Outreach obstetrics training in Western Australia improves neonatal outcome and decreases caesarean sections.

The objective of this study was to determine the effect of a multi-professional outreach obstetric training programme on perinatal and neonatal outcomes. This was a retrospective comparison of 5-min low Apgar scores, stillbirth, perinatal death and moderate/severe hypoxic ischaemic encephalopathy rates in 127,753 infants born in Western Australia before and after the introduction of training in rural and remote areas. Following the introduction of the training programme, there was a highly significant (p = 0.003) decrease in the rate of infants born with low 5-min Apgar scores (from 20.4 to 15.4/1,000 live births). While the changes in the other three outcomes were not significant, all three demonstrated a trend for improvement in the intervention area. This is the second study of an educational intervention in obstetrics to demonstrate improvement in neonatal outcome and the first to be associated with a decrease in caesarean sections.

Excisional surgery versus ablative surgery for ovarian endometriomata.

BACKGROUND: Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured over a laparotomy approach as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. OBJECTIVES: The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. The end-points assessed were the relief of pain, recurrence of the endometrioma, recurrence of symptoms and in women desiring to conceive the subsequent pregnancy rate, either spontaneous or as part of fertility treatment. SEARCH STRATEGY: The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 3rd March 2007), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 3, 2007), MEDLINE (1966-August 2007), EMBASE (1980- March 2007) and reference lists of articles, the handsearching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world. The Cochrane Menstrual Disorders and Subfertility Group Trials Register is based on regular searches of MEDLINE, EMBASE, CINHAL and CENTRAL. SELECTION CRITERIA: Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata. DATA COLLECTION AND ANALYSIS: Reviewers assessed eligibility and trial quality. MAIN RESULTS: No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3cm in size, for the primary symptom of pain were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of the symptoms of dysmenorrhea (OR 0.15 CI 0.06-0.38), dyspareunia (OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56), a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93) and with a reduced requirement for further surgery (OR 0.21 CI 0.05-0.79) than surgery to ablate the endometrioma. For those women subsequently attempting to conceive it was also associated with a subsequent increased spontaneous pregnancy rate in women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29). A further randomised study was identified that demonstrated an increased ovarian follicular response to gonadotrophin stimulation for women who had undergone excsional surgery when compared to ablative surgery (WMD 0.6 CI 0.04-1.16). There is insufficient evidence to favour excisional surgery over ablative surgery with respect to the chance of pregnancy after controlled ovarian stimulation and intra-uterine insemination (OR 1.40 CI 0.47-4.15) . AUTHORS' CONCLUSIONS: There is good evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile, subsequent spontaneous pregnancy . Consequently this approach should be the favoured surgical approach. However in women who may subsequently may undergo fertility treatment insufficient evidence exists to determine the favoured surgical approach.

Excisional surgery versus ablative surgery for ovarian endometriomata.

BACKGROUND: Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured for as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall. OBJECTIVES: The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall, with regard to relief of pain, recurrence of the endometrioma, recurrence of symptoms and the subsequent spontaneous pregnancy rate. SEARCH STRATEGY: The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 15 Nov 2004), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966-Nov 2004), EMBASE (1980- Nov 2004) and reference lists of articles, the handsearching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world. SELECTION CRITERIA: Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata. DATA COLLECTION AND ANALYSIS: Reviewers assessed eligibility and trial quality. MAIN RESULTS: No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3cm in size were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93), reduced requirement for further surgery (OR 0.21 CI 0.05-0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15 CI 0.06-0.38), dyspareunia OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56). It was also associated with a subsequent increased rate of spontaneous pregnancy women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29). AUTHORS' CONCLUSIONS: There is some evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation, with regard to the recurrence of the endometrioma, recurrence of symptoms and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. However we found no data as to the effect of either approach in women who subsequently undergo assisted reproductive techniques.

Review of 17 cases of ectopic pregnancy at the Vila Central Hospital in Vanuatu.

A review of cases of ectopic pregnancy operated upon at Vila Central Hospital during 1992 with an analysis of clinical presenting features and diagnostic factors is presented. Comparison is made between hospital, regional and national figures and possible explanations for the differences are given. Recommendations are made to ensure that ectopic pregnancy is always at the forefront of differential diagnosis in women presenting with abdominal pain.

Induction of labour for trial of vaginal birth after caesarean section in a remote district hospital.

In a retrospective review of 79 women with 1 or more previous Caesarean section, 33 (41.8%) women agreed to a trial of vaginal birth. Twenty nine women had labour induced and 26 (89.7%) of them had a successful vaginal delivery. Four women laboured spontaneously and 1 of them needed an emergency Caesarean section for failure to progress. The overall vaginal delivery rate for women selected to undergo a trial of vaginal birth after Caesarean was 87.9%. The overall emergency Caesarean section rate was 4 of 33 (12.1%). During the study period the Caesarean section rate for the hospital fell from 32.2% to 11%. This study suggests that induction of labour in women with a previous Caesarean section is very successful in achieving vaginal delivery and has a role to play in remote and rural hospitals.

Reducing perinatal mortality in Vila Central Hospital, Vanuatu.

This paper provides accurate figures and detailed analysis of the causes of perinatal mortality in the main referral hospital in Vanuatu in 1992, and discusses possible improvements in management. The perinatal mortality rate for the Vila Central Hospital area was 30.4 per 1000 births (with a stillbirth rate of 14 per 1000). These figures include mothers who presented for the first time in labour without any antenatal care, and cases of very low birthweight (less than 1 kg). These results were achieved with very low intervention rates. The commonest cause of death in Vanuatu was birth asphyxia, with prematurity, unexplained stillbirth and major congenital abnormality as the other main causes. Even though there is still scope for improvement, especially in the prevention of birth asphyxia, the perinatal mortality rate in Vanuatu compares favourably with that in other developing countries. Increased family planning uptake will be expected to lead to a reduction in perinatal mortality.

PIP: A prospective study attempted to establish accurate figures of perinatal mortality (first-week neonatal deaths and stillbirths weighing 500 g or more) occurring in 1992 in patients delivered at Vila, Vanuatu, Central Hospital (VCH). Out of 1445 total births, there were 23 stillbirths and 27 first-week neonatal deaths at VCH during 1992, giving a total perinatal mortality rate of 34.6/1000 births (and a stillbirth rate of 16/1000). If emergency referred cases from other islands are excluded, the perinatal mortality rate for the VCH area was 30.4/1000 births (with a stillbirth rate of 14/1000). These figures include five mothers (with outcomes of four stillbirths and one neonatal death) who presented for the first time in labor without any antenatal care, and eight cases of very low birth weight (1 kg). There were three sets of twins involved in perinatal mortality: one set of twins died because of premature delivery, there was one set of conjoined twins, and an unexplained fetal death in utero of one of a set of twins with a normal outcome of the other twin. The commonest cause of death was birth asphyxia (30% of perinatal deaths or 10.4/1000 births). Careful analysis of the asphyxia deaths identified 10 cases in which more intensive monitoring of the fetal heart rate could have prevented the death. There were two cases of cord prolapse, in which delay in performing caesarean section was the main reason for the fetal death, and a further three cases in which a delay in performing the caesarean section probably contributed to the fetal death. Prematurity accounted for 20% of the perinatal deaths, whereas 10% of the babies born at VCH weighed less than 2.5 kg. The third largest cause of perinatal death was unexplained stillbirth. Major congenital abnormality was the fourth cause of perinatal mortality. Parity over 4, maternal age over 38 years, maternal age under 18 years, and birth spacing of less than 2 years contributed 12.4%, 5.5%, 2.7%, and 13% of the births in VCH, respectively.

The effect of danazol on pulsatile gonadotropin secretion in women with endometriosis.

OBJECTIVE: To determine whether the effect of danazol on gonadotropin pulsatility was due to a direct effect of the drug or the suppression in the estradiol (E2) levels. DESIGN: Prospective analysis of serial blood samples at 10-minute intervals for 5 hours on days 3, 4, or 5 of the control cycle and 2 months after the start of danazol treatment. SETTING: Tertiary institutional outpatient care. PATIENTS, PARTICIPANTS: Six eugonadal women with minimal endometriosis. INTERVENTIONS: Oral administration of danazol, 200 mg three times daily. MAIN OUTCOME MEASURES: Gonadotropin mean levels, pulse frequency, and amplitude. RESULTS: The mean level of E2 was the same in the control cycle as that during danazol treatment (170 pmol/L). Danazol administration resulted in a 16% increase in the mean luteinizing hormone (LH) pulse amplitude (95% confidence interval [CI] 6% to 26%, P less than 0.01), associated with a 20% decrease in LH pulse frequency (95% CI -71% to +31%, P = 0.37). There was a nonsignificant increase in follicle-stimulating hormone (FSH) pulse amplitude (2%, 95% CI -9% to +14%, P = 0.68) and in FSH pulse frequency (27%, 95% CI -4% to +58%, P = 0.08). The 22% decrease in the mean LH level (95% CI -85% to +12%, P = 0.13) and the 20% decrease in the mean FSH level (95% CI -53% to +37%, P = 0.33) were also not significant. CONCLUSIONS: The increase in LH pulse amplitude represents a direct effect of danazol on the hypothalamic-pituitary axis.

The effect of danazol and the LHRH agonist analogue goserelin (Zoladex) on the biological activity of luteinizing hormone in women with endometriosis.

In an attempt to determine whether the suppression in oestradiol levels caused by danazol is due to an effect on the hypothalamic-pituitary axis, we compared the endocrine effects of danazol with those of the LHRH (GnRH) agonist analogue goserelin. Serum levels of immunoreactive LH (I-LH), FSH, 17 beta-oestradiol (E2) and bioactive LH (B-LH) (using a mouse Leydig cell bioassay), were measured in ten and 20 women with endometriosis treated with danazol and goserelin, respectively. I-LH was measured both by radioimmunoassay (RIA) and immunoradiometric assay (IRMA). During 6 months of treatment with 600 mg of danazol daily, mean serum E2 decreased (P less than 0.05) to levels near the upper limit of the post-menopausal range (to a mean (and 95% confidence interval of the mean) of 117 (65-169) pmol/l) whereas FSH, I-LH (both by RIA and IRMA) and B-LH levels were not significantly altered. During 6 months of treatment with monthly depot injections of 3.6 mg goserelin, mean serum E2 decreased (P less than 0.001) to well within the post-menopausal range (to 23 (18-28) pmol/l). The mean FSH, I-LH and B-LH levels also decreased (P less than 0.05) during therapy with goserelin (from 3.9 (3.1-4.7) to 2.0 (1.6-2.4) IU/l for FSH, from 5.3 (4.5-6.1) to 1.9 (1.7-2.1) IU/l for RIA-LH, from 2.9 (2.5-3.3) to less than 0.5 (less than 0.5) IU/l for IRMA-LH and from 9.1 (7.1-11.1) to 2.9 (2.6-3.2) IU/l for B-LH).(ABSTRACT TRUNCATED AT 250 WORDS)

Successful vaginal delivery after caesarean scar rupture: a case report.

A case of successful vaginal delivery following a previous lower segment caesarean scar rupture is presented.