Max Elstein

Comparison of Yuzpe regimen danazol and mifepristone (RU486) in oral postcoital contraception.

OBJECTIVE--To compare the effectiveness and acceptability of three regimens of postcoital contraception. DESIGN--Randomised group comparison of ethinyloestradiol 100 micrograms plus levonorgestrel 500 micrograms repeated after 12 hours (Yuzpe method); danazol 600 mg repeated after 12 hours; and mifepristone 600 mg single dose. SETTING--Community family planning clinic. SUBJECTS--616 consecutive women with regular cycles aged 16 to 45 years. MAIN OUTCOME MEASURES--Number of pregnancies, incidence of side effects, and timing of next period. RESULTS--The raw pregnancy rates (with 95% confidence intervals) for the Yuzpe, danazol, and mifepristone groups were 2.62% (0.86% to 6.00%), 4.66% (2.15% to 8.67%), and 0% (0% to 1.87%) respectively. Overall, these rates differed significantly (chi 2 = 8.988, df = 2; p = 0.011). The differences between the mifepristone and Yuzpe groups and between the mifepristone and danazol groups were also significant. Side effects were more common and more severe in the Yuzpe group (133 women (70%)) than in either the danazol group (58 (30%)) or the mifepristone group (72 (37%)). The Yuzpe regimen tended to induce bleeding early but mifepristone prolonged the cycle. Three women bled more than seven days late in the Yuzpe group compared with 49 in the mifepristone group. CONCLUSIONS--Mifepristone was effective in reducing expected pregnancy rates and the Yuzpe method also had a clinical effect. Danazol had little or no effect. A further multicentre trial is needed.

Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives

Abstract Objective To identify potential risk or mishap in the system of intrapartum care, relating to the deployment of midwives. Design Prospective semistructured observational study. Setting Labour wards of seven maternity units in the north west of England. Participants All midwives working on the labour ward during the observation period in 2000. Main outcome measure “Latent failures” within the system relating to midwifery staffing levels, deployment, and training or updating opportunities. Results Despite the exemplary dedication of midwives, potential risk of mishap due to their deployment occurred within the system of care. A shortfall of midwives existed in all seven maternity units and was most acute in the largest units. Six units relied on bank midwives to maintain minimum staffing levels. High risk practices (oxytocin administration and epidural blockades) continued during midwifery shortfalls in all units. Some adverse events and “near misses” were attributable to midwifery shortages in all units, and near misses remained unreported in all units. Uptake of opportunities for training or updating in interpretation of cardiotocographs and obstetric emergency management remained low owing to midwifery shortages in all units. A poor skill mix of midwives occurred at times in all units. In six units midwives spent time away from clinical areas performing clerical duties. In three units team midwifery systems were reported to erode labour ward skills and confidence. Conclusion Midwives are fundamental components in the system of intrapartum care, and the system cannot operate safely and effectively when the number of midwives is inadequate, midwives are poorly deployed, and they are unable to engage in opportunities for training and updating.

Effects of a Low-oestrogen Oral Contraceptive on Urinary Excretion of Luteinizing Hormone and Ovarian Steroids

The urinary gonadotrophin and ovarian steroid excretion pattern was studied in five women taking an oral contraceptive formulation consisting of mestranol 50 μg and norethisterone 1 mg. Both the pretreatment and post-treatment cycles were normal. The ovulatory peak of luteinizing hormone (LH) during the treatment cycles was uniformly suppressed, but LH continued to be excreted within the normal range. In one fifth of the treatment cycles there was a pronounced and sustained rise of oestrogen output in the absence of ovulation, and in many of the other treatment cycles oestrogen levels suggested that active ovarian steroidogenesis was taking place.

Effect of Copper-containing Intrauterine Contraceptive Devices on Human Cells in Culture

Intrauterine devices containing copper were introduced into cultures of adult and fetal cells. The Dalkon shield had no apparent effect on cell growth. The Gravigard device caused inhibition of growth and an increase in copper concentration in the supranatant medium. When the latter device was transferred through a series of subcultures the rate of release of copper decreased and growth was no longer inhibited.

Clinical Experience with the Dalkon Shield Intrauterine Device

Preliminary acceptability and reliability tests of the Dalkon Shield were done in 377 women over 17 months, amounting to 3,028 months of use. There was a 98% follow-up. The pregnancy rate of 4·7 and expulsion rate of 6·3 do not meet the claims described in initial trials by the developers of the device. Nevertheless, the Dalkon Shield seems to be an advance in intrauterine contraception since it has the advantages of a lower expulsion rate than the “first generation” inert intrauterine devices.

Endometriosis—continuing conundrum

SIR,-I should like to comment on the report by Dr L F Prescott and others (25 October, p 1106) of a case of phenylbutazone overdose. They state that a case of phenylbutazone poisoning apparently had not been reported previously in the United Kingdom. I should like to draw their attention to such a report.1 Despite what Dr Prescott and his colleagues say about phenylbutazone being extensively metabolised and highly bound to plasma proteins, it is inaccurate to state that haemoperfusion is unlikely to enhance elimination significantly. In the case quoted, we were able to show a rapid reduction of blood phenylbutazone concentrations during haemoperfusion through columns of activated charcoal (Haemocol-Smith and Nephew Pharmaceutics Ltd). The use of haemoperfusion in this particular case was almost certainly life saving. The technique would seem to be indicated in severe cases of phenylbutazone overdose. JOHN E STRONG

Contraception, Abortion and Sterilization in General Practice

This is yet another book on family planning. This time it is written by a doctor who has been directly concerned with the provision of contraception for his patients, whom he looks after throughout their reproductive lifetime. Throughout the book, which is well written in an easy style, and behind the text an understanding and empathic doctor is evident, which should appeal to the British general practitioner, for whom it is written. The 16 chapters deal with various aspects of fertility regulation interspersed with anecdotal cases. The first two chapters discuss the need for contraceptive usage at the individual and global level respectively. The author then goes on to discuss the important role of the GP in the provision of contraception at the grass roots. The message of the educative role of the GP comes over loud and clear. The method of evaluating contraceptive methods is then explained in a simple, succinct way. There are then a number of chapters devoted to coitus interruptus, the rhythm method, spermicides, and the mechanically occlusive methods in turn. In each there is a lot of good common sense. The major section of the book concerns oral contraception, and, as the author states in his preface, it needs to be so. The background to steroidal contraception is first dealt with. A section on the beneficial side effects of oral contraceptives is followed by one on annoying side effects, which are placed in perspective, and advice is given on how to deal with them. A section dealing with thromboembolism is particularly well presented in a balanced manner. The section on intrauterine devices has become dated by the developments in the provision of family planning within the NHS as well as by changes in IUDs. Nevertheless, this is a balanced presentation of the subject. Not all teachers of the techniques of insertion of IUDs would agree with some of the comments made, however. The importance of in-service training for doctors learning to insert IUDs is not adequately stressed and should be. The section on sterilisation deals with vasectomy in some detail, implying that perhaps it is within the ambit of the GP. It could have. been made clearer that with suitable training this operation is indeed within the scope of the British GP. There are then two good concluding chapters on choice of contraceptive method and the domiciliary family planning service, whose need should diminish with the increasing involvement of general practitioners in the provision of contraceptive services. This is a splendid and inspiring book written by a GP for his colleagues. It is warmly recommended for all family doctors who see for themselves an increasing involvement in the provision of contraceptive services within the NHS. This book should convince those doctors who are still wavering in their decision on the valuable contribution they can make in the care of their patients by taking part in contraceptive work.

Clinical Experience with the Dalkon Shield

The use of national, multicenter data for IUD assessment is necessar y as they are more representative than those from any single-center study. The Family Planning Research Unit at Exeter University compiled results on the Dalkon Shield from 10-12 centers. The results for 1 year up to September 1972 showed: pregnancy rate 3.8%; expulsion rate 3.9%; and bleeding/pain removal rate 4.6%. The rates were better than those reported by R.W. Jones et al. (British Medical Journal, July 21, 1973).

Vaginal Cytology of the Neonate

nerve fibres,2-4 whether sensory, motor, or proprioceptive (kinaesthetic). If Mr. Pitt Steele thinks we are being pedantic he might care to peruse the medical literature of North America where some etymologists maintain that even the word analgesic is inaccurate. Such purists tell us that if we use the words anaesthesia and anaesthetic we should also use the words analgesia and analgetic-that is, that anaesthesia is to analgesia as anaesthetic is to analgetic.-I am, etc.,