bluuebunny/crossref_metadata_2025 huggingface dataset:
Colour Doppler energy insonation of placental vasculature in monochorionic twins: absent arterio‐arterial anastomoses in association with twin‐to‐twin transfusion syndrome
Authors: Denbow Mark L. , Cox Phillip , Talbert David , Fisk Nicholas M.
Published: August 2005

Objective
To determine in vivo whether monochorionic pregnancies complicated by twin‐to‐twin transfusion syndrome are associated with absence of haemodynamically‐compensatory arterioarterial anastomoses.

Design
Forty monochorionic pregnancies were prospectively recruited for an ultrasonographic survey of the chorionic plate using colour Doppler energy. Arterio‐arterial anastomoses were identified by their characteristic bidirectional interference pattern on spectral Doppler. Angioarchitecture was confirmed by postnatal injection study.

Setting
Fetal medicine tertiary referral centre in London.

Main Outcome measures
Presence of arterio‐arterial anastomoses, development of twin‐to‐twin transfusion syndrome, survival.

Results
Arterio‐arterial anastomoses were detected by colour Doppler energy in 21 pregnancies (53%), and there were no false positives. An arterio‐arterial anastomosis was more commonly found in unaffected (n= 28) compared to pregnancies affected by twin‐to‐twin transfusion syndrome (n= 12), both by colour Doppler energy [20/28 (71%) vs 1/12 (8%); Δ= 63%, 95% CI 40%‐86%] and by postnatal injection study [25/28 (89%) vs 3/12 (25%); Δ= 64%, 95% CI 37%‐91%]. In pregnancies in which no arterio‐arterial anastomoses were detected, a diagnosis of twin‐to‐twin transfusion syndrome was made in 58%, and the perinatal loss rate was 40%, compared with one case of twin‐to‐twin transfusion syndrome (5%) (P < 0.001) and a loss rate of 12% (P = 0.005) in pregnancies in which an arterio‐arterial anastomosis was detected.

Conclusion
Twin‐to‐twin transfusion syndrome is associated with an absence of functional arterio‐arterial anastomoses in vivo in monochorionic twin pregnancies. This contributes to our understanding of the pathophysiology of twin‐to‐twin transfusion syndrome and confirms ex vivo studies demonstrating that twin‐to‐twin transfusion syndrome is associated with a paucity of superficial anastomoses. Prospective studies are indicated to determine the utility of colour Doppler energy for arterio‐arterial anastomoses in predicting risk in monochorionic pregnancies.
Efficacy of minor analgesics in primary dysmenorrhoea: a systematic review
Authors: Zhang W. Y. , Li Wan Po A.
Published: August 2005

Objective
To quantify the efficacy and safety of naproxen, ibuprofen, mefenamic acid, aspirin and acetaminophen (paracetamol) in the treatment of primary dysmenorrhoea through a systemic overview of randomised controlled trials.

Methods
MEDLINE, EMBASE and the Science Citation Index were searched for randomised controlled trials. Efficacy was assessed by measurement of pain relief, requirement for rescue analgesics, restriction of daily life and absence from work or school. The rate ratios of side effects were used to assess safety.

Results
Fifty‐six trials describing 55 comparisons of analgesics with placebo and 12 direct comparisons with other analgesics met our inclusion criteria. Women taking naproxen were over three times more likely to have at least moderate pain relief than those taking placebo. Ibuprofen, mefenamic acid and aspirin were also superior to placebo but acetaminophen was not. The requirement for rescue analgesics, restriction of daily life and absence from work or school were less frequent with naproxen and ibuprofen than placebo but not with aspirin or acetaminophen. Direct comparisons did not show any difference between naproxen and ibuprofen. Side effects occurred more frequently only with naproxen when compared with placebo.

Conclusion
Naproxen, ibuprofen, mefenamic acid and aspirin are all effective in primary dysmenorrhoea. Ibuprofen appears to have the most favourable risk‐benefit ratio. Acetaminophen appears to be less effective than nonsteroidal anti‐inflammatory drugs, but there was only one trial meeting our inclusion criteria and further studies are required.
Obstetric risk factors for periventricular leukomalacia among preterm infants
Authors: Spinillo Arsenio , Capuzzo Ezio , Stronati Mauro , Ometto Alessandra , De Santolo Antonella , Acciano Salvatore
Published: August 2005

Objective
To evaluate the obstetric antecedents of cystic periventricular leukomalacia and transient echodense periventricular lesions among preterm infants.

Design
A cohort study of preterm singleton infants born between 25 and 33 weeks gestation.

Setting
Pavia, Italy.

Population
Three hundred and forty‐nine infants admitted to a Division of Neonatal Intensive Care who were screened for periventricular leukomalacia.

Method
The obstetric factors in infants with either cystic periventricular leukomalacia or transient echodense periventricular lesions were compared to those in infants with negative cranial ultrasonographic findings. Stepwise multiple logistic regression analysis was used to evaluate the association between risk factors and outcomes adjusting for confounders.

Results
The prevalence of cystic periventricular leukomalacia and transient echodense lesions was 5.7% (20/349) and 14% (49/349), respectively. The main risk factors for cystic leukomalacia were first trimester haemorrhage (OR 4.49; 95% CI 1.63–12.39), maternal urinary tract infection on admission (OR 5.71; 95% CI 1.91–17‐07), and neonatal acidosis (PH < 7.2) at birth (OR 5–97; 95% CI 1.93–18.52). Meconium‐stained amniotic fluid (OR 3.95; 95% CI 1.42–10.98) and long term (> 72 hours) ritodrine tocolysis (OR 2.54; 95% CI 1.28–5.05) were associated with an increased risk of echodense lesions. The likelihood of overall leukomalacia (cystic plus echodense periventricular lesions) was increased among cases with meconium‐stained amniotic fluid (OR 4–06; 95% CI 1.65–10.0), long‐term ritodrine tocolysis (OR 2.56; 95% CI 1.38–4.72), maternal infection (OR 1.73; 95% CI 1.0–3.0), and acidosis at birth (OR 1.98; 95% CI 1.0–3.98).

Conclusions
This study confirms that maternal infection, acidosis at birth, and meconium‐stained amniotic fluid increase the risk of periventricular leukomalacia in preterm infants. Long‐term ritodrine use seems to increase the risk for transient echodense lesions.
Risk of myocardial infarction, angina and stroke in users of oral contraceptives: an updated analysis of a cohort study
Authors: Mant Jonathan , Painter Rosemary , Vessey Martin
Published: August 2005

Objectives
To investigate risk of myocardial infarction, angina and stroke in users of contraceptive pills compared with users of other methods of contraception.

Design
Prospective cohort study, with recruitment between 1968 and 1974 and annual follow up until the age of 45 years. After this age, only women who had never used oral contraception or those who had used it for eight or more years continued to be followed up annually until July 1994.

Setting
Seventeen family planning clinics in England and Scotland.

Population
17,032 women aged between 25 and 39 years at entry to the study.

Main outcome measures
Occurrence of angina, myocardial infarction or stroke that was associated with either hospital admission or outpatient referral to hospital or death.

Results
Increased risk of myocardial infarction in oral contraceptive users was observed only in women who were heavy smokers at entry to the study. In this subgroup the relative risk of a myocardial infarction was 4.2 (95% CI 1.4–16.6) in ever users of oral contraception compared with non‐users, 4–9 (1.2–23.6) in current users, and 4–0 (1.3–16.2) in ex‐users. In all current users the relative risk of angina was 0.5 (0.1–1.4), and the relative risk of ischaemic stroke was 2.9 (1.3–6.7). The increased risk of ischaemic stroke did not persist in ex‐users.

Conclusions
Use of oral contraception is associated with increased risk of ischaemic stroke and increased risk of myocardial infarction (only in heavy smokers), but no increased risk of angina. These increased risks need to be considered within the context of the very low absolute risks of cardiovascular disease in this population. 5880 women need to take oral contraception for one year to cause one extra stroke, and 1060 women who are heavy smokers need to take it for one year to cause one extra myocardial infarction.
Risk of hysterectomy after 1000 consecutive endometrial laser ablations
Authors: Phillips Graham , Chien Patrick F. W. , Carry Ray
Published: August 2005

ObjectivesTo determine the hysterectomy rate after endometrial laser ablation, allowing for variable follow up times, and to evaluate the factors that might predict outcome.

DesignObservational cohort study.

SettingSpecialist minimal access gynaecology unit in a district general hospital.

MethodsData were obtained from case notes, theatre records, and follow up postal questionnaires. The risk of hysterectomy following endometrial laser ablation was assessed using survival curve estimates. Proportional hazards regression analysis was used to identify the predictor(s) of this outcome.

ResultsA single endometrial laser ablation was carried out on 746 patients (85.4%); 124 patients (14.2%) underwent one repeat procedure and three (0.4%)) underwent two repeat ablative procedures. The cumulative rate of return of the postal questionnaires was 87.3% (762/873 patients). Survival curve analysis showed that the overall hysterectomy rate projected over a follow up period of 6.5 years was 21% (95% CI 16%‐27%). The age of the patient at endometrial ablation, uterine cavity length, operative time, volume of fluid absorbed, the presence or absence of dysmenorrhoea, premenstrual syndrome and the method of endometrial preparation prior to surgery did not contribute significantly to the regression model. Having a repeat endometrial ablation procedure increased the risk of having a subsequent hysterectomy (RR = 2.93; 95% CI 1.59–5.40;P= 0.0015), whereas the presence of intrauterine pathology (eg, polyps, fibroids and uterine shape abnormalities) decreased the risk of this outcome (RR = 0.26; 95% CI 0.08–0.86;P= 0.0082) after adjustment for confounding due to patient's age and dysmenorrhoea prior to surgery.

ConclusionsEndometrial laser ablation is a safe and effective treatment for menstrual dysfunction. Repeat ablative procedures significantly increased, and the presence of intrauterine pathology decreased, the risk of subsequent hysterectomy. variable follow up times, and to evaluate the factors that might predict outcome.
Severe acute maternal morbidity: a pilot study of a definition for a near‐miss
Authors: Mantel Gerald D. , Buchmann Eckhart , Rees Helen , Pattinson Robert C.
Published: August 2005

Objective
To test the application of a clinical definition of severe acute maternal morbidity.

Design
A one‐year prospective descriptive multi‐centre study.

Setting
Kalafong and Pretoria Academic hospitals, catering for the delivery of indigent women in the Pretoria Health Region.

Methods
A ‘near‐miss’ describes a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death. The case notes of women fitting this definition and all maternal deaths were analysed and compared.

Outcome measure
Determine the primary obstetric factors and the organ systems that failed. Identification of episodes of sub‐standard care and missed opportunities.

Results
One hundred and forty‐seven near misses and 30 maternal deaths were identified. The commonest reasons for a near‐miss were: emergency hysterectomy in 42 women (29%); severe hypotension in 40 (27%); and pulmonary oedema in 24 (16%). The most common initiating obstetric conditions were hypertension in 38 women (26%); haemorrhage in 38 (26%); and abortion or puerperal sepsis in 29 (20%). The primary obstetric factors amongst the maternal deaths were: hypertension (33%); sepsis (27%); and maternal medical diseases (17%) in 10, 8 and 5 women respectively. Sub‐standard care was identified in 82 cases. Breakdown in the health care administration was identified in 33, and patient‐orientated missed opportunities on 34 occasions.

Conclusions
The definition of severe acute maternal morbidity identified nearly five times as many cases as maternal death. This definition allows for an effective audit system of maternal care because it is clinically based, the definition is robust and the cases identified reflect the pattern of maternal death.
Do routine antibiotics after loop diathermy excision reduce morbidity?
Authors: Foden‐Shroff J. , Redman C. W. E. , Tucker H. , Millinship J. , Thomas E. , Warwick A. , Jones P. W.
Published: August 2005

Objective
To evaluate whether routinely giving an antibiotic after loop diathermy excision of the cervical transformation zone reduced post‐operative vaginal loss.

Design
Prospective, randomised, double‐blind placebo controlled parallel study.

Participants
Five hundred women undergoing loop diathermy excision in a colposcopy clinic.

Intervention
Administration of either ofloxacin 400 mg (2 × 200 mg) once daily for 5 days or an identical placebo.

Main outcome measure
Vaginal loss, assessed using a pictorial chart.

Results
No significant difference in post‐operative vaginal loss was found.

Conclusion
Routine antibiotic prophylaxis after loop diathermy excision is not justified.
Screening for endometrial cancer in asymptomatic postmenopausal women with conventional and colour Doppler sonography
Authors: Vuento Maarit H. , Pirhonen Jouko P. , Mäkinen Juha I. , Tyrkkö Juhani E. , Laippala Pekka J. , Grönroos Matti , Salmi Thula A.
Published: August 2005

Objective
To evaluate endometrial thickness and uterine arterial flow measurement as predictors of endometrial cancer.

Design
Prospective study among a cohort of women invited to age‐adjusted, population‐based breast cancer screening by mammography.

Setting
City of Turku, Finland.

Population
1074 postmenopausal women aged 57–61 years (mean 59 years).

Methods
Conventional and colour Doppler sonography. Endometrial biopsy was taken when the endometrial thickness (double layer) was ≥ 4.0 mm, if the uterine artery pulsatility index was ≤ 1.0 or if there was a fluid accumulation in the endometrial cavity.

Main outcome measures
Detection of endometrial cancer in endometrial biopsy. Record linkage with the files of the Finnish Cancer Registry three and a half years after the first ultrasound examination. Major statistical results are based on the analysis of variance and logistic regression models.

Results
An endometrial biopsy was taken from 291 women (27%). One woman had endometrial tuberculosis, three an endometrial polyp, 16 endometrial hyperplasia, three endometrial carcinoma (Stage Ib), and one had cervical carcinoma (Stage Ib). One woman was diagnosed as having endometrial cancer Stage Ib two and a half years after screening; she had refused further examination after a positive screen. A second endometrial cancer (Stage Ib) was diagnosed three years after a negative screening result.

Conclusion
Transvaginal sonography is confirmed to have a very high sensitivity for the detection of early endometrial carcinoma, but the specificity remains low. If endometrial cancer is to be detected at an early stage, further examinations should be carried out when the endometrial thickness is ≥ 4.0 mm, especially when the woman has risk factors such as obesity, late menopause or current use of hormonal replacement therapy. Doppler sonography does not improve the detection of premalignant and malignant endometrial lesions compared with normal ultrasound.
A prospective follow up study of women with colposcopically unconfirmed positive cervical smears
Authors: Milne D. S. , Wadehra V. , Mennim D. , Wagstaff T. I.
Published: August 2005

Objective
To examine a cohort of women with positive cervical smears, but negative colposcopy, in order to ascertain whether there is a subsequent difference in the incidence of squamous dyskaryosis and cervical intraepithelial neoplasia when compared with a control group.

Design
Prospective follow up study.

Setting
Colposcopy clinics, antenatal clinics, GP surgeries.

Methods
A study group of 255 women with reported abnormal cervical smears but negative colposcopy was subdivided into three groups according to referral smears suggesting high grade dyskaryosis (n= 34), mild dyskaryosis (n= 120) and borderline changes (n= 101). They were followed for at least five years and were compared with a control group of 726 women followed up after a negative smear, using the first and worst follow up smears over a five year recall period.

Main outcome measures
Incidence of subsequent cervical cytological and histological abnormalities.

Results
The control group had a similar incidence of squamous dyskaryosis as that expected in the screening population. Forty‐six per cent of the study group with colposcopically unconfirmed (‘false positive’) cervical smears subsequently had abnormal smears. When the three groups were compared with controls using a χ2 test, their incidence of abnormal smears was significantly increased. Cervical intrepithelial neoplasia was found in 19% of the study group, and in 3% of the control group (P < 0.0001).

Conclusions
The analysis demonstrates that women with so‐called ‘false positive’ smears defined by negative colposcopy have an increased risk of subsequent abnormal smears and cervical intrepithelial neoplasia, suggesting that lesions may have been missed on colposcopy. However, in a significant proportion of women, further abnormalities were not detected during the follow up period, indicating that there may be other causes for positive smears and negative colposcopy.
Antenatal screening for hepatitis B infection and syphilis in the UK
Authors: Newell Marie‐Louise , Thorne Claire , Pembrey Lucy , Nicoll Angus , Goldberg David , Peckham Catherine
Published: August 2005

Objectives
To assess antenatal hepatitis B and syphilis screening policies in the UK.

Design
Postal questionnaire survey.

Setting
One hundred and ninety‐two obstetric units and 116 Public Health directorates.

Main outcome measures
Antenatal screening policy and line of responsibility for ensuring vaccine uptake in hepatitis B virus exposed children.

Results
Replies were received from 140 (73%) obstetric centres and 99 (85%) Public Health directors. Forty per cent of obstetric centres now offer hepatitis B virus tests to all pregnant women, and nearly one‐quarter (24.1 %) of all births in the UK in 1996 occurred in centres with a universal testing policy. The prevalence of chronic hepatitis B virus ranged from 0.3 to 17.5 per 1000 deliveries. Universal antenatal screening for serological evidence of syphilis was the norm, but five obstetric centres respondents and three Public Health directors were considering its discontinuation. In the nine London centres, syphilis prevalence was 2.06 per 1000 pregnant women, compared with 0.24 per 1000 elsewhere. Responses from Public Health directors indicated the nonspecific nature of the antenatal care contract. Responsibility for hepatitis B virus vaccination of the newly born infant rests with the hospital paediatrician, with transfer of responsibility to the community usually occurring through a discharge letter. Only two areas had a monitoring system to ensure full hepatitis B virus vaccination coverage of exposed infants.

Conclusions
If antenatal screening policies are to be equitable there is a need for a clear national policy, and systems need to be established to monitor local policy and practice.
An audit of standards and quality in a teaching hospital colposcopy clinic
Authors: Teale Glyn , Etherington Ian , Luesley David , Jordan Joe
Published: August 2005

The National Health Service Cervical Screening Programme has issued minimum standards for a colposcopy service that facilitates audit. We have looked at the performance of a teaching hospital colposcopy service by analysing the case notes of 639 women who underwent large loop excision of the transformation zone over a nine‐month period in 1995. We found delays in patient assessment and communication of results. There was overtreatment, particularly at first visit, and an excessive number of treatments were performed under general anaesthesia. A worrying number of women failed to have a follow up smear performed, but in those that did we found a reassuring treatment success rate. Our findings led to changes in the structure and functioning of the colposcopy clinic that should improve the detection of significant disease and improve the timeliness of diagnosis and the speed with which we communicate results.
Screening for fetal aneuploidies and fetal cardiac abnormalities by nuchal translucency thickness measurement at 10–14 weeks of gestation as part of routine antenatal care in an unselected population
Authors: Schwärzler P. , Carvalho J. S. , Senat M.‐V. , Masroor T. , Campbell S. , Ville Y.
Published: August 2005

Objectives
To evaluate first trimester pregnancy screening for fetal aneuploidy and congenital heart defects by maternal age and nuchal translucency measurement and screening for fetal aneuploidies and congenital heart defects by ultrasound in an unselected population.

Design
A prospective study.

Setting
Fetal medicine unit, St George's Hospital, London.

Sample
4523 consecutive viable fetuses at 10–14 weeks with a crown–rump length between 38 and 80 mm were scanned transabdominally (93%) or transvaginally (7%).

Methods
Screening was performed by calculating the background risk from maternal age, gestational age and obstetric history, which was then adjusted with the nuchal translucency measurement in relation to crown–rump length (adjusted risk).

Main outcome measures
Measurements of crown–rump length and nuchal translucency thickness. An adjusted risk of > 1:270 was considered as a positive screening test. Pregnancy outcome was obtained through karyotyping, outcome questionnaires and examination of the newborn infants.

Results
Mean maternal age was 29.4 years and mean gestational age 12.2 weeks. Screening was positive in 230/4523 fetuses (5.1%), when the adjusted risk (mean 1:2649) was > 1:270. Fetal karyotype was abnormal in 23 (0.51%) cases, including twelve with trisomy 21, five trisomy 18, one trisomy 13, one trisomy 10, one monosomy X and two triploidies. For a false positive rate of 4.7%, the sensitivity of this test was 78% in detecting any fetal aneuploidy. Only one out of nine major congenital heart defects in this population was found within the 110 euploid fetuses with increased nuchal translucency thickness (> 2.5 mm).

Conclusion
Screening for fetal aneuploidy by maternal age and nuchal translucency measurement can be effective in an unselected population. However, our results do not support its effectiveness in the detection of cardiac abnormalities.
Misoprostol compared with methylergometrine for the prevention of postpartum haemorrhage: a double–blind randomised trial
Authors: Amant Frédéric , Spitz Bernard , Timmerman Dirk , Corremans Annick , Van Assche Frans André
Published: August 2005

Objective
To compare the efficacy and side effects of misoprostol, compared with methylergometrine, for the prevention of postpartum haemorrhage.

Design
A double–blind, randomised clinical trial of 200 women with apparently normal pregnancies.

Setting
University teaching hospital.

Participants
Two hundred women with apparently normal pregnancies.

Methods
After the baby had been born, all women received two capsules by mouth and the contents of an ampule by intravenous injection. Each woman only received one active product. The capsules contained either a total of 600 μg misoprostol or placebo, and the ampule 200 μg of methylergometrine or placebo.

Main outcome measures
Need for further oxytocic drugs, blood pressure, the presence of side effects, mean haemoglobin and haematocrit three days after delivery.

Results
Two hundred women completed the study (100 received methylergometrine and 100 misoprostol). Postpartum haemorrhage occurred in 4.3% of the methylergometrine group and 8.3% of the misoprostol group (P= 0.57). The need for further oxytocic drugs was 4.4% and 12.8% after methylergometrine and misoprostol, respectively (P= 0.065). One hour after the birth of the baby there was no difference in the mean systolic blood pressure (117 ± 12 mmHg versus 115 ± 11 mmHg) (P= 0.26) or the mean diastolic blood pressure (72 ± 10 mmHg versus 71 ± 11 mmHg for the groups receiving methylergometrine or misoprostol, respectively) (P= 0.97). The mean temperature in the misoprostol group rose to 37.4°C, compared with 37°C in the methylergometrine group (P < 0.0001). In the misoprostol group 34% developed fever (> 38°C) compared with 3% in the methylergometrine group (P < 0.0001). Shivering (visual analogue score ≥ 8) also occurred more often after misoprostol (42%) than after methylergometrine (8.5%) (P < 0.0001). The haemoglobin level (g/dL) on the third postpartum day was similar for both groups (11.O and 11.2 for methylergometrine and misoprostol, respectively) (P= 0.39).

Conclusions
This study suggests that although protection from postpartum haemorrhage using parenteral methylergometrine and oral misoprostol is nearly equal, misoprostol is associated with more side effects.
Intramuscular opioids for maternal pain relief in labour: a randomised controlled trial comparing pethidine with diamorphine
Authors: Fairlie F. M. , Marshall L. , Walker J. J. , Elbourne D.
Published: August 2005

Objective
To compare the pain relief and side effects of intramuscular pethidine with intramuscular diamorphine in labour.

Design
Double‐blind randomised controlled trial.

Setting
The labour ward in a UK teaching hospital.

Participants
Sixty‐nine nulliparous women and 64 multiparous women in labour who requested narcotic analgesia and remained undelivered one hour after trial entry.

Methods
Nulliparous women were randomised to receive either 150 mg intramuscular pethidine or 7–5 mg intramuscular diamorphine. Multiparous women were randomised to receive either 100 mg intramuscular pethidine or 5 mg intramuscular diamorphine. All participants received the anti‐emetic prochloroperazine at the same time as the trial drugs.

Main outcome measures
Maternal analgesia assessed by a visual analogue score and verbal scales of pain intensity and pain relief, maternal sedation and vomiting, neonatal outcome assessed by Apgar scores and the need for resuscitation.

Results
More women allocated to receiving pethidine than to diamorphine reported slight or no pain relief at 60 minutes after administration of these drugs (P= 0.03). This trend was repeated in most of the other measures for maternal analgesia. There was no difference in maternal sedation, but the incidence of vomiting within 60 minutes was lower for women who received diamorphine (P= 0.02). Pethidine was associated with lower Apgar scores at 1 minute (P < 0.05).

Conclusion
Intramuscular diamorphine in labour appears to have some benefits, compared with intramuscular pethidine, but the trial was small and further research, particularly into alternative opioids and long term effects on the infants is still needed.
The effect of labour and maternal oxytocin infusion on fetal plasma oxytocin concentration
Authors: Patient C. , Davison J. M. , Charlton L. , Baylis P. H. , Thornton S.
Published: August 2005

It is not known whether human labour is associated with increased fetal oxytocin production or transfer of oxytocin across the placenta. Previous reports are contradictory, due in part, to the influence of maternal analgesia on fetal production. We determined plasma oxytocin concentration in the umbilical artery and vein of women after vaginal delivery and after caesarean section with general anaesthesia before or after the onset of labour. The results demonstrate that fetal production of oxytocin is not influenced by general anaesthesia, thus enabling comparison of labour and nonlabour samples at caesarean section. Labour was not associated with an increase in fetal oxytocin production. Oxytocin was also measured in the umbilical artery and vein during maternal oxytocin infusion to assess placental transfer. The results do not support transfer of oxytocin across the placenta in women.
Fetal ultrasound biometry: 1. Head reference values
Authors: Kurmanavicius Juozas , Wright Eileen M. , Royston Patrick , Wisser Joseph , Huch Renate , Huch Albert , Zimmermann Roland
Published: August 2005

Objective
To create reliable reference ranges and calculate Z scores for fetal head ultrasound biometry using a large sample size which is evenly distributed from 12 to 42 weeks of pregnancy.

Design
A prospective, cross‐sectional study.

Setting
Obstetric clinics (outpatient and delivery units) at the University Hospital of Zurich.

Sample
The study data were obtained from 6557 pregnant women.

Methods
Only the first ultrasound examination between 12 and 42 weeks of each fetus with exactly established gestational age was used for analysis. No exclusions were made on the grounds of small‐for‐date birthweight, prematurity or other events several weeks after the examination. Separate regression models were fitted to estimate the mean and standard deviation at each gestational age for each parameter.

Results
A total of 6217 fetal head biparietal diameters and 5510 occipito‐frontal diameters were measured. Both head circumference and cephalic index were derived in 5462 cases where both biparietal diameter and occipito‐frontal diameter could be measured on the same fetus. The centile charts, tables and regression formulae for biparietal and occipito‐frontal diameters, head circumference and cephalic index are presented. An application to calculate 2 scores was developed using Excel (Microsoft Corporation, USA) and macros are presented in detail in the Figure 8 footnote. The comparison of our charts with those of the two most recent studies revealed almost no differences in biparietal diameter centiles. In one publication, occipito‐frontal diameter charts, and in another, head circumference charts were different from the current study.

Conclusions
We have presented centile charts, tables and regression formulae for fetal head ultrasound biometry derived from a large and minimally selected sample size in a carefully designed cross‐sectional study. Complete tables and regression formulae to calculate reference ranges and Z scores are presented for use in computer‐aided evaluation of fetal ultrasound biometry.
An investigation of women's involvement in the decision to deliver by caesarean section
Authors: Graham W. J. , Hundley V. , McCheyne A. L. , Hall M. H. , Gurney E. , Milne J.
Published: August 2005

Objective
To assess the degree and nature of women's involvement in the decision to deliver by caesarean section, and women's satisfaction with this involvement.

Design
Observational study.

Setting
The maternity unit in a large teaching hospital.

Sample
One hundred and sixty‐six women undergoing caesarean section.

Methods
Interviews with the women on the third or fourth day postpartum, questionnaires sent to the women at 6 weeks and at 12 weeks postpartum, and extraction of information from the women's medical records.

Main outcome measures
Women's knowledge, satisfaction, and involvement in making the decision concerning their caesarean section.

Results
The majority of the women were satisfied with the information they received during pregnancy on caesarean section and with their involvement in making the decision, but the proportions were significantly higher for elective than emergency sections. For 7% of the women, maternal preference for caesarean section was a direct factor in making the decision. Just over half of the 166 women reported that they were not debriefed on the reasons for their caesarean section before their discharge from hospital. Almost a third of the women undergoing emergency caesarean section expressed negative feelings towards their delivery, compared with 13% of those undergoing elective caesarean sections.

Conclusion
Women are not a homogeneous group in terms of their requirements for information, nor their desire to be involved in the decision on mode of delivery. Health professionals need to be responsive to this variability and to agree on standards for communicating with women during pregnancy about the possibility of operative delivery and for debriefing women after caesarean section. sarean section, and women's satisfaction with this involvement.
Vaginal misoprostol for pre‐abortion cervical priming: is there an optimal evacuation time interval?
Authors: Singh Kuldip , Fong Y. F. , Prasad R. N. V. , Dong F.
Published: August 2005

Objective
To determine the optimal evacuation time interval in the use of vaginal misoprostol for cervical priming before first trimester termination of pregnancy.

Design
Prospective double‐blind randomised study.

Setting
Fertility Control Centre, National University Hospital, Singapore.

Methods
Sixty healthy nulliparous women requesting legal termination of pregnancy between 6 and 11 weeks of gestation were randomly allocated to either the 400 pg or 600 μg misoprostol group. Vacuum aspiration was performed after three hours in the 400 pg group and at the end of two hours in the women given 600 μg misoprostol. Using Hegar's dilator, degree of cervical dilatation before operation was measured. Other parameters assessed included the amount of additional dilatation required (if < Hegar 8), pre‐operative and intra‐operative blood loss, and associated side effects.

Results
For the 600 pg group, only five women (16.7%) achieved a cervical dilatation of 2.8 nun, compared with 28 women (93.3%) in the 400 μg group. Using the 400 μg misoprostol group as a baseline, the odds ratio was 0.014 (95% CI 0.003–0.080) for 600 pg for successful pre‐operative cervical dilatation of 2.8 mm. The mean cervical dilatation for 400 and 600 μg misoprostol was 8.1 mm and 6.6 mm, respectively (P < 0.001). Despite the shorter evacuation time interval of two hours, the 600 μg dose was associated with an increase in side effects such as vaginal bleeding, abdominal pain and a fever of > 38.°C. However, other than abdominal pain, no significant differences in the frequency of these side effects were shown.

Conclusion
Use of 400 μg misoprostol with a minimal evacuation time interval of three hours still appears the optimal dosage and evacuation time for cervical priming before fiist trimester termination of pregnancy.
Anal incontinence after vaginal delivery: a prospective study in primiparous women
Authors: Zetterstrom Jan P. , López Annika , Anzén Bo , Dolk Anders , Norman Margareta , Mellgren Anders
Published: August 2005

Objective
To investigate the incidence and degree of anal incontinence after vaginal delivery among primiparous women and to define associated risk factors.

Design
Prospective observational study.

Setting
Karolinska Institutet, Danderyd Hospital, Sweden, a university hospital.

Participants
Three hundred and forty‐nine primiparous women.

Methods
Questionnaires distributed within the first days after delivery and re‐distributed five and nine months postpartum. Analysis of delivery records.

Results
Eighty percent of the women answered all questionnaires. At five months postpartum, 2% of the women had symptoms of faecal incontinence and 25% had symptoms of involuntary flatus. At nine months postpartum, 1 % of the women had symptoms of faecal incontinence and 26% had symptoms of involuntary flatus. The majority of the women had infrequent symptoms and a decrease in severity was noted at nine months. Symptoms of incontinence were more common in women who sustained a sphincter tear at delivery. Risk factors for incontinence at five months included maternal age, duration of the second stage of labour, instrumental vaginal delivery, and clinically diagnosed sphincter tear at delivery. Development of incontinence at nine months was associated with maternal age and clinically diagnosed sphincter tear at delivery.

Conclusions
The present study demonstrates that infrequent involuntary flatus is a common symptom after vaginal delivery in primiparous women. These symptoms of involuntary flatus frequently improved and only a few women suffered from frank faecal incontinence. Factors associated with an increased risk of anal incontinence and sphincter tears should be considered during delivery.
Does reducing the frequency of routine antenatal visits have long term effects? Follow up of participants in a randomised controlled trial
Authors: Clement Sarah , Candy Bridget , Sikorski Jim , Wilson Jenny , Smeeton Nigel
Published: August 2005

1117 low risk women, who had been randomly allocated to either the traditional schedule of 13 antenatal visits or a reduced schedule of six to seven visits, were followed up 2–7 years after their delivery. Follow up was by means of a postal questionnaire (assessing the mother‐child relationship, maternal psychological wellbeing, health service use, health‐related behaviour and health beliefs), and patient record data on the frequency of contacts in general practice. There was no evidence of differences between the two groups for any of the outcomes examined. Offering a reduced schedule of routine antenatal visits to low risk women does not appear to have any long term effects.
Doppler fetal circulation in pregnancies complicated by pre‐eclampsia or delivery of a small for gestational age baby: 2. Longitudinal analysis
Authors: Harrington K. , Thompson M. O. , Carpenter R. G. , Nguyen M. , Campbell S.
Published: August 2005

Objective
To observe the longitudinal changes in growth, and associated Doppler measurements, of the fetal circulation in pregnancies with a normal outcome and those complicated by pre‐eclampsia, birth of a small for gestational age baby, or a combination of these complications.

Methods
Two hundred and ninety‐two women had serial ultrasound scans performed from the 24th week of pregnancy. Measurements obtained included: the abdominal circumference, umbilical artery pulsatility index, the middle cerebral artery pulsatility index and time‐averaged velocity, and the thoracic aorta pulsatility index and time‐averaged velocity. Outcome measures included the birth of a small for gestational age infant, pre‐eclampsia or a combination of these complications.

Results
One hundred and sixty‐seven pregnancies ended in the normal birth of an appropriately grown infant at term, while 105 had a complicated outcome. They were divided into three categories: pre‐eclampsia only (i.e. with the birth of an appropriately grown fetus, n= 13); small for gestational age only with no evidence of pre‐eclampsia, n= 55; and pre‐eclampsia complicated by the birth of a small for gestational age infant, n = 37. The group with pre‐eclampsia complicated by small for gestational age was closest in characteristics to true clinical intrauterine growth restriction. A reduction in the abdominal circumference mirrored a rise in the umbilical artery pulsatility index and preceded changes in the middle cerebral artery and thoracic aorta. The greatest degree of change in the fetal circulation was observed during the three weeks preceding delivery. Ratios of the values obtained from the fetal and umbilical circulation demonstrated the greatest deviation from normal.

Conclusions
A reduction in fetal growth velocity preceded changes observed in the fetal circulation. Ratios of the fetal Doppler parameters provided the clearest evidence of deterioration in the fetal condition. The information provided may be of use in the diagnosis and management of the growth‐restricted fetus.
Sweeping of the membranes to prevent post‐term pregnancy and to induce labour: a systematic review
Authors: Boulvain Michel , Irion Olivier , Marcoux Sylvie , Fraser William
Published: August 2005

Objective
To evaluate the effectiveness of sweeping of the membranes to prevent post‐term pregnancy and to induce labour.

Design
A systematic review of randomised controlled trials.

Methods
Potentially eligible trials were identified in Medline and in the Cochrane Controlled Trials Register. Inclusion of studies and data extraction were performed by two reviewers working independently. Summary estimates of the effect of the intervention were computed as relative risks, risk differences and weighted mean differences.

Main outcome measures
Use of formal methods of labour induction, delay before spontaneous onset of labour, prevention of post‐term pregnancy, side effects, maternal and perinaial morbidity.

Results
Sixteen reports were identified. Thirteen were included in the review, with a total of 1992 women. Sweeping of the membranes, when performed at term, reduced the duration of pregnancy and the proportion of women continuing pregnancy beyond 41 and 42 weeks. When sweeping of the membranes was performed, a reduction in the use of formal methods for labour induction was observed (RR = 0.48; 95% CI 0.28485). There was no difference between groups in the mode of delivery or in the risk of infection. Discomfort during vaginal examination and other side effects (e.g. bleeding, irregular contractions) were more frequently reported by women allocated to sweeping.

Conclusions
While sweeping of the membranes reduces the interval to spontaneous onset of labour, there is no evidence of a reduction in maternal or neonatal morbidity. When used as a means of induction of labour, the reduction in the use of formal methods must be balanced against women's discomfort and other side effects attributable to the procedure.
Prophylactic administration of clindamycin 2 % vaginal cream to reduce the incidence of spontaneous preterm birth in women with an increased recurrence risk: a randomised placebo‐controlled double‐blind trial
Authors: Vermeulen Gustaaf M. , Bruinse Hein W.
Published: August 2005

Objective
To test the hypothesis that prophylactic administration of clindamycin 2% vaginal cream can reduce the incidence of preterm birth in a high risk population.

Design
A multi‐centre, randomised, double‐blind, placebo‐controlled trial.

Setting
Twelve city hospitals in The Netherlands.

Participants
One hundred and sixty‐eight women with a singleton pregnancy and a history of a spontaneous preterm delivery in the preceding pregnancy.

Interventions
Clindamycin 2% vaginal cream, or placebo cream, administered daily for seven days at 26 and 32 weeks of gestation.

Main outcome measures
Spontaneous preterm birth at c 37 weeks, admission for threatened preterm labour, neonatal infectious morbidity.

Results
In the intention‐to‐treat analysis no difference was found in overall preterm birth between clindamycin and placebo (23% vs 18%, respectively). In the subgroup who completed the trial and administered all medication, more women delivered before 34 weeks in the clindamycin group (1.4% in the placebo vs 9.0% in the clindamycin group; P < 0.05). The length of admissions for threatened preterm labour did not differ. More infectious neonatal morbidity was seen in the clindamycin group 5/83 vs 0/85; P < 0.05).

Conclusion
Clindamycin 2% vaginal cream given prophylactically to women with a spontaneous preterm birth in the preceding pregnancy did not prevent preterm delivery or reduce the number of admissions for threatened preterm labour. The neonatal infectious morbidity in the group treated with clindamycin was significantly higher and a major concern.
National Confidential Enquiry into counselling for genetic disorders by non‐geneticists: general recommendations and specific standards for improving care
Authors: Harris Rodney , Lane Beverley , Harris Hilary , Williamson Paula , Dodge John , Modell Bernadette , Ponder Bruce , Rodeck Charles , Alberman Eva
Published: August 2005

Objectives
To assess genetic counselling by non‐geneticists and to improve clinical practice.

Design
National retrospective review of casenotes.

Setting
Antenatal, paediatric, medical, and surgical units.

Sample
1293 genetic events were identified, involving potentially avoidable cases of Down's syndrome, neural tube defect, cystic fibrosis, beta thalassaemia major and late onset medullary carcinoma of the thyroid (multiple endocrine neoplasia). Notes were available for review in 888 (69%) of these cases.

Outcomes
Documented counselling, offers of relevant genetic screening and prenatal diagnosis.

Results
Clinical audit was frustrated by poor quality hospital records lacking evidence of counselling. Non‐geneticist clinicians concentrate on the management of disease, and may overlook the need for counselling and recording data which patients will later need for decisions about reproduction or disease prevention. Counselling, screening and prenatal diagnosis were sometimes impossible because of late booking in pregnancy, or because of delayed diagnosis of an earlier affected child with cystic fibrosis. There are marked regional inequalities of access to genetic services, particularly for minority ethnic groups with increased risks of thalassaemia. Although patients were selected for this enquiry because they had known high risks of genetic disorders, on average less than half were referred to medical geneticists. General recommendations relevant for improvement of care for patients and families with medical genetic needs and those specific for each disorder are given.

Conclusions
Assessment of the quality of genetic care becomes increasingly important as genetic counselling spreads beyond the narrow confines of specialist genetic services. Even though the events studied in this enquiry largely occurred between 1991 and 1995, there is little reason to believe that clinicians in general have become markedly better trained in medical genetics. The General Medical Council and Medical Royal Colleges should urgently consider the need for a national policy for improving undergraduate and postgraduate medical, nursing and midwifery education in genetics. Commissioners of clinical services should require that genetic management be at least as well‐documented as surgical operations, drug records and informed consent, perhaps by using a nationally agreed pro‐forma for prenatal diagnosis. Regular audit of counselling provided by non‐geneticists is necessary to confirm that clinical improvements are occurring and standards are being met. The Confidential Enquiry provides data for a systematic approach to clinical governance of genetics in all specialities. This sets the scene for multi‐speciality NHS genetic services capable of giving patients greater consistency both in access and in quality.