British journal of obstetrics and gynaecology最新文献

Objective To assess the maturation of auditory evoked cortical responses in the human fetus using fetal magnetoencephalography.

Design Prospective case series over a three-year period.

Setting Antenatal clinics, university hospital.

Population Singleton pregnancies at 29–40 weeks of gestation.

Methods We used a 31-channel-SQUID-biomagnetometer in a magnetically-shielded room to perform fetal magnetoencephalography. To record auditory evoked fields from the fetal brain we applied 500 monotonal bursts generated by a computerised sound generator directly to the maternal abdominal wall near the fetal head. The continuously recorded data sets were analysed stepwise using a specially developed heart artefact rejection software, Fourier filtering, principle component analysis and half split analysis of the averaged data.

Results In 36 of 64 examinations we detected signals of auditory evoked fields comparable to the P2m component in adults. The earliest recording succeeded in the 29th gestational week. The latencies of the auditory evoked responses declined during the third trimester from 300ms to nearly 150ms at term. The maturation of different components of the auditory evoked field could be demonstrated from the 31st gestational week onwards.

Conclusion The maturation of a fetal auditory cortical function using fetal magnetoencephalography could be assessed directly for the first time. We believe that this method will add information to current indirect methods of assessing the normal maturation of the human fetal brain.

Objective Assess the safety and efficacy of intrauterine contraceptive device (IUCD) insertion immediately after induced or spontaneous abortion.

Design Systematic search for randomised trials that had at least one treatment arm that involved IUCD insertion immediately after an induced or spontaneous miscarriage using Medline, Popline, EMBASE, and review articles supplemented by correspondence with investigators.

Population Women of any age or gravidity who had an IUCD inserted immediately after evacuation for spontaneous or induced abortion.

Methods Articles were abstracted and the raw data from tables were analysed with RevMan 3.1 software. We focused on Tietze-Potter gross life table probabilities with denominators of person-time of exposure.

Main outcome measures Rates of perforation, expulsion, pelvic inflammatory disease, contraceptive failure, and method continuation.

Results Complication rates for immediate post-abortal IUCD insertion were low. Perforation was rare with a rate of approximately one per 1000 insertions. One year gross cumulative expulsion rates ranged from 1.8% to 12.6%, pregnancy rates from 0.6% to 2.1%, and continuation rates from 54% to 90%. The net discontinuation rate due to pelvic inflammatory disease was low, ranging from 0.0 to 0.8 per 100 women at one year. Increasing gestational age at insertion was associated with increased expulsion rates.

Conclusions Post-abortal IUCD insertion is safe and effective. The risks of perforation, expulsion, pelvic inflammatory disease and contraceptive failure were low and similar to those reported for interval insertion. Second trimester gestational age is associated with an increased risk of expulsion. Immediate insertion may have a higher expulsion rate than delayed insertion. However, these risks may be outweighed by the benefit of immediate contraception.

Objective To determine the long term results of treatment of adenocarcinoma in situ by conisation of the cervix using survival analysis.

Design A retrospective study in six teaching hospitals in North West Thames.

Population Eighty-five women with a histological diagnosis of adenocarcinoma in situ of the cervix in punch or cone biopsy were identified from pathology and clinical databases.

Results In one patient a small focus of adenocarcinoma in situ was found in a cervical polyp. Subsequent cytology was normal and no further treatment was undertaken. The 84 remaining women underwent diathermy loop, cold knife cone biopsy, laser cone biopsy, or needle excision of the transformation zone. A hysterectomy or second conisation was performed in 31/84 women (36.9%) as part of the initial treatment. In all, nine (10.6%) had early invasive lesions of which four were squamous. Fifty-nine patients were treated conservatively following one or two conisations (median follow up 78 weeks, range 0–543 weeks). One had a subsequent hysterectomy for menorrhagia. Five women have undergone treatment for suspected recurrence, a 21.5% cumulative rate of further treatment by four years. The cumulative rate of histologically proven recurrence after conservative management was 4.3% at one year and 15% at four years.

Conclusions In those cases with clear margins in the cone biopsy, there is a place for conservative management of a selected group of patients who wish to preserve fertility. However, 16.7% of these will require further treatment after four years because of recurrent cytological abnormalities. Women who opt for conservative management should undergo regular, long term surveillance in a colposcopy clinic. Among those women with involved margins in the initial cone biopsy, there is a high incidence of residual disease. A second cone biopsy may be appropriate ‘definitive treatment’ for young women who wish to preserve their fertility if the margins of the second biopsy are clear and there is no evidence of invasion. Even among those for whom a hysterectomy is the proposed ‘definitive treatment’, a second cone biopsy may be required before hysterectomy to avoid inappropriate treatment of an occult invasive lesion.

Objective To obtain evidence for seasonal variability in pre-eclampsia using the assumption that environmental factors may have a role in the causal mechanisms.

Design Cross sectional population-based study.

Population All 1,869,388 deliveries in Norway in the years 1967 to 1998.

Method For each month, the percentage of births complicated by pre-eclampsia was calculated. The relative risks of pre-eclampsia by month of delivery were estimated as odds ratios using the month with lowest risk as the reference category.

Results Mothers of children born in August had the lowest risk of pre-eclampsia, and the risk was highest in the winter months (for December adjusted OR: 1.26, 95% CI 1.20–1.31). This pattern was independent of parity, maternal age, year and place of living.

Conclusion The finding may provide a new clue for understanding the causes of pre-eclampsia. Environmental factors that show a similar seasonal variation should be investigated as possible causes.

Objective To evaluate the effects of desogestrel 75μg/day, as a progestogen-only pill compared with a copper-bearing intrauterine contraceptive device (IUCD) on lactation and to study the safety of both treatments in mothers and children. Transfer of etonogestrel to breast milk was studied in a subgroup of desogestrel users. The children were to be followed up until 2.5 years of age.

Design An open, non-randomised, group-comparative study in lactating women.

Setting University Hospital, Reykjavik, Iceland.

Participants A total of 83 lactating women; 42 received desogestrel and 41 had an IUCD inserted for seven consecutive treatment cycles of 28 days.

Methods Evaluation visits were planned at baseline and at the end of treatment cycles 1, 4 and 7. The amount of breast milk was determined by weighing the infants before and after feeding, at baseline and after treatment cycles 1 and 4. Milk samples were obtained at the same time for constituent measurements. Safety was studied by structured medical examinations and by recording adverse experiences in mothers and children.

Results There were no significant differences between the desogestrel and IUCD groups in composition and quantity of breast milk nor in growth and development of the children followed up to the age of 2.5 years. In the desogestrel group a slightly higher incidence of mild adverse experiences of a hormonal nature was reported among both mothers and infants. Of the children 82% were followed until 1.5 years of age and 50% until 2.5 years.

Conclusion The use of desogestrel 75μg/day did not change the amount and composition of breast milk nor did it affect growth and development of the breastfed children. It appears to be a safe and effective contraceptive method for lactating women

Objective To determine whether vitamin E is effective in the treatment of primary dysmenorrhoea.

Design A randomised placebo-controlled trial.

Participants One hundred girls, aged 16–18 years old who suffered from primary dysmenorrhoea, among 1000 students attending a public high school in Region 5 in the Greater Tehran Municipality.

Methods Fifty girls were given 500 units of vitamin E (five tablets) per day, and 50 were given five placebo tablets per day. The treatment began two days before the beginning of menstruation and continued through the first three days of bleeding. The severity of pain before and after the treatment was studied. Treatment in both groups was carried out in two consecutive menstrual periods.

Results The severity of pain in the two groups was reduced after treatment, but the reduction was greater in the group treated with vitamin E. These differences were maintained in the second month of therapy.

Conclusion Both placebo and vitamin E are effective in relieving symptoms due to primary dysmenorrhoea, but the effects of vitamin E are more marked.

Objective To assess the maternal, fetal and neonatal safety of enoxaparin in pregnant women who require antithrombotic therapy.

Design Retrospective analysis of case notes of women who received enoxaparin during pregnancy, irrespective of dose, duration and reason for treatment.

Setting Fifty-five French perinatal centres.

Sample Data from 624 pregnancies in 604 women between 1988 and 1997. The incidence of previous thromboembolism was 29.8%, known thrombophilia 15.2%.

Methods Indication, regimen of enoxaparin and outcome measures were reported for each pregnancy. Information was obtained from case records, validated by research staff and analysed by an independent scientific committee.

Main outcome measures Incidence, seriousness and causality of maternal, fetal and neonatal adverse events, pregnancy outcome, and incidence of venous thromboembolism.

Results Enoxaparin was administered for treatment of an acute episode in 49 cases and for thromboprophylaxis in 574 cases. Serious maternal haemorrhage occurred in 11 cases during pregnancy (1.8%), one being reasonably related to enoxaparin, and in nine cases at delivery (1.4%), all unrelated to enoxaparin. Maternal thrombocytopenia was reported in 10 cases (1.6%), two being serious but unrelated to enoxaparin. Eight pregnancies ended in stillbirth (1.1%). Among the 693 live births, 17 major congenital abnormalities (2.5%) and 10 serious neonatal haemorrhages (1.4%) were reported. None of the fetal or neonatal adverse events was related to enoxaparin. Eight venous thromboembolic events (1.3%) were reported.

Conclusions The incidence of adverse events reported could be explained by the high risk profile of the study population. Overall, this retrospective study suggests enoxaparin is well tolerated during pregnancy.

Objectives To determine the range of erythrocyte sedimentation rate values obtained in healthy pregnant women. To examine the effect of gestational age and haemoglobin concentration on erythrocyte sedimentation rate.

Setting Queen Charlotte's Hospital, London, UK.

Design Cross sectional descriptive study.

Population Healthy pregnant women attending for routine outpatient antenatal visits at Queen Charlotte's Hospital in London.

Methods Erythrocyte sedimentation rate was determined by the Westergren method, haemoglobin concentration by automated cell counter and gestational age by ultrasonography. The median and 95% reference range was determined for erythrocyte sedimentation rate values obtained. Linear regression analysis was used to determine the influence of haemoglobin concentration and gestational age on erythrocyte sedimentation rate.

Results For 1019 women examined, the range of erythrocyte sedimentation rate values obtained was 4–112 mm/h. Gestational age and haemoglobin concentration both significantly influenced erythrocyte sedimentation rate. (P<0.0001). For non-anaemic women the 95% reference range rose from 18–48 mm/h in the first half of pregnancy to 30–70 mm/h in the second half of pregnancy. For anaemic women the corresponding reference ranges were 21–62 mm/h and 40–95 mm/h, respectively.

Conclusion For the correct interpretation of erythrocyte sedimentation rate values obtained during pregnancy gestational age and haemoglobin concentration must be taken into account.