Australian and New Zealand Journal of Obstetrics and Gynaecology

SANTNER‐NANAN, Brigitte; PEEK, Michael J.; MCCULLAGH, Peter; NANAN, Ralph

doi: 10.1111/j.1479-828X.2005.00362.xpmid: 15760308

Increasing evidence suggests that stem cells have tremendous potential to facilitate repair of damaged tissue and to exert protective influences that limit the extent of damage. Their inherent capacity to respond to signals generated by damaged tissue, migrate to these regions and either replace dead tissue or deliver protection by secretion of specific growth hormones and protective factors, suggests that they might have unrivalled therapeutic potential in perinatal medicine. A further potential of stem cells is their use in gene repair strategies for genetic disorders; an application which is exceedingly interesting from a perinatal perspective. Because of the relatively small size of infants and their capacity for future growth, stem cell therapy could be more successful in newborns than in older children or adults. In practical terms, the placenta, with its large reservoir of fetal blood, offers the ideal source of autologous stem cells. This affords the opportunity for stem cells to be collected and used, either directly ex vivo or after in vitro modulation, both for disorders in the neonatal period and for those arising later in life. The organs most affected from tissue damage in the neonatal period are the brain and the lung. So far, the most promising application of stem cells might be in the treatment of neurological injury. In this review we discuss recent research findings with adult stem cell therapy and their potential use in perinatal medicine. Furthermore, specific animal models suitable to explore the patho‐physiological mechanisms of stem cell transplantation after neurological injury will be discussed. This review gives an overview of basic science findings and their possible role for clinical application with regards to the therapeutic potential of stem cells in perinatal medicine. Medline was searched for journal selection in peer‐reviewed journals with high impact scores, which were relevant to this topic. All articles were in English and the search was not limited by publication year. However, the oldest publication was dated 1988 (reference 1).

BROWNLEA, Sandra; HOLDGATE, Anna; THOU, Stephen T. P.; DAVIS, Gregory K.

doi: 10.1111/j.1479-828X.2005.00351.xpmid: 15760309

Aim: To examine the impact of a ‘next day’ outpatient clinic, the Early Pregnancy Problem Service, on patients presenting to the Emergency Department with pain or bleeding in the first trimester of pregnancy. This clinic was established in June 1996. Methods: This was a retrospective study involving patients presenting to the Emergency Department with pain or bleeding in early pregnancy. Data was collected from the Emergency Department Information System and the medical records and then compared over the same 2‐month periods in different years. These were in, 1996 (preclinic), 1997, 2000 and 2003. The primary outcome was length of stay in the Emergency Department for women with first trimester pain or bleeding that did not require hospital admission. Secondary outcomes were the proportion of such patients presenting and re‐presenting to the Emergency Department. Results: Following establishment of the clinic there was a significant reduction in the median length of stay in the Emergency Department for patients who were discharged (136 mins in 1996 vs 107 mins in 2003; P < 0.001). There were non‐significant reductions in the proportion of patients presenting to the Emergency Department (1.5% in 1996 vs 1.1% in 2003; P = 0.09) and the number re‐presenting (16% in 1996 vs 7% in 2003; P = 0.15). Conclusion: Following the introduction of the Early Pregnancy Problem Service, women presenting with first trimester pain or bleeding who did not require emergency hospital admission spent significantly less time in the Emergency Department.

PIESSENS, Sofie G.; PALMER, Diane C.; SAMPSON, Amanda J.

doi: 10.1111/j.1479-828X.2005.00364.xpmid: 15760310

Background: Localisation of the non‐palpable Implanon is useful to confirm its presence or to assist the surgeon with its removal. Previous studies have suggested that almost all non‐palpable Implanon implants can be located with ultrasound in phantoms. Aim: To determine whether diagnostic ultrasound is a reliable method for localising non‐palpable Implanon implant in‐vivo. Methods: Ultrasound was carried out to localise the non‐palpable Implanon implant. To ascertain the accuracy of the ultrasound findings, all patients were followed‐up until the implant was removed or until it was proven absent by serial progesterone levels confirming ovulation or by negative etonogestrel levels. Results: In 22 out of 23 patients the Implanon was correctly identified as present. The specificity is 95.7% (95%CI 79.0–99.2%), the positive predictive value is also 95.7%. In six out of seven patients the Implanon was correctly identified as absent. The sensitivity is 85.7% (95%CI 48.7–97.4%), the negative predictive value is also 85.7%. Four patients were excluded due to incomplete follow‐up. Conclusion: Ultrasound is a reliable first line method for localising non‐palpable Implanon. When the Implanon is localised on ultrasound, it is very likely present. When the Implanon is not seen on ultrasound, etonogestrel determination should be carried out to confirm its absence.

MULLER, Peter R.; JAMES, Andra; FELDMAN, Kristin; HERLONG, J. Rene

doi: 10.1111/j.1479-828X.2005.00347.xpmid: 15760311

Aim: Patients at high risk of fetal congenital heart disease are commonly referred for second trimester fetal echocardiogram. The objective of this study was to evaluate the utility of routine fetal echocardiogram in high‐risk patients after the evaluation of the four‐chamber/left ventricular outflow tract (LVOT) views during comprehensive second trimester anatomy ultrasound. Methods: Second trimester comprehensive anatomy ultrasounds, which included a four‐chamber/LVOT view, and subsequent fetal echocardiograms carried out at the Duke University Medical Center from January 1995 and July 2002 were reviewed. Those fetal echocardiograms carried out between 17 and 30 weeks gestation were included in the analysis. Results: A total of 725 individual subjects met the inclusion criteria. Twenty‐nine fetal echocardiograms were ultimately reported as abnormal. Of these, 19 had an abnormal four‐chamber/LVOT view, four had a suboptimal view and six had a normal view. Of the six patients with a normal four‐chamber/LVOT, all had been referred for echocardiogram based on the presence of other significant fetal anomalies noted at the time of second trimester anatomy ultrasound (3), documented aneuploidy (2), and significant fetal arrhythmia (1). Conclusion: Utility in carrying out fetal echocardiogram was seen in patients with an abnormal four‐chamber/LVOT view, a suboptimal view in a high‐risk patient, and the presence of other significant fetal abnormalities. Utility was not seen in patients with pre‐existing diabetes mellitus.

SHELLEY, Julia M.; HEALY, David; GROVER, Sonia

doi: 10.1111/j.1479-828X.2005.00357.xpmid: 15760312

Background: Medical management and expectant care have been considered possible alternatives to surgical evacuation of the uterus for first trimester spontaneous miscarriage in recent years. Aim: To compare the effectiveness and safety of medical and expectant management with surgical management for first trimester incomplete or inevitable miscarriage. Methods: Forty women were recruited following diagnosis of incomplete or inevitable miscarriage, and randomised to surgical, medical or expectant care via an off‐site, computerised enrolment system. The primary outcome was the effectiveness of medical (vaginal misoprostol) and expectant management relative to surgical evacuation, assessed at 10–14 days and 8 weeks post‐recruitment. Infection, pain, bleeding, anxiety, depression, physical and emotional recovery were assessed also. Analysis was by intention‐to‐treat. Results: Effectiveness at 8 weeks was lower for medical (80.0%) and expectant (78.6%) than for surgical management (100.0%). Two women in the medical group had confirmed infections. Bleeding lasted longer in the expectant group than in the surgical group. There were no significant differences in pain, physical recovery, anxiety or depression between the groups. 54.6%, 42.9% and 57.1% of the surgical, medical and expectant groups respectively would opt for the same treatment again. Conclusion: Expectant care appears to be sufficiently safe and effective to be offered as an option for women. Medical management might carry a higher risk of infection than surgical or expectant care.

SIROHIWAL, Daya; DAHIYA, Krishna; DE, Mandira

doi: 10.1111/j.1479-828X.2005.00359.xpmid: 15760313

Objective: To evaluate the efficacy and safety of hyoscine‐N‐butyl bromide (Buscopan) suppositories in the active phase of labour, i.e. once the labour is established. Methods: A non‐randomised controlled prospective study was carried out on 200 women in labour. In the active phase of labour, at 3 cm or more cervical dilatation, 100 women were administered Buscopan via suppository and 100 women (control) were not given any drug. Results: The duration of first stage of labour was 123.86 ± 68.89 (mean+‐standard deviation) minutes in the study group and 368.05 ± 133.0 min in the control group. These differences were statistically significant. There were no differences in the duration of the second and third stages of labour. There was no increased incidence of operative deliveries in the study group. No adverse effects were noted on the mother or fetus. Conclusion: Hyoscine‐N‐butyl bromide (HBB, Buscopan) suppositories were highly effective in shortening the duration of the first stage of labour.

TO, William W. K.; CHAN, Alice M. Y.; MOK, Ka‐Ming

doi: 10.1111/j.1479-828X.2005.00361.xpmid: 15760314

Objective: To compare the sensitivity and specificity of different umbilical‐cerebral ratios in the prediction and detection of fetal growth restriction in near‐term fetuses when the umbilical arterial waveform is within normal. Methods: A prospective cross‐sectional observational study was carried out recruiting consecutive singleton pregnancies with clinically suspected fetal growth restriction after 34 weeks gestation. The umbilical‐cerebral ratios were then calculated from the S/D, RI and PI values and correlated with immediate perinatal outcome. Results: A total of 187 patients were recruited. Twelve cases had abnormal UA Doppler flow velocity waveform studies. Of the 175 with normal UA Doppler findings, 92 (53.1%) were confirmed to have fetal growth restriction (FGR) with birth weights below the tenth centile for gestation. The detection rate of FGR by ultrasound biometry was 96.7%. The mean umbilical artery S/D, RI and PI values were higher in the fetal growth restriction group, while the middle cerebral artery values were lower as compared to fetuses with no growth restriction. A small but significant difference was seen in the umbilical‐cerebral ratios of the different indices between the two groups. Receiver operator characteristic curves showed that there was little difference between the performances of the S/D, RI or PI ratios and all had limited power in predicting fetal growth restriction. Conclusion: In the presence of normal umbilical artery Doppler waveforms, umbilical‐cerebral ratios have limited power to predict fetal growth restriction.

ASHIMA, Taneja; VINITA, Agrawal; SHALINI, Rajaram

doi: 10.1111/j.1479-828X.2005.00380.xpmid: 15760315

Aim: To evaluate a new regimen of mifepristone and misoprostol in early medical abortion up to 49 days of amenorrhoea. Methods: One hundred healthy women requesting pregnancy termination up to 49 days gestation received 200 mg mifepristone followed by 800 µg misoprostol orally 24 h later. Statistical analysis was carried out by unpaired t‐test. Results: Ninety‐six percent of patients aborted completely 4.3 h after they were given misoprostol. No significant side‐effects were noted. The duration of bleeding correlated with gestational age (P‐value 0.009). Conclusion: This new regimen of mifepristone‐misoprostol is effective in terminating early pregnancy, with shorter induction to abortion interval and greater acceptability.