David Burch

Computerised measurement of fetal heart rate variation in a case of fetomaternal haemorrhage

and in the external anal sphincter, but not where the original rectovaginal fistula had been. It seems likely that the tissues of the septum between the rectum and vagina are stretched and rearranged so that the fistula itself moves more distal. Surgeons sometimes use a metal wire through a perianal fistula in a similar principle. The wire is tightened regularly and fistulae disappear in up to 96 % of the patients in one to seven weeks, depending on the location of the fistula in an0 (Misra & Kapur 1988). The seton method, whereby a rubber band is used similarly, also has its advocates (Hanley 1978). In two subsequent patients treated successfully, as described in this case report, it became quite clear that analgesia can be best given per rectum (i.e. indomethacin suppositories, 50 mg qds). Newborns with HIV-related rectovagina fistulae are unlikely to need treatment because they are unlikely to survive long enough to realise the nature of the problem. years. Conventional treatments are very seldom successful, and many surgeons decline to operate if the patient is HIV positive. Other surgeons offer these patients a colostomy, but colostomies are difficult to look after without good supply and support arrangements, and they are more likely to give rise to complications in immuno-compromised patients. In contemplating what treatment might be offered to this woman, the author recalled the reminiscences of a former teacher and colleague, a consultant with a colonial background in the Dutch East Indies. The traction approach to management of rectovaginal fistulae had been practised on those islands in the past, and our patient was willing to try this approach. Apparently, the original method involved use of an open wine bottle filled with water as a weight. Evaporation would make the bottle lighter as the days went by, and this was thought to be appropriate as the tissues distal to the fistula became thinner. The sound of the glass bottle breaking on the floor indicated that the patient was cured. The mechanism of action was explained on the basis that the thread would cut through the tissues and that progressive healing would occur behind it, but observations in the case presented cast doubt on whether this is the main mechanism of action. At the end of the treatment there was only scar tissue very superficially in the skin of the perineum, at the fourchette References

Alternative management of placenta accreta

A 27-year-old lady presented at 32 weeks gestation complaining of shortness of breath, headache, palpitations and feeling generally unwell for 1 day. Her current pregnancy was complicated by major placenta praevia. Because she developed worsening symptoms of pre-eclampsia and raised blood pressure, a decision was made to deliver her by an elective Caesarean section. The Caesarean section was complicated by a morbidly adherent placenta. There was no plane of cleavage between the placenta and the uterine wall. She had severe haemorrhages of 2.5 l following delivery, and to stem the bleeding, a B-lynch suture was placed and a Rusch tamponade balloon was inserted to achieve haemostasis. Although her condition improved and she did not have any further bleeding, she developed infection 3 weeks later and had a hysterectomy. We present this case to demonstrate that balloon tamponade and B-lynch suture are valuable developments in management of obstetric haemorrhage due to placenta accreta.

Can endometrial protection be inferred from the bleeding pattern on combined cyclical hormone replacement therapy.

OBJECTIVE To investigate the relationship between the timing of withdrawal bleeding on hormone replacement therapy and the state of the endometrium. DESIGN Double-blind, prospectively randomised dose-ranging study. SETTING Menopause clinics in the UK and the Netherlands. SUBJECTS Two hundred and seventy one postmenopausal women aged 40-60. INTERVENTIONS Administration of six 28-day treatment cycles of a continuous daily dose of 2 mg of micronised 17beta oestradiol with a randomly allocated dose of 5-20 mg of dydrogesterone added for the last 14 days of each. METHODS Comparison of the timing of the withdrawal bleed recorded in subject-held diaries with an endometrial biopsy obtained toward the end of the last cycle. RESULTS There was a trend towards later withdrawal bleeding with secretory endometrium and earlier bleeding with inactive or atrophic endometrium, but with too much overlap for this to be of clinical relevance. There were two cases of proliferative and one of hyperplastic endometrium, with no characteristic bleeding pattern. CONCLUSION Combined sequential HRT with progestogen given for 12-14 days very rarely fails to protect the endometrium. Such failures can not be detected by noting the bleeding pattern. The only suspicious pattern is non-cyclic bleeding, but this will not detect every case of hyperplasia or persistent proliferative endometrium.

Puerperal group A Streptococcus infection.

Group A Streptococci infection during antenatal period as well as postnally can be very serious and would require intense management—both surgical and medical. Many authors believe the incidence is rising. High index of clinical suspicion is necessary in order to early intervention.

Management of fetal choroid plexus cysts

to deliver within 1 week of testing will be subjected to unnecessary intervention@) with potential harm and unpleasant side-effects3. Since tocolysis with P-agonist is effective in reducing the number of women with threatened preterm labour delivering within 2 days by the expected benefit from a positive test result is further diluted to 1 /8 cases. Based on the above discussion, it is clear that the results from a bedside fetal fibronectin test performed on women with threatened preterm labour will not be able to distinguish effectively those women who will deliver within one week of testing from those who will not. 2. With regards to the asymptomatic group of women, we have suggested delivery < 34 weeks of gestation is an appropriate outcome measure because this reflects current obstetric practice which still dictates the administration of tocolytics for 48 hours5, corticosteroids6, and in utero transfer to an appropriate obstetric unit for delivery. We accept that babies delivered prematurely between 30 and 34 weeks of gestation in most developed countries will survive with a good outcome. However, the probability of a good outcome for these babies can only be maximised if the above interventions have been administered prior to delivery. The purpose of utilising this test at 30-34 weeks of gestation is therefore to identify those women who are at sufficiently high risk of preterm delivery in order for regular antenatal corticosteriod administration to be justified. Conversely, those women with a negative test result and hence deemed to be at low risk of this outcome can be spared from any unnecessary intervention. 3. It is misleading to suggest that the study by Goldenberg et a1.’ is a trial: it was actually an observational study of 2929 asymptomatic, low risk women for preterm delivery. We would agree that this study is the largest to d ate but increasing the sample size only helps to provide more precise confidence intervals. The biases inherent in observational data, which tend to exaggerate efficacy estimates, cannot be overcome simply by increasing the sample size. Thus, the usefulness of fetal fibronectin in clinical practice is far from proven. We omitted this study from our overview because of the lack of sufficient extractable raw data in the published report to generate the likelihood ratios for a positive and negative test result. 4. The suggestion that there is a considerable reduction in anxiety experienced by asymptomatic high risk women for preterm delivery after receiving a negative test is not supported by the evidence (see paragraph 1 ) .

Obesity is a risk factor for thromboembolism

Stotland’s review of obesity and pregnancy hardly mentioned thromboembolism,1 yet pulmonary embolism is the leading direct cause of maternal death in the UK, with 33 deaths between 2003 and 2005. Of …

Vaginal misoprostol for cervical ripening prior to hysteroscopy

Sir, Oppegaard et al. described a study looking at the use of misoprostol for ripening the cervix prior to operative hysteroscopy.1 We are puzzled by three aspects of this study. First, how were women selected to undergo operative hysteroscopy? Asymptomatic endometrial polyps were described as the indication for operative hysteroscopy in 11% of the premenopausal and 27% of postmenopausal subjects studied. How was an asymptomatic intrauterine polyp discovered? Most of the women had intrauterine pathology of some kind, and therefore, this was not an unselected group of women with abnormal uterine bleeding. Presumably, many of these women had had a previous hysteroscopy that could have influenced the findings. Second and more seriously, the authors have chosen inappropriate outcome measures. Preoperative cervical dilatation is unimportant; the only important outcome measure would be difficulty in dilating the cervix sufficiently to insert the resectoscope. It is not clear whether or not that reached statistical significance. The secondary outcome measure of cervical dilatation of 5 mm was suggested as it would allow insertion of a diagnostic scope without further dilatation, but most experienced hysteroscopists rarely dilate, and diagnostic hysteroscopy is irrelevant to the women being studied. The clinical relevance of a 1 mm difference in the cervical dilatation caused by misoprostol and placebo chosen as the primary end-point is questionable. Finally, the dose of misoprostol (1000 micrograms) is higher than that in previous studies.2–4 It is not clear why this dosage was chosen. We also identified that one subject in the postmenopausal group allocated to the placebo arm is unaccounted. j

An unusual case of vaginal tape exposure following tension-free vaginal tape

Vaginal tape exposure following tension-free vaginal tape (TVT) is uncommon. The exact cause of tape exposure is unknown. But tape characteristics, infection and defective healing are thought to be the causes. Presenting symptoms of tape exposure can be very distressing to the patients. Management of tape exposure can sometimes be a challenge to clinicians. In this, we report a case of persistent vaginal tape exposure following TVTwhich eventually turned out to be a secondary vaginal carcinoma. Case report

The interpretation of midstream urine microscopy and culture results in women who present acutely to the labour ward

El-Refaey H. & Templeton A. (1994a) Early abortion induction by a combination of mifepristone and oral misoprostol: a comparison between two dose regimens of misoprostol and of their effect on blood pressure. Br J Obstet Gynaecol 101, 792-796. El-Refaey H. & Templeton A. (1994b) Early induction of abortion by a combination of mifepristone and misoprostol administered by the vaginal route. Contraception 49, 1 11 114. 1741746.