Maternal mortality and Millennium Development Goal 5.

INTRODUCTION: The maternal mortality ratio (MMR) is a key indicator for measurement of progress against Millennium Development Goal 5 (MDG 5). For many countries, especially those with a presumed high number of maternal deaths, only estimates are available. SOURCES OF DATA: Recent global estimates and the reasons for high maternal mortality are reviewed. AREAS OF AGREEMENT: There is international consensus that efforts to reduce maternal mortality globally need to be intensified. AREAS OF CONTROVERSY: Many countries lack accurate data on number of deaths in women of reproductive age and number of births. Therefore, statistical modelling has been used to calculate estimates, which generally have wide confidence intervals and may be disputed by individual countries. GROWING POINTS: There is renewed focus on MMR as 2015 approaches. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need to adapt and implement methods for measuring maternal mortality to generate more accurate estimates. More data on cause of death are needed.

The impact of improving outcomes guidance on surgical management of vulval squamous cell cancer in southwest England (1997-2002).

OBJECTIVE: The objective of this study was to assess the impact of reorganisation of gynaecological services in southwest England following adoption of regionally agreed evidence-based guidelines and publication of the National Improving Outcomes Guidance in 1999. DESIGN: Prospective audit with cross-checking against histological reports. SETTING: All 19 acute hospitals in the four Cancer Networks of southwest England. SAMPLE: All subjects with squamous or verrucous vulval cancer diagnosed between 1997 and 2002. METHOD: A one-page minimum data set proforma agreed by the South West Gynaecology Tumour Panel was completed by surgeons after treatment of each patient, and was sent to South West Cancer Intelligence Service for entry, collation and analysis. Data are presented for the years 1997 to 2002 inclusive, and comparisons were made between each of the three 2-year cohorts. MAIN OUTCOME MEASURES: These are standards derived from the guidance. RESULTS: There were 436 squamous or verrucous vulval cancers registered. Recording of staging was missing in 20% of subjects. The percentage of subjects operated upon by lead gynaecological cancer surgeons increased from 78% in cohort 1 to 93% in cohort 3 (P < 0.001). There is a trend towards more conservative operations, which have lower co-morbidity. High activity surgeons achieved better rates of tumour-free skin margins, but even these were adequate only in 49% of operations. Lymphadenectomy rates did not follow guidance. CONCLUSION: Centralisation of care of this rare cancer should continue, but specialists need to increase their efforts to ensure adequate skin margins and lymphadenectomy rates while balancing morbidity and the likelihood of recurrence in both fit and frail patients.

Pregnancy outcomes following treatment of cancer.

While still rare, cancer has the reputation of being life-threatening in all its forms. Coupled with the survival of cancer comes a growing expectation from the patients that their life should be relatively unaffected. Among the side effects, there is frequently an effect on fertility. In particular, the treatment of the young with anti-cancer therapy raises questions about the patient's ability to achieve normal reproductive function and delivery following treatment. Between 1987 and 1998 we identified 40 women who conceived or delivered a fetus following treatment for cancer. They had undergone a combination of therapies including surgery, chemotherapy and radiotherapy. Four had elected to be sterilised after completion of their family. It did not appear from the data collected that the therapy used for treatment of some cancers has had an adverse effect on delivery outcomes, expected weight of the fetus or the gestation of the pregnancy.

HIV prevalence at reception into Australian prisons, 1991-1997.

OBJECTIVE: To measure the extent and outcome of HIV antibody testing at reception into Australian prisons. DESIGN: Cross-sectional survey at reception into prison. PARTICIPANTS AND SETTING: People received into Australian prisons from 1991 to 1997. MAIN OUTCOME MEASURES: Number of people tested for HIV infection and prevalence of diagnosed HIV infection. RESULTS: In 1991-1997, HIV antibody testing was carried out for 72% of prison entrants in Australia; the percentage tested declined significantly from 76% in 1991 to 67% in 1997 (P < 0.001). In New South Wales, the percentage of entrants tested at reception into prison dropped from almost 100% in 1991-1994 to 45% in 1997, whereas in the Northern Territory, South Australia and Western Australia the extent of testing increased significantly (P < 0.001). HIV prevalence was 0.2% among people received into Australian prisons in 1991-1997, and did not differ by sex. Most people with HIV infection (242/378; 64%) received into prison in 1991-1997 had been diagnosed at a previous entry; 136 people (36% of the total number of diagnoses) were newly diagnosed at reception into prison. CONCLUSIONS: A national monitoring system in place from 1991 indicates generally high rates of HIV antibody testing and a low prevalence of HIV infection among people entering Australian prisons. In each year, people not previously known to the prison health service to have HIV infection were received into prison, indicating continuing HIV infection in the population entering Australian prisons.

Evaluation of a one-stop clinic for the rapid assessment of post-menopausal bleeding.

In this study, we evaluated the management of postmenopausal bleeding at our one-stop clinic where the first line investigations were a transvaginal ultrasound scan and a pipelle endometrial biopsy. The records of 212 women seen in this clinic in 1994 were reviewed. One hundred and forty-four women (67.9%) were evaluated and reassured in one visit. The mean waiting period following referral to the clinic by the general practitioner was 36 days (range 6-157 days), and only 45 women (21%) required a hysteroscopy. The commonest diagnosis made was endometrial atrophy or no significant endometrial pathology (130 women (61.3%). Endometrial cancer was diagnosed in 12 women (5.6%), and one case of previously unsuspected ovarian cancer was detected. Our findings show that most women with post-menopausal bleeding can be assessed in one visit, and hysteroscopy is not always necessary in the initial assessment of this complaint.

Fetal sympatho-adrenal mediated metabolic responses to parturition.

Plasma cortisol and noradrenaline were measured in 15 mothers and babies following vaginal delivery and in 17 following elective caesarean section and related to blood concentration of glucose and glycerol. Significant elevations in umbilical artery cortisol and noradrenaline concentration were found in the vaginal delivery group. Blood glucose and glycerol concentrations were significantly higher in the vaginal delivery group for maternal venous, umbilical artery and vein samples. However, when allowances were made for placental transfer of these substances, little evidence was found to support sympatho-adrenal mediated mobilization of glycerol and glucose in the fetus. The possible explanation for the apparent dissociation between marked sympatho-adrenal activity and metabolic responsiveness during parturition in the fetus is discussed.

Role of labour in the establishment of functional residual capacity at birth.

Intrathoracic pressure and volume changes were measured during the spontaneous first breath in 11 healthy term neonates delivered by emergency caesarean section (CS). Although inspiratory and expiratory rates were higher than those found among babies delivered by elective CS, inspiratory volume was very similar and these babies, unlike those delivered by elective CS, had all formed a functional residual capacity at the end of the first breath. We obtained cord arterial and venous samples for catecholamine analysis concurrently, and found that most of the babies had concentrations of plasma noradrenaline similar to babies delivered by elective CS--high values were found only among infants who had suffered fetal distress. Both catecholamine excretion and method of delivery may be important in the formation of the functional residual capacity at birth.

Plasma noradrenaline levels during labour. Influence of electric lumbar epidural blockade.

Plasma noradrenaline was assayed during augmented labour in nine patients receiving electric lumbar epidural blockade and in 11 patients using other forms of pain relief. Similar noradrenaline levels were seen in each group before induction of labour (epidural subjects 1.28; SEM 0.45 nmol/litre and non-epidural subjects 1.53; SEM 0.44 nmol/litre). At the onset of the second stage of labour the non-epidural patients showed a significant rise in plasma noradrenaline to 2.91; SEM 0.56 nmol/litre (p less than 0.01). The rise to 1.88; SEM 0.55 nmol/litre in the epidural group was not significant. Electric lumbar epidural block may influence plasma noradrenaline during labour.

Circumstances influencing umbilical-cord plasma catecholamines at delivery.

Blood gases and plasma catecholamines were measured in umbilical arterial and venous blood samples after delivery. In all cases umbilical arterial noradrenaline concentrations were higher than venous levels. The lowest concentrations of noradrenaline were found after elective caesarean section. Vaginal delivery, particularly when accompanied by instrumental manipulation, was associated with significantly higher concentrations of arterial noradrenaline. High concentrations of catecholamines were commonly recorded in those deliveries showing evidence of acid-base disturbance. Noradrenaline was the predominant catecholamine in all cases. A linear relation was demonstrated between arterial noradrenaline and arteriovenous noradrenaline difference.

The way we teach: reproductive biology.

At the University of Nottingham, students are taught aspects of reproductive biology throughout the Part I Basic Medical Science Course. Teachers from the Departments of Physiology and Pharmacology, Human Morphology, Biochemistry, Obstetrics and Gynaecology, and Psychiatry are involved, and an obstetrician in training (the author) has been appointed full-time lecturer in Physiology and Pharmacology to provide an additional link between the basic science and clinical content of the course. The Part II course includes an Honours Year, to give students an opportunity to explore further the application of scientific method in clinical practice. One project, in which students were involved in physiological measurement used in current obstetric practice, is described here. In addition to carrying out practical tasks, students were required to submit written reports and to prepare a learning resource on fetal acid-base balance for use by their junior colleagues. Supervision was provided by obstetric and paediatric registrars and senior house officers, and senior midwives, while staff in the Department of Physiology and Pharmacology assisted students with data analysis. Each project task was assessed by a supervisor and an independent observer. The project proved acceptable to students, supervisors and hospital staff, and avoided interfering with the other responsibilities of a busy obstetric unit. It is intended to repeat the exercise with minor modifications.

Effects of dietary carbohydrate on cholesterol metabolism in rats and rabbits.

Semipurified diets produce a marked hypercholesterolemia in rabbits and tend to elevate the level of plasma cholesterol in rats. They also decrease rates of oxidation of [26-14C]cholesterol to respiratory 14CO2 and excretion of label in fecal lipid, compared with commercial feed. In both species, the hypercholesterolemia was prevented and the rate of oxidation of [26-14C]cholesterol increased by using unmodified potato starch as the carbohydrate component of the semipurified diets. Potato starch was poorly digested by rats but appeared to be well utilized by rabbits. A semipurifed diet containing cooked potato starch gave results in rats comparable to those obtained with diets containing other types of carbohydrate. Cooked potato starch produced diarrhea in rabbits, thus complicating interpretation of the results. When the diarrhea was treated with antibiotics, the results were similar to those obtained with other carbohydrates. Rats fed commercial diet which had been heated in an oven or autoclaved had higher plasma levels than those fed untreated commercial diet but no significant differences in rates of oxidation or excretion of cholesterol were observed.

Dietary fiber and cholesterol metabolism in rabbits and rats.

Rabbits fed semipurified diets have elevated plasma cholesterol levels, and they oxidize [26-14C]cholesterol to expired 14CO2 more slowly than rabbits on a natural ingredient diet. Addition of several different types of fibrous material to a semipurified diet failed to prevent the hypercholesterolemic response. Rats on semipurified diets also oxidized [26-14C]cholesterol more slowly and tended to have somewhat higher plasma cholesterol levels than rats on commercial feed. Cholesterol oxidation was not stimulated by addition of fibrous materials to the semipurified diet, but rats fed a semipurified diet containing raw potato starch oxidized cholesterol at a rate comparable to that of rats on commercial diet. Raw potato starch was poorly digested by the rats. Cooked potato starch was well digested and failed to stimulate the rate of oxidation of cholesterol. A semipurified diet containing raw potato starch did not produce a hypercholesterolemic response in rabbits, even though the raw starch was well digested.