Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse.

OBJECTIVE: To undertake a five year follow up of a cohort of women and children delivered by forceps or vacuum extractor in a randomised controlled study. DESIGN: Follow up of a randomised controlled trial. SETTING: District general hospital in the West Midlands. POPULATION: Follow up questionnaires were sent to 306 of the 313 women originally recruited at the North Staffordshire Hospital to a randomised controlled study comparing forceps and vacuum extractor for assisted delivery. Two hundred and twenty-eight women responded (74.5%) and all were included in the study; forceps (n = 115) and vacuum extractor (n = 113). MAIN OUTCOME MEASURES: Bowel and urinary dysfunction, child vision assessment, and child development. RESULTS: Maternal adverse symptoms at long term follow up were relatively common. Urinary incontinence of various severity was reported by 47%, bowel habit urgency was reported by 44% (98/225), and loss of bowel control 'sometimes' or 'frequently' by 20% of women (46/226). No significant differences between instruments were found in terms of either bowel or urinary dysfunction. Overall, 13% (20/158) of children were noted to have visual problems. There was no significant difference in visual function between the two groups: ventouse 11/86 (12.8%), compared with forceps 9/72 (12.5%); odds ratio 0.97, 95% CI 0.38-2.50. Of the 20 children with visual problems, a family history was known in 18, and 17/18 (94%) had a positive family history for visual problems. No significant differences in child development were found between the two groups. CONCLUSIONS: There is no evidence to suggest that at five years after delivery use of the ventouse or forceps has specific maternal or child benefits or side effects.

Indigenous health - a role for private general practice.

BACKGROUND: The Aboriginal and Torres Strait Islander life expectancy gap is associated with lower primary care usage by Indigenous Australians. Many Indigenous Australians regard private general practitioners as their usual source of healthcare. However, a range of barriers results in relatively low access to primary care, with subsequent inadequate prevention and management of chronic disease. Indigenous primary care requires development of a set of attributes by the GP. Clinician autonomy may need to be tempered to be responsive to the needs of local indigenous communities. OBJECTIVE: A partnership between an urban indigenous community and a private general practice is described. DISCUSSION: Over a period of 1 year, registered indigenous patients at the private general practice clinic increased from 10 to 147; monthly attendance increased from five to 40 (p<0.001). Local engagement between private practices and indigenous communities may be implemented widely to reduce the primary care gap.

Behavioural phenotyping of sodium-myo-inositol cotransporter heterozygous knockout mice with reduced brain inositol.

Inositol plays a key role in dopamine, serotonin, noradrenaline and acetylcholine neurotransmission, and inositol treatment is reported to have beneficial effects in depression and anxiety. Therefore, a reduction in brain intracellular inositol levels could be a cause of some psychiatric disorders, such as depression or anxiety. To determine the behavioural consequences of inositol depletion, we studied the behaviour of sodium-dependent myo-inositol cotransporter-1 heterozygous knockout mice. In heterozygous mice, free inositol levels were reduced by 15% in the frontal cortex and by 25% in the hippocampus, but they did not differ from their wild-type littermates in cholinergic-mediated lithium-pilocarpine seizures, in the apomorphine-induced stereotypic climbing model of dopaminergic system function, in the Porsolt forced-swimming test model of depression, in amphetamine-induced hyperactivity, or in the elevated plus-maze model of anxiety. Reduction of brain inositol by more than 25% may be required to elicit neurobehavioural effects.

Calmodulin-binding peptide PEP-19 modulates activation of calmodulin kinase II In situ.

PEP-19 is a 6 kDa polypeptide that is highly expressed in select populations of neurons that sometimes demonstrate resistance to degeneration. These include the granule cells of the hippocampus and the Purkinje cells of the cerebellum. Its only identified activity to date is that of binding apo-calmodulin. As a consequence, it has been demonstrated to act as an inhibitor of calmodulin-dependent neuronal nitric oxide synthase in vitro, although PEP-19 regulation of calmodulin-dependent enzymes has never been characterized in intact cells. The activation of the calmodulin-dependent enzyme calmodulin kinase II (CaM kinase II) was studied in PC12 cells that had been transfected so as to express physiological levels of PEP-19. The expression of PEP-19 yielded a stable phenotype that failed to activate CaM kinase II upon depolarization in high K(+). However, CaM kinase II could be fully activated when calcium influx was achieved with ATP. The effect of PEP-19 on CaM kinase II activation was not attributable to changes in the cellular expression of calmodulin. The cellular permeability of the transfected cells to calcium ions also appeared essentially unchanged. The results of this study demonstrated that PEP-19 can regulate CaM kinase II in situ in a manner that was dependent on the stimulus used to mobilize calcium. The selective nature of the regulation by PEP-19 suggests that its function is not to globally suppress calmodulin activity but rather change the manner in which different stimuli can access this activity.

Concerted inhibition of NADP+-specific isocitrate dehydrogenase by oxalacetate and glyoxylate. I. Oxalomalate formation and stability, and nature of the enzyme inhibition.

Oxalacetate and glyoxylate are each weak inhibitors of NADP+-specific isocitrate dehydrogenase (threo-DS-isocitrate:NADP+ oxidoreductase (decarboxylating), EC 1.1.1.42)9 Together, however, they act in a concerted manner and strongly inhibit the enzyme. The rates of formation and dissociation of the enzyme inhibitor complex, and the rate of formation and the stability of the aldol condensation product of oxalacetate and glyoxylate, oxalomalate, were examined. The data obtained do not support the often suggested possibility that oxalomalate, per se, formed non-enzymatically in isocitrate dehydrogenase assay mixtures containing oxalacetate and glyoxylate, is responsible for the observed inhibition of the enzyme. Rather, the data presented in this communication suggest that oxalacetate binds to the enzyme first, and that the subsequent binding of glyoxylate leads to the formation of a catalytically inactive enzyme-inhibitor complex.

Assay and characterization of IgG binding to endodermal cells of the fetal rabbit yolk sac membrane.

The transfer of passive immunity in the rabbit is mediated by the fetal yolk sac membrane (YSM) and is initiated by the specific binding of IgG to receptors on the microvillar surface of the endoderm from the YSM. This report describes the preparation of suspensions of endodermal absorptive cells of the YSM and their use in equilibrium binding experiments to characterize the nature of the binding reaction. Equilibrium binding is achieved in 4 h at 4 degrees C. The system is more rapid than, affords greater reproducibility of binding data than, and utilizes only about 1/10 the amount of YSM and ligand as the YSM disc assay system (Tsay and Schlamowitz, 1975) used previously. A Scatchard plot of the binding data over a wide range of IgG concentration was non-linear implying the presence of at least 2 binding elements. Apparent binding constant values for the stronger and weaker binding components in this population differed by about 50-fold. For the weaker binding system, binding decreased when temperature was increased indicating that the reaction was not entropy-driven (i.e., dominated by hydrophobic 'forces') and that ionic interactions might be a major factor. At low ionic strengths the measurement of specific binding was complicated by the effects of secondary ionic interactions. At physiological ionic strength the binding of IgG was species-specific.

Identification of a neuronal calmodulin-binding peptide, CAP-19, containing an IQ motif.

Neurons produce polypeptides which can bind the calcium-poor or pre-activated form of calmodulin. It is expected that this class of peptide will serve an important role in maintaining cellular homeostasis since it would modulate calcium-dependent target regulation and redirect intracellular signaling. The lack of conserved sequence has made the identification of these peptides difficult, consequently leading us to exploit their property of binding calcium-poor calmodulin as a means of finding new species. A new peptide termed Calmodulin-Associated Peptide-19 (CAP-19) was purified and characterized. The protein-sequence information was employed in order to recover a cDNA clone from rat which included the entire reading frame for the peptide. Like its counterparts, neuromodulin (GAP-43), neurogranin (RC3) and PEP-19, it contains an IQ motif although the remainder of the peptide is quite different. Northern blot analysis of ribonucleic acid (RNA) from animals of differing ages indicated that the message appears at birth and then persists into adulthood. Antibodies to synthetic peptide were employed for localizing CAP-19. The results indicated that the peptide was localized to neurons in several brain regions. CAP-19 is similar to other calmodulin-binding proteins in that the domain spanning the IQ motif was demonstrated to participate in binding to calmodulin. Database searching showed CAP-19 to be homologous to the silkworm protein, multiprotein bridging factor 1 (MBF1). This homology suggests a potential new role for calmodulin-associated proteins in cellular homeostasis.

Expression of PEP-19 inhibits apoptosis in PC12 cells.

PEP-19 is a calmodulin-regulatory protein found specifically within neurons, though cellular functions of this protein have not been determined. In an effort to define potential effects of PEP-19, PC12 cell lines expressing this protein were generated and subjected to apoptotic stimuli. As measured by LDH release, cell death in PEP-19 expressing cells was 2- to 5-fold less following u.v. irradiation, and 2- to 4-fold less following staurosporine treatment than controls. Additionally, PEP-19-expressing cells displayed decreased DNA ladder formation, chromatin and condensation, caspase activation following staurosporine treatment. Overall, these results demonstrate that PEP-19 can inhibit apoptotic processes in PC12 cells, suggesting a potential regulatory mechanism for pathways leading to cell death.

Role of magnesium sulfate in seizure prevention in patients with eclampsia and pre-eclampsia.

Eclampsia is a leading cause of maternal mortality. The prevention of seizure activity in pre-eclampsia and recurrent seizures in eclamptic patients is an essential aspect of management. Many drugs with anticonvulsant properties have been used to treat patients with pre-eclampsia and eclampsia. Magnesium sulfate is a significantly better drug than either diazepam or phenytoin for preventing recurrent seizures in eclamptic patients. Magnesium sulfate has diverse cardiovascular and neurological effects and also alters calcium metabolism. Although the drug crosses the placenta and may affect the fetus, these effects are clinically small and fetal morbidity has been shown to be reduced in randomised studies comparing magnesium sulfate to either phenytoin or benzodiazepines. Dosage regimens of magnesium sulfate are empirical. Because adverse effects of this agent are related to toxicity, the establishment of greater efficacy by using higher dosage regimens needs to be tested against a greater risk of adverse effects. The most serious toxicity related to magnesium sulfate use is magnesium sulfate use is neuromuscular blockade that may result in respiratory arrest. Magnesium sulfate is now the drug choice for treating eclamptic patients. However, further studies are required to establish the role of this agent as a prophylactic agent in the prevention of eclampsia.

Haemodynamic, invasive and echocardiographic monitoring in the hypertensive parturient.

AIM: To determine the clinical usefulness of invasive and non-invasive haemodynamic assessment in pre-eclampsia. METHOD: A systematic review of the literature was undertaken, using a MEDLINE electronic search using a combination of MESH headings and textwords. Over 1500 abstracts were perused; we obtained 156 full papers that were related to the subject matter. Of the full papers, 55 yielded relevant information. Hand-searching the reference lists of the retrieved papers completed the search. RESULTS: There are no data from randomized controlled clinical trials illustrating the clinical usefulness of pulmonary artery catheters or echocardiographic techniques in hypertensive pregnancy. There are a wealth of data illustrating the haemodynamic profiles of both untreated and treated pre-eclamptic women. Data are also available comparing right heart and left heart filling pressures, demonstrating a relatively poor correlation between the two values. The clinical impact of either measurement is unclear. Data are available illustrating the correlation between echocardiographic techniques and pulmonary artery catheterization.

Techniques for performing caesarean section.

In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the most commonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV. The skin incision and entry into abdominal cavity is best achieved by the modified Cohen's incision. The lower segment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England.Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomized trials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in difficult deliveries.

Outcome in low risk pregnancies.

AIMS: To determine the obstetric and neonatal outcomes of a cohort of very low risk pregnancies in hospital, that would be suitable for home delivery. METHODS: A retrospective analysis was undertaken of computerised records covering five years from July 1988 to August 1993 of 32424 pregnant women who delivered at the North Staffordshire Maternity Hospital, Stoke on Trent, during that period. RESULTS: Of 32424 deliveries, only 1314 (4%) fulfilled our criteria for being low risk. Sixty seven (5.1%) of the low risk group had an operative delivery, with Caesarean section accounting for 32 (2.4%) cases, 16 (23.9%) babies were resuscitated and three were intubated. A normal vaginal delivery occurred in 1245 women, but a paediatrician attended 122 births (9.22%), assisted ventilation was provided in 65 cases (5.2%), and five babies were intubated (0.4%). Fourteen babies in total were admitted to the neonatal unit and one died. CONCLUSIONS: These results suggest that at least 5% of women suitable for delivery at home will require transfer in labour. Midwives attending home births must be skilled in bag and mask resuscitation as only rarely will an urgent intubation be required. The British Paediatric Association Working Party report on neonatal resuscitation suggests a need for resuscitation in only 0.2% of low risk deliveries: but these findings suggest that the need is greater.

Pre-eclampsia, diagnosis and treatment.

Pre-eclampsia is a multisystem disorder of pregnancy usually associated with raised blood pressure (BP) and proteinuria. The pathogenesis is not understood despite decades of research. Abnormal placentation related to immune mechanisms and maladaptation of the placenta may be the first step in the development of the disease. Although there are a number of risk factors and new innovatory tests (e.g., uterine artery Doppler) which can be used to predict pre-eclampsia, none fulfils standard diagnostic criteria. Of possible prophylactic value are antiplatelet agents, calcium supplementation and vitamins C and E. Prevention of eclampsia with magnesium sulfate is the subject of a current international randomised controlled trial (RCT), known as MAGPIE. Therapeutic strategies include avoidance of hypertensive injury and delivery of the baby and placenta. Further research into specific antihypertensive agents and conservative management strategies is required.

Soft versus rigid vacuum extractor cups for assisted vaginal delivery.

BACKGROUND: The original cups used for vacuum extraction delivery of the fetus were rigid metal cups. Subsequently, soft cups of flexible materials such as silicone rubber or plastic were introduced. Soft cups are thought to have a poorer success rate than metal cups. However they are also thought to be less likely to be associated with scalp trauma and less likely to injure the mother. OBJECTIVES: The objective of this review was to assess the effects of soft versus rigid vacuum extractor cups on perineal injury, fetal scalp injury and success rate. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: February 2000. SELECTION CRITERIA: Acceptably controlled comparisons of soft versus rigid vacuum extractor cups. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Nine trials involving 1375 women were included. The trials were of average quality. Soft cups are significantly more likely to fail to achieve vaginal delivery (odds ratio 1.65, 95% confidence interval 1.19 to 2.29). However, they were associated with less scalp injury (odds ratio 0.45, 95% confidence interval 0.15 to 0.60). There was no difference between the two groups in terms of maternal injury. REVIEWER'S CONCLUSIONS: Metal cups appear to be more suitable for 'occipito-posterior', transverse and difficult 'occipito-anterior' position deliveries. The soft cups seem to be appropriate for straightforward deliveries.

Absorbable synthetic versus catgut suture material for perineal repair.

BACKGROUND: Approximately 70% of women will experience some degree of perineal trauma following vaginal delivery and will require stitches. This may result in perineal pain and superficial dyspareunia. OBJECTIVES: The objective of this review was to assess the effects of absorbable synthetic suture material as compared with catgut on the amount of short and long term pain experienced by mothers following perineal repair. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. SELECTION CRITERIA: Randomised trials comparing absorbable synthetic (polyglycolic acid and polyglactin) with plain or chromic catgut suture for perineal repair in mothers after vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. MAIN RESULTS: Eight trials were included. Compared with catgut, the polyglycolic acid and polyglactin groups were associated with less pain in first three days (odds ratio 0.62, 95% confidence interval 0.54 to 0.71). There was also less need for analgesia (odds ratio 0.63, 95% confidence interval 0.52 to 0.77) and less suture dehiscence (odds ratio 0.45, 95% confidence interval 0.29 to 0.70). There was no significant difference in long term pain (odds ratio 0.81, 95% confidence interval 0.61 to 1.08). Removal of suture material was significantly more common in the polyglycolic acid and polyglactin groups (odds ratio 2.01, 95% confidence interval 1.56 to 2.58). There was no difference in the amount of dyspareunia experienced by women. REVIEWER'S CONCLUSIONS: Absorbable synthetic suture material (in the form of polyglycolic acid and polyglactin sutures) for perineal repair following childbirth appears to decrease women's experience of short-term pain. The length of time taken for the synthetic material to be absorbed is of concern. A trial addressing the use of polyglactin has recently been completed and this has been included in this updated review.

Vacuum extraction versus forceps for assisted vaginal delivery.

BACKGROUND: Proponents of vacuum delivery argue that it should be chosen first for assisted vaginal delivery, because it is less likely to injure the mother. OBJECTIVES: The objective of this review was to assess the effects of vacuum extraction compared to forceps, on failure to achieve delivery and maternal and neonatal morbidity. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: February 1999. SELECTION CRITERIA: Acceptably controlled comparisons of vacuum extraction and forceps delivery. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Ten trials were included. The trials were of reasonable quality. Use of the vacuum extractor for assisted vaginal delivery when compared to forceps delivery was associated with significantly less maternal trauma (odds ratio 0.41, 95% confidence interval 0.33 to 0.50) and with less general and regional anaesthesia. There were more deliveries with vacuum extraction (odds ratio 1.69, 95% confidence interval 1.31 to 2.19). Fewer caesarean sections were carried out in the vacuum extractor group. However the vacuum extractor was associated with an increase in neonatal cephalhaematomata and retinal haemorrhages. Serious neonatal injury was uncommon with either instrument. REVIEWER'S CONCLUSIONS: Use of the vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity. The reduction in cephalhaematoma and retinal haemorrhages seen with forceps may be a compensatory benefit.

Continuous versus interrupted sutures for perineal repair.

BACKGROUND: Millions of women worldwide undergo perineal repair after childbirth and the type of repair may have an impact on pain and healing. OBJECTIVES: The objective of this review was to assess the effects of continuous subcuticular versus interrupted transcutaneous sutures on women following perineal repair. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: June 1999. SELECTION CRITERIA: Randomised trials comparing continuous subcuticular versus interrupted transcutaneous sutures for the closure of perineal skin after vaginal delivery. DATA COLLECTION AND ANALYSIS: Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. Study authors were contacted for additional information. MAIN RESULTS: Four studies involving 1864 women were included. The trials were heterogeneous with respect to operator skill and training. Compared with interrupted sutures, a continuous subcuticular suture technique of perineal repair was associated with less pain for up to 10 days post partum (odds ratio 0.68, 95% confidence interval 0.53 to 0.86). No differences were seen in the need for analgesia, need for resuturing of the wound or in dyspareunia. Based on one trial only, there was no difference in long-term pain and failure to resume pain-free intercourse within three months of the birth. The continuous technique was associated with less need for the removal of sutures. REVIEWER'S CONCLUSIONS: The continuous subcuticular technique of perineal repair may be associated with less pain in the immediate postpartum period than the interrupted suture technique. The long-term effects are less clear.

The West Midlands "Severe Hypertensive Illness in Pregnancy" (SHIP) audit.

OBJECTIVE: To study the management of a series of women presenting with acute-onset hypertension in the 21 maternity units in the West Midlands region, in order to measure the standard of care and the outcomes of these patients and their babies. DESIGN: Multicenter audit. SETTING: Twenty-one Maternity Units in the West Midlands region with 85,658 births during the audit period. METHODS: Prospective data collection by named coordinators (multidisciplinary) in each unit using customized proformas. The proformas were then forwarded to the Research Coordinator for input onto a database and observational analyses. RESULTS: The total number of cases was 516. Eighty-one percent were diagnosed as having severe preeclampsia, 14% HELLP syndrome, and 5% eclampsia. Seven percent were admitted to the intensive therapy unit. Seventy percent of births were preterm, 62% of babies were low birth weight (< 2.5 kg), 57% of babies were admitted to the neonatal unit, and the perinatal mortality rate was 5%. The commonest antihypertensive agents were hydralazine and nifedipine. In terms of compliance with audit standards, 61% had both oxygen saturation and noninvasive blood pressure monitoring, 47% had good fluid balance documentation, and 79% had no fluid mismanagement. Seventy-four percent were seen by a consultant obstetrician, 62% were seen by a member of an "expert team," 83% adhered to local guidelines, and 71% of eclamptics received magnesium sulfate (MgSO4). CONCLUSION: Our study shows that severe hypertensive illness of pregnancy remains an important cause of maternal mortality and perinatal mortality. This audit highlights areas in which standards of care can be improved.

Fluid management in severe preeclampsia (VESPA): survey of members of ISSHP.

OBJECTIVE: To determine international expert practice of fluid management and monitoring in severe preeclampsia. METHODS: The 447 members of the ISSHP (International Society for the Study of Hypertension in Pregnancy) were issued a postal questionnaire to determine their views and practices of fluid management in severe preeclampsia. RESULTS: One hundred sixty-six (37%) completed questionnaires were received. Responses indicated that there is no consensus regarding most aspects of management of severe preeclamptic patients. In particular, there is no agreement about which fluid type to administer and how to assess circulatory status in these patients. There were also wide variations in the use of plasma volume expansion as a treatment modality. Statistical comparison of the use of Swan-Ganz catheters in "theoretical" and "actual" practice showed highly significant differences (p < 0.001). The majority of respondents were interested in participating in future research. CONCLUSION: The results reflect genuine uncertainty generated by a lack of evidence from randomized trials addressing the acute management of severe preeclamptic patients. Even where clinicians are confident "in theory" that a particular form of treatment is the best, they do not appear to have the resources or commitment to match this with "practice." The majority of respondents were very keen to develop the questions raised further in the context of multicenter clinical trials.

The North Staffordshire Maternity Hospital prospective study of pregnancy-associated depression.

The objective of the study was to establish the frequency of depression during pregnancy and the puerperium, and its relationship to marital disharmony and sociodemographic variables. A prospective longitudinal study was carried out in a district general hospital in the West Midlands, UK. The cohort consisted of 417 women booked for confinement at the hospital. Depression was measured as a proportion of high scores (> 14) on the Edinburgh Postnatal Depression Scale (EPDS) and marital disharmony was determined by the Spanier Dyadic Adjustment Scale. Using recommended cut-offs, 41/417 (9.8%) of the women were depressed during pregnancy and 31/417 (7.4%) were depressed at 3 months postpartum. There was a significant association between antenatal and postnatal depression, seven of the 31 women who were depressed postpartum had also been depressed in the antenatal period. Only five of the 41 women with antenatal depression and eight of the 31 women with postnatal depression were identified by their general practitioners as depressed. Marital disharmony was sequentially associated with depression before and after delivery. We conclude that antenatal depression is more common than generally thought, and that both antenatal and postnatal depression are frequently missed during routine consultation. Pregnancy-associated depression is more common where marital disharmony exists. More widespread use of the EPDS during pregnancy may help to highlight these often unidentified mental health problems.