bluuebunny/crossref_metadata_2025 huggingface dataset:
Management Dilemmas with Major Placental Abruptions in the Midtrimester
Authors: Hawley J. H. , Stone P. , Murray H.
Published: February 2008

EDITORIAL COMMENT": We agree with the authors that these 2 cases of severe placental abruption with coagulopathy at early gestations, with the fetus still alive, will interest readers. Vaginal evacuation after instrumental cervical dilatation at 20 weeks' gestation in a woman with severe coagulopathy and impaired renal function, was a new reading experience for the editor. We wonder if rupture of the membranes with a Drew Smythe catheter is a safer alternative than prostaglandin pessaries when the cervix is tightly closed in such patients. If the liquor drains away perhaps there is less risk of entry ofthromboplastins into the maternal circulaton thus causing coagulation failure. At a Grand Round at the University of Michigan in 1991 the editor was presented a case of severe abruption at term in a nullipara with a tightly closed cervix where Caesarean section was followed by hysterectomy when bleeding from the uterus could not be controlled. The suggestion was made then that a Drew Smythe catheter could probably have allowed amniotomy and vaginal delivery of the dead fetus since it is uncommon to perform Caesarean section when the patient has had severe abruption. We seldom see a Couvelaire uterus. When we do it can be a frightening sight when huge haematomas bulge the uterine wall and suggest that hysterectomy will be necessary. The editor has experience of such a case where fortunately lower segment Caesarean section did not present difficulties with haemorrhage (as in Case I of this paper) and the patient has subsequently had 2 surviving infants born at term by Caesarean section. Although successful outcomes for mother and fetus have been reported following conservative treatment when mid‐trimester placental abruption has caused coagulation failure, such a complication is sufficient reason to justify delivery of the patient even if the fetus is alive and too immature to survive.
Pelvic Actinomycosis in Association with an Intrauterine Device
Authors: Garland Suzanne M. , Rawling Don
Published: February 2008

Summary: A case of pelvic actinomycosis is described which occurred in association with the use of an intrauterine device (IUD). Initially medical management alone was used, but surgical intervention was necessitated for multiple pelvic abscesses. We would strongly recommend that any IUD be removed should it be associated with actinomyces on genital smears and/or culture. If sepsis is also apparent, IUD removal with use of long‐term antibiotics is required.
Low Birth‐weight in NSW, 1987: a Population‐based Study
Authors: Algert Charles , Roberts Christine , Adelson Pamela , Frommer Michael
Published: February 2008

Summary: The New South Wales perinatal data collection was used to examine the association between low birth‐weight and some of its potential risk factors. The study population comprised all recorded singleton births to residents of NSW in 1987. Low birth‐weight infants were categorized as either small for gestational age (SGA) or preterm (less than 37 weeks). Risk factors were analyzed separately for these categories. The risk factors examined were primarily demographic or reproductive history variables. Univariate analysis and multivariate logistic regression were used to evaluate the risk factors. The factors associated with SGA birth were mainly demographic (maternal age, parity, marital status, socioeconomic status, and ethnic group) while those associated with preterm birth had more reproductive history variables (maternal age, parity, marital status, prior spontaneous abortion, prior induced abortion, prior stillbirth or neonatal death, sex of infant). A first antenatal visit after 12 weeks had a statistically significant but small effect on both SGA and preterm birth.
Randomized, Double Blind, Placebo Controlled Comparison of Ritodrine and Hexoprenaline for Tocolysis Prior to External Cephalic Version at Term
Authors: Stock Anthony , Chung Tony , Rogers Michael , Ming Wong Wai
Published: February 2008

Summary: External cephalic versions in the study period were performed in a double blind design by 2 experienced practitioners. Sixty‐three patients were allocated to treatment with either placebo, ritodrine or hexoprenaline. The main outcome measure studied was successful completion of external cephalic version. Hexoprenaline, but not ritodrine, was statistically more likely to be associated with successful version than placebo (p = 0.04 versus p = 0.22).
Biopsy Diagnosis and Conservative Surgical Treatment of Adenomyosis
Authors: Wood Carl , Maher Peter , Hill David
Published: February 2008

Summary: Fifteen patients with dysmenorrhoea and menorrhagia refractory to medical treatment were referred for surgical treatment.

Pre‐operative diagnosis of adenomyosis was suggested by vaginal ultrasound in 13 patients and was confirmed pre‐operatively by myometrial biopsy in 5 and by transcervical myometrial biopsy at the time of endometrial resection in 7.

Conservative surgery included endometrial resection (7), myometrial reduction by electrocautery (4), and myometrial excision (3).

Marked improvement occurred in 4 of 7 patients after endometrial resection, 3 of 4 after myometrial reduction, and all of 3 having myometrial excision.

Diagnosis of adenomyosis is improved by use of vaginal ultrasound and percutaneous or transcervical myometrial biopsy. Conservative surgical procedures including endometrial resection and myometrial reduction or excision may reduce the need for hysterectomy in the presence of adenomyosis.
Stomas and Pregnancy
Authors: Nicholl Michael C. , Thompson Julia M. , Nursing) Grad Dip (Advanced Clinical , Cocks Phillip S.
Published: February 2008

Summary: Few obstetricians have much experience of the pregnant patient with a stoma. This paper was prompted by the management of 3 such patients in as many months and reviews the limited literature on stomas and pregnancy.
An Australian Experience of Transdermal Oestradiol Patches in a Subtropical Climate
Authors: O'Neill Sheila , Kirkegard Yvonne
Published: February 2008

Summary: Tolerability and efficacy of transdermal oestradiol patches were assessed in 121 menopausal women over a period of 3 months to 2.5 years. Of particular interest, in a subtropical climate such as Brisbane, were the problems associated with adhesiveness and skin irritation during the summer months. We conducted a retrospective study with self‐administered questionnaires. All patients had been selected for the nonoral route because of side‐effects or relative contraindications to oral therapy. There was, overall, good efficacy and acceptability. The majority of the women found the patch very adequate in relieving symptoms of the menopause (vasomotor, genitourinary and musculoskeletal). Most preferred the patch to oral therapy. The oestradiol patch was well tolerated and few side‐effects were reported. Breast tenderness and weight gain were 2 minor problems associated with its use. Skin irritation was minimal, but adhesiveness was a problem during the summer months, especially with swimming or showering. Some practical suggestions were obtained about how to overcome site of application problems.
Idiopathic Hirsutism or Polycystic Ovary Syndrome?
Authors: Jahanfar Shayesteh , Eden John A.
Published: February 2008

Summary: Polycystic ovaries (PCO) were detected using ultrasound imaging in a series of 173 women who presented with significant hirsutism and in some cases with irregular menstruation. Patients were divided into 3 groups. Those with hirsutism and regular menstruation (cycles >8 per year, Group 1, n = 96); those with hirsutism and oligomenorrhoea (cycles < 8 per year, Group 2, n = 44) and those with hirsutism and amenorrhoea (cycles <2 per year, group 3, n = 33). These 3 groups were compared with subjects with normal ovaries and regular cycles of 26–34 days and without hirsutism (n = 29) and also with a group of women with PCO and regular cycles who had no sign of hirsutism (n = 90). PCO were found in 86% of Group 1, 97% of Group 2 and 94% of women within Group 3. The results suggest that the term ‘idiopathic hirsutism’ may not be appropriate.

An abnormal biochemical test consisting of a luteinizing hormone level >9 U/L, testosterone level >2.2 nmol/L, sex hormone binding globulin <32 nmol/L or free androgen index >4.5 was 100%, 91% and 76% sensitive for detecting PCO amongst women with amenorrhoea, oligomenorrhoea and idiopathic hirsutism respectively.
Composite Mucinous and Granulosa‐Theca‐Cell Tumour of the Ovary: An Unusual Neoplasm
Authors: Chandran Ravi , Rahman Hayati , Gebbie Donald
Published: February 2008

Summary: This case represents a unique primary ovarian tumour consisting of malignant mucinous elements and granulosa‐theca‐cell elements, the histogenesis of which remains uncertain. It also underscores the need for thorough sampling of mucinous tumours in order to discover a possible coexisting, different neoplastic component.
The Influence of a Glucose Load on Subsequent Carbohydrate Metabolism in Pregnancy
Authors: Fung Hedy , Baldwin Sally , Rogers Michael
Published: February 2008

Summary: Two separate independent exercises comparing 50 g with 75 g and 100 g oral glucose tolerance tests (OGTT) were performed in Chinese pregnant women. We found a significant difference in fasting values between the paired OGTTs when the 100 g test preceded the 50 g test. The fasting glucose levels on the second occasion of testing were significantly lower than on the first testing. The difference was less pronounced when the first glucose load was 75 g and was insignificant when the 50 g test was given first. The blood glucose response to glucose loads was also significantly altered on the second occasion of testing, again in proportion to the size of the first glucose load. We postulate that this influence of glucose tolerance testing on subsequent carbohydrate metabolism results either from sensitization of the pancreatic islet cells or from sensitization of tissues, resulting in increased rate of glucose utilization. We also suggest that an 1,800 Kcal diet represents an increase in carbohydrate load over their normal diet for many of our patients. In patients with mildly deranged OGTT, improvement in the glucose profile on diet may be due to this phenomenon rather than to a decrease in carbohydrate as is believed.
Corticosteroids for the Enhancement of Fetal Lung Maturity: Impact on the Gravida with Preeclampsia and the HELLP Syndrome
Authors: Magann Everett F. , Martin Rick W. , Isaacs John D. , Blake Pamela G. , Morrison John C. , Jr James N. Martin
Published: February 2008

Summary: This study was undertaken to determine maternal impact of corticosteroids administered for the promotion of fetal lung maturity in mothers with the HELLP syndrome. Twenty‐seven of 427 women with the HELLP syndrome treated between 1980–1991 received a full course of steroids prior to preterm delivery. This group was compared to 27 matched control patients with the HELLP syndrome who received no corticosteroids. Subjects were matched for maternal age, race, sex of the fetus, and severity of the HELLP syndrome. The antepartum platelet count stabilized or increased in 25 of 27 steroid‐treated women in contrast to 0 of 15 control women (p <0.00001). In comparison to control patients, LDH serum concentrations in steroid‐treated patients stabilized or decreased and the SGOT/AST and SGPT/ALT stabilized or decreased during therapy (p < 0.005). The interval from delivery to platelet nadir in patients with Class III HELLP syndrome was shorter in the steroid‐treated group (p<0.008) than in untreated patients.
Prenatal Diagnosis of Hypoplastic Left Heart Syndrome
Authors: Kluckow Martin R. , Cooper Stephen , Sholler Gary F.
Published: February 2008

EDITORIAL COMMENT: Terminate or operate? The editor was recentIy asked to address a meeting of paediatricians on this topic at the Royal Children's Hospital in Melbourne. It became obvious that the paediatric surgeon and the obstetrician can have diametrically opposed points of view on the management of a mother whose fetus is shown by ultmsonogmphy to have a major cardiac abnormality. The care that suggested the need for this meeting was that of an insulin‐dependent diabetic woman whose fetus was shown by ultrasonography at 25 weeks'gestation to have major heart defects there were various administrative and social reasons why the diagnosis was not made before 20 weeks' gestation. The prognosis of such infants who survive is unfavourable and it seems preposterous to suggest the possibility of neonatal cardiac tmnsplantation to a mother and her partner faced with the decision of ‘terminate or operate: The Australian rommunity tolerates an abortion rate of approximate& 20% of clinically confirmed apparently normal pregnancies (I). Therefore termination of a fetus with a major abnormality that is not completely correctable must be defendable and acceptable! mere are a host of problems apart from those of cost and conscience. There is the law, since the diagnosis may be made after 20 weeks’ gestation, when termination is no ronger by legal definition an abortion. However inductions of labour after 20 weeks'gestation and before fetal viability are being performed in increasing numbers when fetal mafformations are detected and when there is no other maternal indication for delivery (renal failure, severe pmclampsia with or without fetal hydrops). In this series reported here 2 of the 4 fetuses were candidates for termination and in I case the parmts elected to continue with the pregnancy. The authors do not tell us the results in the other 28 cases of cardiac abnormality detected in their series. Achiron and colleagues have presented the case for echocadiogmphic examination for detecting can‐liac marformatioons in low risk pregnancies (2). In their series 23 fetuses were born with cardiac anomalies prenatal echocadiogmphy identified N of the 23 cases and 5 pregnancies were terminated. Readers are referred to a provocative discussion on this subject in the Obstetrical and Gynecological Survey (31, since not all will agree that ‘there is compelling rationale for making available fetal echocardiographic screening for all prenatal patients’ (3) and further that ‘there probably is little cost benefit from the antenatal detection of fetaf cadiac anomalies for those patients who choose not to interrupt pregnancy’ (3).
Comparison of Abdominal and Vaginal Examinations for the Diagnosis of Engagement of the Fetal Head
Authors: Knight David , Newnham John P. , McKenna Mark , Evans Sharon
Published: February 2008

Summary: The diagnosis of engagement of the fetal head is mandatory before operative vaginal delivery is to be attempted. There is widespread belief that the fetal head is engaged in the maternal pelvis when vaginal examination reveals that the bony presenting part has reached the level of the ischial spines. However, it is also claimed that in the presence of moulding the vaginal findings may be misleading and that it may be preferable to make the diagnosis by abdominal examination of the level of the fetal
Intrauterine Insemination with Husband's Sperm: Comparison of Pregnancy Rates in Couples with Cervical Factor, Male Factor, Immunological Factor and Idiopathic Infertility
Authors: Kossakowski Jacek , Stephenson Mark , Smith Howard
Published: February 2008

Summary: Intrauterine insemination with husband's sperm (IUI) is offered to couples with infertility due to various causes although there is no general agreement on which of these causes should be so treated. In this report 77 couples were diagnosed as having either cervical factor, male factor, immunological factor or unexplained infertility, insemination was performed 24–32 hours after a rapid rise in the serum LH level. Two of 16 pregnancies which resulted miscarried, 1 was ectopic and the remainder were full term. Eleven occurred in the cervical factor group, 3 in the immunological factor and only 1 in each of the male factor and unexplained infertility groups. The differences in the number of pregnancies between the cervical factor and male and unexplained infertility groups are significant but not between the groups with cervical and immunological factors. The majority of pregnancies (81%) were achieved in the first 4 cycles.

Patients with the cervical factor as the cause of their subfertility are likely to benefit from the IUI with their husband's sperm. The small number of patients with the immunological factor in this study does not allow for a conclusion. In our experience the male factor and unexplained infertility patients are unlikely to benefit from intrauterine insemination with husband's sperm.
Anti‐Kell in Pregnancy and Hydrops Fetalis
Authors: Judith T.W Goh MBBS  , Ewa M. Kretowicz MD  , Stephen Weinstein FRCPA  , Gordon H. Ramsden MD, MRCOG
Published: February 2008

Summary: A case of hydrops fetalis resulting in neonatal death as a result of maternal Kell isoimmunization is presented, with a review of the literature and a suggested protocol for antenatal management of women with Kell antibodies.
Cellular Uterine Myoma Causing Vaginal Bleeding in a 15‐year‐old Girl
Authors: Morad Nader A. , El‐Said Mourad M.
Published: February 2008

Summary: This report describes only the third case of vaginal bleeding due to uterine myoma in a patient younger than 16 years of age with unusual histological features mimicking endolymphatic stromal myosis.
General Practitioners in Public Obstetrics ‐ an Underutilized Resource
Authors: Mar Christopher Del , O'Connor Vivienne
Published: February 2008

Summary: We questioned 229 general practitioners (GPs), 288 women who had recently delivered babies in public hospitals, 26 public hospital doctors, and 33 midwives in South Brisbane. Shared antenatal care was undertaken by 84% of mothers, and recently provided by 88% GPs. Mothers valued having sufficient time with their antenatal clinician, continuity of care, and short waiting and travel times. They preferred a GP to provide antenatal care, and a hospital midwife to deliver them. GPs were interested in providing even more obstetric care ‐ one third in providing intrapartum care ‐ and in gaining continuing education in obstetrics. Hospital doctors and midwives were supportive of women choosing the personnel to deliver them, and of an increased GP and midwife role in public hospital obstetrics, but unenthusiastic about home deliveries. There is widespread support for an increased role for GPs in public obstetrics.
Update of Growth Percentiles for Infants Born in an Australian Population
Authors: Guaran R.L. , Wein P. , Sheedy M. , Walstab J. , Beischer N.A.
Published: February 2008

Summary: Growth percentiles require periodic revision because of changes in the ethnic mix of a population and socioeconomic factors. Anthropometric measurements were derived from singleton livebirths, without lethal malformations, from 22 completed weeks' gestation, at the Mercy Hospital for Women, Melbourne, from 1980 to 1989 (49,429 infants). Infants were included if reasonable assessment of gestation was available. Birth‐weight percentiles were derived for the study group, male and female infants separately and for infants whose mothers were born in South‐East Asia (Vietnam, Laos and Cambodia). Percentile charts for length, head circumference and ponderal index were also prepared. When compared with the intrauterine birth‐weight growth curves reported by Kitchen et al (4) there was generally an elevation of all percentiles. Male infants were larger than female infants. Infants delivered by mothers born in South‐East Asia were smaller than the study group as a whole, although the 10th percentiles for birth‐weight were similar to the study group especially from 36–39 weeks' gestation. Periodic review of local standards is required to correctly categorize newborn infants' growth characteristics; factors such as sex of the infant and ethnic origin of the mother should be considered.
A Review of 19 Sets of Triplets: The Positive Results of Vaginal Delivery
Authors: Clarke J.P. , Roman J.D.
Published: February 2008

Summary: The outcome of 19 triplet pregnancies delivered at Waikato Women's Hospital is analyzed, with particular regard to the mode of delivery. During the period 1981–1992 the incidence of triplets was 1:1,945. Twelve sets of triplets were delivered by Caesarean section (63%) with 6 perinatal deaths occurring in this group, compared to none in 7 sets of triplets delivered vaginally (37%).

All triplet pregnancies were correctly diagnosed antenatally by ultrasound examination at a mean gestational age of 19 weeks (range 11–28 weeks). The most common antenatal complications were preterm labour in 18 pregnancies (95%) and preeclampsia in 4 (21%). The mean gestation at delivery was 33 weeks (range 25–39 weeks).

The outcome of triplet pregnancies was better in the group that delivered vaginally than those delivered by Caesarean section. Greater maturity of the infants delivered vaginally appeared to be the major factor for the lower neonatal morbidity and mortality.
The Prevalence of Polycystic Ovaries on Ultrasound Scanning in a Population of Randomly Selected Women
Authors: Farquhar Cynthia M. , Birdsall Mary , Manning Patrick , Mitchell Jennifer M. , France John T.
Published: February 2008

Summary: Polycystic ovaries (PCO) diagnosed by ultrasound have been commonly reported amongst healthy women. The study aimed to determine the prevalence of PCO in a population of women from the community, and to relate it to clinical and endocrinological data. Twelve hundred women chosen randomly from electoral rolls were invited to take part in the study. Two hundred and fifty five women (21%) who met eligibility criteria agreed to participate and 183 women (16%) finally completed the study. Seventy two women did not attend. An ultrasound scan and blood tests were taken on day 5–9 of their menstrual cycles. Data about their menstrual periods and reproductive history was collected. The prevalence of PCO was 21% (39 of 183). No differences existed between women with PCO and normal ovaries with respect to uterine size, body mass index, luteinizing hormone levels, serum hormone binding globulin levels and fertility status. Hirsutism (Ferriman Gallwey score >7), elevated testosterone levels and irregular menstrual cycles were significantly more frequent amongst women with PCO. Mean ovarian volume was larger in women with PCO irrespective of the use of hormonal contraception. Fifty nine per cent of women with PCO had irregular menstrual cycles or elevated Ferriman Gallwey scores or both. There was no detectable effect of PCO on parity or miscarriage although only 70% of women with PCO had evidence of an adequate ovulation compared to 95% of women with normal ovaries.
Impaired Bladder Emptying in Women
Authors: Dwyer P.L. , Desmedt E.
Published: February 2008

Summary: The clinical and urodynamic findings in 1,193 consecutive women referred for investigation of urinary incontinence and other urinary symptoms were reviewed. Impaired bladder emptying was defined as a repeated maximum flow rate below 15 ml/second or a residual urine volume of 150 ml or more. One hundred and sixty‐five women were diagnosed as having voiding dysfunction. Fifty‐six of the 165 women (34%) had a residual urine volume of 150 ml or more. Voiding dysfunction was the only abnormal urodynamic finding in 27 women and was associated with genuine stress incontinence, detrusor instability or bladder hypersensitivity in a further 138 patients. Overflow incontinence was diagnosed in 7 women (0.5%). Symptoms of impaired bladder emptying were significantly more common in women with proven voiding dysfunction but were absent in a third of these patients. One in 4 women with normal micturition had symptoms of voiding difficulty. Neurological disease, pelvic surgery and psychological factors were important causes of voiding dysfunction. Voiding disorders are a common cause of lower urinary tract dysfunction and should be an important consideration in future patient management.
‘Pregnancy Tumour’ of the Nasal Septum
Authors: Lim Ivor Jiun , Singh Kuldip , Prasad R.N.V. , Chan H.L. , Ratnam S.S.
Published: February 2008

Summary: The origins of pyogenic granulomas are subject to much debate. It is viewed as overexuberant growth of epithelium and capillary loops (i.e. granulation tissue) in response to trauma by some authorities, and is considered a capillary haemangioma with a unique lobular organization by others. Although the pathogenesis of the lesion is unclear, marked variation in sexual distribution suggests a hormonal factor, and the profound metabolic and endocrine changes in pregnancy seem to provide especially fertile soil for its growth. Its appearance and rapid rate of growth might easily lead the practitioner to mistake its identity for something more ominous.
Risk Factors for Wound Infection Following Caesarean Section
Authors: Beattie P. G. , Rings T. R. , Hunter M. F. , Lake Y.
Published: February 2008

EDITORIAL COMMENT: This paper has a special message for readers concerned about post‐Caesarean section wound infections, because of the careful documentation after the patients were discharged from hospital. We all have cared for women who telephone to tell us about a discharge from the Caesarean wound after they have returned home. We advise these women to return for examination if febrile, or if the wound is painful, or if there is a purulent discharge from it. Usually the problem is managed by the woman dressing the area of discharge without any but this verbal consultation. At the postnatal visit the wound is healed but the scar may signal the area of the problem. How important are minor wound infections as defined in this study? The patient and the surgeon would of course prefer to avoid these complications, but it is the major wound infections, with or without disruption, that really matter, and which hopefully have a reduced incidence when intraoperative antibiotic administration is practised. In addition to complete documentation we also require grading of wound infections in terms of risk to life and time spent in hospital.

Response to editorial comment from authors: Although the majority of wound infections diagnosed after discharge from hospital were not ‘major’, with only 2 patients requiring readmission, there was significant morbidity amongst this group and considerable cost to the health services. General practitioners saw and treated 12 of the 30 (40%), and there was also an increase in the workload for the Home Care Midwifery service with 49% of all visits to Caesarean section women being to the 30% that were infected (figure 1). Thus, these nonmajor wound infections would appear to be important for both the woman with her delay in returning to normal activities, and for our already overstretched Home Care Midwives, with an increase in demand for their services.

Summary: A prospective study was performed between April 1,1991 and April 30,1992 to determine factors involved in the development of post‐Caesarean section wound infection. During this period there were 4,857 deliveries, 428 by Caesarean section (8.8%). Complete data were available on 328 (76.6%) patients. Wound infection occurred in 25.3% of women and was confirmed by positive bacteriology in 77.1%; 36% of wound infections were diagnosed following the patients' discharge from hospital. A negative correlation was found between maternal age and development of wound infection up to age 40 (p = 0.03). Maternal weight was a highly significant indicator of subsequent wound infection development (p = 0.0001), the relationship between increasing maternal weight and infection appearing linear. Antibiotic prophylaxis was found to be the most significant protective factor (p = 0.0007) in the reduction of postoperative wound infection. This relationship was independent of maternal weight.
The Incidence of Gestational Diabetes Mellitus in the Illawarra Area of New South Wales
Authors: Moses R. G. , Griffiths R. D. , McPherson S.
Published: February 2008

Summary: The incidence of gestational diabetes in the Illawarra area is 7.2% (95% CI: 6.0–8.4). This was determined by data collected by 2 prenatal clinics and 3 private practitioners during 1993. The incidence rate varied between 5.1% at one hospital to 11.3% with a private practitioner. This variation was mainly due to differences in age and ethnic background. The highest incidence rate of 11.9% was found in women of Asian background.
Fetal Pulse Oximetry: A New Method of Monitoring the Fetus
Authors: Johnson Nicholas , Johnson Valerie A. , McNamara Helen , Montague Imogen A. , Jongsma Henk W. , Aumeerally Zeennat , Gupta Janesh K , van Oudgaarden Elizabeth , Lilford Richard J , Miller David
Published: February 2008

Summary: Experimental pulse oximetry devices, similar to the existing systems used in adult and neonatal monitoring, can be used on the fetus to provide safe, and rapid information about oxygenation. They have been calibrated using fetal lambs and validated in human cross‐sectional studies. Experiments have shown that fetal oxygen saturation decreases during normal labour, and drops after a uterine contraction especially with oxytocin‐induced tachysystole. When the mother is given oxygen the fetal oxygen saturation increases. Readings are effected by caput and movement, and trends seem to be more meaningful than absolute values. Pulse oximetry can predict fetal outcome and a normal oxygen saturation result is specific for a good outcome perhaps even if the CTG is abnormal. However the technique is still experimental and there is insufficient data to support its use as a replacement for fetal blood sampling or a discriminator for an abnormal fetal heart trace.
Sexual Function After Pelvic Surgery in Women
Authors: Poad D. , Arnold E. P.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication since it will remind readers to discuss the possibility of postoperative sexual dysfunction. It should go without saying that sexual function before surgery should also be discussed, particularly since it may determine the type of surgery selected for genital prolapse with or without associated urinary incontinence. Our reviewer stressed the point that in spite of the oft‐quoted opinion of Francis and Jeffcoate (reference 4 in this paper), posterior colporrhaphy will not cause dyspareunia if excessive narrowing of the vagina is avoided. Narrowing in the mid‐vagina is caused either by excessive excision of vaginal epithelium or by excessive approximation of paravaginal connective tissue. Moreover failure to perform posterior colporrhaphy after anterior colporrhaphy, with or without vaginal hysterectomy, can accentuate weakness of the vaginal vault and posterior vaginal wall and result in rapid development of an enterocele or even eversion of the vagina. A final comment is that it should be routine to review women 6 months or so following pelvic floor surgery to review the anatomical and physiological results. The 4–6 week postoperative visit is too soon since many have not recommenced coitus at this time. Furthermore, problems with discharge or postcoital bleeding from vault granulomas are best excluded some time after resumption of coital activity.

Summary: To assess the prevalence of sexual dysfunction after pelvic floor surgery for nonmalignant conditions, a retrospective survey was performed. Replies from a postal survey were received from 66 of the 200 women canvassed. Dyspareunia developed in 10 patients who had never had it before the operation, however of those who had it preoperatively the pain stopped completely in 12 of 23. Reduced libido was noted in 16 of 54 (29%), reduced lubrication in 21 (38%), and reduced genital sensation in 10 (18%). Lack of information about the potential effects of surgery on sexual function was identified as a major deficit and of considerable concern to 35 of the 66 women. Sexual function after surgery should be evaluated more intensively, and the subject discussed openly before any contemplated operation.
Early Discharge Following Major Gynaecological Surgery
Authors: Ng Peng Hoong , Hogston Patrick
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication to remind readers that early discharge from hospital is possible following conventional gynaecological surgery as well as after that done by laparoscopy or associated with laparoscopy. This method of management has long been practised in the United States and recent American literature has even reported that vaginal hysterectomy can be done as an outpatient procedure! The editor's understanding of this paper is that the 40 patients described were not consecutive ones enrolled for the early discharge programme since those who remained more than 3 days were excluded from the study, which therefore does not provide information regarding what proportion of patients undergoing these procedures are suitable cases for early discharge. Nonetheless the paper reminds us that the early discharge option should be explored, not only for cost containment in hospitals, but also because many patients would prefer to convalesce at home. These days visiting hours are seldom rigorously enforced in hospitals and the editor's observation is that many patients after confinement and after gynaecological surgery must look forward to getting home in order to have a rest! Patients often have so many visitors that they are utterly drained coping with them socially when they are in the early stages of their convalescence.

Summary: This prospective study was to assess the safety and acceptability to patients of early discharge after major gynaecological surgery. Selective patients who fulfilled certain criteria were offered early discharge after their operations. Forty patients were discharged within 72 hours. Fourteen of them had undergone abdominal hysterectomy, 5 with a mid‐line incision; 13 had vaginal hysterectomy; 9 laparoscopy and laparotomy for ectopic pregnancy; 3 laparotomy for ovarian surgery and 1 a Manchester repair. The patients were discharged home on average 2.4 days after their operations. All were satisfied with their pain relief at home. There were 4 post discharge complications. Two had superficial drip‐site phlebitis, 1 a possible urinary tract infection and 1 a wound abscess. There was only 1 readmission 2 weeks post discharge for constipation. Thirty‐one out of 40 (77.5%) of the patients had expressed that the home environment was more conducive to speedy recovery and 92.5% of the patients would choose early discharge again if given the option.
Ureaplasma Urealyticum Chorioamnionitis
Authors: Maher Christopher F. , Haran Mano V. , Farrell David J. , Cave Donald G.
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication to remind readers that Ureaplasma urealyticum, which is a common vaginal commensal, can be associated with and apparently the cause of chorioamnionitis, premature labour, premature rupture of the membranes and intrauterine infection. As the authors note, antepartum cultures for Ureaplasma urealyticum are not useful in predicting pregnancy outcome (14). What then is the takeaway message from these cases? It seems to the editorial subcommittee that, since prematurity and premature rupture of the membranes tend to reoccur, that when the conditions have been associated with chorioamnionitis and culture of U. urealyticum, there is a case for prophylactic, long‐term treatment with an appropriate antibiotic in any future pregnancy. This is more strongly recommended if there is a past history of perinatal mortality associated with chorioamnionitis.

The authors of this paper consider (communication to the editor in response to this editorial comment) that further research is required to establish risk factors for the development of Ureaplasma urealyticum chorioamnionitis, although they believe that previous uterine or cervical surgery may be a risk factor. Further trials of antibiotic therapy in women with a past history of premature labour and premature rupture of the membranes associated with or with Ureaplasma infection are required. Since about 40% of all perinatal deaths occur in the 1% of women who deliver between 20–28 weeks' gestation (A), it also seems necessary to reevaluate if women without a past history of the above obstetric complications should receive treatment when antepartum cultures for Ureaplasma urealyticum are positive.

In summary, there is not much good news about prevention of the 2 main perinatal killers, prematurity and premature rupture of the membranes, but we should pursue all leads such as chorioamnionitis with Ureaplasma urealyticum or other bacteria (group B beta haemolytic streptococci) as its provocant.

Summary: Controversy reigns over the role of Ureaplasma urealyticum in determining pregnancy outcome. U. urealyticum infection of the chorioamnion is strongly associated with chorioamnionitis (1–3), premature birth (2–4), and perinatal morbidity (4–6). We present 4 cases of U urealyticum chorioamnionitis and associated morbidity and mortality.
The Effect of Scavenging on Nitrous Oxide Pollution in the Delivery Suite
Authors: Heath B.J. , Done M. , Balog O. , Ziccone S. , Rosewarae F.
Published: February 2008

Summary: United States standards recommend limits to occupational exposure to nitrous oxide. This can be achieved by the scavenging of waste anaesthetic gases, a routine practice in the operating suite, but less common in the delivery suite. In this study, nitrous oxide levels in the delivery room were measured, and scavenged and unscavenged levels were compared. Unacceptable levels of nitrous oxide were found in unscavenged delivery rooms, and in the majority of cases, scavenging reduced nitrous oxide pollution to within recommended limits.
Cervical Pregnancy Following In Vitro Fertilization: Evacuation After Uterine Artery Embolization with Subsequent Successful Intrauterine Pregnancy
Authors: Pattinson H. Anthony , Dunphy Bruce C. , Wood Steven , Saliken John
Published: February 2008

Summary: A case is described in which a cervical pregnancy followed in vitro fertilization. Treatment was delayed at the request of the patient until the second trimester, and was successfully managed by preoperative bilateral angiographic uterine artery occlusion, surgical evacuation, and postoperative balloon tamponade. Subsequent embryo transfer of previously cryopreserved embryos resulted in a normal intrauterine pregnancy and delivery without complications. This case highlights the need for awareness of cervical pregnancy following in vitro fertilization and the success of management which preserves fertility.
The Value of Routine Early Pregnancy Ultrasound in the Antenatal Booking Clinic
Authors: Peek Michael J. , Devonald Katherine J. , Beilby Ruth , EllwoodJ David
Published: February 2008

Summary: The value of routine antenatal booking ultasound as an adjunct to, or as an alternative to the 18 to 20 week ultrasound, is not known. A study into the possible benefits of routine antenatal booking ultrasound was undertaken. One year's experience, involving 1,372 scans is described. The main medical benefits include the establishment or correction of gestational age (41.7% of all pregnancies) and the identification of multiple pregnancies (0.7%), nonviable pregnancies (1.4%) and other pregnancies requiring specialist antenatal clinic referral (0.7%), resulting in a total of 44.5% of patients in whom some benefit was obtained.
Laparoscopic Management of Ovarian Masses: The Initial Experience and Learning Curve
Authors: Yuen Pong Mo , Rogers Michael S.
Published: February 2008

Summary: Fifty two consecutive patients undergoing laparoscopic surgery for ovarian masses were reviewed. The operative time depended on the experience of the surgeon and size of the tumour. It dropped progressively within the first 10 cases and then remained static until after 40 cases when there was a further decline. Postoperative pain was minimal and the median hospital stay was 2 days (range 1–7 days). The majority of patients returned to full activity within 2 weeks. The overall morbidity was 7.8% and was mild in nature without sequelae.
OCCASIONAL REVIEW: Twin‐Twin Transfusion Syndrome: Intraamniotic Pressure Measurement in the Assessment of Volume Reduction at Serial Amniocenteses
Authors: Meagher Simon , Tippett Christine , Renou Peter , Baker Lesleigh , Susil Beatrice
Published: February 2008

EDITORIAL COMMENT: We accepted this paper for publication because we consider it contains important information on management of patients with acute polyhydramnios. However the editorial committee considers that there is still doubt regarding how commonly fetofetal transfusion is the aetiological mechanism of the acute polyhydramnios syndrome seen in uniovular twins. We have reviewed the clinical data of the 13 cases reported by Steinberg and colleagues(A) with a particular emphasis on the haemoglobin discrepancies between the twins and whether or not the polyhydramnios was associated with the recipient twin. The findings were that there were only 4 cases where there were haemoglobin measurements performed on both twins; in only 2 of the 4 was the difference more than 4 g/dL and in both cases the smaller twin had a higher haemoglobin value. In 1 of the cases the haemoglobin values of the twins were 5.5 and 9.8 g/dL respectively and the smaller twin had the higher haemoglobin value; there was polyhydramnios in both sacs. In the other case where there was a haemoglobin discrepancy of more than 4 g/dL the smaller twin had the higher haemoglobin (20.7 g/dL) and the larger twin had a haemoglobin value of 16.6 g/dL and only this larger twin had a polyhydramniotic sac. It seems to us that the mechanism of acute polyhydramnios may not be the same in all cases and it is not proven that fetofetal haemorrhage is a convincing explanation for all cases. One of the problems in elucidating the problem is that these patients are often incompletely documented because of stillbirth or uncertainty as to whether the small or large twin occupied the polyhydramniotic sac.

Summary: Two cases of severe twin‐twin transfusion syndrome are described. In both, serial amniocenteses were followed by resolution of the disordered inter‐twin haemodynamics with 4 intact term survivors. In all reports to date of aggressive reduction with or without successful outcome, volume reduction has been dictated by subjective or semiquantitative ultrasonic estimates of liquor volume. With the use of intraamniotic pressure estimation we describe a more rational basis for the removal of these large volumes of amniotic fluid.
Singleton and Twin Confinements Associated with Infertility Treatments
Authors: Kurinczuk Jennifer J. , Pemberton Richard J. , Binns Sarah C. , Parsons Deborah E. , Stanley Fiona J.
Published: February 2008

EDITORIAL COMMENT: This paper provides important data concerning the contribution of the different infertility treatments (clomiphene plus gonadotropin versus GIFT plus IVF) to the community incidence of twin pregnancy. It seems to us that sampling only 0.6% of singleton pregnancies and 50% of twin pregnancies (table 3) may have underestimated the contribution to singleton pregnancy of both CC/GT and GIFT/IVF. Ideally, what we require is documentation on all the perinatal data forms of whether the index pregnancy resulted from treatment with CC/GT or GIFT/IVF ‐the multiple pregnancies rates (twin and higher order multiples) associated with these different treatment regimens could then be evaluated for the total population. This would give a new dimension to informed decision by the doctor and the infertile couple in selection of the method of treatment of infertility in those women who have patent tubes and are thus suitable candidates for either regimen. Knowledge of the twin and higher order multiple pregnancy rate, not to mention the rate of singleton pregnancy, associated with these 2 different regimens would also indicate if present drug regimens require further refinement to be competitive with GIFT and IVF, if. in terms of the community incidence of twin delivery but exclusive of other cost considerations.

Summary: A cross‐sectional sample of 150 singleton and 159 twin confinements delivered in Western Australia in 1991 were randomly sampled in 1993; 63% of the women responded to a postal questionnaire. Thirteen percent of respondents with singletons and 26% of those with twins reported having problems conceiving at some stage in their life. Six percent of those who had singleton confinements and 22% of those women who had twin confinements sought fertility advice prior to the conception of the index pregnancy. One percent (95%CI 0.03%, 5.5%) of women with singletons received infertility treatment compared with 17% (95%CI 10.4%, 26.3%) of those with twins. Overall 82.7% (95%CI 75.2%, 90.1%) of twin confinements followed spontaneous conception, 11.2% (95%CI 5.7%, 19.2%) followed ovarian stimulation treatment alone and 6.1% (95%CI 2.3%, 12.9%) followed IVF or GIFT procedures. The probability of a spontaneous twin confinement was 1 in 95. It was concluded that nearly twice as many twin pregnancies were associated with ovarian stimulation treatment given alone than with IVF and GIFT combined. The routinely collected data about assisted twin conceptions provide an incomplete picture with regard to the role of different infertility treatment modalities.
The Effect of Vigorous Exercise During Pregnancy on Birth‐Weight
Authors: Bell Robin J. , Palma Sonia M. , Lumley Judith M.
Published: February 2008

EDITORIAL COMMENT: When this paper was reviewed the question was raised that the period of gestation is an obvious factor which can determine birth‐weight and the authors were asked how this may have affected their results The authors response was as follows:

The mean gestation at delivery in the 2 groups was not different statistically ‐ controls n = 41, mean = 39.96 weeks, standard deviation = 1.37 weeks; exercisers n = 58, mean = 39.48 weeks, standard deviation = 1.94 weeks. We were interested in the finding in our study that preterm delivery occurred in 4 of 58 exercisers and only 1 of 41 controls. However, the number of preterm deliveries in this study is small (a total of 5) and as the calculation of sample size was based on a shift in mean birth‐weight, this is the outcome which should be emphasized.

Clearly, gestation is a very important determinant of birth‐weight. However, in terms of trying to determine whether exercisers deliver earlier, it would not help to put gestation in our analysis of variance and covariance. Gestational age would need to be the dependent variable for such an exercise and, for meaningful results, would require a larger study.

Summary: The aim of this study was to assess the effect on birth‐weight of continuing a programme of vigorous exercise into late pregnancy. ‘Potential exercisers’ were women who had been doing vigorous exercise prior to pregnancy and intended to continue exercising during pregnancy. Controls were healthy pregnant women who did not do regular vigorous exercise. Both groups kept 2, 7‐day food ± exercise diaries at 25 and 35 weeks. The primary outcome variable was birth‐weight. Women who continued doing at least 30 minutes of vigorous exercise at least 3 times weekly at 25 weeks and either maintained this minimum level or had delivered by 35 weeks were classified as ‘exercisers’. Women doing more than 4 sessions of vigorous exercise weekly at 25 weeks had babies whose mean birth‐weight was 315 g lower than the mean birth‐weight of babies born to controls.
Female Circumcision
Authors: Erian Mark M.S. , Goh Judith T.W.
Published: February 2008

Summary: Three cases of female circumcision are presented together with a literature review. Unfortunately, this procedure frequently results in genital mutilation. Treatment with deinfibulation enables restoration of the external genitalia and vagina. Obstetric and gynaecological complications have been documented, but emotional and psychological effects may be difficult to assess. These women should be treated without bias and with sensitivity.