The contraceptive implant for long acting reversible contraception in patients undergoing first trimester medical termination of pregnancy.

BACKGROUND: Increasing the uptake of long acting reversible contraception (LARC) is part of the UK strategy to reduce the number of unintended pregnancies. The subdermal contraceptive implant is a safe and effective option however lack of skilled providers can be a barrier to its use. We conducted a pilot study to investigate whether insertion during the first part of medical termination of pregnancy rather than after completion would be acceptable to patients and whether, being a progestogen, this has any effect on the efficacy of medical termination with mifepristone and misoprostol. METHODS: Prospective observational study comparing outcomes in patients who chose the subdermal implant for contraception, inserted during the first part of medical termination of pregnancy, against patients who chose an alternative method of contraception commenced after the termination was complete; 39 patients in each group. RESULTS: The efficacy of medical termination of pregnancy in patients in the implant group was 89.7% compared to 97.4% in controls (p=0.3584). Patients in the implant group tended to require more doses of misoprostol to complete the termination than controls. The incidence of complications was very low in both groups. CONCLUSIONS: Implant insertion earlier in the treatment process was acceptable to patients and none changed their minds about their decision for termination. The efficacy of medical termination was slightly reduced in those in the implant group. Larger controlled studies are needed to investigate whether this is a true effect and whether increasing the uptake of LARC actually reduces the number of repeat terminations.

Vaginal hysterectomy is made easier with ERBE Biclamp forceps.

The ratio of vaginal hysterectomy to abdominal hysterectomy in the UK is 1:3. It is well known that patients who have had a vaginal hysterectomy recover better compared with abdominal hysterectomy. However, abdominal hysterectomy is the preferred method in most hospitals because it is deemed easier to do. With ERBE Biclamp diathermy forceps, vaginal hysterectomy could be safely and easily performed by gynaecologists. This study showed a different surgical technique for performing vaginal hysterectomy. It allowed easier and safer operations in patients with large uterus, fibroid uterus, where there was no uterine descent and narrow introitus. Also it allowed the adnexal appendages to be removed easily by the vaginal route. We compared 100 patients who had a vaginal hysterectomy performed using this method, with patients who had a vaginal hysterectomy performed by the conventional method using sutures. We found that we could safely perform vaginal hysterectomy with greater ease. Also, the need for postoperative analgesia was less and the patients were discharged earlier. Consequently, the patients' convalescence period was shorter and better.

Medical termination of missed abortion.

Missed abortions are a common occurrence and represent a heavy gynaecological emergency workload to both medical and nursing staff. The conventional method using vacuum aspiration of uterus is associated with morbidity and mortality. Medical termination of pregnancy is accepted as a safe and effective alternative method. However, medical evacuation of uterus in missed abortions had not been fully investigated. In this study we hope to examine the efficacy of medical methods for terminating missed abortions. Mifepristone and misoprostol prescribed to 100 women with an ultrasonically confirmed missed abortion was compared with 100 women who had surgical evacuation under general anaesthesia for their missed abortion. The disparity in complications between medical and surgical groups was not significantly different (Student's t-test, P=0.5). This study showed medical evacuation of missed abortion to be an effective, safe and cost-effective, alternative to surgical evacuation of the uterus and is particularly suited to women not wanting hospital admission or a surgical procedure under general anaesthesia. It represents an option of management that can be less intrusive and gives the woman some control but is both safe and effective.

Balloon ablation: is this an outpatient procedure?

Menorrhagia is associated with considerable health consequences. First-line therapy is medical, but when this proves unsuccessful a surgical procedure is often undertaken. It is estimated that as many as one in five women will have a hysterectomy before the age of 60 years. While a curative procedure this is a major operation with both morbidity and mortality associated with it. More conservative procedures have therefore been sought. Balloon therapy was developed in 1994 and it was introduced to Royal Bolton Hospital in 1998. Initially offered under general anaesthesia, an overall a success rate of 91% was achieved in this study, with amenorrhea in 18% of cases. Dysmenorrhea was improved in 60% of patients. Twenty-eight patients received outpatient therapy, under a paracervical block. All patients were given voltarol pretreatment. Subjectively the procedure was well tolerated by most, and objectively 89% of patients rated the procedure as acceptable. Sixty-one per cent of patients would be happy to undertake the procedure again under local anaesthesia. Findings from this study would indicate that balloon ablation does provide an effective, less invasive, alternative treatment for menorrhagia. Despite limited numbers, it would also seem appropriate, in selected patients, to offer this therapy as an outpatient procedure.

Efficacy of large loop excision of the transformation zone for cervical intraepithelial neoplasia.

This study showed the efficacy of large loop excision of the transformation zone (LLETZ) in the management of cervical intraepithelial neoplasia (CIN). Eighty-three women with abnormal cervical cytology were recruited. Colposcopic examination and directed punch biopsy were performed and the women had LLETZ therapy as an outpatient procedure. There were 2 cases of microinvasive cervical carcinoma that were missed by directed punch biopsy, the diagnosis being made after the patients underwent LLETZ treatment. There was a large disparity in the histological analysis between directed punch biopsy and LLETZ specimen. This disparity would not have been detected if the women were treated by ablative methods. In women with cervical dysplasia, LLETZ procedure is preferred as the whole excised lesion can be examined histologically and diagnostic error is reduced.

Locked twins: a successful outcome.

Twin interlocking is a rare complication that has a high fetal mortality and morbidity rate. We report a successful outcome of locked twins at 32 weeks gestation following spontaneous labor.

Immunological and immunogenetic investigation of recurrent spontaneous abortion.

Investigations have been performed in 80 couples with unexplained recurrent spontaneous abortions and no live birth (1 degree RSA), as well as in 33 couples with unexplained RSA following one live birth (2 degrees RSA), compared with control couples with no history of repeated early pregnancy failure. A significant bias towards a family history was given for 1 degree RSA women. Elevated total serum IgE levels and tissue-reactive autoantibodies were not significantly more prevalent in the RSA groups, and both 1 degrees and 2 degrees RSA patients had a similar incidence of serum lymphocytotoxic antibody. HLA typing indicated a trend towards parental HLA sharing which did not achieve clear significance at any locus, whereas there was significant apparent HLA-B locus homozygosity for 1 degree RSA women. An elevated prevalence of HLA-A2, B12 haplotypes was also noted for 2 degrees RSA, which may indicate some form of linkage disequilibrium in this population. These results, overall, did not provide evidence to identify a major subgroup of unexplained RSA patients.

Trophoblast membrane infusion for unexplained recurrent miscarriage.

A novel protocol is described which has been developed for immunotherapy in unexplained recurrent miscarriage. This is based on a single intravenous infusion with isolated placental trophoblast plasma membrane vesicle preparations. Clinical experience gained with this approach is described. A total of 16/21 (76%) patients who subsequently had pregnancies have now achieved a live birth or are currently pregnant at greater than 28 weeks gestation.