Determination of Fat in Raw and Processed Milks by the Gerber Method: Collaborative Study

The Gerber method is used worldwide as a simple and rapid method for determining fat in raw and processed milks. However, the volume of the test portion used in the method has not been internationally agreed upon. A collaborative study was conducted to evaluate performance of the Gerber method using either a weighed test portion (11.13 g) or by a 10.77 mL test portion delivered by pipet. For each method, laboratories received 10 test samples: 5 raw and 5 pasteurized homogenized milks, 2 of which were blind duplicate pairs. Eleven and 10 laboratories participated in the evaluation of aliquot addition by weight and pipet, respectively. Mojonnier ether extraction (Method 989.05) was used as the reference method. Interlaboratory study statistics were similar between methods of test portion addition and between raw and processed materials; therefore, summary interlaboratory study statistics were pooled. The fat content of milk samples ranged from 0.96 to 5.48%. Absolute reproducibility and repeatability were not affected by fat level, and pooled statistical performance (invalid and outlier data removed) was (g fat/100 g milk) sr = 0.026, sR = 0.047, r = 0.074, and R = 0.132. Relative standard deviations increased with decreasing fat content, and were summarized by fat level: 1–2% fat milk, mean = 1.437, RSDr = 1.809%, RSDR = 3.271%; 2–6% fat milk, mean = 4.156, RSDr = 0.626%, RSDR = 1.131%. Compared with ether extraction, test results by the Gerber method were slightly lower (0.02% fat) using a weighed test portion and significantly lower (0.06% fat) using a 10.77 mL volume addition by pipet. A trend toward underestimating fat content at lower fat concentrations (1–2% fat) was observed with the weighed test portion but not when a pipet was used. The Associate Referee recommends that the Gerber method using a weighed test portion be adopted as First Action with applicability limited to whole milk.

Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598]

OBJECTIVES

To evaluate the effectiveness of a decision aid for women with a breech presentation compared with usual care.

DESIGN

Randomised controlled trial.

SETTING

Tertiary obstetric hospitals offering external cephalic version (ECV).

POPULATION

Women with a singleton pregnancy were diagnosed antenatally with a breech presentation at term, and were clinically eligible for ECV.

METHODS

Women were randomised to either receive a decision aid about the management options for breech presentation in addition to usual care or to receive usual care only with standard counselling from their usual pregnancy care provider. The decision aid comprised a 24-page booklet supplemented by a 30-minute audio-CD and worksheet that was designed for women to take home and review with a partner.

MAIN OUTCOME MEASURES

Decisional conflict (uncertainty), knowledge, anxiety and satisfaction with decision making, and were assessed using self-administered questionnaires.

RESULTS

Compared with usual care, women reviewing the decision aid experienced significantly lower decisional conflict (mean difference -8.92; 95% CI -13.18, -4.66) and increased knowledge (mean difference 8.40; 95% CI 3.10, 13.71), were more likely to feel that they had enough information to make a decision (RR 1.30; 95% CI 1.14, 1.47), had no increase in anxiety and reported greater satisfaction with decision making and overall experience of pregnancy and childbirth. In contrast, 19% of women in the usual care group reported they would have made a different decision about their care.

CONCLUSIONS

A decision aid is an effective and acceptable tool for pregnant women that provides an important adjunct to standard counselling for the management of breech presentation.

Cephalic version by moxibustion for breech presentation

BACKGROUND

Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) to the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of correcting breech presentation. As caesarean section is often suggested for breech babies due to the potential difficulties during labour, it is preferable to turn the baby before labour starts.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality for breech presentation.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (30 August 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (1966 to March 2004), EMBASE (1980 to March 2004), CINAHL (1982 to March 2004), MIDIRS (1982 to March 2004), CISCOM (9 March 2004) and bibliographies of relevant papers.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised controlled trials comparing moxibustion (either alone or in combination with acupuncture) with a control group (no moxibustion), or other methods (e.g. external cephalic version, acupuncture) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Both authors assessed eligibility and quality of trials independently. The outcome measures were baby's presentation at birth, need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events.

MAIN RESULTS

Three trials involving a total of 597 women were included. Due to differences in interventions and sample size it was not appropriate to perform a meta-analysis for the main outcome. Only one trial reported on other outcome measures relevant to this review. Moxibustion reduced the need for ECV (relative risk (RR) 0.47, 95% confidence interval (CI) 0.33 to 0.66) and resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries (RR 0.28, 95% CI 0.13 to 0.60).

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of moxibustion to correct a breech presentation. Moxibustion may be beneficial in reducing the need for ECV, and decreasing the use of ocytocin, however there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.

Trends in place of birth for preterm infants in New South Wales, 1992-2001

OBJECTIVE

To examine trends in preterm births, especially those less than 33 weeks gestation, occurring in perinatal centres in New South Wales (NSW) from 1992 to 2001.

METHODS

Population data were obtained from the NSW Midwives' Data Collection. Trends in the proportion of births in perinatal centres by gestation and by type of preterm birth (spontaneous or elective), and in Apgar scores and neonatal mortality were determined.

RESULTS

The preterm birth rate increased from 6.1% in 1992 to 6.7% in 2001. Factors contributing to the increase in preterm births were multiple births and elective preterm deliveries. Births less than 33 weeks gestation in perinatal centres increased from 76% to 83% and for multiple births from 77% to 87%. This coincided with a decrease in 1-minute Apgar scores less than 4 but no significant change in 5-minute Apgar scores or neonatal mortality.

CONCLUSIONS

Progress has been made towards the National Health and Medical Research Council guideline that births less than 33 weeks gestation occur in perinatal centres. Preterm births are increasing, creating greater demands for neonatal intensive care unit care and ventilation services.

Antibiotics for ureaplasma in the vagina in pregnancy

BACKGROUND

Preterm birth is a significant obstetric problem in high-income countries. Genital infection including ureaplasmas are suspected of playing a role in preterm birth and preterm rupture of the membranes. Antibiotics are used to treat women with preterm prelabour rupture of the membranes and results in prolongation of pregnancy and lowers the risks of maternal and neonatal infection. However, antibiotics may be beneficial earlier in pregnancy to eradicate potentially causative agents.

OBJECTIVES

The objective of this review is to assess whether antibiotic treatment of pregnant women with ureaplasma in the vagina reduces the incidence of preterm birth and other adverse pregnancy outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (April 2003).

SELECTION CRITERIA

All randomised controlled trials that compared any antibiotic regimen with placebo or no treatment in pregnant women with ureaplasma detected in the vagina.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed eligibility and trial quality and extracted data.

MAIN RESULTS

One trial involving 1071 women was included. Of these, 644 randomly received antibiotic treatment (174 erythromycin estolate, 224 erythromycin sterate, and 246 clindamycin hydrochloride) and 427 received placebo. This trial did not report data on preterm birth. Incidence of low birthweight less than 2500 grams was only evaluated for erythromycin (combined) (n = 398 ) compared to placebo (n = 427) and there was no statistically significant difference between those treated and those not treated (relative risk (RR) 0.70, 95% confidence interval (CI) 0.46 to 1.07). In regards to side-effects sufficient to stop treatment, data were available for all women, and there were no statistically significant differences between any antibiotic (combined) and the placebo group (RR 1.25, 95% CI 0.85 to 1.85).

REVIEWER'S CONCLUSIONS

There is insufficient evidence to show whether giving antibiotics to women with ureaplasma in the vagina will prevent preterm birth.

Differences and trends in obstetric interventions at term among urban and rural women in New South Wales: 1990-1997

The aim of this study was to compare the management of term births among rural and urban women, including the effect of indigenous status and out-of-area-birth for rural women. Data were obtained from the NSW Midwives Data Collection (MDC), on 619,298 women who gave birth to a live, singleton infant at term (37-45 weeks gestation) from 1 January 1990 to 31 December 1997. Compared with urban non-indigenous women, rural women and indigenous women had lower rates of obstetric interventions both before birth (induction of labour, planned Caesarean section and epidural) and at the time of birth (Caesarean after labour, instrumental delivery and episiotomy). This was especially true for rural women giving birth in the their local area. The differing pregnancy risk profile of rural women did not explain the differences in intervention rates but differences were partly explained by higher rates of epidural anaesthesia in urban areas.

Rates for obstetric intervention among private and public patients in Australia: population based descriptive study

OBJECTIVE

To compare the risk profile of women receiving public and private obstetric care and to compare the rates of obstetric intervention among women at low risk in these groups.

DESIGN

Population based descriptive study.

SETTING

New South Wales, Australia.

SUBJECTS

All 171,157 women having a live baby during 1996 and 1997.

INTERVENTIONS

Epidural, augmentation or induction of labour, episiotomy, and births by forceps, vacuum, or caesarean section.

MAIN OUTCOME MEASURES

Risk profile of public and private patients, intervention rates, and the accumulation of interventions by both patient and hospital classification (public or private).

RESULTS

Overall, the frequency of women classified as low risk was similar (48%) among those choosing private obstetric care and those receiving standard care in a public hospital. Among low risk women, rates of obstetric intervention were highest in private patients in private hospitals, lowest in public patients, and generally intermediate for private patients in public hospitals. Among primiparas at low risk, 34% of private patients in private hospitals had a forceps or vacuum delivery compared with 17% of public patients. For multiparas the rates were 8% and 3% respectively. Private patients were significantly more likely to have interventions before birth (epidural, induction or augmentation) but this alone did not account for the increased interventions at birth, particularly the high rates of instrumental births.

CONCLUSIONS

Public patients have a lower chance of an instrumental delivery. Women should have equal access to quality maternity services, but information on the outcomes associated with the various models of care may influence their choices.

Term breech birth in New South Wales, 1990-1997

Data on 636,708 women delivering a singleton infant of gestational age > or =37 weeks in NSW from 1 January 1990 to 31 December 1997 were used to examine trends in breech births at term and the mode of delivery. From 1990 to 1997, although the crude rate of breech births at term remained stable at 3.4%, the adjusted odds ratio for breech birth compared with cephalic birth decreased over time. Among live breech births, the crude rate of vaginal breech birth declined from 29.4% to 19.7%, with an attendant increase in elective Caesarean sections from 49.1% to 58.4%. Most of this increase was at 38 and 39 weeks gestation. There was no change in the perinatal mortality rate among breech births during the study period. Despite increasing maternal age, the adjusted odds of a breech birth at term decreased over time. This could be due to offsetting factors, such as increased use of external cephalic version. If the decrease in vaginal breech birth continues, it may lead to the skills for this procedure being lost.

Small fetal size: a risk factor for breech birth at term

OBJECTIVE

To examine fetal size as a risk factor for breech birth at term.

METHODS

Singleton breech or cephalic births of gestational age > or = 37 weeks in New South Wales (NSW), Australia from 1990 to 1996 were analyzed. Birthweight percentile was used as a measure of fetal size at the time of birth. Factors associated with breech birth at term were analyzed using logistic regression.

RESULTS

There were 18914 singleton breech and 540164 cephalic births in the study period. The important independent predictors of breech birth at term were advancing maternal age, primiparity, female sex and small size for gestational age. Infants < 10th percentile had an adjusted odds ratio of 1.33 (95% CI 1.28-1.38) for breech birth at term compared with 25th-75th percentile infants.

CONCLUSIONS

Breech birth at term was associated with smaller fetal size for gestational age. This was shown directly through an association with birthweight-for-gestational-age percentiles and indirectly through association with female sex, primiparous birth and congenital anomalies.

Cystic fibrosis and pregnancy

The case records of 11 patients with cystic fibrosis (CF) who had 13 completed pregnancies between 1975 and 1995 were retrospectively reviewed to assess: (1) the changes in spirometry and body mass index (BMI) during pregnancy; and (2) maternal and neonatal complications and outcomes. Prepregnancy the mean age of the group was 24 (range 17-27) years. Two patients were exsmokers, 7 had pancreatic insufficiency and 7 had chest X-ray evidence of bronchiectasis. None of the patients had diabetes mellitus but 3 developed gestational diabetes. The mean +/- SEM (% predicted) forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) prepregnancy were 2.3 +/- 1.0 (83%) litres and 3.0 +/- 0.9 (85%) litres respectively. Five patients had normal spirometry (FEV1 and FVC >80% predicted) prior to 6 pregnancies. The mean body mass index (kg/height(m)2) for the group was 20.5 +/- 2.0. There was a significant decline in spirometry during pregnancy (FEV1 15.5 +/- 6.6% p<0.01; FVC 14.0 +/- 8.3% p<0.5). However, FVC but not FEV1 recovered to prepregnancy values by 12 months postpartum. There was a significant increase in both weight (7.1 kg) and BMI (2.6 kg/height(m)2) at the time of delivery compared with prepregnancy (p=0.0004). However, postpregnancy both weight and BMI had returned to their prepregnancy values (p<0.2). Mothers with an FEV1>80% had less decline in FEV1 related to pregnancy, better outcomes, fewer operative and instrumental deliveries, fewer preterm infants and fewer neonatal complications. Suggestions for the planning and management of pregnancy in women with CF are discussed.

Pregnancy and argininosuccinic aciduria

We present the outcome of a pregnancy in a woman with mild argininosuccinic lyase deficiency to add to the collective experience of the maternal and fetal effects of urea cycle defects. In females affected with argininosuccinic lyase deficiency, careful clinical and biochemical monitoring of pregnancy will minimize the risk of metabolic decompensation in the perinatal period. Furthermore, it would appear that argininosuccinate is not teratogenic to the development of the human fetus.

Maternal and neonatal outcome of patients classified according to the Australasian Society for the Study of Hypertension in Pregnancy Consensus Statement

OBJECTIVE

To outline the maternal and perinatal features and outcome of patients referred to a tertiary referral obstetric hospital for management of their hypertension.

SETTING AND PATIENTS

205 consecutive public patients admitted for assessment of hypertension (either full admission or day-stay) to King George V Hospital's Hypertension in Pregnancy Unit, between February 1993 and January 1994.

DESIGN

A prospective study in which patients were classified according to the Australasian Society for the Study of Hypertension in Pregnancy (ASSHP) Consensus Statement classification.

RESULTS

Of the 205 patients, 25% did not meet the criteria for pre-eclampsia or chronic hypertension, 33% had mild pre-eclampsia, 34% had severe pre-eclampsia and the remainder had chronic hypertension. The mean gestation at delivery for those with mild pre-eclampsia was 38.3 weeks and for severe pre-eclampsia 35.3 weeks. For the mild and severe groups respectively, the rate of elective delivery for raised blood pressure was 56% and 53%; for caesarean section, 17% and 61%; and for perinatal death, 2% and 4%. In the severe group, 49% had fetal problems and 25% required intravenous antihypertensives.

CONCLUSIONS

The multisystem nature of pre-eclampsia makes comparison of management protocols difficult. Ongoing audit is needed of maternal and perinatal outcomes and features of disease in patients with hypertension in pregnancy under a universal classification. The ASSHP classification system successfully identifies patients who require more intensive management and intervention.

Pregnancy complicated by maternal phenylketonuria

Pregnant women who have elevated levels of serum phenylalanine are more likely to have a spontaneous abortion or to give birth to an infant with congenital cardiac anomalies, symmetrical growth retardation, microcephaly and mental retardation than pregnant women with normal levels of this amino acid (1). Nine pregnancies in 7 women were managed in conjunction with the staff of the Children's Hospital, Sydney. In 6 patients, satisfactory serum levels of phenylalanine were attained and 6 offspring are all normal at follow-up, ranging from 15 years to 1 year. The 2 children of the poorly controlled mother were of low birth-weight and both had microcephaly at birth. The poor control of serum phenylalanine was due to poor compliance with the strict dietary regimen. It is concluded that dietary control of serum phenylalanine levels below 600 umol/l in pregnant women with PKU is possible and desirable and may improve perinatal and long-term outcome. This requires close co-operation between paediatrician, dietician, obstetrician and patient. Further data are required to confirm these findings in larger numbers and to provide long-term neurological follow-up.

Laparoscopic salpingostomy with electrocautery in the management of tubal pregnancy

From August, 1990 to May, 1991, all cases of tubal pregnancy presenting to King George V Hospital for Mothers and Infants were considered for laparoscopic salpingostomy. This procedure involved opening the affected Fallopian tube with diathermy, removal of ectopic tissue via the laparoscope, achieving haemostasis and leaving the tubal incision to heal by secondary intention. The procedure was undertaken in 35 patients and was successfully performed in 31 patients with an average operating time of 66.4 minutes (+/- 20.1 minutes). Average hospital stay was 2.1 days (+/- 1.3). This paper examines the technique and results of the initial learning curve for laparoscopic salpingostomy and finds that with knowledge of potential hazards and care in surgery, this operation can be safely carried out in a selected group of patients.

Nasal symmetry: a 10-year comparison between the Pigott and McComb nasal correction

The objective assessment of the symmetry of the cleft lip nose has not been properly evaluated. A simple technique using enlarged photographs and area assessment is described. Two different techniques were assessed, the Pigott "alar leapfrog" technique and the McComb alar lift technique. The children were assessed at 10 years of age. The results show no differences in the linear measurements or when the symmetry is assessed in the frontal view. In the worm's eye view, the Pigott correction was shown to produce a more asymmetric nose when compared with the McComb technique. Both corrections produce significant asymmetry when compared with a control group.

Second trimester abortion by extra-amniotic PGF2 alpha infusion: experience of 178 cases

There is a continuing need for second trimester induced abortions, most recently due to the increase in the use of antenatal diagnostic procedures, amniocentesis, high resolution ultrasound and cordocentesis. To evaluate the efficacy and safety of extraamniotic infusion of PGF2 alpha for this purpose a retrospective review of 178 procedures was undertaken. There were 4 failures of the technique and the major complication rate was 5.6%. This rate was independent of gestational age. The mean induction to abortion interval was 29.6 (+/- 16.3) hours. The conclusion reached after comparison with other published data is that extraamniotic PGF2 alpha infusion is a slow and painful but safe and effective technique, but that at gestational ages less than 17 weeks, a comparative trial of Dilatation and Evacuation versus extraamniotic PGF2 alpha infusion would be justified.

Experience with silastic slings for female urinary incontinence

Between September 1, 1985 and December 31, 1987, 54 patients with stress urinary incontinence were treated with a reinforced silastic sling using an abdominovaginal approach; 42 patients were cured, two improved and nine were the same or worse. Five patients who are continent required periodic intermittent self-catheterization. Eight patients developed detrusor instability postoperatively. One patient had to have the sling removed due to a persistent sinus. Fifteen patients had to have the sling adjusted.

Perinatal factors and the development of chronic lung disease in preterm infants: a case control study

A case control study of neonates was performed to determine those factors contributing to the development of chronic lung disease (CLD). During the 5 years 1981-84 there were 487 neonatal survivors at gestations of 25-32 weeks; 391 of these developed respiratory failure (oxygen therapy required for more than 6 h). Fifty-six of the latter developed CLD (oxygen therapy required for more than 28 days and a coarse reticular pattern on chest X-ray). These neonates were predominantly of the shortest gestational ages, regardless of the initial chest X-ray diagnosis. Forty-three of these infants with CLD were matched for gestation and initial chest X-ray appearance (respiratory distress syndrome, n = 20; normal, n = 15; non-specific, n = 8) with 42 control infants. The mean duration of oxygen therapy (P less than 0.001), maximum FiO2 (P less than 0.001), incidence (P less than 0.01) and duration of intermittent positive pressure respiration (IPPR; P less than 0.05) and peak IPPR (P less than 0.05) were significantly greater in the CLD group. Mean birthweight (P less than 0.001), arterial cord pH (P less than 0.05) and base excess (P less than 0.05) were significantly lower in the CLD group. Factors that were not statistically significant in the development of CLD included antenatal fetal heart rate abnormality, hypertensive disease of pregnancy, acute intrauterine infection (chorioamnionitis or umbilical vasculitis), administration of antenatal steroids, sex, patent ductus arteriosus and pneumothorax. The association between CLD and ventilator/oxygen therapy is confirmed. Contrary to other reports, male sex, clinical patent ductus arteriosus and pneumothorax were not associated with CLD.

Vascular and neural changes in the rat optic nerve following induction of diabetes with streptozotocin

This study was undertaken to determine whether or not changes occur in blood vessels, axons or glia of the optic nerve as the result of streptozotocin-induced diabetes. Diabetes was induced in 4 weeks old Sprague-Dawley rats. At 12 and 16 weeks of age, the rats were killed and the optic nerves prepared for examination. The number and density of blood vessels was found to be significantly increased in the diabetic rats. No alteration in the structure of the blood vessels was noted. A decrease in the percentage volume of axons and an increase in the percentage volume of glial elements accompanied the increase in blood vessels in the diabetic rats. No difference was found in the spectrum of fibre diameters.