Cyclical variation in paroxysmal supraventricular tachycardia in women

88

Citations from the literature/International Journal of Gynecology & Obstetrics 55 (19%) 81-91

curred after the procedure had a normal umbilical artery pulsatility index before it was carried out. Conclusions. These preliminary data suggest that trisomic fetuses have an abnormally increasedumbilical artery pulsatility index in early pregnancy. Becausethe number of casesis too small to draw any firm conclusions, the use of a single measurementfor screening purposes needs to be confirmed by further investigation, and the clinical significance of referencecurves of normal values in the detection of pathologic conditions has still to be determined. The potential of umbilical artery pulsatility index as an additional parameter along with others previously established for Down’s syndrome screening,such as nuchal edema,needsto be explored further. llw

mehdaess of KG

and ummjugated

oestriol in prenatal

d@~asBoflriaaary18 Leporrier N.; Herrou M.; Herlicoviez M.; Leymarie P. FRA BR J OBSTET GYNAECOL 1996 10314(335-338) Objective. To evaluate the usefulnessof the two maternal serum markers, human chorionic gonadotropin (hCG) and unconjugated estriol (uEs), in the prenatal diagnosis of trisomy 18. Design. Retrospective evaluation of uEs and hCG levels at mid-trimester in casesof trisomy 18pregnanciesidentified from a series of women screened for Down’s syndrome. Setting. From a seriesof 53 893 women screenedin the antenatal center of the University Hospital of Caen, France, 22 casesof trisomy 18 were diagnosed either after amniocentesisfor maternal age, elevated risk of Down’s syndrome or fetal abnormalities and/or growth retardation on ultrasound assessment,or after birth. In addition, I I cases of trisomy 18 identified prenatally in two other centers were included. Results. Individual hCG and uEs levels for pregnancieswith trisomy 18 were significantly lower than in unaffected pregnancies: mean hCG was 0.62 multiples of the median (MOM) and median hCG was 0.5 MOM. uE, was a much more effective marker than hCG. Mean uE, was 0.40 MOM and median uE, was 0.37 MOM. It was observed that screeningfor trisomy 18 based on selection for amniocentesis with cut-off values of 0.55 for hCG and 0.60 for uE, would lead to a detection rate of 48% for a 0.8% false-positive rate. Using cut-off values of 0.70 MOM for each one of the two markers would detect 79% of cases of trisomy 18 with a 3% false-positive rate. Conclusions. Our results confirm that low hCG and uE, levels observed in the mid-trimester are predictive of an increasedrisk for trisomy 18. Since most fetuseswith trisomy 18exhibit morphologic abnormalities which should be detected following a careful ultrasonographic examination, biochemical screeningcould help in the detection of those anatomical defects in selecting for scanning a group of high-risk women. Trsmsdemal oestrogen for tveatment of severe postnatal de-

Gregoire A.J.P.; Kumar R.; Everitt B.; Henderson A.F.; Studd J.W.W. GBR LANCET 1996347/9006(930-933) Background. Postnatal depression can have long-term ad-

verse consequencesfor the mother and for the infant. Such depressionscan be severe and resistant to both support and counseling, and to therapy with antidepressant drugs. We investigated the antidepressant efficacy of estrogen given transdermally. Methods. In a double-blind, placebo-controlled study, 61 women with major depression, which began within 3 months of childbirth and persisted for up to 18 months postnatally, were allocated randomly active treatment (n = 34; 3 months of transdermal 17t!&es.tradiol200pg daily alone, then 3 months with added cyclical dydrogesterone 10mg daily for 12 days each month) or placebo (n = 27; placebo patches and tablets according to the same regimen). The women were assessedmonthly by self-ratings of depressivesymptoms on the Edinburgh Postnatal Depression Scale (EPDS) and by clinical psychiatric interview (schedule for affective disorders and schizophrenia [SADS] -change scale). Findings. On pretreatment assessmentsthe women in both groups were severely depressed(mean EPDS score 21.8 [S.D. 3.01active group, 21.3 [2.9] placebo roup; SADS scores,66.3 [I 1.41and 64.3 HO.71). During the first month of therapy the women receiving estrogen improved rapidly and to a significantly greater extent than the controls (mean EPDS scores 13.3 [S.D. 5.71vs. 16.5 [5.3]). Patients receiving placebo also improved over time but, on average, their scoresdid not fall below the screening threshold for major depression for at least 4 months. The estimated overall treatment effect of estrogen on the EPDS was 4.38 points (95% C.I. 1.89-6.87). None of a range of other factors (age, psychiatric, obstetric and gynecologic history, severity and duration of current episode of depressionand concurrent antidepressant medication), influenced the response to estrogen. Interpretation. This study has shown that transdermal estrogen is an effective treatment for postnatal depression.Further studies are required to establish the minimum effective dose and shortest necessaryduration of treatment as well as the mechanism of antidepressant action of estrogen.

GENERAL INTEREST Cyclical variation in paroxysmal supravehcdar

tachycardia in

WOlB?O

Rosano G.M.C.; Leonardo F.; Sarrel P.M.; Beale C.M.; De Luca F.; iollins P. GBR LANCET 1996347/9004(786-788) Background. Paroxysmal supraventricular tachycardia (SVT) in premenopausalwomen is often judged to be related to anxiety and may be associated with the menstrual cycle. The aim of this study was to determine whether a cyclical variation of episodesof SVT exists and to correlate such variation with cyclical variation in plasma ovarian hormones. Method. Twenty-six women (mean age 36 [S.D. 8)) years; with paroxysmal SVf were screened;those with regular menseswho experienced at least three episodes of paroxysmal SVT in two consecutive 48-h ambulatory ECG recordings were included. Thirteen patients (aged 32 [6] years) met thesecriteria, Patients underwent 48-h ambulatory ECG monitoring and detennination of plasma concentrations of l’l&estradiol and progesterone on day 7, 14, 21 and 28 of their menstrual cycle.

Ciroiions from rhe literature /International

Journal of Gynecology & Obstetrics 55 (19%) 81-91

Findings. An increase in the number and duration of episodes of paroxysmal SVT was observed on day 28 as compared to day 7 of the menstrual cycle. A significant positive correlation was found between plasma progesterone and number of episodes and duration of SVT (5.6 [2.2] rig/ml; r = 0.83, P = 0.0004;and r = 0.82, P = 0.0005),while a significant inverse correlation was found between plasma 176estradiol and number of episodes and duration of SVT (155 [22] pg/ml; r = -0.89, P < 0.0001; and r = -0.81, P = 0.0007).Interpretation. Women with paroxysmal SVT and normal mensesexhibit a cyclical variation in the occurrence of the arrhythmia with their menstrual cycle. There is a closecorrelation between the episodesof paroxysmal SVT and the plasma concentrations of ovarian hormones. These data suggest that changes in plasma levels of ovarian hormones (and their interaction) may be of importance in determining episodes of arrhythmia in such patients. The mechanismsof these effects are unknown. BlLoding rod exclmiom after allocation in randomised controlled trilb: survey of puMisbed parallel group trials in obstetrics and w-WY

Schulz K.F.; Grimes D.A.; Altman D.G.; Hayes R.J. USA

BR MED J 1996312/7033(742-744) Objective. To assessthe methodological quality of approaches to blinding and to handling of exclusions as reported in randomized trials from one medical specialty. Design. Survey of published, parallel-group, randomized, controlled trials. Data sources.A random sample of I IO reports in which allocation was described as randomized from the 1990and 1991volumes of four journals of obstetrics and gynecology. Main outcome measures.The adequacy of the descriptions of double blinding and exclusions after randomization. Results. Although 31 trials reported being double-blind, about twice as many could have been. Of the 31 trials only eight (26%) provided information on the protection of the allocation schedule and only five (16%) provided some written assuranceof successfulimplementation of double blinding. Of 38 trials in which the authors provided sufficient information for readers to infer that no exclusions after randomization had occurred, six (16%) reported adequate allocation concealment and none stated that an intention-totreat analysis had been performed. That compared with I4 (27%)and six (12%), respectively, for the 52 trials that reported exclusions.Conclusions. Investigators could have double blinded more often. When they did double blind, they reported poorly, and rarely evaluated it. Paradoxically, trials that reported exclusions seemed generally of a higher methodological standard than those that had no apparent exclusions. Exclusions from analysis may have been made in some of the trials in which no exclusions were reported. Editors and readersof reports of randomized trials should understand that flawed reporting of exclusions may often provide a misleading impression of the quality of the trial. Prepaacy, abortioa ad birth rates among US adolescents 1980, I!385 alal 1990

Spits A.M.; Velebil P.; Koonin L.M.; Strauss L.T.; Goodman K.A.; Wingo P.; Wilson J.B.; Morris L.; Marks J.S. USA

89

J AM MED ASSOC 1996275113(989-994) Objective. To analze pregnancy, abortion and birth rates among US adolescentgirls in 1980,1985and 1990.Design. Retrospective analysis of trends in data on pregnancies, abortions and births. Population. US adolescent girls aged 13-19 years. Main outcome measures.Pregnancy, abortion and birth rates (with and without adjustment for sexual experience) among teenage girls aged 15-19 years and girls under I5 years. Results. Although pregnancy rates among all teenage girls l5- 19 years old remained fairly stable from 1980 to 1985, they increasedby 9% during the last half of the decade, totaling 95.9 pregnanciesper 1000teenagegirls l5- 19years old by 1990.Because rates of sexual experience increased even faster, pregnancy rates among sexually experienced teens aged 15-19 actually declined between 1980and 1990by approxiately 8%. Abortion rates among these teens remained stable during the l98Os,with 35.8 and 36.0 abortions per 1000in 1980and 1990, respectively. As with overall pregnancy rates, abortion rates among thesesexually experienced teenagegirls declined during the 1980s.Between 1980and 1985,birth rates among teenage girls aged 15-19 years declined by 4%, but they increased by 18%during the latter half of the decade,totaling 59.9 births per 1000 inJl990. Among these sexually experienced teenagers, birth rates also declined between 1980and 1985and then increasedover the next 5 years. In 1990,pregnancies and abortions among girls younger than I5 years accounted for only 3% of all adolescent pregnancies and abortions. However, the number of births among these younger adolescents increased by 15%over the decade.In that age group, trends in pregnancy, abortion and birth rates over the decade were similar to those for older teens. However, during the late l98Os, the abortion rate declined and the pregnancy rate remained stable, resulting in a 26% increasein the birth rate. Conclusions. Despite efforts to reduceadolescentpregnancy in the United States, pregnancy and irth rates for that group continue to be the highest among developed countries. Considering that 95% of adolescent pregnanciesare unintended, increasedefforts to prevent thesepregnancies are warranted. Maternal immunization with Haemopbilns injliwtzae type b poIysaWtctam protein conjugate vaccine in the Gambia

Mulholland K.; Suara R.O.; Siber G.; Roberton D.; Jaffar S.; N’Jie J.; Baden L.; Thompson C.; Anwaruddin R.; Dinan L.; Glexen W.P.; Francis N.; Fritxell B.; Greenwood B.M. CHE

J AM MED ASSOC 1996275/15 (1182-1188) Objective. To evaluate maternal responsesto Hemophilus in/luen.zae type b (Hib) polysaccharide-tetanus protein conjugate vaccine (polyribosylribitol phosphate-tetanus or PRP-T) given to pregnant Gambian women, the transplacental transfer of antibody and the effect of maternal immunization on infant responsesto the vaccine. Design. An open, randomized immunogenicity study. Setting. A busy urban health center in the Gambia. Study participants. A total of 451 pregnant women enrolled during the third trimester of pregnancy. Intervention. Study participants were randomized to three groups. in one group, mothers were given PRP-T during the third trimester and their infants were given PRP-T at 2, 3 and 4 months of age. In the secondgroup, mothers received PRP-T and infants were