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Objective: The aims of this study were to evaluate a prototype bedside test for fetal fibronectin detection in women with symptoms of preterm labor, to compare the efficacy of obtaining fetal fibronectin swabs with and without a speculum, and to assess the value of combining the fetal fibronectin test with cervical dilatation for predicting delivery within 10 days., Study Design: This investigation prospectively studied a cohort of women with symptoms of preterm labor (n = 121), gestational age between 24 and 33 6/7 weeks, and cervical dilatation /=1 cm predicted delivery within 10 days with sensitivity, specificity, and positive and negative predictive values of 71%, 87%, 46%, and 95%, respectively, with positive and negative likelihood ratios of 5.5 and 0.33, respectively. Combination of fetal fibronectin testing with cervical dilatation >/=1 cm did not significantly improve the fetal fibronectin test characteristics. After exclusion of women with slight vaginal bleeding, cervical dilatation >/=1 cm and fetal fibronectin status remained the only independent variables associated with delivery within 10 days., Conclusion: Fetal fibronectin testing according to this prototype may have a limited role in clinical decision analysis. In this study a cervical dilatation >/=1 cm had predictive values equivalent to those of the fetal fibronectin test, and it should be evaluated further in a clinical setting.

We examined the association between antenatal indomethacin exposure and adverse neonatal outcome in a matched retrospective cohort study of infants born to 72 mothers at less than 31 weeks' gestation. Indomethacin-exposed mothers were matched to controls by gestational age at delivery, antenatal corticosteroid exposure, prolonged spontaneous rupture of membranes, multiple pregnancy, thyrotrophin releasing hormone (TRH) exposure, and neonatal sex. Periventricular haemorrhage was significantly increased for infants delivered within 48 hours of maternal indomethacin exposure (Grade 1 and 2 19% versus 6%, and Grades 3 and 4 28% versus 3% (p<0.03)). Persistent patent ductus arteriosus was more common in those infants delivered within 48 hours of maternal indomethacin exposure (40% versus 20% (p<0.04)). More neonates exposed to antenatal indomethacin failed to respond to postnatal indomethacin to close a patent ductus arteriosus, 60% versus 0% (p<0.04). There were no adverse effects demonstrated of indomethacin administered greater than 48 hours from delivery. We have confirmed a probable association between antenatal indomethacin administration and an increased incidence of neonatal periventricular haemorrhage, patent ductus arteriosus, and impaired renal function. The adverse neonatal effects appear to be greatest when indomethacin is administered within 48 hours of delivery. We recommend that indomethacin should be used with caution as a tocolytic agent for the treatment of preterm labour at gestations less than 31 weeks.

Short-acting oral nifedipine has been withdrawn from the Australian market because of reports of its adverse effects after long-term treatment in non-pregnant patients with heart disease. This will have a major impact on the treatment of acutely hypertensive pregnant women, in whom the drug has proven to be safe, effective and easy to administer. Should pregnant women be forced to use less suitable agents, thus threatening their own and their babies' health?

The Levonorgestrel-releasing intrauterine device (LNG IUD) provides excellent contraception; it may reduce the rate of pelvic inflammatory disease (PID) and ectopic pregnancy compared to other 'modern' copper releasing IUDs; it can safely be used in the puerperium for breast-feeding mothers, and it significantly reduces menstrual blood loss and pain. While it was developed primarily as a contraceptive, its potential role in managing heavy and painful menstruation and the symptoms of the climacteric may eventually be just as important. Amongst developed countries New Zealand and Australia have some of the highest hysterectomy rates. By the age of 50 years 1 in 4 women in New Zealand and 1 in 5 women in Australia will have had a hysterectomy (A,B). In New Zealand 90% of these are performed for heavy menstrual bleeding and fibroids (A). The LNG IUD has been shown to be effective treatment for both these conditions and its introduction to New Zealand and Australia would offer women an additional choice beyond surgery.

A case of placenta praevia accreta is described. Delivery was achieved by Caesarean section and the placenta was left in place because of the risk of haemorrhage. Successful internal iliac artery embolization was performed 9 days postpartum to control uterine bleeding. Hysterectomy was performed at 55 days postpartum because of bleeding and sepsis.

The aim of this retrospective study was to identify risk factors for meconium-aspiration syndrome, and to identify antenatal and intrapartum risk factors which might be preventable. We analyzed maternal and neonatal records of the 210 infants who had meconium-stained liquor and who also developed respiratory distress necessitating admission to the Special Care of Intensive Care Baby Units at National Women's Hospital, Auckland in 1992. Meconium-aspiration syndrome occurred in 6.6% of meconium exposed babies and in 1.3% of total births. Severe meconium-aspiration syndrome developed in 18 infants, moderate in 48, mild in 60 respiratory distress in 84. An association was found between meconium aspiration syndrome and primiparity (p = 0.001) and Pacific Island ethnicity (p = 0.0002). An association was also found between the severity of meconium and low umbilical artery pH (p = 0.0002). Thick meconium and an abnormal cardiotocograph were more common in severe meconium-aspiration syndrome. All deaths and long-term morbidity occurred in babies with abnormal cardiotocographs or in unmonitored infants. Preventable antenatal and intrapartum factors were not identified in this study.

Objective: To investigate if chronic hypertension in the absence of superimposed pre-eclampsia is associated with increased perinatal morbidity (especially small for gestational age babies and preterm deliveries) when compared to the general obstetric population., Design: A retrospective cohort study., Setting: A tertiary referral obstetric hospital., Participants: One hundred and fifty-five pregnant women with chronic hypertension who had a diastolic blood pressure of greater than 90 mmHg before 20 weeks or had pre-existing essential hypertension were studied. The study period was January 1 1991 to June 30 1993., Main Outcome Measures: Perinatal related loss rate, birthweight less than the fifth centile (small for gestational age) preterm delivery, placental abruption and development of superimposed pre-eclampsia., Results: Women with chronic hypertension without superimposed pre-eclampsia had an increased rate of small for gestational age babies (10.9%) compared with the general population (4.1%) (odds ratio 2.9 -confidence interval 1.6 to 5.0). Women with chronic hypertension without superimposed pre-eclampsia did not have a significant increase in preterm delivery or perinatal loss. Severe hypertension (diastolic blood pressure > or =110) at less than 20 weeks was associated with a trend to an increased risk of small for gestational age babies (odds ratio 3.8 -confidence interval 1.0 to 13.7-), increased rate of delivery at less than 32 weeks (odds ratio 7.4 -confidence interval 1.9 to 29.5-) and increased rate of superimposed pre-eclampsia (odds ratio 5.2 -confidence interval 1.5 to 17.2-). Women with superimposed pre-eclampsia had the greatest perinatal morbidity., Conclusions: Women with chronic hypertension without pre-eclampsia have an increased risk of delivering a small for gestational age baby. Perinatal morbidity and pre-eclampsia is greatest in women with severe hypertension at less than 20 weeks. Preterm delivery is more common in women with superimposed pre-eclampsia.

Aim: The aim of the study was to examine knowledge of and perceived availability of the emergency contraceptive pill as well as reasons for its non use., Methods: One hundred women each attending Epsom day unit or the Auckland medical aid clinic in Auckland seeking termination of pregnancy, and 100 women seeking contraceptive advice from the Alice Bush centre in Auckland, were asked to take part in the study., Results: At Alice Bush centre 57% of women had previously used the emergency contraceptive pill compared with 43% women at Epsom day unit and 32% women at Auckland medical aid clinic. Only 7% of women attending Epsom day unit or Auckland medical aid clinic had used the emergency contraceptive pill in the month they conceived. When asked why they had not used the emergency contraceptive pill 38% of respondents said they had not heard of it and 41% did not know where to obtain it. Pacific Island women were least likely to have heard of it. Approximately 50% knew the correct time interval for using the emergency contraceptive pill. Sixty two percent attending the abortion clinics would have used the emergency contraceptive pill if they had a supply at home and 57% stated they would have used it if it was available over the counter through pharmacies., Conclusions: The discrepancy between the numbers of women who knew of the emergency contraceptive pill (72%) and the numbers who used it to try to prevent pregnancy (7%) indicates that there are barriers to obtaining and using the emergency contraceptive pill. This study demonstrated a lack of knowledge of the emergency contraceptive pill in women attending the abortion clinics. The majority of women seeking termination of pregnancy would have used the emergency contraceptive pill if they had it available at home or over the counter through a pharmacy. Doctors prescribing the pill and barrier methods of contraception should consider providing a supply of emergency contraceptive pill at the same time and consideration should be given to over the counter prescribing of the emergency contraceptive pill in New Zealand.

1. A heterogeneous group of randomized trials have been conducted using low-dose aspirin to prevent preeclampsia. The results do not support widespread use of low-dose aspirin to prevent preeclampsia. 2. On the basis of existing literature, it is reasonable to use prophylactic low-dose aspirin from early pregnancy in the following groups: (i) Women with prior fetal loss after the first trimester, with placental insufficiency (ii) Women with severe fetal growth retardation in a preceding pregnancy either due to preeclampsia or unexplained (iii) Women with severe early-onset preeclampsia in a previous pregnancy necessitating delivery at or before 32 weeks' gestation. 3. On the basis of existing literature, it is recommended that aspirin not be used in the following groups: (i) Healthy nulliparous women (ii) Women with mild chronic hypertension (iii) Women with established preeclampsia. 4. The data are sufficient to support further trials in more homogeneous select subgroups of women considered at risk of developing preeclampsia.

Aim: The aim of the study was to assess the contraceptive knowledge and practices of women attending the abortion service at Epsom day unit, Green Lane Hospital., Methods: Women attending the unit in December 1992 and January 1993 were asked to take part in the study. A questionnaire was administered to consenting women to assess demographic details and previous contraceptive education. If a contraceptive method was used the reason for failure was explored and if no method was used the reason for non use was explored., Results: Sixty-one percent of women were using a contraceptive method in the month of conception. The condom was used by 48% and the pill by 42%. Eight percent of women had never used contraception and 30% were not using a method in the month of conception. Forty-three percent had a household income of less than $22,000 and financial barriers were the reason for non use in 32% of those not using a method. Of women who did not use contraception, only 11% used emergency contraception, whereas 78% of those surveyed said they knew about emergency contraception. Sixty-three percent of women said they had received enough contraceptive education to select and use a method effectively. Pacific Island women were least likely to have received adequate contraceptive education or to have been using a method of contraception., Conclusions: A number of technical problems were identified with condom use. These problems need to be emphasised by sexuality education programmes and contraceptive prescribers. Omitting pills, diarrhoea, vomiting and drug interactions were important causes of pill failure. The seven day rule needs more emphasis when teaching women how to take the pill and when antibiotics are prescribed. Costs were an important barrier to the use of contraception for a significant proportion of women. Section 99 approval should be utilised more readily and the provision of free contraception, especially to low income groups, needs to be urgently explored.

Background: Beckwith-Wiedemann syndrome is a genetically complex congenital disorder with variable clinical features at birth, including malformations, excessive body and/or organ growth, and endocrine dysfunction. Both maternal gestational proteinuric hypertension and placental abnormalities have been reported infrequently in Beckwith-Wiedemann syndrome, but the occurrence of three cases with both features at one institution within a year suggests that this may be an underreported association., Cases: Severe gestational proteinuric hypertension in three women led to termination of one pregnancy at 22 weeks' gestation, delivery by cesarean in another at 27 weeks of an infant who had hyperinsulinism and died at age 3 days, and stillbirth at 31 weeks in the third. All three infants had features diagnostic of Beckwith-Wiedemann syndrome. Placentomegaly had been identified by ultrasound in each case and was determined pathologically as mainly attributable to stromal expansion of the villous tree. Cysts resulting from hydrops in stem villi were identified ultrasonographically in one placenta; this lesion may be specific for Beckwith-Wiedemann syndrome. The third placenta was associated with a discrete complete hydatidiform mole., Conclusions: A diagnosis of Beckwith-Wiedemann syndrome should be considered in all cases in which gestational proteinuric hypertension is associated with ultrasound findings of placentomegaly, with or without associated cystic changes in the placenta, and an examination should be made for other confirmatory features.

Doppler studies of the uterine and umbilical arteries were performed in 24 acutely hypertensive pregnant women. Women were divided into 2 groups: Group 1 (diastolic blood pressure (DBP) > 110 mm Hg) received placebo (n = 6) or 10 mg oral nifedipine (n = 9); Group 2 (DBP > or = 110 mm Hg) received 10 mg oral nifedipine (n = 5) or 10 mg intravenous hydralazine (n = 4). Treatment allocations were random within groups and the investigator and patient were blind to the treatments. Baseline flow velocity waveforms (FVW) and posttreatment FVW's at 30, 60 and 120 minutes were recorded. There was no significant difference between baseline and posttreatment FVW indices within or between groups. Placebo was as effective as nifedipine in lowering blood pressure over 2 hours of study. There were no significant adverse effects of treatment.

Doppler studies of the arcuate and umbilical arteries were performed longitudinally commencing at 24 weeks or less, in 29 pregnant women with chronic hypertension. The hypothesis was that pregnant women with chronic hypertension who develop superimposed gestational proteinuric hypertension and/or deliver small for gestational age babies are those who have abnormal arcuate and/or umbilical flow velocity waveforms. Abnormal arcuate waveforms occurred in 7 women and abnormal umbilical waveforms in 12. Nine babies were small for gestational age, and 6 of them had abnormal arcuate waveforms. Abnormal arcuate waveforms were significantly associated with the delivery of a small for gestational age baby (p = .001) and identified those babies where early delivery was necessary for fetal reasons. All small for gestational age babies had abnormal umbilical waveforms. Superadded gestational proteinuria (or preeclampsia) occurred in 8 pregnancies, however, only 3 had abnormal arcuate waveforms. An abnormal arcuate waveform did not predict the later development of gestational proteinuria. An abnormal umbilical waveform however, was associated with the subsequent development of gestational proteinuria. We consider that these findings need to be confirmed in a larger study.

High speed rotational coronary atherectomy was undertaken using the Rotablator in 42 patients who were suboptimal candidates for balloon angioplasty. Most patients (71%) had diffuse coronary artery disease, defined as a stenosis greater than 1 cm in length. Previous restenosis after balloon angioplasty was present in 21% and 10% had an ostial lesion. Adjunctive balloon angioplasty was not used to reduce residual stenosis after atherectomy. The procedure was successful in 76% of patients. Procedural success was achieved in 92% of patients with a lesion less than or equal to 1 cm in length, but in only 70% of patients with a lesion greater than 1 cm in length (p less than 0.01). One patient sustained abrupt closure of the target vessel, resulting in emergency bypass surgery and death. Small non-Q wave myocardial infarction occurred in eight patients (19%) and was associated with a longer lesion. The mean peak creatine kinase value in patients with non-Q wave myocardial infarction was 683 U/liter. Transient regional wall motion abnormalities were noted on the postatherectomy left ventricular angiogram in four of the eight patients with non-Q wave myocardial infarction. Follow-up angiography (at a mean interval of 6.2 +/- 2.6 months) was performed in 91% of patients and revealed restenosis (greater than 50% narrowing) in 59% The resistance rate was 22% for short lesions (less than or equal to 1 cm) and 75% for long lesions (greater than 1 cm) (p less than 0.05). In this study, the results of high speed rotational coronary atherectomy were strongly influenced by lesion length.(ABSTRACT TRUNCATED AT 250 WORDS)

A double-blind study of 73 patients was undertaken to evaluate the prophylactic effect of short-term metronidazole in caesarean section. Metronidazole, 500 mg, given intravenously prior to making the incision, followed by 2 g, rectally, on completion of surgery failed to reduce the incidence of infection post-operatively. There was no reduction in the number of patients requiring antibiotics or in the quantity of post-operative pyrexia, as assessed by the fever index. The incidence of post-operative pyrexia was not affected by the duration of ruptured membranes or the use of a fetal scalp electrode.

Umbilical artery Doppler studies were performed close to delivery in 17 women (seven with healthy pregnancies and 10 complicated by intrauterine growth retardation), and results were analyzed by calculating the pulsatility index. In each case the placenta was examined histologically, and the small arteries and arterioles were counted in the tertiary stem villi. A highly significant negative linear relationship was found between pulsatility index and mean small arterial vessel count per field (r = 0.71, p less than 0.01). This suggests that when the pulsatility index is raised (indicating increased resistance), one possible explanation may be obliteration of small placental arteries.

An electrical analogue model of an artery that terminates into a vascular bed is presented. The model consists of an uniform transmission line that represents the artery and a load impedance that represents the vascular bed. The transmission line parameters are based on a well-established first-order approximation of the Navier-Stokes equations for fluid flow in distensible tubes. The model can be used to predict the incident and reflected components of both the arterial pressure and flow waveforms. In addition, it can predict the vessel diameter change and the mean blood velocity waveforms. In this study, the model was applied to the uterine artery so that the characteristics of the utero-placental circulation can be related to Doppler ultrasound recordings. It was found that the presence of the dicrotic notch in the uterine artery time-velocity waveform is the result of wave reflection and that a persistent notch past 20 weeks' gestation may be indicative of an abnormally high placental bed resistance. It is shown that the simulation results are consistent with the known physiological data and the clinically recorded uterine Doppler waveforms.

Uterine artery flow velocity waveforms were measured by continuous-wave Doppler ultrasound in 15 normal pregnant women studied from midgestation until term. Results were analyzed by calculation of the pulsatility index and the systolic/diastolic blood velocity [corrected] ratio. Both indices decreased from 16 to 20 weeks (indicating a lowering of resistance) and thereafter remained stable until term. Resistance was lower when waveforms were recorded directly over the placenta or from the uterine artery close to the placenta. A group of women with severe intrauterine growth retardation were also studied. In preeclampsia, uterine artery resistance was increased in almost all patients. In pregnancies complicated by intrauterine growth retardation of non preeclamptic origin, a wide range of results was obtained.

Umbilical artery Doppler studies were performed on the day of delivery in 15 singleton preterm pregnancies. In each case the fetus was significantly growth retarded on ultrasound examination and the attending obstetrician had made a decision to deliver the patient of the infant. Eight women had severe preeclampsia, three had mild chronic hypertension, and in four there was no recognized maternal disorder. Doppler studies were analyzed by use of the pulsatility index and the A/B ratio. In 14 of the 15 cases both were markedly abnormal. Three early neonatal deaths occurred. A positive correlation was found between the degree of abnormality of the pulsatility index and A/B ratio and a poor neonatal outcome (p less than 0.001 and p less than 0.02). Umbilical artery Doppler studies were not helpful in differentiating between intrinsic and extrinsic causes of growth retardation but seemed to identify the pregnancy at increased risk of a poor neonatal outcome.