Is HIV testing in antenatal clinics worthwhile? Can we afford it?

Since 0.2-0.4% of pregnant women attending antenatal clinics (ANC) at St Thomas's Hospital are HIV positive, and as the Department of Health (DH) have recommended that universal voluntary HIV testing be made available to women attending ANC in areas of "known or suspected higher prevalence of HIV infection", we examined the implications of the DH initiative in an Inner London Teaching Hospital as well as in a General Practice involved in shared care. The cost of the programme (148,300 pounds to 193,900 pounds), 80% of which relates to the need to obtain informed consent, was approximately 2.7-3.5 times that calculated by the DH. The DH based much of their costing on additional time for counselling rather than calculating the additional staff required. We estimated that 25% of women will require specialized counselling since 17% are of African ethnicity and others are injecting drug users or 'worried well'. Various means of reducing costs were considered but, until such time as explicit, informed consent is no longer considered necessary, the above resources will be required. Unless the DH continues to provide central direction to Providing Agencies to give priority to these recommendations and, where necessary, provides additional funding, we fear that this important public health initiative will be unsuccessful.

Successful pregnancy in a patient with a single ventricle

Single ventricle is an uncommon form of congenital heart disease. We report a successful pregnancy and delivery in a mother with surgically confirmed single ventricle.

Screening of pregnant women for evidence of current hepatitis B infection: selective or universal?

This paper reports the findings of a retrospective survey which assessed the accuracy of the selective screening programme for hepatitis B infection. The survey was undertaken in the antenatal clinics of West Lambeth Health Authority during 1988 and 1990. Forty per cent of hepatitis B positive patients were not screened, which highlights the problems associated with selective screening programmes. The implications for obstetricians and midwives are discussed, and recommendations are made.

Histological differences between colposcopic-directed biopsy and loop excision of the transformation zone (LETZ): a cause for concern

Colposcopic examination and biopsy were performed on 100 patients with abnormal cervical cytology. All were suitable for ablative therapy but were treated by loop excision of the transformation zone (LETZ) as outpatients. Histological comparison between the colposcopic biopsies and LETZ samples showed poor agreement with only 43% of cases illustrating identical degrees of dysplasia. The dysplasia was underestimated by colposcopic biopsy in 16% of cases and overestimated in 41% of cases, when compared to the LETZ specimen. Microinvasive carcinoma was diagnosed in 3 cases on the LETZ histology, having been missed by the preceding colposcopy and colposcopic biopsy. The disparity between histological findings is of great concern and would not have been detected if the patients were treated by ablative therapy. It is the authors' view that LETZ should replace ablative therapy in the treatment of localized cervical dysplasia and that it may avoid the need for pretreatment colposcopic biopsy. LETZ limits the possibility of inadequate treatment and also provides a method of audit for the colposcopist.

The design, preparation, and use of immunopurification reagents

Immunoaffinity chromatography using immobilized monoclonal antibodies has become one of the most powerful macromolecular separation methods available. In many cases, simple one-step immunoaffinity separations will produce a several thousand-fold purification with yields of better than 80%. Monoclonal antibodies are now available with specificities for many different antigens, and the technology for producing new monoclonal antibodies has become widespread througout the world since its invention (1; see vol. 1 of this series). It has been estimated that a new monoclonal antibody is produced every 40 min worldwide.

Maternal and neonatal death due to pneumococcal infection

A 27-year-old woman died from pneumococcal meningitis associated with pneumococcal endometritis two days after being delivered of a .1.75-kg infant. The infant also had pneumococcal septicemia and died six days after birth. The pneumococcus isolated from the mother and the baby was type 8. The membranes had ruptured 21 hours before delivery, and the mother had received a salbutamol infusion in an attempt to inhibit labor with injections of betamethasone to prevent neonatal respiratory distress. This case typified the dramatic onset and lethal nature of some pneumococcal infections.

Failed laparoscopic clip sterilisation

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A case of locked twins managed under lumbar epidural analgesia

A case of locked twins is described in which delivery of the aftercoming head of the first infant, which presented by the breech, was prevented by the presence below it of the head of the second infant, which presented by the vertex. Disimpaction under lumbar epidural analgesia was achieved, the head of the second infant being pushed up out of the pelvis. Both infants survived. This is thought to be the first case to be described in which disimpaction was achieved rapidly under lumbar epidural analgesia, thereby minimising the period of hypoxia to which the first infant was subjected.