A comparison of gemeprost (Cervagem) pessaries and Lamicel tents for cervical preparation for abortion by dilatation and suction.

In a randomized, single-blind trial, 78 women having vaginal termination of pregnancy were treated with either a 1-mg gemeprost (Cervagem) pessary or a Lamicel tent inserted 3-4 h before operation. Both agents produced satisfactory cervical softening but dilatation was significantly easier after gemeprost. Pre-operative side-effects were more frequent after gemeprost but did not increase the need for analgesia. There were no differences between the two groups with regard to either postoperative symptoms and analgesic requirements or pre-operative and postoperative temperature, pulse rate and blood pressure. Gemeprost pessaries are easier, faster and less uncomfortable to administer.

PIP: In a clinical trial, a physician treated 78 women having an abortion with either a Lamicel tent or a 1 mg gemeprost (Cervagem) pessary 3-4 hours before surgery. Researchers matched the women to age, parity, gestational age, and previous uterocervical surgery. The physician or the assistant chose the specific treatment in strict numerical order from randomly ordered sealed envelopes. Prior to surgery, an assistant used a speculum to empty the vagina of all traces of the Lamicel tent or the gemeprost pessary. Therefore each surgeon remained "blind" to the treatment used to dilate the cervix. Even though there was no significant difference in the blood and fluid loss between the 2 groups (t = .67; p = .5), both surgeons did observe a greater resistance of cervices to dilate after Lamicel than after gemeprost (p .001). Patients who received gemeprost experienced more adverse effects preoperatively, especially abdominal pain (74%) and bleeding (18%), than did those who were treated with Lamicel (50%. and 7.5% respectively). Despite a higher percentage of women experiencing side effects with gemeprost, there was not a corresponding increased need to administer analgesia. Postoperative side effects were similar in both the gemeprost and Lamicel groups. Additionally, no significant differences existed between the 2 groups in regards to postoperative analgesic requirements or preoperative and postoperative temperature, pulse rate, and blood pressure. Notwithstanding the side effects of gemeprost, it was more effective in dilating the cervix, easier to insert, and less uncomfortable than Lamicel.

Unusual presentation of translocated intrauterine contraceptive device.

PIP: A woman who had a copper 7 coil inserted without difficulty, in 1978 decided to have another baby, and in February 1980, she asked for the device to be removed. Her (GP) general practitioner could not find the threads so she was referred to me. She did mention to her GP that she had noticed the threads appearing at her anus after defecation. The GP did a rectal examination and reassured her, suggesting that she had a vivid imagination. I saw her later that month and found no abnormality apart from a retroverted uterus and could not feel the coil with the uterine sound or hook within the uterine cavity. An X-ray of the abdomen showed that the IUD was identifiable in the midline front of the sacrum, and would appear to be in the uterus. In May 1980, she was admitted to hospital for removal of the coil. She told my senior house officer that she had felt the strings rectally: this observation was dismissed and not recorded in the notes. At operation I found a normal pelvis with retroverted uterus but no coil. Laparoscopy revealed no adhesions and no evidence of pelvic infection, but something seemed to be distorting the cavity of the sigmoid colon. It was then that my senior house officer mentioned that it was this patient who had thought she had felt the strings coming out of the rectum. She was asked to return as an outpatient 2 weeks later for sigmoidoscopy, after full bowel preparation. On sigmoidoscopy, the coil threads were readily visible and the copper 7 was found embedded 1/2 under the mucosa of the sigmoid colon at 17 cm. I grasped the free end with biopsy forceps and withdrew the coil, considerable force being needed. I prescribed ampicillin and metronidazole for 4 days and warned her about possible complications. However, the procedure caused no discomfort and there were no complications. Assuming the coil had been inserted into the uterine cavity, it it suprising that it had perforated the uterus and the sigmoid colon without causing pelvic sepsis and withoutt leaving adhesions. Edelman et al., in their review found 10 cases of bowel perforation with IUDs (4 Dalkon shields, 3 Lippes loops, and 3 copper T's or copper 7's). All cases presented with pelvic sepsis apart from 1 case of small bowel perforation with a Dalkon shield, but even then at laparotomy extensive adhesions were found between the fundus of the uterus and the small bowel in which the coil was embedded.^ieng

Hysterectomy, hormones, and behaviour. A prospective study.

60 premenopausal women were assessed before and after hysterectomy for menorrhagia or fibroids or both. Their mood, sexual functioning, and plasma oestrogens and gonadotrophins were regularly assessed for a period of up to 3 years. Patients were randomly assigned to receive either oestrone sulphate or placebo tablets during the trial. No evidence was found that this group of patients showed depression or sexual difficulties related to the hysterectomy. In comparison with their baseline gynaecological condition, they showed improved mood and vigour and unimpaired sexual activity.

A comparison between midline and mediolateral episiotomies.

A randomised prospective study of 407 primiparous patients compared the consequences of midline and mediolateral episiotomies. The patients' estimates of the pain from their episiotomies were similar. Anal sphincter injury was significantly more common after a midline procedure but no rectovaginal fistulae occurred. Scarring was less noticeable after the midline incision and intercourse began earlier.

Estrogen replacement therapy: its benefits and risks.

PIP: A carefully taken history and clinical examination are necessary for assessing the relative benefits and risks of estrogen replacement therapy for an individual patient. The patient's weight, blood pressure and urine need to be checked. Benefits of estrogen replacement are seen in relation to vasomotor symptoms, atrophy of the genital tract, bone metabolism, psychological symptoms, libido, skin, and cardiovascular effects. Estrogens are contraindicated with a history of previous deep vein thrombosis, ischemic heart disease or carcinoma of the breast. Care needs to be taken with liver disease, hyperlipidemias, diabetes, gallbladder disease, gross obesity, or in heavy smokers. Progesterones should always be administered if the uterus is present to prevent endometrial hyperplasia and adenocarcinoma. When properly selected and carefully monitored, many women may be relieved of unnecessary suffering due to menopause.^ieng

Dicentric X isochromosomes in man.

Four cases of Turner's syndrome are presented in which an apparent X isochromosome i(Xq) has been found to possess two regions of centromeric heterochromatin. It is suggested that these chromosomes were isodicentric structures capable of functioning as monocentric elements as a result of the inactivation of one centromere. The prevalence of mosaicism is believed to be a consequence of the dicentric nature of these chromosomes, and it is considered possible that a high proportion of X isochromosmes are structurally dicentric. Banding patterns showed that the exchange site involved in the formation of the dicentric chromosome was different in at least three of the cases.

Cervical diameter after suction termination of pregnancy.

The diameter of the internal cervical os was measured in several groups of patients in an attempt to assess any damage caused by suction termination of pregnancy. Pregnant women who had had a previous abortion by vacuum aspiration had significantly greater cervical diameters than those who had not, and there was a statistically significant correlation between dilatation of the cervix at operation and cervical diameter at six weeks' follow-up. Cervical dilatation to 10 mm or less was subsequently associated with a normal cervical diameter, but the diameter was often large when the extent of dilatation was greater than 12 mm or not known. Cervical dilatation at termination of pregnancy should, if possible not exceed 10 mm.