Nutritional stress of reproduction. A cohort study over two consecutive pregnancies

BACKGROUND

The evaluation of nutritional stresses of reproduction is far more complex than perceived in the literature so far. The use of inappropriate outcome measures, the lack of adjustment for the complex inter-relationships among confounding variables, and the poverty of analytical models, has led to conflicting results. Our objective was to evaluate, using a new analytical framework, the maternal and fetal effects of the nutritional stress imposed by reproduction in a cohort of 278 women followed over two consecutive pregnancies.

METHODS

The analytical framework evaluated nutritional stress over successive pregnancies. The effect of birth interval on change in maternal weight, body mass index and hemoglobin over two consecutive pregnancies was evaluated using multiple linear regression accounting for the effects of maternal age, parity and weight or body mass index or hemoglobin in the first of the two pregnancies. For change in fetal birth weight correction was made for the confounding effect of maternal age, parity and weight, and fetal gestational age, sex and birth weight.

RESULTS

Birth interval was associated with change in maternal weight (p=0.001); change in body mass index (p=0.002); and change in birth weight (p=0.048). No association was found between birth interval and change in hemoglobin.

CONCLUSIONS

The nutritional stress imposed by reproduction affects maternal and fetal outcomes. Maternal nutrient stores can be depleted and fetal growth can be restricted in association with shorter birth intervals. Perinatal nutrition may be improved by adequate spacing of pregnancies with appropriate birth control.

To peritonealize or not to peritonealize? A randomized trial at abdominal hysterectomy

OBJECTIVES

Our purpose was to determine whether nonclosure of the visceral and parietal peritoneum alters the intraoperative or postoperative course at abdominal hysterectomy.

STUDY DESIGN

The setting was a gynecology unit in a university teaching hospital. A parallel-group, single-blind randomized controlled trial was performed on 144 women who underwent abdominal hysterectomy with or without salpingo-oophorectomy. Seventy-six women were allocated to the control "closed" group and 68 women to the study "open" group. The main outcome measures were operative time, estimated blood loss, postoperative pain assessed by visual analog scale, and amount of postoperative analgesia.

RESULTS

The mean operative time was shorter by 10 minutes (p < 0.001) and there was a 45 ml reduction of estimated blood loss in the nonclosure group (p=0.03). There were no differences in postoperative pain in the two groups.

CONCLUSIONS

Peritoneal closure at abdominal hysterectomy provides no immediate postoperative benefits while unnecessarily lengthening surgical time and anesthesia exposure. We suggest that the traditional practice of visceral and parietal peritoneal closure be abolished at abdominal hysterectomy.

A two-term MEDLINE search strategy for identifying randomized trials in obstetrics and gynecology

OBJECTIVE

To develop and test a simple MEDLINE search strategy for identification of randomized controlled trials (RCTs) in obstetrics and gynecology.

METHODS

To develop our search strategy, we asked clinicians in our department to indicate, from a list of search terms, the terms they would use to identify RCTs in MEDLINE. The two most common terms, controlled-clinical-trial (publication type) and randomized-controlled-trial (publication type), were combined with the link word, OR, and then used to identify RCTs in four obstetrics and gynecology journals for the years 1975, 1980, 1985, 1990, and 1995. Concurrently, a handsearch of these same journals and years was performed to identify RCTs. The sensitivity and precision of MEDLINE and handsearch were calculated using the total number of RCTs identified by both methods as a reference standard. Sensitivity is the RCTs identified by search strategy as a percentage of all RCTs identified by reference standard. Precision is the RCTs identified by a search strategy as a percentage of all articles identified by it.

RESULTS

The overall sensitivity of our MEDLINE search strategy was 72.5%, and the precision was 83.4%. Over 2 decades, sensitivity of our MEDLINE search increased from 0% to 94.9% (P < .001), while its precision dropped from 100% to 75.5% (P=.003). For 1990 and 1995 combined, sensitivity and precision of our MEDLINE search strategy were 90.3% and 79.6%, respectively. Overall sensitivity for handsearch was 96.5%; its precision was 5.0%. Over 2 decades, the sensitivity of handsearch dropped insignificantly from 100% to 92.3% (P=.05), while the precision increased from 2.6% to 6.3% (P < .001).

CONCLUSION

Our simple MEDLINE search strategy has a high sensitivity and precision, especially in more recent years. Obstetricians and gynecologists may use it to search quickly for RCTs to guide patient care.

Ethics, equity and renewal of WHO's health-for-all strategy

The renewal of WHO's strategy for health for all raises questions about human and societal values that have to be fully taken into account. Discussions to date have highlighted the principle of equity in the context of ethics and human rights.

Seizure prophylaxis in hypertensive pregnancies: a framework for making clinical decisions

OBJECTIVE

To describe a framework for generating therapeutic recommendations using seizure prophylaxis in hypertensive pregnancies as an example.

DESIGN

A decision-making framework was built using: 1. evidence of therapeutic benefit, with number needed to treat as the effect measure; 2. baseline rates of the target disorder that the treatment was designed to prevent; and 3. a treatment threshold, determined by weighting the potential risks against the potential benefits of the treatment.

METHODS

Evidence of therapeutic benefit (i.e. reduction in eclamptic seizures associated with magnesium sulphate therapy in hypertensive pregnancies) was determined by a systematic quantitative overview of controlled clinical trials. Baseline rates of seizures without magnesium sulphate therapy were derived from a recent cohort study. A treatment threshold was generated using estimates of treatment associated morbidities which were weighted against the potential reduction in seizures from magnesium sulphate therapy considering the relative values assigned to these outcomes by obstetricians practising in our hospital.

RESULTS

The number of hypertensive women needed to be treated with magnesium sulphate to prevent a single case of eclamptic seizures varied in a curvilinear fashion dropping from 1000 to 14 as the baseline rate of seizures increased from 0.1% to 10%. The treatment threshold as measured by number needed to treat was 64 (range 57-77). The number needed to treat for nonproteinuric hypertension was 1000 (95% CI 180-40,000), whereas it was 32 (95% CI 20-57) for proteinuric hypertension. Considering the uncertainty in estimation of the numbers needed to treat and treatment threshold, magnesium sulphate therapy may be recommended for women at high risk of eclampsia (e.g. severe pre-eclampsia) while it should be withheld in cases at low risk (e.g. nonproteinuric hypertension and mild pre-eclampsia).

CONCLUSION

While awaiting further research obstetricians intuitively make decisions about seizure prophylaxis in hypertensive pregnancies. Our decision-making framework generated therapeutic recommendations by explicit consideration of the available evidence.

Evaluating measurement variability in clinical investigations: the case of ultrasonic estimation of urinary bladder volume

OBJECTIVE

To evaluate the quality of studies seeking to establish measurement properties (reliability and validity) of ultrasonic estimation of urinary bladder volume.

DESIGN

Online searching of the MEDLINE database between 1966 and 1995, and scanning of bibliography of known studies on ultrasonic bladder volume estimation. Study selection and study quality assessment were performed independently by two reviewers. Each article was evaluated for suitability of the reference standard, adequacy of reported blinding of the observers and appropriateness of the statistical index of concordance. The last two of these guidelines were applied to reliability studies (evaluating the relation among observed ultrasonic estimations), and all three guidelines were applied to validity studies (evaluating the relation of ultrasonic estimation with a definitive measurement).

POPULATION

One hundred and twenty-five participants enrolled in the five reliability studies and 769 participants in the 27 validity studies selected for appraisal of their quality.

MAIN OUTCOME MEASURE

Rate of study compliance with preset criteria for high quality.

RESULTS

None of the studies complied with all of the criteria for high methodologic quality. In the five reliability studies, investigators did not report adequate blinding of observers in three (60%) and an appropriate index of reliability was not used in any. Among the 27 validity studies, there was a lack of a suitable reference standard in 6 (22%), an inadequate blinding in 25 (93%), and an inappropriate index of validity in all (100%).

CONCLUSION

Based on our guidelines for quality assessment, a large proportion of studies on measurement properties was found to have inadequate methods, raising concern about the credibility of the reliability and validity estimates reported. These deficiencies highlight the lack of rigour employed in the design, conduct and analysis of reliability and validity studies, which has the potential for leading to patient mismanagement due to biases in the assessment of measurement variability in clinical investigations.

The diagnostic accuracy of cervico-vaginal fetal fibronectin in predicting preterm delivery: an overview

OBJECTIVE

To determine the accuracy with which cervico-vaginal fetal fibronectin predicts preterm delivery using systematic quantitative overview of the available literature.

DESIGN

Online searching of MEDLINE database (1966 to April 1996), scanning of bibliography of known primary and review articles and review of recent journal issues. Study selection, assessment of study quality and data extraction were performed in duplicate under masked conditions. Likelihood ratios were generated in subgroups of symptomatic and asymptomatic pregnant women by pooling data from different studies. An LR of > 10 or < 0.1 indicated conclusive changes in the pretest probability of preterm delivery while an LR of 5-10 or 0.2-0.1 indicated only moderate changes.

PARTICIPANTS

Seven hundred and twenty-three symptomatic women with threatened preterm labour included in nine studies and 847 asymptomatic women (635 low risk and 212 high risk) included in six studies selected for meta-analyses.

MAIN OUTCOME MEASURES

Likelihood ratios for positive and negative test results using delivery at < 37 and < 34 weeks of gestation, and within one week of testing as outcome measures.

RESULTS

In symptomatic women a positive test predicted delivery < 37 weeks of gestation with a pooled likelihood ratio (LR) of 4.6 (95% CI 3.5-6.1) while a negative test had a pooled LR of 0.5 (95% CI 0.4-0.6). For delivery < 34 weeks of gestation, the pooled LR was 2.6 (95% CI 1.8-3.7) for a positive test and 0.2 (95% CI 0.1-0.5) for a negative test. For delivery within one week of testing, the pooled LR was 5.0 (95% CI 3.8-6.4) for a positive test and 0.2 (95% CI 0.1-0.4) for a negative test. In asymptomatic women at low risk of delivery < 37 weeks of gestation the pooled LR was 3.2 (95% CI 2.2-4.8) for a positive test and 0.8 (95% CI 0.7-0.9) for a negative test. In high risk asymptomatic women using delivery < 37 weeks of gestation as an outcome measure the pooled LR was 2.0 (95% CI 1.5-2.6) for a positive test and 0.4 (95% CI 0.2-0.8) for a negative test. For delivery < 34 weeks of gestation in high risk, asymptomatic women the pooled LR was 2.4 (95% CI 1.8-3.2) for a positive test and 0.6 (95% CI 0.4-0.9) for a negative test.

CONCLUSION

The presence of fetal fibronectin in cervico-vaginal mucus has limited accuracy in predicting preterm delivery as the likelihood ratios for positive and negative test results generated only minimal to moderate changes in the pretest probability of preterm birth.

Magnesium sulphate in the treatment of eclampsia and pre-eclampsia: an overview of the evidence from randomised trials

OBJECTIVE

To evaluate the effectiveness of magnesium sulphate in the treatment of eclampsia and pre-eclampsia by a systematic quantitative overview of controlled clinical trials.

DESIGN

Online searching of the MEDLINE database between 1966 and 1995, and scanning of the bibliography of known primary studies and review articles on the use of magnesium sulphate in eclampsia and pre-eclampsia. Study-selection, study quality assessment and data extraction were performed independently by two reviewers under masked conditions. Where possible outcome data from trials were pooled and summarised using the Mantel-Haenszel method.

PARTICIPANTS

One thousand seven hundred and forty-three women with eclampsia and 2390 with pre-eclampsia included in nine randomised trials that evaluated the effects of magnesium sulphate.

MAIN OUTCOME MEASURES

Seizure activity and maternal death.

RESULTS

In eclampsia, recurrence of seizures was less common with magnesium sulphate therapy compared with phenytoin (odds ratio [OR] 0.27, 95% CI 0.17-0.45, P = 0.00) and diazepam (OR 0.41, 95% CI 0.30-0.57, P = 0.00). As indicated by the point estimate, there was a trend towards a reduction in maternal mortality with magnesium sulphate in eclampsia (OR 0.51, 95% CI 0.24-1.07, P = 0.10 versus phenytoin; OR 0.78, 95% CI 0.41-1.45, P = 0.52 versus diazepam). When used for seizure prophylaxis in pre-eclampsia, magnesium sulphate was found to be more effective than phenytoin (OR 0.15, 95% CI 0.03-0.72, P = 0.01).

CONCLUSION

Magnesium sulphate is a superior drug in preventing the recurrence of seizures in eclampsia and in seizure prophylaxis in pre-eclampsia.

The importance of quality of primary studies in producing unbiased systematic reviews

BACKGROUND

Traditional and largely qualitative reviews of evidence are now giving way to much more structured systematic overviews that use a quantitative method to calculate the overall effect of treatment. The latter approach is dependent on the quality of primary studies, which may introduce bias if they are of poor methodologic quality.

OBJECTIVE

To test the hypothesis that the inclusion of poor-quality trials in meta-analyses would bias the conclusions and produce incorrect estimates of treatment effect.

METHODS

An overview of randomized trials of antiestrogen therapy in subfertile men with oligospermia was performed to test the hypothesis. Data sources included online searching of MEDLINE and Science Citation Index databases between 1966 and 1994, scanning the bibliography of known primary studies and review articles, and contacting experts in the field. After independent, blind assessment, nine of 149 originally identified studies met the inclusion criteria and were selected. We assessed study quality independently. Outcome data from each study were pooled and statistically summarized.

RESULTS

There was a marginal improvement in pregnancy rate with antiestrogen treatment (odds ratio, 1.6; 95% confidence interval, 0.9 to 2.6). Sensitivity analyses on the basis of methodologic quality demonstrated that poor-quality studies produced a positive effect with treatment, whereas no benefit was observed with high-quality studies.

CONCLUSION

The results of a meta-analysis are influenced by the quality of the primary studies included. Methodologically, poor studies tend to exaggerate the overall estimate of treatment effect and may lead to incorrect inferences.

Risk of uterine rupture after the partographic 'alert' line is crossed--an additional dimension in the quest towards safe motherhood in labour following caesarean section

To determine if prolonged active phase of labour is associated with increased risk of uterine scar rupture in labour following previous lower segment caesarean section, a retrospective cohort study (1988-91) was done to analyse active phase partographs of 236 patients undergoing trial of labour following caesarean section, 7 (3%) of whom had scar rupture. After onset of active phase (3 cm cervical dilatation), a 1 cm/h line was used to indicate "alert". A zonal partogram was developed by dividing the active phase partographs into 5 time zones: A (area to the left of "alert" line), B (0-1 h after "alert" line), C (1-2 h after "alert" line), D (2-3 h after "alert" line) and EF (> 3 h after "alert" line). The relative risk of uterine scar rupture was calculated for different partographic time zones. The relative risk of uterine scar rupture was 10.5 (95% confidence interval 1.3-85.5, p = 0.01) at 1 hour after crossing the "alert" line; 8.0 (95% confidence interval 1.6-40.3, p = 0.009) at 2 hours after crossing the "alert" line; and 7.0 (95% confidence interval 1.6-29, p = 0.02) at 3 hours after crossing the "alert" line. In women undergoing trial of labour following caesarean section, prolonged active phase of labour is associated with increased risk of uterine rupture. A zonal partogram may be helpful in assessing this risk in actively labouring women who cross the partographic "alert" line.

Plasma glucose and pre-eclampsia

OBJECTIVE

To determine whether there is a relationship between plasma glucose level in a glucose screening test and the occurrence of pre-eclampsia in non-diabetic pregnant women.

METHODS

All pregnant non-diabetic women attending the antenatal clinic at the Aga Khan University Medical Center were screened with a 75 g-2 h glucose challenge test (GCT). From 1988-90, a data base of 1316 cases was compiled for use in this study. Of these, 67 had to be excluded because of one or more abnormal levels in the 75 g-3 h oral glucose tolerance test (GTT) that required treatment to maintain euglycemia. Among the remaining patients (n = 1249) who had no evidence of glucose intolerance and were included in the analysis, there were 42 cases of pre-eclampsia. The association between pre-eclampsia and plasma glucose level in the GCT was evaluated using logistic regression analysis that adjusted for effects of age and gravidity.

RESULTS

The odds of having pre-eclampsia were increased by 20% (95% confidence interval 0%-44%) per mmol/l rise in plasma glucose level in the GCT. The same statistic for age was 9% (95% confidence interval 2%-17%), and for primigravidity it was 210% (95% confidence interval 55%-517%). There was no significant interaction between these variables.

CONCLUSIONS

Minor degrees of glucose intolerance, age and primigravidity are associated with a higher occurrence of pre-eclampsia in non-diabetic pregnant women.

Empirical evidence of bias in infertility research: overestimation of treatment effect in crossover trials using pregnancy as the outcome measure

OBJECTIVE

To determine whether crossover trials with simple pooling of data over different study periods leads to a different estimate of treatment effect compared with parallel group trials in infertility research using pregnancy as the outcome measure.

DESIGN

An observational study using nine overviews that included trials with both crossover and parallel group designs. These overviews comprised 17 crossover and 17 parallel group trials. In total, there were 5,291 outcomes including 775 pregnancies. The association between study design and treatment effect estimate was analyzed using multiple logistic regression, controlling for differences in the therapeutic interventions and variations in the methodological quality of the trials.

SETTING

Infertile patients in an academic research environment.

PATIENTS

Infertile patients undergoing treatment efficacy evaluation in controlled trials.

INTERVENTIONS

Random allocation to a variety of treatments including clomiphene citrate, hCG, IUI, tamoxifen, and bromocriptine.

MAIN OUTCOME MEASURE

Estimate of bias between study designs, based on the interaction of study design and treatment in the logistic regression model.

RESULTS

Crossover trials produced a larger average estimate of treatment effect compared with trials with a parallel group design, overestimating the odds ratio by 74% (95% confidence interval, 2% to 197%).

CONCLUSION

The use of a crossover design for evaluating infertility treatments with outcomes that prevent patients from completing later phases of the trial should be avoided because it leads to exaggerated estimates of treatment effect and may result in erroneous inferences and clinical decisions. Furthermore, the type of study design should be taken into account when assessing the methodological quality of therapy trials in infertility.

Dynamic and steady state response of heart rate to orthostatic stress in normotensive and hypertensive pregnant women

We determined the dynamic and steady state responses of heart rate (HR) to orthostatic stress (standing up) in normotensive and hypertensive pregnant women. Using a continuous recording with servo-photosphygmography, HR response to change in posture from left lateral recumbent position to standing was analysed. The subjects were divided into five groups comprising: Groups I, II and III: normotensive pregnant women in each of the three trimesters of pregnancy (total n = 77); Group IV: women with gestational proteinuric hypertension (GPH) in the third trimester (n = 16); Group V: age-matched non-pregnant normotensive controls (n = 15). The HR reacted with a typical overshoot response to this orthostatic change with HR rising to a peak and then settling to a new but higher steady state. Change in steady state HR from lying to standing (delta HR), rate of rise of HR in response to standing (i.e. the acceleration slope (HRon)), and rate of fall of HR after reaching the peak (i.e. deceleration slope (HRoff)) were evaluated from standing heart rate time curves. HRon in response to standing showed a downward trend with gestation (ANOVA, P < 0.05) in normotensive gravida. The deceleration slope (HRoff) showed a distinct gestational age-related decrease from first to third trimester in normotensive women (ANOVA, P < 0.01). The most striking observation was that the slope of HRoff for the GPH group was significantly steeper than that of normotensive women of comparable gestational age (unpaired t-test P < 0.01) and approximated to that of the non-pregnant group. The difference in HR response between normotensive women and those with GPH in the third trimester suggests it may have potential as a new marker for pre-eclampsia.

The partograph in the management of labor following cesarean section

OBJECTIVE

To determine whether graphic labor record (partogram) can be used to predict the risk of uterine scar rupture in labor following lower segment cesarean section.

METHODS

Between 1988 and 1991, 236 women had a trial of labor following cesarean section. After the onset of the active phase (3 cm cervical dilatation), a 1 cm/h line was used to indicate an alert line on the partogram. All the active phase partograms were divided into five time zones: A (area to the left of the alert line), B (0-1 h after the alert line), C (1-2 h after the alert line), D (2-3 h after the alert line), and E and F (> 3 h after the alert line). For the action line, different lag times after the alert line were defined according to the time zones. Sensitivity, specificity, cesarean section rates and rupture rates were calculated for the different lag times after the alert line, and a receiver-operating characteristic curve was constructed.

RESULTS

Fifty-five (23.3%) trials of labor ended in a repeat emergency cesarean. There were seven (2.9%) cases of scar rupture. Of the 181 vaginal deliveries, 151 (83%) occurred within 2 h after the progress of labor had crossed the alert line (zones A-C). Five out of seven cases of scar rupture occurred more than 2 h after the alert line had been crossed (zones D-F). The 2- and 3-h lag time after the alert line had a sensitivity of 71% and 43%, respectively, and a specificity of 78% and 96%, respectively, in predicting uterine scar rupture. If cesarean sections were performed at 2 or 3 h after crossing the alert line, the projected cesarean rates would have been 36% and 27%, respectively. The scar rupture rates would in turn be 0.8% and 1.6%, respectively.

CONCLUSION

In women undergoing a trial of labor following cesarean section, the partographic zone 2-3 h after the alert line represents a time of high risk of scar rupture. An action line in this time zone would probably help reduce the rupture rate without an unacceptable increase in the rate of cesarean section.

Setting health care priorities in Pakistan

OBJECTIVE

To describe a health priority setting exercise in Pakistan and its relevance to traditional medical care and care providers.

METHODS

Literature search of local and regional data was performed to identify priority health problems, those with high disease burden and with cost-effective interventions.

RESULTS

Major causes of ill-health were communicable (diarrhoea, respiratory infections, childhood immunizable diseases, malaria, tuberculosis) and pregnancy related diseases. Factors that contributed to these disorders included malnutrition, anemia, poor sanitation and water supply, low level of education, high fertility rates and poverty. For these conditions, cost-effective interventions for prevention included environmental control (provision of clean water and sanitation), education programmes, expanded programme of immunization and family planning and those for treatment included case management of diarrhoea, respiratory infections, tuberculosis and complications of pregnancy and childbirth.

CONCLUSION

Priority health problems include factors outside the domain of traditional medical care. Their definition is important for directing policy reform, medical curricula and health research.

Audit changes clinical practice! Impact on rate of justification of hysterectomy indication

After performing a baseline audit in 1986-89, an ongoing quality assurance process was initiated in January, 1990 and all hysterectomies performed over the next 2 year period were analyzed. Hysterectomy indications were divided into two groups: one in which the uterine specimen was expected to show pathology and another in which no pathology was expected. The hysterectomy was considered justified in the former if the pathology report verified the indication or showed a significant alternate pathology. In the latter, validation criteria showing documentation of certain prerequisite diagnostic procedures performed before reverting to hysterectomy, were used to ascertain justification. The overall rate of justification in the ongoing audit was 96%, being 97% for the group where hysterectomy indication was potentially confirmable by pathologic study and 93% for the one where it was not. Comparison with baseline analysis showed that the justification rates were higher for all indications not potentially confirmable by pathologic study (93% vs 89%, p < 0.05), for recurrent uterine bleeding (90% vs 83%, p < 0.05) and for leiomyoma (97% vs 95%, p < 0.05). The improvement was associated with less frequent use of multiple indications in the ongoing study (10% vs 16%, p < 0.05). The justification rates for hysterectomy indication can be improved by prospective audit and by avoiding use of multiple indications.

Are non-diabetic women with abnormal glucose screening test at increased risk of pre-eclampsia, macrosomia and caesarian birth?

To determine, in non-diabetic women, the relationship of abnormal glucose screening test, with the incidence of pre-eclampsia, macrosomia and caesarian delivery, from 1988-92, 5646 consecutive women attending antenatal clinic were screened with a glucose challenge test (GCT) on their first visit (usually at 16-20 weeks); those with risk factors i.e., history of unexplained perinatal loss, macrosomia or family member with diabetes and an initial abnormal screening test were rescreened at 28-32 weeks. In 482 cases the GCT was abnormal (plasma glucose value was > 140 mg% 2 hours after 75 g glucose challenge). Of these, 292 had one or more abnormal critical values at a 75 g-3 hour oral glucose tolerance test (GTT) and they were treated to maintain euglycaemia. The rest (n = 190) had no evidence of glucose intolerance with no abnormal values at the GTT. The subjects were divided into 3 groups based on GCT values; A, randomly selected subjects with a normal GCT (n = 1000); B, those with abnormal GCT but normal GTT (n = 190); and C, those with abnormal GTT (n = 292). The variables studied were age, gravidity, parity, gestational age at delivery, pre-eclampsia, birth-weight and mode of delivery. The incidence of pre-eclampsia and caesarian birth varied, being the lowest in Group A (3.9% and 11.9% respectively) and then rising through group B (6.3% and 16.3% respectively) to the highest in Group C (12.6% and 26.0% respectively; test of linear trend, p < 0.05). For macrosomia, the incidence increased from Group A to B but there was a drop in Group C.(ABSTRACT TRUNCATED AT 250 WORDS)

Retrospective study of alleged sexual assault at the Aga Khan Hospital, Nairobi

A retrospective audit of all the rape cases reported at the Aga Khan Hospital, Nairobi over a two year period was carried out. Out of 37 victims, 86.6% were less than 30 years old and 73.4% did not know who the assailant was. 80% of the victims reported to the hospital within 24 hours of the incident taking place and in 4 (10.8%) of the victims-vaginal swabs grew N. gonorrhoea. None of the victims opted for prosecution and none were referred for further counselling. We recommended that alleged rape victims be seen by a qualified gynaecologist or police surgeon and that they should be examined, investigated and managed by a standard protocol.

Relationship of fetal macrosomia to a 75g glucose challenge test in nondiabetic pregnant women

We determined in nondiabetic women, the relationship of plasma glucose values obtained 2 hours after a 75 g oral glucose challenge test (GCT) at 16-20 weeks' gestation, with the incidence of macrosomia in term deliveries (37-41 weeks' gestation). From 1988-1990, in a systematic screening programme data collected prospectively from 1,331 women were analysed retrospectively. Women with gestational diabetes or impaired glucose tolerance (n = 53) were excluded. The rest (n = 1,278) had no evidence of glucose intolerance including 1,215 women with normal plasma glucose by GCT (< 7.8 mmol/L 2 hours after 75 g oral glucose load) and 63 women with abnormal GCT but not abnormal value at a glucose tolerance test. The GCT values were divided into 5 groups: Group A (< 4.5 mmol/L), B (4.5-5.5 mmol/L), C (5.6-6.6 mmol/L), D (6.7-7.7 mmol/L) and E (> 7.8 mmol/L). The variables studied were age, parity, gestational age at delivery and incidence of macrosomia. Using > 4 kg birth-weight as the definition of macrosomia, the incidence increased from 1.2% to 9.5% with increasing plasma glucose values in the GCT from Group A (> 4.5 mmol/L) to E (> 7.8 mmol/L). Similar trends of increasing incidences from 7.2% to 15.8% and 2.9% to 9.5% were noted when 90th and 95th birth-weight percentiles, respectively were used as definitions of macrosomia. The test of linear trend in this association was significant (p < 0.01). These results were not influenced by parity or gestational age at delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic appraisal of infertility and pelvic pain in Pakistani women: a 5 years audit

Five hundred and nine Laparoscopic examinations performed between 1987-91, (147 procedures for evaluation of gynaecologic pelvic pain and 313 for infertility) revealed ectopic pregnancy (27%), twisted ovarian cyst (18%) and acute pelvic inflammatory disease (14%) in cases of acute gynaecologic pain, and endometriosis (17%) and chronic pelvic inflammatory disease (16%) in chronic pelvic pain. Adhesions (20%), tubal block (15%), endometriosis (9%) and polycystic ovary (7%) were common findings in cases of infertility. These data support the usefulness of this minimally invasive procedure in accurate diagnosis of gynaecological disorders and provides insight into the spectra of diseases seen in Pakistani women with pelvic pain and infertility.

Bacteriuria and pregnancy outcome: a prospective hospital-based study in Pakistani women

The prevalence of bacteriuria in Pakistani women and its association with complications of pregnancy was studied. Out of 1579 women, 77 had bacteriuria (4.8%). There was no association of age, gravidity, parity, haemoglobin, pre-eclampsia, mode of delivery, gestational age at delivery, preterm delivery and low birth-weight with presence of bacteriuria. With detection and treatment the pregnancy outcome of women with bacteriuria in pregnancy was the same as that of those without.