Dying to give birth: the Pakistan Liaison Committee's strategies to improve maternal health in Pakistan.

Pakistan has one of the worst maternal mortality ratios worldwide: 260-490 women die for every 100,000 live births in Pakistan. The Pakistan Liaison Group (PLG) was formed to work with and through the international office of the Royal College of Obstetricians and Gynaecologists (RCOG). It works with the RCOG representative committee in Pakistan to improve the health of women. It aims to contribute to improving maternal morbidity and mortality through strategies directed at improving the education and training of health professionals. In addition, the PLG aims to promote changes in the legislature to allow for the notification of maternal deaths so that accurate figures can be obtained, and so that health parameters can be accurately assessed and, in the long term, a confidential enquiry into maternal deaths can be initiated.

A randomized trial investigating an iron-rich natural mineral water as a prophylaxis against iron deficiency in pregnancy.

Spatone Iron-Plus is a naturally occurring mineral water from Trefriw Wells Spa in Conwy County, North Wales, UK. It contains approximately 0.20 mg of iron per millilitre as ferrous sulphate and has been shown to provide iron in a highly bio-available form. A 24 ml sachet contains approximately 5 mg of iron. Iron deficiency is common in the obstetric population. However, compliance with traditional iron supplements is poor because of gastrointestinal side-effects. We designed a randomized, double-blind, placebo-controlled trial. A total of 102 low-risk antenatal patients, who were noncompliant with routinely prescribed ferrous sulphate tablets, were randomized to receive 48 ml of Spatone water or placebo. The study was conducted between 22 and 28 weeks gestation. Primary outcome measures were compliance, gastrointestinal side-effects and changes in ferritin levels during the trial period. Compliance in the intervention group was 57% compared with 67% in the control group, P = 0.22. Dyspepsia scores, as determined by a recognized and well-validated questionnaire, did not differ between the two groups. During the trial period, mean ferritin levels fell by 24% in the Spatone Iron-Plus group compared with a mean fall of 51% in ferritin levels among the control group, P = 0.016.

Incidence and risk factors for ventricular septal defect in "low risk" neonates.

AIMS: To quantify the incidence of ventricular septal defect in "low-risk" neonates; and to define any associated risk factors. METHODS: One hundred and seventy three patients with ventricular septal defects from a scanned population of 3971 clinically normal neonates were compared with scanned controls, considered to be clinically normal. A subset of the group with defects was compared with normal infants delivered over the same period, to identify any seasonal variation. RESULTS: Ventricular septal defects were detected in 4.36 % of the "scanned" group (173 out of 3971). Ten had perimembranous defects and the remainder apical or muscular lesions. Eleven neonates had multiple defects. The incidence of ventricular septal defect was independent of most tested risk factors. There were significantly more girls in the group with defects compared with the controls (p = 0.004). The defects group also contained fewer infants born during summer months (p = 0.04). CONCLUSIONS: The incidence of ventricular septal defects was much higher than might be expected, given that "high risk infants" were excluded. The observations that gender and season of birth affect the rate suggest that both genetic and environmental factors may be involved in the aetiology.

Early amniocentesis: effect of removing a reduced volume of amniotic fluid on pregnancy outcome.

In mid-trimester amniocentesis (MTA), 12-15 ml of amniotic fluid is aspirated for cytogenetic analysis. When a similar volume of amniotic fluid is removed by early amniocentesis (EA), it represents a significant proportion of the total amniotic fluid volume in the first trimester. The fluid depletion, which may persist for 7 to 10 days, is considered to impair development of fetal lungs and extremities and, possibly, contribute towards procedure-related congenital abnormalities and miscarriages. By only removing 7 ml of amniotic fluid, we have demonstrated a total miscarriage rate (3.8 per cent) comparable with previous large studies (Table V), a low incidence of respiratory difficulties at birth (2.7 per cent) and a low incidence of fixed flexion deformities (1.6 per cent), at the expense of a small increase in the incidence of culture failure (2.2 per cent).

Transplacental early amniocentesis and pregnancy outcome.

The effect on pregnancy outcome of transplacental needle insertion was studied in 401 consecutive women attending for early amniocentesis between 10 and 14 completed weeks of pregnancy. Transplacental early amniocentesis was associated with a significantly higher incidence (P < 0.001) of blood-stained amniotic fluid taps but a lower incidence (not significant; P > 0.05) of pregnancy loss and miscarriages. Women in the nontransplacental early amniocentesis group had a significantly higher (P < 0.01) incidence of late procedure-related antenatal complications, such as preterm rupture of membranes or preterm labour. Our study showed that transplacental early amniocentesis is a safe procedure; contrary to present recommendations, the study also showed that avoiding the placenta during early amniocentesis is an unnecessary practice.

Transabdominal cervicoisthmic cerclage: initial experience.

Pregnancy outcome before and after insertion of transabdominal cervical cerclage is evaluated. The series also reports on the first cases of second pregnancies with the original suture left in situ. It is our view that transabdominal cervical cerclage should only be performed in units that have specialists in Perinatal Medicine.

Evaluation of routine ultrasound in the prenatal diagnosis of structural anomalies of the fetus.

The objective of this study was to evaluate routine obstetric ultrasound in detecting fetal structural anomalies and the impact of changing clinical practice on success rates. A retrospective study of routine ultrasound in a population of 6,869 pregnancies was performed during 1985-86 (phase 1) to establish efficacy of ultrasound in the detection of fetal anomalies. Changes in ultrasound practice comprised timing, personnel and technique of fetal examination. After alterations in practice, a prospective study of 6,969 pregnancies during 1987-89 (phase 2) was performed. All abnormal fetuses (cases) were assessed in both studies. Random samples of normal infants (controls) were chosen from both populations to establish specificity. In 83 cases in phase 1,116 anomalies were diagnosed postnatally of which 11 were suspected by routine prenatal ultrasound at < 24 weeks (sensitivity 9%, 95% C.I. 4-15). In 72 cases in phase 2, 89 anomalies were identified postnatally of which 27 were suspected by routine prenatal ultrasound at < 24 weeks (sensitivity 30%, 95% C.I. 21-41). The change in sensitivity was statistically significant (p = 0.0003). Of the 382 control infants randomly selected in phase 1, false abnormal scans were not identified (specificity 100%, 95% C.I. 99-100). Of the 367 control infants in phase 2, 12 false abnormal scans were identified (specificity 96.7%, 95% C.I. 95-99). The decrease in specificity was statistically significant (p = 0.0013). The detection of urorenal and to a lesser degree central nervous system anomalies showed most improvement between the two phases. The alterations to routine ultrasound practice in timing, personnel and technique have significantly improved the detection of all fetal structural anomalies but at the cost of a small but significant loss of specificity.

Is evening primrose oil of value in the treatment of premenstrual syndrome?

A systematic literature search of clinical trials of evening primrose oil (EPO) for the treatment of the premenstrual syndrome (PMS) was carried out with a view to performing a meta-analysis. Only seven placebo-controlled trials were found but only in five trials was randomization clearly indicated. Inconsistent scoring and response criteria made statistical pooling and hence a rigorous meta-analysis inappropriate. The two most well-controlled studies failed to show any beneficial effects for EPO, although because the trials were relatively small modest effects cannot be excluded. Nonetheless, on current evidence EPO is of little value in the management of premenstrual syndrome.

Clinical trials of treatments of premenstrual syndrome: entry criteria and scales for measuring treatment outcomes.

OBJECTIVE: To demonstrate similarities and differences between the various instruments used by clinical trialists for measurement of premenstrual syndrome to encourage development of consensus of measurement to aid future research. DESIGN: Computer and manual searches of all trials of drugs used for premenstrual syndrome supplemented by retrieval of all questionnaires and scales cited. Letters were sent to the main manufacturers to identify trials not in the public domain. MAIN OUTCOME MEASURES: Number of scales in current use for classifying premenstrual syndrome; the symptoms included within them; their organisation of symptoms into clusters; the numerical values used in the scaling; the most frequently used items; and the extent of overlap in the criteria used. RESULTS: Three hundred and fifty clinical trials of 115 different drugs were identified. The most common symptoms or signs used in the scales were (frequency in square brackets) irritability [44], headache or migraine [40], depression [37], tearfulness [34], tension [31], anxiety [31], breast tenderness [31], mood swings or lability [30], back pain [30], weight gain [29], abdominal bloating [28], lack of concentration [28], food craving [28], and increased appetite [26]. Sixty-five different questionnaires or scales were used to classify premenstrual syndrome and for assessing entry eligibility and treatment outcomes; of these 65, 47 included sufficient details for a formal analysis and 18 scales grouped the symptoms or items into clusters or subgroups. CONCLUSION: There is wide diversity in the scales used for assessing entry eligibility and treatment outcomes in premenstrual syndrome. This makes comparative evaluation of possible treatments extremely complex and difficult. It is recommended that authorities and organisations involved in conducting trials of treatments for premenstrual syndrome develop a consensus statement about the best instrument to be used. Regulatory authorities could perhaps provide guidance to which scales they would accept when clinical trials of drugs for premenstrual syndrome are submitted to them for assessment. This would ensure that industry-sponsored trials provide objective data. Consensus is required given the poor performance of most current treatments of premenstrual syndrome.

Evaluation of biophysical fetal assessment in high-risk pregnancy to assess ultrasound parameters suitable for screening in the low-risk population.

During a 1-year period, 662 pregnant women at 24-43 weeks' gestation were referred to the Department of Obstetrics and Gynaecology, at the Queens University Belfast, for fetal assessment because they were clinically suspected to be at high risk of perinatal complications. The results of our investigations were made available to the referring obstetricians who undertook the further management of the pregnancies. Subsequently six pregnancies resulted in perinatal deaths and 97 (14.7%) in the delivery of small-for-gestational-age infants. We restrospectively analyzed the data from ultrasonographic evaluation of the fetus and subjective and objective assessments of the amniotic fluid volume to determine their value in the prediction of adverse perinatal outcome. A fetal abdominal circumference < 10th centile for gestation or a subjectively reduced amniotic fluid volume identified 87 (90%) of small-for-gestational-age infants and five of the six perinatal deaths. When comparing the abdominal circumference and subjective liquor volume, both were sensitive in predicting delivery of a small-for-gestational-age fetus (sensitivity 86% vs. 53%, respectively) and perinatal death (sensitivity 50% vs. 83%, respectively). We suggest that, since assessments of these two factors are complementary in evaluating a high-risk pregnancy and can be measured in under 5 min, they now warrant consideration for screening in a prospective randomized trial in an unselected low-risk population.

Antenatal detection of renal abnormalities.

The aim of this retrospective study is to assess the value of routine ultrasonography in the detection of renal abnormalities. Twenty-nine pregnancies (one set of twins) with suspected renal abnormalities (i.e. renal cystic spaces, oligohydramnios or hyperechoic kidneys) were delivered over a two year period (1.8.1987-31-7-1989) in a unit where 90% of pregnancies (6,562) were scanned routinely at 18-20 weeks gestation or later, if booking for confinement was delayed. In pregnancies with suspected anomalies prenatal ultrasound was performed monthly until 28 weeks and fortnightly until delivery. Non survivors [5] had histological or postmortem examination. Liveborn infants [25] had renal ultrasonography in the neonatal period and paediatric follow-up if abnormal. Sixteen (53%) of the 30 cases (one set of twins) suspected of renal abnormalities by routine prenatal ultrasonography had renal anomalies confirmed postnatally. Five women were non survivors, all of which had associated anomalies. In the eleven survivors the diagnoses were pelvi-ureteric junction obstruction [6], renal dysplasia [2], vesicoureteric reflux [2] and suspected ureterocele [1]. Fourteen infants with pelvicalyceal dilatation had normal postnatal renal ultrasound. Although abnormal prenatal renal ultrasound is a useful indicator of postnatal disease and aids decisions on the management of pregnancy, further large collaborative studies with extended paediatric follow-up are required to assess the significance of pelvicalyceal dilatation.