bluuebunny/crossref_metadata_2025 huggingface dataset:
Umbilical artery Doppler velocimetry in unselected and low risk pregnancies: a review of randomised controlled trials
Authors: Goffinet François , Paris‐Llado Josefa , Nisand Israel , Bréart Gérard
Published: August 2005

Objective
Meta‐analysis of data from controlled trials performed in populations at high risk have shown that umbilical artery Doppler velocimetry (umbilical Doppler) can reduce perinatal mortality. The individual published trials among unselected or low risk populations have found no beneficial effect. Our objective was to evaluate the effect of routine use of the umbilical Doppler in unselected or low risk pregnancies by reviewing all published and unpublished randomised controlled trials.

Study design
Systematically reviewing published and unpublished trials, we selected trials for the overview only if they were completed randomised trials of umbilical Doppler in unselected or low risk pregnancies. Of the seven trials examined, three were not included in the meta‐analysis because of methodological problems or because they did not meet the inclusion criteria. We therefore included four trials: two in unselected and two in low risk populations. These four groups were comparable in their degree of maternal and perinatal risk. Using the Mantel‐Haenzel statistical method and pooling the data, we considered 11,375 women in the meta‐analysis.

Results
Systematic use of the Doppler umbilical artery velocimetry had no statistically significant effect on perinatal deaths in unselected populations (odds ratio [OR] 1.28; 95% confidence interval [CI] 0.61–2.67), low risk populations (OR 0.51; 95% CI 0.20–1.29) or overall for the four trials (OR 0.90; 95% CI 0.50–1.60); nor was there any significant effect on stillbirths (global OR 0.94; 95% CI 0.42–1.98). However, the number of participants remain insufficient and further information is required to arrive at a definite conclusion on the absence of effect. The meta‐analysis showed no significant difference between the Doppler groups and the control groups for antenatal hospitalisation, obstetric outcome or perinatal morbidity.

Conclusion
Based on the results of the published trials, routine use of the umbilical Doppler cannot be recommended.
A meta‐analysis of low dose aspirin for the prevention of intrauterine growth retardation
Authors: Leitich Harald , Egarter Christian , Husslein Peter , Kaider Alexandra , Schemper Michael
Published: August 2005

Objective
To determine more precisely the effect of prophylactic low dose aspirin on intrauterine growth retardation and perinatal mortality.

Design
Meta‐analysis of 13 published randomised clinical trials.

Methods
We searched 18 medical databases, including MEDLINE since 1964 and EMBASE since 1974, review articles and the references from each retrieved report to identify all studies evaluating the effect of aspirin in pregnancy and including both intrauterine growth retardation and perinatal mortality as outcome measures.

Results
Among 13,234 women from 13 studies between 1985 and 1994, aspirin showed a significant reduction in intrauterine growth retardation (IUGR) (OR 0.82; 95% CI 0.72–0.93; P= 0.003) and a nonsignificant reduction in perinatal mortality (OR 0.84; 95% CI 0.66–1.08; P= 0.18). Subgroup analyses revealed that aspirin was effective at lower doses between 50 and 80 mg/day (IUGR: OR 0.87; 95% CI 0.76–0.99; mortality: OR 0.90, 95% CI 0.70–1.16), but that the preventive effect was greater at higher doses between 100 and 150 mg/day (IUGR: OR 0.36, 95% CI 0.22–0.59; mortality: OR 0.40, 95% CI 0.16–0.97) and among women entered before the 17th week of gestation (IUGR: OR 0.35, 95% CI 0.21–0.58; mortality: OR 0.43, 95% CI 0.17–1.06). We did not identify any specific subgroup of women most likely to benefit from aspirin treatment.

Conclusion
The results of this meta‐analysis showed that early aspirin treatment reduced the risk of intrauterine growth retardation. Low dose aspirin should not be used routinely in pregnant women until those most likely to benefit from aspirin treatment have been clearly identified.
Effects of SR 49059, an orally active V1a vasopressin receptor antagonist, on vasopressin‐induced uterine contractions
Authors: Bossmar Thomas , Brouard Rémi , Döberl Anton , Åkerlund Mats
Published: August 2005

Objective
To test the effect of SR 49059, an orally active, nonpeptide, selective and specific antagonist of the vasopressin V1a receptors in humans.

Design
A placebo‐controlled, double‐blind, cross‐over trial.

Setting
The Department of Obstetrics and Gynaecology, Lund University Hospital, Sweden.

Participants
Twelve healthy women, who had previously been sterilised by tubal ligation.

Interventions
The women participated on days 1, 2 or 3 of two menstrual cycles, with intrauterine pressure recordings and intravenous bolus injections of 10 pmol/kg body weight of lysine vasopressin given 1 h before and at 1,2 and 3 h after oral administration of 300 mg of the study drug or of placebo.

Main outcome measures
The area between the recording curve and zero level of pressure. Vital signs, safety parameters and drug plasma concentrations were also measured.

Results
The spontaneous uterine activity as well as the response to lysine vasopressin injections before administration of the test drugs were almost identical at the two experiments. Following intake of SR 49059 the area under the recording curve (0–10 min) after the second, third, and fourth injection of lysine vasopressin were reduced by 57, 42, and 66%, respectively, compared with placebo. Trough plasma concentrations of lysine vasopressin were markedly higher and systolic blood pressure slightly lower after antagonist administration than after placebo, whereas no significant difference between treatments was observed in diastolic pressure, heart rate or plasma osmolality.

Conclusions
This study demonstrates for the first time a biological effect of an orally active vasopressin V1a antagonist in humans in vivo and the results support the importance of vasopressin in uterine activation. The differences between study drug and placebo treatments in lysine vasopressin levels and systolic blood pressure, but lack of difference in osmolality indicate that SR 49059 antagonises the effect of lysine vasopressin on the vasopressin V1a receptor, but not that on the vasopressin V2 one. It is suggested that SR 49059 be explored therapeutically in dysmenorrhoea.
Bradykinin stimulates interleukin‐6 and interleukin‐8 secretion of human decidua derived cells
Authors: Rehbock J. , Chondromatidou A. , Buchinger P. , Hermann A. , Jochum M.
Published: August 2005

Cytokines are known to participate in the process of parturition within a paracrine network in fetal membranes. Bradykinin can also contribute to this process, increasing the release of eicosanoids from decidua cells. In this study, we present evidence for a cross‐link between bradykinin and the cytokines. Short and long term cultures of human decidua cells were incubated for 4 h and 24 h with and without bradykinin. IL‐6 and IL‐8 were determined in the supernatants by ELISA. Results show a large intermdividual variability in the basal secretion of IL‐6 and IL‐8 and a clear increase in the secretion of both ILs in response to bradykinin. By this amplifying effect on cytokine secretion, bradykinin can initiate local and systemic effects of amniochorionitis.
The effect of nifedipine and methyldopa on maternal cerebral circulation
Authors: Serra‐Serra Vicente , Kyle Phillipa M. , Chandran Ravi , Redman Christopher W. G.
Published: August 2005

Objective
To study how the treatment of severe gestational hypertension affects maternal middle cerebral artery velocimetry.

Design
Prospective, clinical, descriptive study.

Setting
John Radcliffe Maternity Hospital, Oxford, England.

Participants
Pregnant and puerperal women who required acute or chronic antihypertensive treatment with nifedipine (n= 46) or methyldopa (n= 26), respectively.

Methods
Transcranial Doppler ultrasound examinations of maternal middle cerebral arteries were performed before and 45 min after nifedipine; and before and 48 hours after the onset of methyldopa therapy. Blood pressure and heart rate were also recorded.

Main outcome measures
Clinical and transcranial Doppler changes induced by the antihypertensive medication.

Results
Blood pressure and middle cerebral artery velocities decreased significantly following both short‐ and long‐acting antihypertensive therapy. Nifedipine‐induced changes were more pronounced and uniform than those found after methyldopa (16.7% and 6.4% decrease in middle cerebral artery mean velocity, respectively). The middle cerebral artery mean velocity decrease was independent of changes in the blood pressure or heart rate.

Conclusions
Maternal cerebral haemodynamics are influenced by antihypertensive treatment. The reduction of middle cerebral artery flow velocities following administration of nifedipine and methyldopa may suggest that cerebral vasodilatation is occurring, which is consistent with the concept that cerebral vasospasm is present in women with pre‐eclampsia. The cerebral vasodilatation could result from a direct effect of the medication on the arteries in question.
Steady‐state pharmacokinetics of oestradiol gel in post‐menopausal women: effects of application area and washing
Authors: Järvinen A. , Granander M. , Nykänen S. , Laine T. , Geurts P. , Viitanen A.
Published: August 2005

Objective
To investigate the effect of cutaneous application area on oestradiol absorption using an oestradiol gel for transdermal use. Furthermore, the effect of washing of the application site on oestradiol pharmacokinetics was studied.

Design
Open‐label, randomised, three‐way cross‐over study.

Setting
A clinical pharmacokinetic research unit.

Subjects
Sixteen healthy postmenopausal volunteers.

Interventions
During three treatment periods, subjects were treated with 1 mg oestradiol (1.0 g Divigel®/Sandrena® 0.1% gel), applied on the thigh to a skin area of 200 cm2,400 cm2, or on an area ‘as large as possible’. Blood samples were drawn during steady‐state (on days 14–15) immediately before application and at regular time intervals thereafter.

Main outcome measures
Serum oestradiol levels were measured for determination of peak concentration (Cmax), time to peak concentration (tmax) and bioavailability using the area under the time concentration curve (AUC0–24).

Results
Bioavailability from a 200 cm2 area was 2‐fold higher than that from the largest possible area ((P<0.05)). Oestradiol peak plasma concentration from a 200 cm2 area was higher than from the two larger areas ((P<0.05)), which did not differ significantly from each other. Washing of the application site 30 min after application reduced the bioavailability from both the 200 cm2 and 400 cm2 application areas ((P<0.01)), but peak plasma concentration from the 200 cm2 area only ((P<0.01)). Time to reach peak plasma concentrations was significantly reduced with all three application areas by washing.

Conclusion
A higher oestradiol absorption was achieved from a smaller application area. No marked differences were observed in the pharmacokinetics between 200 cm2 and 400 cm2 application areas, which are those recommended for this oestradiol gel preparation.
24‐hour blood pressure monitoring to evaluate the effects of nifedipine in pre‐eclampsia and in chronic hypertension in pregnancy
Authors: Benedetto Chiara , Zonca Marina , Giarola Maurizio , Maulà Vincenza , Chiarolini Luciano , Carandente Franca
Published: August 2005

Objective
To investigate the effect of 7 to 14 days of therapy with nifedipine (sustained‐release preparation) on the 24‐hour blood pressure patterns of pregnant women with pre‐eclampsia or chronic hypertension, and to test the utility of blood pressure monitoring in modulating the timing and dosage of the drug.

Design
24‐hour automatic blood pressure monitoring of pregnant women with pre‐eclampsia or chronic hypertension before and after nifedipine treatment.

Setting
Centre for Prevention, Diagnosis and Treatment of Hypertension in Pregnancy, University of Turin, Italy.

Population
Sixteen pregnant women with pre‐eclampsia and 17 with chronic hypertension.

Methods
24‐hour blood pressure monitoring was performed before the beginning of the therapy and after 7 to 14 days of treatment with sustained‐release nifedipine.

Main outcome measures
Chronobiological analysis of systolic and diastolic blood pressure values was performed; MESOR, amplitude, acrophase, hyperbaric index, percent time elevation and significance of rhythm were calculated before and after treatment.

Results
6336 blood pressure measurements were analysed. Systolic and diastolic MESOR values were significantly decreased after nifedipine treatment both in pre‐eclampsia and in chronic hypertension. However, the antihypertensive effect of nifedipine in pre‐eclampsia was especially pronounced during evening and night, while in chronic hypertension it was more constant during the 24‐hour period. 24‐hour blood pressure monitoring allowed adjustment, when necessary, to the timing and dosage of nifedipine in accordance with the blood pressure patterns of each patient, using the hyperbaric index and percent time elevation as objective parameters for the evaluation of treatment efficacy.

Conclusions
24‐hour blood pressure monitoring is a good method to optimise treatment, and confirms that nifedipine is useful for the control of maternal blood pressure in pregnancy.
Routine antenatal screening for syphilis in Lothian: a study of the results 1988 to 1994
Authors: Cameron S. T. , Thong K. J. , Young H. , Liston W. A.
Published: August 2005

A retrospective study was carried out of the cases of positive syphilis serology detected by routine antenatal screening within Edinburgh (and surrounding district) over the six years 1988 to 1994. The study demonstrated a low incidence of syphilis with only 15 pregnancies in 58,445 screened. In eight cases serology and history were suggestive of late latent syphilis and in the remainder of previous infection which had been treated. All women were delivered of liveborn infants at term without stigmata of congenital syphilis. Lack of identifiable risk factors in women with positive serology suggests that routine rather than selective screening should continue.
Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial
Authors: Shipman M. K. , Boniface D. R. , Tefft M. E. , McCloghry F.
Published: August 2005

Objective
To study the effects of antenatal perineal massage on subsequent perineal outcomes at delivery.

Design
A randomised, single‐blind prospective study.

Setting
Department of Obstetrics and Gynaecology, Watford General Hospital.

Participants
Eight hundred and sixty‐one nulliparous women with singleton pregnancy and fulfilling criteria for entry to the trial between June 1994 and October 1995.

Results
Comparison of the group assigned to massage with the group assigned to no massage showed a reduction of 6.1% in second or third degree tears or episiotomies. This corresponded to tear rates of 75.1% in the no‐massage group and 69.0% in the massage group (P= 0.073). There was a corresponding reduction in instrumental deliveries from 40.9% to 34.6% (P= 0.094). After adjustment for mother's age and infant's birthweight these reductions achieved statistical significance (P= 0.024 and P= 0.034, respectively). Analysis by mother's age showed a much larger benefit due to massage in those aged 30 and over and a smaller benefit in those under 30.

Conclusion
Antenatal perineal massage appears to have some benefit in reducing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above.
Is conservative surgery for tubal pregnancy preferable to salpingectomy? An economic analysis
Authors: Mol Ben W. J. , Hajenius Petra J. , Engelsbel Simone , Ankum Willem M. , Hemrika Douwe J. , van der Veen Fulco , Bossuyt Patrick M. M.
Published: August 2005

Objective
The traditional treatment of ectopic pregnancy is salpingectomy, while conservative surgery aims to save the function of the uterine tube. This study compares the effectiveness and the economic costs of salpingectomy and conservative tubal surgery in women with a tubal pregnancy.

Methods
Salpingectomy and conservative tubal surgery were compared economically, based on a combined retrospective and prospective cohort study and a review of the literature. A model was developed in which conservative surgery and salpingectomy with in vitro fertilisation and embryo‐transfer (IVF‐ET) were compared with salpingectomy alone.

Participants
One hundred and fifteen consecutive women treated laparoscopically for tubal pregnancy.

Main outcome measures
Complete removal of the tubal pregnancy; subsequent intrauterine pregnancy rate; economic analysis.

Results
Tubal pregnancy was always treated successfully by both methods, sometimes with additional treatment for persistent trophoblast. In the short term costs per patient were £1554 (95% confidence interval [CI] £1501–£1656) for salpingectomy and £1787 (95% CI £1683–£1930) for conservative surgery. The mean difference between costs of salpingectomy and costs of conservative surgery was £233 (95% CI £80–£371). Concerning subsequent intrauterine pregnancy, conservative surgery is slightly more effective than salpingectomy but is more expensive. Costs per subsequent intrauterine pregnancy are £4063. If IVF‐ET is performed in all women who are not pregnant within three years after salpingectomy, costs per subsequent intrauterine pregnancy are £15,629.

Conclusions
Salpingectomy is the treatment of choice in women not desiring future pregnancy. Salpingectomy seems less effective than conservative surgery when future pregnancy is desired, but is less costly. Conservative surgery seems more cost effective than salpingectomy with additional IVF‐ET.
The prevalence and consequences of missed abortion in twin pregnancies at 10 to 14 weeks of gestation
Authors: Sebire N. J. , Thornton S. , Hughes K. , Snijders R. J. M. , Nicolaides K. H.
Published: August 2005

In singleton pregnancies at 10 to 14 weeks of gestation the prevalence of missed abortion is about 2%. In an ultrasound screening study at 10 to 14 weeks of gestation involving 492 twin pregnancies the prevalence of missed abortion was about twice as high as in singletons. The risk of subsequent miscarriage in twin pregnancies with one missed abortion was about ten times higher than in normal twin pregnancies. These findings may have important implications both in terms of counselling and for future research into the causes of miscarriage.
Exoanal ultrasound of the anal sphincter: normal anatomy and sphincter defects
Authors: Peschers Ursula M. , DeLancey John O. L. , Schaer Gabriel N. , Schuessler Bernhard
Published: August 2005

Objective
To describe the sonographic appearance of normal anal sphincter anatomy and sphincter defects evaluated with a conventional 5 MHz convex transducer placed on the perineum.

Design
Prospective, single‐blind study.

Setting
Department of Obstetrics and Gynecology, University of Michigan Medical Center, USA.

Population
Twenty‐five women with symptoms of faecal incontinence, 11 asymptomatic nulliparous women, and 32 asymptomatic parous women.

Methods
A convex scanner was placed on the perineum with the woman in lithotomy position. Images were taken at three levels of the sphincter canal. Pictures were evaluated by two examiners who were blinded to the case history of the women and to the results of each other for the presence or absence of sphincter defects.

Main outcome measures
Description of anal sphincter appearance on endoanal ultrasound. Reproducibilty of the evaluation of sphincter defects.

Results
The internal anal sphincter is visible as a hypoechoic circle; the external anal sphincter shows a hyperechoic pattern. Proximally the sling of the puborectalis muscle is visible. Sphincter defects were detected in 20 women. In all five women who subsequently underwent surgery, the presence and location of the defect was confirmed at the time of surgery. Examiners were in agreement 100% of the time on the presence or absence of internal defects. They disagreed in one patient on the presence of an external defect.

Conclusion
Exoanal ultrasound provides information on normal anatomy and on defects of the anal sphincter.
Evaluating measurement variability in clinical investigations: the case of ultrasonic estimation of urinary bladder volume
Authors: Khan Khalid S. , Chien Patrick F. W. , Honest Matthew R. , Norman Geoffrey R.
Published: August 2005

Objective
To evaluate the quality of studies seeking to establish measurement properties (reliability and validity) of ultrasonic estimation of urinary bladder volume.

Design
Online searching of the MEDLINE database between 1966 and 1995, and scanning of bibliography of known studies on ultrasonic bladder volume estimation. Study selection and study quality assessment were performed independently by two reviewers. Each article was evaluated for suitability of the reference standard, adequacy of reported blinding of the observers and appropriateness of the statistical index of concordance. The last two of these guidelines were applied to reliability studies (evaluating the relation among observed ultrasonic estimations), and all three guidelines were applied to validity studies (evaluating the relation of ultrasonic estimation with a definitive measurement).

Population
One hundred and twenty‐five participants enrolled in the five reliability studies and 769 participants in the 27 validity studies selected for appraisal of their quality.

Main outcome measure
Rate of study compliance with preset criteria for high quality.

Results
None of the studies complied with all of the criteria for high methodologic quality. In the five reliability studies, investigators did not report adequate blinding of observers in three (60%) and an appropriate index of reliability was not used in any. Among the 27 validity studies, there was a lack of a suitable reference standard in 6 (22%), an inadequate blinding in 25 (93%), and an inappropriate index of validity in all (100%).

Conclusion
Based on our guidelines for quality assessment, a large proportion of studies on measurement properties was found to have inadequate methods, raising concern about the credibility of the reliability and validity estimates reported. These deficiencies highlight the lack of rigour employed in the design, conduct and analysis of reliability and validity studies, which has the potential for leading to patient mismanagement due to biases in the assessment of measurement variability in clinical investigations.
Sex ratios: are there natural variations within the human population?
Authors: Maconochie Noreen , Roman Eve
Published: August 2005

Objective
To investigate on a population basis the suggestion that certain factors naturally alter the odds of having a boy or a girl, and that some women are predisposed towards having children of one particular gender.

Design
Routine data analysis.

Population
Routinely collected data on singleton infants born in Scotland from 1975 to 1988, linked so that births (live and still) to the same mother could be identified. The analyses relate to 549,048 first to fifth order births occurring to 330,088 women whose records were complete from the first delivery onwards.

Main outcome measures
Gender of infant.

Results
Of 549,048 births, 51.4% were male. Apart from random variation, the sex ratio of 1.06 remained constant at all birth orders (P= 0.18). The probability of a male infant appeared unrelated to the genders of the preceding siblings (P > 0.20 in second to fifth deliveries), and there was no evidence of variation with maternal age (P= 0.31), maternal height (P= 0.69), paternal social class (P= 0.12), maternal social class (P= 0.57), year of delivery (P= 0.84) or season of birth (P= 0.41). Whilst mothers whose children were all the same gender were more likely to continue childbearing than those with children of different genders, there was no evidence that those with daughters were more likely to continue than those with sons.

Conclusions
The suggestion that some women have a natural predisposition towards having children of a particular gender is not supported by these data. On a population basis there is no evidence to suggest that gender determination is anything other than a chance process.
Is a rising caesarean section rate inevitable?
Authors: Wilkinson Chris , McIllwaine Gillian , Boulton‐Jones Clare , Cole Susan
Published: August 2005

Objective
To determine the indications for singleton caesarean sections in Scotland in 1994.

Design
Prospective survey of singleton caesarean sections using information provided by clinicians entering data onto a computer in labour wards.

Setting
Twenty‐three consultant‐led obstetric units in Scotland.

Population
Women undergoing caesarean section in participating Scottish maternity units during 1994.

Results
Using routinely collected data it was found that the caesarean section rate varied by maternal age, parity, gestation, history of previous section and hospital of delivery, but there was no difference by area of deprivation. 87.4% (8369/9573) of Scottish caesarean sections were included in the survey of which 8098 were in women with singleton pregnancies. Most singleton caesarean sections were undertaken in primiparae (50.5%), 31.2% were in women with a history of previous section and 18.3% were in multiparous women who had not had a previous section; 38.9% of the operations were elective, 13.9% were emergencies before labour and 47.2% were emergencies during labour. Four main indications—elective section for breech presentation (10.7% of all sections); emergency Caesarean section before labour because of fetal problems (2.8%); emergency caesarean section during labour for fetal distress and/or failure to progress (30.3%); repeat section for reasons other than above (16.2%) accounted for 60% of all Caesarean sections in women with no other recorded complications. 7.7% of all singleton caesarean sections (19.8% of elective operations) were associated with maternal request for the operation.

Discussion
The survey has identified why caesarean sections are performed by Scottish obstetricians and highlighted some areas where there would be scope to increase the vaginal delivery rate. Before this can be attempted, agreement must be reached by clinicians about effective management of particular problems. Women also need to have ready access to evidenced‐based information about caesarean section.
Effect of spinal anaesthesia on the lower urinary tract in continent women
Authors: Haeusler Guenther , Sam Christine , Chiari Astrid , Tempfer Clemens , Hanzal Engelbert , Koelbl Heinz
Published: August 2005

Objective
To evaluate the effect of spinal anaesthesia on the bladder neck position and the urethral closure function in the resting state and during clinical stress test in healthy, continent women.

Design
Controlled clinical trial.

Setting
Department of Gynaecology and Obstetrics, Vienna University Medical School.

Participants
Fourteen continent women, of which seven were nulliparous and seven parous, underwent minor gynaecological procedures under spinal anaesthesia. Urodynamics and ultrasound investigations were performed before and during spinal anaesthesia.

Main outcome measures
Changes in the bladder neck position and the urethral closure function before and during spinal anaesthesia.

Results
Bladder neck position was found to be lower and more posterior during spinal anaesthesia as compared with pre‐operative assessment. The posterior urethrovesical angle increased significantly both at rest and during maximum straining. We observed a significant increase in bladder compliance, and all parameters of the urethral pressure profile decreased significantly. While none of the nulliparous women had a positive clinical stress test during spinal anaesthesia, 4/7 parous women demonstrated leakage (Fisher's exact test, P= 0.03).

Conclusions
Blockage of nerve supply to the pelvic floor muscles in continent women is associated with a significant loss of support of the bladder neck region confirming the theory of an active mechanism of muscular elements providing continence.
Is there an incremental rise in the risk of obstetric intervention with increasing maternal age?
Authors: Rosenthal Adam N. , Paterson‐Brown Sara
Published: August 2005

Objective
To determine whether increasing maternal age increases the risk of operative delivery and to investigate whether such a trend is due to fetal or maternal factors.

Design
Analysis of prospectively collected data on a maternity unit database.

Setting
A postgraduate teaching hospital.

Population
6410 nulliparous women with singleton cephalic pregnancies delivering at term (37–42) weeks of gestation) between 1 January 92 and 31 December 95.

Main outcome measures
Mode of delivery, rates of prelabour caesarean section, induction of labour and epidural usage.

Results
There was a positive, highly significant association between increasing maternal age and obstetric intervention. Prelabour (P < 0.001) and emergency (P < 0.001) caesarean section, instrumental vaginal delivery (spontaneous labour P < 0.001; induced labour P= 0.001), induction of labour (P < 0.001) and epidural usage in spontaneous labour (P = 0.005) all increased with increasing age. In the second stage of labour fetal distress and failure to advance, requiring instrumental delivery, were both more likely with increasing maternal age (in both P < 0.001). Epidural usage in induced labour and the incidence of small for gestational age newborns did not increase with increasing maternal age (P = 0.68 and P = 0.50, respectively).

Conclusions
This study demonstrates that increasing maternal age is associated with an incremental increase in obstetric intervention. Previous studies have demonstrated a significant effect in women older than 35 years of age, but these data show changes on a continuum from teenage years. This finding may reflect a progressive, age‐related deterioration in myometrial function.
Intra‐umbilical vein injection and retained placenta: evidence from a collaborative large randomised controlled trial
Authors: Carroli Guillermo , Belizan José M. , Grant Adrian , Gonzalez Laura , Campodonico Liana , Bergel Eduardo ,   on behalf of the Grupo Argentino de Estudio de Placenta Retenida
Published: August 2005

Objective
To determine whether intra‐umbilical vein injection with saline solution, with or without oxytocin, reduces the need for manual removal of placenta compared with expectant management.

Design
Multicentre, randomised controlled trial.

Setting
Eleven hospitals in four cities of Argentina: Buenos Aires, Corrientes, Rosario, and Salta.

Participants
Two hundred and ninety‐one women showing no evidence of placental separation thirty minutes after vaginal delivery.

Interventions
Three different management strategies: 1. intra‐umbilical vein injection of saline solution plus oxytocin; 2. intra‐umbilical vein injection of saline solution alone; and 3. expectant management.

Main outcome measures
Primary: manual removal of the placenta. Secondary: blood loss after trial entry, haemoglobin level at 24 to 48 hours and at 40 to 45 days after delivery, blood transfusion, curettage, infection, and days of hospital stay.

Results
Rates of subsequent manual removal were similar: intra‐umbilical vein injection of saline solution plus oxytocin (58%; RR 0.92; 95% CI 0.73–1.15), or saline alone (63%; RR 1.00; 95% CI 0.80–1.24), compared with expectant management (63%). There were also no detectable effects of the active managements on any of the secondary measures of outcome.

Conclusions
Based on evidence available from randomised controlled trials, including this trial, it is unlikely that intra‐umbilical injection with or without oxytocin, is clinically useful. We recommend that this intervention should not be used in third stage management of labour.
Mandatory prenatal screening for the human immunodeficiency virus: the experience in south‐eastern France of a national policy, 1992–1994
Authors: Rey Dominique , Carrieri Maria‐Patrizia , Obadia Yolande , Pradier Christian , Moatti Jean‐Paul
Published: August 2005

Objective
To evaluate the impact of the 1993 French National Policy which made it mandatory to offer screening for the presence of human immunodeficiency virus (HIV) to all pregnant women who planned to give birth, although women remained free to refuse the test.

Design
Successive surveys in April 1992 and May 1994 in south‐eastern France. Logistic regressions were performed to identify factors which affected access to HIV testing for women who gave birth and those who terminated their pregnancy, and for each year of study.

Main outcome measures
Attitudes and access to HIV testing among pregnant women, irrespective of pregnancy outcome.

Setting
All obstetrics and gynaecology departments and abortion clinics in the region.

Population 3497 women in 1992 (2775 who were delivered and 722 who chose termination) and 3407 in 1994 (2701 who were delivered and 766 who chose termination). The response rates were 82% and 88%, respectively.

Results
In 1994 of women who were delivered, 73% had an HIV test, compared with 63% in 1992 (P < 0.001); however of women who terminated their pregnancy, only 28% had an HIV test, compared with 245% in 1992 (P not significant), although they were more at risk for HIV infection. Socioeconomic differences affecting access to testing were reduced between 1992 and 1994, but only among women who gave birth.

Conclusion
Introduction of a policy which makes it mandatory to offer HIV screening to all women who intended to have their baby improved access to screening but did not improve the rate of preventative counselling. A mandatory requirement to offer HIV screening should be extended to women who request termination of pregnancy.
The Collaborative Randomised Amnioinfusion for Meconium Project (CRAMP): 1. South Africa
Authors: Hofmeyr G. J. , Gülmezoğlu A. M. , Buchmann E. , Howarth G. R. , Shaw A. , Nikodem V. C. , Cronje H. , de Jager M. , Mahomed K.
Published: August 2005

Objective
To evaluate transcervical amnioinfusion for meconium stained amniotic fluid during labout.

Design
Multicentre randomised controlled trial.

Setting
Four urban academic hospitals in South Africa. Obstetric surveillance included the use of electronic fetal heart rate monitoring in most cases.

Participants
Women in labour at term with moderate or thick meconium staining of the amniotic fluid.

Interventions
Transcervical amnioinfusion of 800 mL saline at 15 mL per minute, followed by a maintenance infusion at 3 mL per minute. The control group received routine care. Blinding of the intervention was not possible.

Main outcome measures
Caesarean section, meconium aspiration syndrome and perinatal mortality.

Results
Caesarean section rates were similar (amnioinfusion group 70/167 vs control group 68/159; RR 0.98, 95% CI 0.76–1.26). The incidence of meconium aspiration syndrome was lower than expected on the basis of previous studies (4/162 vs 6/163; RR 0.67, 95% CI 0.19–2.33). There were no perinatal deaths. There were no significant differences between any of the subsidiary outcomes.

Conclusions
This study concurred with three previous trials which found no effect of amnioinfusion for meconium stained amniotic fluid on caesarean section rate, though the pooled data from all identified trials to date show a significant reduction. The findings with respect to meconium aspiration syndrome were inconclusive in this study alone because of the small number of babies affected, but the point estimate of the relative risk was consistent with the finding of a significant reduction in previous studies and with the Zimbabwe arm (CRAMP 2) of this study. Pooled data clearly support the use of amnioinfusion for meconium stained amniotic fluid to reduce the incidence of meconium aspiration syndrome.
Flexible outpatient hysteroscopy without anaesthesia: a safe, successful and well tolerated procedure
Authors: Kremer Christian , Barik Sukumar , Duffy Sean
Published: August 2005

The objective of this study was to assess the feasibility and tolerance of diagnostic outpatient flexible hysteroscopy without anaesthesia. Records from 554 consecutive patients were analysed retrospectively. Success rate, reasons for failure, adverse reactions and level of pain were the main outcome measures. Hysteroscopy was successful in 90.5% of patients and well tolerated in 93.3%; 5.4% experienced moderate to severe pain. Inability to negotiate the cervical canal accounted for 47% of failed procedures and poor view for 42%. These results suggest that flexible outpatient hysteroscopy without anaesthesia is a successful and well tolerated procedure.
The value of screening for Down's syndrome in a socioeconomically deprived area with a high ethnic population
Authors: Ford C. , Moore A. J. , Jordan P. A. , Bartlett W. A. , Wyldes M. P. , Jones A. F. , MacKenne W. E.
Published: August 2005

Objective
To assess the utility of biochemical antenatal screening for Down's syndrome in a socioeconomically deprived area with a high proportion of Asian women from the Indian Subcontinent.

Design
Audit of Down's syndrome biochemical screening service over a four‐year period.

Setting
Teaching hospital and community antenatal clinic in inner city Birmingham.

Population
Women booked between October 1992 and December 1996.

Methods
Blood for screening was collected between 14 and 21 weeks gestation, alpha‐fetoprotein and intact human chorionic gonadotrophin were measured in serum and the risk of Down's syndrome was calculated.

Main outcome measures
Uptakes of screening and amniocentesis, screen positive rate, odds of being affected given a positive result, miscarriages associated with amniocentesis offered following a high risk result, detection rate, number of Down's cases prevented and a cost analysis. Outcome measures were compared between Asians and Caucasians.

Results
Overall 11,974 women (71%) accepted serum screening. The screen positive rate was 8.3% in Asians and 5.0% in Caucasians. The uptake of amniocentesis in women following a high risk result was 54% overall (35% Asian, 67% Caucasian). Nineteen cases of Down's syndrome were identified, of which 13 occurred in women who opted for biochemical screening. The detection rate of the biochemical screening programme was 85% (11/13). Of these 11 cases, six (none of whom were Asian) elected to have an amniocentesis, of whom four thereafter had a termination.

Conclusion
In this study the public health benefits of screening for Down's syndrome in a socioeconomically deprived area with a high Asian population, were small.
A double‐blind, randomised trial comparing the effects of tibolone and continuous combined hormone replacement therapy in postmenopausal women with menopausal symptoms
Authors: Hammar M. , Christau S. , Nathorst‐Böös J. , Rud T. , Garre K.
Published: August 2005

Objective
To compare the effects of two postmenopausal regimens on menopausal symptoms, bleeding episodes, side effects and acceptability.

Design
Double‐blind, randomised controlled trial.

Setting
Twenty‐nine sites in Denmark, nine in Norway and six in Sweden.

Participants
Four hundred and thirty‐seven postmenopausal women with menopausal complaints. None of these women had had a hysterectomy.

Interventions
Daily treatment with tibolone 2.5 mg (n = 218) or 17β‐oestradiol 2 mg plus norethisterone acetate 1 mg (E2/NETA) (n = 219).

Main outcome measures
Hot flushes, sweating episodes, vaginal dryness, assessment of sexual life and bleeding patterns; at baseline and after 4,12,24 and 48 weeks.

Results
Treatment with either preparation significantly reduced mean scores for hot flushes, sweating episodes and vaginal dryness. The overall discontinuation rate was 28% (tibolone 25%, E2/NETA 31%; P = 0.14), mostly during the first six months. There was a markedly lower cumulative incidence of bleeding or spotting episodes with tibolone compared with E2/NETA (P < 0.0001), mainly during the first six treatment cycles.

Conclusions
Both tibolone and E2/NETA effectively alleviate menopausal symptoms. However, tibolone caused significantly fewer bleeding or spotting episodes, which were reflected by lower overall rates of bleeding, as well as lower drop‐out rates due to bleeding.
An open study of the bladder neck support prosthesis in genuine stress incontinence
Authors: Moore Kate H. , Foote Andrew , Burton Gil , King Janet
Published: August 2005

Objective
To determine the proportion of unselected women with genuine stress incontinence in whom a bladder neck support prosthesis could be fitted successfully by three gynaecologists with no prior knowledge of the device, and to measure efficacy of the device.

Design
Prospective interventional study.

Setting
Two metropolitan urodynamic units.

Sample
Eighty women with genuine stress incontinence.

Main outcome measures
Average number of leaks per day on a frequency volume chart, average number of pads worn per day, urine loss on a one‐hour pad test, and urine flow rate.

Results
Of the 80 recruits, 11 had exclusion criteria and four could not be fitted at the first visit. Of 65 participants, 39 (58%) withdrew from the study before week four. In 20 of 39 women (51%) post‐surgical scarring made fitting difficult, and six (15%) withdrew for unrelated personal or medical reasons. In five women (13%) the device was never effective; six withdrew because of adverse events and two required devices that were larger or smaller than those presently available. Thus 38 of 65 participants (58%) could be fitted by the three gynaecologists. Of 26 women who wore the device for four weeks, median leaks per day fell from 2.5 (interquartile range (IQR) 1.9–4.6) to 1.0 (IQR 0–2); median number of pads per day fell from 1.5 (IQR 0.5–3) to 0 (IQR 0–1); and median pad test loss fell from 19 g/h (IQR 8–49) to 2 g/h (IQR 0–8). Sixteen of these 26 patients (62%) achieved objective success, six (23%) were socially continent, one failed to respond and three declined to complete all outcome measures. Urine flow rates revealed no evidence of outflow obstruction. At the sixth month, 18 of 26 patients (69%) were wearing the device successfully; 15 of these women continued to the 12th month, and all but one were objectively dry.

Conclusions
The bladder neck support prosthesis is a useful addition to the range of treatments available for the management of genuine stress incontinence, but may be difficult to fit in women who are oestrogen‐deprived or have undergone multiple surgical procedures. The demands of the trial protocol were found to be onerous by frail elderly women.
A study of the follow up patterns of women treated for CIN 2 and 3 before and after the introduction of the 1992 Guidelines
Authors: Mann C. H. , Kehoe S. , Brown A. , Luesley D. M.
Published: August 2005

Objective
To analyse the five year cytology follow up data after discharge on women treated for histologically proven cervical intraepithelial neoplasia (CIN) 2 and 3. To assess whether the introduction of the 1992 Guidelines for Clinical Practice and Programme Management affected follow up patterns. To identify who was lost to follow up and for what reasons.

Design
A retrospective cohort study of cervical cytological follow up data from 186 women treated for CIN 2 and 3.

Setting
Primary care services, West Midlands, United Kingdom.

Population
One hundred and eighty‐six women with CIN 2 or 3 treated with large loop excision of the transformation zone at the City Hospital, Birmingham, in whom the first follow up smear at six months was normal. The women were divided into two groups: Group 1 consisted of women treated before the introduction of the Guidelines (1988–1990), and Group 2 consisted of women treated at the time of the introduction of the Guidelines in 1992.

Intervention
Introduction of the 1992 Guidelines for Clinical Practice and Programme Management.

Main outcome measures
To determine the number of follow up smears each woman had over a five year period, to determine the number of women who had the recommended number of follow up smears, and to identify the number of women lost to follow up.

Results
The median (interquartile range) number of smears in Group 1 was five (four to six) and in Group 2 was four (four to five). A similar proportion of women in both groups subsequently had abnormal smears (15% and 13.6%). Only one woman required further treatment. 22% of women in Group 1 and 10.2% of women in Group 2 had the correct number of smears to fulfil the 1992 Guidelines. There were 21 women (11.3%) who only had one smear following discharge from the clinic in the five year follow up period.

Conclusions
The data from both cohorts shows follow up to be poor, and the introduction of the 1992 Guidelines has yet to result in an improvement in follow up patterns. The absence of a national cervical cytology database means that surveys of cytology follow up data will continue to be difficult due to the problems of data collection from numerous health authorities and the mobility of women in this age group.
Congenital diaphragmatic hernia: prenatal diagnosis, outcome and continuing morbidity in survivors
Authors: Huddy Charlotte L. J. , Boyd Patricia A. , Wilkinson Andrew R. , Chamberlain Paul
Published: August 2005

Objective
To improve counselling by investigating the prenatal diagnosis, outcome and morbidity in survivors of congenital diaphragmatic hernia.

Setting
Prenatal Diagnosis Unit, Oxford Radcliffe Women's Centre, Oxford.

Design
Cohort study.

Sample
Babies with congenital diaphragmatic hernia diagnosed postnatally and born to women scanned prenatally identified between January 1991 and December 1996.

Methods
Associated anomalies, outcome of pregnancy and final diagnoses were determined from hospital records. A report from the general practitioner and paediatrician recorded health and development information.

Main outcome measures
Accuracy of prenatal diagnosis, survival of cases of congenital diaphragmatic hernia and presence of ongoing morbidity in survivors.

Results
There were 35 pregnancies with congenital diaphragmatic hernia, nine of which were not diagnosed prenatally. In 22 pregnancies with isolated congenital diaphragmatic hernia, four were terminated, there were six perinatal deaths and two later deaths. Thirteen of 35 cases (37%) with congenital diaphragmatic hernia were associated with other abnormalities: four with abnormal karyotype and nine with other structural anomalies. Five of these women continued with their pregnancy; there were two neonatal deaths and three survivors. Thirteen of 35 infants (37%) survived, eight with chronic disorders requiring specialist intervention including respiratory problems (n= 6); developmental delay (n= 4); poor growth (n= 5); artificial feeding (n= 3); gastro‐oesophageal reflux (n= 3); recurrent hospital admissions (n= 6); and further surgery (n= 4).

Conclusions
The survival for infants born alive with congenital diaphragmatic hernia was 56% (13/23), 61% of whom have persistent disorders. Despite advances in neonatology there is a high mortality and morbidity with congenital diaphragmatic hernia. Prenatal counselling should reflect this.
Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision
Authors: Ayres‐de‐Campos D. , Bernardes J. , Costa‐Pereira A. , Pereira‐Leite L.
Published: August 2005

Inter‐observer agreement in the interpretation according to the FIGO guidelines of 33 cardiotocographic tracings by experts and subsequent clinical decision was evaluated, using the kappa statistic (K) and the proportions of agreement (Pa). Overall agreement in the classification of tracings was fair (K = 0.48) and was better for normal (Pa = 0.62), than for suspicious (Pa = 0.42) or pathologic tracings (Pa = 0.25). Overall agreement on clinical decision was slightly higher (K = 0.59), but mostly was centred on the decision to take ‘no action’ (Pa = 0.79). Experts especially disagreed over the decisions to ‘monitor closely’ (Pa = 0.14) or to ‘intervene immediately’ (Pa = 0.38). These limitations should be taken into account in clinical audits and in medical jurisprudence.