bluuebunny/crossref_metadata_2025 huggingface dataset:
The relation between fetal abdominal circumference and birthweight: findings in 3512 pregnancies
Authors: Smith G. C. S. , Smith M. F. S. , McNay M. B. , Fleming J. E. E.
Published: August 2005

Objectives
To establish the relation between fetal abdominal circumference and birthweight in a large population of fetuses; to identify whether the error in estimating birthweight by abdominal circumference varied with the magnitude of abdominal circumference; and to establish whether adding femur length to abdominal circumference caused a clinically important reduction of error in predicting birthweight.

Design
A retrospective study.

Setting
The ultrasound department of a teaching maternity hospital offering a tertiary referral service.

Sample
From 3512 nondiabetic women with a normally formed singleton fetus, an abdominal circumference measurement of the infant was made within seven days of delivery; of these, 1213 had a femur length measurement performed at the same time.

Results
There was a linear relation between abdominal circumference and birthweight. There was a strong inverse correlation between the proportional error in predicting birthweight from the abdominal circumference and the magnitude of the abdominal circumference. Both the Campbell and Wilkin equation (abdominal circumference alone) and the Hadlock equation (abdominal circumference and femur length) were associated with systematic errors, especially with larger birthweight infants. The median absolute errors for the two equations were not significantly different overall (6.98% and 6.86% respectively), although the Hadlock equation was significantly more accurate in predicting birthweight in infants weighing greater than 4500 g. However, no threshold value of abdominal circumference or of estimated fetal weight using the Hadlock equation had a positive predictive value in estimating infants of > 4500 g of greater than 35%.

Conclusions
Prediction of birthweight should be by abdominal circumference alone. Table 1 presents robust estimates of the error of predicting birthweight using fetal abdominal circumference.

The relation between fetal abdominal circumference (AC) and birthweight (BW).

AC (mm)
n
Median BW(g)
10th‐90th centile BW (g)
Range BW(g)

200‐209
13
900
750‐1030
740‐1040

210‐219
20
1040
830‐1370
780‐1400

220–229
20
1060
750‐1410
650‐1460

230‐239
28
1255
980‐1470
900‐1860

240‐249
36
1435
1200‐1790
1080‐1950

250‐259
37
1580
1290‐1925
1180‐2260

260‐269
56
1835
1490‐2190
1340‐2400

270‐279
89
2000
1640‐2320
1390‐2620

280‐289
134
2265
1920‐2660
1530‐2910

290‐299
219
2530
2130‐2900
1820‐3100

300‐309
350
2685
2340‐3080
2010‐3420

310‐319
387
2850
2470‐3290
2110‐3650

320‐329
484
3060
2700‐3470
2350‐3770

330‐339
439
3260
2880‐3700
2570‐3980

340‐349
423
3380
3040‐3860
2670‐4240

350‐359
314
3615
3240‐4040
2890‐4460

360‐369
245
3750
3330‐1190
3020‐4610

370‐379
117
3840
3480‐4360
3180‐4790

380‐389
66
4140
3660‐4640
3470‐4820

390‐399
35
4290
3665‐4675
3640‐5000
An ultrasound study of gestational and postural changes in the deep venous system of the leg in pregnancy
Authors: Macklon Nicholas S. , Greer Ian A. , Bowman Adrian W.
Published: August 2005

Objective
To investigate gestational and postural changes in diameter and blood flow in the proximal deep leg veins during pregnancy.

Design
A longitudinal, prospective observational study.

Setting
The ultrasound department of a teaching maternity hospital.

Population
Twenty‐four healthy women with uncomplicated singleton pregnancies.

Methods
Real‐time and duplex Doppler ultrasound assessments of the vessel diameter, flow velocity and respiratory flow fluctuation in the proximal deep leg veins of women serially measured from the first trimester of pregnancy to six weeks postnatally.

Main outcome measures
The effects of increasing gestation and the adoption of the left lateral position on the above parameters.

Results
An increase in vessel diameter and a fall in flow velocity with increasing gestation was observed. However, no change in venous flow variation was observed. Delivery had reverse effects. Flow velocity was slower in the left than the right legs, but on adoption of the left lateral position an increase in flow velocity and venous flow variation was observed in both legs during pregnancy.

Conclusions
These data are consistent with the observed increase in incidence and pattern of deep venous thrombosis in pregnancy and may aid interpretation of duplex Doppler ultrasound examinations for deep venous thrombosis in pregnancy. Postural changes should be part of this evaluation. The gravid uterus may not be the sole cause for postural changes in deep venous flow velocity.
A randomised comparison between amniotic fluid index and maximum pool depth in the monitoring of post‐term pregnancy
Authors: Alfirevic Zarko , Luckas Murray , Walkinshaw Steve A. , McFarlane Maureen , Curran Rosemary
Published: August 2005

Objective
To compare the impact of two different ultrasound methods for assessing amniotic fluid volume on the incidence of obstetric interventions in post‐term pregnancies.

Design
A prospective randomised controlled trial.

Setting
Liverpool Women's Hospital.

Participants
Five hundred women with singleton, uncomplicated pregnancies with gestational age 290 days.

Interventions
Random allocation to fetal monitoring by either: 1. amniotic fluid index and computerised cardiotocography, or 2. maximum pool depth and computerised cardiotocography.

Main outcome measures
Primary: caesarean section. Secondary: the number of abnormal monitoring tests, induction of labour, intrapartum management and neonatal outcome.

Results
The number of abnormal amniotic fluid indices was significantly higher than the number of abnormal maximum pool depths (10%vs 2.4%; OR 4.51, 95% CI 1.82–11.21; P= 0.0008) which resulted in more inductions for abnormal post‐term monitoring in the amniotic fluid index group (14.8%vs 8.4%; OR 1.89; 95% CI 1.07–3.33; P= 0.0362) and more intrapartum electronic fetal monitoring (94.4%vs 88.4%; OR 2.21; 95% CI 1.13–4.29; P= 0.0255). There were no other statistically significant differences in outcomes related to labour and delivery, but there was a trend towards more caesarean sections in the amniotic fluid index group (18.8%vs 13.2%), in particular caesarean sections for fetal distress (8%vs 4%). There were no perinatal deaths and no statistically significant differences in perinatal outcome between the two groups.

Conclusions
Published reference ranges for amniotic fluid index overestimate the number of abnormal results in post‐term pregnancies. Their use, when compared with maximum pool depth, is likely to increase the number of obstetric interventions with, as yet, an uncertain impact on perinatal mortality and morbidity. It is possible that antepartum fetal assessment in pregnancies where the risk of adverse perinatal outcome is very low may cause, rather than prevent morbidity.
Is loop excision adequate primary management of adenocarcinoma in situ of the cervix?
Authors: Houghton S. J. , Shafi M. I. , Rollason T. P. , Luesley D. M.
Published: August 2005

Objective
To assess the efficacy of cervical loop excision as primary management of adenocarcinoma in situ.

Design
A two‐centre retrospective study.

Setting
Birmingham and Midlands Hospital for Women and City Hospital NHS Trust.

Population
Nineteen women with a histological diagnosis of adenocarcinoma in situ (high grade CIGN) of the cervix made on diathermy loop excision.

Main outcome measures
Presence or absence of adenocarcinoma in situ at loop specimen margins, results of cervical cytological examinations following loop excision, results of histopathological assessment of any surgical specimens taken after initial loop excision.

Results
Of the 19 women with confirmed adenocarcinoma in situ on loop excision, the median age was 31, and 8 (42%) were nulliparous. The median follow up of these women was 19 months. Eleven women were treated by loop excision alone and have had normal follow up to 18 months. Five women have undergone further surgical procedures, four had a hysterectomy and one had a repeat loop excision. No residual disease was found in any of these surgical specimens, confirming that loop excision was adequate primary management of the disease. Three women have had abnormal endocervical follow up cytology suggestive of residual disease. One of these three women may represent a case of residual endocervical disease. Excision margins of the loop specimen were not involved by adenocarcinoma in situ in 11 women. However, excision margin status of the loop specimen did not appear to be predictive of residual disease.

Conclusions
Our small retrospective study suggests that diathermy loop excision of the cervix is adequate primary management of adenocarcinoma in situ of the cervix. Cytological and colposcopic follow up, including cytobrush endocervical cytological sampling and long term follow up, is recommended in these women.
Maternal fever in term labour in relation to fetal tachycardia, cord artery acidaemia and neonatal infection
Authors: Herbst Andreas , Wolner‐Hanssen Pål , Ingemarsson Ingemar
Published: August 2005

Objective
To determine 1. whether maternal fever during term labour is associated with acidaemia at birth and neonatal infection and 2. whether fetal tachycardia precedes maternal fever and is associated with neonatal infection.

Design
Retrospective matched‐pair case‐control study.

Subjects
Two hundred and forty‐eight newborn infants whose mothers developed fever during term labour (cases) and 248 control infants. The women were matched for parity and duration of labour.

Main outcome measures
Cord artery acid‐base status, Apgar scores, neonatal infections, and fetal heart rate before maternal fever.

Results
Mean pH, as well as the rate of cord artery acidaemia at birth (pH < 7.10) was equal in cases and controls (in both groups 7.24% and 6%, respectively). Signs of septicaemia and/or pneumonia were identified in 17 case newborns (7%) and in one control (0.4%; OR 17.0, P < 0.001). Of 212 pairs with complete heart rate data, fetal tachycardia preceded maternal fever in 39 cases (18%) and in 16 controls (8%) (OR 2.6, P= 0.003). Tachycardia before maternal fever was not associated with increased neonatal infectious morbidity.

Conclusions
Maternal fever during term labour was associated with perinatal infection, but not with acidaemia at birth. Elevated fetal heart rate preceded maternal fever in a minority of cases and was not associated with perinatal infection.
Maternal serum inhibin‐A and free β‐hCG concentrations in trisomy 21 pregnancies at 10 to 14 weeks of gestation
Authors: Noble P. L. , Wallace E. M. , Snijders R. J. M. , Groome N. P. , Nicolaides K. H.
Published: August 2005

Objective
To determine the relation between maternal serum inhibin‐A and free β‐hCG concentrations in chromosomally normal pregnancies and to compare the two biochemical markers for their sensitivity in identifying trisomy 21 pregnancies.

Sample
Inhibin‐A and free β‐hCG were measured in maternal serum samples from 800 chromosomally normal singleton pregnancies at 10 to 14 weeks of gestation and 76 singleton pregnancies with fetal trisomy 21.

Results
In the normal group maternal serum inhibin‐A was significantly associated with both maternal weight and gestational age (F= 11.2, P < 0.0001). In pregnancies with trisomy 21 the maternal serum inhibin‐A and free β‐hCG concentrations were significantly increased (mean difference inhibin = 0.51 SD, F= 18, P < 0.0001 and mean difference free β‐hCG = 1.13 SD, F= 80, P < 0.0001). For a 5% false positive rate, the sensitivity of maternal serum free β‐hCG in identifying pregnancies with trisomy 21 was 28.9% compared with 12.8% for maternal serum inhibin‐A. Delta inhibin‐A was significantly associated with delta‐free β‐hCG (r= 0.345, P < 0.01) and the deviation from the normal mean for free β‐hCG was significantly greater than the deviation for inhibin‐A (t= 4.0, P < 0.0001). For a 5% false positive rate, the sensitivity achieved by combining information from delta inhibin‐A and delta free β‐hCG was similar to the sensitivity of free β‐hCG alone (30.3% compared with 28.9%)

Conclusion
At 10 to 14 weeks of gestation fetal trisomy 21 is associated with increased maternal serum inhibin‐A and free β‐hCG levels. However, the degree of elevation of inhibin‐A is less than that of free β‐hCG, and there is a significant association between levels of the two proteins. The sensitivity for trisomy 21 achieved with the combination of maternal serum inhibin‐A and free β‐hCG is not significantly different from that achieved with maternal serum free β‐hCG alone.
Late termination of pregnancy in North Holland
Authors: Bosnia Jacqueline M. , van der Wal Gerrit , Hosman‐Benjaminse Sylvia L.
Published: August 2005

Objectives
To estimate the extent to which late termination of pregnancy (gestational period > 24 weeks) is practised, to find out what fetal diseases and abnormalities lead to termination and to obtain insight into the clinical judgement and decision‐making process by gynaecologists with regard to termination.

Design
A retrospective study.

Place
Province of North Holland, The Netherlands.

Methods
An anonymous printed questionnaire, was sent to all associations or departments of gynaecology in the 21 hospitals in North Holland. The period of study covered the years 1990 to 1994.

Results
Completed questionnaires were received from 19 associations or departments in the 21 hospitals (90% response). In the five‐year period under study in 14 of these hospitals had terminated 103 pregnancies beyond the 24th week of gestation. Antenatal sonography had been performed on all these pregnancies. Anencephaly was diagnosed before termination in 21% and severe chromosomal defects in a further 21%. Other severe abnormalities were neural groove defects, such as hydrocephaly and/or spina bifida (16%), no renal function (12%) and skeletal abnormalities (11%). In 87% the antenatal diagnosis was verified postnatally; in 78% this was done by autopsy. The diagnosis was confirmed in all these cases (‘almost confirmed’ in two cases). In every case the pregnant woman herself had asked for her pregnancy to be terminated. In 78% the prognosis was discussed with other medical specialists and the professionals concerned with management; there was a consultation about the termination in 91% of the cases. A report was always compiled for the medical records.

Conclusion
Late termination of pregnancy is practised on a substantial scale in North Holland. The reasons for termination were severe structural abnormalities which, in most cases, were not compatible with survival. The gynaecologists in North Holland dealt prudently and responsibly with late termination of pregnancy, although they did not always adhere to the guidelines set out in the 1994 report of the Netherlands Association for Obstetrics and Gynaecology.
Early amniotomy increases the frequency of fetal heart rate abnormalities
Authors: Goffinct François , Fraser William , Marcoux Sylvie , Bréart Gérard , Moutquin Jean‐Marie , Daris Marlene ,   the Amniotomy Study Group
Published: August 2005

Objective
To determine whether early amniotomy, when practised as an isolated intervention, increases the hourly rate of fetal heart rate record abnormalities.

Design
This is a secondary analysis of the results of a multicentre randomised trial of early versus late amniotomy in labour.

Setting
Secondary and tertiary level teaching hospitals.

Intervention
Early amniotomy versus an attempt to conserve the amniotic membranes.

Main outcome measures
The hourly rates of early, mild variable, severe variable and late decelerations; caesarean section rates.

Results
Severe variable decelerations, when classified as categorical events ( 1/h to 2/h, 2/h to < 4/h, 4/h), were more frequent in the amniotomy group (χ2 for trend = 5.7, P= 0.017). The mean hourly rates of severe variable and late fetal heart rate decelerations were increased in the amniotomy group (severe variable: amniotomy group 1.4/h, control 0.7/h, P= 0.021; late: amniotomy group 3.3/h, control 2.3/h, P= 0.011). Although the overall rate of caesarean was similar in the two groups (OR 1.2; 95% CI 0.8–1.8), there was an increase in caesarean section for fetal distress (OR 2.3; 95% CI 1.1–4.5) associated with amniotomy.

Conclusion
Our data suggest that early amniotomy increases the hourly rate of severe variable fetal heart rate decelerations without evidence of an adverse effect on neonatal outcome. In settings where the diagnosis of fetal compromise is based primarily on electronic monitoring, caesarean section for fetal distress may be increased by early amniotomy.
Influence of hypertensive disorders and cigarette smoking on placental abruption and uterine bleeding during pregnancy
Authors: Ananth Cande V. , Savitz David A. , Bowes Watson A. , Luther Edwin R.
Published: August 2005

Objective
To assess the influence of hypertensive disorders in pregnancy on the subsequent risk of placental abruption and uterine bleeding of unknown aetiology, and to examine the combined effects of hypertensive disorders and cigarette smoking during pregnancy on the risk of uteroplacental bleeding disorders.

Design
Retrospective cohort study.

Setting
Data for this study were derived from the Nova Scotia Atlee Perinatal database, Canada, comprising of women who were delivered in the province between 1980 and 1993.

Population
120,666 pregnancies resulting in singleton births, of which 13,360 pregnancies were complicated by pre‐eclampsia and/or chronic hypertension.

Main outcome measures
Risks and relative risks of placental abruption and uterine bleeding of unknown aetiology in pregnancies complicated by chronic hypertension, mild and severe pre‐eclampsia, and chronic hypertension with superimposed pre‐eclampsia, each compared with normotensive patients. Adjusted relative risks were obtained through the fit of multivariable logistic regression models based on the method of generalised estimating equations.

Results
Chronically hypertensive women had no increased risk of abruption (RR 1.4; 95% CI 0.5–3.6), while women whose pregnancies were complicated by severe pre‐eclampsia (RR 3.8; 95% CI 2.1–6.9), and chronic hypertension with superimposed pre‐eclampsia (RR 2.8; 95% CI 1.2–6.3) showed strong associations with placental abruption. However, none of the hypertensive disorders were associated with uterine bleeding of unknown aetiology. The association between placental abruption and hypertensive disorders varied by parity. Parous women with chronic hypertension and superimposed pre‐eclampsia were at greater risk of placental abruption (aRR 3.8; 95% CI 1.9–7.8) than nulliparous women with chronic hypertension and superimposed pre‐eclampsia (aRR 1.6; 95% CI 0.5–4.9). The joint effects of smoking and hypertension had a greater effect on the risk of placental abruption than would have been expected based on their individual effects.

Conclusions
The pattern of association between placental abruption and hypertension varied in relation to the specific type of hypertensive disorder. However, uterine bleeding of unknown aetiology was not associated with hypertension. Findings from this study suggest that placental abruption and uterine bleeding of unknown origin are aetiologically distinct obstetric complications with respect to hypertensive disorders during pregnancy.
Vaginal endoscopic oophorectomy with vaginal hysterectomy: a simple minimal access surgery technique
Authors: Hefni M. A. , Davies A. E.
Published: August 2005

The main advantage of laparoscopic assisted vaginal hysterectomy (LAVH) is ease of access to the ovaries; despite this, LAVH is infrequently performed due to the inherent difficulty of the technique. Lower morbidity, shorter length of surgery, reduced hospital stay and more rapid recovery are the main advantages of vaginal hysterectomy, but one of its limitations is the accessibility of the ovaries. Three methods of vaginal endoscopic oophorectomy following vaginal hysterectomy are described in this paper. Endoscopic vaginal oophorectomy was successfully perfomed during 82 cases of vaginal hysterectomy and the results show that the technique is simple, safe and easy to learn, and an alternative to laparotomy and LAVH in the absence of pelvic adhesions.
The metabolic consequences of treating postmenopausal women with non‐oral hormone replacement therapy
Authors: Crook D.
Published: August 2005

Objective
To define the metabolic profile of postmenopausal hormone replacement therapies when delivered through gels, patches, implants or other non‐oral routes. Such information may be useful in the absence of reliable clinical data on the effects of these therapies on the risk of cardiovascular disease.

Design and methods
Selective literature review.

Patients
Postmenopausal women.

Results
Non‐oral oestrogen therapies fail to invoke the hepatic response associated with oral therapy. Changes in hepatic protein synthesis are minimal and so plasma levels of binding globulins and other proteins tend to be normal. Many of the perturbations of the haemostatic system seen with oral therapy are avoided. In the absence of hepatic over‐synthesis of apolipoproteins, plasma lipoprotein levels are unchanged or reduced. The direct effects of oestrogen on vascular function are apparent when the hormone is administered non‐orally.

Conclusions
The net effect of non‐oral oestrogen therapies on the risk of cardiovascular disease is difficult to predict on the basis of current data. Some changes in plasma lipoprotein levels, such as the reduced fasting levels of triglycerides, would be considered desirable, but the cardioprotective increase in levels of high‐density lipoproteins is absent. The differential effect on haemostasis markers is promising, but preliminary data relating to transdermal patches fail to support the idea that non‐oral therapies will avoid the increased risk of venous thromboembolism associated with oral therapy. The ability of non‐oral therapies to improve vascular function implies that they will offer postmenopausal women at least some of the cardiovascular protection seen with oral therapy.
Metabolic changes induced by peroral oestrogen and transdermal oestradiol gel therapy
Authors: Karjalainen A. , Heikkinen J. , Savolainen M. J. , Bäckström A‐C. , Salinto M. , Kesäniemi Y. A.
Published: August 2005

Objective
To investigate changes in plasma lipid and lipoprotein levels induced by peroral oestrogen replacement and transdermal oestradiol gel therapy.

Design
The effects of peroral oestradiol valerate tablets (2 mg) and placebo gel were compared with 1g transdermal oestradiol gel (1mg oestradiol) and placebo tablets in a randomised, double‐blind, double‐dummy study for 6 months.

Setting
Department of Internal Medicine, University of Oulu and Oulu Deaconess Institute, Oulu, Finland.

Population
Seventy‐nine hysterectomised, postmenopausal women, 39 women in the peroral oestrogen group and 40 in the gel group.

Main outcome measures
Cholesterol and triglycerides in total plasma and in various lipoprotein fractions, and sex hormones.

Results
In the peroral oestrogen group total and LDL cholesterol were decreased and HDL cholesterol and triglycerides were increased. In the oestradiol gel group plasma total, LDL and VLDL cholesterol and the ratio of LDL/HDL cholesterol were significantly decreased, but no change in HDL cholesterol and triglycerides was observed. Overall the decrease in LDL levels was correlated with the increase in oestrogen levels.

Conclusions
Both peroral and transdermal replacement therapy had beneficial effects on plasma lipids by lowering total and LDL cholesterol and LDL/HDL cholesterol ratio. These changes seem to be associated with changes in oestrogen levels.
Transvaginal Doppler ultrasound of the uteroplacental circulation in the early prediction of pre‐eclampsia and intrauterine growth retardation
Authors: Harrington K. , Carpenter R. G. , Goldfrad C. , Campbell S.
Published: August 2005

Objective
To evaluate the predictive value of transvaginal Doppler ultrasound studies of the uterine and umbilical arteries in early pregnancy, in identifying pregnant women at risk of subsequently developing pre‐eclampsia, or the delivery of a small for gestational age infant.

Design
A multivariate logistic regression of Z scores of Doppler indices obtained from the uterine and umbilical arteries of 652 women with singleton pregnancies at 12 to 16 weeks of gestation. Measurements included the presence or absence of a notch, bilateral (right and left waveform) notching, vessel diameter, the resistance index, the pulsatility index, time averaged mean velocity (cm/s), maximum systolic velocity (cm/s), and volume flow (mL/min). Stepwise logistic regression and multivariate analysis of all the parameters measured was used to construct several scoring systems.

Main outcome measures
Pre‐eclampsia, birthweight, preterm delivery.

Results
In women that developed complications, there was a trend towards increased resistance and reduced velocity and volume flow. If bilateral notches were present there was an increased risk of pre‐eclampsia (odds ratio [OR] 21.99, 95% CI 6.55–73.79), premature delivery (OR 2.38, 95% CI 1.19–4.75), and the delivery of a small for gestational age baby (OR 8.63, 95% CI 3.95–18.84). Using multivariate analysis, a seven parameter model was selected (after removal of vessel diameter, uterine and umbilical resistance index). This model produces a scoring system with a sensitivity of 92.9% and a specificity of 85.1% for the prediction of pre‐eclampsia. A three parameter model (bilateral notches, uterine resistance index, umbilical pulsatility index) provides similar sensitivities, but lower specificities, when compared with the seven parameter model.

Conclusion
These data indicate that there are differences in uterine and umbilical artery Doppler blood flow indices at 12 to 16 weeks, in pregnancies with a normal or complicated outcome. Scoring systems derived from multivariate analysis of Doppler indices demonstrate the potential of being able to identify, in early pregnancy, a group of women at increased risk of the subsequent development of pre‐eclampsia, premature delivery, or the birth of a small for gestational age baby.
Maternal serum free β‐hCG at 10 to 14 weeks of gestation in trisomic twin pregnancies
Authors: Noble P. L. , Snijders R. J. M. , Abraha H. D , Sherwood R. A. , Nicolaides K. H.
Published: August 2005

Maternal serum free β‐hCG was measured at 10 to 14 weeks of gestation in 136 normal twin pregnancies and in 12 twin pregnancies where one or both fetuses had trisomy 21. The values were compared with a normal range from 4181 singleton pregnancies. In the normal twins the median free β‐hCG (65 ng/mL) was about twice as high as in singletons (34 ng/mL z=−12.1, P < 0.0001). In the trisomy 21 group the median free β‐hCG (95 ng/mL) was significantly higher than in normal twins (z= 2.1, P < 0.05). However, only one of the trisomic pregnancies had a level above the 95th centile. In twin pregnancies maternal serum free β‐hCG at 10 to 14 weeks of gestation is unlikely to be useful in the prediction of fetal trisomy 21.
Recombinant human relaxin as a cervical ripening agent
Authors: Brennand Janet E. , Calder Andrew A. , Leitch Craig R. , Greer Ian A. , Chou Min Min , MacKenzie Ian Z.
Published: August 2005

Objective
The aim of this study was to investigate the efficacy and safety of recombinant human relaxin (rhRIx) as a cervical ripening agent in women with an unfavourable cervix before induction of labour at term.

Design
A multi‐centre, double‐blind, placebo‐controlled trial performed in Edinburgh, Glasgow and Oxford. Women were treated with 0, 1, 2 or 4 mg of rhRIx in a gel vehicle administered intravaginally. Analysis of variance tests were performed on all continuous variables, and Cochran Mantel‐Haenszel tests employed for all discrete variables.

Participants
Ninety‐six women at 37 to 42 weeks of gestation with a singleton pregnancy and a modified Bishop score of 4 were recruited.

Results
There was no significant difference in the change in modified Bishop score between the four treatment groups. The lengths of the first and second stages of labour were similar in all 4 groups. PGE2 and oxytocin requirements were similar in all groups, as was the mode of delivery. There was no evidence that relaxin was absorbed systemically when given in this way.

Conclusion
Recombinant human relaxin 1 to 4 mg, administered as an intravaginal gel, has no effect as a cervical ripening agent before induction of labour at term.
Routine oxytocin in the third stage of labour: a placebo controlled randomised trial
Authors: Nordström Lennart , Fogelstam Kerstin , Fridman Gunilla , Larsson Anita , Rydhstroem Hakan
Published: August 2005

Objective
To compare intravenous oxytocin administration (Partocon® 10 IU) with saline solution in the management of postpartum haemorrhage in the third stage of labour.

Design
A double‐blind, randomised controlled trial involving 1000 parturients with singleton fetuses in cephalic presentation and undergoing vaginal delivery, randomly allocated to treatment with oxytocin (n=513) or 0.9% saline solution (n=487).

Setting
Labour ward at a central county hospital.

Main outcome measures
Mean blood loss (total, and before and after placenta delivery); frequencies of blood loss > 800 mL, need of additional oxytocic treatment, postpartum haemoglobin < 10 g/dL; and duration of postpartum hospitalisation.

Results
As compared with saline solution, oxytocin administration was associated with significant reduction in mean total blood loss (407 versus 527 mL), and in frequencies of postpartum haemorrhage > 800 mL (8.8%versus 15.2%), additional treatment with metylergometrine (7.8%versus 13.8%), and postpartum Hb < 10 g/dL (9.7%versus 15.2%), and a nonsignificant increase in the frequency of manual placenta removal (3.5%versus 2.3%). There was no group difference in the mean duration of postpartum hospitalisation (4.6 versus 4.5 days, respectively).

Conclusions
Administration of intravenous oxytocin in the third stage of labour is associated with an approximately 22% reduction in mean blood loss, and approximately 40% reductions in frequencies of postpartum haemorrhage (> 500 mL or >800 mL) and of postpartum haemoglobin < 10 g/dL. Identification of risk groups for oxytocin treatment does not seem worthwhile. Oxytocin is a cheap atoxic drug and should be given routinely after vaginal delivery.
Gestational age and induction of labour for prolonged pregnancy
Authors: Gardosi Jason , Vanner Tracey , Francis Andy
Published: August 2005

Objective
To examine the length of gestation according to menstrual and ultrasound scan dates, and the rate of induction of labour in a unit with a routine induction policy for prolonged pregnancy.

Design
Retrospective analysis of computer files of 24,675 pregnancies delivered in a teaching hospital between 1988 and 1995, which had a record of the last menstrual period and a dating ultrasound scan. Detailed survey of 168 casenotes of consecutive inductions of labour to establish the indications given.

Setting
Teaching hospital with policies of routine mid‐trimester ultrasound scan and routine induction for prolonged pregnancy at 290 to 294 days.

Main outcome measures
Gestational age at delivery by menstrual history and ultrasound biometry in spontaneous and induced labours

Results
The single largest category of reasons given for induction of labour was prolonged pregnancy.‘Post‐term pregnancy’, from the date of expected delivery as recorded in the notes, together with ‘maternal request’ and ‘social factors’, were the reasons given for induction of labour in 71.3% of cases. Menstrual dates systematically overestimated gestational age at term when compared with scan dates. After 41 weeks, this difference exceeded the confidence limits for second trimester scan dating error, suggesting that most pregnancies which are considered ‘prolonged’ according to menstrual dates are in fact mis‐dated. The median gestational age for induced labours was 286 days by last menstrual period but only 280 days by scan, and most (71.5%) inductions done post‐term (> 294 days) according to menstrual dates were not post‐term if scan dates alone are used to calculate the gestational age. The average induction rate over the seven year study period was 16.6%. It was higher when there was any gestational age error in either direction (16.8%) compared with when menstrual and scan dates were in complete agreement (13.7%, OR 1.27, CI 1.09–1.47, P < 0.001). The induction rate was highest (up to 21.8%) in the cases where menstrual dates overstated gestational age without exceeding the usual limits for adjusting dates according to scan. Such over‐estimation within tolerance limits of 7, 10 or 14 days occurred in 37.1%, 45.8%, or 52.6% of all pregnancies, respectively.

Conclusions
Most pregnancies undergoing post‐term induction are not post‐term when assessed by ultrasound dates. Regardless of whether prolonged pregnancy is considered to be a risk factor requiring intervention, the proportion of pregnancies considered ‘post‐term’ can be reduced considerably by a dating policy which ignores menstrual dates and establishes the expected delivery date on the basis of ultrasound dates alone.
Analysis of collagen status in premenopausal nulliparous women with genuine stress incontinence
Authors: Keane Declan P. , Sims Tevor J. , Abrams Paul , Bailey Allen J.
Published: August 2005

Objective
To determine if differences exist in the collagen status of premenopausal nulliparous women with genuine stress incontinence compared with continent controls.

Design
Thirty‐six premenopausal nulliparous women with urodynamically‐proven genuine stress incontinence were compared with 25 controls. All the women studied had a periurethral vaginal biopsy taken of approximately 30–50 mg in wet weight. This biopsy was then analysed to determine the collagen content, the type I:III collagen ratio and the collagen cross‐link content.

Setting
A tertiary referral urodynamic unit.

Results
The nulliparous women with genuine stress incontinence had significantly less collagen in their tissues (P < 0.0001) compared with the continent controls. In addition, there was a decreased ratio of type I to type III collagen (P= 0.0008), and the cross‐link content was also significantly reduced in the women with genuine stress incontinence (P < 0.0001).

Conclusion
Genuine stress incontinence is present in a significant number of women before childbirth. The aetiology of their incontinence appears to be due to a defect in their connective tissue, with both a quantitative and qualitative reduction in their collagen.
Randomised trial of one versus two doses of prostaglandin E2 for induction of labour: 1. Clinical outcome
Authors: Mackenzie I. Z. , Burns Ethel
Published: August 2005

Objective
To compare the outcome of induction of labour using a single versus two doses of prostaglandin E2 vaginal gel.

Design
Prospective randomised trial comparing a single dose of prostaglandin E2 2 mg vaginal gel in the evening with two doses of prostaglandin E2 (2 mg), the second being given after six hours if labour had not started or the cervix was still unripe. Amniotomy and oxytocin titration were performed when necessary for both protocols. Nulliparae and multiparae were analysed separately by treatment intention.

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

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

Main outcome measures
Need for formal amniotomy and oxytocin augmentation, use of epidural analgesia, rate of intrapartum interventions, mode of delivery and neonatal condition at birth.

Results
For multiparae two prostaglandin doses resulted in a significant reduction in the need for formal amniotomy (15%vs 30%) and oxytocin augmentation (28%vs 38%) compared with those receiving a single dose; there was no significant difference for nulliparae. Other interventions during labour, length of labour, and mode of delivery were similar in both protocols. Failed induction occurred only in nulliparae and was similar in both protocols (1%). There was no discernible difference in fetal or neonatal outcome although passage of meconium was more common in labour if two doses had been given, as was neonatal admission to the special care baby unit.

Conclusions
There was little clinical benefit from inducing labour with two doses of prostaglandin E2 at a six‐hour interval, compared with a single dose. There may be financial advantages with a two‐dose regimen.
Introducing external cephalic version at 36 weeks or more in a district general hospital: a review and an audit
Authors: Healey Martin , Porter Richard , Galimberti Andrea
Published: August 2005

Objective
To audit the effect of introducing external cephalic version at 36 weeks on breech delivery rates and modes, and to assess factors that affect external cephalic version success rates.

Design
A prospective unblinded study over 12 months of factors affecting external cephalic version success. A retrospective review of breech deliveries for 12 months before introducing external cephalic version and the first 12 months of practising external cephalic versions.

Setting
Royal United Hospital, Bath.

Population
One hundred and three women ( 36 weeks) with breech presentation booked for external cephalic version, and 324 women with a singleton breech presentation at delivery between November 1992 and October 1994.

Methods
External cephalic version attempted on 89 women. Tocolysis was used on 41 of these women.

Main outcome measures
External cephalic version success rate. Breech presentation rates (suitable for external cephalic version) at delivery. Delivery mode rates for breeches.

Results
External cephalic version was successful in 39% of women. The breech presentation rate (external cephalic version suitable) at delivery fell from 2.7% to 2.4% of all deliveries. The vaginal breech delivery rate fell from 0.98% to 0.51%. The caesarean section rate was 63% for breeches (external cephalic version suitable) before external cephalic version introduction, and 47% among women who had an attempted external cephalic version.

Conclusions
Attempted external cephalic version reduces the woman's risk of vaginal breech delivery and caesarean section. It provides individual women with a third management option and the possibility of avoiding a vaginal breech delivery or a caesarean section. To avoid one caesarean section takes 5.9 attempted external cephalic versions. This approach is expensive in operator time. Operator, placental site, position of fetal back and amniotic fluid index had a significant effect on the success of external cephalic version.
Maternal middle cerebral artery velocimetry in normal pregnancy and postpartum
Authors: Serra‐Serra Vicente , Kyle Phillipa M. , Chandran Ravi , Redman Christopher W. G.
Published: August 2005

Objective
To study changes throughout gestation and the puerperium of middle cerebral artery flow velocity waveforms obtained by transcranial Doppler ultrasound.

Design
Prospective, observational study.

Setting
John Radcliffe Maternity Hospital, Oxford, UK.

Participants and Methods
Middle cerebral artery velocities were measured by transcranial Doppler ultrasound in 25 nonpregnant women, 22 women longitudinally followed throughout pregnancy and 21 women serially studied from delivery until the late puerperium.

Main outcome measures
Transcranial Doppler changes in pregnancy and the puerperium.

Results
The transcranial Doppler ultrasound measurements showed good reproducibility. Signals from one middle cerebral artery could not be obtained in 4.6% of the examinations, but otherwise readings were similar on both sides. Women in the second half of pregnancy had lower middle cerebral artery mean velocities than nonpregnant women. Velocities decreased with advancing gestation but increased in the immediate puerperium to levels comparable to those found in nonpregnant women.

Conclusions
Transcranial Doppler ultrasound is a noninvasive technique suitable for studying maternal cerebral haemodynamics in pregnancy and postpartum. Middle cerebral artery mean velocity decreased with advancing gestation and increased to nonpregnant values in the immediate puerperium. These physiological changes need to be considered when comparing data with measurements taken in abnormal pregnancy states.
Does sweeping of the membranes reduce the need for formal induction of labour? A randomized controlled trial
Authors: Boulvain Michel , Fraser William D. , Marcoux Sylvie , Fontaine Jean‐Yves , Bazin Sylvie , Pinault Jean‐Jacques , Blouin Daniel
Published: August 2005

Objective
1. To evaluate the effectiveness of sweeping of the membranes to reduce the need for a formal induction of labour; 2. to evaluate the side effects of this intervention.

Design
A randomised controlled clinical trial.

Setting
Three tertiary care hospitals of the province of Quebec, Canada.

Population
Two hundred women for whom non‐ urgent induction of labour was medically indicated.

Methods
Women were randomly allocated to sweeping of membranes, or vaginal examination for Bishop scoring only.

Main outcome measures
1. Cumulative incidence and relative risk of induction of labour by either oxytocin, prostaglandins or amniotomy; 2. women's discomfort and side effects attributable to sweeping of the membranes.

Results
Women allocated to sweeping of the membranes required formal induction of labour less frequently than women in the control group, but this difference was not statistically significant (49%vs 60%, RR 0.83, 95% CI 0.64–1.07). Pain during vaginal examination and other side effects were more frequently reported by women allocated to the sweeping group.

Conclusions
The observed reduction in the need for formal induction of labour is smaller than in previous studies. Side effects and discomfort associated with sweeping of the membranes must be taken into account when counselling women who require induction of labour.
The role of ultrasonographic markers for trisomy 21 in women with positive serum biochemistry
Authors: Verdin Stuart M. , Economides Demetrios L.
Published: August 2005

Objective
To assess the value of particular markers detected by second trimester ultrasound examination among those women whose fetuses were shown to be at increased risk of Down's syndrome on the basis of biochemical screening.

Design
A retrospective study of 459 pregnancies.

Setting
Fetal Medicine Unit, Royal Free Hospital.

Participants
Four hundred and fifty‐nine regnant women, including four twin pregnancies, registered at the Royal Free Hospital, who were considered screen positive (risk > 1: 250) based on the results of mid‐trimester biochemical markers (maternal serum free β human chorionic gonadotrophin and α fetoprotein).

Main outcome measures
The ultrasound markers that were examined included structural defects, shortened femur length, echogenic bowel, dilation of the renal pelvis and choroid plexus cysts. The likelihood ratios for trisomy 21 for each of these markers were calculated.

Results
Of the 463 fetuses which were screen positive, 449 (97%) had a normal karyotype detected by amniocentesis (n= 344) or postnatal follow up (n = 105). Fourteen fetuses had an abnormal karyotype including 11 (2.4%) with trisomy 21. Ultrasound markers were found in 9/11 (81.8%) fetuses with trisomy 21, compared with 44/449 (9.8%) with a normal karyotype. Detection of one or more ultrasonographic markers in a screen positive pregnancy increased the risk of trisomy 21 by a likelihood ratio of 8.4, and the absence of such markers decreased the risk by a likelihood ratio of 0.2. The risk was considerably increased when the presence of two or markers were detected (likelihood ratio 41). In trisomy 21 fetuses the two most commonly detected markers, shortened femur and dilation of the renal pelvis, had llkelihood ratios of 49.3 and 20.5, respectively. Choroid plexus cysts were detected in 27 of the normal karyotypic fetuses compared with none of those with trisomy 21.

Conclusion
The presence or absence of abnormal ultrasonographic markers can significantly change the risk of Down's syndrome among pregnant women already found to have abnormal serum biochemistry. This data may be useful in counselling such women.
Treatment of menopausal keratoconjunctivitis sicca with topical oestradiol
Authors: Sator Michael O. , Joura Elmar A. , Golaszewski Thomas , Gruber Doris , Frigo Peter , Metka Markus , Hommer Anton , Huber Johannes C.
Published: August 2005

Objective
To investigate the effect of 17β‐oestradiol ophthalmic drops in comparison with a traditional

Design
Randomised prospective trial.

Setting
Menopause clinic.

Participants
Eighty‐four postmenopausal women suffering from keratoconjunctivitis sicca and necessitating a hormone replacement therapy (HRT) for general climacteric symptoms.

Methods
The women were randomised into two groups and were given 17β‐oestradiol eye drops (n=42, group 1) or a tear substitute (n=42, group 2). Both groups received a systemic HRT.

Main outcome measures
A Schirmer's test was performed immediately before the beginning of therapy and after four months. In addition, eye symptoms were assessed using a visual analogue scale.

Results
A comparison of visual analogue scores at four months in the women who received 17β‐oestradiol eye drops versus those who received a tear substitute demonstrated a statistically significant difference in all observed ocular symptoms (P<0.0001) The Schirmer's test revealed a significant difference of results before and after treatment in the oestradiol group (P<0.0001) while in group 2 no significant difference was found.

Conclusions
Our study demonstrates that topical oestrogen is successful in treating keratoconjunctivitis sicca while it seems that the blood‐eye barrier prevents systemic oestrogens from acting on the conjunctivae.
An audit of anti‐D sensitisation in Yorkshire
Authors: McSweeney Ellen , Kirkham Jan , Vinall Paul , Flanagan Peter
Published: August 2005

Objective
To determine the likely factors that contribute to RhD sensitisation.

Design
Retrospective study of all new cases of RhD sensitisation occurring between 1988 and 1991.

Setting
Leeds Blood Centre, National Blood Service, Yorkshire.

Population
One hundred and forty‐seven cases of RhD sensitisation from 15 obstetric units within the Yorkshire region, of which 129 (312 pregnancies) could be assessed.

Main outcome measures
Identification of potential immunising events and adherence with recommendations on anti‐D immunoglobulin administration.

Results
Twenty‐eight women (22%) had immune anti‐D antibodies during their first pregnancy or at delivery and 50 (39%) in their second pregnancy. Overall, 98 potential immunising events were identified in 62 women, excluding delivery; 67 women (52%) had no events, other than delivery. Miscarriages and medical terminations of pregnancy accounted for 81% of all identified events. Iatrogenic failure to adhere to recommendations for the administration of anti‐D immunoglobulin occurred in a significant proportion of women who subsequently developed immune anti‐D antibodies. Anti‐D immunoglobulin failed to protect against immunisation despite adherence to the protocol in 20 events (20%), 13 of which involved miscarriages or termination of pregnancy < 20 weeks of gestation. Potentially, antenatal prophylaxis might have prevented 86% of immunisations that were identified during the first pregnancy.

Conclusions
The introduction of antenatal administration of anti‐D immunoglobulin could significantly reduce the level of sensitisation in primigravidae, and adherence to recommendations for administration of anti‐D immunoglobulin could be improved. Consideration should be given to reviewing the current recommendation that a dose of 250 IU of anti‐D immunoglobulin is adequate following termination of pregnancy before a gestational age of 20 weeks.