R.J. Lilford

The relative risks of caesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre‐existing physiological disturbances

Objective–To compare maternal mortalities attributable to vaginal delivery, elective caesarean section (CS) and intrapartum CS.

Randomised controlled trial of day care for hypertension in pregnancy

Our aim was to assess the effect of the introduction of a day-care unit on the care of women with non-proteinuric hypertension in pregnancy. A randomised controlled trial was carried out on 54 women who presented at 26 weeks of pregnancy or later with non-proteinuric hypertension (systolic blood pressure 150-170 mm Hg and/or diastolic pressure 90-105 mm Hg on two occasions at least 15 min apart). 30 women were allocated to care by the day unit and 24 were managed according to the established practice of their clinicians without access to the day unit (control group). Women in the control group spent on average 4.6 times longer as inpatients (difference in mean stay 4.0 days [95% confidence interval 2.1-5.9 days]) than the day-unit group and were 8.8 times (95% CI 3.0-25.8) more likely to be admitted to hospital. Induction of labour was 4.9 times (95% CI 1.6-13.8) more likely in the control than in the day-unit group and the development of proteinuria 11.4 times (95% CI 1.8-71.4) more likely. The control group had a mean of 1.5 fewer hospital outpatient visits (95% CI 0.36-2.64). The groups did not differ in their use of antihypertensive drugs. Day-unit care for hypertension in pregnancy significantly reduced the need for and the length of antenatal inpatient admissions and the number of medical interventions, at the cost of an increase in outpatient attendances. Our results are further evidence that inpatient care does not improve outcomes or prevent the development of proteinuria in this disorder.

SIMULATION OF CERVICAL CHANGES IN LABOUR: REPRODUCIBILITY OF EXPERT ASSESSMENT

A carefully designed set of simulators showing cervical effacement and dilatation was used to assess the error within and between observers in a group of 36 midwives and 24 obstetricians. No observer was correct in every case. There was no significant difference between the obstetricians and the midwives in assessment of effacement or overall assessment of dilatation. However, midwives were significantly more likely than obstetricians to assess dilatation inaccurately by more than 1 cm. Inaccuracy was greatest in the simulators 5-7 cm dilated. These findings have implications for labour management and teaching.

The results of tubal surgery in the treatment of infertility in two non‐specialist hospitals

Summary. The results of surgery for tubal damage, other than reversal of sterilization, were studied in two large hospitals. This is the first recent study from centres claiming no special expertise in this surgery. An unusually high follow‐up rate was obtained. The term pregnancy rate for patients operated on for bilateral distal tubal occlusion was 4%. The success rate is lower than the lowest reported, overall success rates for each cycle of in vitro fertilization (IVF) and very much lower than cumulative term pregnancy rates for tubal surgery reported by most other authors. Patients with distal tubal occlusion but minimal adhesions had the best prognosis. Our results suggest that, provided in vitro fertilization is available, only those patients with good prognostic factors should undergo tubal surgery. These represent the minority of all patients with non‐iatrogenic tubal blockage.

Has in-vitro fertilization made salpingostomy obsolete ?

Etude comparative entre la fecondation in vitro et la salpingostomie. Les taux de reussite, ainsi que les couts sont analyses

Transabdominal chorion villus biopsy: 100 consecutive cases

A series of 100 transabdominal chorionic villus biopsies were carried out for maternal age (34 patients), fetal sexing (15), previous aneuploidy (21), biochemical analysis (5), gene-probe analysis (17), and oligohydramnios or fetal anomaly (6). 18 patients were over 14 weeks pregnant at the time of sampling. Tissue samples were obtained from 98 patients, including one set of twins. All 99 tissue samples proved adequate for laboratory diagnosis. Chromosome mosaicism was encountered in 4 cases (among direct preparation karyotypes in 1 case, between direct and cultured cells in 2 cases, and between chorion cells [both direct and cultured] and the fetus in 1 case). No patient miscarried but 1 had a stillbirth and 1, who had undergone transcervical biopsy before referral to our hospital, started to bleed before termination of pregnancy because of a diagnosis of cystic fibrosis. These data suggest that the transabdominal method of chorion biopsy will fulfil its theoretical and early promise.

The action of squatting in the early postnatal period marginally increases pelvic dimensions.

Summary. X‐ray pelvimetry was performed on 43 women in the squatting and erect positions within 1 week of delivery. The act of squatting increased the transverse and antero‐posterior pelvic dimensions by 1 %. The theoretical mechanisms by which posture may affect dimensions are discussed.

A tale of two prior probabilities—avoiding the false positive antenatal diagnosis of autosomal recessive polycystic kidney disease

We describe a case in which the typical ultrasound diagnosis of infantile polycystic kidney in a woman with no family history of renal disease was not confirmed by histology following termination of the pregnancy. This is contrasted with the situation in another couple who were known carriers of autosomal recessive polycystic kidney disease and where the prenatal ultrasound diagnosis was confirmed histologically. When prior genetic risk is low, the possibility of a normal or less severe outcome must be discussed with parents when fetal ultrasound shows large, echogenic kidneys but normal amniotic fluid volume.

Trade-off between gestational age and miscarriage risk of prenatal testing: does it vary according to genetic risk?

It has been generally assumed that as genetic risk rises, so the higher procedure-related miscarriage rates of diagnostic tests done earlier in gestation become more acceptable. To test the hypothesis a decision tree was used, in which the only differences between two tests A and B were that A was carried out earlier in pregnancy and was more likely to cause miscarriage. Over a wide range of rankings for the three outcomes (procedure-related miscarriage of a normal baby, early termination of pregnancy after test A, late termination of pregnancy after test B), the expected utility (relative desirability) of an earlier, but more risky, test was greater at a high (1 in 4) than at a low (1 in 100) genetic risk.