Author: quinlivanj

Are your women’s health records secure?

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IMG_0201

A recent scandal making headlines in Australia involved unauthorised access of a healthcare record by 13 clinical staff. Worse, the issue of unauthorised access only came to media attention because the individual whose privacy was breached was a central figure in a murder trial linked to Australia’s favourite sporting past-time. The AFL.

How private are your electronic health records?

Not as private as you might like them to be!

Apart from the risk of healthcare staff gaining unauthorised access, there is the bigger risk of hackers. Several hospitals have now faced payouts as a result of privacy and data security breaches of patient records (1). One US FBI investigation into the hacking of a computer system at a medical facility found that “the system had been hacked into by 11 other groups before the breach under investigation had been identified” (1).

How concerned are patients about privacy?

Some US patients are sufficiently concerned over loss of privacy they have transferred their healthcare contracts to companies that do not use electronic health records (2). Data from a New Zealand consumer patient survey reported high levels of concern about hackers (79.4%), vendor access (72.7%) and malicious software (68%) (3).

Our own Australian research found pregnant women shared these concerns (4). We conducted a survey study of 528 pregnant women asking about their preferences in medical record systems. Despite the surveyed women having high levels of familiarity with computers, and using them on an almost daily basis, nearly half preferred a hospital held paper-based system. Only a third ranked electronic records first (4).

One key finding in our research was that pregnant women had concerns over loss of privacy with an electronic health record compared to a paper-based hospital system.

One woman stated:

“You hear about people breaking into computers and stealing information. You know, like Wikileaks, only they just want to cause trouble. I’m not sure I want all my medical information out there to be discovered. Who reads it? I also don’t want my husband or kids seeing things either and if its (sic) there they might want to see. I’m not convinced it would be safe.”

How concerned are patients about loss of control?

Our research also found patients were concerned about a loss of control of their record (4).

One woman stated:

“They say that only you can see it, but in a few years that will change. All those politicians will want to ransack our records for things and you won’t get a say in how they use them. Once somethings (sic) on-line you’ve lost control.”

One way that loss of control might occur is through data entry errors. This could happen if information from one source is merged with another without the “safety check” of consumer involvement.

Instances of inaccurate data ending up in patient’s records were identified in an evaluation of the English Summary Care Record (5). Patients were found to have drugs listed that they were not prescribed and in other cases medications they used were omitted from the record (5).

Some positive aspects to electronic health records

Our research did identify some strong positive findings in favour of electronic health records (4). Pregnant women found then to be less likely to be lost, and they felt they were the “way of the future”.

One woman wrote:

“Everything is on line now. I find a lot of it easier, like banking. Why should medical records be different?”

And another said:

“By the time my kids are my age paper will old fashioned. In school now they don’t use paper. Why should hospitals be different?” 

Electronic healthcare records are inevitable

The move to fully integrated electronic healthcare records is inevitable.

Governments around the world are spending billions (literally) on electronic health record systems. By example, in 2012 the Australian government spent $766 million for a new personally controlled e-health record (PCEHR) system (6,7).

Electronic health records should improve access to patient information by bringing together information from multiple sources into a single record. There are real benefits to bringing together pathology, radiology and clinical notes from community, private and public healthcare services into one site. Research studies have documented benefits in greater adherence to guideline-based care, enhanced surveillance and monitoring and fewer medication errors (8,9,10).

The key to electronic healthcare records will be to ensure patients do not lose their privacy and retain control of their records.

In women’s health, where sensitive issues such as domestic violence, sexual assault, and sexually transmitted infections are common, the right to privacy and control remain critical.

References

  1. Gupta A. Hackers, Breaches and other threats to electronic records. Health Data Management 2011; 19: 54-55.
  2. Chanabhai P, Holt A. Consumers are ready to accept the transition to online and electronic records if they can be assured of the security measures. Med Gen Med 2007; 9(1): 8
  3. Gaylin DS, Moiduddin A, Mohamoud S, Lundeen K, Kelly JA. Public attitudes about health information technology, and its relationship to health care quality, costs and privacy. Health Services Research 2011; 46(3): 920-938.
  4. Quinlivan JA, Lyons S, Petersen RW. Attitudes of pregnant women towards personally controlled electronic (PCEHR), hospital held and patient held medical record systems: a survey study. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 07/2014. DOI: 10.1089/tmj.2013.0342
  5. Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HW. Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study. BMJ 2010;340:c3111.
  6. Avery B. Opinion: Why national e-health is not for everyone. Authoritative. Strategic, IDG Communication, published 13 May 2013. Accessed on 21 July 2013 at http://www.cio.com.au/article/461628/opinion_why_national_e-health_everyone,
  7. Haikerwal M. PCEHR set to make life easier for doctors, improve care. Australian Medicine, Australian Medical Association, published 4 May 2013. Accessed on 21 July 2013 at https://ama.com.au/ausmed/pcehr-set-make-life-easier-doctors-improve-care
  8. Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in ‘early adopter’ hospitals. BMJ 2011; 343: d6054 doi:10.1136/bmj.d6054
  9. Jha AK. The promise of electronic health records. JAMA 2011; 306(8): 880-881
  10. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E et al. Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine 2006; 144: 742-752.

 

Two common myths about breastfeeding

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IMG_0077

Breastfeeding myths

There are many myths about breastfeeding. We recently conducted research in fathers in the setting of teenage pregnancy as part of our Australian Father’s Study and were disappointed to read comments made by some young fathers who thought the benefits of  breastfeeding were a myth (1). If you are interested in reading more about our Australian Father’s Study go to australianfathersstudy.com.

After discovering this disappointing news, we decided to write a blog dispelling two common myths about breastfeeding.

 

Myth 1. It is too hard to breastfeed

Whilst some women cannot breast feed for medical reasons, most can!

Published Australian figures report that 92% of women are able to start breastfeeding in hospital (2). In our DOMINO trial of 2399 pregnant women (3), we found a similar success rate, with 2148 (90%) women successfully initiating breastfeeding in hospital (4).

However, by six months, only 50% of Australian women will continue to breastfeed their infant (2).

There are many services available for women who are breastfeeding and experience difficulties. You just need to ask for help. We can identify who you are even before you leave hospital and offer you additional postpartum support.

In our latest research published in the International Breastfeeding Journal, we followed 2148 women who initiated breastfeeding in hospital. Of these, 877 continued to breastfed either partially (N = 262) or fully (N = 615) until six months postpartum and 1271 ceased breastfeeding early. Median breastfeeding duration in women who ceased early was under 4 weeks (4). In multivariate analysis, we could correctly identify 83% of women who started, but then prematurely ceased breastfeeding. This means there is a four week window where help should be sought and provided.

If you would like to read the complete published research article then please click here.

Myth 2. The benefits of breastfeeding are overstated

Breastfeeding has short and long term benefits to mother and baby (5-11).

There are many short term maternal benefits including

  • reduction in post partum bleeding,
  • rapid uterine involution,
  • greater reduction in post partum weight loss and
  • greater intervals between children (secondary to lactational amenorrhoea).

Long term maternal benefits include:

  • a reduction in risk of ovarian and breast cancer,
  • possible reduction in osteoporosis and hip fracture later in life.

Short term benefits for the baby include:

  • reduced risk of infections (respiratory, otitis media, gastrointestinal, meningitis, bacteraemia, urinary tract),
  • reduced incidence of necrotizing enterocolitis in preterm infants,
  • reduced atopic disease, and
  • protective effects against autoimmune diseases (e.g. Celiac disease and type 1 diabetes and inflammatory bowel disease) (4, 5).

Long term benefits for the child include:

  • reduced incidence of obesity, hypercholesterolaemia, type 2 diabetes and lower risk of hypertension
  • neurodevelopmental benefits. 

One strong piece of evidence supporting the argument that breastfeeding increases the IQ of children came from the PROBIT study. This study reported  a positive IQ increase in babies delivered at Baby Friendly Health Initiative hospitals (8).

Baby Friendly Health Initiative hospitals have  higher associated rates of breast feeding compared to other hospitals (8).

Our own research also supports a finding that breastfeeding increases IQ. We performed a prospective multicenter Australian study examining the association between breastfeeding and child IQ at 18 months. Expectant mothers were recruited from antenatal clinics between 12 and 20 weeks gestational age. Infants were subsequently followed to 18 months of age (12).

The primary outcome was infant intelligence quotient (IQ). At eighteen months infants attended for an assessment where a trained psychologist undertook a Bayley Scales of Infant Development, second edition (BSID-II) assessment. The BSID-II is a widely used assessment tool for identifying developmental delays in children ages 1–42 months.

We found that the infants of women who breastfed had significantly higher scores in cognitive and language domains compared to infants of women who formula fed their infants (12).

Although our study measured IQ at the age of 18 months, many other studies have demonstrated persistence of a positive impact from breastfeeding at older ages, even up to the age of 18 years (13-15).

Have a go and seek help if you run into trouble

So the short message is to “have a go” at breastfeeding.

Most women can breastfeed their baby.

Breastfeeding has many short and long term benefits to you and your child.

In fact, breastfeeding may be the best investment you can make in your child’s future. After all, parents pay thousands of dollars for private school education to help their child have a bright future. Breastfeeding is a lot cheaper and may help your child’s health, wellbeing and IQ score!

References

  1. Lam D, Highet V, Petersen RW, Quinlivan JA. Australian Father’s Study – Expectant teenage fathers attitudes and roles during pregnancy. RCOG World Congress 2015, 12–15 April, Brisbane, Queensland, Australia Volume 122, Issue Supplement S1 Pages 1–414Article first published online: 15 APR 2015 | DOI: 10.1111/1471-0528.13380, At brisbane, Queensland, Australia, Volume: Volume 122, Issue Supplement S1 Page 326 | DOI: 10.1111/1471-0528.13380
  2. Australian Bureau of Statistics. 4364.0.55.002 – Australian Health Survey: Health Service Usage and Health Related Actions, 2011-2012. Canberra: Australian Bureau of Statistics; [updated 2013 Mar 26; cited 2013 Jun 15]. Available from: http://www.abs.gov.au<http://www.abs.gov.au/>
  3. Makrides M, Gibson RA, McPhee AJ, Yelland L, Quinlivan J, Ryan P. Effect of DHA supplementation during pregnancy on maternal depression and neurodevelopment of young children: a randomized controlled trial. JAMA. 2010;304(15):1675-83
  4. Quinlivan JA, Kua S, McPhee A, Gibson R, Makrides M. Can we identify women who initiate and then prematurely cease breastfeeding? An Australian multicentre cohort study. INTERNATIONAL BREASTFEEDING JOURNAL 10(1) · DECEMBER 2015DOI: 10.1186/s13006-015-0040-y
  5. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics. 2005; 115(2): 496-506. DOI: 10.1542/peds.2004-2491
  6. Verduci E, Banderali G, Barberi S, Radaelli G, Lops A, Betti F, Riva E et al. Epigenetic Effects of Human Breast Milk. Nutrients. 2014;6(4) 1711-1724. DOI 3390/nu6041711
  7. Caspi A, Williams B, Kim-Cohen J, Craig I, Milne B, Poulton R, Schalkwyk L et al. Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism. PNAS. 2007 Nov 20;104(47):18860-18865. DOI: 10.1073/pnas.0704292104.
  8. Kramer M, Chalmers B, Hodnett E, Sevkovskaya Z, Dzikovich I, Shapiro S, Collet JP et al. Promotion of Breastfeeding Intevention Trial (PROBIT): A Randomized Trial in the Republic of Belarus. JAMA. 2001 Jan 24;285(4):413-420. DOI 1001/jama.285.4.413.
  9. Kramer M, Aboud F, Mironova E, Vanilovich I, Platt R, Matush L, Igumnov S et al. Breastfeeding and Child Cognitive Development. Arch Gen Psychiatry. 2008;65(5):578-584.
  10. Der G, Batty G, Deary I. Effect of breastfeeding on intelligence in children: prospective study, sibling pairs analysis, and meta analysis. BMJ. 2006 Oct 4;333:945. DOI 1136/bmj.38978.699583.55
  11. Gibson-Davis C, Brooks-Gunn J. Breastfeeding and Verbal Ability of 3-Year Olds in a Multicity Sample. Pediatrics. 2006; 118(5): e1444:1451. DOI: 10.1542/peds.2006-0072. Online ISSN: 1098-4275.
  12. Kua S, Quinlivan JA. Breastfeeding for six months is an independent association of language and cognitive intelligence in infants at 18 months. RANZCOG WA/SA ASM 2014. DOI: 10.13140/2.1.3221.8245
  13. Whitehouse A, Robinson M, Li J, Oddy W. Duration of breast feeding and language ability in middle childhood. Paediatr Perinat Epidemiol. 2010; 25:44-52. DOI: 10.1111/j.1365-3016.2010.01161.x.
  14. Horwood LJ, Fergusson DM. Breastfeeding and Later Cognitive and Academic Outcomes. Pediatrics. 1998;101(1):e9. ISSN: 1098-4275
  15. Eriksen HL, Kesmodel US, Underbjerg M, Kilburn T, Bertrand J, Mortensen EL. Predictors of Intelligence at the Age of 5: Family, Pregnancy and Birth Characteristics, Postnatal Influences, and Postnatal Growth. PLOS ONE. 2013;8(11):e79200. doi:10.1371/journal.pone.0079200

 

Ovarian cysts in teenagers

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ovcyst

Most ovarian cysts in teenagers do not require surgery. Yet, over the years as a clinician, I have seen many teenagers who have presented to emergency centres and been subjected to an unnecessary surgical procedure.

Ovarian cysts are common in teenagers

Ovarian cysts are common in teenagers. The vast majority are simple cysts that develop following ovulation of an egg from the ovary. These “functional” or “simple” cysts are usually smaller than 4cm in diameter.

The image above is a simple ovarian cyst from one of my patients (provided with consent). The finding of the simple ovarian cyst was incidental when she was having a laparoscopy for another indication. Needless to say, I left her ovary well alone and four months later an ultrasound reported the cyst had spontaneously resolved.

Most “simple” ovarian cysts will resolve within six months and are asymptomatic.

Ovarian cysts can bleed or rupture

Occasionally “simple” ovarian cysts do cause problems.

This usually happens if they rupture, releasing fluid that irritates the lining of the abdomen to cause pain. Alternatively, there might  be bleeding from a small blood vessel lining the cyst wall. The blood causes the cyst to swell and become painful.

In both cases the pain is usually mild and resolves within few days.

However, occasionally pain may be more severe and result in hospital presentation.

This is where things can go astray. One typical scenario I have encountered after the event (that is after the teenager has had her ovary removed surgically!) involves the teenager being brought into the emergency department after hours by an anxious mother. The teenager reports she has developed pelvic pain. An ultrasound is performed and the “simple” ovarian cyst is misreported as being “complicated.” This is because blood inside the cyst causes ultrasound waves to be reflected and the cyst appears to have “internal echoes”.

A CT may be ordered to examine the cyst in more detail. Apart form exposing the teenager to a dose of radiation, this adds little to the diagnostic process. However, the intervention cascade that follows often ends up with emergency surgery, rather than the correct management of pain relief.

Even pain relief can go wrong. Keen young resident doctors frequently prescribe strong  codeine based analgesics. This can result in the patient re-presenting a few days later with a different cause of pain – constipation.  If a  CT was not ordered the first time around, it is certainly ordered on re-presentation. If the patient avoided surgery the first time, she may not be so lucky again facing an eager young registrar champing to operate.

The message is simple.

First, don’t operate on cysts in young women unless a consultant has reviewed the films and determined this is not a “simple” cyst or it is one of those very rare situations described below where emergency surgery is indicated.

Secondly, be careful with strong codeine based analgesia in young women. It leads to constipation and can confuse the presentation.

Ovarian torsion

Of course there are exceptions to every rule.

Ovarian torsion is the first exception.

Ovarian torsion occurs when the ovary twists around on its own blood supply. This stops blood flowing to the ovary and the lack of oxygen causes the ovary to become swollen and painful. It is a rare condition occurring in 4.9 per 100,000 women. It is more common in women over 20 years of age (1-3).

Ovarian torsion is a medical emergency as the ovary will die unless torsion is corrected.

Fortunately ovarian torsion can usually be distinguished by the clinical story (onset of pain is abrupt and there is frequently vomiting), the size of the cyst (larger cysts) and ultrasound features (abnormal blood flow seen on doppler of the ovarian vessels).

Ovarian tumours

These are rare in young women – exceedingly rare. Tumours usually look different on ultrasound. They may be solid, or have solid components with internal septations that delineate compartments within the cyst. Blood tests may demonstrate elevations in proteins called tumour markers, that rise in association with certain ovarian tumours.

Suspicious cysts in teenagers should always involve specialist management. It is usually wise to gather the correct information, and refer the teenager to a specialist hospital to be managed by gynaecology oncology staff, rather than rush and operate as an emergency. Even if specialist deem the cyst to be suspicious, and a decision is made to operate, it will still often be benign or harmless. In one series of 52 UK teenagers with suspicious ovarian cysts requiring surgery , only 3 tumours were eventually reported to be a malignant cancer (4).

Do unnecessary surgical procedures happen on simple ovarian cysts in teenagers?

The short answer is yes.

In one retrospective survey of children and teenagers presenting to the Royal Children’s Hospital in Melbourne with an ovarian cyst, 60% of the admitted patients had a “simple” cyst. despite this, many of the teenagers with “simple” cysts underwent a surgical procedure (5).

However, if the cyst is large, or the presentation is unusual, then consideration must be given to exclude a tumour.

So when in doubt, ask for a more senior opinion, and ask for your management options. Being admitted and observed is reasonable in some cases, rather than rushing to surgery.

References

  1. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol. 1985;152:456–61.
  2. Dunnihoo DR, Wolff J. Bilateral torsion of the adnexa: a case report and review of the world literature. Obstet Gynecol. 1984;64:55S–59S.
  3. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg. 2000;180:462–5.
  4. Tsikouras P1, Liberis V, Galazios G, et al. A 15-year report of pathological and benign ovarian tumors in teenagers. Eur J Gynaecol Oncol. 2008;29(6):602-7.
  5. de Silva KS, Kanumakala S, Grover SR, et al. Ovarian lesions in children and adolescents–an 11-year review. J Pediatr Endocrinol Metab. 2004 Jul;17(7):951-7.

 

 

 

Management of Zika virus in pregnancy

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Cropped fetal face

Link between viruses and abnormalities in pregnancy

The link between adverse pregnancy outcomes and infectious disease is well known (1,2,3). Infections in pregnancy can cause miscarriage, preterm birth and fetal death in utero (1,2,3).

A specific link between some viral infections in pregnancy and birth defects in newborns has also been established.  In 1941, Australian Norman Gregg determined that maternal rubella caused birth defects by linking the infection to congenital deafness (4).

The recent observation of an increased risk of microcephaly in newborns whose mothers acquired Zika virus in pregnancy has again brought the issue of viral infections and pregnancy to world attention (5,6).

What is microcephaly?

Microcephaly literally means small head, and occurs when the head circumference of a newborn is below the 3rd centile, meaning 97% of all other newborn babies have a head that is larger in size and only 3% have a head size the same or smaller. Head circumference is affected by age, gender, ethnicity and culture, so it is important to take accurate measurements and apply these to validated local charts to determine the correct centiles and confirm the diagnosis (7)

The significance of a small head is obvious. It suggests the development of the brain has been delayed or impaired. A smaller head means the baby might have fewer neurones (brain cells), synapses and myelin coated axons (connectors between brain cells) capable of transmitting and processing information around the nervous system. This delay or lack of integration within the brain is associated with an increased risk of developmental delay and intellectual disability.

However, in some cases a small head may be normal. After all, some people have small heads and other people large ones. That is why there are differences in hat size.

What is Zika virus?

Zika virus is carried by Aedes mosquitoes. The virus was first identified in Uganda in 1947. The first cases involving transmission to humans were reported from Africa and Asia, however it was not until 2007 that an outbreak in Micronesia brought the virus to the attention of authorities (5).

The clinical presentation is usually mild with a fever, rash and watery eyes. Some people report fatigue, malaise  and muscle pains. Symptoms usually last less than a week. The incubation period, or time between being bitten by an affected mosquito and the onset of symptoms, is not yet clear (6).

However, it is the link to abnormalities in pregnancy that has caused international concern.

Zika virus and pregnancy

There have been a number of outbreaks of Zika virus around the world in recent years, the most recent before the current outbreak was in Micronesia in 2013.

However, the 2015 Brazilian outbreak and epidemiological association with microcephaly  has been the precipitating factor to hone world attention onto the virus.

What to do if you’re pregnant and worried about Zika?

Firstly, if you live in a region where the Zika virus has not been detected, you can be reassured. There is no good evidence of person to person transmission, although the first case of potential sexual transmission of the virus has been noted.

However, if you live in an affected area, or have travelled to such an area, then read on.

The general principles of management are as follows

  1. Prevention
  2. Diagnosis
  3. Management
  4. Follow up

Prevention

As there is no vaccine or cure for the infection, the current focus of management is prevention.

The key to prevention is to avoid being bitten by an Aedes mosquito in a region where the virus circulates. Unfortunately this includes many regions in Africa, the Americas, Asia and the Pacific (6). Pregnant travellers should avoid these regions.

If you live in an endemic region, the principle of management is a public health approach.

Public health strategies involve reducing the capacity of mosquitoes to breed by controlling breeding grounds, and by adapting local lifestyles to minimise the risk of being bitten. This can include changing the way you dress, using topical repellants, sleeping under nets and erecting physical barriers such as screens on windows and doors.

Diagnosis

If a pregnant woman suspects she may have contracted Zika virus infection she should immediately seek medical attention.

General practitioners should refer the woman to an obstetrician or clinical microbiologist.

Diagnosis of infection is made by blood sample tested using PCR for viral isolation. A positive result should be double checked as there is the potential for cross reactivity with other viral infections such as dengue, yellow fever and West Nile fever (6).

Management

The primary infection may be easily managed using supportive therapy such as paracetamol to reduce the risk of fever and manage muscle pains. It is important to keep well hydrated and women should be encouraged to drink water to keep their urine from being concentrated. Rest and adequate diet are also important to improve the body’s capacity to fight infection.

If a blood test confirms infection, then referral to a maternal fetal medicine specialist is recommended.

A tertiary level ultrasound can determine if there is any discordance between the centiles of growth of the fetal head compared to other parts of the baby such as its abdominal circumference or femur bone length in the leg. An amniocentesis may also be performed and a sample of amniotic fluid removed for PCR analysis. A positive result will confirm intrauterine infection.

Serial ultrasound examination can help document the progress of fetal growth and look for any other abnormalities.

Once all the information is available, women should be carefully counselled according to the specific findings in their case. If tests are negative, they can be reassured. If positive, counselling will depend upon the specific positive findings.

Follow up

Any newborn born to a women with Zika viral infection in pregnancy should be enrolled into a follow up program. This is important as we currently lack sufficient information to provide counselling about the long term consequences of infection.

It may be that most children born are normal and follow a normal developmental pathway. We do not know the answer to this question.

However, if a child does have a problem, then a follow up program will ensure the problem is detected early, and interventions can be applied to improve outcomes. By example, if a learning problem was diagnosed, specialist education interventions could be started. In some countries, such as Australia, parents may be eligible for funds to support early intervention disability services.

Establishing a database of long term outcomes is critical to improve the counselling for affected parents. As more cases are added to the data base, clinicians will be able to provide parents with more accurate advice about outcomes.

Summary

The association between Zika virus and microcephaly is a new development. There is still insufficient information to establish this is causal, and other explanations still need to be excluded.

However, the epidemiological link has resulted in a global effort focussed on prevention and management of Zika virus infection in pregnancy.

References

  1. Mendz GL, Kaakoush NO, Quinlivan JA Bacterial aetiological agents of intra-amniotic infections and preterm birth in pregnant women. Frontiers in Cellular Infection and Microbiology. 2013, 3: 58. doi: 10.3389/fcimb.2013.00058
  2. Quinlivan JA, Kaakoush NO, Mendz GL. Acinetobacter Species Associated with Spontaneous Preterm Birth and Histological Chorioamnionitis. British Journal of Medicine & Medical Research, 2014; 4(33): 5293-5297.
  3. Mendz GL, Petersen R, Quinlivan JA, Kaakoush NO. Potential involvement of Campylobacter curvus and Haemophilus parainfluenzae in preterm birth. BMJ Case Reports 2014: published online 1 October 2014, doi:10.1136/bcr-2014-205282.
  4. Lancaster PA. Causes of birth defects: lessons from history. Congen Anom. 2011 ;51(1) :2-5.
  5. Ioos S, Mallet H, Leparc-Goffart I et al. Macdecine et Maladies Infectieuses. 2014; 44(7). DOI: 10.1016/j.medmal.2014.04.008. 
  6. World Health Organisation. Zika virus. Published by WHO in January 2016. Accessed on 6 February 2016. Available from http://www.who.int/mediacentre/factsheets/zika/en/
  7. Woods CG, Parker A. Investigating microcephaly. Arch Dis Child 2013; 98:707.