Gilbert's syndrome is not associated with HELLP syndrome

The HELLP syndrome has been associated with postpartum unconjugated hyperbilirubinaemia. Several types of disorders cause unconjugated hyperbilirubinaemia, Gilbert's syndrome being the most common. In Caucasians a genetic defect in the TATA box of the promotor region of the gene encoding for bilirubin UDP-glucuronyltransferase is tightly associated with Gilbert's syndrome. This defect was assessed by polymerase chain reaction in 237 women with the HELLP syndrome in their obstetric history and 236 controls. Fifteen percent of the cases and 10% of the controls had a homozygous genetic defect (  χ²= 2.9; P = 0.23  ). No evidence was found that Gilbert's syndrome is associated with the HELLP syndrome.     

Incidence of urinary incontinence and constipation during pregnancy and postpartum: survey of current findings at the Rotunda Lying-in Hospital

Objective To assess the impact of pregnancy upon continence and constipation.
Design A questionnaire survey.
Setting Maternity wards in the Rotunda Lying In Hospital, Dublin, Republic of Ireland.
Population 7771 women who were delivered of liveborn infants.
Methods Questionnaires were delivered and collected by physiotherapy staff as part of routine postnatal care.
Results Analysis of data using χ² tests showed significant differences between three parity groups [primigravidae, multigravidae (2–4) and multigravidae (5+)] for symptoms of both urinary incontinence (  χ²= 119.54  , df = 2, P = 0.000) and constipation (  χ²= 12.53  , df = 3, P = 0.002); the incidence of both constipation and urinary incontinence increased with parity.
Conclusion The results of this survey have emphasised the relation between parity and postpartum incontinence which stresses the importance of early diagnosis and intervention.     

A randomised controlled trial of epidural compared with non-epidural analgesia in labour

Objectives To investigate possible short and long term side effects of epidural analgesia, compared with non-epidural analgesia for pain relief in labour.
Design Randomised controlled study, with long term follow up by questionnaire. Analysis by intention-to-treat.
Setting Busy maternity unit within a district general hospital in England.
Participants Three hundred and sixty nine primigravid women in labour were included (randomised allocation: epidural   n = 184  , non-epidural   n = 185  ).
Main outcome measures Backache at three and twelve months after delivery, instrumental delivery rates and maternal opinion of pain relief in labour.
Results No significant differences were found in the reported incidence of backache between the groups at three months: middle backache [  22% vs 20%, χ ²= 0.057, P = 0.81; odds ratio (95% CI) 1.4(0.9-2.3)  ]; low backache [  35% vs 34%, χ ²= 0.009, P = 0.92  ; odds ratio  (95% CI) 1.0(0.6-1.6)  ]. Nor were there significant differences at 12 months: [middle backache 16% vs 16%,   χ ²= 0.013, P = 0.91; odds ratio (95% CI) 1.0(0.5-1.8)  ]; or low backache [  35% vs 27%, χ ²= 1.91, P = 0.17; odds ratio (95% CI) 1.4(0.9-2.3)  ]. The incidence of instrumental delivery was somewhat higher in the epidural group [30% vs 19%, odds ratio (95% CI) 1.77 (1.09-2.86)]. Maternal satisfaction was not significantly different between the groups.
Conclusions This study provided no evidence to support the suggestion of a direct association between the use of epidural anaesthesia in labour and the incidence of long term backache. Despite a significant proportion of women in each group not receiving their allocated analgesia, a significant difference in terms of instrumental delivery rates remained. Satisfaction in both groups of women was high.     

Infection by human papillomavirus types 6, 11, 16, 18, 31, 33 and 35 of the cervix in Japanese women

Exfoliated cervical cells from 321 Japanese women were examined for human papillomavirus (HPV) DNA types 6, 11, 16, 18, 31, 33 and 35 using polymerase chain reaction (PCR) and dot-blot hybridization methods. HPV DNA was present in 9.3% of patients with normal cervixes, 72.7% of patients with cervical intraepithelial neoplasia (CIN) and 77.8% of patients with invasive carcinoma. Younger patients (29 years) with normal cervixes had a 18.5% incidence of HPV DNA, whilst similar older patients (50 years) had a 1.9% incidence, a significant difference (χ²= 6.478, P < 0.01). In the CIN I and II groups, an incidence of 11.1% of types 16 and 18 was found, while in the CIN III or invasive carcinoma group the incidence was 58.1%, again a significant difference (χ² = 12.075, P < 0.01). Furthermore, persistence or progression of CIN showed a significant correlation with infections by types 16 and 33 (χ²= 4.904, P < 0.01). However, no significantly different incidence of HPV infection was found between the CIN and the invasive carcinoma groups. It is suggested that (a) younger patients with normal cervixes have a higher incidence of HPV infection than do older patients; (b) HPV types 16, 18 and 33 are important etiologic agents of CIN III and invasive carcinoma, as well as in the persistence and progression of CIN; (c) progression of CIN to invasive carcinoma may depend on factors other than HPV infection in the cervix.     

Platelet angiotensin II binding sites in normotensive and hypertensive women

Summary. Specific binding of angiotensin II (AII) to platelets was measured in 89 women, 25 nulliparous non-pregnant women and 64 primigravida in the third trimester of pregnancy. There was significantly lower binding in the 25 pregnant women who were normotensive (2.3 fmol/10⁹ cells) when compared with the non-pregnant women (9.0 fmol/10⁹ cells   P <0.001  ). Significantly higher platelet AII binding levels were found in the 39 women who had pregnancy induced hypertension (PIH) (5.5 fmol/10⁹ cells) when compared with the 25 normotensive pregnant women (   P <0.001  ). Of the 39 women with PIH, platelet AII binding was higher in the 23 women who had pre-eclampsia (7.0 fmol/10⁹ cells), when compared with the 16 who had non-proteinuric PIH, (4.6 fmol/10⁹ cells) although the difference was not statistically significant (   P <0.04  ). The pressor response to AII is also diminished in pregnancy, yet less so if pregnancy induced hypertension develops. Platelets may provide a readily accessible tissue with which to study AII responsiveness in pregnancy.     

Serum concentrations of cancer antigen 125, placental alkaline phosphatase, cancer-associated serum antigen and free beta human chorionic gonadotrophin as prognostic markers for epithelial ovarian cancer

Objective To investigate the prognostic significance of elevated levels of cancer antigen 125 (CA125), placental alkaline phosphatase (PLAP), free β human chorionic gonadotrophin (hCG) and cancer-associated serum antigen (CASA) in women with primary epithelial ovarian carcinoma.
Design A two year follow up study of survival.
Setting A tertiary care gynaecological oncology unit.
Participants One hundred and eleven women with histologically confirmed epithelial ovarian cancer.
Main outcome measures Survival over a two year period.
Results Stage corrected log-rank χ² tests demonstrated a significant effect on survival for all four tumour markers (CA125   P = 0.0142  ; PLAP   P < 0.0001  ; CASA   P = 0.0098  ; hCG   P = 0.0002  ). This was confirmed when each variable was fitted together with disease stage in Cox proportional hazard models. When fitted as multiple variables in a Cox proportional hazard model, the addition of free β- hCG and CASA to disease stage, PLAP concentrations and CA125 levels did not demonstrate further prognostic value.
Conclusions Levels of all four markers correlate with survival in patients with epithelial ovarian cancer. The combination of PLAP and CA125 concentrations together with disease stage may be used to predict survival but the addition of hCG and CASA levels do not give additional prognostic information.     

A case-control study of the effects of birth by caesarean section on intrapartum and neonatal mortality among twins weighing 1500–2499 g

Summary. . The aim of this nationally-based, matched case-control study was to assess the impact of birth by caesarean section on intrapartum, and neonatal mortality among twins weighing 1500–2499 g, born in Sweden between 1973 and 1983. By using data held at the National Medical Birth Registry, Stockholm, 91 such pregnancies (study cases) where one or both twins died were identified. For each case, two controls (in all 182 pregnancies) were allotted at random from the rest of the twin pregnancies, with similar birthweight (±100 g) and year of delivery (±1 year). The number of twins that died was reduced from 73 during the first four years to 22 between 1977 and 1980, and to 6 during the last 3 years of the study period. Almost a quarter (23.1%) had a lethal malformation. The caesarean section rate increased during the study period, but did not differ between cases and controls (  χ²= 1.0  ;   P >0.05  ). The analysis could not confirm a significant difference between cases and controls regarding the number of infants born vaginally in non-vertex presentation (  χ²= 0.1  ;   P >0.05  ). The results of this study appear to indicate that birth by caesarean section was not a major factor related to the improved fetal outcome.     

Physical Abuse, Smoking, and Substance Use During Pregnancy: Prevalence, Interrelationships, and Effects on Birth Weight

Objective: To establish the singular and combined occurrence of physical abuse, smoking, and substance use (i.e., alcohol and illicit drugs) during pregnancy and its effect on birth weight.
Design: Prospective cohort analysis.
Setting: Urban public prenatal clinics.
Participants: 414 African American, 412 Hispanic, and 377 white pregnant women.
Main outcome Measure(s): Occurrence of physical abuse was 16%; smoking, 29-5%; and alcohol/illicit drug use, 11.9%. Significant relationships existed between physical abuse and smoking for African American and white women. For African American women, 33.7% of women who were not abused smoked, versus 49.5% of women who were abused (χ²= 8.21; df= 1; p < 0.005). Alcohol/illicit drug use was 20.8% for nonabused women compared with 42.1% for abused women (χ²= 18.18; df= 1 ;p < 0.001). For white women, 46.6% of women who were not abused smoked, versus 59.6% of those who were abused (χ²= 5.22; df= 1 ; p < 0.005). As a triad, physical abuse, smoking, and alcohol/ illicit drug use were significantly related to birth weight ( F [3,1040] = 30.19, p < 0.001).
Conclusions: Physical abuse during pregnancy is common, readily detected with a five-question screen, and associated with significantly higher use of tobacco, alcohol, and illicit drugs. Clinical protocols that integrate assessment and intervention for physical abuse, smoking, and substance use are essential for preventing further abuse and improving smoking and substance cessation rates.     

Psychosocial characteristics of women and their partners fearing vaginal childbirth

Objectives To examine the personal characteristics and socio-economic background of women and their partners fearing vaginal childbirth.
Design Questionnaire survey by the 30th week of pregnancy.
Setting Sixteen outpatient maternity centres in the capital area of Finland.
Participants Two hundred and seventy-eight women and their partners.
Main outcome measures Personality traits, socio-economic factors, life and partnership satisfaction and pregnancy- and delivery-associated anxiety and fear.
Results The more anxiety, neuroticism, vulnerability, depression, low self-esteem, dissatisfaction with the partnership, and lack of social support the women reported, the more they showed pregnancy-related anxiety and fear of vaginal delivery. In multiple regression analyses psychological variables of the woman contributed most to the prediction of pregnancy-related anxiety (increase in  R²  =0.20,   P <0.001  ), the strongest predictor being general anxiety (beta  = 0.28, P <0.001  ). Lack of support contributed most to the prediction of severe fear of vaginal delivery (increase in   χ ²= 13.66, P <0.01  ), the strongest predictor being dissatisfaction with the partnership (Wald  8.61, P <0.01  ). Life-dissatisfaction reported by the partner contributed to pregnancy-related anxiety and his dissatisfaction with the partnership contributed to the woman's fear of vaginal delivery.
Conclusions The personalities of a pregnant woman and her partner, and their relationship, influences the woman's attitude to her pregnancy and her forthcoming delivery.     

The serum pregnancy-specific β1-glycoprotein to betahuman chorionic gonadotrophin ratio as an index of prognosis in patients with choriocarcinoma

Summary. The ratio of serum pregnancy-specific β₁-glycoprotein (SP1) to the β-subunit of human chorionic gonadotrophin (β-hCG) before and after chemotherapy was measured in 12 patients with metastatic choriocarcinoma. The ratios before chemotherapy ranged between 0^.03 and 0^.75, with a mean value of 0^.34 (SD 0^.21). The ratio increased to over 1^.0 (1^.05–53^.3) after one or two courses of chemotherapy in seven of the 12 patients. These women achieved complete remission. In the other five patients who died of the disease due to drug resistance of the tumour, the ratio after chemotherapy was low (0^.04–0^.74) and tended to decline. These data suggest that the serum SPl/β-hCG ratio can be used to predict the prognosis of patients with choriocarcinoma.     

Relationships between circulating leptin concentrations and other hormonal parameters in obese and non-obese women with polycystic ovary syndrome

Aim: To clarify the role of leptin in women with polycystic ovary syndrome (PCOS), we analyzed whether serum leptin levels correlate with other hormonal parameters in obese and non-obese women with PCOS.
Methods: We studied 20 obese (body mass index, BM ≥25 kg/m²) and 20 non-obese (BMI <25 kg/m²) women with PCOS diagnosed by the existence of menstrual disturbance, elevated serum level of luteinizing hormone (LH) with normal follicle-stimulating hormone (FSH) and the characteristic polycystic appearance of the ovaries on transvaginal ultrasound images. Blood samples for LH, FSH, estradiol, testosterone (T), androstenedione (Δ₄) and leptin were obtained, and the relationships between variables were examined by calculating Spearman correlation coefficients.
Results: Mean levels of leptin, T and Δ₄ in obese PCOS women were significantly higher than those in non-obese PCOS women, but this was not the case for BMI, bodyweight and waist to hip ratio. In all the 40 PCOS women considered together, there were significant positive correlations of leptin with BMI, waist to hip ratio, and Δ₄ levels. However, in each group separately, serum leptin levels in obese PCOS women correlated only with BMI and bodyweight, whereas serum leptin levels in non-obese PCOS women correlated with serum A4 levels.
Conclusion: Although further study is needed to assess the role of leptin on ovarian function in non-obese women with PCOS, present findings do not support the fact that leptin is involved in the development of hormonal abnormalities in obese women with PCOS. (Reprod Med Biol 2002; 1 : 49–54)     

Is ureteral endometriosis an asymmetric disease?

Six cases of endometriosis obstructing the left ureter were observed among 1054 consecutive patients undergoing surgery in an eight-year period. In addition, 125 women with ureteral endometriosis (left-sided,   n = 66  ; right-sided,   n = 40  ; bilateral,   n = 19  ) were described in 62 articles identified in a systematic review of the English language literature between 1980 and 1998. Considering only the patients with unilateral ureteral endometriosis and combining the published figures with those of our surgical series, the observed proportion of left lesions (72/112, 64%; 95% CI 55% to 73%) was significantly different from the expected proportion of 50% (χ²i, 9.14,   P = 0.002  ). The lateral asymmetry found in the location of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomical differences of the left and right hemipelvis     

First trimester ultrasonographic diagnosis of fetal structural abnormalities in a low risk population

Objectives Ultrasonographic screening between 12⁺⁰¹ and 13⁺⁶ weeks for fetal structural abnormalities using transab dominal sonography and, where necessary, transvaginal sonography in a low risk population.
Design A prospective observational study
Setting London teaching hospital
Methods Pregnant women with a total of 1632 low risk viable fetuses between 12⁺⁰ and 13⁺⁶ weeks of gestation were scanned using transabdominal and, where necessary, transvaginal sonography (40%). If the anatomical survey was normal, the women underwent routine 18-20 week anomaly scans. Pregnancy outcomes were obtained from radiological and neonatal computerised databases, and postal or telephone patient enquiry.
Results Seventeen (1.0%) major structural abnormalities were diagnosed in the study group. Of these, 11 (64.7%) were diagnosed at the 12-13 week scan, three diagnosed in the mid-trimester and three postnatally. Of the fetal abnormalities diagnosed antenatally, 78.6% were diagnosed in the first trimester. The sensitivity of abnormality detection by the combination of both first and second trimester scans was 82.3%. In addition, a significant number of missed abortions (   n = 36  ) were also diagnosed by the first trimester scan.
Conclusion This study has demonstrated the potential of screening a low risk population for fetal abnormalities at 12-13 weeks of gestation using transabdominal sonography and, where necessary, transvaginal sonography. Larger studies are required to establish the clinical value of the first trimester scan.     

Site of origin of epithelial ovarian cancer: the endometriosis connection

To investigate the left- and right-sided distribution of ovarian malignant surface epithelial tumours, data were collected on 209 women undergoing first-line surgery for Stage I and II disease. Considering the unilateral cancers, the observed proportion of left-sided lesions was 35/54 (65%) in the endometrioid, 20/45 (44%) in the serous, 19/35 (54%) in the clear cell, 13/29 (45%) in the mucinous, 2/8 (25%) in the mixed, and 2/5 (40%) in the undifferentiated histological type group. The proportion of left-sided unilateral endometrioid cancers was significantly different from the expected 50% (χ²₁, 4.74,   P = 0.03  ) and very similar to that previously observed for benign endometriotic cysts, constituting further evidence in favour of a possible development of endometrioid cancers from the latter lesions.     

Gamma-glutamyltransferase level in pregnancy is an independent risk factor for gestational diabetes mellitus

Aim:  To evaluate the relationship between gamma-glutamyltransferase (GGT) level in pregnant women at oral glucose tolerance test (OGTT) and the diagnosis of gestational diabetes (GDM).
Methods:  Blood was taken for analyzing GGT level from women at high risk of GDM at the time of their scheduled OGTT. GDM was diagnosed according to World Health Organization 1999 criteria.
Results:  GGT level correlated positively with the 2-hour glucose level (Spearman's rho = 0.112: P  < 0.05). GGT values that were stratified into quartiles demonstrated a significant trend with diagnosis of GDM (χ² for trend; P  = 0.03). Multivariable logistic regression analysis taking into account maternal age, gestational age at OGTT, body mass index and a positive 50-g glucose challenge test (GCT) indicated that high GGT was an independent risk factor for GDM (adjusted odds ratio [AOR] 2.1 95% CI 1.2–3.8: P  = 0.01). In the subset of women identified by a positive GCT, on multivariable logistic regression analysis, only high GGT was an independent risk factor for GDM (AOR 2.3 95% CI 1.3–4.2: P  = 0.007).
Conclusion:  Raised GGT level is an independent risk factor for GDM in high risk pregnant women undergoing OGTT.     

Circulating antithrombins in pregnancy

Summary. In a cross-sectional study circulating levels of antithrombins, antithrombin III¹α-antitrypsin and α₂-macroglobulin were measured in groups of 20 women before pregnancy, during each trimester and post partum . Blood levels of antithrombin III were signicantly lower, α¹ antitrypsin higher and %aL₂-macroglobulin no different when compared with those of the non-pregnant and puerperal states. These findings suggest that there may be not only an increase in total antithrombin production, but also a qualitative change in antithrombin'activity', the principal protein during pregnancy being α¹-antitrypsin.     

Localization of anti-endometrial antibody binding in women with endometriosis using a double-labelling immunohistochemical method

Summary. Anti-endometrial antibody binding was localized using a double-labelling immunohistochemical method on frozen sections of endometrium taken from a woman without pelvic disease. Serum from 40 women with endometriosis was tested and, as controls, serum samples from 20 adult males and 20 umbilical cords. The method allowed compensation for endogenous immunoglobulins in endometrium and accurate localization of anti-endometrial antibody binding in the cytoplasm of the glandular epithelium. Significantly more women with endometriosis (14/40) were found to have anti-endometrial antibodies than controls (1/40) ( P < 0.001; χ²). There was no correlation between disease severity and the presence of anti-endometrial antibodies or the intensity of staining.     

A multicentre study comparing cervicography and cytology in the detection of cervical intraepithelial neoplasia

Objective To evaluate in a multicentre setting the performance of cervicography compared with
Design Prospective comparative multicentre study.
Setting Three hospitals with outpatient gynaecology clinics and three cancer screening clinics.
Participants and methods Cervical cytology and cervicography were performed on 5724 women. If one or both tests showed an abnormality suggestive of at least a low grade squamous intraepithelial lesion, a colposcopy with directed biopsy was carried out. Cervicograms were evaluated by four experienced 'senior' assessors and by ten new 'junior' assessors.
Results Results were fully analysed for 5192 women (9l%). A cervical biopsy was carried out on 228 women and this confirmed a true positive lesion in 116 cases (incidence rate: 2.2%). Of these, 72 cases (62.1%) were detected by cervicography and 64 (55.2%) by cytology. This difference was not statistically significant (McNemar:   P = 0.475  ). Only 20 cases of CIN (17%) were concordantly detected by both tests. Senior assessors performed significantly better with a detection capacity of 80.6% compared to a detection capacity of 56.6% for the junior assessors (χ² test:   P = 0.034  ).
Conclusions Cervicography must be considered as a complementary test to cytology. Overall detection of CIN is improved, but this is mainly due to the detection of more low grade lesions. The lower sensitivity and specificity in high grade lesions compared with cervical cytology is the main limitation of cervicography in screening for CIN. An important finding was that the performance of cervicography was highly dependent on the assessors' experience.     

Circulating markers of oxidative stress are raised in normal pregnancy and pre-eclampsia

Objective To determine whether circulating markers of oxidative stress are elevated in pre-eclampsia when appropriate precautions are taken to prevent in vitro oxidation
Design A prospective study.
Setting Nuffield Department of Obstetrics and Gynaecology, Oxford and The William Harvey Institute, London.
Sample Three groups of women: those with pre-eclampsia (  n = 19  ), control pregnant (  n = 19  ) matched for gestation, age and parity and a group of non pregnant individuals reproductive age (n = 7).
Methods Citrated plasma was stored at −80°C with 20 μmol β hydroxytoluene to prevent auto-oxidation. Plasma samples were assayed for levels of 8 epi-prostaglandin F_2α, lipid hydroperoxides, malondialdehyde and also the lipid soluble antioxidant vitamin E.
Results There were no differences in 8 epi-prostaglandin F_2α lipid peroxide or malondialdehyde levels between the groups of women with pre-eclampsia and those acting as pregnant controls. However, lipid hydroperoxides and malondialdehyde were significantly raised in both pre-eclampsia and normal pregnancy, compared with nonpregnant women. Vitamin E levels were similar in women with pre-eclampsia and those with a normal pregnancy, but in both groups levels were significantly higher than in nonpregnant women.
Conclusion Circulating markers of oxidative stress are raised in normal pregnancy and pre-eclampsia.     

Insulin sensitivity in pre-eclampsia

Objective To investigate whether pre-eclampsia is associated with an exaggeration of the insulin resistance seen in normotensive pregnancy.
Design Minimal model analysis of a frequently sampled intravenous glucose tolerance test to assess insulin sensitivity.
Setting Royal Maternity Hospital, Belfast.
Participants Eleven women with pre-eclampsia and 11 matched normotensive pregnant women.
Results Insulin sensitivity (S_I) was increased in the group with pre-eclampsia compared with the normotensive women (mean [±SEM]: 2.6 [0.4] vs 1.6 [0.2] 10⁻⁴ min⁻¹ per mU/L;   P = 0.028  ). This was accompanied by a decrease in glucose effectiveness (S_G) (1*1 ±0.1 vs 1.7 ±0.1 10⁻² mid,   P = 0.006  ) in the pre-eclamptic women. In the normotensive group there was a significant inverse correlation between S, and mean arterial blood pressure ( Y =−0.65;   P = 0.03  ), but no such relation existed in the group with pre-eclampsia.
Conclusions As with other forms of secondary hypertension, and unlike essential hypertension, the pathophysiology of pre-eclampsia is not associated with insulin resistance.