A retrospective study over a 6-year period was undertaken to determine the trend in age at booking for antenatal care at West Hertfordshire Hospitals NHS Trust and to investigate the relationship between maternal age at booking for antenatal care and mode of delivery. Between 2006 and 2011, there was an 80% increase in the number of women over the age of 40 years booking for antenatal care. The overall caesarean section rate in this cohort of women increased from 34.6% in 2006 to 53.7% in 2011, comprising of an increase in both elective and emergency caesarean sections. It appears that increasing maternal age may explain a significant proportion of the rising caesarean section rate in our unit.

References Bonnet P , Waltregny D , Reul O et al . 2005 . Transobturator vaginal tape inside out for the surgical treatment of female stress urinary incontinence: anatomical considerations . Journal of Urology 173 : 1223 – 1228 . de Leval J . 2003 . Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out . European Urology 44 : 724 – 730 . Richards SR , Balaloski SP . 2006 . Vulvar hematoma following a transobturator sling (TVT-O) . International Urogynecology Journal and Pelvic Floor Dysfunction 17 : 672 – 673 . Sun M-J , Chen G-D , Lin K-C . 2006 . Obturator hematoma aft er the transobturator suburethral tape procedure . Obstetrics and Gynecology 108 : 716 – 718 . Sung VW , Schleinitz MD , Rardin CR et al . 2007 . Comparison of retropubic vs transobturator approach to midurethral slings: a systematic review and meta-analysis . American Journal of Obstetrics and Gynecology 197 : 3 – 11 .

"Fallopius: The great anatomist, surgeon and botanist." Journal of Obstetrics and Gynaecology, 33(2), pp. 107–108

Pre-eclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn child. Affecting at least 5-8% of all pregnancies, it can be a rapidly progressive condition characterised by hypertension and proteinuria. Oedema, sudden weight gain, headaches and changes in vision are important symptoms. However, some women with rapidly advancing disease report few symptoms.

Calculating rates of ectopic pregnancy in a reliable and reproducible way can be challenging. To date, there is no consensus as to which denominators to use but the authors suggest using the total number of deliveries as a benchmark. In many developing countries where ectopic pregnancy is a major cause of maternal morbidity and mortality, standardisation of epidemiological data is arguably even more important. Using the number of deliveries is probably the most pragmatic and reliable way of quoting ectopic pregnancy rates in developing countries, as structures are usually already in place to record births/deliveries. This would ensure greater consistency and allow more meaningful comparisons to be made, both within individual units over time as well as globally. Using additional denominators is more labour intensive and lends itself to inaccuracy but may nevertheless be useful depending on the issues being addressed. Ultimately, the correct denominator(s) to use should be determined by the clinical question(s) of interest. The authors acknowledge that the statistical analysis used in this paper is based on one retrospective study alone and that further work is required in this area before definitive conclusions can be made.

Primary ovarian ectopic pregnancy (OEP) remains a rare but important type of ectopic pregnancy which is normally diagnosed at surgery. The aetiology is unknown. We have found fertility treatments (18.1%) and intrauterine contraceptive devices (19.3%) remain important associated risk factors. We undertook a world literature review of all cases since 1995. We found that 52% of cases were managed laparoscopically, which is less than the reported UK rate of all ectopics, of 85.9%. Over that time period, eight patients were treated medically with a success rate of 50%. While the original 1878 Spiegelberg's criterion still holds for the diagnosis, the addition of modern ultrasound scanning has made a radiological diagnosis possible. In a few cases, the management of OEP remains similar to that of a tubal ectopic pregnancy with the same challenges. Laparoscopy with ovarian sparing in the stable woman is today the surgical treatment of choice.

Dr Robert Lawson Tait (1845–1899) had a profound influence on the development of gynaecology, and an intriguing personal life.Dr Robert Lawson Tait.Dr Robert Lawson Tait was born in Edinburgh on 1 ...

A 28-year-old primigravida, with a spontaneous conception of 8 weeks’ gestation presented with a 1-week history of increasing abdominal distension. Examination revealed marked abdominal distension and tenderness. Her haemoglobin was 11.9 g/dl, haematocrit 0.343, with normal urea and electrolytes and coagulation profile, normal alanine aminotransferase (ALT) at 65, and CA125 was 391 IU/ml. An abdominal-pelvic ultrasound showed a single, viable intrauterine pregnancy of 8 weeks’ gestation, with bilateral enlarged ovaries, the right ovary measuring 120653677 mm and the left ovary measuring 2006 656 71 mm, and ascites (Figure 1). The diagnosis was in doubt and ovarian cancer was considered a possibility. When seen by a consultant Gynaecological Oncologist, the diagnosis of ovarian cancer was considered unlikely due to the following: her age; the fact that the ovarian cysts were bilateral, thin walled, multi-loculated without papillary projections and also the fact she was pregnant (Padwick 2010, pers. comm.). A diagnosis of spontaneous ovarian hyperstimulation (OHSS) was made and the woman was managed conservatively as an outpatient. All results except for AAT, which was 116, and her liver ultrasound scan were normal. At her 20-week anomaly scan, the ovaries were said to be hyperstimulated, both approximately 1206 70690. She remained well, without abdominal pain. She was delivered, by ventouse for delay in the second stage, of a male infant at 41 weeks’ gestation, weighing 3.3 kg. When seen for her postnatal check at 6 weeks, she was well and ultrasound scan of her pelvis showed normal ovaries.

"Modern management of acute biliary pancreatitis in pregnancy." Journal of Obstetrics and Gynaecology, 30(4), pp. 410–411 AcknowledgementsWe would like to thank the Watford Gynaecology Research Fund (WGRF) for their part-funding.

Our clinical impression is that the incidence of ectopic pregnancy in West Hertfordshire in the UK has been steadily rising to almost ‘epidemic’ proportions. On the basis of our clinical suspicion, a retrospective study was performed looking at the ectopic pregnancy rates in the region from 1993 to 2007. All histologically proven ectopic pregnancies were obtained using the hospital histology database and all deliveries (live births and stillbirths) were obtained using the Ciconia Maternity information System (CMiS). The numbers of legal terminations of pregnancy (NHS and non-NHS) as well as women of reproductive age were obtained using the databases from the Office for National Statistics and Department of Health. In terms of absolute numbers of histologically proven ectopic pregnancies, there were 38 cases in 1993, rising to a peak of 68 cases in 1998 and 59 cases in 2007. This equates to 6.5/1,000 deliveries in 1993, 11/1,000 deliveries in 1998 and 10.7/1,000 deliveries in 2007. Although there have been fluctuations in ectopic pregnancy rates over 15 years, this did not reach statistical significance. Therefore, contrary to our clinical suspicion, the incidence of ectopic pregnancy in West Hertfordshire has remained stable.

A 34-year-old Asian woman was referred to the General Surgeons by her General Practitioner with a 2-day history of lower abdominal pain and ‘inability to lie flat’. She was taking Marvelon for cont...

A 31-year-old primigravida diagnosed with dichorionic diamniotic twin pregnancy in the first trimester, was booked under consultant care at 15 weeks' gestation. The anomaly scan at 20 weeks reveale...

Reported incidence of ectopic pregnancy (EP) varies widely in the literatures. Due to individual definition of the denominator used the incidence of EP, it has been expressed in various ways that are not easily comparable. Controversy has arisen over the best denominator in reporting the incidence of EP. The three commonly used denominators are the number of births, the number of pregnancies and the number of women of reproductive age (15-44 years).A reliable calculation of the incidence of EP is necessary to provide accurate information on the rate of this condition which is vital in planning health policies.

The multipotent growth factor transforming growth factor (TGF)-beta1 is consistently linked with fibrosis and scarring. The perfect (scarless) healing of cutaneous wounds in early gestational age fetuses is proposed to be due to this tissue's predominance of the TGF-beta3 isoform over the profibrotic TGF-beta1 and 2. Nevertheless, TGF-beta1 is present during wound healing in the early fetus and recently we demonstrated that relevant intracellular signaling pathways are activated (albeit transiently) on TGF-beta1 stimulation. This study aimed to determine whether TGF-beta1 has different effects on gene transcription in human fetal (<14 weeks) vs. human postnatal dermal fibroblasts, using real-time polymerase chain reaction. The regulation pattern of a number of TGF-beta response genes differed dramatically between the two cell sources. The typical autocrine loop of TGF-beta1 autoinduction did not occur in fetal fibroblasts and genes that are normally up-regulated, connective tissue growth factor and collagen type I were actually down-regulated. Furthermore, other response genes responded in a delayed fashion (TGF-beta3) compared with that seen in the more developmentally mature postnatal fibroblasts. Finally, genes unaltered by TGF-beta stimulation in postnatal cells, TGF-beta2 and collagen III, were up-regulated in fetal cells. These developmentally related differences in fibroblast response to TGF-beta1 may influence wound-healing outcome, i.e., perfect regeneration or fibrosis.

Early human fetuses regenerate cutaneous wounds perfectly without scarring. However, transforming growth factor-beta 1 (TGF-beta 1), the cytokine linked with scarring in mature tissue, is also present during fetal wound repair, albeit transiently. We present a comparison of response to TGF-beta 1 by fibroblasts derived from early human fetal skin (non-scarring) and their mature ( scarring) postnatal counterparts, which revealed that although fetal fibroblasts do indeed differentiate into myofibroblasts, this response is altogether more rapid and short-lived. Fetal fibroblasts also failed to exhibit the TGF-beta 1-induced increase in collagen ( mRNA and protein) demonstrated by their postnatal counterparts. Fetal cells exhibited a comparatively short-lived or rapid phosphorylation of several components of the TGF-beta 1 signaling pathways: Smad2/3 and c-Jun N-terminal kinase. Unlike quiescent postnatal fibroblasts, quiescent fetal fibroblasts also phosphorylated extracellular signal-regulated kinases in response to TGF-beta 1. These altered responses to TGF-beta 1 may well contribute to the transition between perfect regeneration and scar formation seen during development.

Background It has been well established that human fetuses will heal cutaneous wounds with perfect regeneration. Insulin-like growth factors are pro-fibrotic fibroblast mitogens that have important roles in both adult wound healing and during development, although their relative contribution towards fetal wound healing is currently unknown. We have compared responses to IGF-I and -II in human dermal fibroblast strains derived from early gestational age fetal (<14 weeks) and developmentally mature postnatal skin to identify any differences that might relate to their respective wound healing responses of regeneration or fibrosis. Results We have established that the mitogenic response of fetal cells to both IGF-I and -II is much lower than that seen in postnatal dermal fibroblasts. Further, unlike postnatal cells, fetal cells fail to synthesise collagen in response to IGF-I, whereas they do increase synthesis in response to IGF-II. This apparent developmentally regulated difference in response to these related growth factors is also reflected in changes in the tyrosine phosphorylation pattern of a number of proteins. Postnatal cells exhibit a significant increase in phosphorylation of ERK 1 (p44) in response to IGF-I and conversely the p46 isoform of Shc on IGF-II stimulation. Fetal cells however only show a significant increase in an unidentified 100 kDa tyrosine-phosphorylated protein on stimulation with IGF-II. Conclusion Dermal fibroblasts exhibit different responses to the two forms of IGF depending on their developmental maturity. This may relate to the developmental transition in cutaneous wound healing from regeneration to fibrosis.

SummaryThe mainstay of management of ectopic pregnancies is laparoscopic surgery. Other treatment options include open laparotomy, methotrexate or expectant approach. Recently the Royal College of Obstetricians and Gynaecologists (RCOG) revised its guidelines regarding management of suspected ectopic pregnancies. We undertook a retrospective study looking at management of ectopic pregnancies over a defined 12-month period (1 October 2003 – 30 September 2004) in a district general hospital to the north of London and compared this with the recommended RCOG guidelines . Cases of ectopic pregnancy were identified from the theatre, ward log, and cross-referenced with histopathological reports. The case notes of these women were reviewed and data extracted according to a drawn-up questionnaire. A total of 64 cases met the diagnostic criteria and were included in the study. Nine of the 64 cases were haemodynamically unstable and seven underwent rapid laparotomy. All of the stable 55 cases underwent laparoscopy, which was converted to open laparotomy in 13 cases (23.6%). Three patients were treated with methotrexate all of whom had been previously managed surgically. The majority of cases of ectopic pregnancy were managed according to the RCOG recommendations. Further changes in practice will be required to incorporate expectant and primary medical management as proposed by the recent guidelines (RCOG ). This study reveals progress achieved in management of ectopic pregnancies in UK with the introduction of RCOG guidelines .