The potential requirement for HIV counselling and voluntary testing in women of childbearing age.

This paper compares estimates of the potential HIV counselling and testing requirements in a genito-urinary medicine (GUM) clinic, where a formal HIV counselling service is provided, and in an antenatal clinic (ANC), where there is no formal HIV counselling service. Data were collected by means of questionnaires completed by women attending both clinics. Only 31% and 16% of counselling needs were being met at the GUM clinic and antenatal clinic respectively. At the GUM clinic 11% of respondents had had an HIV antibody test, and at the antenatal clinic 1% had been tested. In contrast 68% and 58% of respondents at the GUM and antenatal clinics respectively would accept the offer of an HIV antibody test. In low prevalence areas the universal offer of testing would greatly increase specialist counselling requirements, but alternative models of provision and selective testing may lead to a more efficient use of resources.

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.

A survey of UK diabetic pregnancy management.

The provision of care and current management strategies for diabetic pregnancy in the United Kingdom were assessed by canvassing British diabetologists. Questionnaires were sent to 376 Consultant Physicians known to have an interest in diabetes, in 239 Health Districts. The response rate was 52% providing information from 182 (76%) Districts. In 66 (36%) Districts, there was an existing combined diabetes/obstetric clinic, with median annual caseloads of 13 (range 1-200) patients. Preconception counselling was offered in 22 clinics. In 153 (84%) of the clinics, the standard WHO diagnostic criteria for diabetes were applied to pregnant patients and 149 (97%) of the clinics using WHO criteria treated patients with 'Impaired Glucose Tolerance' as if they were overtly diabetic. Reflectance meters for home monitoring were employed in 119 (65%) clinics. Target pre-meal blood glucose values were less than or equal to 6.0 (range 3.0-12.0) mmol l-1 (n = 172) and post-meal less than or equal to 8.0 (5.0-10.5) mmol l-1 (n = 139). Insulin was introduced when blood glucose values exceeded 7.0 (5.0-12.0) mmol l-1 (n = 162) pre-meal or 9.0 (5.5-15.0) mmol l-1 (n = 129) post-meal. No unit used oral hypoglycaemic agents during pregnancy. Sixty percent of respondents were unable to provide accurate fetal loss/perinatal mortality rates, usually due to lack of recorded data. Where data were available, fetal loss was almost always intra-uterine. Only 78 (43%) centres allowed pregnancy to progress to term.(ABSTRACT TRUNCATED AT 250 WORDS)

Crohn's disease of the vulva in childhood.

A case of vulval Crohn's disease in childhood is presented. The presentation of this disease as a vulval lesion is well recognised, either as the initial complaint, or as a metastatic lesion. Crohn's disease in childhood is well recognised and up to 49% of sufferers may have perianal disease. Vulval Crohn's disease in children, however, is uncommon, especially when it is the presenting symptom.

Inconsistencies in clinical decisions in obstetrics.

Analysis of the increasing incidence of caesarean section in an English teaching hospital over a 15-year period revealed that emergency caesarean section for the diagnosis of fetal distress in labour made a major contribution to this increasing trend. A retrospective audit of a sample of these operations by the consultants of the hospital indicated that 30% of the operations were unnecessary. There were two other disturbing findings in our audit. First, there was significant disagreement between auditors in the decision whether to do a caesarean section or not. Second, and perhaps more importantly, when faced with identical information at a different time, the auditors were inconsistent in 25% of cases. The disturbing clinical situation highlighted by this study may have implications for medical jurisprudence.

Using Lamicel to expose high cervical lesions during colposcopic examinations.

Women with abnormal cervical cytology and an unsatisfactory colposcopic examination were offered Lamicel in an attempt to expose the entire transformation zone. The sponge, which softens, dilates and effaces the cervix, was passed intracervically in 41 patients in whom the entire squamocolumnar junction could not be seen. After 3-4 h the sponge was removed and colposcopy repeated. In 29 of the 41 patients the lesion and the squamocolumnar junction were now fully visible. Twenty-five of these patients were spared a cone biopsy.

Haemorheological consequences of oestrogen and progestogen therapy.

A clinical investigation was undertaken of the haemorheological effects of short-term administration of synthetic sex hormones. In a randomised controlled investigative trial, groups of 20 women taking ethynyloestradiol, norethisterone, combined norgestrel and ethynyloestradiol or no therapy had their blood viscosity and its major determinants measured before and after 3 months of treatment. Oestrogens and progestogens, singly or in combination, were found to cause a rise in blood viscosity. Oestrogens did so by raising haematocrit and plasma fibrinogen, parameters that are similarly raised in other conditions such as pregnancy and following surgery when venous thromboembolism is common. The synthetic progestogen, on the other hand, raised the blood viscosity by increasing the haematocrit and decreasing erythrocyte deformability, parameters that are similarly altered in occlusive arterial disease. The combined preparation raised blood viscosity by altering all three parameters. These observations indicate the pathways whereby various synthetic oestrogens and progestogens in oral contraceptives or replacement therapy may be associated with different types of cardiovascular pathology.

MEDTUTOR: a microcomputer-based training program for MEDLINE.

MEDTUTOR is an interactive, microcomputer-based training package designed to teach medical and health professionals, as well as librarians and information specialists, how to use MEDLINE effectively. The objective of MEDTUTOR is to provide a comprehensive package for teaching the various commands and search techniques required for utilizing the MEDLINE database through the MEDLARS system. MEDTUTOR's menu-driven design allows novice users to learn about the content and use of MEDLINE, such as author searching, text word searching, MeSH indexing, etc., at their own pace and with considerable program feedback. In addition, MEDTUTOR provides the skilled searcher with a way to reinforce or recall previously-learned search techniques without incurring online charges. MEDTUTOR may be used in place of formal training, as a precursor to or as a refresher following formal training, or for review of a particular concept. It provides inexpensive and easily accessible instruction for searching MEDLINE.

Screening for the small-for-dates: a clinical and biochemical appraisal.

To find an effective routine screening method for small-for-dates (SFD) infants 500 consecutive patients were recruited at one antenatal clinic. Weight gain during pregnancy, daily fetal movements counts (DFMC) and plasma schwangerschafts protein 1 (Sp1) levels were measured and their efficacy in identifying SFD infant compared. Mothers delivered of SFD infants had a significantly lower weekly weight gain (P less than 0.01) but no significant difference in either DFMC or plasma Sp 1 level. This study shows that epidemiological and clinical data which are inexpensive and easily available at the antenatal clinic are more valuable than more complicated and expensive assays in the prediction of SFD infants.

Pain after episiotomy--a comparison of two methods of repair.

Episiotomy is a very common operation but little is known of its short-term or long-term morbidity.A prospective study was designed to record postpartum perineal discomfort and to investigate the presence and persistence of dyspareunia following episiotomy in 140 primigravidae. A comparison was made between those whose perineal skin was sutured with a subcuticular polyglycolic acid (;Dexon') stitch and those sutured with interrupted black silk stitches.Patients sutured with subcuticular ;Dexon' had significantly less perineal discomfort on the third, fourth, and fifth postpartum days. Patients who had epidural analgesia in labour had significantly more pain during the first five postpartum days irrespective of the suture material used.The timing of first coitus after delivery did not influence the presence or persistence of dyspareunia. Dyspareunia was commoner and lasted longer in patients sutured with ;Dexon' and it was also commoner in older primigravidae irrespective of the suture technique.

Evaluation and modification of whole blood filtration in the measurement of erythrocyte deformability in pregnancy and the newborn.

This study was designed to investigate the deformability of erythrocytes from pregnant women and full-term newborn infants, with healthy female adults as a comparison, using a whole blood filtration method. Delay in measurement, white cells, haematocrit, plasma viscosity, temperature and pH all significantly affected the rate of whole blood filtration and could thereby obscure or exaggerate changes in erythrocyte deformability. A new method was developed which eliminated or minimized these sources of error and the study was completed. Fetal erythrocytes were found to be significantly less deformable than adult erythrocytes which were in turn found to be significantly less deformable than erythrocytes from pregnant women. These differences appear to be related to the varying plasma fibrinogen concentrations in the three groups of subjects. The significance of these findings in the special haemodynamic situations found in the neonate and during pregnancy are discussed.

Altered haemorheology in oral-contraceptive users.

The haemorheological profile of the menstrual cycle was determined in 12 women who did not take oral contraceptives and compared with that in two groups of women (n = 8 and n = 30) who had been taking oral contraceptives for at last six months. Packed cell volume, platelet count, erythrocyte deformability, plasma fibrinogen concentration, and plasma and whole-blood viscosity varied cyclically throughout the menstrual cycle in the 12 non-users. This variation was abolished by the use of oral contraceptives, and the values of these indices were raised by an amount likely to predispose to thrombosis.

Emotional stress in childbirth and its modification by variations in obstetric management. Epidural analgesia and stress in labor.

Emotional stress before, during and after labor was measured in 20 primigravidae by serial estimation of plasma 11-hydroxycorticosteroids and by stress assessment interviews. The anticipation of epidural analgesia and internal fetal monitoring was a significant source of emotional stress to women awaiting induction of labor, despite explanation and attempted reassurance. During labor epidural analgesia reduced stress by abolishing pain, so eliminating the progressive rise in 11-hydroxycorticosteroids normally seen throughout labor. Epidural analgesia does not, however, block the potential for the adrenocortical response to stress and the physical work, emotional stress and surgical trauma of delivery stimulate a considerable output of 11-hydroxycorticosteroids.

Pathogenesis of neonatal hyperbilirubinaemia after induction of labour with oxytocin.

To determine the pathogenesis of neonatal hyperbilirubinaemia after oxytocin-induced labour venous cord blood from 95 healthy newborn infants was examined. Of these, 15 were delivered by elective caesarean section, 40 after spontaneous labour, and 40 after oxytocin-induced labour. There was no significant difference in any haematological or biochemical variable between the first two groups. Infants born after oxytocin-induced labour, however, showed clear evidence of increased haemolysis associated with significantly decreased erythrocyte deformability (P less than 0.001). In-vitro studies showed a time- and dose-related reduction in erythrocyte deformability in response to oxytocin. The findings suggest that the vasopressin-like action of oxytocin causes osmotic swelling of erythrocytes leading to decreased deformability and hence more rapid destruction with resultant hyperbilirubinaemia in the neonate.

Maternal hormone profile in oxytocin induced labour.

Serial blood samples were collected from ten patients at between 40 and 42 weeks gestation, who were having labour induced by amniotomy and intravenous oxytocin. The plasma levels of human placental lactogen and pregnancy-specific beta 1 glycoprotein showed no more than their normal late pregnancy variability during labour; oestradiol-17 beta showed a small rise in early labour followed by a fall in the second stage of labour; unconjugated oestriol and 11-hydroxycorticosteroids showed a progressive rise throughout labour and progesterone a progressive fall. The ratio of progesterone to oestradiol-17 beta fell throughout labour. The significance of these changes in our understanding of the control of placental hormone secretion and of the hormone profile of spontaneous labour is discussed.

Enterohepatic circulation of oestriol: a study of the effects of ampicillin on plasma oestriol levels.

Plasma total oestriol was measured daily before and during ampicillin therapy in five pregnancy patients and in eight patients, four of whom were receiving ampicillin, for four days following delivery. Ampicillin caused a fall in plasma oestriol of 25 per cent during the first three days of treatment, thereafter the level remained stable with a lower day-to-day variability than in untreated patients. Ampicillin reduced the plasma half life of total oestriol by 60 per cent. This study illustrates how the re-entry of oestriol from the gut leads to irregular fluctuations in plasma oestriol levels and helps to keep up the plasma concentration of the steroid when inflow from the fetoplacental unit is cut off.