatore S.
Published: August 2005

Objectives To design and validate a condition‐specific quality of life questionnaire for the assessment of women with urinary incontinence, and to use the questionnaire to assess the quality of life of women with specific urodynamic diagnoses.

Setting A tertiary referral Urogynaecology unit at King's College Hospital, London

Design The questionnaire was designed following six different pilot studies; in this study it was tested for validity and reliability using standard psychometric techniques. The questionnaire was used in 293 consecutive women referred for investigation of urinary incontinence.

Results The questionnaire was shown to be reliable both by test‐retest analysis and by measurement of its internal consistency. The construct of the questionnaire and the answers by respondents confirmed its face and content validity. Criterion validity was measured by correlation with scores obtained on a validated generic measure of quality of life, the Short Form 36. Women with detrusor instability had greater quality of life impairment than women with other urodynamic diagnoses.

Conclusion The questionnaire was easy for the women to use and was a valid and reliable instrument for the assessment of quality of life in women with urinary incontinence. It will be useful for the rapid appraisal and follow up of women with urinary incontinence in many different clinical settings, including the evaluation of new treatments of urinary incontinence in controlled clinical trials.
The management of cervical carcinoma within the South West Region of England
Authors: Jackson S. , Murdoch J. , Howe K. , Bedford C. , Sanders T. , Prentice A. ,   On behalf of the Expert Tumour Panel: R. Anderson, V. Barley, T. Clarke, A. Falconer, J. Graham, L. Hirschowitz, A. Hong, R. Owen, J. Richardson, G. Swingler
Published: August 2005

Objective
1. To audit the management of cervical carcinoma in the South West Region with the aim of identifying and addressing deficiencies. 2. To determine whether recent NHS restructuring has affected the provision of cancer care.

Design
Retrospective review of hospital case notes.

Setting
All hospitals in the South West Region of England.

Population
Three hundred and twenty‐four women with a diagnosis of cervical carcinoma: 191 were diagnosed in 1989 and 133 in 1993.

Main outcome measures
Documentation of patient assessment and management.

Results
There was a mean delay of 17 days (range 0–66) from cervical smear to cytology report and 34 days (range 1–380) from general practitioner referral to attendance at a hospital clinic. Overall, 175 women (54%) had evidence of cytological assessment prior to treatment and 137 (42%) had a colpo‐scopic assessment; 49% had cytological assessment and 37% had colposcopy in 1989, compared with 60% and 50%, respectively, in 1993. Excluding 49 cases of micro‐invasive carcinoma, 238 case notes (86%) contained evidence of clinical examination; 195 women (71%) had had an examination under anaesthesia, 115 (42%) a chest radiograph, 123 (45%) an intravenous urogram or renal ultrasound, and 92 (33%) cystoscopy. One hundred and forty‐seven women (53%) had FIGO staging recorded in the notes. As first line treatment, 69 had conservative surgery (39 for Stage IA), 138 had radiotherapy, and 107 had radical surgery. Ten had radical surgery for Stage IA but eight had a > 3 mm invasion or lymphatic/vascular spread. Thirty‐one had Stage IB treated with radiotherapy of whom 14 were younger than 50 years of age. Following radical surgery 30% had evidence of sampling 10 nodes, and 9% had tumour extending to the resection margins.

Conclusions
Record keeping was inadequate but appeared to indicate inconsistent cytological, clinical, colposcopic and radiological assessment, leading to inappropriate clinical delays and conservative surgery. Radical surgery often appeared inadequate, but poor node sampling rates may also reflect insufficient histopathological preparation or reporting. There was a reduction in the number of new cases of cervical carcinoma diagnosed in 1993, perhaps reflecting an observed increase in cytological surveillance. No other alterations in clinical practice were observed over the four‐year period. We feel it is imperative to standardise assessment throughout the region with a minimum clinical and histopathological dataset.
Management of twin pregnancies discordant for anencephaly
Authors: Sebire Neil J. , Sepulveda Waldo , Hughes Karen S. , Noble Penny , Nicolaides Kypros H.
Published: August 2005

Objective
To examine options of management and outcome of twin pregnancies discordant for anencephaly.

Design
Retrospective study.

Setting
Research Centre for Fetal Medicine.

Population
Twenty‐four twin pregnancies discordant for anencephaly.

Methods
A computer search was made of our database for twin pregnancies discordant for anencephaly. The data were reviewed for gestation at presentation, chorionicity, management and pregnancy outcome.

Main outcome measures
Pregnancy outcome in relation to chorionicity and management.

Results
There were 13 dichorionic and 11 monochorionic twin pregnancies discordant for anencephaly. In the dichorionic group five pregnancies had selective fetocide at 17 to 21 weeks; one pregnancy resulted in spontaneous abortion but in the others a healthy infant was born at a median gestation of 37 weeks. The other eight dichorionic pregnancies were managed expectantly, but three developed polyhydramios at 26 to 30 weeks; in one case amniodrainage was performed and in another selective fetocide was carried out. In this group the median gestation at delivery was 35 weeks. All 11 monochorionic pregnancies were managed expectantly and in three there was intrauterine death of both fetuses. In the other eight cases the normal twin was liveborn at a median gestation of 34 weeks; in four of these pregnancies polyhydramnios developed and two were managed by amniodrainage.

Conclusions
In monochorionic pregnancies, expectant management is associated with a high rate of intrauterine lethality of the normal twin. In dichorionic pregnancies selective fetocide in the second trimester prevents the development of polyhydramnios and is associated with a lower risk of preterm delivery but can cause miscarriage.
Liver function tests in pre‐eclampsia: importance of comparison with a reference range derived for normal pregnancy
Authors: Girling J. C. , Dow E. , Smith J. H.
Published: August 2005

Objectives
To determine reference ranges for liver function tests in uncomplicated pregnancy and to relate abnormal results by these criteria to outcome in pre‐eclampsia.

Design
Prospective, cross‐sectional study to establish the reference ranges. Prospective observational study of women with pre‐eclampsia.

Setting
Antenatal clinics and obstetric unit of St Mary's Hospital, London.

Participants
Four hundred and thirty women with uncomplicated pregnancies and 85 consecutive women with gestational hypertension.

Main outcome measures
Aspartate transaminase (AST), alanine transaminase (ALT), bilirubin and gamma glutamyl transferase (GGT) were measured to determine their ranges in normal pregnancy. The severity of pre‐eclampsia was determined by the maximum blood pressure, creatinine and 24 h urinary protein; minimum platelet count; maternal complications; mode of and gestation at delivery; and fetal outcome with centile weight adjusted for gestational age and sex.

Results
AST, ALT, bilirubin and GGT were each lower in uncomplicated pregnancy than the nonpregnant laboratory reference ranges. Of those cases with elevated liver function tests in the pre‐eclampsia group, 37% were abnormal only by the new reference ranges. Using the new ranges, the prevalence of elevated liver function tests was significantly higher in the pre‐eclampsia group (54%) than in those with pregnancy induced hypertension (14%) (P < 0.01). Amongst those with pre‐eclampsia, abnormal liver function tests were associated with greater proteinuria(P < 0.05), lower platelet count(P < 0.001) and more maternal complications(P < 0.01) than normal liver function tests; there was no difference in the severity of hypertension between the groups.

Conclusions
Liver function tests are lower in normal pregnancy than the reference ranges currently used. Our pregnancy‐derived ranges allow more precise identification of abnormal liver function in women with pre‐eclampsia than is possible using standard reference ranges derived from a nonpregnant population.
Normal findings in vulvar examination and vulvoscopy
Authors: van Beurden Marc , van der Vange Nine , de Craen Anton J. M. , Tjong‐A‐Hung Stevcn P. , ten Kate Fiebo J. W. , ter Schegget Jan , Lammes Frits B.
Published: August 2005

Objective
To determine the normal vulvar findings by naked eye examination and by vulvoscopy in healthy women without vulvar complaints.

Design
Observational study.

Population
Forty healthy volunteers without vulvar complaints recruited via a newspaper advertisement.

Methods
Vulvar examination, human papillomavirus (HPV) polymerase chain reaction of vulvar and cervical swabs, saline and KOH smears and vulvoscopy before and after the application of 5% acetic acid.

Main outcome measures
Prevalence of vestibular erythema, vestibular papillomatosis, HPV infection on the vulva and in the cervix and vulvoscopic findings.

Results
The mean age of the women was 37.8 years (median 38.0, range 21–56). Nine women were current smokers and 21 had previously smoked. Naked eye vulvar examination showed vestibular papillomatosis in 13 women (33%) and vestibular erythema in 17 women (43%). The touch test was positive in 9 of the 17 women (53%) with vestibular erythema. Vulvoscopy after the application of acetic acid 5% showed an acetowhite vestibule in all women. Twelve women (30%) had acetowhite lesions outside the vestibule. Six women (15%) were positive for HPV DNA. The presence of HPV DNA did not correlate with vestibular erythema or vestibular papillomatosis. There was a weak association between HPV DNA and acetowhite lesions outside the vestibule (P= 0.055, Fisher's exact test). In this group the younger women significantly more often had vestibular papillomatosis (t‐statistic = 3.07; P= 0.003) and women who smoke more often had a genital HPV infection (P= 0.016, Fisher's exact test).

Conclusions
Vestibular erythema, vestibular papillomatosis, and acetowhite lesions are common in this group of healthy women without vulvar complaints.
The B‐Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported
Authors: B‐Lynch Christopher , Coker Adeyemi , Lawal Adegboyega H. , Abu Jaf , Cowen Michael J.
Published: August 2005

The B‐Lynch suturing technique (brace suture) may be particularly useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus fertility. Satisfactory haemostasis can be assessed immediately after application. If it fails, which has not yet been the case, other more radical surgical methods as mentioned in this paper and in the literature can be considered. The special advantage of this innovative technique is an alternative to major surgical procedures to control pelvic arterial pulse pressure or hysterectomy. This suturing technique has been successfully applied with no problems to date and no apparent complications.
Complications of laparoscopy: a prospective multicentre observational study
Authors: Jansen Frank Willem , Kapiteyn Kitty , Trimbos‐Kemper Trudy , Hermans Jo , Trimbos J. Baptist
Published: August 2005

Objective
To determine the incidence and describe the complications of laparoscopic procedures in The Netherlands.

Design
A nationwide prospective multicentre observational study.

Methods
Data on complications were registered from 1 January to 31 December 1994 by 72 hospitals. Any unexpected or unplanned event requiring intra‐operative or post‐operative intervention was defined as a complication. Complications were classified in two groups: approach and technique related complications. Complication rates were compared with these already published.

Results
Of 25,764 laparoscopic procedures, 145 complications occurred (rate 5.7 per 1000 [%0]); two deaths occurred. In 84 women laparotomy was necessary (rate 3.3%0). In 83 cases (57%; 95% CI for approach = 49–65%) the complication was caused by the surgical approach; in 62 cases (43%) the technique was at fault. Haemorrhage of the epigastric vein and intestinal injury, often requiring laparotomy (90% of cases) were the most frequently observed complications. The complication rate was 2.7%0 for diagnostic laparoscopic procedures, 4.5%0 for sterilisation and 17.9%0 (χ2= 127; dF = 2; P <0.001) for operative laparoscopy. The highest incidence was registered for complications occurring during laparoscopic (assisted) hysterectomy. Stepwise logistic regression analysis showed that previous laparotomy and surgical experience were associated with complications requiring laparotomy.

Conclusions
Most complications occurred during operative laparoscopic procedures (rate 17.9%0). Residents in training are required to learn diagnostic laparoscopy and sterilisation and this training programme results in a fall in the risk of the complications. However, operative laparoscopic procedures are still hazardous, especially laparoscopic hysterectomy. Women with a previous laparotomy are particularly at risk.
Familial puerperal alactogenesis: possibility of a genetically transmitted isolated prolactin deficiency
Authors: Zargar Abdul Hamid , Masoodi Shariq Rashid , Laway Bashir Ahmad , Shah Nissar Ahmad , Salahudin Mohammed
Published: August 2005

Isolated prolactin deficiency is a rare disorder of which only few cases have been reported. In this study we report a woman and her mother who during their eight pregnancies had puerperal alactogenesis. Hormone evaluation revealed isolated prolactin deficiency in both of them. This report demonstrates the dominant role played by prolactin in puerperal lactation. We postulate the possibility of a genetically transmitted isolated prolactin deficiency.
Transdermal oestradiol gel in the treatment of the climacterium: a comparison with oral therapy
Authors: Hirvonen E. , Lamberg‐Allardt C. , Lankinen K. S. , Geurts P. , Wilén‐Rosenqvist G.
Published: August 2005

Objective
To compare two doses of a transdermal oestradiol gel (Divigel®/Sandrena®) plus oral sequential medroxyprogesterone acetate (MPA) with oral oestradiol valerate plus oral sequential MPA (Divina®/Dilena®).

Design
Two‐year, randomised, open‐label, comparative study.

Setting
Menopausal outpatient clinic in Helsinki.

Subjects
Postmenopausal women with climacteric complaints or already using HRT.

Interventions
(1) One gram gel containing 1 mg oestradiol for 3 months plus 20 mg oral MPA during the last 14 days; (2) 2 g gel containing 2 mg oestradiol for 21 days plus 10 mg oral MPA during the last 14 days; (3) 2 mg oestradiol valerate tablets for 3 weeks plus 10 mg oral MPA during the last 10 days. In all groups, each treatment period was followed by a 7‐day medication‐free interval.

Main outcome measures
Climacteric complaints, bleeding control, bone mineral density, biomarkers of bone metabolism, lipid profile, tolerability and safety.

Results
With each preparation, climacteric complaints were significantly reduced and good bleeding control was obtained. In addition, maintenance of bone mineral density as well as a reduction of bone turnover was achieved in all groups. Lipid parameters showed no unfavourable changes. Continuation rates were similar in all groups with overall 74% of patients completing the first year, whereas 94% of patients who elected to continue completed the second year. Tolerability of the gel was good: only 1.7% of patients discontinued treatment due to skin irritation.

Conclusions
Transdermal oestradiol gel and oral oestradiol valerate tablets, used in combination with oral sequential MPA, are effective regimens of HRT in postmenopausal women. Transdermal oestradiol gel is an efficient, well‐tolerated form of HRT.
Maternal birthweight and diet in pregnancy in relation to the infant's thinness at birth
Authors: Godfrey K. M. , Barker D. J. P. , Robinson S. , Osmond C.
Published: August 2005

Objective
To examine how maternal diet in pregnancy and parental body size and birthweight influence an infant's thinness at birth measured by a low ponderal index.

Design
An observational study of newborn infants and their parents.

Setting
Southampton, England.

Population
Five hundred and thirty‐eight infants born at term.

Main outcome measure
Ponderal index at birth.

Results
Women who had a high intake of carbohydrate in early pregnancy and a low intake of dairy protein in late pregnancy tended to have infants that were thin at birth (P= 0.01 and P= 0.03, respectively, in a simultaneous analysis). Women who themselves had a low birthweight also tended to have thin infants, ponderal index falling from 28.3 kg/m3 to 26.2 kg/m3 as the women's birthweights decreased from more than 4.0 kg to 2.5 kg or less (P < 0.0001). Tall fathers had thin infants, but ponderal index was not related to the women's heights or the fathers’ birthweights.

Conclusion
These associations may reflect constraints on placental development imposed by a woman's nutrition in pregnancy and during her own intrauterine life. Effects of the father's height may be mediated through genetic influences on skeletal growth.
Simultaneous effects of aneuploidy and oncogenic human papillomavirus on histological grade of cervical intraepithelial neoplasia
Authors: Monsonego Joseph , Valensi Pierre , Zerat Laurent , Clavel Christine , Birembaut Philippe
Published: August 2005

Objective
To investigate whether ploidy and oncogenic human papillomavirus types can be correlated with the histological grade of cervical intraepithelial neoplasia (CIN) in the same tissue sections.

Design
Histological data were obtained from 292 dysplastic lesions of the cervix and classified according to the CIN and the Bethesda terminologies. The samples were analysed using Feulgen‐stained image analysis cytometry for ploidy and Human papillomaviruses DNA typing by in situ hybridisation, respectively.

Setting
Colposcopy Clinic at Alfred Fournier Institute, Paris.

Population
Three hundred and forty women referred for an abnormal cervical smear.

Results
The ploidy data strongly segregate high grade from low grade squamous intraepithelial lesions (aneuploidy 78%versus 21%; P < 0.0001). There was a significant association between aneuploidy and the severity of the lesions (94% for CIN 3, 55% for CIN 2 and 14% for CIN 1; P < 0.0001). Both classifications showed a significant association of histological grade with oncogenic human papillomavirus types (HPV 16–18–33: 20% in low grade and 78% in high grade squamous intraepithelial lesions, 31% and 75% in CIN 1 and CIN 3, respectively; P < 0.0001). The simultaneous effects of these viruses and ploidy demonstrate an association in aneuploid cells between the presence of oncogenic human papillomavirus types and histological grade (76% and 18% in high and low grade squamous intraepithelial lesions, respectively; P < 0.0001). Such an association was not observed in diploid cells (20% in both low and high grade squamous intraepithelial lesions).

Conclusion
High risk human papillomavirus types do not exert an independent effect on the histological grade of cervical intraepithelial neoplasia.
Randomised trial of expectant versus surgical management of spontaneous miscarriage
Authors: Chipchase Jeremy , James David
Published: August 2005

Thirty‐five women with retained products of conception after spontaneous miscarriage were randomised to expectant (n=19) or surgical (n=16) management, respectively. Women were reviewed at one week, two weeks and six months. There were no significant differences in the number of days of pain, bleeding, sick leave or return to normal periods. Nine of twelve women from the expectant group and six of nine from the surgical group who attempted to conceive did so by six months. All 16 women were satisfied with conservative management. This study provides further reassurance when considering expectant management for spontaneous miscarriage both in the short and medium term.
Randomised placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study
Authors: Nagele Fritz , Lockwoodb Gillian , Magos Adam L.
Published: August 2005

An increasing number of diagnostic hysteroscopies are being performed in an outpatient setting. Most women tolerate the examination well, but die single commonest reason for failure is pain. We assessed the efficacy of a nonsteroidal, anti‐inflammatory analgesic as premedication before hysteroscopy in a double‐blind, placebo controlled trial. Our results showed that 500 mg mefenamic acid given one hour before hysteroscopy had no significant benefit in the discomfort experienced during the procedure but did signficantly reduce pain after hysteroscopy. A larger dose or a longer interval between premedication and hysteroscopy may possibly be associated with greater benefits.
Medical causes on stillbirth certificates in England and Wales: distribution and results of hierarchical classifications tested by the Office for National Statistics
Authors: Alberman Eva , Blatchley Nick , Botting Beverley , Schuman Jeremy , Dunn Alistair
Published: August 2005

Objective
To produce a classification of stillbirths registered in England and Wales compatible with a previously described classification for neonatal deaths; to compare national data for intrapartum stillbirths with those for the remaining stillbirths; and to report on stillbirths with a gestational age of 24 to 27 completed weeks first made registrable on 1 October 1992.

Design
Algorithms were developed and tested to derive hierarchical cause classifications making use of multiple causes mentioned on stillbirth certificates.

Results
The additional information available since 1986 on cause and time of death of stillbirths, classified in a hierarchical fashion allows a more meaningful interpretation of the available information on the causes of stillbirth than was previously possible and does not perturb ongoing trends. Antepartum deaths without a classifiable cause contributed the majority: between 1992 and 1994 they accounted for 43% if mentions of asphyxial conditions are regarded as classifiable causes, and 82% if not considered as causal. Stillbirths described as occurring intrapartum are consistently of higher gestational age and birthweight than the remainder, lending validity to the time of death given.

Conclusions
The national use of a classification including reported time of death of the fetus and mentions of asphyxial conditions is justifiable, providing a distinction is made between associated mentions and causal conditions. Better and more complete clinical information on stillbirth certificates will contribute further to understanding of their causes.
Randomised trial of one versus two doses of prostaglandin E2 for induction of labour: 2. Analysis of cost
Authors: MacKenzie I. Z. , Magill Patrick , Burns Ethel
Published: August 2005

Objective
To compare the impact upon maternity unit resources and finances of two protocols for induction of labour using prostaglandins.

Design
A prospective randomised trial comparing a single dose of prostaglandin E2 (2 mg) in the evening with two doses of prostaglandin E2 (2 mg), the second being given after six hours if labour had not started or the cervix was still unripe, followed if necessary by formal induction of labour by amniotomy and oxytocin infusion 14 to 20 hours after the initial prostaglandin E2 dose. Outcome for nulliparae and multiparae were analysed separately, by treatment intention.

Setting
A maternity unit in a district general hospital delivering > 6000 women annually.

Participants
Nine hundred and fifty‐five women with viable singleton pregnancies and cephalic presentation at term without previous history of caesarean section who were advised to have labour induced with prostaglandins.

Main outcome measures
Costs incurred in managing all aspects of labour, including time spent on the antenatal ward and, in the delivery unit; costs associated with formal induction, augmentation of labour and epidural analgesia; costs of intrapartum maternal morbidity, mode of delivery and immediate neonatal care. Costs of postpartum hospital stay were estimated from unit statistics.

Results
The overall mean cost of induction of labour was £5.00 and £7.22 less per woman for nulliparae and multiparae, respectively, if the two dose regimen was used. The main reason for the differences was due to delivery suite costs from the slightly greater rate of assisted deliveries in the single treatment groups. In contrast, costs for neonatal care were marginally lower if only one prostaglandin dose was used.

Conclusions
The increased drug costs providing two prostaglandin E2 doses when required were off‐set by reductions in the costs of other intrapartum interventions for both nulliparae and multiparae. The advantages of less time spent on the antenatal ward for multiparae when two prostaglandin E2 doses were used may be eliminated if amniotomy and oxytocin infusion was commenced six hours after the initial prostaglandin dose had been given if labour had not started.
Activated protein C resistance in normal pregnancy
Authors: Peek Michael J. , Nelson‐Piercy Catherine , Manning Richard A. , de Swiet Michael , Letsky Elizabeth A.
Published: August 2005

This prospective cross‐sectional (10 women on each occasion) and longitudinal (20 women) study investigated activated protein C (APC) ratio in normal pregnancy. The APC ratio was measured at booking, 20, 30 and 36 weeks of gestation, and compared with a sample of normal nonpregnant women. No significant difference was found between APC ratios for pregnant women at any gestation and those of the nonpregnant population in either the longitudinal or cross‐sectional studies. There was a significant decrease in APC ratios throughout pregnancy, but in all but one case values remained within the normal nonpregnant range. The APC ratio can therefore be used as a screening test for the factor V Leiden mutation during pregnancy.
Unsuccessful treatment of missed abortion with a combination of an antiprogesterone and a prostaglandin E1 analogue
Authors: Nielsen S. , Hahlin M. , PtetZrChristensen J. J.
Published: August 2005

In a prospective clinical trial the effectiveness of a combination of 400 mg of mifepristone (antiprogesterone) and 400 g misoprostol (synthetic prostaglandin E1 analogue), both taken orally, was evaluated for the treatment of missed abortion. Of the 31 patients included, 16 (52%) had an empty uterine cavity at follow up six days after inclusion, 11 (35%) required surgical evacuation for retained intrauterine products of conception found at follow up, and four (13%) required emergency surgical evacuation due to severe pain or bleeding. The results do not support the use of mifepristone and misoprostol for women wishing the miscarriage to be resolved quickly.