I.Z. MacKenzie

CRITICAL ASSESSMENT OF DILATATION AND CURETTAGE IN 1029 WOMEN

Of 1029 dilatation-and-curettage operations carried out in a 12-month period, more than half were in women aged under 40, and 38% were for menstrual disturbances. The yield of intrauterine disease in these groups was low--curettage for post-menopausal bleeding or discharge in 150 women detected 15 endomettrial carcinomas and a similar number of other endometrial lesions. The complication-rate resulting from curettage was 1.7%--i.e., equivalent to the overall rate of detection of endometrial carcinoma. Selection of patients submitted to uterine curettage could be better, but postmenopausal bleeding remains an indication for mandatory uterine curettage.

Secondary postpartum haemorrhage: incidence, morbidity and current management

Objective To determine the incidence, risk factors, presentation, treatment and morbidity associated with secondary postpartum haemorrhage.

What is a reasonable time from decision‐to‐delivery by caesarean section? Evidence from 415 deliveries

Objective To determine how long it takes from the decision to achieve delivery by non‐elective caesarean section (DDI), the influence on this interval, and the impact on neonatal condition at birth.

Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity.

OBJECTIVE: To investigate trends in the incidence of shoulder dystocia, methods used to overcome the obstruction, and rates of maternal and neonatal morbidity. METHODS: Cases of shoulder dystocia and of neonatal brachial plexus injury occurring from 1991 to 2005 in our unit were identified. The obstetric notes of cases were examined, and the management of the shoulder dystocia was recorded. Demographic data, labor management with outcome, and neonatal outcome were also recorded for all vaginal deliveries over the same period. Incidence rates of shoulder dystocia and associated morbidity related to the methods used for overcoming the obstruction to labor were determined. RESULTS: There were 514 cases of shoulder dystocia among 79,781 (0.6%) vaginal deliveries with 44 cases of neonatal brachial plexus injury and 36 asphyxiated neonates; two neonates with cerebral palsy died. The McRoberts’ maneuver was used increasingly to overcome the obstruction, from 3% during the first 5 years to 91% during the last 5 years. The incidence of shoulder dystocia, brachial plexus injury, and neonatal asphyxia all increased over the study period without change in maternal morbidity frequency. CONCLUSION: The explanation for the increase in shoulder dystocia is unclear but the introduction of the McRoberts’ maneuver has not improved outcomes compared with the earlier results. LEVEL OF EVIDENCE: II

Diagnostic dilatation and curettage: is it used appropriately?

OBJECTIVE--To determine patterns of use of dilatation and curettage in Britain as compared with those in the United States; to examine variations in utilisation rates within one regional health authority. DESIGN--Analysis of routinely collected hospital inpatient statistics. SETTING--Statistics for England, Scotland, and the United States; local statistics for Oxford region. SUBJECTS--All inpatient episodes in which dilatation and curettage was performed but excluding those related to pregnancy. RESULTS--Dilatation and curettage rates remained stable in Britain between 1977 and 1990, whereas in the United States they declined dramatically. In 1989-90 the rate was 71.1 per 10,000 women in England as compared with only 10.8 per 10,000 in America. In 1989, 6936 women underwent diagnostic dilatation and curettage in the Oxford region, making it the most common elective operation. A total of 2726 (39%) of these women were under 40. There was a more than twofold variation in usage of the procedure among district health authorities within the region and even greater variation in rates in women under 40. The proportion of patients treated as day cases in the district general hospitals ranged from 22% to 82%. CONCLUSIONS--Dilatation and curettage may frequently be used inappropriately. The considerable variations in usage of dilatation and curettage internationally and nationally indicate differences in clinical perception of its appropriateness. This makes it suitable for audit. In developing guidelines it will be important to agree on the most appropriate patients and the relative merits of alternative methods of endometrial sampling. Probably this could result in considerable cost savings at no risk and possibly some benefit to patients.

Prospective 12 month study of 30 minute decision to delivery intervals for “emergency” caesarean section

Editorial by James Papers p 1330 Clinical governance requires evidence based standards of clinical relevance to assess performance. The recommended interval between the decision to perform an “emergency” caesarean section and the procedure is 30 minutes 1 2 but there is little objective evidence to support this recommendation. We conducted a prospective 12 month study in a large consultant obstetric teaching unit to examine whether the time between the decision to perform a caesarean section to actual delivery affects the success of the delivery. Time intervals between a decision to deliver and actual delivery were collected prospectively for all caesarean sections from 1 January 1996 to 31 December 1996. Clinical staff were not aware of the audit since by April 1995 all staff had been required to record these times with the guidelines expecting all deliveries within 30 minutes. Caesarean sections were classified as emergency (decision made during labour because of evolving fetal distress, failing …

Effect of oxytocin antagonists on the activation of human myometrium in vitro: Atosiban prevents oxytocin-induced desensitization

OBJECTIVE Our purpose was to investigate whether the sensitivity of myometrial cells to oxytocin is affected by prolonged exposure to oxytocin antagonists. STUDY DESIGN Tissue slices or cultured myometrial cells were exposed to peptides in vitro. Myometrial activation was studied by measuring the formation of inositol phosphates and the changes in intracellular calcium. Oxytocin binding was measured by saturation analysis. RESULTS Atosiban and related peptides inhibited oxytocin-induced myometrial activation as pure antagonists (inhibition constant 10 nmol/L) but had no effect on prostaglandin E2-induced activation. Long-term (> or = 24 hours) exposure to atosiban had no residual effect on oxytocin sensitivity. However, long-term exposure to oxytocin resulted in homologous desensitization and loss of oxytocin receptors. Oxytocin-induced desensitization was prevented by coincubation with atosiban. CONCLUSIONS Atosiban is a pure oxytocin antagonist and has a specific, reversible effect on myometrial cells in vitro. Its potential use for the management or even prevention of idiopathic preterm labor or to reverse uterine hypertony during oxytocin-induced labor should be tested in controlled clinical trials.

Vaginal prostaglandins and labour induction for patients previously delivered by caesarean section.

Summary. Labour was induced at term with vaginal instillation of prostaglandin E2 in 143 patients who had been delivered by caesarean section in a previous pregnancy. The method was simple, safe and effective with 76% achieving a vaginal delivery, and even when the cervix was very unfavourable at the time of prostaglandin treatment, 68% achieved vaginal delivery. The procedure reduces the need for repeat caesarean section with its potential morbidity, without evidence of undue risk of lower segment scar rupture.

Decision to delivery intervals for assisted vaginal vertex delivery

Objective To describe the time interval between decision for assisted vaginal delivery and the birth of the baby in different clinical circumstances.

A simpler approach to labor induction using lipid-based prostaglandin E2 vaginal suppository

The outcome of labor induced by use of a glyceride-based vaginal suppository of prostaglandin E2 (PGE2) inserted 3 hours before amniotomy, when the cervix is favorable, has been assessed. Using 5 mg PGE2 for primigravidas and 2.5 mg for multigravidas, 63% of the former and 81% of the latter established labor and were delivered of their infants without oxytocin augmentation, allowing ambulation during early labor. No maternal complications were detected as a result of the PGE2 treatment. Compared with patients undergoing conventional induction by amniotomy and immediate oxytocin titration there was no difference in the duration of labor, with a few patients establishing labor and giving birth quickly with both induction methods. Fetal distress was less common following PGE2 treatment than following conventional induction, with three patients in each group requiring delivery by cesarean section. Cephalopelvis disproportion in the second stage of labor requiring cesarean section to deliver occurred more frequently in the prostaglandin-treated group, possibly as a result of reduced upper segment contractility in the first stage of labor with subsequent poor fetal head molding. Epidural analgesia and postpartum hemorrhge were both reduced following PGE2-induced labor.