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This article contains summaries of the four presentations made during this panel. David Eby provides a framework for questions every organization should consider before deciding to proceed with litigation. Derek Olson discusses the criminal law of aggravated sexual assault as related to the strategic litigation in R v. Mabior. Jonathan Shime stresses the need for players in the legal sector to educate themselves better on the science surrounding HIV. Finally, Elin Sigurdson outlines the legal arguments advanced in SWUAV, British Columbia's parallel litigation to Ontario's Bedford case, challenging the constitutional validity of provisions of the Criminal Code that endanger the lives of sex workers. more...

Objective: This trial compared two instruments for transcervical chorionic villus sampling (CVS)., Design: Randomised controlled trial., Setting: Regional university prenatal diagnosis and treatment centre., Population: Two hundred women were randomised at 10(+0)-12(+6) weeks of gestation to transcervical CVS using cannula aspiration (CA) or biopsy forceps (BF)., Methods: Women undergoing indicated CVS signed informed consent. Randomisation after decision to perform transcervical CVS., Primary Outcome: the rise in maternal serum alpha-fetoprotein (alpha-FP)., Secondary Outcomes: (i) placental trauma (fetomaternal haemorrhage [FMH]); (ii) laboratory, procedure, and cytogenetic results and pregnancy outcomes; (iii) patient and operator satisfaction; and (iv) economic analyses. Analyses were performed by intention to treat., Results: The -FP rise did not differ between groups; there was no other evidence of placental trauma. BF were better tolerated by women, provided culturable tissue, after fewer instrument passes, with greater ease and in less time. BF were associated with cost savings., Conclusions: Unlike -FP, other markers of FMH were unaltered, questioning the reliability of alpha-FP as an indicator of FMH. Compared with CA, transcervical BF caused comparable placental trauma, appeared to be similarly effective and safe and were preferred by operators and patients. more...

Objective: To construct and test the reliability of the Laparoscopic Skills Index (LSI) as a new, multi-item, objective measure of laparoscopic skills in gynaecology., Methods: Construction of the LSI involved (1). item selection, (2). choosing a method to scale responses, (3). design, and (4). choosing a scoring method. Internal consistency and rater reliability were tested. One community-based gynaecologist (rater A) and 3 teaching faculty gynaecologists (raters B, C, and D) reviewed 20 videotaped gynaecologic laparoscopy operations and scored operator (subject) performance., Results: Cronbach's a was 0.95, indicating a high level of internal consistency. The intraclass correlation coefficient (ICC) for all 4 raters was 0.51 (95% confidence interval [CI], 0.20-0.76), indicative of moderate interrater reliability. A systematic observer bias was seen wherein rater A's scores closely paralleled, but were consistently higher than, those of raters B, C, and D. The ICC for raters B, C, and D only was 0.77 (95% CI, 0.56-0.90), which is consistent with very good rater agreement., Conclusion: The LSI appears to have the properties of a reliable, unidimensional index, in which the item variables are true components of the overall attribute, that is, laparoscopic skill. more...

Objective: To determine whether the menses cup is well tolerated by menstruating women., Design: Prospective descriptive clinical study., Setting: Normal human volunteers in an academic research environment., Participants: Fifty-one menstruating women recruited between June to December 1991., Interventions: Each participant was provided with two menses cups and an instruction sheet. Baseline information, including age, occupation, martial status, parity, description of menstrual flow, and current method used to cope with menstrual flow was collected. Subjects were asked to describe their experience with the cup at 1-, 2-, 6-, and 12-month intervals., Main Outcome Measure: The proportion of women who found the cup acceptable., Results: The cup was used by 51 subjects for a total of 159 cycles. Overall, 23 women (45%) found the cup an acceptable method for coping with menses. Among 29 (57%) women who used the cup for two or more cycles, 62% found it acceptable., Conclusion: The menses cup may be an acceptable method for some women for coping with menstrual flow. more...

Recent studies have suggested that a fetal blood lead level of 0.48 mumol/L (much lower than 1.21 mumol/L, which is the level previously believed to be toxic to the developing brain) may impair brain development permanently. We measured the maternal and umbilical cord blood levels of lead and free erythrocyte protoporphyrin (FEP) among 95 consecutive mother-infant pairs to determine whether neonates in Toronto are in the high-risk group. There was a significant correlation between the maternal and the cord blood lead levels (r = 0.59, p less than 0.0001). Most (99%) of the infants had cord blood lead levels below 0.34 mumol/L; in 11 cases the levels were below the detection limit of 0.01 mumol/L. The cord blood FEP levels were higher than the maternal levels. The US Centers for Disease Control, Atlanta, currently finds acceptable a blood FEP level of 0.62 mumol/L among children up to 10 years of age; however, this is not applicable to newborns since their higher FEP levels apparently reflect immature heme synthesis and increased erythrocyte volume rather than lead poisoning. Our data suggest that living in Toronto does not impose increased teratogenic risk from intrauterine exposure to lead; however, residents in high-risk areas should be followed up. more...

This study compares anxiety levels in women undergoing prenatal testing by means of chorionic villus sampling versus genetic amniocentesis. Chorionic villus sampling can be performed earlier in a pregnancy (8 to 12 weeks' gestation) but has a higher risk of miscarriage. Randomized to undergo chorionic villus sampling or genetic amniocentesis as part of a trial examining the safety and accuracy of these procedures, the women were studied at four time periods: time 1, before prenatal testing (9 to 12 weeks' gestation); time 2, after the chorionic villus sampling results were received (13 weeks); time 3, before the genetic amniocentesis results were known (18 weeks), and time 4, after all results were known (22 weeks). Although they were still at risk for miscarriage, members of the chorionic villus sampling group showed a sharp drop in anxiety levels immediately after receiving their results. The genetic amniocentesis group remained anxious until the last test time. In summary, prenatal testing by means of chorionic villus sampling resulted in earlier and sustained anxiety reduction. more...

The perinatal events in 184 term control pregnancies and 129 prolonged pregnancies were prospectively compared. Fetal surveillance consisted of weekly biophysical profile testing. Thirty-two infants were dysmature, and 10 of these had advanced dysmaturity. The incidence of advanced dysmaturity rose quickly after 44 weeks. This group was at greater risk for fetal distress, lower Apgar scores, and emergency cesarean section. The combination of oligohydramnios, a suboptimal nonstress test, and a low profile score was highly predictive of a neonate with advanced dysmaturity. In the control pregnancies, the rate of induction of labor was 13.81% compared with 39.84% in the prolonged pregnancies. The induced labor group had a 51.32% cesarean section rate. Our approach to prolonged pregnancy consists of elective induction of labor when the cervix is favorable and biweekly profile testing when it is not; however, the high incidence of advanced dysmaturity after 44 weeks warrants delivery. more...

beta-endorphin and adrenocorticotropic hormone (ACTH) are derived from the same precursor protein, and the plasma levels of beta-endorphin and ACTH are thought to be representative of the pituitary secretion of these peptides. Simultaneous measurements of immunoreactive beta-endorphin and ACTH were done on plasma samples from pregnant women at term and found to be normal, but a significant increase was observed during the stress of labor. Simultaneous measurement of immunoreactive beta-endorphin and ACTH in the umbilical vein at time of vaginal delivery demonstrated elevated levels of both peptides. The newborn also demonstrated an increased ratio of beta-endorphin to ACTH, of which the role is uncertain at present. more...

Although prolonged pregnancy has been associated with a twofold to sevenfold increase in perinatal morbidity and mortality, few investigators have addressed the question of long-term outcome for postterm infants. The existing information, spanning several decades, is confounded by several factors, such as different treatment eras, different population demographics, limited predictive value of testing preschool children, absence of term controls, retrospective nature of many surveys and unreliable criteria used to define prolonged pregnancy. At the University of Toronto a prospective, controlled study to determine the extent and frequency (if any) of developmental disturbances associated with prolonged pregnancy in both eutrophic and dysmature neonates is nearing completion. The results obtained could be important when one is faced with a decision on how to manage a postterm pregnancy. more...

Isolated reports of developmental disturbances following prolonged pregnancy led us to compare, prospectively, at 1 and 2 years of age, infants born after normal term gestations with those born after prolonged pregnancies (exceeding 294 days). The infants were subgrouped according to their physical condition at birth, that is, normal or dysmature (mild or advanced dysmaturity). Infant assessments included: (1) height and weight, (2) hospitalizations, and (3) mental development by the Griffiths Mental Development Scales. Follow-up testing was obtained on 130 term control infants and 89 infants of prolonged pregnancies at 1 year of age and 111 term control infants and 76 infants of prolonged pregnancies at 2 years of age. At 1 and 2 years the general intelligence quotient, physical milestones, and intercurrent illnesses for normal infants and those of prolonged pregnancies were not significantly different. more...

Shoulder dystocia is an uncommon complication of delivery with a high morbidity rate. Ninety-one cases were coded for shoulder dystocia at the Toronto General Hospital from 1980 through 1985. True shoulder dystocia was found in 24 cases, an incidence of 0.23%. There was no significant difference in average weight and percentage of macrosomia between cases of true shoulder dystocia and those merely coded as such. True shoulder dystocia was associated with a neonatal morbidity rate of 42%, consisting of a respiratory arrest and neurological and orthopedic damage. Fundal pressure, in the absence of other maneuvers, resulted in a 77% complication rate and was strongly associated with orthopedic and neurologic damage. Delivery of the posterior shoulder and the corkscrew maneuver were associated with good fetal outcome. more...