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Notes: Menorrhagia is a symptom denoting excessively heavy menstrual bleeding. It is a complaint that is difficult to verify objectively in many cases, even with a detailed case history. Issues of perception and tolerance of symptoms are important in whether a patient presents to a doctor, and this varies considerably from one society to another. Research studies indicate that the upper limit of normal blood loss is between 60 and 80 ml/month. Above this level women tend to become progressively iron deficient. Hence, any development which may help the precision of this assessment is valuable, and several of these will be discussed. Causes of menorrhagia can be divided into three groups: (1) pelvic diseases, such as myomata and adenomyosis; (2) systemic disorders, such as coagulopathies and hypothyroidism; and (3) dysfunctional uterine bleeding—a diagnosis of exclusion. Investigations are mainly aimed at improving the precision of the underlying diagnosis, defining the severity of the condition and excluding anaemia. Hence, the most important investigations are a full blood count, a diagnostic hysteroscopy and endometrial sampling. In clinical practice, other specific investigations need only be carried out if there are unusual features in the history or examination, or if previous treatments have failed. In a research situation there have been numerous studies aimed at elucidation of the mechanisms of heavy bleeding and some of these will be reviewed.

Notes: Objective To examine the association between fetal outcome and the steady state haematology of mothers with homozygous sickle cell disease.Design A retrospective observational study. The data were taken from dockets kept at the Sickle Cell Clinic and verified by interview with 45% of the patients.Setting The Sickle Cell Clinic at the University Hospital of the West Indies or two peripheral clinics operated by the staff of the MRC Laboratories.Subjects All women aged 14 years or older with homozygous sickle cell disease who had experienced at least one pregnancy in the period 1977 to 1986.Main outcome measures Three fetal outcomes including miscarriages, perinatal deaths, and birthweight.Results There were 270 singleton pregnancies in 175 women with an overall fetal wastage of 32.2%. There was a significant increased risk of perinatal death with low maternal fetal haemoglobin level, but there were no haematological associations with miscarriages or birthweight.Conclusions These data suggest that maternal steady-state haematology has little influence on fetal outcome, with the exception that mothers with high HbF levels are less prone to perinatal deaths. Further study is required to investigate acute haematological changes associated with pregnancy.

Notes: Objectives In a cohort of term infants with cerebral depression at delivery, to investigate the association of perinatal signs of birth asphyxia, particularly abnormal fetal heart rate patterns in labour, acidaemia, and serious neonatal encephalopathy, with neurodevelopmental outcome at age five years.Design Five year follow up study of a birth cohort.Setting Regional maternity hospital.Subjects One hundred and eighty-four singleton infants with a 1 min Apgar score ≤ 3, born at term between January 1984 and September 1985.Main outcome measures Neonatal death, cerebral palsy, and scores on a battery of neurodevelopmental tests at age five.Results Seven infants had a cluster of perinatal signs suggestive of birth asphyxia; all included serious neonatal encephalopathy. Three of these infants died neonatally, three had spastic quadriparesis with profound developmental delay, and one was unimpaired at the age of five. Among the remaining infants, no association was found between severely abnormal fetal heart rate patterns in labour and scores on neurodevelopmental tests, or between acid–base status at delivery and test scores.Conclusions Birth asphyxia, identified by a cluster of abnormal perinatal signs, including serious neonatal encephalopathy, has a poor prognosis. If serious encephalopathy is not present, cerebral depression at birth preceded by abnormal fetal heart rate patterns in labour, or with acid–base derangement, is not predictive of later impairment.

Notes: Objective To determine whether there is a dose-iresponse effect of percutaneous oestradiol implants on the skeletons of postmenopausal women using a range of doses available in clinical practice.Design One year randomised study.Subjects Forty-five postmenopausal women who requested oestrogen replacement therapy were randomised to receive 25 mg, 50 mg, or 75 mg oestradiol implants. The bone mineral density changes were compared with a control group of 15 untreated women.Main outcome measures Dual energy X-ray absorptiometry using Hologic 1000 QDR before treatment and after one year of treatment. Plasma oestradiol and follicle stimulating hormone levels before treatment and after one year.Results There were significant correlations between the plasma oestradiol levels and the percentage increase in bone density at the lumbar spine, the total hip, the femoral neck, and the trochanter. The median (range) plasma oestradiol level was 327 pmol/1 (114–853) in the 25 mg group, 358 pmol/1 (220–957) in the 50 mg group and 518 pmol/1 (167–828) in the 75 mg group. Three women who lost a significant amount of bone from the clinically relevant sites in the 25 mg oestradiol group all had plasma oestradiol levels below 300 pmol/1. None of the women in either the 50 mg or 75 mg oestradiol groups lost bone from these sites.Conclusions Oestradiol implants resulted in a wide range of circulating oestradiol levels with each of the doses used. There was a significant relation between plasma oestradiol levels and the increases in bone density at both the lumbar spine and the proximal femur. None of the women lost bone density at the clinically important sites of the spine and femoral neck if their plasma oestradiol levels were above 300 pmol/1.

Notes: Objectives 1. To investigate the efficacy of 800 μg misoprostol (a PGE1 analogue) when administered to women pretreated with mifepristone for early pregnancy termination. 2. To establish means of minimising gastrointestinal side effects by comparing two different misoprostol regimens. The impact of these regimens on blood pressure was investigated in a subgroup of patients.Design A randomised study of 150 women of 56 days gestation, or less, allocated to receive oral misoprostol either in a single dose of 800 μg or as two doses of 400 μg administered sequentially 2 h apart; in each case misoprostol was administered 36 to 48 h after receiving mifepristone 200 mg orally.Main outcomes Complete abortion rates, the frequency and severity (patients' perception) of gastrointestinal side effects, and blood pressure changes in response to prostaglandin administration.Results The overall success rate was 93%. Seventy-one (95%) women who received a single dose of misoprostol and sixty-nine (92%) who received the sequential dose aborted completely. There were two ongoing pregnancies in the first group (2.5%) and three (4%) in the second. The overall ongoing pregnancy rate was 3%. The incidence of diarrhoea was significantly lower for women receiving the sequential dose, and no significant differences were found in the incidence of the other gastrointestinal side effects. The only noted significant change in blood pressure was in diastolic pressure 4 h after the administration of the higher dose of prostaglandin, but this was slight.Conclusions The combination of mifepristone and oral misoprostol provides an alternative method to inducing abortion of pregnancies of up to eight weeks gestation. Patients receiving the single dose of 800 μg were more troubled by diarrhoea than those on the sequential regimen. The ongoing pregnancy rate was higher than previously reported with vaginal or parenteral administration of prostaglandin.

Notes: Objective To assess the value of ultrasonography and Doppler to predict the severity of fetal haemolytic anaemia.Design Ultrasonographic measurements of the fetal liver, spleen, umbilical vein and placenta, and Doppler measurements of umbilical venous and fetal aorta flow velocities were performed before the first intrauterine blood transfusion. Multivariate regression models for the prediction of the fetal haemoglobin level were derived from the measurements.Setting National referral centre for management of alloimmunised pregnancies.Subjects Forty fetuses in 39 severe red cell alloimmunised pregnancies.Results A logistic regression model, incorporating the two Doppler parameters only, predicted the presence or absence of severe anaemia in nonhydropic fetuses with an accuracy of 90 %. Positive predictive value was 89% and negative predictive value was 100%.Conclusion In severe red cell alloimmunised pregnancies, Doppler blood flow velocity studies can be used to predict the severity of fetal anaemia. This may lead to a reduction of invasive diagnostic tests, to more accurate timing of intrauterine transfusions, and thus to a higher survival rate.

Notes: Objective To investigate trophoblast invasion and vascular changes in placental bed spiral arteries in normal and severe pre-eclamptic pregnancies.Design A histological and immunohistochemical study of placental bed biopsies containing spiral arteries.Setting The University Hospital, Leuven, Belgium.Subjects Twenty-one placental bed biopsies from 21 normal pregnancies and 24 placental bed biopsies from 24 severe pre-eclamptic pregnancies, taken at caesarean section.Observations Histological and immunohistochemical appearance of spiral arteries (stained with haematoxylin and eosin), periodic acid schiff, and a monoclonal antibody to low molecular weight cytokeratin.Results One hundred and twenty-seven spiral arteries were studied. In the 21 biopsies from clinically normal pregnancies at term, 100% of the decidual spiral arteries and 76% of the myometrial arteries showed trophoblast invasion. In the 24 biopsies from women with severe pre-eclampsia, trophoblast invasion was seen in 44 % and 18 % of the decidual and myometrial segments, respectively. Endovascular trophoblast invasion was complete, partial or isolated. A variety of morphological features was present not only in different spiral arteries from the same biopsy but also in different segments of the same artery. The vascular change most commonly associated with normal pregnancies was physiological change and subintimal thickening of both segments of the spiral arteries. In pre-eclampsia medial disorganisation and hyperplasia in the myometrial arteries and acute atherosis in decidual arteries were common.Conclusion Endovascular trophoblast did not show an all or none invasive phenomenon in normal and pre-eclamptic pregnancies. More decidual than myometrial arteries were invaded in both groups of patients, and there was a gradient in the percentage of decidual and myometrial arteries invaded from normal pregnancy to pre-eclampsia. Morphological features in one spiral artery may not necessarily be representative of all of those in a placental bed.

Notes: Objective To compare the expression of cell adhesion molecules by endometrium and endometriosis.Design A comparative study of integrin expression, determined immunohistochemically, in eutopic and ectopic endometrium biopsied synchronously from patients with endometriosis diagnosed at laparoscopy or laparotomy.Setting University Departments of Obstetrics and Gynaecology, and Pathology, Southampton; Department of Obstetrics and Gynaecology, Newcastle upon Tyne.Samples Eighteen paired samples of endometria and endometriosis.Results A wide distribution of collagen-laminin receptor proteins was demonstrated. α1 integrin expression was limited to secretory endometrium. β3 expression was only demonstrated on proliferative endometrium.Conclusions Expressions of the integrin proteins differed between the various elements of the endometrium. Cyclical changes in integrin expression also were demonstrated. No difference in cell adhesion molecule expression was seen when comparing endometrial and endometriosis samples.

Notes: Objective To determine whether the use of human chorionic gonadotrophin (hCG) would reduce the recurrent miscarriage rate in women with polycystic ovarian disease.Design Double-blind, prospective, randomised controlled trial.Setting A pregnancy loss clinic in a London teaching hospital.Subjects One hundred and ninety-one women with a history of three consecutive spontaneous first trimester miscarriages and polycystic ovary syndrome.Intervention 10000 i.u. of hCG or a placebo were given when the leading follicle was ≥ 21 ram, then 5000 i.u. of hCG or a placebo were given twice weekly until miscarriage or the tenth week of pregnancy.Main outcome measure Miscarriage rate.Results Women with polycystic ovaries who received hCG treatment had a lower miscarriage rate (14%) compared with women who received placebo (43%). In women with follicular phase luteinising hormone ≥ 10 iu/1, those who received hCG therapy had a miscarriage rate of 10% compared with a rate of 44% in women who received the placebo. When clomiphene was used for ovulation induction, women treated with hCG had a miscarriage rate of 14% compared with a rate 47 % in women who received the placebo. There was no significant benefit from hCG therapy in natural cycles.Conclusion The use of hCG in women with recurrent miscarriage and polycystic ovary syndrome improves the pregnancy outcome.

Notes: Objective An investigation of excitatory vascular responses in the human ovarian vein, a blood vessel normally exposed to high concentrations of ovarian steroid hormones and capable of adaptation to circulatory changes associated with reproductive life.Design Pharmacological responses of surgical specimens of human ovarian vein to electrical field stimulation of sympathetic nerves, noradrenaline, α,β-methylene adenosine 5′-triphosphate (α,β-MeATP), endothelin-1 (ET-1), and 5-hydroxytryptamine (5-HT) were studied. Comparisons were made between in vitro pharmacological responses and the diagnostic category, age, smoking status, reproductive history and hormonal status of patients.Setting Research laboratory.Results Maximal contractile responses in longitudinal preparations, expressed as a percentage of the response to potassium chloride 125mmol 1−1, were 28% (SE 7.2) to electrical field stimulation and 107% (SE 15.1) to noradrenaline. In ring preparations, maximal responses to various agents were: noradrenaline 93% (SE 10.2); 5-HT 79% (SE 8.0); α,β-MeATP 48% (SE 8.4); and ET-1 87% (SE 10.1). pD2(–log EC50) values for noradrenaline were 5.82 (SE 0.21) in longitudinal preparations and 5.65 (SE 0.10) in ring preparations; for ET-1 in ring preparations these values were 7.88 (SE 0.74). Responses to sympathetic nerve stimulation were attenuated by the adrenoceptor antagonist phentolamine; any residual responses were blocked by desensitisation of P2-purinoceptors with α,β-MeATP or the addition of suramin, indicating that noradrenaline and adenosine 5′-triphosphate may be co-transmitters in these nerves. pD2 values for 5-HT were 5.97 (SE 0.12) in specimens from unsterilised patients (n= 19) compared with 5.20 (SE 0.24) in specimens from those who had previously undergone sterilisation (n= 6) (P 〈 0.05). No other relation between clinical characteristics and pharmacological responses were detected and, in particular, there were no apparent changes associated with ageing or hormonal status.Conclusions Three main conclusions may be drawn from this study: (1) adenosine 5′-triphosphate is a co-transmitter in sympathetic nerves in the human ovarian vein; (2) tubal sterilisation affects vascular responsiveness to 5-HT; and (3) ovarian steroid hormones are likely to influence sympathetic vascular control via effects on catecholamine and adenosine 5′-triphosphate synthesis, storage, release, degradation or re-uptake, rather than via effects on vascular smooth muscle receptors.

Notes: Objective To determine whether Doppler waveforms from the uteroplacental circulation could improve the prediction of pregnancy outcome in women with raised maternal serum alpha-fetoprotein and a structurally normal fetus. The study further attempts to determine whether the presence of an early diastolic notch would constitute a better screening test than waveform patterns.Design An observational study.Setting A tertiary referral obstetric service.Subjects All women referred to St George's Hospital with a raised maternal serum alpha-fetoprotein had waveform measurements from the uteroplacental circulation after exclusion of fetal abnormalities. Pregnancy outcome was determined by questionnaire sent to the referring clinicians.Main outcome measures Adverse perinatal outcome in the form of preterm labour, low birthweight and perinatal mortality.Results Data from 332 cases were available for analysis. Women with a normal pattern of uteroplacental waveforms had a perinatal mortality of 9.6/1000. Women with a uniform high resistance pattern had a perinatal mortality of 846/1000, and those with a mixed resistance pattern had a perinatal mortality of 268/1000. Overall there were 27 cases of placental abruption which accounted for eight of the 50 perinatal deaths. The remainder were due to prematurity or low birthweight or both. The presence of the early diastolic notch did not improve on the waveform patterns in the prediction of perinatal death.Conclusion Women with raised maternal serum alpha-fetoprotein and normal Doppler waveform patterns from the uteroplacental circulation can be reassured, but mixed or uniform high resistance patterns should encourage increased surveillance and a search for intervention therapies.

Notes: Objective To investigate the incidence of post-operative infection after first trimester abortion in women treated with a long-acting cephalosporin (ceftriaxone) compared with low risk patients receiving no treatment and with high risk patients receiving our standard treatment of ampicillin/pivampicillin and metronidazole.Design A prospective, randomised controlled trial.Setting Department of Obstetrics and Gynaecology, Rigshospitalet, University of Copenhagen, Denmark.Subjects Nine hundred and ninety-six women, admitted on an outpatient basis for legal termination of pregnancy at 12 weeks or less of gestation, were included in the study after giving informed consent. The women were divided into high risk and low risk categories and allocated either to treatment with ceftriaxone or to standard treatment. For high risk patients the standard treatment was initiated by a peroperative injection of ampicillin and metronidazole, followed by oral doses of metronidazole and pivampicillin three times daily for four days. No prophylactic antibiotics were given to the women randomised to standard treatment in the low risk group.Interventions All women were kept under observation, and, between six and 14 days post-operatively, underwent pelvic examination. Clinical endpoints were noted.Main outcome measures Post-operative pelvic inflammatory disease in women applying for legal first trimester abortion.Results Seven hundred and eighty-six women fulfilled the criteria for evaluation. A tendency toward a prophylactic effect of ceftriaxone was observed in most clinical findings. A significant prophylactic effect of ceftriaxone was found in the low risk group.Conclusions This study demonstrated a significant reduction in post-operative pelvic inflammatory disease in low risk patients, who were applying for legal first trimester abortion, treated peroperatively with ceftriaxone. No significant difference was demonstrated between high risk patients treated with ceftriaxone or ampicillin/pivampicillin and metronidazole.

Notes: Objective To compare the prognostic capability of clinical stage, tumour differentiation, myometrial invasion, age and DNA content in endometrial carcinoma. Then to use the results to identify a small, high risk group suitable for more intensive adjuvant therapy.Design A prospective five year follow up between June 1980 and June 1987.Setting Department of Oncology, gynaecological section, University Hospital, Lund, Sweden. Endometrial tissue was obtained immediately prior to treatment for flow cytometric DNA analysis.Subjects Two hundred and fifty-one patients referred for treatment.Interventions None.Results Age, myometrial invasion of greater than 50%, and number of DNA populations (ploidy) were the only significant parameters related to survival. By combining myometrial invasion and number of DNA populations, we divided the patients into four groups. A very small high risk group was identified (7%) with a low survival rate (61%). Two intermediate groups with either myometrial invasion exceeding 50% or with more than one DNA population present constituted 34% of the patients and these had an overall survival rate of 75% and a relatively large low risk group of 59% of the patients (with a survival rate of 95%) was constructed out of those without deep myometrial invasion and demonstrating only one DNA population.Conclusions These data suggest that number of DNA populations and depth of myometrial invasion could be combined to identify a small high risk group (7%) with a low survival rate (61%) suitable for adjuvant therapy.

Notes: Objective To demonstrate the perinatal transmission and persistence of the cancer associated human papillomavirus types 16, 18, 31 and 33.Design Cervical swabs were taken from pregnant women between 20 and 38 weeks of gestation. Buccal and genital swabs were taken from infants at 24 h and at six weeks after delivery and examined for HPV-16, -18,–31 and –33 DNA by the polymerase chain reaction.Setting Maternity Unit at St Thomas' Hospital, London.Subjects Thirty-one pregnant women, 16 with a previous history of cervical intraepithelial neoplasia or genital warts, or both, and their 32 infants (one set of twins).Results Twenty of the 31 (65 %) women were positive for HPV-DNA prior to delivery. Twelve of 32 (38%) and eight of 31 (26%) infants were HPV-DNA positive at 24 h and six weeks respectively. Swabs taken at 24 h demonstrated HPV type 16 in five mother-infant pairs and HPV type 18 in two mother-infant pairs. Dual infections with HPV types 16 and 18 were demonstrated in swabs from three mother-infant pairs. At six weeks, HPV-16 was demonstrated in swabs from six infants and HPV-18 in swabs from two infants.Conclusions Perinatal transmission of human papillomavirus types 16 and 18 occurred in 55% cases. Persistent human papillomavirus infection was demonstrated at six weeks of age. Whether acquisition of human papillomavirus during the perinatal period predisposes to an increased risk of cervical intraepithelial neoplasia among female infants in later life remains to be established. Information on the persistence of perinatally acquired human papillomavirus is required before rational vaccination programmes can be considered.

Notes: Objective To obtain an overview of current abortion practice in Scotland for comparison with agreed criteria for good quality care based on literature review.Design Postal questionnaire survey.Subjects All 132 consultant gynaecologists practising in the NHS in Scotland.Results Response rate 92%. The survey revealed regional inequalities in the availability of services, particularly with regard to early medical abortion and second trimester procedures. It also revealed great individual variations in many areas of practice notably in screening for genital tract infection, the use of cervical predilatation, contraceptive provision, and follow up. Several aspects of practice compared poorly with the agreed criteria for good quality care.Conclusions The postal questionnaire approach achieved a good response rate and has provided an informative overview of current practice on a national basis. Variations in the provision of services and in clinical practice, both among regions and among individual consultants, have been identified. Elements of abortion care in which great variations exist and in which current practice compares poorly with the agreed criteria have been highlighted as appropriate areas for the development of national guidelines and for educational initiatives. Such a questionnaire approach to assessing current practice can complement, and possibly replace, some aspects of casenote review audit.

Notes: Objective To assess the value of elevated serum CA 125 levels and ultrasonography in predicting deep myometrial invasion of endometrial cancer.Design We assessed pre-operatively serum CA 125 levels and myometrial invasion by ultrasonography in women undergoing laparotomy because of endometrial cancer. The results were compared with histological determination of myometrial invasion of endometrial cancer. Invasion was classified as superficial (less than one-half of myometrium involved) or deep (more than one-half of myometrium involved).Setting University hospital.Subjects Seventy-eight women with a histologically proved endometrial carcinoma confined to the uterus: nine had Stage IA disease, 45 Stage IB, five Stage 1C, one Stage IIA, four Stage IIB and 14 Stage IIIA. The myometrial invasion was found to be superficial in 57 (73%) patients and deep (more than half) in 21 (27%), respectively.Results CA 125 levels were above 35 iu/1 in 17 (21.8 %) of 78 patients: nine (42.8 %) of 21 with deep myometrial invasion and eight (14%) of 57 with superficial invasion (P 〈 0.01). The positive predictive value of an elevated CA 125 level for deep myometrial invasion was 52.9% and the negative predictive value 80.3 %. Sonography correctly estimated invasion in 69 cases (88.5%). Deep invasion was assessed by ultrasound with a significantly (P 〈 0.01) higher sensitivity than CA 125 (95.2% vs. 42.8). Positive and negative predictive values for deep myometrial invasion of sonography were 71.4% and 98%, respectively.Conclusion Ultrasonography was more accurate than serum CA 125 levels in predicting myometrial invasion of endometrial carcinoma.

Notes: Objective To assess the results of the sacrospinous colpopexy procedure for the treatment of vault prolapse following hysterectomy and marked uterovaginal prolapse.Design A prospective study of all patients undergoing sacrospinous colpopexy for vault and marked uterovaginal prolapse between December 1991 and December 1992.Setting Kent and Canterbury Hospital, Canterbury.Subjects Forty women with vault prolapse following hysterectomy and 24 with marked uterovaginal prolapse.Interventions All patients underwent posterior vaginal repair, enterocele sac obliteration and sacrospinous colpopexy. In 48 patients an anterior vaginal repair with suburethral buttressing sutures was also performed. A long-needle bladder neck suspension operation (Raz procedure) was included for three women with coexistent stress incontinence. In 13 patients a vaginal hysterectomy was performed and in 11 the uterus was conserved. A postanal sacrorectopexy was performed on one patient with marked rectal prolapse.Results The mean follow up period was five months. So far, there have been three failures in the group treated for vault prolapse. One of these underwent a successful repeat sacrospinous colpopexy and repair. The main long term complication was cystocele formation. One sexually active patient complained of dyspareunia following surgery.Conclusion The sacrospinous colpopexy is effective in the treatment of vault prolapse and compares favourably with abdominal vault supporting procedures. It avoids major abdominal surgery and allows the surgeon to correct coexistent cystocele and rectocele. This procedure is also a useful adjuvant when treating marked uterovaginal prolapse.

Notes: Objective To determine the structural characteristics of the rupture site of term fetal membranes (amniochorion and decidua) that rupture spontaneously after the onset of labour.Design Fourteen term fetal membranes were examined immediately after delivery at the light microscope level. Multiple samples were taken along the whole rupture site and along an axis between this site and placental edge. Morphometric analysis of the thickness of the constituent layers of the fetal membranes was performed.Setting Leicester Royal Infirmary Maternity Hospital.Results A restricted zone of extreme altered morphology, characterised by marked swelling and disruption of the connective tissue, thinning of the trophoblast layer and thinning or absence of decidua, was identified in the rupture site of all patients. Morphometric analysis of the thickness of membrane layers showed that these changes and the ratio between the thickness of the connective tissue layers and that of the trophoblast and decidua (termed fetal membrane morphometric index) were significant between the zone of extreme altered morphology and the rest of the membranes.Conclusions The morphological features of the zone of extreme altered morphology suggests that it represents an area of structural weakness of the membranes. Since this zone did not include the whole length of the rupture site, it is likely that it was present before membrane rupture and was generated during pregnancy. We hypothesise that the zone of extreme altered morphology represents the site of initial rupture after which the tear is transmitted through the membranes to produce the rupture site. It is possible that if these changes become more extreme, then prelabour membrane rupture may occur. Further characterisation of this zone may help to understand the mechanism of its genesis and its role in predisposing the fetal membranes to rupture.

Notes: Objective To examine the relation between indices of maternal nutrition during pregnancy, including haemoglobin concentration, skinfold thickness and body weight, and the child's blood pressure at 10 to 12 years of age.Design Follow up study of children whose mothers had haemoglobin estimations, weights and skinfold thicknesses recorded during pregnancy.Setting Kingston, Jamaica.Subjects Seventy-seven children whose mothers took part in a prospective study of nutrition during pregnancy in relation to fetal growth.Main outcome measure Blood pressure at 10 to 12 years of age.Results The child's mean systolic pressure adjusted for current weight rose by 2.6 mmHg (95 % CI 0.5–4.6, P= 0.01) for each 1 g/dl fall in the mother's lowest haemoglobin during pregnancy. Mothers with a lower haemoglobin had thinner skinfold thicknesses, especially over the triceps (P= 0.005). In multiple regression analyses, taking account of the child's sex and current weight, there was a strong association between thin maternal triceps skinfold thickness at 15 weeks of gestation and raised blood pressure in the offspring. Taking account of the mother's triceps skinfold thickness abolished the relation between lower haemoglobin and raised blood pressure in the child. Lower weight gain between 15 and 35 weeks of gestation was independently associated with raised children's blood pressure. Systolic pressure rose by 10.7 mmHg (95 % CI 5.7 to 15.6, P= 0.0001) for each log mm decrease in the mother's triceps skinfold thickness, and by 0.6 mmHg (95% CI 0.1 to 1.0, P= 0.02) for each 1 kg decrease in the mother's weight gain during pregnancy.Conclusions These results parallel animal experiments suggesting that impaired maternal nutrition may underlie the programming of adult hypertension during fetal life.

Notes: Objective To assess maternal mortality.Design Prospective community-based survey, a sisterhood method survey and hospital data.Setting The study was performed in communities in a rural area in Northwestern Tanzania and the local district hospital.Results Four hundred and forty-seven pregnant women in the community survey were followed up as far as six weeks after delivery; there were 2865 respondents in the sisterhood survey; the hospital study involved 7526 deliveries. Maternal morality ratios derived from the prospective community-based survey, the sisterhood method survey and hospital data analysis were 241, 297, and 845 per 100000 live births, respectively.Conclusions Hospital data tend to overestimate maternal mortality in these communities. The sisterhood method is easier and more convenient than a prospective community-based study.

Notes: Objective To study fetal immunological and haematological changes to intrauterine infection.Design In 37 pregnancies at risk of intrauterine infection, fetal blood obtained by cordocentesis at 20 to 36 weeks gestation was used for differential leucocyte counts, platelet count, enumeration of lymphocyte subpopulations, and neutrophil adhesion receptor expression.Setting Harris Birthright Research Centre for Fetal Medicine, London.Results All four fetuses with viral infections had platelet counts below the 5th centile and three had natural killer (NK) cell counts greater than the 95th centile of the normal range. Similarly, all five fetuses with bacterial or candidal infection had neutrophil counts greater than the 95th centile of the normal range; lymphocyte subpopulations were normal.Conclusions In pregnancies complicated by intrauterine infection, fetuses exhibit NK cell lymphocytosis and thrombocytopenia in response to viraemia, and neutrophilia in response to bacteraemia from at least 21 weeks gestation.

Notes: Objective To investigate the oestrogen and progesterone receptor distribution in endometrium from reproductive age and perimenopausal women with and without menorrhagia.Design A comparative observational study.Subjects Forty-five women with objective menorrhagia (27 categorised as reproductive age and 18 as perimenopausal) and a control group of 44 women (31 reproductive age and 13 perimenopausal) with menstrual blood loss of less than 80 ml per period.Main outcome measures Oestrogen receptor and progesterone receptor semi-quantitative immunostaining scores.Results Comparison of control and menorrhagic endometrium in this study (whether from reproductive age or perimenopausal subjects) failed to demonstrate any major differences in either sex steroid receptor mean immunostaining score. The results demonstrated a great degree of variability in sex steroid receptor immunoreactivity between individuals. Irrespective of clinical group, significant increases in immunostaining were demonstrated in the proliferative phase of the cycle for immunoreactivity of oestrogen receptor in glands (P 〈 0.0005), and stromal (P= 0.002) compartments of endometrium and progesterone receptor immunoreactivity in glands (P= 0.009). Progesterone receptor immunostaining in the stromal compartments did not significantly decline (P= 0.06) in the secretory phase.Conclusions Endometrium from women with objective evidence of menorrhagia is indistinguishable in terms of sex steroid immunoreactivity from endometrium of women with normal monthly blood loss. This pattern of sex steroid receptor immunostaining pattern was maintained into the perimenopausal years.

Notes: Objective To investigate the effect of the gonadotrophin releasing hormone (GnRH)-agonist goserelin, given by monthly subcutaneous injection for three months prior to total abdominal hysterectomy for uterine leiomyomata, on the pre-operative symptoms, difficulty of operation and operative blood loss.Design Randomised placebo-controlled study.Setting Patients were recruited from the gynaecological outpatient departments from hospitals in Edinburgh, Glasgow and Newcastle.Subjects Seventy-one premenopausal women with uterine leiomyomata who were on the waiting list for hysterectomy.Interventions After the presence of leiomyomata was confirmed using ultrasonography, the women were randomised to receive either the GnRH-agonist goserelin by monthly subcutaneous injection or a sham injection for three months prior to operation. At the monthly visits, patients were asked about treatment related symptoms, fibroid related symptoms, and their bleeding patterns. Blood was taken for haematological assessment.Main outcome measures Haemoglobin concentrations at recruitment, at operation and post-operatively, pre-operative symptoms, operative difficulty and blood loss and post-operative complications.Results Treatment with goserelin induced amenorrhoea in over 80% of the women, and this was associated with a significant rise in haemoglobin level. At the time of operation, fibroid related symptoms were less in the goserelin group than in the placebo group. The hysterectomy was technically easier and the median (range) operative blood loss was significantly lower in the goserelin group compared with the placebo group (187 (60–600) ml vs 308 (118–1000) ml respectively; P 〈 0.05, Wilcoxon signed rank test). There was no difference between the two groups in the duration of hospital stay or the frequency of post-operative complications. The fibroids were smaller at the time of operation in the goserelin group, and more women treated with goserelin were able to have their operations through a transverse incision.Conclusions This study demonstrates the benefits of goserelin in women having total abdominal hysterectomy for uterine leiomyomata.