British journal of obstetrics and gynaecology最新文献

To determine whether increased vascular resistance in the uterine artery is associated with carriership of factor V Leiden, a retrospective study was undertaken of 231 pregnant women who were monitored with Doppler velocimetry of the uterine arteries. These women had been part of a prospective study of 2480 pregnant women in whom factor V Leiden had been analysed. When compared with non-carriers of factor V Leiden, carriers had a tendency towards an increased proportion of pathological Doppler measurements, including a significant increase in bilateral uterine artery notches (7/33 vs 16/198, relative risk 3.1; 95% CI 1.2–8.1). This suggests an increased vascular resistance in the uteroplacental circulation among carriers of factor V Leiden.

Objectives To document the pattern of recurrence of disease following large loop excision of the transformation zone (LLETZ) to identify a low risk group of women who might benefit from less intensive cytological surveillance.

Design Analysis of prospectively collected information with retrospective review of follow up smears.

Population Three thousand, five hundred and sixty women who underwent LLETZ (median age 31 years; IQR 12 years).

Setting Colposcopy clinic at Northern Gynaecological Oncology Centre, Gateshead.

Methods Women treated with LLETZ from 1988 to 1995 were reviewed. Information on the pathology from LLETZ was collected prospectively and information on the subsequent smears was obtained from the family health authorities.

Results Invasive cancer was detected on the original LLETZ in 134 women who were excluded from the study. Of the remaining 3426 women, histology of LLETZ showed high grade CIN (II and III) in 2371 (69%). At least one follow up smear was undertaken in 3385 women (99%). This constituted 9765 women years of follow up with a mean duration of 35 months. Four hundred and seventeen women (12.2%) had a dyskaryotic follow up smear. Incomplete excision of the lesion and an age of ≥ 50 years at the time of the LLETZ were associated with an increased risk of recurrent CIN. Based on these risk factors the study group was divided into three risk groups: 1. women aged < 50 with no disease at the margins (n=1680); 2. women aged ≥ 50 with disease at the margins (n=93); and 3. women aged < 50 with positive margins, or aged ≥ 50 with negative margins (n=1653). The cumulative survival without recurrent CIN at five years for these groups were 92%, 57% and 86%, respectively.

Conclusion Women aged ≥ 50 with CIN at the margins of excision constituted a small minority high risk group (3%). Consideration should be given to repeat treatment of these women rather than surveillance. Women aged < 50 with complete excision of low grade CIN comprised 51% of the study group. These women were at low risk of recurrent CIN and might benefit from less intensive cytological surveillance following LLETZ.

Objective To study the impact of previous induced abortions on preterm delivery, small for gestational age and low birthweight in subsequent pregnancies.

Design Survey of a national sample of births in France in 1995.

Setting All public and private maternity hospitals in France.

Population 12,432 women who had a singleton live birth during one week.

Methods Data were collected during the women's postpartum stay in hospital, partly obtained by interview and partly abstracted from hospital medical records. Rates of preterm delivery, small for gestational age and low birthweight were compared according to existence and number of previous induced abortions. Maternal age, parity, history of previous adverse pregnancy outcome, maternal weight before pregnancy, marital status, educational level, maternal employment status during pregnancy, nationality, smoking during the third trimester of pregnancy and antenatal care were controlled for using multiple logistic regression and polytomous logistic regression.

Results Twelve percent of women reported one previous induced abortion, and 3% two or more. Previous induced abortion was associated with an increased risk of preterm birth (OR 1.4; 95% CI 1.1–1.8); the risk of preterm delivery increased with the number of previous induced abortions (OR 1.3; 95% CI 1.0–1.7 for one previous abortion and OR 1.9; 95% CI 1.2–2.8 for two or more). The relationship was the same for very preterm and moderately preterm deliveries and for spontaneous and indicated preterm deliveries. After controlling for potential confounders, the association between previous induced abortions and small for gestational age and low birthweight infants was no longer significant.

Conclusion This study suggests that a history of induced abortion increases the risk of preterm delivery, particularly for women who have had repeated abortions. The respective role of the surgical and medical techniques used for induced abortions needs to be explored.

Objective The aim of this study was to compare the use of a cervical vacuum cap cannula with the traditional metal cannula.

Design A prospective, randomised, single-blinded comparative study.

Sample Fifty consecutive infertile women undergoing hysterosalpingography for evaluation of infertility

Methods Hysterosalpingography was performed either with the traditional metal cannula (n=25) or a cervical vacuum cap cannula (n=25).

Main outcome measures Length of procedure, fluoroscopic time, amount of contrast medium, pain to the patient while applying the cannula and injecting the contrast medium, level of difficulty to the performer, the need to reapply the cannula, complications, and results of the hysterosalpingography.

Results Using the cervical vacuum cap cannula, compared with the metal cannula, the duration of the procedure was significantly shorter (5.3 vs 9.3 minutes; P<0.001), less fluoroscopic time was needed (0.9 vs 1.8 minutes; P<0.001), a smaller amount of contrast medium was used (4.6 vs 15.7 mL; P<0.001), the procedure caused less pain to the patient (3.2 vs 6.8, respectively; on a scale of 1–10; P<0.001), and was easier for the physician to perform (1.4 vs 3.4; on a scale of 1–10; P<0.001). No significant differences were encountered between the two groups in the need to reapply the cannula, in the rate of complications or in the results of the hysterosalpingography.

Conclusions The cervical cap cannula appears to be superior to the traditional metal cannula for performing hysterosalpingography.

Objective To investigate the effects of mode and place of delivery on first mother–infant contact and maternal emotional wellbeing.

Design A prospective, longitudinal study.

Participants A sociodemographically representative sample of 203 consecutive primiparous women was recruited, of whom 81% (n=164) were followed up.

Setting Four metropolitan hospitals, including one accredited baby friendly hospital, in Melbourne, Australia, 1997.

Methods During the postnatal hospital stay women were interviewed and medical records were inspected. Participants completed two self-report psychometric measures: the Edinburgh Postnatal Depression Scale (EPDS) and the Profile of Moods States (POMS). Follow up at eight months postpartum comprised completion of a postal questionnaire and repeat administration of the standardised self-report psychometric mood questionnaires.

Results The First Contact Index provides a measure of the first contact between a mother and her baby after the birth. Two-way analysis of variance revealed significant differences in First Contact Index between three modes of delivery groups: spontaneous, instrumentally-assisted, and caesarean section (P<0.001) and four hospital of delivery groups (P<0.001), but there was no significant interaction effect (P=0.55). Significant negative correlations existed between the First Contact Index and both the POMS and EPDS scores at two days postpartum (POMS, r = -0.339, 95% CI -0.46 to -0.22; EPDS, r = -0.279, 95% CI -0.41 to -0.16), even within delivery groups, and these were still present at eight months postpartum (POMS, r = -0.298, 95% CI -0.44 to -0.14, EPDS, r = -0.206, 95% CI -0.36 to -0.03).

Conclusion Instrumental and surgical delivery exert a negative impact on first postnatal contact between a mother and her baby which has persistent adverse maternal emotional correlates. Hospital practices associated with obstetric intervention in delivery also varied and are amenable to change, enabling optimal first mother–baby interaction regardless of mode of delivery.

Objective To assess the effectiveness of antenatal screening for trisomy 21 by first trimester sonography followed by second trimester biochemical screening.

Design Retrospective five-year review.

Setting Maternity unit of a university hospital.

Population An unselected group of 7447 pregnant women who had a first trimester scan and nuchal translucency measurement in our unit after January 1995 and had an estimated date of delivery before 1 January 2000. 11.9% were ≥ 37 years old. A subgroup (n=4864) also had second trimester biochemical testing by alpha-fetoprotein and free β-human chorionic gonadotrophin.

Main outcome measures Prenatal and postnatal diagnosis of trisomy 21.

Results There were 23 fetuses affected with trisomy 21. The overall prenatal detection rate was 87% (20/23; 95% CI 66% to 97%) and we performed invasive procedures in 8.5% of our population. First trimester sonography identified 74% (95% CI 51.6% to 89.8%) of affected fetuses. Second trimester biochemical screening detected half of the fetuses with trisomy 21 which were missed by first trimester screening, increasing the sensitivity to 90.5% (19/21; 95% CI 69.6% to 98.8%) for an invasive procedure rate of 4.2% performed in screened positive women. However, the positive predictive value of the biochemical test was very low (0.5%). In screen negative women, karyotyping for advanced maternal age did not detect any affected fetuses.

Conclusion First trimester nuchal translucency measurement is an effective screening test for the prenatal detection of fetuses with Down's Syndrome. Although the measurement of biochemical markers in the second trimester can detect additional affected fetuses this may be outweighed by the delay in diagnosis, the extra visits and cost so that the right time for biochemical screening is most likely to be in the first trimester.

Objective To investigate the relationship between breech presentation, external cephalic version and levels of cord blood thyroid stimulating hormone.

Design Case–control study.

Setting University teaching hospital.

Population The study group consisted of 289 consecutive singleton deliveries at term over a four-year period, all of whom had an attempt at external cephalic version performed near term for breech presentation. The control group included 23,001 singleton term deliveries during the same four-year period.

Methods Between group differences were compared with the Mann-Whitney U test or χ² test when appropriate.

Main outcome measures Levels of cord blood thyroid stimulating hormone and the incidence of false positive screening results for congenital hypothyroidism.

Results Babies who were born vaginally after prior successful external cephalic version had significantly higher median levels of cord blood thyroid stimulating hormone (6.4 vs 6.0mIU/L, P=0.034) and the incidence of false positive screening for thyroid stimulating hormone (12.9% vs 7.2%, P=0.016, OR 1.9) compared with babies with spontaneous cephalic presentation. In babies with a breech presentation born by elective caesarean section, previous attempts at external cephalic version had no effect on cord blood thyroid stimulating hormone levels. There was also no difference in the levels of cord blood thyroid stimulating hormone between cephalic and breech-presenting fetuses born by elective caesarean section. However, breech-presenting babies born by emergency caesarean section after onset of labour had higher median levels of cord thyroid stimulating hormone than those with cephalic presentation (5.1 vs 4.5 mIU/L, P=0.008).

Conclusion Levels of cord blood thyroid stimulating hormone are elevated in babies born vaginally after a successful external cephalic version. This finding may represent a biological difference in fetal response to the stress of labour in breech-presenting fetuses, which is not correctable by a successful external cephalic version.

Objective To assess the relationship between selenium levels in human blood and hair, and the risk of recurrent miscarriages.

Design Case–control study.

Participants Two groups of non-pregnant women: 18 women with one or more successful pregnancies and no history of miscarriage (control group); 26 women with a history of recurrent miscarriage (≥ 3) with no subsequent successful pregnancies (study group).

Methods Samples of venous blood and scalp hair were collected and the selenium content analysed by inductively coupled plasma mass spectrometry.

Results No significance difference was found between the level of selenium in the blood samples of the women in each group. There was a significant reduction in the mean hair selenium level in the recurrent miscarriage group compared with the control group (0.14μg/g vs 0.34μg/g). Further analysis of the recurrent miscarriage group revealed no relationship between levels of serum or hair selenium with parity. There was a significantly greater proportion of women in the control group who ate cereals, vitamin supplements, and liver or kidney.

Conclusion There was evidence of selenium deficiency in women with recurrent miscarriages compared with a control group of women with a good reproductive performance. This difference was seen in hair samples but not serum samples and therefore may not represent a simple nutritional deficiency. The importance of selenium deficiency in miscarriage has still not been determined.

Objective To examine the influence of possible risk factors on fetal loss rate following amniocentesis.

Design Retrospective analysis of case records between 1993 and 1998.

Setting Fetal medicine unit of a large teaching hospital.

Population One thousand and six women with singleton pregnancies formed the study group. Seven hundred and eight of them had bleeding during the current pregnancy before the procedure, while 298 had a history of three or more first trimester abortions and/or a second trimester miscarriage or termination of pregnancy. Four thousand and twenty-four women who had amniocentesis and had no risk factors served as controls. Both groups were also classified according to maternal age. Group 1: 1610 women aged 20–34 years; Group 2: 2850 women aged 35–39 years; Group 3; 570 women > 40 years.

Methods Women of both groups underwent a second trimester amniocentesis between 16 and 21 weeks of gestation. Fetal losses following amniocentesis were examined in three time intervals: 1. in the first two weeks after the procedure; 2. up to the 28^th week; 3. from the 28^th week to term.

Results There was a statistically significant difference in the fetal loss rate between women aged 20–34 years (2.54%) and those > 40 years (5.1%). Women with a history of vaginal bleeding during the current pregnancy had a higher fetal loss rate compared with controls (6.5% vs 2.8%), which corresponds to an odds ratio of 2.4 (95% CI 1.69–3.42). A similar difference was found between the group of women with a history of previous abortions/terminations and the controls (8% vs 2.8%): OR 3.03 (95% CI 1.92–4.79).

Conclusions There is a higher risk of fetal loss following amniocentesis in women > 40 years of age compared with those aged 20–34 years. Bleeding in the current pregnancy, a history of three or more first trimester abortions, a second trimester miscarriage or termination of pregnancy seem to be significant predisposing factors for fetal loss after an amniocentesis.