bluuebunny/crossref_metadata_2025 huggingface dataset:
External Cephalic Version at a Military Teaching Hospital: Predictors of Success
Authors: Calhoun Byron C. , Edgeworth Deborah , Brehm Walter
Published: February 2008

Summary: The purpose of this prospective study was to analyze our experience with external cephalic version under tocolysis. This included an expected (1) high success rate of version, (2) infrequent occurrence of reversion, (3) reduction in the incidence of intrapartum breech presentation, avoiding the need for Caesarean delivery, and (4) predictors of success in our series. The study spanned the period from 1985 to 1993, enrolling 113 subjects who presented to our OB/GYN Department with any type of breech presentation at 37 weeks' gestation or greater and met the following criteria: (1) absence of labour or ruptured membranes, (2) singleton pregnancy, (3) absence of medical or obstetrical complications and amniotic fluid index of greater than 8 cm. After a reassuring fetal assessment, IV terbutaline was given prior to an attempt at version.

The results revealed a 46% (53 or 113) version success rate with a 4% (2 of 53) reversion within a week after procedure. There was a 2% (2 of 113) complication rate, with 1 being a minor incident of fetal bradycardia that responded easily to intrauterine resuscitation. One major complication occurred with placental abruption during the attempt, which required immediate Caesarean delivery.

Predictors of success in our series included: multiparity, fundal/posterior placenta, and fetal head and spine on the corresponding side of the maternal sagittal plane. External cephalic version in a controlled setting can be a safe procedure for residents in training that lowers Caesarean delivery rate for breech presentation.
Repair of the Perineal Defect After Radical Vulvar Surgery: Direct Closure Versus Skin Flaps Reconstruction
Authors: Landoni Fabio , Proserpio Maria , Maneo Andrea , Cormio Gennaro , Zanetta Gerardo , Milani Rodolfo
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication to remind readers that the trend towards more humanitarian surgical treatment of gynaecological (including breast) carcinoma also applies to cancer of the vulva. A recent editorial in this Journal summarized the modern, less radical, principles of excisional surgery for malignant lesions of the vulva. This paper describes improvements in functional results that can be achieved by skin flaps reconstruction versus the traditional method of direct closure of the wound when radical excisional surgery is required in women with carcinoma of the vulva.

Summary: From 1987 to 1990, 72 consecutive patients with primary untreated vulvar cancer underwent radical vulvar surgery with skin flaps reconstruction of the perineal defect. Postoperative complications, anatomical and functional results of this group of patients were compared with those of an historical control group of 77 patients submitted, at the same institution, to radical vulvectomy without reconstructive procedure from 1982 through 1986. The time of operation was significantly longer (180 minutes ± 15 versus 120 minutes ± 20) (p = 0.05) for patients submitted to the reconstructive procedure, while there was no statistically significant difference in intraoperative blood loss and hospital stay between the 2 groups. In comparison with direct closure, reconstructive procedures resulted in a significant lower rate of wound dehiscences (26% versus 64%) (p = 0.0001), vaginal introitus stenosis (2 versus 8) (p = 0.0001), sexual dysfunction (10% versus 50%) (p = 0.0001) and misdirection of the urinary stream (1 versus 5) (p = 0.001). It was concluded that skin flaps reconstruction is simple, reduces postoperative morbidity, and provides better anatomical and functional results than direct closure of the perineal defect.
Visual Effect of Partogram Designs on the Management and Outcome of Labour
Authors: Tay Sun‐Kuie , Yong Tze‐Tein
Published: February 2008

Summary: A prospective study of 3 partogram designs was performed in 990 women in labour with singleton pregnancy. Partogram A, B and C showed a progressively flatter steepness of the curve of labour progression. Oxytocin was administered in 35.1% of partogram‐A users, 45.9% of partogram‐B users (p = 0.001) and 44.1% of partogram‐C users (p = 0.035). Significantly fewer patients among the partogram‐A users (10.2%) were administered oxytocin too early compared to 18.6% of partogram‐B users and 20.5% of partogram‐C users. Of those with spontaneous onset of labour, a significantly smaller total dose of oxytocin was administered to the partogram‐A users compared to the other 2 groups. Ominous electrocardioto‐cographic fetal heart rate patterns were detected less frequently during the first stage of labour in partogram A users (0.4%) compared to partogram‐B users (1.1%) and partogram‐C users (3.0%). Significantly fewer infants born to partogram‐A users had depressed Apgar scores at 1 and 5 minutes. Partograms displaying a flat graph, compared to a steep graph, were more often considered to have a slow progress of labour. Adoption of partograms showing a steep graph of progress of cervical dilatation is recommended.
Management of Ovarian Remnant Syndrome
Authors: Orford Victoria P.C. , Kuhn Raphael J.P.
Published: February 2008

Summary: Ovarian remnant syndrome is a rare condition which develops when functional ovarian tissue which is left in situ after intended bilateral oophorectomy produces clinically significant symptoms, namely chronic pelvic pain and/or dyspareunia. Women with this syndrome may have a pelvic mass palpable on bimanual examination, or visible on transvaginal ultrasound. However, visualization of an ovarian remnant is sometimes difficult because it is small and multiple previous pelvic operations have usually produced dense adhesions and distorted pelvic anatomy. Identification of these remnants may be facilitated by ovarian stimulation. Surgical removal is the optimal treatment, but hormonal suppression of ovarian activity may provide temporary relief of pain.
Low Dose Ketoconazole is an Effective and a Relatively Safe Alternative in the Treatment of Hirsutism*
Authors: Işrk Ahmet Zeki , Gökmen Oya , Zeyneloǧlu Hulusi B. , Şenoz Selim , Zorlu C. Gürkan
Published: February 2008

Summary: Efficacy, clinical and hormonal effect of ketoconazole in 400 mg/day dose was tested in a prospectively‐designed study. Twenty four patients with hirsutism according to the Ferriman and Gallwey score (>8) and elevated blood androgen levels were administered 400 mg/day ketoconazole for 6 months. Basal and posttherapy early follicular phase androgens and biochemical parameters were evaluated. In 22 patients significant improvement and in 2 slight improvement was seen in subjective complaints. No side‐effects were observed in these patients other than 2 cases of pruritus (transient), 2 mild gastric upset and 1 mastodynia. All patients completed the study. Low dose ketoconazole seems to be effective in the treatment of hirsutism with relatively few side‐effects but still should be reserved as an alternative choice due to the potential for deleterious hepatic effects.
Leiomyoma of the Vagina
Authors: Sangwan K. , Khosla A. Huria , Hazra PC.
Published: February 2008

Summary: Approximately 250 cases of leiomyoma of the vagina have been reported. A case of a 46‐year‐old female with leiomyoma of the anterior vaginal wall, not associated with uterine leiomyomas is presented. The practical approach to such a vaginal mass entails immediate careful excision.
Positive Kleihauer Result Following an Ectopic Pregnancy
Authors: Krause Hannah G. , Goh Judith T.W.
Published: February 2008

Summary: The case presented highlights the risk of fetomaternal haemorrhage in ectopic pregnancy. With the current shortages of anti‐D, it may be necessary to reduce administration of anti‐D, but this may result in an increase in rhesus isoimmunization. As Kleihauer testing may be of limited value (1), recommendations by deCrespigny and Davison (2) for the use of a reduced dose of 30 meg anti‐D in all rhesus negative women with early pregnancy complications including ectopic pregnancy, would seem appropriate.
Regression Pattern of Beta Human Chorionic Gonadotrophs in Blood after Chemotherapy for Gestational Trophoblastic Neoplasia
Authors: Burrows A. , Faddy M.J. , Khoo S.K.
Published: February 2008

Summary: Although beta human chorionic gonadotrophin (beta‐HCG) is a clinically‐useful tumour marker in gestational trophoblastic neoplasia, there is limited information on how serum beta HCG regresses in molar pregnancy and choriocarcinoma during chemotherapy. The study included 41 patients who had been treated by single‐ and multidrug regimens, and decay curves for regression of beta HCG in the circulation in these patients were fitted to the data. Thirty‐three patients achieved a biochemical remission (‘cured’) by first‐line chemotherapy; this gave an overall efficacy rate of 80%. The beta HCG decay curves convey useful information of the chemosensitivity of the tumour, and may assist in determining the time required for treatment and earlier change in treatment for the chemoresistant tumour.
Misdiagnosis of an Interstitial Ectopic Pregnancy After Unilateral Salpingectomy
Authors: Yim So‐fan , Fung Hedy Y.M. , To Ka‐fai
Published: February 2008

A 36‐year‐old primigravida presented to us with symptoms and signs of ectopic pregnancy repeatedly but was misdiagnosed to have an intrauterine pregnancy based on 1 early ultrasound examination showing an ‘intrauterine sac’. She suffered the morbidity due to ectopic pregnancy which included hysterectomy which may have been prevented had the correct diagnosis been made.
Fetal Sex as a Risk Factor for Fetal Distress Leading to Abdominal Delivery
Authors: Lau T.K. , Chung Tony K.H. , Haines C.J. , Chang A.M.Z.
Published: February 2008

Summary: A retrospective analysis of perinatal information of 7,924 confinements in the calendar year of 1994 was performed to determine whether fetal sex was a significant risk factor for fetal distress in labour leading to abdominal delivery. The sex of the fetus (male) was a significant, independent, risk factor for Caesarean section (odds ratio =1.26, 95% CI=1.05 to 1.50). This increase was wholly attributable to the increased risk of having fetal distress in labour (odds ratio = 1.76, 95% CI=1.32 to 2.34). Male fetuses are at higher risk of developing fetal distress during labour.
Career Paths of Obstetricians and Gynaecologists Trained at The Royal Women's Hospital, Melbourne
Authors: Ratten Graeme
Published: February 2008

Summary: This study documents the contribution made to women's health by the 177 obstetricians and gynaecologists trained at The Royal Women's Hospital in the 35‐year period 1960–1994. Whilst there were no female graduates during the first 15 years of the study period, female trainees now outnumber male trainees. Royal Women's Hospital‐trained specialists are less likely to practise in Victorian provincial cities than graduates who have trained elsewhere. During the study period there has been a notable increase in the proportion of graduates entering subspecialist practice with a consequent decrease in the proportion providing obstetrics care.
Vaginal Vault Cytology in the Routine Follow‐up of Patients Treated for Endometrial Carcinoma: Is It Useful?
Authors: Ng T.Y. , Ngan H.Y.S. , Cheng D.K.L. , Wong L.C.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because the series reported and the literature reviewed indicates that follow‐up for endometrial carcinoma is unlikely to detect a recurrence that can be successfully treated. Perhaps a sensible compromise would be to see the patient annually after the first year especially when the patient knows which symptoms should be reported promptly should they occur. Follow‐up is important for the purposes of documentation and also for maintenance of the patient's morale by knowing that her treating practitioner maintains an interest in her welfare. (See previous editorial comment Kerr‐Wilson RHJ, McCrumA. Follow‐up of patients with gynaecological cancer. AustNZJ Obstet Gynaecol 1995; 35: 298.) Owen and Duncan (A) reported similar findings in a follow‐up of 97 women after treatment for endometrial cancer. Recurrent disease was diagnosed in 17 women, 7 of whom were asymptomatic at the time of diagnosis; there was no difference in survival between women with asymptomatic and symptomatic recurrences.

Summary: Routine follow‐up visits and vault cytology following treatment for endometrial carcinoma generates a considerable workload and takes up valuable resources. A review is needed to evaluate the usefulness of this practice. Eighty six patients treated and followed‐up from January, 1987 to July, 1994 were reviewed. The standard follow‐up protocol consisted of physical assessment and vault cytology every 1 to 2 months for the first 2 years, every 3 months for the third year and every 6 months thereafter for at least 5 years. Recurrences were defined as histologically proven disease after a 3‐month disease free interval. Fourteen patients (17%) developed recurrences. Two of the 14 patients (14%) had local recurrences in the pelvis. Only 3 of these recurrences were detected during routine follow‐up. Vault cytology was negative in all patients with recurrences even when the recurrence occurred locally in the pelvis. Traditional surveillance protocols were ineffective in the detection of recurrences. Vault cytology was particularly ineffective. It was calculated that 1 recurrence was detected for every 606 visits. In this age of budgetary constraints, alternative follow‐up protocols should be explored.
Sterilization of Women with Eisenmenger Syndrome: Report of 4 Cases
Authors: Temelcos Catherine , Kuhn Raphael , Stribley Claris
Published: February 2008

Summary: Maternal mortality exceeding 50% and perinatal loss of more than 45% contraindicate pregnancy in females with Eisenmenger syndrome. Sterilization is the contraceptive method of choice. Any operation carries a very significant risk in persons with Eisenmenger syndrome; the anaesthetic mortality has been reported to be 19%. This paper details the successful sterilization of 4 women with Eisenmenger syndrome at our institution.
Gestational Diabetes Mellitus; Resource Utilization and Costs of Diagnosis and Treatment
Authors: Moses R. , Fulwood S. , Griffiths R.
Published: February 2008

Summary: The recommendation to test every woman for gestational diabetes mellitus (GDM) has a defined cost. The management of women diagnosed with GDM will use additional health resources. This study examines the cost and resource utilization of a consecutive group of women diagnosed over a 1‐year period. The cost of testing a woman for GDM is around $10.00 with slight variations depending on the testing procedure. The annual cost of testing in NSW would be less than 1 million dollars. Women diagnosed with GDM used the resources of a diabetes education centre for an average of 2.8 hours and attended for 3.4 (2.3) medical visits. Insulin was required by 18.7% of the women for 9.7 (4.7) weeks using 47.7 (21.2) units each day. Testing women for GDM is a low‐cost item. Managing a woman diagnosed with GDM may cost several hundred dollars. Cost reductions could be made by reducing the amount of insulin used and by avoiding hospitalization.
Outpatient Hysteroscopy ‐ Problems
Authors: Bellingham F. Richard
Published: February 2008

Summary: Outpatient hysteroscopy is now a routine procedure, but difficulties may be encountered. It was decided to assess the problems found in one practice over a period of time. Between August 1, 1989 and July 31, 1996 there were 1,080 examinations performed by the author; pain was sometimes significant, but already has been well covered in the literature. The other important problems were vasovagal reactions and failure to complete an adequate examination. This report emphasizes these problems. Being aware of potential problems allows one to anticipate them and often allows the procedure to be carried out successfully. At the very least, this awareness should save the patient major medical problems or discomfort.
Hysterectomy and Endometrial Ablation in New South Wales, 1981 to 1994–1995
Authors: Yusuf Farhat , Siedlecky Stefania
Published: February 2008

Summary: This study analyses the New South Wales hospital data on hysterectomies from 1981 to 1994–1995, and on endometrial ablations since 1991. The hysterectomy rate declined by about 16% during 1981–1991 and has risen since; the endometrial ablation rate has increased by 28% between 1991 and 1994–1995. Other findings indicate a trend towards older mean age at operation, a swing to vaginal hysterectomy with or without laparoscopy, a shift to private hospitals, and a dramatic decline in length of hospital stay. The majority of endometrial ablations were performed on a day‐only basis. Immigrant and Aboriginal women experienced lower hysterectomy rates. Endometrial ablation techniques introduced in the late 1980s, as an alternative to hysterectomy for dysfunctional uterine bleeding, have had a major impact on hysterectomy rates; without these techniques the rates would be much higher.
The Safety of Laparoscopy Performed by Direct Trocar Insertion and Carbon Dioxide Insufflation Under Vision
Authors: Woolcott Robert
Published: February 2008

Summary: The records of 6,173 laparoscopics performed by specialist gynaecologists in the course of routine gynaecological care using the technique of direct insertion of the umbilical trocar and insufflation of carbon dioxide under vision were reviewed to ascertain the incidence of serious complications. A review of the published literature on laparoscopy methodology was also undertaken to complement the data obtained from this study. The nature of the records precluded accurate assessment of both indications and minor complications. There were 4 perforating bowel injuries (0.06%) requiring laparotomy (2 small intestine, 2 large intestine). There were no cases of major vascular injury or gas embolus necessitating surgical or resuscitaiivc measures. On 3 of the 4 occasions where bowel injury occurred the patients had undergone prior abdominal surgery and had midline vertical subumbilical incisions. Review of the published literature demonstrated bowel or vessel perforation rates (requiring laparotomy or resuscitation) of 1 in 1,000 regardless of whether the method of gaining peritoneal access was open (Hasson) technique. Verres needle insufflation. or direct trocar. Direct trocar insertion may reduce the risk of gas embolism by insufflating only after intraperitoneal replacement has been confirmed, moreover it allows immediate recognition and rapid treatment of major blood vessel laceration, both of which have been identified as being crucial in reducing laparoscopy associated mortality. When compared to other available methods of gaining peritoneal access for laparoscopy, direct trocar insertion followed by insufflation of carbon dioxide under vision can be performed with the same degree of safety for the patient. It is simply wrong to deduce from the available data that one particular technique of gaining peritoneal access is superior to another. Each have their individual advantages and disadvantages and similar morbidity when performed by experienced operators with appropriate indications. In light of this observation, each alternative should be considered by the individual surgeon to assess which would best suit his or her operating technique and the particular circumstance of each patient. Indeed preference should be given to the method with which the surgeon is most comfortable or with which he or she has the most experience.
High‐Dose Medroxyprogesterone Acetate for the Treatment of Dysfunctional Uterine Bleeding in 24 Adolescents
Authors: Aksu M. Feridun , Madazli Riza , Budak Erdal , Cepni Ismail , Benian AH
Published: February 2008

EDITORIAL COMMENT": This classic study presents a very large experience of successful treatment of adolescent women with severe dysfunctional uterine bleeding all of whom responded to high‐dose oral medroxyprogesterone acetate therapy. It is interesting to note that none of these patients had underlying haematological disorders such as idiopathic thrombocytopenic purpura or Von Willebrand disease. In the editor's experience at least 1 such case would be expected in a series of 24 patients with adolescent dysfunctional uterine bleeding requiring hospitalization because of anaemia. The authors have not told us the further management or results of follow‐up of these patients. The editorial subcommittee considers that patients with severe dysfunctional bleeding should, after control of the presenting episode of bleeding, be given a 3–6 month course of either a low‐dose oral contraceptive pill or progestogen therapy for the last 18 days of the menstrual cycle; follow‐up is then necessary to check that menstrual function was normal and that anaemia had not recurred. These patients also warrant oral iron therapy during this interval. It is noteworthy that none of these 24 patients had demonstrable endometrial pathology with abdominal ultrasonography and none of them required curettage.

Authors'Response to Editorial Comment:

Our study group was purposely selected as adolescents with severe dysfunctional uterine bleeding without an underlying haematological disorder. We agree that one would expect to see such a case in a series of 24 adolescents with dysfunctional uterine bleeding sufficient to warrant admission to hospital. Our follow‐up regimen was the same as mentioned in the Editorial Comment and none of the 24 patients returned with the same complaint.

Summary: The objective of the study was to evaluate the effectiveness of high‐dose oral medroxyprogesterone acetate therapy in the management of excessive dysfunctional uterine bleeding in adolescents. The study group consisted of 24 adolescents who were hospitalized with the diagnosis of excessive uterine bleeding and anaemia. Oral medroxyprogesterone acetate tablets were administered at a total dose of 60–120 mg during the first day of admission and 20 mg per day for the following 10 days. The blood loss was reduced to acceptable levels in all patients, and actually stopped in 6 (25%) within the first 24 hours of the treatment; bleeding ceased in 29.2%, 20.8% and 25% on the second, third and fourth days respectively. Significant correlation was identified between the initial haemoglobin concentration and the time required for cessation of bleeding (r=0.5, p=0.001). Rapid saturation of the endometrium with progestogens seems to be an highly effective mode of treatment for excessive dysfunctional uterine bleeding in adolescents.
The Predictive Value of the Sperm‐Cervical Mucus Interaction Test on the Outcome of In Vitro Fertilization and Ovulation Induction Combined with Intrauterine Insemination
Authors: Abu‐Heija A.T. , Fleming R. , Jamieson M.E. , Yates R.W.S. , Coutts J.R.T.
Published: February 2008

Summary: We investigated the effect of the sperm‐cervical mucus penetration tests (SPT) on the fertilization rate (FR) and pregnancy rate (PR) in patients treated with either in vitro fertilization (IVF) or ovulation induction combined with intrauterine insemination (OI+IUI). Infertile couples where the women had normal ovarian function and a normal pelvis at laparoscopy and her partner had normal seminology who had failed at least 2 SPTs were treated with either IVF or OI+IUI. These patients were compared with similar couples in whom SPTs were satisfactory (SPT+ve). Group A (SPT+ve) consisted of 46 patients who underwent 78 treatment cycles of IVF and Group B (SPT‐ve) comprised 31 patients who underwent 35 IVF cycles. Group C (SPT+ve) consisted of 39 patients who underwent 84 treatment cycles with OI+IUI, and Group D (SPT‐ve) consisted of 15 patients who underwent 37 cycles witfi die same treatment. In patients treated with IVF, the FR and PR per embryo transfer were 77.0% and 20.0% respectively in Group A, and 64.0% and 22.6% respectively in Group B. The difference in FRs was statistically significant (p>0.001) but there was no difference in die PRs. In patients treated with OI+IUI, the PR per cycle were 22.0% in Group C and 16.2% in Group D. These results indicate that SPT failure was associated with a lower FR in IVF but this did not affect the PRs. Similarly there was no difference in PRs following OI+IUI.
Intractable Pelvic Pain Following Filshie Clip Application
Authors: Robson Stephen , Henshaw Richard
Published: February 2008

EDITORIAL COMMENT": We accepted this case for publication since it seems to demonstrate conclusively that a clip on the Fallopian tube can produce persistent pain without associated pathology such as infection, adhesions or damage to other organs. Why then is this complication so rare? Why was the postoperative pain unilateral in this woman? Can readers provide the answer to this riddle? One of the reviewers made the comment that this complication is not rare only under‐reported and that he has heard a number of anecdotal reports of cases where Filshie clips have been removed and the patient's pain has resolved. This comment from the reviewer is of course anecdotall.
Women Who Spontaneously Quit Smoking in Early Pregnancy
Authors: Panjari M. , Bell R.J. , Astbury J. , Bishop S.M. , Dalais F. , Rice G.E.
Published: February 2008

EDITORIAL COMMENT: The takeaway message from this sophisticated audit of smoking behaviour of pregncny Seems to be that during pregnancy. seems to be that spontaneous quitters who lapse back to the habit should be identifed, since they comprise about 35% of smokers who a n likely to quit after counselling during pregnancy. This paper gives important insight into the logistics of planning a policy of prevention of smoking during prenancy. We await, with interest, the authors' findings in their randomized controlled trial of a smoking cessation intervention

Summary: Spontaneous quitters are prepregnancy smokers who quit by the time of their first antenatal visit. We recruited 192 self‐declared spontaneous quitters and 407 smokers at their first visit to the antenatal clinic at the Royal Women's Hospital during April, 1994‐May, 1995. Spontaneous quitters made up 23% of prepregnancy smokers. Information about self‐declared quitters and smokers was collected by self‐completed questionnaires. Urine samples collected at the first visit and in late pregnancy were assayed for cotinine to validate smoking status. A cut‐off urinary concentration of >653 nmol/L cotinine was used to determine active smoking. At the first visit, 20% of the self‐declared spontaneous quitters were smoking and by late pregnancy, regardless of their initial biochemically verified status, 27% were smoking. Spontaneous quitters were different from women who said they were still smoking at their first antenatal visit, in a range of demographic variables and measures of addictive behaviour.
Lag Times Between Blood Sampling, Spinning and Plasma Glucose Estimation
Authors: McIntyre S. , Crowther C.A. , Hiller J.E. , McPhee A.J.
Published: February 2008

Summary: This study investigated the effect of lag times between blood sampling and glucose analysis on plasma glucose results from 6 volunteers. Our aim was to determine whether glucose tolerance test protocols should include instructions on the handling of blood between sampling and analysis. Plasma glucose levels remained stable for all lag times between spinning and analysis. With a lag time between blood sampling and spinning, plasma glucose levels did not remain stable, and a significant lowering of plasma glucose was found in the first 2 hours of lag. With increased lag time there was no further decrease in plasma glucose levels. Glucose tolerance test protocols should include clear guidelines on the handling of the blood samples between collection and analysis, and the spinning down of samples needs to be prioritized.
Measuring Venous Capacitance and Blood Flow in Pregnancy
Authors: Martin Allison , Brown Mark A. , Bucci Joseph , Whitworth Judith A.
Published: February 2008

Summary: Forearm or calf venous plethysmography has been used in pregnant women to examine the effects of pregnancy on the vascular system and more recently to measure blood flow changes in response to intra‐arterial infusion of vasoactive substances. To examine the assumption that venous capacitance and blood flow measurements are the same in the forearm and calf, venous plethysmography was conducted simultaneously on the forearm and calf in normal (NP) and hypertensive pregnant women (HTP) in their third trimester and in normal nonpregnant women (N). Ail studies were made on the right forearm and calf with subjects in the left lateral recumbent position. There was no significant difference between venous capacitance in the forearm (median: 124 times 103rruV100mIVmrnHg for both NP and HTP) and leg (134 [NP] and 106 [HTP] x lO'mL/lOOmlVmmHg) for both pregnant groups but venous capacitance in the nonpregnant group was greater in the leg than arm (174 versus 112 x lO'mUlOOmL/mmHg, p <0.001). Blood flow was similar in the leg and forearm (median: 4.9 versus 3.9mL/100mL/min respectively) in nonpregnant women. Forearm blood flow was also similar to calf flow in NP women (6.2 versus 4.3mL/100mL/min respectively) but greater man calf blood flow in HTP (9.7 versus 5.3ml7100mL/min, p <0.01). Using left lateral recumbency, forearm and calf vein capacitances are similar in pregnant women, in contrast to nonpregnant women. Blood flow is higher in the forearm than the calf only in hypertensive pregnant women. These observations should be borne in mind when interpreting studies of regional blood flow in pregnancy.
Clostridium Difficile Diarrhoea Associated with Chemotherapy for Ovarian Cancer
Authors: Paterson David L.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication as it will interest readers involved with the management of gynaecological oncology patients, especially those with diarrhoea after chemotherapy. The paper makes the point that diarrhoea associated with chemotherapy may be due to Clostridium difficile, which can be effectively treated with metronidazole and should be looked for more frequently.
Fetus Papyraceous Covering the Site of Uterine Perforation Found During Caesarean Section
Authors: Bagga Rashmi , Goel Poonam , Prasad G.R.V. , Gupta Indu
Published: February 2008

EDITORIAL COMMENT: We accepted this case for publication because, as the authors indicate, fetus papyraceous is a complication seen in multiple and not singleton pregnancy. Apart from its anecdotal interest, the case supports the view that pressure on a dead second trimester fetus is the important aetiology information of a fetus papyraceous. If the condition occurred only when one twin died in the second trimester, with the pregnancy continuing with the surviving twin (the usual circumstance), then the hormonal production by the living placental tissue could be a factor in the state of preservation of the dead fetus. This occurs with both uniovular and binovular twins. Our editorial committee and reviewer know of no case of fetus papyraceous situated in the uterus in a singleton pregnancy. A lithopaedion can occur in a singleton abdominal pregnancy and presumably has a different pathology to that of the preservation of a fetus papyraceous, although in the present case there was some calcification of both the fetus and placenta.
Differences Among Obstetricians in Caesarean Section Rates
Authors: Menticoglou Savas M.
Published: February 2008

EDITORIAL COMMENT: The editor was once engaged in what was said to be the longest ever running case of medical investigation in Australia against an obstetrician whose Caesarean section rate was claimed to be excessive. The leading expert witnesses on both sides of the case were required to table the Caesarean section rates in their private practices. Who will be surprised to learn that both, including the editor, reported a rate above 20%. We are all charitable to ourselves when relating the high‐risk nature of our private practices, with many women referred with previous Caesarean section or poor perinatal result. This paper is carefully restricted to low‐risk nulliparas. In Melbourne, for a time, it was practice to notify each consultant of his/her Caesarean section rate and each was provided with an anonymous list of his/her colleagues' rates. In the Mc Bride case referred to above, the Judge asked the expert witness ‐ ‘do not the doctors in your institution with notification of low Caesarean rates fear accusation of malpractice?’

Summary: This retrospective study examined the Caesarean section rates of 15 obstetricians at 1 hospital delivering 5,559 nulliparas with a single cephalic baby of birth‐weight ≥ 2,500 g. There was a wide variation in obstetricians' Caesarean rates, whether considering all their deliveries (5.5% to 20.1%), deliveries of their own patients (8.9% to 28.2%), or deliveries of their colleagues' patients (4.5% to 17.9%). There was no relation between Caesarean rates and perinatal outcome. The different Caesarean section rates among the obstetricians could not be explained by institutional factors, physician convenience, patient differences, or self‐serving economic incentives.
Large Meningioma Complicating Pregnancy
Authors: Otton Geoffrey R. , PhD Warwick Giles; , Walters William A.
Published: February 2008

EDITORIAL COMMENT:This case report was accepted for publication because of the clinical lesson it delivers, namely that intracranial tumours, although rare in pregnancy, may as the authors state ‘produce a wide variety of symptoms that are difficult to distinguish from the more common symptoms of pregnancy, including nausea, vomiting and headache’. This case suggests that examination of the optic fundi is essential in patients with neurological symptoms even when/especially when there is a history of psychiatric illness.
Failed Caesarean Section: An Obstetrician's Nightmare
Authors: Yuen Pong Mo , Yim So Fan
Published: February 2008

EDITORIAL COMMENT: In medicine, human judgment is fallible, but obstetrics is the discipline in which an error of judgment is most rapidly revealed, to the obstetrician, the patient and the labour ward staff, due to the unpredictability of the duration of labour and imminence of delivery in any individual patient. When the editor was a house officer he was called to the antenatal ward because a multipara, near term had abdominal pain. Vaginal examination revealed an undiluted cervix, but within the minute or so it took a walk to the handbasin to wash his hands the woman had delivered a live baby into the bed. It is always wise, and should be a routine. unless operating in haste for an emergency such as bleeding from placenta praevia, to perform a vaginal examination after anaesthesia is established before commencing Caesarean section in a woman in labour. The editor has performed many safe easy‐forceps deliveries in this circumstance, in theatre, in women in whom Caesarean section was planned for cephalopelvic disproportion with or without fetal distress. This finesse is more important if the consultant has agreed to perform a Caesarean on the findings recorded by others, but the fact remains that labour and delivery can accelerate most unexpectedly. We accepted this case report for publication, not merely because it is the first such case reported, but also for the opportunity it provided to stress to readers the need for final evaluation of the stage of labour before Caesarean section, when the conditions are most favourable for assessment. Nonetheless, as this case tells us. it is possible for labour and delivery to proceed faster than the obstetrician can perform a Caesarean section.
Nonunion of Uterine Incision: A Rare Cause of Secondary Postpartum Haemorrhage: A Report of 2 Cases
Authors: Nanda Smiti , Singhal Savita , Sharma Damyanti , Sood Madhulika , Singhal S.K.
Published: February 2008

EDITORIAL COMMENT: We accepted these case reports for publication because they carry a message for readers, namely that secondary postpartum haemorrhage associated with nonunion of a Caesarean section scar can require a difficult and dangerous (for the patient) hysterectomy. The editor recalls such a case seen more than 30 years ago at the Royal Women's Hospital, Melbourne where at laparotomy the uterus, especially around the classical Caesarean wound, appeared gangrenous although no organisms were cultured. The pathologist considered the hysterectomy specimen resembled a treated case of Clostridium welchii infection. In this case the tissues were necrotic and sutures cut through all pedicles so that, eventually, a clamp hysterectomy was performed, with the instruments being removed, uneventfully, the following day. This patient survived; the memory of her operation remains! One reviewer raised the question of whether or not in Case 1 the vaginal examination with palpation of the lower uterine segment incision could have disrupted it, unknowingly, while finding it to be deficient. It is well recognized that curettage for secondary postpartum liaemorrhage has the risk of perforation of the uterus and/or disruption of a Caesarean section scar.

Summary: Secondary postpartum haemorrhage after Caesarean section due to nonunion of the uterine incision is an unusual complication. Two women who had had lower segment Caesarean section for placenta praevia presented after 2 and 3 weeks respectively with shock due to massive postpartum haemorrhage. The uterine scars had not healed in both of these women who were managed by emergency subtotal
Ascites ‐ an Unusual Association with Pelvic Inflammatory Disease
Authors: Gregora Michael G. , McNamara Tim
Published: February 2008

Summary: A case is reported of clinically subacute pelvic inflammatory disease associated with exudative ascites, which resolved after laparoscopic restoration of pelvic anatomy and antibiotic therapy.
Management of the Entrapped Second Twin: The Benefits of Sublingual Glyceryl Trinitrate
Authors: Dalton Russell V. , Ray Robert
Published: February 2008

EDITORIAL COMMENT: The complications of manipulative delivery are dear to the heart of every obstetrician. Problems such as head entrapment with breech delivery at Caesarean section, uterine inversion and difficult manual removal are all extremely unpleasant situations that may be assisted by the use of glyceryl trinitrate. This paper emphasizes the use of glyceryl trinitrate in another situation where uterine relaxation may be beneficial, namely malpresentation of a second twin in the presence of a uterine fusion abnormality and a constriction ring in the second stage. Obviously general anaesthesia would be an alternative, but all modern obstetricians are faced with an extreme reluctance of anaesthetists to give general anaesthetics in labour ward. It was unusual in this case to bring the baby down into the pelvis cephalically rather than perform an internal version and breech extraction. This manoeuvre was obviously felt to be the most appropriate improvisation at the time. There seems nothing inherently wrong with guiding the head down past the constriction ring into the vagina and then applying forceps. One can imagine that it may have been less traumatic than an internal version and breech extraction which may have risked the head being trapped above the constriction ring with the body‐below should uterine relaxation have been incomplete. The statements made about the dilution necessary for intravenous administration of glyceryl trinitrate and the relevant safety of the sublingual application are important to bring to the attention of obstetricians. We agree with the authors statement that glyceryl trinitrate needs to be on hand before delivery if it is to be used in the emergency situations described in this paper. It seems to the Editorial Board that the most likely use of the technique described would be at Caesarean section under epidural analgesia with oligohydramnios and a growth‐retarded fetus presenting by the breech when there is a poorly formed lower uterine segment.
A Truly Knotted Cord
Authors: Jones Ian
Published: February 2008

Summary: A case of 4 true knots in an umbilical cord, which did not cause any detectable harm, is presented. Careful examination of the placenta, membranes and umbilical cord continues to be encouraged.
Three Recurrent Ectopic Pregnancies Case Report and Review of the Literature
Authors: Mustafa Mohamed Siddoq , Adelusi Babatunde , Sporrong Bengt
Published: February 2008

EDITORIAL COMMENT: We accepted this case report for publication not solely because of its unusual anecdotal interest, or for its glimpse into reproductive requirements and wishes of women in Saudi Arabia, but for its summary of the literature on repeat ectopic pregnancy which should interest readers. Although preservation of the Fallopian tube by laparascopic salpingostomy is becoming the established treatment of unruptured ectopic pregnancy, we are unaware of a prospective trial comparing subsequent fertility in women with salpingostomy versus partial salpingectomy for unruptured ectopic pregnancy when the opposite Fallopian tube appears normal. In the present case there is no evidence that the preserved tube was useful from the reproductive point of view, although it remained patent. One reviewer of this paper performed a medline search and found that ‘there are no prospective studies and only a few retrospective reports comparing fertility rates after salpingostomy and salpingectomy. Three major retrospective studies found no significant difference infertility or incidence of repeat ectopic pregnancy between the 2 procedures, but salpingostomy carries a 5–8% risk of persistent ectopic pregnancy, contributing to increased morbidity and cost. Fertility after ectopic pregnancy is affected much more by the status of the contralateral tube than by the procedure performed, with fertility rates exceeding 80% after salpingectomy when the opposite tube is normal’(A).

A. Rulin MC. Is salpingostomy the surgical treatment of choice for unruptured tubal pregnancy? Obstet Gynecoi 1995; 86: 1010–1013.

Summary: Further studies on the obstetric performance of women after recurrent ectopic pregnancies are needed to adequately counsel women who are still interested in future fertility, even after their third ectopic pregnancy.
Ectopic Pregnancy in Lower Segment Uterine Scar
Authors: Roberts H. , Kohlenber C. , Lanzarone V. , Murray H.
Published: February 2008

Summary: A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.
Extraovarian Endometrioid Carcinoma Associated with Unopposed Oestrogen Replacement Therapy
Authors: Sidhu S. , Edwards L. , Rainer S. , O'Connor T.
Published: February 2008

EDITORIAL COMMENT: We accepted this case report for publication because, apart from being interesting, it raises the question of the appropriate hormone replacement therapy after bilateral oophorectomy (usually with hysterectomy) has been performed when there is evidence of endometriosis. Menopausal symptoms in these women can be relieved by oestrogen therapy without return of pelvic pain or dyspareunia. The authors report a case of endometrial‐like carcinoma in a woman with known endometriosis after a hysterectomy and prolonged unopposed oestrogen therapy. Although this is a solitary case report, the authors explain that there are 8 others in the literature where malignancy occurred in extraovarian endometriosis after bilateral oophorectomy associated with unopposed oestrogen. One of our reviewers commented that a combination of oestrogen and progestogen should always be considered when prescribing hormone replacement therapy in women with a known history of endometriosis, following total hysterectomy and bilateral oophorectomy.
Incidence of Preterm Delivery in Hong Kong Chinese
Authors: Leung T.N. , Roach V.J. , Lau T.K.
Published: February 2008

Summary: A retrospective analysis of the obstetric database between January, 1995 and December, 1996 was conducted to establish the rate of preterm birth and the incidence of babies with low birth‐weight amongst Hong Kong Chinese in an obstetric teaching unit in Hong Kong, and to investigate possible risk factors for spontaneous preterm deliveries. In the series of 13,641 Chinese women who delivered during the study period, the incidence of preterm births before 37 weeks'gestation was 7.4% while the incidence of low birth‐weight infants (<2,500g) was 6.4%. When only singleton pregnancies were included, the incidences of preterm births and low birth‐weight were 6.5% and 5.1% respectively. This study has demonstrated results contrary to the belief that premature delivery is uncommon in a Chinese population. In addition, we have found that, similar to Caucasian populations, hypertensive disorders of pregnancy, gestational diabetes, antepartum haemorrhage and congenital malformation are significant risk factors for spontaneous preterm labour in singleton pregnancy in our Chinese population.
A Systematic Review of Single‐Dose Intramuscular Methotrexate for the Treatment of Ectopic Pregnancy
Authors: Parker Jim , Bisks Andrew , Proietto Anthony M.
Published: February 2008

EDITORIAL COMMENT: The authors state that their review of the literature of single‐dose intramuscular methotrexate for the treatment of ectopic pregnancy‐revealed cases where the woman represented with shock secondary to ruptured ectopic pregnancy, requiring emergency laparotomy, but no report of a maternal death. The Annual Report for the year 1996 of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity of Victoria, Australia, released in April 1998, provided details of such a case: (page 74 of report) ‘A 38‐year‐old woman had an ectopic pregnancy diagnosed and was treated conservatively with methotrexate. She developed anaemia and a haemoperitoneum and laparotomy was performed. The woman then developed a massive pulmonary thromboembolism and died 1 day later despite embolectomy’.

Summary: The use of single‐dose intramuscular methotrexate for the primary treatment of ectopic pregnancy is increasing in frequency in many countries. We performed a systematic review of all available studies and case reports of intramuscular methotrexate to examine the therapeutic efficacy, side‐effects and complication rates of this new treatment approach. The pooled data show a successful resolution rate of 71% (95% confidence interval 58% to 81%) after a single dose of intramuscular methotrexate and 84% (95% confidence interval 77% to 90%) after 1 or 2 doses. Side‐effects were experienced by 24% (95% confidence interval 9% to 47%) of patients and 10% (95% confidence interval 7% to 14%) had a ruptured ectopic pregnancy. The pooled data show that single‐dose intramuscular methotrexate is associated with a high failure rate. Follow‐up is prolonged and there is a significant incidence of minor side‐effects. Serious complications and side‐effects have occurred. The use of intramuscular methotrexate should be confined to clinical trials until more evidence is obtained to support its more widespread use.