A mass shooting at Port Arthur, Tasmania, Australia: a study of its impact on early pregnancy losses using a conception time-based methodology.

STUDY QUESTION: Does an acute calamity in a community cause early miscarriage and is this association the same for male and female fetuses? SUMMARY ANSWER: Estimated losses of 29.5% of first trimester pregnancies in the affected region could be associated with an acute calamity, with no statistically significant difference in estimated losses by fetal sex. WHAT IS KNOWN ALREADY: There are very few studies on the impact of a calamity on early pregnancy loss and its differential effects on male and female fetuses. A decline in the human sex ratio at birth associated with the events of 9/11 in New York has been documented. STUDY DESIGN, SIZE, DURATION: This is a retrospective descriptive study of birth register data in Tasmania, Australia, from 1991 to 1997, covering the period in which the calamity occurred. The register contains data on all pregnancies that proceeded to >20 weeks gestation. The conception date was calculated by subtracting gestational age from birth date. We estimated that 40 318 pregnancies were conceived in the period 1991-1996 inclusive. These were aggregated to 4-weekly blocks classified by region and sex. PARTICIPANTS/MATERIALS, SETTING, METHODS: The acute calamity was at Port Arthur, Tasmania, Australia. On 28 April 1996, a gunman opened fire on visitors and staff in a tourist cafe. A very stressful 20 h period, ended with 35 people dead and 22 injured. A negative binomial regression model was used to assess the association between this calamity and pregnancy loss. This loss is evidenced by a shortfall in the registration of pregnancies that were in their first trimester at the time of the calamity. MAIN RESULTS AND THE ROLE OF CHANCE: We estimated a shortfall of 29.5% or 229 registered pregnancies among those in the first trimester at the time of the calamity (P < 0.001), in the region surrounding the calamity site. There was no sex effect in this shortfall (P = 0.911). There was no corresponding shortfall in other parts of Tasmania (P = 0.349). LIMITATIONS, REASONS FOR CAUTION: The study is descriptive and cannot produce causal inferences. These first trimester miscarriages are estimated statistically and it is understood that gestational age is an estimate. The use of maternal residential postcodes at birth as a surrogate for geographic area or space assumes that the mother has not moved into the postcode area after the calamity and before the reporting of a birth. WIDER IMPLICATIONS OF THE FINDINGS: The results of this study suggest that calamities bring about significant pregnancy loss affecting both sexes. The methodology presented of inferring conception date from birth date and using this for analysis, provides a more accurate assessment of first trimester pregnancy losses than raw birth data or sex ratio at birth.

Management of subsequent pregnancy after an unexplained stillbirth.

PURPOSE: To review the management of pregnancy after an unexplained stillbirth. EPIDEMIOLOGY: Approximately 1 in 200 pregnancies will end in stillbirth, of which about one-third will remain unexplained. Unexplained stillbirth is the largest single contributor to perinatal mortality. Subsequent pregnancies do not appear to have an increased risk of stillbirth, but are characterized by increased rates of intervention (induction of labor, elective cesarean section) and iatrogenic adverse outcomes (low birth weight, prematurity, emergency cesarean section and post-partum hemorrhage). CONCLUSIONS: There is no level-one evidence to guide management in this situation. Pre-pregnancy counseling is very important to detect and correct potential risk factors such as obesity, smoking and maternal disease. As timely delivery is the mainstay of management, early accurate determination of gestational age is vital. There is controversy regarding the pattern of surveillance, but evidence exists only for ultrasound and not for regular non-stress testing, nor formal fetal movement charting. There is an urgent need for more studies in this important area.

Vibroacoustic stimulation for fetal assessment in labour in the presence of a nonreassuring fetal heart rate trace.

BACKGROUND: Fetal vibroacoustic stimulation is a simple, non-invasive technique where a device is placed on the maternal abdomen over the region of the fetal head and sound is emitted at a predetermined level for several seconds. It is hypothesized that the resultant startle reflex in the fetus and subsequent fetal heart rate acceleration or transient tachycardia following vibroacoustic stimulation provide reassurance of fetal well-being. This technique has been proposed as a tool to assess fetal well-being in the presence of a non-reassuring cardiotocographic trace during the first and second stages of labour. OBJECTIVES: To evaluate the clinical effectiveness and safety of vibroacoustic stimulation in the assessment of fetal well-being during labour, compared with mock or no stimulation for women with a singleton pregnancy exhibiting a non-reassuring fetal heart rate pattern. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (January 1966 to January 2005), EMBASE (January 1966 to January 2005) and reference lists of all retrieved articles. We sought unpublished trials and abstracts submitted to major international congresses and contacted expert informants. SELECTION CRITERIA: All published and unpublished randomised trials that compared maternal and fetal/neonatal/infant outcomes when vibroacoustic stimulation was used to evaluate fetal status in the presence of a non-reassuring cardiotocographic trace during labour, compared with mock or no stimulation. DATA COLLECTION AND ANALYSIS: Two independent review authors identified potential studies from the literature search and assessed them for methodological quality and appropriateness of inclusion, using a data extraction form. Attempts to contact study authors for additional information were unsuccessful. MAIN RESULTS: The search strategies yielded six studies for consideration of inclusion. However, none of these studies fulfilled the requirements for inclusion in this review. AUTHORS' CONCLUSIONS: There are currently no randomised controlled trials that address the safety and efficacy of vibroacoustic stimulation used to assess fetal well-being in labour in the presence of a non-reassuring cardiotocographic trace. Although vibroacoustic stimulation has been proposed as a simple, non-invasive tool for assessment of fetal well-being, there is insufficient evidence from randomised trials on which to base recommendations for use of vibroacoustic stimulation in the evaluation of fetal well-being in labour in the presence of a non-reassuring cardiotocographic trace.

Breast cancer in premenopausal women: recurrence and survival rates and relationship to hormone replacement therapy.

OBJECTIVES: To determine any association between hormonal replacement therapy (HRT) usage and breast cancer recurrence and survival rates in women who were premenopausal at the time of diagnosis of breast cancer. METHODS: The study group comprised 524 women who were diagnosed with breast cancer when they were premenopausal. Of these, 277 women reached menopause before recurrence of the disease, being lost to follow-up, or reaching the end of the study. In this group, 119 women took HRT to control menopausal symptoms. The majority took combined continuous estrogen-progestin treatment. Times from diagnosis to cancer recurrence or new breast cancer, to death from all causes, and to death from primary tumor were compared between HRT users and non-users. RESULTS: Women who used HRT after their menopause had an adjusted relative risk of recurrence or new breast cancer of 0.75 (95% confidence interval (CI), 0.29-1.95) compared to that of non-users. The relative risk of death from all causes was 0.36 (95% CI, 0.11-1.16) and that of death from primary tumor was 0.24 (95% CI, 0.05-1.14). CONCLUSION: HRT use in women who were premenopausal at the diagnosis of primary invasive breast cancer is not associated with worse outcomes in terms of breast cancer recurrence or mortality.

Quality of life of breast cancer survivors: the impact of hormonal replacement therapy.

OBJECTIVES: The aims of this non-randomized qualitative study were to compare the quality of life (QOL) of breast cancer survivors who received hormone replacement therapy (HRT) and those who did not, and to describe the impact of breast cancer on their social, physical, psychological and spiritual domains. A QOL self-evaluation questionnaire was used to determine the most important concerns and changes described by women that affected, or were likely to affect, their QOL as a result of breast cancer. METHODS: In total, 220 patients who had finished treatment for breast cancer were contacted; 190 agreed to participate, of whom 123 (64.8%) completed and returned their questionnaires, which comprised demographic data, Quality of Life Breast Cancer Version Questionnaire and Quality of Life Self Evaluation Questionnaire. The results for women taking HRT were compared with results for those who were not. RESULTS: There were no significant differences in time between surgery for breast cancer and the survey, age at last birthday, number of pregnancies and live births, employment, breast cancer surgery and adjuvant therapy between HRT and non-HRT groups. No differences were found in the social, physical, psychological and spiritual domains between the two groups; however, significant differences were found between survival time and quality of life in some domains. During the study, none of the 123 women developed a recurrence of their breast cancer. CONCLUSION: There were no significant differences in any demographic variables between the users of HRT and the non-users. The same level of QOL was observed between HRT and non-HRT groups in the four domains of well-being. The majority of women with breast cancer recovered to a near normal level of QOL after a 4-year adjustment period, and lead fulfilling lives. This adjustment period cannot be quantified, as individual factors such as emotional, social and financial concerns will differ for each individual.

Donor insemination: attitudes of parents towards disclosure.

OBJECTIVE: To determine attitudes of parents of children conceived by donor insemination to telling the children of their origin. DESIGN: Questionnaire survey, in 1992-1993, of parents who had had a child by donor insemination at four New South Wales clinics from 1979 to 1990. SETTING: Three hospital-based clinics (two public, one private) and a private clinic service. PARTICIPANTS: 276 families who altogether had had 420 children by donor insemination. MAIN OUTCOME MEASURES: Number of children told that they had been conceived by donor insemination; parents' intentions, before conceiving and after the birth, of informing the child; and whether other people were informed of the child's origin. RESULTS: Of 393 families who could be contacted, 353 agreed to participate and 276 (70%) replied to the questionnaire. Only 22 of the 420 children (5.2%) had been informed of their origin. Before conceiving, 18% of parents (49/273) planned to tell the child. Seventy-one per cent of families (182/257) had told others of the origin of the child, but 94% (241/257) had not told the child. Of the 29% of families (75/257) who had not told others of the child's origins, none had told the child. As the children grow older, more parents decide not to tell them of their origin. CONCLUSIONS: Most parents of children conceived by donor insemination do not plan to tell their child, but most of these parents have told others, creating the potential for accidental disclosure. Because of the small number of children who are told of their origin, there may not be a need for government-regulated donor registers, provided donor insemination units maintain a high standard of record-keeping.

Donor insemination: effects on parents.

OBJECTIVE: To examine the psychosocial effects of donor insemination on couples. DESIGN: Questionnaire survey of couples who had a child by donor insemination at four NSW clinics over a 15-year period. RESULTS: Forty-seven per cent of couples thought their marriage had improved, while 3% thought their marriage had deteriorated as a result of having a child by donor insemination. Seventy-six per cent felt it had a positive personal effect and almost all couples had no regrets about having a child this way. Over 90% of respondents felt very close to these children. In those who also had children not conceived by donor insemination (60 couples), men were significantly closer to their children by donor insemination than to their "other" children (P < 0.001). There was a significant sex difference in perceptions of the child's resemblance (P < 0.0001): 61% of women thought their child conceived by donor insemination resembled their partner, while 89% of men thought the child resembled their partner. Twenty-one per cent of couples were concerned about having to tell the child about donor insemination. CONCLUSION: Donor insemination can have positive psychosocial effects on couples and close relationships exist between the parents and their children conceived by donor insemination. The concern about the physical appearance of children conceived by donor insemination can be allayed by our finding that the majority of couples see a resemblance between the child and their partner.

Continuous intrapartum fetal monitoring: a prospective randomized comparison of 2 types of fetal scalp electrode.

This trial was conducted to compare 2 commonly used fetal scalp electrodes with regard to ease of use, frequency and extent of neonatal injury and quality of cardiotocographic record. A randomized design was employed to study a group of 106 patients divided between a Surgicraft Copeland clip fetal scalp electrode (52 patients) and a Meditrace spiral single helix scalp electrode (54 patients). Patients were eligible for trial entry if they required an intrapartum fetal scalp electrode, at term with a singleton cephalic pregnancy. Ease of application was rated by the operator using a linear analogue score. Unidentified traces were reviewed independently for quality by 2 obstetricians and neonates were examined on day-2 postpartum for injury. The Meditrace spiral fetal scalp electrode was significantly easier to apply (unpaired t-test p < 0.02). It also obtained higher ratings for trace quality (unpaired t-test p < 0.02). There were no serious neonatal injuries and no difference was found between the 2 electrodes in this regard.

Vaginal delivery after caesarean section.

In a prospective study of 318 consecutive pregnancies complicated by previous Caesarean section, 193 (61%) had an elective repeat Caesarean section, 125 (39%) had a trial of labour and 80 (64%) of these women achieved a vaginal delivery. The incidence of uterine rupture was 0.8% (1 of 125). The vaginal delivery rate was not influenced by the indication for the first Caesarean section (including cephalopelvic disproportion), birth-weight, health insurance status, use of epidural analgesia or oxytocin in labour. Perinatal morbidity was unaffected by the mode of delivery and maternal morbidity was comparable following elective and emergency repeat Caesarean section. Patients having a vaginal deliver spent significantly less time in hospital. We conclude that vaginal delivery after lower segment Caesarean section is safe and should be considered in most patients after a critical review of the indication for the first Caesarean section.

The use of clearplan home ovulation detection kits in unexplained and male factor infertility.

One hundred and five couples with unexplained infertility and 43 couples whose infertility was thought to be due to reduced sperm motility were recruited. The median duration of infertility was 36 months (range 12-168). Couples were randomly allocated to either using Clearplan home ovulation detection kits for 3 cycles or were advised about the optimal time during their menstrual cycle to achieve a pregnancy. The clinical details of the 2 groups were similar. In couples with unexplained infertility over the study period 10 (20.4%) in the Clearplan group and 9 (16%) in the control group conceived with 58% of pregnancies occurring in the first cycle. In couples with reduced sperm motility, the results were disappointing with only 2 (8%) pregnancies in the Clearplan group and 2 (11.1%) in the controls. Assisted reproduction technology may not be justified as the first line of management in patients with unexplained infertility.

The clinical value of Clearplan home ovulation detection kits in infertility practice.

A home ovulation testing kit, Clearplan, that detects the urinary luteinizing hormone (LH) surge was used by 32 patients on a donor insemination programme for 50 cycles to indicate when to first attend the clinic for a serum LH test to determine ovulation. Using Clearplan significantly reduced the number of clinic attendances (4.06 +/- 1.5) compared to the preceding control cycle (7.06 +/- 2.0 p less than 0.001). One serum LH peak was missed using Clearplan. Ovulation was predicted within 2 days of the serum LH surge in 77% of cycles. Home ovulation determination has the potential to reduce the stress and cost of fertility programmes.

The effect of ethanol on habituation and the cardiovascular response to stimulation in fetal sheep.

Fetal cardiovascular (CVS) changes, forelimb movements (FM) and rates of habituation to repeated stimulation, with suffusions of cold saline over the skin, were measured in 12 chronically catheterized fetal sheep aged 130-145 days. Stimulation of the fetuses caused a significant rise in heart rate (HR) (p less than 0.01) and blood pressure (BP) (p less than 0.001) and FM (p less than 0.01). When the ewe was given an intravenous (i.v.) infusion of ethanol which produced fetal ethanol levels of 87 +/- 1.1 mg/100 ml, the number of spontaneous FM decreased (p less than 0.05). After i.v. ethanol, repeated stimulation of the fetuses still caused an increase in FM (p less than 0.01) and a rise in HR (p less than 0.05) and BP (p less than 0.02) but the fetuses habituated more rapidly (7.25 +/- 1.28 stimuli) compared to control experiments performed prior to (21.5 +/- 3.57 stimuli) or after the ethanol (17.75 +/- 5.83, p less than 0.01). Fetal exposure to low concentrations of ethanol does affect the patterns of response and habituation of the developing fetal central nervous system.

Effect of hypoxia and catecholamines on the habituation rates of chronically catheterized ovine fetuses.

Integrated electromyographic, electrocortical (ECoG) and electro-ocular activity were recorded in 13 chronically prepared fetal sheep (130-145 days). Fetal movements and the rate of habituation to repeated suffusions of cold saline against the fetal skin were recorded. Experiments were repeated during an intravenous infusion of noradrenaline to the fetus (0.4 microgram/kg estimated fetal weight/min) and during hypoxia induced by altering the oxygen content of the inspired air to the ewe to 9%. Repeated stimulation with cold saline resulted in an increase in fetal movements (p = 0.009). The number of stimuli for habituation was similar in high-voltage and in low-voltage ECoG activity. The rate of fetal habituation was significantly faster during the infusion of noradrenaline compared with control measurements (p = 0.009). During hypoxia, the number of spontaneous fetal movements prior to stimulation decreased (p = 0.002). Habituation rates were also faster during hypoxemia compared with control measurements (p = 0.003). These findings may help to explain the rapid habituation rates seen in some human fetuses in at 'at risk' pregnancies.

The changes in fetal habituation patterns due to a decrease in inspired maternal oxygen.

Habituation is widely regarded as a basic form of learning. A fully functioning central nervous system is probably required for a normal habituation pattern. Habituation of the behavioural response to vibroacoustic stimulation was studied in 23 normal human fetuses whose gestational age was 36 or more weeks. Eighteen were tested whilst their mothers breathed either air or a 12% oxygen in nitrogen mixture. The test was repeated the following day with the order of the gases reversed. In addition five fetuses were tested while their mothers breathed air on both occasions. Of the 18 fetuses 17 had a normal habituation pattern when tested in air but only two had a normal pattern when their mothers breathed 12% O2. Four of the five fetuses tested both days in air had normal patterns on the second day. Altering the amount of inspired maternal O2 alters the fetal habituation pattern.

Measurement of fetal responses to vibroacoustic stimuli. Habituation in fetal sheep.

Electrocortical (ECoG) and integrated electromyographic (EMG) activity was recorded in 6 chronically prepared fetal sheep (132-145 days). Recording were made in fetuses prior to and during repeated vibroacoustic stimulation. In the undisturbed fetus, two patterns of ECoG activity were apparent; high (HV) and low voltage (LV). The fetus responded to this broad spectrum stimulus during both LV and HV ECoG activity. In 18 of the 20 experiments, repeated stimulation was not associated with a change in the background ECoG activity. All fetuses responded at least once to the stimulus. Habituation of the EMG response was observed during both HV and LV ECoG activity. The rate of habituation was independent of the background ECoG activity and was unchanged when experiments were repeated at intervals of more than 3 days. These results show that fetal sheep also respond to vibroacoustic stimulation and with repetition habituation occurs.

Fetal responses to vibrotactile stimulation, a possible predictor of fetal and neonatal outcome.

This study measured the antenatal fetal heart rate changes in response to a single vibrotactile stimulus. In a group of 11 normal patients, this resulted in a significant change in the fetal heart rate (P less than 0.001). Sixty-eight high risk patients were also tested. In the group of 25 patients whose fetuses showed no response to the stimulus, there were 4 stillbirths and 4 neonatal deaths; 23 of these 25 infants were small for gestational age (SGA) compared to only 15 of the 43 that showed a response to the stimulus. Fetal habituation to a repeated vibrotactile stimulus was measured in a control group of 40 patients who had a normal antepartum and intrapartum course and delivered infants in an optimal condition. The same was done in a study group of 48 patients who delivered infants that were SGA. These infants were assessed at 1 year of age by the Griffiths Mental Developmental Scale (GMDS). Infants that were SGA did not differ significantly from the control group. However, infants who had a normal antenatal habituation pattern had a significantly better performance (P less than 0.01) compared to infants who had an abnormal antenatal habituation pattern.

The assessment and significance of habituation to a repeated stimulus by the human fetus.

Habituation is the progressive decrease in response by an organism when it is stimulated repeatedly. This process is a basic form of learning and a normal pattern may be one indication of intact central nervous system function. This study assessed habituation of a behavioral response by the human fetus to repeated vibrotactile stimuli. Of the 40 normal fetuses studied 37 habituated after 10 to 50 stimuli. The gestational age at which the fetus first responded to the stimulus ranged from 22 to 30 weeks. Female fetuses responded 2 weeks earlier than males. The possible value of this assessment in obstetrical practice is presented.

Fetal habituation in high-risk pregnancies.

Habituation is a basic form of learning and probably requires an intact central nervous system. Habituation in the behavioural response to vibration in 40 normal human fetuses was compared with that in a group of high-risk pregnancies with an increased risk of fetal neurological damage. Highly significant differences in habituation patterns between the high-risk groups and normal control subjects were found. This test may offer a method of assessing the integrity of the fetal central nervous system.

Fetal movements and fetal outcome: a prospective study.

Two hundred sixty-four antenatal patients were monitored by maternal observation of fetal movements to predict fetal condition at birth. Abnormal fetal movements were significantly associated with fetal death as well as with poor fetal condition at birth. The sensitivity, specificity, and predictive value of monitoring abnormal fetal movements are presented. The mean weekly count decreased with advanced gestational age but not predictably so in each patient. Fetal outcome was studied prospectively in 138 patients with normal fetal movements and 23 patients with abnormal movements at term. Perinatal outcome was significantly poorer in the group with abnormal movements (P = .0015). Cognizance should be taken of patients reporting a decrease in fetal activity at term, as this may include fetal compromise.