bluuebunny/crossref_metadata_2025 huggingface dataset:
The Training of the Obstetrician—Gynaecologist for the 21st Century
Authors: Hinde F.C.
Published: February 2008

EDITORIAL COMMENT: It is, perhaps, impertinent to precede an oration with a comment—but we are afraid that some readers may need encouragement to read the views expressed therein—these are opinions held by many but not carried before in the pages of this journal. What is wrong with specialist training?—do our patients' needs drive the engine, or the ambitions of the officers of the Colleges who direct our training programmes? The cost of ever increasing preregistration programmes affects everybody—ultimately the taxpayer, because the State must meet the impressive salaries now paid to consultants‐in‐training, especially in their senior years; although the inevitable overtime component of remuneration is a major factor, these extra hours worked do not compete with the extra time on duty the registered specialist will experience when he/she begins in full‐time private practice. Is there a need for change?—are our plans for subspecialization properly drawn?—this oration directs our attention to many of these problems and suggests some possible solutions.
Povidone‐Iodine in the Treatment of Metronidazole‐Resistant Trichomonas vaginalis
Authors: Wong Conroy A. , Wilson P. Don , Chew Trevor A.
Published: February 2008

EDITORIAL COMMENT: Resistance of Trichomonas vaginalis to metronidazole has been controversial because of the inability to confirm conclusively the resistance of strains isolated from patients with refractory vaginal trichomoniasis. Treatment failure has thus been attributed to reinfection by the sexual partner, noncompliance, poor absorption or inactivation by vaginal flora. The authors of this study do appear to have conclusively demonstrated resistance to metronidazole using an appropriate test method. They do not however, exclude noncompliance or possible poor absorption. The treatment of refractory trichomoniasis is usually to treat again with higher doses of metronidazole. This has sometimes been successful but in other cases has been unsuccessful despite high doses and prolonged courses of treatment. Povidone‐iodine (Betadine) has often been used successfully in the treatment of vaginal trichomoniasis, but treatment failures have occurred. It is believed that treatment failures are due to the inability of topical therapy to eradicate the organism from extravaginal sites, e.g. urethra, Bartholin glands. The fact that the authors of this paper found povidone‐iodine douches more effective on the second occasion could relate to the fact that povidone‐iodine releases iodine slowly. Antiprotozoal action is dependent upon the release of iodine. Thus a 10‐minute douche could be more effective than a 2‐minute douche. There remains the possibility of spontaneous resolution in the reported patient. Although povidone‐iodine douches are generally safe, it is possibly not a good idea to recommend such a practice unreservedly. There have been several reports of neonatal hypothyroidism following maternal use of povidone‐iodine in pregnancy (negative feedback in the fetus, the iodine causing inhibition of thyroid stimulating hormone release); also hypersensitivity reactions to iodine can be expected in approximately 1 in 3,000 patients.
Conception in the Resistant Ovary Syndrome Occurring during Hormone Replacement Therapy: A Report of 2 Cases
Authors: Jequier Anne M.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication as it provides readers with a useful account of the resistant ovary syndrome and information comparing the doses of hormones in the oral contraceptive pill and hormone replacement therapy.

ABSTRACT Two patients with resistant ovary syndrome are described. Both patients conceived while on hormone replacement therapy. Both women were taking the phasic preparation containing mestranol and norethisterone known as ‘Menophase’ (Syntex Pharmaceuticals Ltd). The possible mechanism of action of this type of hormone preparation in the induction of ovulation in patients with resistant ovary syndrome is discussed.
A Rare Case of Intersex: 46XY Gonadal Dysgenesis
Authors: Holland Michael J. , Fray Randall E.
Published: February 2008

EDITORIAL COMMENT: We accepted this case for publication not only because of its rare interest but because it will remind readers that patients with primary amenorrhoea require karyotyping and consideration of gonadal dysgenesis that may indicate gonadectomy. There is a useful review of tumours arising in dysgenetic gonads and summary of management of patients with 46XY gonadal dysgenesis.
The Short‐term Outcome of Singleton Infants Delivered Before 28 Weeks' Gestation
Authors: Nicholl Michael C. , Giles Warwick B.
Published: February 2008

EDITORIAL COMMENT: : This and the following paper present the survival rates and incidence of major impairment in infants who survive birth before 28 weeks' gestation in singleton and multiple pregnancies. Readers should consider the authors' careful words that period of gestation rather than estimation of birth‐weight is the parameter obstetricians should rely on when judging whether or not Caesarean section is indicated for a fetal indication; for singleton pregnancies the rubicon is 26 weeks' gestation. The authors consider that their findings lend further support for routine pregnancy ultrasound screening to confirm gestational age since the occurrence of problems in the second trimester can seldom be predicted.

Summary: : The short‐term outcome of 271 singleton infants born at Westmead Hospital between 20 and 28 weeks' gestation, during a 5‐year period are reported. The earliest gestation at which there was a survivor was 23 weeks. Survival rates from 23‐23+6 weeks to 27‐27+6 weeks, excluding congenital abnormalities, were 8.3% to 77.5% respectively. Overall 21.9% of deaths occurred in the delivery suite, 63.4% in the neonatal period, 3.7% in the postneonatal period in hospital and a further 11% after discharge from hospital. Of survivors at 12 months, 18.8% were judged to have a major impairment.
Group B Streptococcus (GBS) and Neonatal Infections: The Case for Intrapartum Chemoprophylaxis
Authors: Garland Suzanne M. , Fliegner John R.
Published: February 2008

EDITORIAL COMMENT: This paper presents important information concerning improvement in neonatal mortality and morbidity rates of infants born to mothers who are carriers of Group B streptococci by use of intrapartum penicillin treatment of these colonized women. These data indicate that to be effective chemotherapy must be given to the mother before delivery to minimize the risk of significant infection in the infant. Implementation of the protocol described in this paper could achieve significant improvement of neonatal results, but would not prevent stillbirths due to this infection. We still require introduction of a rapid sensitive antigen test for detection of GBS carrier status in early labour to identify those at risk patients who merit chemoprophylaxis ‐such a test could also be used to quickly identify GBS carrier status in patients with premature rupture of membranes where intrauterine infection may become established before the onset of labour.

Summary: : At the Royal Women's Hospital, Melbourne over an 8‐year period (1981–1988) all public antenatal patients were screened at 32 weeks' gestation for group B streptococcus (GBS). In a total of 30,197 livebirths there were no early onset neonatal GBS infections in infants of treated asymptomatic carrier mothers. By contrast there were 27 infections with 8 deaths in an unscreened control group of private patients (total livebirths 26,915).

It is recommended that GBS screening occur antenatally at 28 weeks and that intrapartum chemoprophylaxis be offered at least to those carriers with obstetric risk factors.
Occasional Review: Systemic Lupus Erythematosus and Pregnancy at the Royal Women's Hospital, Brisbane 1979–1989
Authors: Nicklin J. L.
Published: February 2008

Summary: : The management and obstetric outcome of 17 patients with systemic lupus erythematosus (SLE) complicating 42 pregnancies is presented. Similar to world figures there was a 14.3% incidence of therapeutic abortion, a 4.8% incidence of ectopic pregnancy, a 16.7% incidence of spontaneous abortion, a 23.8% incidence of prematurity, a 4.8% incidence of fetal death in utero (FDIU) and a 9.5% incidence of intrauterine growth retardation (IUGR). In patients with antiphospholipid antibodies the obstetric outcome was significantly worse. Pregnancies complicated by preexisting renal compromise all concluded with an adverse outcome to the conceptus. In light of the experiences at the Royal Women's Hospital and a review of the world literature, the need for a standardized approach to SLE in pregnancy and more importantly the need for a large, prospective randomized trial of low dose aspirin in these pregnancies is highlighted.
THE AUSTRALIAN & NEW ZEALAND JOURNAL OF OBSTETRICS & GYNAECOLOGY
Authors: Beisdiei Norman , Brown James , Parkinson Patricia , Walstab Janei
Published: February 2008

Summary: During the years 1971–1984 urinary oestriol excretion was tested in 51,427 patients (group 1). One or more low oestriol value was found in 10.7% of patients; in this group the stillbirth rate was 6.8 times higher, the neonatal death rate 3.8 times higher, and fetal growth retardation rate 3.5 times higher than in patients with normal oestriol values (all p 0.00001).

During the years 1985–1989 a further 20,635 patients were tested (group 2) and 7.6% had one or more low oestriol value. The perinatal mortality rate in patients with normal oestriol excretion fell from 0.8% in group 1 to 0.5% in group 2 (p< 0.005), and in patients with low oestriol excretion from 4.2% in group 1 to 2.4% in group 2 (p 0.002). However, patients in group 2 with low oestriol values still had significantly unfavourable results, compared to those with normal oestriol values ‐ stillbirth rate 3.3 times higher, neonatal death rate 4.6 times higher, and fetal growth retardation rate 3.2 times higher (all p < 0.00001).

Intravenous dextrose and aminoacid infusions were given to 967 patients who had persistently low oestriol values in spite of rest in hospital, in an attempt to correct fetoplacental function; the perinatal mortality rate was 0.9% in the 660 (68.3%) who responded favourably, and 9.8% in the 307 (31.7%) who did not respond (p<0.0001).

Although perinatal results have improved, fetal growth retardation and the risk of perinatal death are still identified by urinary oestriol estimation.
Rupture of the Pregnant Uterus ‐ A 21‐year Review
Authors: Rachagan S. P. , Raman S. , Balasundram G. , Balakrishnan S.
Published: February 2008

Summary: Uierine rupture is still a common problem in developing countries although even here the incidence varies from urban to rural settings. This article is a review of uterine rupture in an urban referral hospital in Malaysia. It examines aetiology, clinical presentation, complications and management of the problem. Meticulous screening of patients together with optimal antenatal and intrapartum care will markedly reduce the incidence of uterine rupture. Early diagnosis and prompt treatment will further help reduce morbidity and mortality to both mother and fetus.
Randomized Trial of 2 Hormonal and 2 Prostaglandin‐inhibiting Agents in Women with a Complaint of Menorrhagia
Authors: Fraser Ian S. , McCarron Gay
Published: February 2008

Summary: A series of 45 ovulatory women with a complaint of menorrhagia were randomized into 3 treatment groups, before receiving therapy with mefenamic acid in 2 cycles and 1 of 3 other agents in 2 cycles: naproxen (group 1; n = 14), a low dose monophasic combined oral contraceptive (group 2; n = 12) or low dose danazol (group 3; n = 12). Menstrual blood loss was measured in 2–4 control cycles and during therapy. Mefenamic acid reduced measured blood loss by 20%; 38%; and 39% in groups 1–3 respectively. Naproxen reduced blood loss by 12%; the oral contraceptive by 43%; and danazol by 49%. There was no statistically significant difference in blood loss reduction (mean of 2 cycles) between any of the treatments, although women on danazol experienced a dramatic and highly significant further reduction in blood loss after the first treatment cycle (p < 0.003). These were all effective therapies in a majority of women, but some ‘non‐responders’ were seen in each group. The ‘non‐responders’ had a significantly lower pretreatment blood loss than responders. Several women in group 1 showed anomalous responses to prostaglandin inhibitors with consistent and substantial exacerbation of menorrhagia during therapy. A number of reasonable therapies exist for the medical treatment of menorrhagia, but because none is suitable for everyone management needs to be individualized for each patient.
Trends in Contraception and Sterilization in Australia
Authors: Santow Gigi
Published: February 2008

EDITORIAL COMMENT: The purpose of this comment is to encourage readers to give this paper the close attention it deserves ‐ the summary is too modest, and the important information in the tables may be overlooked if readers do not study them in conjunction with the text. It is noteworthy that of women aged 40–44 years in 1986, 35% had had a tubal ligation, another 11% had had a hysterectomy and a further 16% of these women had partners who had undergone vasectomy. In these data, which were collected in 1986, the condom made a miserable showing as a contraceptive, but as noted by the author ‘this is not to say that coitus‐related methods may not gain some support if the motivation for their use is not entirely contraceptive ‐ sexually transmitted diseases in general and AIDS in particular’. Enquiry of the manufacturers surprised the editor by revealing that total sales of condoms in Australia (2 per person per year or 34 million per year) have increased only about 50% in the last 10 years. This is in accord with the data in this paper and indicates that there has been little change since 1986.

Summary: Life‐history data collected in a national survey of women in 1986 are used to derive the first national estimates of trends in contraception and sterilization in Australia over the last 30 years. The pill rapidly became the method of choice after its release in 1961. The intrauterine device, the other truly modern method, has never attained the same popularity. The move toward sterilization dates from the early 1970s and has been so complete that women of 35 or older are now more likely to be protected by a ligation or laparoscopic sterilization than by the pill or, indeed, by all other methods combined. Unmarried women are now indistinguishable from married women on the basis of their use of contraception, and childless married women are now more likely to be using a reversible method than married women with children.
Influence of Epidural Anaesthesia on the Course of Labour in Patients with Antepartum Fetal Death
Authors: Lurie Samuel , Blickstein Isaac , Feinstein Michael , Matzkel Avi , Ezri Tiberiu , Soroker David
Published: February 2008

Summary: The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for parity and gestational age, who received narcotic pain relief. Both groups had similar preinduction cervical dilatation and the induction was performed by amniotomy and oxytocin infusion. The mean first stage of labour was 5.4 hours in the epidural group, and 8.7 hours in the controls (p = 0.0192). The mean cervical dilatation rate was 3.3 cm/hour and 1.0 cm/hour respectively (p = 0.0142). The second stage was similar in both groups. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus.
Intractable Postpartum Haemorrhage Managed by Angiographic Embolization: Case Report and Review
Authors: Duggan P. M. , Jamieson M. G. , Wattie W. J.
Published: February 2008

EDITORIAL COMMENT: We accepted this case report because it gives a comprehensive review of a technique that should be available in all major centres although not in obstetric institutions unless affiliated with a general surgical hospital. Table I shows that angiographic embolization was successful in most cases reported in the literature but so too is ‘return to theatre’ surgery even if the patient requires more than one such journey. The case reported here was one of secondary postpartum haemorrhage. The technique of embolization is less likely to be suitable in a case of continuing primary postpartum haemorrhage after Caesarean section or Caesarean hysterectomy although this would depend upon the circumstances of the previous surgery and whether or not resuscitation and control of coagulation failure had been problems. Also a patient who has a haemoperitoneum requires reoperation; moreover, it is sometimes difficult to know whether there is a haemoperitoneum or not in these patients and this is often the case when there is a postoperative problem. The authors make the important point that bilateral internal iliac artery ligation may not control haemorrhage even from the region of the vaginal vault, a comment referred to previously in this journal This paper gives a comprehensive review of the literature on this subject and should interest many readers.

Return to theatre ‐ experience at the Mercy Maternity Hospital, Melbourne 1971–1982. Aust NZ Obstet Gynaecol 1985; 25: 159.

Internal iliac and ovarian artery ligation in the control of pelvic haemorrhage. Aust NZ Obstet Gynaecol 1989; 29: 22.

Summary: A case of intractable postpartum haemorrhage successfully managed by angiographic embolization is presented. The literature concerning angiographic embolization and internal iliac artery ligation is reviewed. Angiographic embolization is a superior method to internal iliac artery ligation in appropriately selected cases of obstetric haemorrhage, and may also be used successfully in cases where internal iliac ligation and/or hysterectomy has failed to control pelvic haemorrhage. Angiographic embolization is a potentially life‐ and fertility‐saving procedure.
Cognitive and Social Influences on Smoking Behaviour During Pregnancy
Authors: Wakefield Meianie A. , Jones Warren R.
Published: February 2008

Summary: Random sample of 292 women attending a hospital antenatal clinic for routine care was surveyed concerning smoking behaviour and beliefs about smoking in pregnancy. Among women who continued to smoke during their pregnancy, most had cut down. Many expressed a desire to quit, felt guilty about not being able to do so, but reported that smoking offered important benefits relating to relaxation and mood control. Forty (27.8%) of the 144 women who were smokers at the time they became pregnant had quit during pregnancy. In a multivariate analysis, a nonsmoking household, and being more convinced about the health effects of maternal smoking, were most strongly associated with successful cessation. These 2 variables alone were able to correctly classify 83.8% of women as quitters or continuing smokers. Implications for health promotion programmes and messages are discussed.
Norplant
Authors: Cooper Michael
Published: February 2008

EDITORIAL COMMENT: Although Norplant is not available in Australia (see conclusion) this review makes a very strong case for its introduction and the information provided will interest readers.
Expression of Tumour Markers CA125, CASA and OSA in Minimal/Mild Endometriosis
Authors: Ward Bruce G. , McGuckin Michael A. , Ramm Louise , Forbes Kevin L.
Published: February 2008

EDITORIAL COMMENT: This study confirms most of the findings reported by Fraser et alA in their study of serum CA‐12S levels in women with endometriosis before and after medical therapy. Both studies showed that serum CA‐125 levels were suppressed during treatment but tended to rise after treatment even in women in whom the disease had not recurred. There is an extensive literature concerning the use of serum CA‐125 as a marker of recurrence or persistence of ovarian carcinoma after treatment; it would seem that the assay is of limited value and does not for example replace the need for second look laparotomy by identification of women with residual disease requiring further chemotherapy. It is difficult to judge how troublesome raised serum CA‐125 levels due to endometriosis are to oncologists ‐ how many of their patients with ovarian cancer still have functioning ovarian tissue? We accepted this paper for publication because the authors have 2 new serum tumour markers, which apparently are superior to CA‐125 in detecting small volume ovarian cancer, and yet, as this study shows, do not show elevated levels in patients with mild endometriosis. As stated in a previous editorial comment* we require a marker for ovarian cancer that is cheap enough to apply as a screening test to identify asymptomatic lesions ‐ to be useful it must be cheaper than vaginal ultrasonography; we look forward to the results of the authors' study using these markers to screen 10,000 asymptomatic women for malignant disease; presumably this paper indicates that such a study could include premenopausal patients since the 2 markers are not tricked by endometriosis in the 23 cases reported here.

Fraser IS, McCarron G, Markham R. Serum CA‐125 levels in women with endometriosis. Aust NZ J Obstet Gynaecol 1989; 29: 416–420.

Ward BG, McGuckin MA, Hurst TG, Khoo SK. Expression of multiple tumour markers in serum from patients with ovarian carcinoma and healthy women. Aust NZ J Obstet Gynaecol 1989; 29: 340–345.

Summary: Ovarian cancer associated antigens CA125, CASA and OSA were measured in serum from 23 patients with mild endometriosis before, during and after medical therapy. Pretreatment CA125 levels were elevated above 35/ml in 4 (17%), and above 25/j/ml in 7 (30%) patients. Mean CA125 levels decreased during treatment, but in only 10 patients did levels reflect disease response. There was no correlation between CA125 levels and disease severity as measured by modified American Fertility Society Scoring. Neither CASA nor OSA were detected in these women.
Caesarean Section Rates, Australia 1986: Variations at State and Small Area Level
Authors: Renwick Manoa Y.
Published: February 2008

EDITORIAL COMMENT: This paper presents important data regarding Caesarean section rates in the various Australian States and Territories according to metropolitan or nonmetropolitan area and whether or not the patient was medically insured or was a private patient. The different rates between the States are less than the differences between insured and uninsured patients. High Caesarean section rates increase the hospital costs of obstetric practice although it should be noted that the average number of days in hospital in Australia, after either vaginal or Caesarean delivery are about double that in the United States of America, where the Caesarean section rate exceeds Australia's ‐ but then the Caesarean section rate in China exceeds America's by a similar margin to that which the USA's rate exceeds that in Australia! What are the reasons for the very high Caesarean section rate in this nation where most women have only one confinement? Surely what needs to be settled is whether these higher Caesarean section rates are necessary ‐are we practising good medicine? Does the alarming increase in the Medical Defence Association rates for obstetricians contribute to defensive medicine and earlier decision to perform Caesarean section and satisfy the woman and her partner when the going gets tough in labour. It may be noted that 47% of all patients' claims against doctors in Victoria involve obstetricians. Patients expectations of a favourable outcome for mother and child are increasing, especially as the new technology is viewed as a guarantee of normality. Readers are referred to previous papers and comments on this subject.

Summary: The first national study of Caesarean section rates was made possible by combining 1986 data from hospital morbidity collections and medicare claims. Rates per 100 births, based on the area of usual residence of the mother, were calculated for statistical local areas, which were aggregated to statistical subdivisions, statistical divisions and States.

The rate for mainland Australia was 16.9% (Tasmania could not be included). Variations in rates were of the order of one and a half‐ to two‐fold. The highest rates were found in Canberra and central Brisbane (26.3% and 25.4% respectively). The rates for Northern Territory, South Australia, and Queensland were higher than those for other States.

There were few consistent patterns in the variations. Generally rates were highest in the State capital cities and for insured women. This suggests an association with the supply of obstetricians and with demand factors such as the expectations of obstetricians and consumers.
Use of Prescription Drugs in the First Trimester and Congenital Malformations
Authors: Correy J. F. , Newman NM , Collins J. A. , Burrows E. A. , Burrows R. E. , Curran J. T.
Published: February 2008

Summary: A prospective survey of prenatal use of prescription drugs in Tasmania yielded detailed information on drug exposure, delivery and outcome for 56,037 births from 1982 to 1989. First trimester drug use was reported by 30.9% of women, and 17.9% used only supplements of vitamins and/or minerals; 40% used alcohol during the first trimester, and 28.8% smoked cigarettes. There were 1,035 (1.85%) congenital malformations, of which 885 (85.5%) were major. The malformation rate was not significantly different in the following exposure categories: supplements only (1.62%); other pharmaceuticals (1.92%); smokers (1.88%); alcohol users (1.89%); and maternal age 35 or more years (1.95%). Adjusting for alcohol use, smoking, maternal age and diabetes mellitus, significant associations [expressed as adjusted odds ratio and 95% confidence intervals (CI)] were found between aspirin and hypospadias (3.5, 95% CI 1.4 to 8.8); dicyclomine and phocomelia (4.4, 95% CI 1.0 to 19.5); and between oral contraceptive use and pes cavus (9.7, 95% CI 2.3 to 40.4). Although significant, these associations were based on very few cases and no direct supporting evidence could be found from other data sources.
A Survey of Women Undergoing a Pelvic Examination
Authors: Vella Paul V.
Published: February 2008

Summary: This study attempts to evaluate patients' satisfaction with certain aspects of a first visit antenatal or gynaecological consultation and the reaction to and preferences during a pelvic examination.

Embarrassment and apprehension were emotions experienced by at least half those surveyed and the speculum examination was uncomfortable to more women than the bimanual examination.

However, less than 10% found the pelvic examination worse than they had anticipated.
‘Erosion’ of the Uterine Cervix; an Anachronism
Authors: Chang Alexander Russell
Published: February 2008

Summary: The conclusion arrived at after a review of the relevant literature, coupled with current knowledge of the morphophysiological changes which take place in the transformation zone of the cervix, is that the term cervical erosion is an anachronism. The term should therefore be abandoned. More appropriate terms for the clinical appearance of the cervix are ectropion or ectopy. The metaplastic process and its role in neoplasia is also discussed.
Antenatal Loss of One of Twins
Authors: Sonneveld S. W. , Correy J. F.
Published: February 2008

EDITORIAL COMMENT: It would appear to the reviewer that the takeaway message of this paper is that intrauterine death of one twin, in the absence of maternal complication (placental abruption, preeclampsia) or fetal compromise (cardiotocography, ultrasonography, ultrasonographic assessment of fetal blood flow), should be managed conservatively if the pregnancy has not reached 37 weeks' gestation. Caesarean delivery is not specifically indicated by intrauterine death of one twin, except in the case of monoamniotic twin pregnancy, unless tests of fetoplacental function are abnormal. It is likely that the maternal risk of disseminated intravascular coagulopathy has been exaggerated in the literature, and is unlikely to occur unless one twin has been dead for more than 4 weeks. One of the problems is that the duration of fetal death is often not known in these cases. The risk of coagulation failure seems to be much less in the case of fetus papyraceous where the dead twin is very small although the time from death until delivery is usually many months rather than weeks.

Readers are referred to other editorial comments on this subject; 1990; 30: 134 and 1990; 30: 137.

Summary The antepartum loss of a twin with survival of the second twin to delivery was studied in the Tasmanian population from 1980 to 1989 inclusive. No previous study of an Australian population has been reported. This rare complication occurs in 3.5% of twin pregnancies. The outcome of these pregnancies and the outcome for the surviving twin are discussed.
Prognosis in Fetal Cystic Hygroma
Authors: Anderson Nigel G. , Kennedy John C.
Published: February 2008

EDITORIAL COMMENT: This paper was accepted for publication to inform readers of the current consensus regarding management when ultrasonography reveals fetal cystic hygroma. After counselling the parents, amniocentesis is performed to identify the high proportion of fetuses with an abnormal karyotype, assuming that the parents would opt for termination under this circumstance, and that the period of gestation renders this act an option. If the karyotype is normal, and there are no other malformations apparent, especially hydrops, then most would agree that treatment should be conservative. In many such cases the lesions will resolve spontaneously. Figure 1A illustrates a large cystic hygroma in a newborn male infant; the child was growth retarded (birth‐weight 2,970 g at 39.2 weeks' gestation) but otherwise normal. The tumour disappeared spontaneously when the infant was aged 6 months and due for operation! The child is now aged 18 years, lives in Queensland, and according to his father who is a psychiatrist, is ‘doing brilliantly’! There is also controversy regarding management when ultrasonography identifies fetal choroid plexus cysts. Although an abnormal karyotype was identified in 6.5% of fetuses (4 of 62) in one reported series (A) all 4 of these fetuses had other ultrasonographic abnormalities. This suggests that genetic counselling and cytogenetic studies are indicated only when the choroid plexus cyst, irrespective of size or bilaterality, is associated with additional abnormalities. In all other cases choriodplexus cysts can be expected to resolve, usually within 2–5 weeks.

A. Piatt LD, Carlson DE, Medearis AL, Walla CA. Fetal choroid plexus cysts in the second trimester of pregnancy: A cause for concern. Am J Obstet Gynecol 1991; 164: 1652–1656.

Summary Axillary and lateral cervical fetal cystic hygromas in a fetus with normal karyotype are described. Fetal death at 25 weeks' gestation occurred. A literature review revealed that for cystic hygroma 42% of infants are 45XO, 38% have a normal karyotype, and 18% have trisomies. Prognosis is grim if the karyotype is abnormal or if hydrops or bilateral pleural effusions are present. Survival rate progressively improves with normal karyotype (27%), unilateral pleural effusion (40%), atypical location (56%), and resolution of cystic hygroma (71%). No single feature signifies 100% survival. The overall survival rate for fetal cystic hygroma is 10%. Prognosis remains guarded regardless of all other factors until the fetus reaches 26 weeks' gestation, after which time a 67% chance of ultimate survival can be expected. Only 42% of documented survivors were completely normal at follow‐up.
The Diagnostic Value and Patient Acceptability of Outpatient Endometrial Sampling with Gynoscann
Authors: Sun‐Kuie Tay , Sian‐Ann Tan , Ka‐Mui Chua , Soo‐Kim Lim‐Tan
Published: February 2008

EDITORIAL COMMENT: Several recent reports have suggested that procedures short of curettage under anaesthesia are sufficient to exclude the possibility of intrauterine cancer. Nasri and colleagues (1) found that endometrial thickness, as assessed by vaginal scan, was greater than 5 mm in all of 29 patients with abnormal endometrial histology. Our pathologist reviewer reminded us of a recent patient with a tiny invasive lesion less than 3 mm in depth in a hysterectomy specimen, but he cannot be sure that endometrial thickness did not exceed 5 mm before the curettage that obtained the tissue that indicated the hysterectomy. How expert does the practitioner and his/her equipment need to be for endometrial thickness of 5 mm to be ‘an appropriate cut‐off level for conservative management of women with postmenopausal bleeding’ (1)? The Editorial Committee is reluctant to endorse a policy of not performing curettage for postmenopausal bleeding, and wishes to remind readers that in patients with this symptom, carcinoma of the endocervix or endometrium is found in at least 8–12% of cases in most series. It should be noted that in this report evaluating endometrial sampling, there were very few patients past the menopause. The cervix is more difficult to cannulate in older women which is another factor when considering whether outpatient instrumentation by any means, including hysteroscopy, is sufficient for sampling or assessment of the endometrium.

1. Nasri MN, Shepherd JH, Setchell ME, Lowe DG, Chard T. The role of vaginal scan in measurement of endometrial thickness in postmenopausal women. Br J Obstet Gynaecol 1991; 98: 470–475.

Summary Endometrial sampling with Gynoscann was performed in the outpatient department in 70 women with abnormal vaginal bleeding prior to dilatation and curettage (D&C). Successful endometrial sampling was achieved in 62 (89%) patients; Of the samples obtained 44 (71.0%) were adequate for cytological assessment and 46 (74.2%) for histological assessment, compared to 80% of D&C samples being adequate for histological examination. In those patients in whom outpatient endometrial sampling was adequate, both the cytological and histological diagnosis agreed with the D&C. The outpatient endometrial sampling was well tolerated by the patients since the majority (89%) experienced either no or little pain. Vaginal bleeding following the procedure was minimal in all except 1 patient. Endometrial sampling with Gynoscann may be useful for endometrial assessment prior to commencement of hormonal therapy and hysterectomy. It is a potentially useful screening test for early detection of endometrial cancer in patients at risk.
Ruptured Ectopic Pregnancy in an Amenorrhoeic Woman After Transcervical Resection of the Endometrium
Authors: Lam Alan M. , Al‐Jumaily R.Y. , Holt E.M.
Published: February 2008

EDITORIAL COMMENT: We all know to remember the possibility of ruptured ectopic pregnancy when a woman who ‘wears’ an intrauterine device or has had a tubal sterilization procedure performed, presents with abdominal pain; beta unit HCG assay and vaginal probe ultrasonography is then required for diagnosis when laparoscopy/ laparotomy is not clearly indicated on clinical grounds. This case report shows that ectopic pregnancy is also possible after endometrial resection, even when the woman has had cessation of menstruation. Since laparoscopy is usually employed to exclude uterine perforation and extrauterine trauma during endometrial ablation, at least during the surgeon's learning phase, it would seem wise to offer the woman simultaneous tubal sterilization during the procedure although this operation has approximately a 1 in 1,000 failure rate. Our endometrial ablationist reviewer informs us that at a meeting he attended in 1990 in the United States of America, 6 cases of ectopic pregnancy following endometrial resection were reported ‐ he could not recall whether or not they all had postresection amenorrhoea. These cases stress the need for pre and postoperative hormone therapy in women having endometrial resection. Simultaneous sterilization at the time of endometrial ablation certainly increases the duration of the operation but the patient is still able to leave hospital on the same day.
Amniocentesis and Its Complications
Authors: Anandakumar C. , Wong Y.C. , Annapoorna V. , Arulkumaran S. , Chia D. , Bongso A. , Ratnam S. S.
Published: February 2008

Summary: This study was conducted in order to evaluate whether the performance of an experienced operator had any significant influence in reducing the incidence of complications in amniocentesis; 1,459 women had amniocentesis performed under ultrasound guidance; 1,324 were performed by experienced operators and 135 cases by less experienced operators. Complications like fetal loss, blood‐stained amniotic fluid, culture failure, multiple needle puncture, leaking liquor, fetal trauma and error in results were compared in the 2 groups. This study demonstrated that amniocentesis performed by an experienced operator decreased the various complications associated with amniocentesis.
The Effect of Smoking During Pregnancy on the Incidence of Low Birth Weight Among Chinese Parturients
Authors: Lam S. K. , To W. K. , Duthie S. J. , Ma H. K.
Published: February 2008

Summary: The incidence and effect of smoking in Chinese parturients are not well known. In a retrospective case‐controlled study of 213 patients who smoked during pregnancy, it was found that the incidence of low birth‐weight was doubled. On average the babies were smaller by 200 g, shorter by 1 cm and the head circumference was smaller by 0.3 cm. These anthropometric deficits may have significant long‐term effects. Although the incidence of smoking in Chinese parturients is low (2%), the rising trend in recent years should prompt all physicians to advise expectant mothers to avoid smoking before and during pregnancy.
Diagnosis and Surgical Management of Endometriomas
Authors: Wood Carl , Maher Peter , Hill David
Published: February 2008

Summary: Fifty two patients with endometriomas ≥ 1 cm were treated by surgical excision either with or without ovarian closure.

Diagnosis is reliable when clinical features of the pain, vaginal ultrasound, and laparoscopy, including ovarian mobilization and needling, are considered.

Fifty of 52 patients were free of pain after 1 year and 26 (50%) became pregnant within 1 year.

A second laparoscopy is justified if pain persists or pregnancy does not occur. Adhesive disease was the most common complication (40%), and persistent or recurrent endometriosis occurred in 15%.

Surgery by laparoscopy with drainage and excision of the endometrioma without ovarian sutures may be more effective than excision of the endometrioma and ovarian suture.
Undiagnosed Maternal Fallot Tetralogy Presenting in Pregnancy
Authors: Larsen‐Disney P. , Price D. , Meredith I.
Published: February 2008

EDITORIAL COMMENT: We accepted this case report for publication not only because we wish to help spread the authors' message regarding team management during pregnancy of high risk patients with cardiac disease, but also to remind readers that significant cardiac anomalies may be recognized for the first time during routine antenatal examination.
Antiphospholipid Antibodies in Pregnancy
Authors: Birdsall Mary , Pattison Neil , Chamley Lawrence
Published: February 2008

Summary: We assessed the relationship between antiphospholipid antibodies and recurrent miscarriage, fetal deaths, and the pregnancy complications ‐ placental abruption, fetal growth retardation and preeclampsia. The subjects were 81 women with a history of 3 or more miscarriages, 62 with a history of fetal death in the index pregnancy, 105 with a poor obstetric history or pregnancy complications and 13 with systemic lupus erythematosus. Antiphospholipid antibodies were found in 41% of women with a history of recurrent miscarriages, 29% with a history of recent intermediate fetal death or stillbirth, 19% with a poor obstetric history and 69% with systemic lupus erythematosus. There is a high incidence of antiphospholipid antibodies in complicated pregnancies. Patients presenting with the above pregnancy disorders should be tested for antiphospholipid antibodies because of the risk conferred on a fetus by their presence and to expand the treatment options.
Laparoscopic Adnexectomy ‐ Indications, Technique and Results
Authors: Wood Carl , Hill David , Maher Peter , Lolatgis Nick
Published: February 2008

Summary: Laparoscopic adnexectomy was performed successfully in 38 patients in whom the procedure was attempted. Failure may result from inexperience of the surgeon or when preliminary dissection near bowel suggests trauma is likely. The duration of the operation was between 15 and 105 minutes, blood loss was minimal and all but 2 patients were discharged within 24 hours of surgery. Pain was relieved in 33 of 35 patients in whom this was the dominant symptom. In 1 patient a small ovarian remnant implanted on the bladder was removed at subsequent laparoscopy.

Preliminary experience of this procedure suggest it may be preferable to laparotomy because of the reduced risk of wound complications, pain, time in hospital and duration of convalescence.
Ultrasound Diagnosis and Laparoscopic Excision of an Interstitial Ectopic Pregnancy
Authors: Wood Carl , Hurley Victor
Published: February 2008

EDITORIAL COMMENT: We accepted this case report as readers may well marvel at the elegant details of careful removal of an interstitial pregnancy at laparoscopy. The procedure seems brave since the editor can recall being called by the junior author of this paper to lend a hand in a case of ruptured interstitial pregnancy with frightening haemorrhage at laparotomy ‐ in this case ergometrine lessened the bleeding that was then controlled by a mattress suture in the uterine wall. Dr Eric Bieber from Chicago delivered an interesting account of laparoscopic management of ectopic pregnancy in Melbourne in May, 1992, and strongly emphasized a point about the pathology of tubal ectopic pregnancy which seems important and was new to his audience ‐ namely that the pregnancy usually lies outside the tubal lumen having distended not the tube but the outer layer of the tubal wall beneath the peritoneum. This apparently explains how an ectopic pregnancy can be incised and evacuated without affecting tubal patency in a high proportion of cases. Our editorial committee would welcome a contribution giving details of this concept and its relevance to the success of conservative treatment of unruptured ectopic pregnancy.

Summary: Interstitial tubal pregnancy occurs in about 5% of ectopic tubal pregnancies and is associated with an increased risk of severe haemorrhage (1). Diagnosis prior to rupture of the pregnancy into the peritoneal cavity is very important to avoid haemorrhage. Its presence has been considered to be a contraindication to laparoscopic surgery (2), although most ectopic pregnancies can be managed laparoscopically by an experienced endoscopist. We report the diagnosis of an interstitial pregnancy by ultrasound before rupture and treatment by laparoscopic excision of the pregnancy.
Delayed Fetal Death Following Electrical Injury in the First Trimester
Authors: Steer Roger G.
Published: February 2008

EDITORIAL COMMENT: The editor was recently ‘zapped’ on the back when repairing a fence with his neighbour's electrical contribution not turned off (a foolish venture) ‐ the single wire had a jolt far greater than that usually received from a farmer's fence, which reinforces the point made by the author ‐ keep away from electric fences and especially avoid contact with your head, and of course the pregnant abdomen or pelvis.

Summary: A case of possible delayed fetal death following electrical shock in the first trimester is reported.

Evidence from the literature of delayed effects of electrical injury later in pregnancy is presented, suggesting that delayed as well as immediate detrimental effects in the first trimester should not be discounted.

Perhaps the spectrum of effects of electrical shock on the fetus could be investigated in animal experiments to elucidate the pathogenesis of such injury to the fetus.

Electric fences are a possible hazard to pregnant women in rural areas.
Topical Application of Honey in Treatment of Abdominal Wound Disruption
Authors: Phuapradit Winit , Saropala Nopadol
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because it should interest all readers, some of whom may decide they have the occasional patient suitable for this method of honey wound care. The healed wound shown in figure (d) would be cosmetically unacceptable to most women but perhaps resuture would have had a similar result. In the editor's experience, sew sanguineous discharge from a wound postoperatively invariably means dehiscence best treated by resuture once any precipitating ileus has resolved; when the skin sutures are removed the wound falls apart in these women and usually loops of bowel are adherent to the edges of the wound (figures A and B). In the case illustrated in this paper the peritoneum appears to be intact as if the problem was an infected haematoma which is an unusual cause of wound disruption in the editor's experience; yet the authors encountered 15 cases in 19 months, and quoted no case of the complete wound dehiscence referred to above!

Summary: The usefulness of honey application as an alternative method of managing abdominal wound disruption was assessed. Fifteen patients whose wound disrupted after Caesarean section were treated with honey application and wound approximation by micropore tape instead of the traditional method of wound dressing with subsequent resuturing. We achieved excellent results in all the cases with complete healing within 2 weeks. Honey application is inexpensive, effective and avoids the need to resuture which also requires general anaesthesia.
Congenital Malformations, Reproductive Wastage and Consanguineous Mating
Authors: Jain V. K. , Nalini P. , Chandra R. , Srinivasan S.
Published: February 2008

Summary: A study was undertaken in Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, South India, to understand the relation between congenital developmental disorders and consanguinity and also reproductive wastage and consanguinity. Four hundred children with existing congenital developmental disorders were studied with regard to their consanguineous parentage and compared with 1,000 randomly selected patients attending the paediatric outpatient department. There was a significantly higher prevalence of consanguinity in the study group (p < 0.001) and greater frequency in rural areas. The common types of consanguineous marriages were between first cousins (50.6%) and uncle and niece (42.4%). Frequency of consanguinity was not significantly related to religion and caste. The mean coefficient of inbreeding was 0.056. Consanguinity had no significant effect on average pregnancy rate and reproductive wastage. The frequency of consanguinity was significantly higher especially with autosomal recessive disorders (p< 0.001), congenital heart diseases (p < 0.001), multiple malformations (p < 0.001), neurological malformations (p < 0.005), chromosomal disorders (p< 0.01), genitourinary disorders (p< 0.02) and mental retardation‐developmental disorders (p< 0.02). These observations stress the need for communicating the deleterious effects of inbreeding to the public through regular health education.
Laparoscopic Culdotomy
Authors: Wood Carl , Hill David , Maher Peter
Published: February 2008

Summary: Laparoscopic culdotomy has been performed in 32 patients. The indications for the procedure included the removal of organs or tissue excised by operative laparoscopy, excision of vaginal endometriosis involving the pouch of Douglas and drainage of a pelvic haematoma. The surgical technique is described and no complications resulted from this technique. Laparoscopic culdotomy has advantages for the removal of lumps exceeding 1 cm, and for the drainage of a pelvic haematoma or pelvic abscess. It is also an integral step in the removal of infiltrating endometriotic lesions in the pouch of Douglas which are attached to the vagina.