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The article provides an overview of the most important current EU initiatives contributing to sustainable finance. After an introduction on how the concept of sustainability entered the domain of European policy, the definition of sustainable finance from the EU perspective is discussed, as well as its relationship to the concept of green finance. After outlining the need for sustainable finance to achieve EU and international policy goals, the article provides a discussion of sustainable finance from a theoretical perspective, taking into account already existing perspectives from literature. A brief overview is given of what the EU could theoretically do to foster sustainable finance. The article then proceeds with an overview of the most important existing EU initiatives to foster sustainable finance: the Action Plan on financing sustainable growth adopted in March 2018, the EU Emissions Trading System and EU financial support contributing to sustainable finance. Finally, the article provides a discussion of the challenges and political implications of current sustainable finance policies for the EU, followed by conclusions. Der Artikel gibt einen Überblick über die wichtigsten aktuellen EU-Initiativen, die zu einer nachhaltigen Finanzierung beitragen. Nach einer Einführung in der Frage, wie das Konzept der Nachhaltigkeit in die europäische Politik aufgenommen wurde, wird die Definition des Begriffs „nachhaltige Finanzierung“ aus der EU-Perspektive sowie dessen Zusammenhang mit dem Konzept der „grünen Finanzierung“ erörtert. Weiterhin wird dargelegt, warum ein nachhaltiges Finanzwesens notwendig ist, um die klima- und umweltpolitischen Ziele der EU und der internationalen Gemeinschaft zu erreichen. Der Artikel beinhaltet eine Debatte über nachhaltige Finanzierung aus theoretischer Sicht, wobei bereits bestehende Sichtweisen aus der Literatur berücksichtigt werden. Es wird ein kurzer Überblick darüber gegeben, was die EU theoretisch tun könnte, um nachhaltige Finanzierung zu fördern. Anschließend wird ein Überblick über die wichtigsten bestehenden EU-Initiativen zur Förderung eines nachhaltigen Finanzwesens gegeben: der im März 2018 angenommene Aktionsplan zur Finanzierung nachhaltigen Wachstums, das EU-Emissionshandelssystem und die finanzielle Unterstützung durch die EU, die zu einer nachhaltigen Finanzierung beitragen. Schließlich beinhaltet der Artikel eine Diskussion über die Herausforderungen und die politischen Auswirkungen der derzeitigen Politik für nachhaltige Finanzierung in der EU, gefolgt von Schlussfolgerungen.

Objective Birthweight discordance amongst twins is associated with an increase in perinatal morbidity and mortality. Clinical decisions regarding the management of twins are often made on the basis of estimated fetal weight in the third trimester. This study assesses the efficacy of routine third trimester ultrasound fetal biometry, third trimester fetal growth velocity and first trimester differences in size in the prediction of subsequent birthweight discordance. Study design Structurally and chromosomally normal dichorionic twin gestations resulting in two live births after 24 weeks gestation were identified. Ultrasound examinations of dichorionic twin pregnancies between 10 and 14 weeks of gestation were evaluated for inter-twin biometric disparity in crown-rump length (CRL). Estimated fetal weight (EFW) was calculated from the last scan before delivery. Fetal growth velocity (FGV) was calculated from two estimates of fetal weight between 21 and 35 days apart and incorporating the last EFW before delivery. EFW and FGV were expressed as standard deviation scores ( Z scores). Disparity between these ultrasound parameters was correlated to inter-twin birthweight difference. Birthweight discordance was defined as ≥20% difference in birthweight relative to the heavier twin. Fishers exact and Spearman rho tests were used for statistical analysis. Test performance is expressed as area under the ROC curve and likelihood ratios (LR). Results One hundred and thirty-five dichorionic gestations were identified over a consecutive 3-year-period. One hundred and eight twin gestations had both crown-rump length (CRL) and sufficient ultrasound measurements in the third trimester to calculate FGV. Twenty-six pregnancies (24%) had discordant birthweight. Only EFW Z score difference was correlated with birthweight disparity ( r =0.36, p = Z score difference of 0.6 had an area under the ROC curve of 0.70 (95% C.I. 0.59–0.79) but this did not differ significantly from first trimester prediction of growth discordance which had an area of 0.55 (95% C.I. 0.44–0.66). The LR for first and third trimester prediction of discordance were low. Conclusion Ultrasound measurement of fetal growth velocity and size both in the first and third trimesters is a poor predictor of birthweight discordance. Disparate fetal growth is exhibited as early as 10–14 weeks gestation and differences at this early stage in fetal development are no less accurate than EFW within 1 month of delivery. First trimester ultrasound, third trimester growth velocity and third trimester EFW do not accurately predict the delivery of twins with discordant birthweight.

To evaluate the performances of estimated fetal weight (EFW) and fetal growth velocity (FGV) in the prediction of birth weight95th centile amongst women with impaired glucose tolerance (IGT); the prediction of neonatal hypoglycaemia was a secondary endpoint.Two hundred and forty-two consecutive women (61 type 1 diabetes mellitus, 14 type 2 diabetes mellitus, 49 gestational diabetics and 118 with impaired glucose tolerance) receiving routine care at the combined diabetes/antenatal clinic, Jessop Hospital for Women, Sheffield. EFW was routinely calculated at approximately two-week intervals in the third trimester with the last EFW prior to delivery used in the analysis. FGV was calculated from two estimates of fetal weight between 21 and 35 days apart. EFW and FGV were both expressed as standard deviation (Z) scores.The mean gestational age at delivery was 37 weeks (range 26-40 weeks). Sixty-five (27%) infants were of birth weight95th centile. Mean EFW Z scores were 2.7 and 0.99 for95th and95th centile, respectively (p0.001). Receiver operator characteristics (ROC) curve analysis gave area under the curve 0.8; using a cut-off Z score of 1.7 (=95.5 centile), EFW has sensitivity 80% and specificity 72% in predicting an LGA neonate (likelihood ratios 2.8 and 0.27 for positive and negative test). Mean FGV Z scores were 0.85 and 0.4 for95th and95th centile, respectively (p0.05); ROC curve analysis indicated no discriminatory capacity. Estimates of fetal size and growth performed poorly in the prediction of neonatal hypoglycaemia.In routine clinical practice, EFW has limited utility in the prediction of the LGA infant. FGV does not identify the LGA infant. EFW and FGV do not predict neonatal hypoglycaemia.

During polyketide biosynthesis, malonyl groups are transferred to the acyl carrier protein (ACP) component of the polyketide synthase (PKS), and it has been shown that a number of type II polyketide ACPs undergo rapid self-acylation from malonyl-CoA in the absence of a malonyl-CoA:holo-acyl carrier protein transacylase (MCAT). More recently, however, the observation of self-malonylation has been ascribed to contamination with Escherichia coli MCAT (FabD) rather than an intrinsic property of the ACP. The wild-type apo-ACP from the actinorhodin (act) PKS of Streptomyces coelicolor (synthetic apo-ACP) has therefore been synthesized using solid-state peptide methods and refolded using the GroEL/ES chaperone system from E. coli. Correct folding of the act ACP has been confirmed by circular dichroism (CD) and 1H NMR. Synthetic apo-ACP was phosphopantetheinylated to 100% by S. coelicolor holo-acyl carrier protein synthase (ACPS), and the resultant holo-ACP underwent self-malonylation in the presence of malonyl-CoA. No malonylation of negative controls was observed, confirming that the use of ACPS and GroEL/ES did not introduce contamination with E. coli MCAT. This result proves unequivocally that self-malonylation is an inherent activity of this PKS ACP in vitro.

The levonorgestrel-releasing intrauterine system was initially developed for contraception but is now widely used for a variety of gynaecological conditions. Compliance can sometimes be hampered by troublesome side effects (principally breakthrough bleeding) but appropriate counselling can reduce unnecessary discontinuation.

Objective: To determine the safety and effectiveness of managing intrauterine death after 24 weeks gestation using a combination of mifepristone and misoprostol. Study design: Two regimens are compared. Twenty-nine women (group one) were managed using a combination of oral mifepristone and vaginal/oral misoprostol. After a change in dosage and route of administration, a further 20 women were managed with oral mifepristone and vaginal misoprostol (group two). Results: All women delivered vaginally. The mean induction to delivery interval in group one was 7 h compared with 10.2 h in group two. Group two experienced fewer gastrointestinal side-effects than group one. Conclusion: This study confirms that the combined use of mifepristone and misoprostol is a safe and effective way of managing IUD after 24 weeks gestation. Regimen one results in a shorter induction to delivery interval but is associated with a higher incidence of gastrointestinal side-effects.

Premenstrual dysphoric disorder is a complex disorder characterized by severe physical and psychological symptoms. The pathophysiology and effective treatment of premenstrual dysphoric disorder are presented. Evidence for the effective treatment of premenstrual dysphoric disorder by correction of neuroendocrine abnormalities or suppression of cyclical ovarian activity is reviewed.

Objectives 1.To determine the value of third trimester customised estimated fetal weight centile ranking in the prediction of infants born with anthropometric features of intrauterine growth restriction (IUGR). 2. To compare the performance of customised centiles with fetal growth velocity in the prediction of IUGR. Design Prospective, observational study. Setting Department of Obstetric Ultrasound. Population Two hundred and seventy-four women with low risk pregnancies who were participants in a previously published longitudinal study of fetal biometry. Methods Third trimester estimated fetal weight customised centiles were obtained after adjustment for gestational age at the time of ultrasound, birth order and gender, maternal weight, height and ethnic origin. Fetal growth velocity was calculated using the increment in the fetal abdominal area over a mean 28-day interval. Fetal abdominal area growth velocity was expressed as a standard deviation ( Z score). Three neonatal anthropometric measures were used to define IUGR: subscapular or triceps skinfold thickness Main outcome measure Likelihood ratios for the prediction of neonatal anthropometric features of IUGR. Results Two hundred and fifty-eight infants had an estimated fetal weight customised centile calculated and one or more anthropometric measurements. The mean customised estimated fetal weight centile for cases with and without a low skinfold thickness were 16.4 vs 41.7 ( P vs 42.7 ( P vs 40.5 ( P > 0.05). A customised estimated fetal weight centile of 5 or less had likelihood ratios (95% CI) of 4.9 (2.7–6.3), 6.8 (4.5–10.6) and 6.3 (3.7–14) for skinfold thickness P = 0.04) but is not significantly higher for the other outcomes. The fetal abdominal area velocity likelihood ratio is not significantly higher than the likelihood ratios for the fifth estimated fetal weight customised centile for any of the three outcomes. Conclusion Customised estimated fetal weight centiles in the late third trimester are moderately useful in the identification of infants with IUGR but are less accurate than calculated growth velocity in the prediction of an infant with a low ponderal index.

Objectives To describe how data from antenatal fetal ultrasound biometry, amniotic fluid index and umbilical artery Doppler can be appropriately combined using multivariable models and to investigate how the addition of these ultrasound parameters influences the ability to predict intrauterine growth restriction (IUGR). Methods This was a prospective cohort study involving 274 low-risk pregnancies undergoing serial ultrasound examination at predetermined intervals. Standard deviation (Z) scores of the last values for fetal abdominal area (FAA), growth velocity of the FAA, amniotic fluid index (AFI) and umbilical artery Doppler pulsatility index prior to delivery were calculated for 260 fetuses. Customized estimated fetal weight (cEFW) centiles were also calculated using the last EFW before delivery after adjustment for fetal gender, gestational age, birth order and maternal weight, height and ethnic origin. Following delivery the neonatal ponderal index was calculated and centile position obtained. A neonatal ponderal index

Objective To compare the performance of unconditional and conditional standard deviation scores (Z scores) of fetal abdominal area (FAA) measurements in the antenatal identification of infants born with anthropometric features of intrauterine growth restriction. Methods A prospective observational study, involving 274 low-risk women participating in a longitudinal study of serial ultrasound in pregnancy. Conditional Z scores were established for the last FAA prior to delivery with reference to measurements made both 28 and 56 days previously. Unconditional Z scores (size) were calculated from the last FAA measurement prior to delivery. Receiver–operator characteristics curves were employed to determine an optimal cut-off point for Z scores to predict intrauterine malnourishment. The main outcome measures were: likelihood ratios (LR) for conditional and unconditional Z scores of FAA in the prediction of infants with skinfold thickness 10 generates significant changes in the pretest probability of growth restriction, whereas an LR of 5–10 generates only moderate changes. Results Conditional Z scores with 28- and 56-day separations predicted growth restriction with LR 7.5 (95% confidence interval [CI], 3.7–14.7) and 4.8 (95% CI, 2.8–7.8) for ponderal index but did not usefully predict skinfold thickness or MAC/OFC. Unconditional Z scores did not usefully predict any of the parameters of growth restriction. Conclusions Quantifying third trimester fetal growth by means of FAA conditional Z scores is moderately useful in predicting infants with a low ponderal index and is superior to unconditional FAA Z scores in late pregnancy. Copyright © 2000 International Society of Ultrasound in Obstetrics and Gynecology

Women with twin pregnancy are at high risk of spontaneous preterm delivery. Three large randomized trials have shown that progesterone reduces the rate of preterm delivery in high-risk singleton pregnancies, although evidence of significant reduction in perinatal mortality or clear neonatal benefit in singleton women is lacking. The STOPPIT study was a randomized, double-blind, placebo-controlled trial designed to evaluate the potential benefit of progesterone for prevention of preterm birth in women with twin pregnancy. Between 2004 and 2008, 500 women with twin pregnancy were enrolled from 9 antenatal clinics at hospitals in the United Kingdom. At 24 weeks of gestation, the study subjects were randomized to either 90 mg of vaginal progesterone gel (n = 250) or placebo gel (n = 250) daily for 10 weeks. The primary study outcome was delivery or intrauterine death before 34 weeks of gestation. Analysis was performed according to intention to treat. The investigators also performed a meta-analysis of all published and unpublished studies in which women with twin pregnancy were randomly allocated to treatment with a progesterone (including progesterone). No significant difference was found between the 2 groups in the combined proportion of twin pregnancies that resulted in intrauterine death or delivery before 34 weeks (24.7% or 61/247 in the progesterone group vs. 19.4% or 48/247 in the placebo group; odds ratio, 1.36; 95% confidence interval, 0.89-2.09; P = 0.16). The meta-analysis, which included pooled data from 2 studies fulfilling inclusion criteria and data from the present study, confirmed that progesterone does not reduce the risk of early preterm birth or intrauterine death in twin pregnancies (pooled odds ratio, 1.16; 95% confidence interval, 0.89-1.51). No difference between the 2 groups was found in the rate of adverse events. These findings are consistent with previous studies showing that progestogens do not prevent preterm delivery in women with twin pregnancy.

Objectives To determine whether single or serial estimates of both the amniotic fluid index (AFI) or pulsatility index (PI) of the umbilical artery Doppler waveform can usefully identify infants with anthropometric features of intrauterine growth restriction (IUGR). Methods A total of 274 women underwent serial antenatal ultrasound examinations at predetermined intervals. Four biophysical parameters were considered: AFI and PI prior to delivery and change in AFI and PI over a 28-day period in the third trimester. All values were expressed as standard deviation scores. IUGR was diagnosed if the neonate demonstrated skinfold thickness < 10th centile, ponderal index < 25th centile or mid-arm circumference to occipitofrontal circumference (MAC : OFC) < −1 SD. Receiver operator characteristic curves were used to determine an optimal cut-off point, and test performance of the biophysical parameters were expressed as likelihood ratios (LR). Results The test performances of all four ultrasound parameters for any of the three diagnostic criteria for IUGR was poor. The highest positive LR was only 2.5 (95% CI 1.5–4.1) for PI prior to delivery in the prediction of ponderal index < 25th centile. Conclusion Despite positive associations between single and serial estimates of AFI and PI with abnormal neonatal morphometry, the likelihood ratios remained low. The results of this study do not support the use of single or serial estimates of AFI or umbilical artery PI in the prediction of IUGR. Copyright © 1999 International Society of Ultrasound in Obstetrics and Gynecology

A total of 274 low-risk pregnancies underwent predetermined, scheduled, serial ultrasound examinations and measurement of the biparietal diameter, fetal abdominal area, femur length and estimated fetal weight. The longitudinal nature of this dataset permits the construction of conditional centiles for these measurements, whereby the dimensions of an individual fetus at a given gestational age can be extrapolated to give a range of expected values (expressed as centiles) at a later gestational age. Examples of conditional centiles based upon 4-week measurement separations are presented. These conditional centiles permit the appropriate quantification and subsequent evaluation of time-dependent changes in fetal dimensions to be made. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

Two-hundred-and-seventy-four low-risk pregnancies underwent serial ultrasound examinations in order to determine the mean and standard deviation of the change in umbilical artery resistance indices with advancing gestation. There is an almost constant rate of reduction in the A B ratio and the Pulsatility index over time from 28 weeks gestation until term. By calculating the standard deviation score of such changes, these reference ranges allow the change in the A B ratio and Pulsatility index to be quantified. Such appropriately derived standards permits the further investigation of the evolution of abnormalities of feto-placental perfusion with regards to perinatal outcome.

A total of 274 low-risk pregnancies underwent predetermined scheduled serial ultrasound examinations and measurements of the amniotic fluid index (AFI). As expected from previous cross-sectional studies, there is a gradual decline in the AFI from mid-trimester until term. The longitudinal nature of this data set permits the construction of conditional Gentiles for AFI whereby the AFI of an individual fetus at a given gestational age can be extrapolated to give a range of expected values for AFI (expressed as centiles) at a later gestational age. Examples of conditional centiles based upon 4-week measurement separations are presented. These conditional centiles permit the appropriate evaluation and quantification of time-dependent changes in AFI to be made. Copyright © 1996 International Society of Ultrasound in Obstetrics and Gynecology

We demonstrate the utility of a new 206.5-nm continuous-wave UV laser excitation source for spectroscopic studies of proteins and CVD diamond. Excitation at 206.5 nm is obtained by intracavity frequency doubling the 413-nm line of a krypton-ion laser. We use this excitation to excite resonance Raman spectra within the π → π amide transition of the protein peptide backbone. The 206.5-nm excitation resonance enhances the protein amide vibrational modes. We use these high signal-to-noise spectral data to determine protein secondary structure. We also demonstrate the utility of this source to excite CVD and gem-quality diamond within its electronic bandgap. The diamond Raman spectra have very high signal-to-noise ratios and show no interfering broad-band luminescence. Excitation within the diamond bandgap also gives rise to narrow photoluminescence peaks from diamond defects. These features have previously been observed only by cathodoluminescence measurements. This new continuous-wave UV source is superior to the previous pulsed sources, because it avoids nonlinear optical phenomena and thermal sample damage; Photoluminescence.

Preterm labour and delivery remain a major cause of perinatal morbidity, mortality and long-term adverse neurodevelopmental outcome. An effective primary prevention strategy is desirable, but current approaches appear largely ineffective at present. Understanding the aetiology of the onset of preterm labour continues to improve with the recognition of the role played by subclinical infection in a significant proportion of cases. The investigation of hormonal influences in the aetiology of preterm labour is at an early stage, but there appears to be a relationship between raised serum relaxin concentrations and preterm delivery (Petersen et al, 1992). The naturally occurring phospholipase A2-inhibitor gravidin, believed to be important in pregnancy maintenance, is found in a reduced concentration in women delivering preterm (Wilson, 1993). The relationship between hormonal levels, socio-economic influences, subclinical infection and actual preterm labour and delivery remains to be established. Secondary prevention with tocolysis remains unsatisfactory, owing to the low therapeutic index of currently available agents and their varied maternal and neonatal adverse effects. The investigation of newer tocolytic agents remains a worthwhile pursuit, whilst the underlying aetiology of preterm labour and effective prevention remains to be elucidated. The widespread recognition of the benefits of antenatal corticosteroid administration and subsequent adoption into clinical practice has reduced, and will continue to reduce, the morbidity associated with preterm birth while newer methods of accelerating fetal maturation are explored and applied in clinical practice.

SHP and SH-PTP2 are related cytoplasmic protein-tyrosine phosphatases having two tandem amino-terminal src homology 2 domains linked to a single catalytic domain. There is growing evidence that these two molecules may exhibit opposing effects within specific signaling pathways. However, the relative contributions of the src homology 2 domains or the catalytic domains to these opposing effects are not well known. To evaluate the potential contribution of the catalytic domains, we compared the substrate specificity of the two phosphatases. As seen previously, the catalytic activities of bacterially expressed SHP and SH-PTP2 were regulated by the presence of the linked src homology 2 domains. In addition, we characterized a cryptic thrombin cleavage site within the carboxy-terminus of SHP that led to a striking increase in the activity of the catalytic domain. Employing a panel of phosphopeptide substrates whose sequences were modeled after intracellular phosphorylation sites, both SHP and SH-PTP2 demonstrated a similar specificity pattern. Similar to SH-PTP2, SHP failed to elicit detectable phosphate release from several phosphopeptide substrates, while displaying catalytic efficiencies that ranged over approximately 40-1.6 x 10(3) M-1 s-1 towards other substrates. In contrast, the PTP-1B phosphatase dephosphorylated all of the phosphopeptide substrates tested with approximately equal ease. The overall similarity demonstrated by the catalytic domains of SHP and SH-PTP2 suggested that differences in the in vivo behavior of these two molecules might not stem from differences in the substrate specificity of the catalytic domains, suggesting instead that the specificity of the src homology 2 domains is more important in this regard.

SummaryA 30-minute labour admission cardiotocogram was performed on 231 women considered to be at ‘low obstetric risk’. On admission, 14-7 per cent of the cardiotocograms were considered abnormal when assessed by the attending midwife or resident obstetrician, the commonest abnormality being reduced fetal heart rate variability. Intervention based on this assessment ranged from repeating the recording to caesarean section. With the exception of meconium staining of the amniotic fluid, which was more common in the abnormal group (p

Publisher Summary The synthetic chemokines have been employed for investigations of their functions, structure- activity relationships, and three-dimensional structure. These studies have demonstrated that chemical synthesis is a straightforward route to chemokines and novel analogs. This chapter describes the rationale and procedures that have developed based on experience with the synthesis of chemokines. The first and foremost requirement for the study of a particular chemokine is obtaining sufficient pure material for the experiments, Furthermore, the study of structure-activity relationships involves building conclusions from the results of multiple analogs. This requires the generation of large numbers of analogs, so the methods chosen must be capable of fulfilling this need. Natural sources are not useful because the amounts that can be derived are very low, and it is not possible to modify the sequence. Both the chemical and DNA approaches can provide native chemokines and analogs with specific changes. The two approaches are fundamentally different, with the synthesis method being less known, and therefore some comparisons are useful.

Background Out-patient endometrial sampling is a commonly performed procedure in the investigation of post-menopausal bleeding. We hypothesized that an 'insufficient' Pipelle sample reliably reflected the absence of serious endometrial pathology. Methods and results A review of 141 consecutive cases reported as 'insufficient' for diagnostic purposes revealed 29 (20%) cases to have uterine pathology after secondary investigation. These included two cases of endometrial carcinoma and two other cases of uterine malignancy. Conclusion These results do not support the initial hypothesis and suggest that in women presenting with post-menopausal bleeding, an 'insufficient' sample is an indication for further investigation.

P-selectin glycoprotein ligand 1 (PSGL-1) is central to the trafficking of immune effector cells to areas of inflammation through direct interactions with P-selectin, E-selectin and L-selectin. Here we show that PSGL-1 was also required for efficient homing of resting T cells to secondary lymphoid organs but functioned independently of selectin binding. PSGL-1 mediated an enhanced chemotactic T cell response to the secondary lymphoid organ chemokines CCL21 and CCL19 but not to CXCL12 or to inflammatory chemokines. Our data show involvement of PSGL-1 in facilitating the entry of T cells into secondary lymphoid organs, thereby demonstrating the bifunctional nature of this molecule.

Objective Fetal hyperinsulinaemia secondary to maternal hyperglycaemia is considered to be the driving force behind excessive fetal growth. We hypothesised that insulin pump therapy (continuous subcutaneous insulin infusion, CSII) would improve maternal glycaemic control and normalise fetal growth parameters. To this end, this study compares maternal glycaemic control and fetal growth of women receiving insulin pump therapy with those receiving conventional insulin therapy. Study design Prospective non-randomised study of 42 women with pre-existing diabetes attending a joint obstetric diabetic clinic. Each woman was offered the choice of commencing insulin pump therapy or remaining on a conventional insulin regime. Estimated fetal weight and fetal growth velocity were calculated from routinely collected third trimester ultrasound biometry and expressed as standard deviation ( Z ) scores. Results Eighteen women commenced insulin pump therapy. There was no difference in pre-conception glycosylated haemoglobin A1c concentrations (HbA1c) between pump and conventional therapy groups (mean HbA1c 7.62 versus 8.01; p = 0.49) or third trimester glycaemic control (mean HbA1c 6.63 versus 6.44; p = 0.51). Women using pump therapy had similar mean growth velocity Z scores (1.5 versus 1.36; p = 0.83), similar mean estimated fetal weight Z scores prior to delivery (2.80 versus 2.16; p = 0.16) and similar mean birthweight Z scores (2.09 versus 2.00; p = 0.86) compared to women using conventional insulin therapy. Conclusion This small, non-randomised study suggests that the use of insulin pump therapy offers no benefit in terms of normalising fetal growth velocity, fetal size, birthweight or improving maternal glycaemic control compared to conventional insulin therapy.

Risk scoring Accurate prospective identification of a subgroup of pregnancies at increased risk of preterm labour and delivery permits the rational use of interventions aimed at prolonging gestation. Several epidemiological and obstetric associations are well recognised (Chapter 1) including low socioeconomic status, young age and primiparity, ethnic group and previous preterm delivery or mid-trimester loss (Lumley 1993). In an effort to provide a useful screening test for preterm delivery risk, several scoring systems have evolved that quantify a variety of epidemiological and pregnancy features, together with digital assessment of the cervix. By applying the scoring system described by Creasy et al . (1980) to a San Fransisco population, Holbrook et al . (1989) found that gestational age at delivery was inversely correlated with risk score. However, in this series in which 15.8% of women were classified as high risk, the positive predictive value (PPV) of a high score was only 22.8%. Other studies have also found risk scoring to perform poorly, particularly in primigravidae since there is no past obstetric performance upon which to assign risk. This is illustrated by the study of Mercer et al . (1996) who constructed a scoring system using over 100 clinical variables obtained at 23–24 weeks' gestation in nearly 3000 women. Women were considered to be at high risk if their risk for spontaneous preterm delivery was > 20%.

Obstetric intervention in the second stage of labour is frequently indicated. An appreciation of the physiology of the second stage and an awareness of the range of interventions with their appropriate selection and application will contribute towards ensuring a safe delivery.

To determine the relationship between customised birthweight centiles (adjusted for maternal and fetal physiological variables) and neonatal anthropometric features of intrauterine growth restriction (IUGR).Observational study.Two-hundred and seventy women with low risk pregnancies participating in a cohort study of serial ultrasound biometry.Customised birthweight centiles were calculated following adjustment for maternal weight, height and ethnic origin, gestational age at delivery, birth order, and sex of the infant. Three separate neonatal anthropometric measures were used to define IUGR: subscapular or triceps skinfold thickness10th centile; ponderal index25th centile; and mid-arm circumference to occipito-frontal circumference ratio (MAC/OFC)- 1 standard deviation (SD). Relationship of the centiles to these outcomes was evaluated using likelihood ratios (LR) and kappa statistic. These approaches allowed us to examine the strength of the association: an LR of 5-10 would be expected to generate moderate changes in the pre-test probability of IUGR, whereas a kappa value of 0.2-0.4 would reflect fair agreement between customised birthweight centiles and neonatal anthropometric measures.Customised birthweight centile of 10 or less had the following LR values for the various anthropometric criteria for IUGR: 5.1 (95% CI 3-8.5) for low skinfold thickness; 4.3 (95% CI 2.5-7.1) for low ponderal index; and 3.9 (95% CI 2-6.6) for low MAC/OFC ratio. The kappa values were: 0.4 (95% CI 0.26-0.51) for low skinfold thickness; 0.33 (95% CI 0.21-0.46) for low ponderal index; and 0.13 (95% CI 0-0.26) for low MAC/OFC ratio.In a low risk population, customised birthweight centiles can only be moderately useful in the identification of neonates with low skinfold thickness and low ponderal index.

We provide the solution to a fusion of two fundamental problems in mathematical finance. The first problem is that of maximizing the expected utility of terminal wealth of an investor who holds a short position in a contingent claim, and the second is that of maximizing terminal wealth where the utility function allows the investor to have negative wealth. Under assumptions of reasonable asymptotic elasticity on the investor's utility function, we present an optimal investment theorem and simultaneously treat the corresponding dual problem.

Objective: To determine the influence of the interval between fetal measurements on performance of fetal growth velocity for predicting infants with anthropometric features of fetal growth restriction (FGR). Methods: Two hundred seventy-four low-risk women had serial fetal biometry at scheduled intervals. Growth velocity of the fetal abdominal area for each was calculated with 2-, 4-, and 6-week scan intervals in which the second measurement was the last scan before delivery. Fetal abdominal area velocity over a 4-week interval in the early third trimester also was included. Fetal growth restriction was defined as skinfold thickness under the tenth percentile, ponderal index under the 25th percentile, midarm circumference–to–occipitofrontal circumference ratio of under −1 standard deviation (SD). Test performance was expressed as likelihood ratios with 95% confidence intervals (CI). Results: Fetal abdominal area velocity calculated over a 4-week interval predicted FGR with a likelihood ratio of 10.4 (95% CI 3.9, 26) for skinfold thickness; 9.5 (95% CI 4.6, 19) for ponderal index; and 4.7 (2.3, 8.4) for midarm circumference–to–occipitofrontal circumference ratio. Intermeasurement intervals of 6 weeks had a likelihood ratio of 8.5 (95% CI 4, 17) for skinfold thickness; 7.5 (95% CI 3.4, 16.1) for ponderal index; and 14 (6.7, 28) for midarm circumference–to–occipitofrontal circumference ratio. The likelihood ratios for the 2-week interval and the early third trimester 4-week interval were all less than 5. Conclusion: Four- and 6-week measurement intervals were useful for predicting infants with FGR and were superior to a 2-week interval. Fetal growth velocity is influenced by proximity of the last fetal measurement to date of delivery, which adversely affects clinical use of growth velocity for predicting FGR.