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Multiple-target tracking algorithms generally operate in the local frame of the sensor and have difficulty with track reallocation when targets move in and out of the sensor field-of-view. This poses a problem when an unmanned aerial vehicle (UAV) is tracking multiple ground targets on a road network larger than its field-of-view. To address this problem, we propose a Rao-Blackwellized Particle Filter (RBPF) to maintain individual target tracks and to perform probabilistic data association when the targets are constrained to a road network. This is particularly useful when a target leaves and then re-enters the UAV's field-of-view. The RBPF is structured as a particle filter of particle filters. The top level filter handles data association and each of its particles maintains a bank of particle filters to handle target tracking. The tracking particle filters incorporate both positive and negative information when a measurement is received. We implement two path planning controllers, receding horizon and deep reinforcement learning, and compare their ability to improve the certainty for multiple target location estimates. The controllers prioritize paths that reduce each target's entropy. In addition, we develop an algorithm that computes the upper bound on the filter's performance, thus facilitating an estimate of the number of UAVs needed to achieve a desired performance threshold., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Moore, Bidstrup, Peterson and Beard.)

Purpose: Pelvic congestion is diagnosed by transuterine venography, an invasive procedure requiring sedation and irradiation. Ultrasound may be an alternative but is hindered by slow flow within pelvic veins. In an attempt to counter this, we investigated the possible role of transvaginal power Doppler ultrasound., Material and Methods: 42 women with a clinical suspicion of pelvic congestion underwent transvaginal ultrasound. Adnexal veins were examined and a congestion score established. Planimetric measurements of adnexal vessels were obtained using power Doppler ultrasound, and uterine and ovarian morphology noted. All women then underwent transuterine venography and agreement with the ultrasound congestion score and morphologic features was determined., Results: There was a trend towards weak positive correlation between ultrasound and venography congestion scores (r = 0.29, p = 0.06). However, agreement between scores was poor on an individual basis (95% limits of agreement, -3.9 to +2.7). Planimetric power Doppler assessments of adnexal vascularity were unrelated to venographic congestion. Instead, there was correlation between the number and diameter of ovarian follicles and venographic congestion: women with congestion tended to have significantly more (0.04) and smaller follicles (p = 0.001)., Conclusion: There was poor individual agreement between ultrasound and venographic estimates of congestion. However, there was a direct relationship between venographic congestion score and ovarian morphology.

Objective: Pelvic venous congestion is a common finding in women with chronic pelvic pain. While the pathophysiology of this condition is poorly understood, there are clear indications that it involves vascular dysfunction. The present studies sought abnormalities in microvascular function in these patients., Design: Prospective longitudinal study., Setting: A teaching hospital tertiary referral., Population: Eighteen women with pelvic congestion and 13 normal women., Methods: Parameters of microcirculatory function were measured in the calves of women using venous congestion plethysmography during the midfollicular and midluteal phases of the menstrual cycle. The women with pelvic congestion were studied again after treatment for the condition., Main Outcome Measures: Isovolumetric venous pressure, microvascular filtration capacity and limb blood flow., Results: Of the measured parameters of microvascular function, only isovolumetric venous pressure (Pvi) was significantly higher in women with congestion when compared to the controls during the same phase of the cycle. There were no menstrual cycle related differences in any of the other measured parameters in either patients or controls. Following successful treatment for the condition, values of Pvi in women with pelvic congestion were significantly reduced, achieving a level similar to that observed in the controls., Conclusion: The observed changes in Pvi suggest that this parameter is intimately associated with the pathophysiology of pelvic congestion. The increase in Pvi, without alterations in other measured microvascular parameters, may be attributable to systemic increases in postcapillary resistance secondary to neutrophil activation. These findings support the notion of systemic microvascular dysfunction in these women.

Objective: To examine the maternal and foetal risks of adverse pregnancy outcome in relation to maternal obesity, expressed as body mass index (BMI, kg/m(2)) in a large unselected geographical population., Design: Retrospective analysis of data from a validated maternity database system which includes all but one of the maternity units in the North West Thames Region. A comparison of pregnancy outcomes was made on the basis of maternal BMI at booking., Subjects: A total of 287,213 completed singleton pregnancies were studied including 176,923 (61.6%) normal weight (BMI 20--24.9), 79 014 (27.5%) moderately obese (BMI 25--29.9) and 31,276 (10.9%) very obese (BMI> or =30) women., Measurements: Ante-natal complications, intervention in labour, maternal morbidity and neonatal outcome were examined and data presented as raw frequencies and adjusted odds ratios with 99% confidence intervals following logistic regression analysis to account for confounding variables., Results: Compared to women with normal BMI, the following outcomes were significantly more common in obese pregnant women (odds ratio (99% confidence interval) for BMI 25--30 and BMI> or =30 respectively): gestational diabetes mellitus (1.68 (1.53--1.84), 3.6 (3.25--3.98)); proteinuric pre-eclampsia (1.44 (1.28--1.62), 2.14 (1.85--2.47)); induction of labour (2.14 (1.85--2.47), 1.70 (1.64--1.76)); delivery by emergency caesarian section (1.30 (1.25--1.34), 1.83 (1.74--1.93)); postpartum haemorrhage (1.16 (1.12--1.21), 1.39 (1.32--1.46)); genital tract infection (1.24 (1.09--1.41), 1.30 (1.07--1.56)); urinary tract infection (1.17 (1.04-1.33), 1.39 (1.18--1.63)); wound infection (1.27 (1.09--1.48), 2.24 (1.91--2.64)); birthweight above the 90th centile (1.57 (1.50--1.64), 2.36 (2.23--2.50)), and intrauterine death (1.10 (0.94--1.28), 1.40 (1.14--1.71)). However, delivery before 32 weeks' gestation (0.73 (0.65--0.82), 0.81 (0.69--0.95)) and breastfeeding at discharge (0.86 (0.84--0.88), 0.58 (0.56--0.60)) were significantly less likely in the overweight groups. In all cases, increasing maternal BMI was associated with increased magnitude of risk., Conclusion: Maternal obesity carries significant risks for the mother and foetus. The risk increases with the degree of obesity and persists after accounting for other confounding demographic factors. The basis of many of the complications is likely to be related to the altered metabolic state associated with morbid obesity.

Aim: To determine if transvaginal ultrasound, including power Doppler examination, can distinguish between women with and without pelvic congestion., Materials and Methods: Thirty-six women with pelvic congestion were prospectively examined using transvaginal ultrasonography and standard uterine and ovarian measurements made. Additionally, planimetric measurements of each ovary were taken using an image analysis program to determine the cross-sectional area of ovarian stroma and follicles, if any. Power Doppler images of adnexal vessels were obtained and planimetric estimates of surface area calculated. A congestion score was assigned to each patient, based on vein number, diameter and morphology on grey-scale scanning. Identical measurements were obtained from 19 asymptomatic women and results compared., Results: There was no significant difference between women with pelvic congestion and controls with respect to power Doppler or grey-scale images of adnexal vessels, or congestion score. However, women with pelvic congestion had significantly larger and multicystic ovaries when compared to controls., Conclusions: Transvaginal ultrasound measurements of adnexal vasculature, including power Doppler measurements, cannot reliably distinguish women with pelvic congestion from controls. However, ultrasound may remain useful for diagnosis of pelvic congestion, predominantly because it is able to visualize multi-cystic ovaries in these patients.

Follicular fluid steroid content and theca and granulosa cell steroidogenesis in pelvic congestion cystic ovaries were compared with steroidogenic function in both normal and polycystic ovaries. Ovaries were obtained at oophorectomy for benign gynaecological conditions, and classified according to gross morphology at dissection. Individual follicles were dissected out, follicular fluid aspirated, and granulosa and theca cells cultured in vitro. Androstenedione, progesterone and oestradiol content of the follicular fluid and overlying culture medium were measured by radioimmunoassay. There was a significant elevation of both basal and LH-stimulated androstenedione production by theca from both polycystic ovaries (n = 10; P < 0.005) and pelvic congestion cystic ovaries (n = 8; P < 0.05 and < 0.01 respectively) as compared with normal ovaries (n = 5). Granulosa cells from pelvic congestion ovaries (n = 7) had a diminished oestradiol response to FSH as compared with those from normal ovaries (n = 8). Follicular fluid from the majority of follicles in the pelvic congestion cystic ovaries had a high androgen:oestrogen ratio consistent with atresia. For the first time, pelvic congestion ovaries characterized by predominantly atretic follicles scattered throughout the stroma in a normal volume ovary are reported. Follicular atresia was reflected by reduced granulosa cell responsiveness to FSH, theca cell hyperplasia and increased basal and LH-stimulated androgen production. These ovaries are functionally distinct from polycystic ovaries, which do not have a higher proportion of atretic follicles than normal ovaries.

Pelvic venous congestion is a common cause of chronic pelvic pain in women of reproductive age. Although this condition represents a functional disturbance of the pelvic circulation which is related to the menstrual cycle, its aetiology remains unknown. Indirect techniques demonstrate that the vasoconstrictive reflex response of the microcirculation of the foot to a rise in venous pressure is attenuated throughout the menstrual cycle. We wished to develop a simple and non-invasive direct measure of pelvic blood flow to aid diagnosis of this condition. Laser doppler blood flux measurements of the skin of the big toe and of the vaginal and rectal mucosa in the follicular and luteal phases of the menstrual cycle in 12 healthy asymptomatic premenopausal women (mean age 30 years) with regular cycles and in four healthy asymptomatic postmenopausal women (mean age 59 years) were carried out both in the supine position and in response to 40 degrees head-up tilt. The coefficient of variation of resting vaginal flux was lower for measurements in postmenopausal women (0.04) and in premenopausal women in the follicular phase (0. 07) compared with those in the luteal phase (0.16). At rest, vaginal blood flow was higher than rectal and skin flux in both premenopausal and postmenopausal women. In the follicular phase a decrease in flow was observed in response to head-up tilt in the skin (-32.0%), vagina (-34.3%) and rectum (-9.4%). In the luteal phase this reflex was attenuated at these three sites (-8.6%, +6.7% and +7.4% respectively). There were no significant reflex changes in postmenopausal women. Thus laser doppler fluximetry is a reproducible method for comparing the flux of blood in the microcirculation of the skin and of the vaginal and rectal mucosa. The skin is the least sensitive site for testing vascular reactivity in response to cyclical changes. The vaginal and rectal microcirculations are the most sensitive sites for testing visceral cyclical reactivity, and have the advantage of direct anatomical relevance. The follicular phase of the menstrual cycle is associated with greatest vascular reactivity and is the most appropriate phase during which to test for abnormal vascular responses.

Objective: To test the hypothesis that women with pelvic venous congestion have a reduction of reactivity of their peripheral circulation., Design: Comparison was made between 20 women with chronic pelvic pain due to congestion and a control group of 15 pain-free women matched for age, parity and body weight. A comparison of these results was made with those from six postmenopausal women taking hormone replacement therapy., Methods: Study and control groups were investigated during the mid-follicular phase of the menstrual cycle (days 5-9) and the mid-luteal phase (days 19-23). The study group was also investigated during the fifth month of treatment with suppression of ovarian activity with leuprorelin or medroxyprogesterone acetate or six months after hysterectomy and bilateral salpingo-oophorectomy. Head-up tilt sufficient to increase intra-vascular pressure in the toe by a standard 40 mmHg was used as a means of raising venous pressure in the lower limb. Skin capillary red blood cell velocity (flux) was measured using a laser Doppler flow probe placed over the pulp of the big toe. Heart rate and blood pressure were also recorded. The change in skin blood flow following head-up tilt was expressed as a percentage of baseline flow in the supine position., Main Outcome Measures: Percentage change in skin red blood cell flux, heart rate and blood pressure in response to 40 degrees head-up tilt., Results: In the control group the median response to head-up tilt in the follicular phase was one of a reduction in flux, whereas in the luteal phase it was more variable ranging from an increase to a decrease in flux. The responses in the pelvic congestion group in both the follicular and luteal phases were similar to those of the control group in the luteal phase. A small but significant increase in heart rate in response to tilt in the pelvic pain group, compared with the control group, was interpreted as being due to a fall in venous return. Treatment of the pelvic congestion group by medical suppression of ovarian activity or total hysterectomy with bilateral salpingo-oophorectomy resulted in a significant change in response to head-up tilt from the variable type of luteal response to one of a more constant reduction in flux, similar to that of the control group in the follicular phase. A reduction in flux was also found consistently in postmenopausal women., Conclusion: The study confirms the hypothesis that women with pelvic pain due to congestion show a change in peripheral vascular reactivity which returns to normal after suppression of ovarian activity. It seems likely that some alteration of normal ovarian function is responsible for the observed changes in peripheral blood flow in response to a rise in venous pressure in women with pelvic congestion.

The human placenta transports glucose by facilitated diffusion down a concentration gradient from mother to fetus. It has previously been considered incapable of glucose synthesis. However, recent work has demonstrated the presence in placental tissue of glucose-6-phosphatase, which is required for the final step in the synthesis of glucose. Following continuous intravenous infusion into the maternal circulation of the stable isotope, 6,6-(2)H(2)glucose, during elective caesarean section, we have observed isotope dilution in the umbilical vein, without further dilution in the umbilical artery. Using a mathematical model containing maternal, placental and fetal compartments, the data were compatible with the release of glucose by the placenta. We conclude that the human placenta at term can produce glucose., (Copyright 1999 Harcourt Publishers Ltd.)

Chronic pelvic pain is a common gynecological problem. There has long been an assumption that social and psychological factors play a part in its genesis in a significant subgroup, but their precise role remains unclear. More recently, childhood sexual abuse has been implicated as a specific risk factor. For this review, PSYCHLIT and MEDLINE searches for relevant publications were supplemented by tracing back through the latter's related reference lists. One hundred thirty-one references directly concerning pelvic pain were identified with varying emphasis on social and psychological aspects. A further 449 references were in related fields. Forty-three were considered to be helpful in directly exploring the link between chronic pelvic pain and sociopsychological factors and 22 of these reported specific studies directly relevant. In common with other research into chronic pain conditions, it appears unhelpful to separate this type of pain into "psychogenic" and "organic" categories. Clear case definition is essential. The specificity of childhood sexual abuse as a risk factor is unclear. It may be helpful to consider clearly defined subgroups with the condition in future studies. An example of such a subgroup with pelvic venous congestion is discussed.

Social and psychological factors have long been proposed as being of importance in a sizeable subgroup of women complaining of unexplained chronic pelvic pain (CPP). The aim of this study was to examine this in two subgroups of CPP patients, thereby eliminating pain alone as the determining variable. Consecutive attenders at a clinic for CPP were assessed on a range of somatic, historical, social, and psychological variables using detailed interviews and questionnaires. They were subsequently allocated to one of two groups, based on the presence or absence of pelvic venous congestion (PVC). Significant associations emerged between some social arrangements, paternal parenting, and patterns of hostility in the group with pelvic venous congestion. The groups also differed in patterns of family illness, and the congested group tended to report more childhood sexual abuse (CSA). Clear case definition in CPP is important. In the subgroup with pelvic venous congestion early social experience may play an important role. Father-daughter relationships may be particularly relevant. Hostility patterns may influence the development of the condition. CSA does not appear to play a specific role in all unexplained CPP cases, but may have relevance for the subgroup with pelvic venous congestion.

Objective: To investigate local vascular control in the isolated perfused premenopausal human ovary by measuring flow-induced release of vasoactive substances., Design: Release of adenosine 5' triphosphate (ATP), substance P (SP), endothelin (ET), and vasopressin (AVP) from the ovarian vascular endothelium was estimated in perfusate under basal conditions and during two periods of increased flow., Main Outcome Measures: Vascular resistance; ATP, SP, ET and AVP release., Results: The mean ratio (pressure/flow during increased flow):(pressure/flow at basal flow) was 1.27 +/- 0.04 for the first, and 1.15 +/- 0.05 for the second period of increased flow (n = 10), indicating significant vasoconstriction (P < 0.01 and 0.05, respectively), present to a greater extent during the first period of increased flow compared to the second (P < 0.05). ATP release was seen in response to increased flow (n = 8, P < 0.05). From 12 ovarian bed preparations, five released ET and SP and three of these released AVP. Four of the five perfused ovaries that released peptides contained either a developing follicle or a corpus luteum while all those that showed no peptide release were inactive., Conclusions: ATP release may play a role in the local control of the human premenopausal ovarian vasculature independent of ovulatory status. Peptides may also contribute to local vascular control in the ovary and their release from predominantly active ovaries suggests a relationship between ovulation and vascular endothelial function.

Objective: To assess the suitability of the standard primipara (a subset of the obstetric population that has relatively low risk or intervention and of adverse outcome) for making inter-unit comparisons of indicators of the process and outcome of maternity care., Design: Inter-unit comparison of 10 indicators of obstetric intervention and adverse outcome derived from routinely collected computerised data held on the St Mary's Maternity Information System., Setting: Fifteen maternity units in the former North West Thames Region., Participants: 15,463 primiparae who were delivered in 1992., Main Outcome Measures: Proportion of primiparae within the standard definition; degree to which standard primiparae are associated with lower rates of intervention and adverse outcome, as compared to other primiparae., Results: Within the database, 42.6% of all primiparae were found to be standard, with rates varying between units from 25.9% to 57.7%. As expected, the standard primiparous woman is at less risk of intervention or adverse outcome than other primiparae. All but one component variable of the standard definition is a significant risk factor for at least four of the 10 indicators. Statistically significant differences in indicator rates are seen between standard and nonstandard primiparae within units. Within the standard group, significant differences in rates of intervention and adverse outcome are seen between units. Units with relatively high levels of intervention within the higher risk nonstandard group also have relatively high levels of intervention within the standard group., Conclusions: Use of the standard primipara, rather than the whole obstetric population, as the basis for inter-unit comparisons of maternity care will control for the substantial difference in case mix seen in different units, thereby increasing the validity of those comparisons. The technique has the additional benefit of clarifying the relationship between everyday clinical decision making and a unit's performance in comparative indicator reports. The approach must be combined with a separate study of the other groups in the case mix, such as multiparae and high risk primiparae. Additional nonoverlapping groups, homogeneous in terms of risk factors, should be defined and used to extend the basis on which comparisons may be made.

The large-for-gestational-age (LGA) infant, defined as > 90th birthweight percentile, is associated with mild disturbances of maternal glucose tolerance. In the UK the same birthweight percentile charts are used for all ethnic groups when assessing LGA infants. The influence of maternal hyperglycaemia on LGA infants of Asian (Indian Subcontinent) mothers in the UK is likely to be under-reported, as Asian birthweights tend to be lower than White/Europid birthweights. We assessed the number of LGA infants born consecutively to 21 Asian and 26 White/Europid mothers with gestational diabetes mellitus (GDM), delivered between 37 and 42 weeks gestation, and also in 34 Asian and 121 White/Europid mothers with a positive screening test for GDM but a normal 75 g oral glucose tolerance test (OGTT). Large-for-gestational-age infants were identified using both the standard UK percentile charts of the Medical Research Council and percentile charts constructed from 30,418 Asian and 162,477 White/Europid singleton births, delivered between 37 and 42 weeks gestation to non-diabetic mothers delivered in the North West Thames Region of England. The standard Medical Research Council percentile charts, compared with the ethnically derived charts, identified fewer LGA Asian (7/56 vs 15/56) but more White/Europid infants (33/147 vs 21/147). When correcting for ethnicity more Asian than White/Europid GDM mothers delivered LGA infants (9/21 vs 3/26, chi 2 = 4.76, p < 0.05). The maternal 2 h OGTT plasma glucose was a significant independent contributor to birthweight in the Asian (r2 = 0.319, p < 0.0005) but not the White/Europid infants, in whom gestational age and maternal height were significant independent contributors to birthweight (r2 = 0.158, p < 0.0001). We conclude that ethnic influences are important when defining LGA infants and that mild disturbances of maternal glycaemia have a greater influence on the birthweight of Asian than White/Europid infants.

The diagnosis and management of lower abdominal pain is difficult, particularly for the inexperienced accident and emergency (A&E) or surgical trainee. In women, potential gynaecological causes may further confuse the picture. We analysed the incidence, spectrum of presentation and immediate management of 322 women presenting consecutively to an inner city A&E department over a 6-month period with lower abdominal pain. A standard questionnaire relating to history, examination, immediate investigations and preliminary diagnosis was completed by the attending A&E doctor. The cause of abdominal pain, according to the A&E doctor's diagnosis, was gynaecological in 61%, gastroenterological in 23%, urological in 7% and non-specific in 9% of cases. Of the women, 39% (124/322) were referred to a duty specialist, of whom 86% (107/124) required admission for investigation and/or treatment. Women initially diagnosed as having pain of gynaecological origin formed the largest group of patients to be referred. In 69% (67/97) of these cases, the A&E doctor's initial diagnosis was confirmed by the gynaecologist. This study shows that pain of gynaecological origin was the largest single cause of lower abdominal pain in women presenting to our A&E department and that, in the majority of cases, these women needed to be referred to the duty gynaecologist for immediate treatment. Although overall diagnostic accuracy rate was relatively high, the management of potentially life-threatening gynaecological conditions such as ectopic pregnancy was poor. These results emphasise the need to improve in-service gynaecological training in A&E departments.

Objective: To investigate the possible role of substance P as an endothelial factor in the local regulation of vascular tone in the human ovarian vein., Methods: We performed immunolocalization of substance P in human ovarian venous endothelium in situ and in culture, and observed responses to substance P in preconstricted ring preparations of human ovarian vein in the presence of either the prostaglandin synthesis inhibitor indomethacin or the inhibitor of nitric oxide synthesis L-nitro arginine methyl ester (L-NAME), with and without luminal rubbing., Results: Substance P was localized in a subpopulation of ovarian vein endothelial cells. Maximal relaxation induced by substance P was not significantly affected by indomethacin (10 mumol/L), but was reduced from 58.7% (95% confidence interval [CI] 41.3-76.1) in control experiments to 24.7% (95% CI 18.3-31.1) after luminal rubbing and to 32.3% (95% CI 19.8-44.8) after exposure to L-NAME (0.1 mmol/L) (P = .001)., Conclusion: The localization of substance P in ovarian vein endothelium together with vasodilator effects mediated partially via the endothelium suggests that the peptide has a role in the local control of vascular tone in this vessel.

Cognitive biases are increasingly implicated as vulnerability factors in emotional and physical disorders. This issue is examined here in chronic pain sufferers using a recall memory paradigm. A sample of chronic pelvic pain patients undergoing hysterectomy and oophorectomy were assessed prior to the intervention, 8 weeks post-surgery, and again 6 months post-surgery. On each occasion patients were aurally presented four mixed lists of sensory, affective, neutral and gardening words, matched for frequency and length. No difference in the recall of neutral and gardening words was found, suggesting that selective memory for pain-related information cannot be attributed to superior recall of words belonging to a common semantic category. A clear pattern of more pain-related words being remembered before surgery, but better recall of non-pain-related words 6 months post-surgery when pain intensity ratings are significantly reduced, was evidenced. These results suggest that selective memory for pain-related words is more likely to be a secondary consequence of the long term experience of pain than a stable, enduring cognitive vulnerability factor.

Abnormalities of insulin secretion rather than insulin sensitivity are described in women fulfilling the American criteria for gestational diabetes. We examined insulin secretion and insulin sensitivity in 38 women at risk of gestational diabetes categorized according to the less stringent WHO criteria, based on the 75 g oral glucose tolerance test, performed at 24 weeks gestation. Insulin sensitivity was assessed at 28 and 36 weeks using the short insulin tolerance test. Applying WHO criteria, 18 women had GDM. Age and body mass index of the GDM and glucose tolerant women were similar (32.4 +/- 1.1 (SE) vs 32.3 +/- 1.9 yr; 28.7 +/- 1.5 vs 28.8 +/- 1.7 kg m-2, respectively). Fasting glucose was higher in the GDM women than controls (5.1 +/- 0.2 vs 4.5 +/- 0.1 mmol l-1, p < 0.025) while fasting insulin was similar (75 +/- 18 vs 90 +/- 16 pmol l-1). The 30-min insulin concentration during the OGTT was lower in the GDM women than controls (436 +/- 61 vs 788 +/- 152 pmol l-1, p < 0.05), while the insulin sensitivity at 28 (87 +/- 5 vs 76 +/- 5 mumol l-1 min) and 36 weeks (73 +/- 8 vs 76 +/- 8 mumol l-1 min) was similar. A negative correlation existed between the 30-min insulin and 120-min glucose concentration during the OGTT (Rho -0.328, p < 0.05). The WHO criteria for GDM identify women with similar abnormalities of insulin secretion as the more stringent American criteria.

Objective: To assess the validity of clinical information held on a regional maternity database, the St Mary's Maternity Information System (SMMIS)., Design: A retrospective review of 892 maternity case notes and matched SMMIS records, by a midwife trained in clinical coding techniques., Setting: Three maternity units in the North West Thames Region., Main Outcome Measures: Percentage agreement for 17 directly recorded SMMIS data items and equivalent data abstracted from the notes. Frequencies of diagnosis codes abstracted from case notes, as compared with those generated by SMMIS on the basis of directly recorded data., Results: A generally high level of agreement was observed between the abstracts of the notes and the SMMIS records. Of the 17 data items examined, 10 showed 95% agreement or better, and all but two exceeded 80% agreement. Little difference was found between the levels of agreement observed at the three sites. A greater number and range of diagnosis codes were abstracted from the notes than were generated by SMMIS., Conclusions: The directly recorded clinical data held on the SMMIS regional database is largely accurate and consistently recorded across a variety of units. The database can therefore be considered a valuable resource for the comparative audit of maternity practice. The SMMIS technique for deriving, on a semi-automatic basis, diagnosis codes from the directly recorded fields, appears to work moderately well. We suggest that the direct method of data collection used in SMMIS could provide a model for other specialties in the National Health Service.

There is a general recognition that the health of women in Europe can be improved by collaboration between obstetricians and gynaecologists in EU and EFTA countries. The way in which collaborative approaches are developing are discussed, including the problems that have to be addressed if such an initiative is to be successful.

The underlying cause of anovulation in polycystic ovary syndrome is unknown. Circulating levels of immuno- and bioactive FSH are within the normal range, and the follicles contain measurable levels of bioactive FSH. The aim of this study was to compare estradiol (E2) production in response to FSH by granulosa cells from normal ovaries with those from polycystic ovaries derived from both anovulatory (anovPCO) and ovulatory subjects (ovPCO). Intrafollicular levels of immunoactive FSH, E2, and androstenedione in follicles of less than 12 mm were also measured. Follicular fluid steroid concentrations were obtained from 41 pairs of normal ovaries and 23 pairs of polycystic ovaries (8 anovPCO and 15 ovPCO). In size-matched follicles from each group there were no significant differences in follicular fluid FSH or E2 concentrations, but androstenedione levels were significantly higher in 5- to 11-mm follicles from ovPCO than in corresponding follicles from normal ovaries. Dose responses to FSH were determined in granulosa cells derived from 9 pairs of normal ovaries, 7 anovPCO, and 8 ovPCO. Cells from anovPCO produced 6- to 10-fold more E2 in response to FSH than normal cells, although there was no significant difference in the ED50 values. The response in cells from ovPCO was reduced compared to normal, but this difference did not reach significance. In summary, as judged by their FSH and E2 contents, polycystic ovaries do not have a higher proportion of atretic follicles than normal. Indeed, cells from anovPCO are hyperesponsive to FSH in vitro. This could be explained by stimulation of aromatase in vivo by either paracrine or, more probably, by endocrine factors, of which insulin is an arguable candidate.

Objective: To determine the diagnostic effectiveness and treatment of women with chronic lower abdominal pain due to residual ovaries or ovarian remnants., Design: A prospective observational study., Setting: Tertiary referral pelvic pain clinic., Subjects: Seventeen women complaining of chronic pelvic pain of up to 25 years' duration, of whom seven had residual ovaries and 10 ovarian remnant(s)., Main Outcome Measures: Persistent lower abdominal pain, pelvic tenderness and quality of life one year post-operatively., Results: Six of the seven women with residual ovaries, and nine of the 10 women with presumed ovarian remnants experienced relief of the original pain, loss of pelvic tenderness and an improved quality of life., Conclusions: Residual ovaries after hysterectomy and ovarian remnants are established causes of chronic pelvic pain. Diagnosis and surgical removal is frequently difficult. Management strategies are proposed for both conditions.

The aim of this study was to examine the hypothesis that hypersecretion of ovarian androgens in polycystic ovary syndrome results from an intrinsic abnormality of androgen biosynthesis by thecal cells. Steroid accumulation by human thecal cells from normal and polycystic ovaries (PCO-theca) was examined under basal and LH-stimulated conditions. A method for dispersing and culturing human thecal cells as primary monolayers in serum-free medium was developed. LH increased androstenedione (A), progesterone (P), 17 alpha-hydroxyprogesterone, dehydroepiandrosterone, and estradiol accumulation in the overlying medium in a dose-dependent manner at a maximum effective dose of 2.5 ng/mL. The principal variables affecting the magnitude of steroid accumulation were plating density, duration of incubation, and follicle size. Using only theca from follicles less than 10 mm and keeping plating density constant, 48-h steroid production by theca from five normal ovaries was compared to that from nine polycystic ovaries isolated from both anovulatory and ovulatory women. There was a significant increase in both basal (median, 32.1 pmol/1000 cells.48 h; range, 18.7-250) and LH-stimulated (56 pmol/1000 cells; range, 40.7-406) A accumulation by PCO-theca compared to basal (1.7 pmol/1000 cells; range, 1.1-4.3) and LH-stimulated (2.8 pmol/1000 cells; range, 2.0-8.1) A accumulation by normal theca, with no overlap in values between the two. Although P production was also increased in the PCO-theca, the A to P ratios under both basal and LH-stimulated conditions were significantly higher in the PCO-theca [A/P ratio normal; PCO basal, 0.1 and 0.53 (P < 0.01); LH-stimulated, 0.04 and 0.65 (P < 0.001)], suggesting increased conversion of P to A. The steroid response to LH was similar in both groups. This is the first report of a difference in thecal androgen production between normal and polycystic ovaries and supports the hypothesis that there is a primary abnormality in the regulation of androgen production in PCOS.

The human ovarian vein is of particular interest as an adult vessel which changes with the different phases of reproductive life. At the ultrastructural level we have characterised the endothelium, vascular smooth muscle and autonomic innervation of the human ovarian vein. Transmission electron micrographs were prepared from surgical specimens of the human ovarian vein (n = 11) to demonstrate the features of the vessel wall. The pattern of innervation was investigated using an image analysis system which was also used with high-magnification micrographs to count and measure axonal vesicle types. Possible relationships between ultrastructural features and age and reproductive history were investigated. Endothelial cells contained Weibel-Palade bodies and numerous microfilaments. There were 3 muscle coats: no elastic lamina separated the endothelium from an inner layer of smooth muscle; a middle smooth muscle layer consisted of cells orientated in a circular fashion; an outer smooth muscle layer was made up of longitudinally arranged smooth muscle bundles with collagen and nerves penetrating throughout. The percentage of the vessel thickness occupied by the middle circular smooth muscle layer ranged from 0 to 33% and fell with increasing age (r = -0.67, P < 0.05). Penetration of nerves into the circular layer was observed only in 2 of 9 specimens. The observed ultrastructural features are consistent with the ability of the ovarian vein to distend substantially in response to changing circulatory demands. The vascular endothelium may have a role in the local control of haemostasis via the synthesis and storage of von Willebrand factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Study Objective: To investigate the consequences of different levels of caesarean section (CS) rate in terms of fetal and maternal outcomes., Design: Comparison of outcome variables between four categories of maternity units stratified according to CS rates. Data were collected concurrently., Settings: All 17 maternity units in one health region., Subjects: Data for the perinatal mortality analysis: all 221,867 deliveries in 1983-87 (excluding severe malformations) (1462 deaths); maternity information analysis system: all 36,727 women with singleton pregnancies who delivered in 1988., Outcome Measures: Perinatal mortality, Apgar scores at one and five minutes, onset of respiration after one minute, postnatal transfusion, postnatal infection, thromboembolism, low haemoglobin concentration at discharge, and puerperal psychosis were determined., Results: Teaching hospitals with an increased proportion of high risk cases had the highest CS rate, but the other three categories were found to serve comparable populations. Perinatal mortality showed a birthweight specific pattern--for very low birthweight infants, but not for other deliveries, mortality rates were lower in units with higher CS rates. Apgar scores showed no trend, but the onset of respiration after one minute was significantly more frequent in units with a CS rate of less than 10%. Increased maternal postnatal blood transfusion was associated with higher CS rates but no trend was observed for the other maternal variables., Conclusions: CS rates in general maternity units should be 10 to 12% or lower in the singleton population as a whole, but a more interventionist approach is indicated for very low birthweight infants. If confirmed, these recommendations could easily be incorporated into clinical audit.

Objective: An investigation of excitatory vascular responses in the human ovarian vein, a blood vessel normally exposed to high concentrations of ovarian steroid hormones and capable of adaptation to circulatory changes associated with reproductive life., Design: Pharmacological responses of surgical specimens of human ovarian vein to electrical field stimulation of sympathetic nerves, noradrenaline, alpha,beta-methylene adenosine 5'-triphosphate (alpha,beta-MeATP), endothelin-1 (ET-1), and 5-hydroxytryptamine (5-HT) were studied. Comparisons were made between in vitro pharmacological responses and the diagnostic category, age, smoking status, reproductive history and hormonal status of patients., Setting: Research laboratory., Results: Maximal contractile responses in longitudinal preparations, expressed as a percentage of the response to potassium chloride 125 mmol l-1, were 28% (SE 7.2) to electrical field stimulation and 107% (SE 15.1) to noradrenaline. In ring preparations, maximal responses to various agents were: noradrenaline 93% (SE 10.2); 5-HT 79% (SE 8.0); alpha,beta-MeATP 48% (SE 8.4); and ET-1 87% (SE 10.1). pD2(-log EC50) values for noradrenaline were 5.82 (SE 0.21) in longitudinal preparations and 5.65 (SE 0.10) in ring preparations; for ET-1 in ring preparations these values were 7.88 (SE 0.74). Responses to sympathetic nerve stimulation were attenuated by the adrenoceptor antagonist phentolamine; any residual responses were blocked by desensitisation of P2-purinoceptors with alpha,beta-MeATP or the addition of suramin, indicating that noradrenaline and adenosine 5'-triphosphate may be co-transmitters in these nerves. pD2 values for 5-HT were 5.97 (SE 0.12) in specimens from unsterilised patients (n = 19) compared with 5.20 (SE 0.24) in specimens from those who had previously undergone sterilisation (n = 6) (P < 0.05). No other relation between clinical characteristics and pharmacological responses were detected and, in particular, there were no apparent changes associated with ageing or hormonal status., Conclusions: Three main conclusions may be drawn from this study: (1) adenosine 5'-triphosphate is a co-transmitter in sympathetic nerves in the human ovarian vein; (2) tubal sterilisation affects vascular responsiveness to 5-HT; and (3) ovarian steroid hormones are likely to influence sympathetic vascular control via effects on catecholamine and adenosine 5'-triphosphate synthesis, storage, release, degradation or re-uptake, rather than via effects on vascular smooth muscle receptors.

Type 2 (non-insulin dependent) diabetes is so common that it has been hypothesized that in the course of evolution the predisposition to it may have conferred some advantage, before or during the reproductive years. It is frequently preceded by gestational diabetes. In order to test the basis for the hypothetical advantage, energy expenditure was investigated in 10 women with documented transient diabetes in a previous pregnancy. They were studied early in a subsequent pregnancy while glucose tolerance wa still normal and 9 were re-studied after pregnancy. Their results were compared with normal matched controls. During pregnancy, resting energy expenditure was similar in the study group and controls (6.58 (5.77-7.55) median (range) vs 6.91 (6.56-7.36) MJ day-1, respectively). However, the energy response to a mixed meal (42 kJ, kg-1 lean body mass) was decreased in the study group (45 (33-68) vs 76 (50-89) kJ, p < 0.05). After pregnancy resting energy expenditure was again similar in the two groups, but the decrease in postprandial thermogenesis persisted (78 (59-84) vs 92 (79-105) kJ, p < 0.05). The patients were resistant to exogenous insulin, 0.05 U kg-1 intravenously (slope of the plasma glucose decline in the 15 min after insulin; during pregnancy patients 52 (37-92) vs controls 111 (104-121) mumol l-1 min-1, p < 0.01; after pregnancy 130 (88-156) vs controls 186 (152-221) mumol l-1 min-1, p < 0.01). The postprandial energy saving in these women could constitute an evolutionary advantage. Insulin resistance may be the mechanism for limiting postprandial thermogenesis.

One of the clinical applications of electrical impedance tomography (EIT) is the measurement of volume changes of body fluids. However, the spatial sensitivity of images produced by the Sheffield Mark I system is non-uniform and if quantitative comparisons of resistivity images resulting from volume changes are to be mad, this non-uniformity must be corrected for. All experimental data were collected from a phantom consisting of semi-permeable membrane tubes fixed vertically at different distances from the centre of a cylindrical tank which was filled with a saline solution of resistivity 5 omega m. Individual images were obtained when each tube was filled with a saline solution of resistivity 1.5 omega m. Analysis of these images, using the resistivity integral described by Thomas et al, yielded the sensitivity of EIT at different positions within the tank. Combinations of tubes were then filled with saline (1.5 omega m) and an image produced for each combination. Cross sections of the images were taken and used to confirm that the principle of superposition is valid for EIT. A simple pixel scaling correction, derived from the sensitivity data, was then applied to the images and the results re-analysed to demonstrate a reduction in volume measurement error. The application of this correction to in vivo images is discussed.

In both diabetic and non-diabetic pregnancies fetal insulin is an important anabolic hormone. Fetal hyperinsulinaemia is associated with accelerated fetal growth and increased birth weight. Insulin and C-peptide concentrations in both umbilical cord and amniotic fluid reflect fetal beta-cell secretion and are correlated with birth weight. In the present study umbilical venous proinsulin and insulin concentrations were measured in 54 term infants born to women with and without mild disturbances of glucose tolerance. Umbilical venous cord proinsulin, assayed using a highly specific immunoradiometric assay, was independently correlated with infant birth weight (Rho = 0.53, p < 0.0001) and birth percentile (Rho = 0.65, p < 0.0001). The correlation between birth weight and birth percentile weight with umbilical venous insulin, measured using a non-specific insulin assay, was lost following correction for the influence of proinsulin. Umbilical venous cord proinsulin appears to be a good indicator of fetal beta-cell activity, and in this study, a superior marker to insulin assayed using a non-specific insulin radioimmunoassay. The longer half-life of proinsulin compared with insulin may contribute to proinsulin being a more robust marker of overall fetal beta-cell activity than insulin.

Circulating proinsulin was assessed during a 75g OGTT in 55 pregnant women who fulfilled WHO criteria for impaired glucose tolerance before the 32nd gestational week. Proinsulin was assayed retrospectively using a two-site immunoradiometric assay and immunoreactive insulin by radioimmunoassay. Of the 55 women, 19 required insulin treatment in addition to diet later in pregnancy. Fasting proinsulin concentrations were significantly higher in the 19 women who later required insulin treatment compared with the 36 women treated with diet alone (3.4 +/- 0.7 vs 1.8 +/- 0.2 pmol l-1, p < 0.005). There was no difference between the treatment groups of 60 and 120 min proinsulin values during the OGTT. Fasting plasma glucose and immunoreactive insulin were similar in the insulin-treated and diet-treated women and remained similar during the OGTT. No women within the insulin-treated group had a fasting plasma proinsulin value < 1.1 pmol l-1 in contrast with 12 women in the diet-treated group (p = 0.0123). Ten of the 19 insulin-treated women had a fasting plasma proinsulin > 2.5 pmol l-1 compared with 8 of the 36 diet-treated women (p = 0.0346). Fasting proinsulin values early in pregnancy have prognostic implications in women with gestational diabetes.

It is well established that pregnancy is associated with temporary changes in maternal metabolism which include a decrease in maternal insulin sensitivity to values similar to those associated with Type 2 diabetes. Fasting glucose concentrations fall throughout pregnancy, postprandial values rise. The maintenance of glucose tolerance in pregnancy requires a two- to three-fold increase in postprandial maternal insulin secretion. Glucose intolerance develops in women unable to compensate for the metabolic changes incurred by pregnancy. Increasing maternal hyperglycaemia is associated with increasing pregnancy morbidity and an increased likelihood of subsequent diabetes in the mother. In addition, maternal hyperglycaemia has a direct effect on the development of the fetal pancreas and is associated with an increased susceptibility to future diabetes in the infant, an effect which is independent of genetic factors. Gestational diabetes mellitus (GDM) is defined as glucose intolerance first recognized in pregnancy, and by definition includes a small number of women with previously unrecognized diabetes or impaired glucose tolerance (IGT). Figures on the prevalence of GDM vary between maternity units, depending on screening methods and the ethnic distribution of the populations. However, in a comprehensive study of a multi-ethnic antenatal population in inner London, UK it was found that only 2% of pregnant women develop significant glucose intolerance. Obstetricians and physicians debate the importance of identifying this 2% of women. The lack of agreed criteria for diagnosing gestational diabetes and the questionable obstetric benefits of treating all women with mild disturbances of glucose tolerance in pregnancy has resulted in few UK centres undertaking universal screening for GDM.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients with chronic pelvic pain attending a tertiary referral centre show certain social, developmental and psychological characteristics. Specifically, they appear to have fewer children and to report more paternal overprotection, and a trend towards low maternal care compared to normals. They also show more depression, free-floating anxiety and somatic anxiety than such populations. The levels are similar to those found in other outpatient populations presenting with migraine or irritable bowel syndrome. Hostility levels are greater than those in normal subjects. Overall the present patient population reports the same degree of childhood sexual abuse as do many other female clinic and community sample populations. Sexual abuse is unlikely to be a specific aetiological factor in the development of chronic pelvic pain though it may yet be found to be important in subsets of the population.

Objective: To assess whether GnRH analogues are effective in relieving pelvic pain and congestion and whether menopausal symptoms caused by GnRH analogues can be minimised by supplementation with low dose continuous combined hormone replacement therapy (HRT)., Design: Open prospective study., Setting: Tertiary referral clinic at a teaching hospital., Patients: Twenty-one women with chronic pelvic pain., Intervention: Four months' therapy with goserelin 3.6 mg/month combined with continuous oestradiol valerate 1 mg daily and medroxyprogesterone acetate 5 mg daily., Main Outcome Measures: Visual analogue scale for pain, menopausal symptoms, bleeding patterns, uterine area, endometrial status, oestradiol concentrations and venogram scores., Results: Amenorrhoea was maintained in all but two women. Endometrial atrophy was maintained despite HRT supplementation. Two women had moderate menopausal symptoms but none had severe symptoms. Significant reduction of uterine cross sectional area was maintained throughout the study. There was no significant relief of pain., Conclusions: HRT supplementation of GnRH analogues abolishes menopausal symptoms and thus may improve patient acceptability. Potentially beneficial effects such as endometrial atrophy, reduction of uterine volume and amenorrhoea were not negated by HRT. This combination is not effective in the treatment of chronic pelvic pain and congestion.