bluuebunny/crossref_metadata_2025 huggingface dataset:
Haemodynamic changes in the brain after vaginal delivery and caesarean section in healthy term infants
Authors: Dani C. , Martelli E. , Bertini G. , Pezzati M. , Rubaltelli F.F.
Published: December 2003

Objective
To investigate whether the mode of delivery may affect neonatal cerebral haemodynamics during the first hour of life.

Design
Prospective study.

Sample
Healthy infants with gestational age ≥37 weeks and birthweight appropriate for gestational age, born after uncomplicated pregnancy by vaginal delivery or elective caesarean section, two to five hours after the delivery.

Methods
Near infra‐red spectroscopy was used to measure changes of oxygenated haemoglobin, deoxygenated haemoglobin, oxidized‐reduced cytochrome aa3, and mean cerebral oxygen saturation (mixed cerebral oxygen saturation = oxygenated haemoglobin/total haemoglobin). Changes in cerebral blood volume were calculated.

Results
Near infra‐red spectroscopy data did not show significant differences between infants born by vaginal delivery or by caesarean section. There was a significant decrease of oxygenated haemoglobin and change of cerebral blood volume values at 120 and 180 minutes in both the groups, while deoxygenated haemoglobin and oxidized‐reduced cytochrome aa3 were unchanged.

Conclusions
A decrease of cerebral blood volume occurs after birth and this occurs both in infants born by vaginal delivery and by caesarean section.
Vitamin D deficiency in pregnant women from a non‐European ethnic minority population—an interventional study
Authors: Datta S. , Alfaham M. , Davies D.P. , Dunstan F. , Woodhead S. , Evans J. , Richards B.
Published: December 2003

Objective
To determine the vitamin D status of pregnant women from non‐European ethnic minorities in South Wales.

Design
Prospective study.

Setting
Llandough Hospital, Cardiff, South Wales.

Sample
One hundred and sixty pregnant women from a non‐European ethnic minority population in South Wales.

Methods
Biochemical screening of vitamin D status was carried out at the first antenatal visit. Women found to be deficient in vitamin D were subsequently supplemented and vitamin D status was rechecked at delivery.

Main outcome measure
Vitamin D status at delivery.

Results
Eighty of 160 women had a vitamin D level below 8 ng/mL at their first antenatal visit and were treated with oral vitamin D. Factors that could influence vitamin D status such as religion, fluency in English and dressing habits did not appear to have any effect, although a higher proportion of women who had lived in Britain for longer than three years had subnormal vitamin D levels. In 58 of those checked at delivery, the mean plasma vitamin D level increased from 6 to 11 ng/mL although the mean parathyroid hormone level was unchanged.

Conclusion
In view of the high incidence of subnormal vitamin D levels in women from ethnic minorities, we recommend biochemical screening of these women in early pregnancy, with subsequent supplementation where indicated.
Prediction of chorionicity in twin pregnancies at 10–14 weeks of gestation
Authors: Carroll Stephen G.M. , Soothill Peter W. , Abdel‐Fattah Sherif A. , Porter Helen , Montague Imogen , Kyle Phillipa M.
Published: December 2003

Objective
To examine the accuracy of sonographic determination of chorionicity in twin pregnancies at 10–14 weeks of gestation.

Design
Prospective study on the sonographic prediction of chorionicity at 10–14 weeks of gestation.

Participants
During a 30 month period, from October 1997 to May 2000, 165 women attending the departments of fetal medicine or ultrasound.

Methods
Sonographic criteria used in the diagnosis of chorionicity were the number of placental sites, the lambda (λ) and T signs and the thickness of the inter‐twin membrane. The diagnosis of chorionicity was made at the time of the ultrasound examination using all these features and subsequently compared with the postnatal diagnosis, confirmed either by placental histology or discordancy in infant sex.

Results
In 150 cases with confirmation of chorionicity following delivery, 116 were postnatally classified as dichorionic and 34 monochorionic. Prenatal ultrasound examination correctly identified chorionicity in 149 (99.3%) cases. The most reliable indicator for dichorionicity was a combination using the λ sign or two separate placentae with a sensitivity and specificity of 97.4% and 100%, respectively. The most useful test in predicting monochorionicity was the T sign with a sensitivity of 100% and specificity of 98.2%. Measurement of the inter‐twin membrane thickness was a less reliable indicator where the sensitivity for dichorionicity and specificity for monochorionicity was only 92.6%.

Conclusions
Ultrasound examination of twin pregnancies at 10–14 weeks of gestation predicts chorionicity with a high degree of accuracy using a combination of the number of placentae, λ and T signs and inter‐twin membrane thickness. All hospitals should encourage departments providing ultrasound services to undertake chorionicity determination when examining women with twin pregnancies at this gestation.
Short term complications of the tension free vaginal tape operation for stress urinary incontinence in women
Authors: Bodelsson Gunilla , Henriksson Lars , Osser Stellan , Stjernquist Martin
Published: December 2003

Objective
To assess the prevalence of intra‐ and post‐operative complications with the tension free vaginal tape operation for female urinary incontinence.

Design
Non‐control case series.

Setting
University Hospital.

Population
One hundred and seventy‐seven operations on women who were diagnosed urodynamically to have genuine stress incontinence. In 26 cases (15%) there was symptomatic urge incontinence.

Main outcome measures
Intra‐ and post‐operative complications in relation to individual surgeons and mode of anaesthesia (local or spinal), and continence at short term follow up.

Results
Bladder or urethral perforation occurred in 26 cases (15%) and three operations were abandoned for these reasons. A failure to void after the first 24 hours was registered in 35 (20%); 21 (12%) had to undergo urethral dilatation while five patients (2.8%) had persistent urinary retention which required excision of the sling. These problems were significantly associated to the experience of surgeon. In seven cases (4%) haemorrhage required intravaginal tamponade. In three (1.7%) sling rejection occurred post‐operatively. When followed up six to eight weeks post‐operatively, 154 patients (88%) reported subjective cure, 21 (11%) significant improvement and two (1%) no improvement. The use of spinal anaesthesia increased the frequency of peroperative bladder perforation but affected neither the incidence of post‐operative bladder obstruction nor the outcome at follow up.

Conclusions
This study identifies short term complications which relate partly to the experience of the individual surgeon. Nevertheless the 88% subjective cure rate was independent of these factors.
The risk of preterm delivery in women from different ethnic groups
Authors: Aveyard Paul , Cheng K.K. , Manaseki Semira , Gardosi Jason
Published: December 2003

Objective
To examine whether routinely measured variables explained the increased risk of preterm delivery in some UK ethnic groups.

Design
Cross sectional study of deliveries recorded in the Child Health Record System.

Setting
North Birmingham, UK.

Population
All North Birmingham women delivering singletons, 1994–1997 inclusive.

Method
Logistic regression.

Main outcome measures
Odds ratio (OR) and 95% confidence interval (CI) for preterm delivery, defined as less than 37 weeks, less than 34 weeks and less than 28 weeks, unadjusted and adjusted for maternal age, an area‐based socio‐economic status measure, and marital status, year of birth, fetal sex and past obstetric history.

Results
For Afro‐Caribbean women, the ORs (95% CIs) were: for delivery less than 37 weeks, 1.44 (1.26–1.64) unadjusted and 1.22 (1.07–1.41) adjusted; for delivery less than 34 weeks, 1.55 (1.25–1.92) unadjusted and 1.29 (1.02–1.61) adjusted; for delivery less than 28 weeks, 1.66 (1.08–2.55) unadjusted and 1.32 (0.84–2.06) adjusted. For African women, the risk of delivery less than 37 weeks was not significantly raised; for delivery less than 34 weeks, the OR (95% CI) was 1.88 (0.99–3.58) unadjusted and 1.78 (0.93–3.40) adjusted; for delivery less than 28 weeks, the OR (95% CI) was 4.02 (1.60–10.12) unadjusted and 4.10 (1.66–10.16) adjusted. In Afro‐Caribbeans, deprivation and marital status explained the differences between the unadjusted and adjusted ORs. There was a linear relation between deprivation and preterm delivery for all ethnic groups, except for Asians.

Conclusions
Factors associated with deprivation and marital status explain about half of the excess of preterm births in Afro‐Caribbeans, but not Africans. The risk of preterm delivery might not be related to deprivation in Asians.
Does a traumatic birth experience have an impact on future reproduction?
Authors: Gottvall Karin , Waldenström Ulla
Published: December 2003

Objective
To investigate whether women's experiences of their first birth affects future reproduction.

Design
Prospective cohort study.

Setting
South Hospital, Stockholm, Sweden.

Population
Six hundred and seventeen women who gave birth to their first child 1989–1992.

Methods
A global measure of women's experiences of their first birth, assessed two months postpartum, was available from a birth centre trial, together with information on a range of background variables. This information was linked to the Swedish Medical Birth Register, which included information on the number of subsequent births during the following 8–10 years.

Main Outcome Measures
Number of births (0 or ≥1) following the first birth.

Results
Women with a negative experience of their first birth had fewer subsequent children and a longer interval to the second baby (RR 1.7, 95% CI 1.3–2.3). Being 35 years and older (RR 2.6, 95% CI 1.6–3.7), or single (RR 2.6, 95% CI 1.7–3.9) was also associated with subsequent infertility.

Conclusion
A negative birth experience was associated with subsequent infertility, and women's experiences should therefore be considered seriously in the provision of maternity care.
Glucocorticoid treatment in an ischaemic‐like excitotoxic model of periventricular leucomalacia in mice
Authors: Arquié Cyrille , Leroux Philippe , Bodenant Corinne , Laquerrière Annie , Marpeau Loıuml;c , Marret Stéphane
Published: December 2003

Objective
To determine the effects of fluorinated glucocorticoids on the occurrence and extent of ischaemic‐like excitotoxic grey and white matter cerebral injuries in an animal model.

Design
A study of the influence of single or repeated doses of glucocorticoids when creating excitotoxic lesions in mice pups, mimicking some aspects of periventricular leucomalacia and cortical–subcortical stroke as observed in human neonates.

Sample
Four hundred and sixty‐seven mouse pups out of more than 30 liters.

Methods
An excitotoxic lesion was created by intracerebral injection of ibotenate, a glutamatergic agonist, in day five postnatal mice pups. A single dose of betamethasone or dexamethasone was administered, in a dose of 0.006–6 and 0.001–1 mg/kg, respectively, 24 hours before or 15 minutes after each ibotenate injection. Repeated doses of dexamethasone (0.01 mg/kg per day) or betamethasone (0.006 mg/kg) were given for five days before or after ibotenate injections. The measurement of white matter and grey matter lesions and the occurrence of cysts were assessed under light microscope on cresyl violet‐stained brain sections.

Main outcome measures
Size of white matter cystic lesions.

Results
A single injection of betamethasone or dexamethasone had a significant neuroprotective effect when administered after the excitotoxin. Betamethasone injected once prior to ibotenate also had a protective effect. Repeated administration of each steroid before or after excitotoxin injection provided more protection than a single injection.

Conclusion
Fluorinated glucocorticoids reduced neonatal brain lesions observed in a mouse model treated by excitotoxin injection.
Minimally invasive surgery for obstructed labour: a review of symphysiotomy during the twentieth century (including 5000 cases)
Authors: Björklund Kenneth
Published: December 2003

Objective
To compile and make available essential data on symphysiotomy for evaluation in the struggle against maternal and fetal mortality and morbidity from obstructed labour, which causes the death of 50,000 women each year in low‐resourced countries.

Design
Retrospective review of literature.

Sample
Five thousand symphysiotomies and 1200 caesarean sections from 28 countries on four continents.

Methods
The review is based on original papers published 1900 to 1999, stepwise traced through reference lists. Inclusion criteria were: firstly, that the cases reported be consecutive, secondly the presence of an acceptable description of methodology and thirdly, the study size was set at a minimum of 25 cases for analysis of maternal and fetal mortality. Papers comprising only five to 24 cases were included in other analyses. All studies were retrospective, except the follow up studies.

Main Outcome Measures
Maternal and fetal mortality; causes of maternal death; fetal mortality in previous deliveries; mode of delivery in subsequent pregnancies; symphyseal width after symphysiotomy; immediate, short and long term complications; maternal and fetal mortality comparing symphysiotomy and caesarean section.

Results
Symphysiotomy has been extensively studied, modified and refined over the last century, and the scientific documentation is substantial. The results indicate that symphysiotomy is safe for the mother from a vital perspective, confers a permanent enlargement of the pelvis and facilitates vaginal delivery in future pregnancies, and is a life saving operation for the child. Severe complications are rare. Symphysiotomy compares favourably with caesarean section in terms of risk for the mother's life.

Conclusion
If valid conclusions can be drawn from one hundred years of retrospective studies, there is considerable evidence to support a reinstatement of symphysiotomy in the obstetric arsenal, for the benefit of women in obstructed labour and their offspring.
Transient hyperthyroidism of hyperemesis gravidarum
Authors: Tan Jackie Y.L. , Loh Keh Chuan , Yeo George S.H. , Chee Yam Cheng
Published: December 2003

Objective
To characterise the clinical, biochemical and thyroid antibody profile in women with transient hyperthyroidism of hyperemesis gravidarum.

Design
Prospective observational study.

Setting
Hospital inpatient gynaecological ward.

Population
Women admitted with hyperemesis gravidarum and found to have hyperthyroidism.

Methods
Fifty‐three women were admitted with hyperemesis gravidarum and were found to have hyperthyroidism. Each woman was examined for clinical signs of thyroid disease and underwent investigations including urea, creatinine, electrolytes, liver function test, thyroid antibody profile and serial thyroid function test until normalisation.

Main outcome measures
Gestation at which thyroid function normalised, clinical and thyroid antibody profile and pregnancy outcome (birthweight, gestation at delivery and Apgar score at 5 minutes).

Results
Full data were available for 44 women. Free T4 levels normalised by 15 weeks of gestation in the 39 women with transient hyperthyroidism while TSH remained suppressed until 19 weeks of gestation. None of these women were clinically hyperthyroid. Thyroid antibodies were not found in most of them. Median birthweight in the infants of mothers who experienced weight loss of >5% of their pre‐pregnancy weight was lower compared with those of women who did not (P= 0.093). Five women were diagnosed with Graves' disease based on clinical features and thyroid antibody profile.

Conclusions
In transient hyperthyroidism of hyperemesis gravidarum, thyroid function normalises by the middle of the second trimester without anti‐thyroid treatment. Clinically overt hyperthyroidism and thyroid antibodies are usually absent. Apart from a non‐significant trend towards lower birthweights in the infants of mothers who experienced significant weight loss, pregnancy outcome was generally good. Routine assessment of thyroid function is unnecessary for women with hyperemesis gravidarum in the absence of any clinical features of hyperthyroidism.
Efficacy of pre‐operative gonadotrophin hormone releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy: a systematic review
Authors: Lethaby Anne , Vollenhoven Beverley , Sowter Martin
Published: December 2003

Objective
To evaluate the role of pretreatment with gonadotrophin releasing hormone (GnRH) analogues (GnRHa) prior to surgery for women with uterine fibroids.

Design
A systematic review was undertaken of all randomised controlled trials assessing the efficacy of GnRHa treatment prior to surgery (myomectomy or hysterectomy) in women with fibroids.

Setting
Secondary care.

Sample
Premenopausal women with fibroids awaiting surgery attending hospitals or clinics.

Methods
Electronic searches of Medline, EmBase, Current Contents, the Cochrane Library, National Research Register, NLM's Clinical Trials Register and the Cochrane group's Trials Register were performed, between 1980 and 2000. Twenty‐six randomised controlled trials were identified that compared GnRHa with no treatment, placebo or other medical treatment. The quality of the trials was assessed and data were extracted independently by two of the reviewers. Statistical analysis was performed in Revman according to Cochrane guidelines and where possible outcomes were pooled in a meta‐analysis.

Main outcome measures
Pre‐operative assessment (reduction in uterine and fibroid volume, change in haemoglobin and haematocrit, change in patient's symptoms), intra‐operative assessment (duration of operation, blood loss, proportion with vertical incision, proportion undergoing vaginal rather than abdominal procedure, frequency of blood transfusions), post‐operative assessment (complications, duration of hospital stay, recurrence of fibroids).

Results
Pre‐ and post‐operative haemoglobin and haematocrit were significantly improved by GnRHa therapy prior to surgery, and uterine volume, uterine gestational size and fibroid volume were all reduced. Pelvic symptoms were also reduced but some adverse events were more likely during GnRHa therapy. Hysterectomy appeared to be easier after pretreatment with GnRHa therapy; there was reduced operating time and a greater proportion of hysterectomy patients was able to have a vaginal rather than an abdominal procedure. Duration of hospital stay was also reduced. Blood loss and rate of vertical incisions were reduced for both myomectomy and hysterectomy. Evidence of increased risk of fibroid recurrence after GnRHa pretreatment in myomectomy patients was equivocal and few data were available to assess change in post‐operative fertility.

Conclusions
The use of GnRHa for three to four months prior to fibroid surgery reduces both uterine volume and fibroid size. They are beneficial in the correction of pre‐operative iron deficiency anaemia, if present, and reduce intra‐operative blood loss. If uterine size is such that a midline incision is planned, this can be avoided in many women with the use of GnRHa. For women undergoing hysterectomy, a vaginal procedure is more likely following the use of these agents.
A scoring system for the assessment of bowel and lower urinary tract symptoms in women
Authors: Hiller L. , Bradshaw H.D. , Radley S.C. , Radley S.
Published: December 2003

Objective
To develop a simple scoring system for a validated 22‐item questionnaire used to assess bowel and urinary dysfunction in women.

Setting
A urogynaecology clinic, a functional bowel clinic, a district general hospital and a general practice.

Population
One hundred and one women referred with functional bowel and/or urinary symptoms and 131 asymptomatic controls.

Methods
A user manual has been prepared. Individual responses to questions are categorised into normal and abnormal and odds ratio tests applied to reflect their sensitivity.

Results
Scoring methods have been detailed, and appropriate and sensitive cutoff points defined.

Conclusions
The use of this validated questionnaire is now aided by a user manual, facilitating health care evaluation research into the effects of pelvic surgery on pelvic floor symptomatology. A simple scoring system is provided, making the questionnaire a valuable and accessible research tool.
Medical management of late intrauterine death using a combination of mifepristone and misoprostol
Authors: Wagaarachchi Prabhath T. , Ashok Premila W. , Narvekar Nitish N. , Smith Norman C. , Templeton Allan
Published: December 2003

Objective
To assess the efficacy and safety of mifepristone in combination with misoprostol in the management of late fetal death.

Design
Observational study.

Setting
Aberdeen Maternity Hospital, Aberdeen.

Methods
A consecutive series of 96 women with intrauterine death after 24 weeks of gestation were studied. Each woman received a single dose of 200mg mifepristone orally, following which a 24–48 hour interval was recommended before administration of misoprostol. For gestations of 24–34 weeks, 200μg of intravaginal misoprostol was administered, followed by four oral doses of 200μg at three hourly intervals. Gestations over 34 weeks were given a similar regimen but a reduced dose of 100μg misoprostol.

Results
The average induction to delivery interval was 8.5 hours. Ninety‐five women (98.9%) were delivered within 72 hours of administration of first dose of misoprostol, with 66.7%, 87.5%, 92.7% and 95.8% women delivering within 12, 24, 36 and 48 hours, respectively. No significant correlation was found between mean induction to delivery interval and maternal age, parity, Bishop's score, birthweight and mifepristone/misoprostol interval. The induction to delivery interval was shorter with increasing gestation (P= 0.04). Mild side effects were noted in eight (8.3%) women. Three (3.1%) women had treatment for presumed or proven pelvic sepsis. No cases of uterine tachysystole, haemorrhage or coagulopathy were recorded.

Conclusion
The combination of mifepristone and misoprostol for induction of labour following late fetal death is an effective and safe regimen. The induction to delivery interval with this regimen appears shorter than studies using mifepristone or misoprostol.
Reproductive risk factors, pregnancy characteristics and obstetric outcome in female doctors
Authors: Heinonen Seppo , Saarikoski Seppo
Published: December 2003

Objectives
To compare maternal risk factors, pregnancy characteristics and outcome in female doctors, teachers, and the general obstetric population.

Design
We analysed obstetric outcomes among 331 female doctors and 656 teachers with singleton pregnancies who gave birth at Kuopio University Hospital from March 1989 to December 2000. The general obstetric population (n= 21,997) was selected as the reference group and logistic regression analysis was used to assess pregnancy outcomes in each group separately.

Results
Reproductive risk factors among female doctors and teachers were similar to those in the general obstetric population with the exception of advanced maternal age, number of previous terminations, marital status, maternal smoking, obesity, infertility treatment and pre‐eclampsia. Interestingly, the number of operative deliveries did not vary between the groups. Pregnancy outcome among doctors and teachers was comparable with that in the general population.

Conclusions
Although doctors and teachers appear to represent a group of health‐conscious women, obstetricians do not vary their management of pregnant doctors and teachers during pregnancy and labour.
Influence of omental biopsy on adjuvant treatment field in clinical Stage I endometrial carcinoma
Authors: Nieto Jose J. , Gornall Robert , Toms Ellen , Clarksono Suzanne , Hogston Patrick , Woolas Robert P.
Published: December 2003

In this study to assess the role of omental biopsy in the diagnosis of extrapelvic disease, data from 100 consecutive women with clinical Stage I endometrial cancer undergoing primary surgical treatment in our institution were analysed: 80 women had an omental biopsy, 20 did not, and six had adenocarcinoma in the omentum. No obvious morbidity attributable to this rapid and easily performed surgical procedure was recorded. We conclude that visual inspection and palpation of the omentum at the time of abdominal surgery for endometrial carcinoma is worthwhile and advisable. In addition, adopting a protocol of histological assessment upstaged a further two cases of this series. These data suggest that this technique might influence the prescription of adjuvant pelvic radiation in approximately one in 10 women currently considered for such therapy, as disease can be easily documented as having extended beyond the conventional radiotherapy field.
Loop diathermy excision compared with cervical laser vaporisation for the treatment of intraepithelial neoplasia: a randomised controlled trial
Authors: Dey P. , Gibbs A. , Arnold D.F. , Saleh N. , Hirsch P.J. , Woodman C.B.J.
Published: December 2003

Objective
To determine whether loop diathermy excision of the transformation zone and laser vaporisation are equally effective in the treatment of cervical intraepithelial neoplasia.

Design
Randomised controlled trial.

Population
Women referred for evaluation of cytological abnormality who were considered suitable for outpatient local destructive treatment.

Setting
Seven colposcopy units in the North West Region.

Methods
Loop diathermy excision of the transformation zone and laser vaporisation.

Main outcome measure
Smear reported as moderate dyskariosis or worse following treatment.

Results
Of 289 women randomised, 285 had one or more smears following treatment. Women were more likely to have a smear reported as moderate dyskariosis or worse following laser vaporisation [hazard ratio 3.01 (95% CI 1.27 to 7.12)]. The cumulative risk of a smear reported as moderate dyskariosis or worse was 6.0% at six months and 12.1% at three years in those allocated laser vaporisation, and 2.0% at six months, and 3.3% at three years in those allocated loop diathermy excision of the transformation zone.

Conclusions
Loop diathermy excision is a more effective treatment of cervical intraepithelial neoplasia than laser vaporisation.
The VALUE national hysterectomy study: description of the patients and their surgery
Authors: Maresh M.J.A. , Metcalfe M.A. , McPherson Klim , Overton C. , Hall V. , Hargreaves J. , Bridgman S. , Dobbins J. , Casbard A.
Published: December 2003

Objectives
To describe hysterectomies practised in 1994 and 1995: the patients, their surgery and short term outcomes.

Design
One of two large cohorts, with prospective follow up, recruited to compare the outcomes of endometrial destruction with those of hysterectomy.

Setting
England, Wales and Northern Ireland.

Population
All women who had hysterectomies for non‐malignant indications carried out during a 12‐month period.

Methods
Gynaecologists in NHS and independent hospitals were asked to report cases. Follow up data were obtained at outpatient follow up approximately six weeks post‐surgery.

Main outcome measures
Indication for surgery, method of hysterectomy, ovarian status post‐surgery, surgical complications.

Results
37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically‐assisted hysterectomy were 67%, 30% and 3%, respectively. Forty‐three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post‐operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There were no operative deaths; 14 deaths were reported within the six‐week post‐operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95% CI 0.25–0.64).

Conclusions
This large study describes women who undergo hysterectomy in the UK, and presents results on early complications associated with the surgery. Operative complications occurred in one in 30 women, and post‐operative complications in at least one in 10. Laparoscopic techniques tend to be associated with higher complication rates than other methods.
Intra‐operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: a randomised clinical trial
Authors: Magann Everett F. , Chauhan Suneet P. , Bufkin Laura , Field Karen , Roberts William E. , Martin James N.
Published: December 2003

Objective
To determine whether the method used to expand the uterine incision for caesarean delivery affects the incidence of intra‐operative haemorrhage.

Design
A prospective randomised study of women undergoing a low segment transverse caesarean delivery. Participants were assigned to have their uterine incision either sharply or bluntly expanded.

Participants
Between June 1998 and June 2000, 470 women drew assignments to the sharp expansion group and 475 to the blunt group.

Results
The maternal demographics of age, race, nulliparity, and body mass index as well as pre‐operative haematocrit were similar between groups. Compared with the blunt group, the estimated blood loss (886 versus 843mL, P= 0.001), change in the mean haematocrit (6.1%versus 5.5%, P= 0.003), incidence of postpartum haemorrhage (13%versus 9%; relative risk = 1.23, 95% CI 1.03, 1.46) and need for a transfusion (2%versus 0.4%; relative risk = 1.65, 95% CI 1.25, 2.21) were significantly greater in the sharp group.

Conclusion
In caesarean delivery, sharply expanding the uterine incision significantly increases intra‐operative blood loss and the need for subsequent transfusion.
A two‐centred pragmatic randomised controlled trial of two interventions of postnatal support
Authors: Reid M. , Glazener C. , Murray G.D. , Taylor G.S.
Published: December 2003

Objectives
To establish whether providing additional postnatal support during the early postnatal months influences women's physical and psychological health and to identify health service benefits.

Design
Pragmatic randomised controlled trial with a 2 × 2 factorial design with two interventions.

Setting
Community centres, Ayrshire and Grampian, Scotland.

Population
One thousand and four primiparous women, 83% completed the baseline questionnaire, 71% at six months.

Methods
(1) An invitation to a local postnatal support group run weekly with a facilitator, starting two weeks postpartum. (2) A postnatal support manual, posted two weeks postpartum.

Main outcome measures
Data regarding primary outcome postnatal depression (Edinburgh Postnatal Depression Scale, EPDS), secondary outcomes, general health measures (SF‐36), social support (SSQ6), use of health services and women's views of interventions were collected at two weeks postpartum and at three and six months.

Results
There were no significant differences in EPDS scores between the control and trial arms at three and six months, nor were there differences in the SF‐36 and the SSQ6 scores. The 95% CI for the difference in EPDS effectively excluded a change in mean score of more than 10% with either intervention. There were no differences in health service attendances in primary or secondary care between the control and trial arms. Of those women who attended the groups, 40% attended six or more. Women reported favourably on the ‘pack’ with the majority reading it a few times and feeling that it was aimed at them.

Conclusions
Wide‐scale provision by the National Health Service of either support groups or self‐help manuals is not appropriate if the aim is to improve measurable health outcomes.
Autofluorescence spectroscopy for the diagnosis of cervical intraepithelial neoplasia
Authors: Weingandt Helmut , Stepp Herbert , Baumgartner Reinhold , Diebold Joachim , Xiang Wei , Hillemanns Peter
Published: December 2003

Objective
To assess the feasibility of autofluorescence spectroscopy in the diagnosis of cervical intraepithelial neoplasia (CIN) using broadband light excitation.

Design
Feasibility study.

Setting
Colposcopy clinic of an university hospital.

Population
Sixty‐eight patients at risk for CIN.

Methods
After excitation with a broadband light between 375 and 440 nm, spectral distribution of native tissue fluorescence (autofluorescence) was acquired from 685 cervical sites for the localisation and differentiation of CIN, and compared with colposcopically directed biopsy and human papillomavirus (HPV) DNA testing.

Main outcome measure
Detection of CIN.

Results
The evaluation of spectral measurements revealed significantly lower autofluorescence values for CIN 3 lesions compared with normal tissue (P < 0.001), and compared with CIN 1 or CIN 2 (P < 0.002). High grade CIN lesions (CIN 2/3) presented with a significant reduced autofluorescence compared with CIN 1 (P < 0.002). Patients with a positive HPV DNA testing showed a significantly lower autofluorescence than patients tested negative for HPV DNA (P < 0.05). Severe inflammation such as chronic cervicitis may lead to false positive results.

Conclusions
Autofluorescence spectroscopy represents an interesting approach for the detection of cervical neoplasia. Using an excitation wavelength band between 375 and 440 nm, significant differences between normal and precancerous lesions of the cervix can be seen.
Longitudinal measurement of peak systolic velocity in the fetal middle cerebral artery for monitoring pregnancies complicated by red cell alloimmunisation: a prospective multicentre trial with intention‐to‐treat
Authors: Zimmermann Roland , Durig Peter , Carpenter Robert J. , Mari Giancarlo
Published: December 2003

Objective
To evaluate the utilisation measurements of peak systolic velocities in the middle cerebral artery combined with B‐mode ultrasound imaging to predict anaemia in an unselected population of pregnancies complicated by alloimmune antibodies known to cause immunological hydrops.

Design
Prospective study on an intention‐to‐treat basis.

Setting
Multicentre study in five large tertiary referral centres.

Population
One hundred twenty‐five fetuses with maternal alloantibodies known to cause immunological hydrops.

Methods
If peak systolic velocity and B‐mode scan were reassuring the pregnancy was monitored at 7–14 days interval. If either method showed signs of anaemia, an umbilical fetal blood sampling was performed. When the gestational age was greater than 35 weeks, labour was induced.

Main outcome measure
Moderate to severe anaemia at delivery.

Results
Overall sensitivity to detect moderate to severe anaemia below 35 weeks (haemoglobin level below 0.65 multiples of median) was 88%. Specificity was 87%; positive predictive value was 53% and negative predictive value was 98%. The diagnosis of severe anaemia was missed in one fetus; however, the final outcome was good. The method was not useful after 35 weeks.

Conclusions
Middle cerebral artery peak systolic velocity is a highly sensitive non‐invasive means for determining the degree of anaemia present in red blood cell alloimmunised pregnancies. The widespread use of the Doppler method will minimise fetal complications associated with amniocentesis and fetal blood sampling. Non‐invasive measurement of middle cerebral artery peak systolic velocities is more convenient and acceptable to alloimmunised pregnancies and may significantly lower health care costs. A Doppler interval of seven days is recommended.
What is a reasonable time from decision‐to‐delivery by caesarean section? Evidence from 415 deliveries
Authors: MacKenzie I.Z. , Cooke Inez
Published: December 2003

Objective
To determine how long it takes from the decision to achieve delivery by non‐elective caesarean section (DDI), the influence on this interval, and the impact on neonatal condition at birth.

Design
Twelve months prospective data collection on all non‐elective caesarean sections.

Methods
Prospective collection of data relating to all caesarean sections in 1996 in a major teaching hospital obstetric unit was conducted, without the knowledge of the other clinicians providing clinical care. Details of the indication for section, the day and time of the decision and the interval till delivery were recorded as well as the seniority of the surgeon, and condition of the baby at birth.

Results
The mean time from decision‐to‐delivery for 100 emergency intrapartum caesarean sections was 42.9 minutes for fetal distress and 71.1 minutes for 230 without fetal distress (P < 0.0001). For 22 ‘crash’ sections the mean time from decision‐to‐delivery was 27.4 minutes; for 13 urgent antepartum deliveries for fetal reasons it was 124.7 minutes and for 21 with maternal reasons it was 97.4 minutes. The seniority of the surgeon managing the patient did not appear to influence the interval, nor did the time of day or day of the week when the delivery occurred. Intrapartum sections were quicker the more advanced the labour, and general anaesthesia was associated with shorter intervals than regional anaesthesia for emergency caesarean section for fetal distress (P < 0.001). Babies born within one hour of the decision tended to be more acidaemic than those born later, irrespective of the indication for delivery. Babies tended to be in better condition when a time from decision‐to‐delivery was not recorded than those for whom the information had been recorded.

Conclusion
Fewer than 40% intrapartum deliveries by caesarean section for fetal distress were achieved within 30 minutes of the decision, despite that being the unit standard. There was, however, no evidence to indicate that overall an interval up to 120 minutes was detrimental to the neonate unless the delivery was a ‘crash’ caesarean section. These data thus do not provide evidence to sustain the recommendation of a standard of 30 minutes for intrapartum delivery by caesarean section.
Managing severe loin pain in pregnancy
Authors: Irving Stuart O. , Burgess Neil A.
Published: December 2003

Objective
To investigate whether the intravenous urogram used in an appropriate setting is a valuable investigation for managing severe loin pain in pregnancy.

Design
Prospective obsevational study.

Setting
University teaching hospital.

Population
Fifteen pregnant women referred with severe loin pain.

Methods
A prospective study collecting data over a 24‐month period was performed. Women with severe loin pain believed to be of renal origin that had failed to respond to conservative treatment were referred by their obstetricians. The intravenous urogram was performed that consisted of a two‐film series (plain film and a 20‐minute postmicturition film).

Main outcome measures
Management of severe loin pain in pregnancy based on the findings of the intravenous urogram.

Results
Over the two‐year period, 15 women had an intravenous urogram performed at a median gestation of 32 weeks (24–36 weeks). All women had undergone a prior urinary tract ultrasound examination within 24 hours of referral, which showed dilatation on the symptomatic side in 15/15 cases. The intravenous urogram confirmed dilatation on the ipsilateral side in 14/15 cases and revealed the level of dilatation in all of these cases. Delayed excretion of contrast was seen in all 14/15 cases. Three patients had obstructing ureteric calculi revealed by the intravenous urogram and one patient had a non‐dilated and non‐obstructed system.

Conclusions
An intravenous urogram is a safe investigation in the appropriate setting. It allows for an accurate diagnosis to be made and for appropriate treatment to be instigated with joint decisions from urologic, obstetric and radiologic teams. This multidisciplinary approach care can be specifically tailored to the individual patient, which we feel is safer for both mother and baby.
Possible association between amniotic fluid micro‐organism infection and microflora in the mouth
Authors: Bearfield Caroline , Davenport Elizabeth S. , Sivapathasundaram Vythil , Allaker Robert P.
Published: December 2003

ObjectiveTo determine whether oral bacteria are found in the amniotic cavity.

DesignLaboratory based analysis of clinical samples.

SettingRoyal London Hospital, Whitechapel.

PopulationForty‐eight women attending for elective caesarean section.

MethodsDental plaque, a high vaginal swab, amniotic fluid and chorioamnion tissue were taken from women with intact membranes.

Main outcome measuresSamples were investigated using culture and microscopy for the presence of micro‐organisms. Amniotic fluid was analysed by polymerase chain reaction (PCR) for the presence of the ubiquitous 16S rRNA gene specific to most eubacteria. Samples were analysed using PCR genus and species specific primers directed to bacterial taxa found as part of the normal oral microflora (Streptococcusspp. andFusobacterium nucleatum). Levels of prostaglandinE2and cytokines were measured in amniotic fluid.

ResultsAmniotic fluid was positive for universal bacteria PCR,Streptococcusspp. PCR andF. nucleatumPCR in 34/48, 20/48 and 7/48 of cases, respectively.Streptococcusspp. andF. nucleatumwere cultured from the dental plaque, vagina and amniotic fluid of 48/48, 14/48, 0/48 and 29/48, 6/48, 0/48 subjects, respectively. A significant association was found between detection of microbial DNA (universal andF. nucletum) and complications in previous pregnancies including miscarriage, intrauterine death, neonatal death, preterm delivery and premature rupture of membranes (P< 0.05 andP< 0.01, respectively). ProstaglandinE2and cytokine levels, with the exception of IL‐1α, were not significantly different between women with and without evidence of infection.

ConclusionsThe results indicate thatStreptococcusspp. andF. nucleatumin the amniotic fluid may have an oral origin.
Endothelial function is preserved in pregnant women with well‐controlled type 1 diabetes
Authors: Ang Christine , Hillier Chris , Johnston Fiona , Cameron Alan , Greer Ian , Lumsden Mary Ann
Published: December 2003

Objective
Pregnant women with diabetes mellitus have a higher incidence of adverse pregnancy outcomes. Vascular, and in particular, endothelial function may be significantly modified in diabetes resulting in impaired endothelium‐dependent relaxation. This study aims to investigate endothelium‐dependent relaxation in pregnant women with pre‐existing type 1 diabetes mellitus.

Methods
Small arteries (mean luminal diameter ∼295 μm) were isolated from biopsies of subcutaneous fat from pregnant women with pre‐existing type 1 diabetes mellitus, non‐diabetic pregnant women, and non‐diabetic non‐pregnant women. Endothelial and smooth muscle function were determined using wire myography, and the contributions of nitric oxide, vasodilator prostanoid and endothelial hyperpolarisation were studied using specific inhibitors.

Results
Arteries obtained from the diabetic pregnant women did not demonstrate any difference in either endothelial or smooth muscle function when compared with non‐diabetic pregnant women. The contribution of nitric oxide to endothelium‐dependent relaxation was ∼20% in the pregnant women regardless of whether they were diabetic, and ∼11% in the non‐pregnant women. Endothelial hyperpolarisation appeared to contribute largely to vasorelaxation in human subcutaneous arteries, and was at least twice that of nitric oxide in pregnant women and fivefold greater in non‐pregnant women.

Conclusions
This study provides evidence that pregnant women with well‐controlled pre‐existing type 1 diabetes mellitus have both normal endothelial and smooth muscle function. Endothelium‐dependent hyperpolarisation appears to play a large role in vascular relaxation in human subcutaneous resistance arteries. This study suggests that the problems associated with diabetic pregnancies are unlikely to be due to vascular dysfunction.
Fertility results after conservative treatment of advanced stage serous borderline tumour of the ovary
Authors: Camatte Sophie , Morice Philippe , Pautier Patricia , Atallah David , Duvillard Pierre , Castaigne Damienne
Published: December 2003

Objective
To assess the fertility of patients treated conservatively for a Stage II or III borderline ovarian tumour.

Design
A retrospective study.

Setting
Gynaecological oncology department in a French anti‐cancer centre.

Population
Seventeen patients treated with conservative management for a Stage II (n= 6) or III (n= 11) borderline ovarian tumour were followed up. Fifteen patients underwent a unilateral salpingo‐oophorectomy (with contralateral cystectomy in six patients), one had unilateral cystectomy and one a bilateral cystectomy. Fourteen patients had non‐invasive implants and three had invasive implants.

Main outcome measures
Pregnancy rates and outcome.

Results
Eight pregnancies were observed in seven patients in a median delay of eight months following the surgical procedure. Six pregnancies were observed spontaneously, one occurred after an ovarian stimulation and one after an IVF procedure. None of these patients recurred under the form of invasive ovarian carcinoma on the spared ovary. Two patients (one with a non‐invasive disease and one with an invasive one) had recurrence in the form of evolutive invasive implants, but neither woman died.

Conclusion
Spontaneous pregnancy can occur after conservative treatment of advanced stage borderline tumour of the ovary (with non‐invasive implants). Such management, performed in a close follow up of the patients, does not affect the overall survival. Conservative surgery could be proposed in patients with borderline tumour of the ovary and non‐invasive peritoneal implants.
Obstetric cholestasis, outcome with active management: a series of 70 cases
Authors: Kenyon Anna P. , Piercy C. Nelson , Girling J. , Williamson C. , Tribe R.M. , Shennan A.H.
Published: December 2003

Objective
To determine the nature and outcome of obstetric cholestasis in a United Kingdom population.

Design
Prospective analysis of clinical outcome in women diagnosed with obstetric cholestasis that is actively managed.

Setting
Antenatal population of three London hospitals between August 1999 and April 2001.

Population
Seventy women with obstetric cholestasis defined as abnormal liver function (one or more abnormality in gamma‐glutamyl transpeptidase, alanine amino‐transferase, aspartate amino‐transferase and total bile acids) in a pregnant woman with pruritus, in the absence of other pathology.

Methods
All women were interviewed weekly regarding their symptoms. All were actively managed according to a standardised protocol, which included early delivery before 38 weeks. Obstetric outcome was recorded.

Results
Seventy women of mean age 30 (6) years delivered 73 infants. The median gestation at onset of pruritus was 30 (range 4–39) weeks and at diagnosis of obstetric cholestasis was 33.7 (range 21–40.7) weeks. Asian women were more likely to be diagnosed with obstetric cholestasis. Pruritus was usually severe and generalised, and commonly worst on the palms and/or soles of the feet. There were no stillbirths or perinatal deaths. Twenty‐five women required caesarean section (36%); only four (16%) were for fetal distress. Twelve women (17%) delivered before 37 weeks, of which eight (67%) were iatrogenic. Ten (14%) infants required admission to the special care baby unit of which four (40%) were ventilated.

Conclusions
Policies of active management result in increased intervention and associated complications. This must be balanced against possible reductions in perinatal mortality.