Acupuncture for pain relief during induced labour in nulliparae: a randomised controlled study.

OBJECTIVE: To assess the role of acupuncture for analgesia during labour. DESIGN: Double-blind study of manual, electro and sham acupuncture, and single-blind study comparing acupuncture with a control group for analgesia for labour induction. SETTING: A major obstetric unit in the UK. POPULATION: A cohort of 105 nulliparae undergoing labour induction at term. METHODS: Twenty-three subjects needed to be randomised to each group to have an 80% power of detecting a 50% relative reduction in epidural rate with an alpha value of 0.05. MAIN OUTCOME MEASURES: The primary end point was the rate of intrapartum epidural analgesia, and the secondary end points were parenteral analgesia requirement, labour length, delivery mode, neonatal condition and postpartum haemorrhage. RESULTS: There was no difference in epidural analgesia between acupuncture and sham acupuncture, relative risk 1.18 (95% CI 0.8-1.74), or between acupuncture and control, relative risk 0.88 (95% CI 0.66-1.19). There were no significant differences in the secondary end points between the acupuncture groups and the control group. Side effects or complications of acupuncture were not identified. CONCLUSIONS: Using the protocols studied, there was no analgesic benefit with acupuncture for pain relief during induced labour in nulliparae.

Failure and regret after laparoscopic filshie clip sterilization under local anesthetic.

OBJECTIVE: To estimate the failure, regret, and reversal rates 5 or more years after laparoscopic Filshie clip sterilization using local anesthesia. METHODS: A total of 1,101 women underwent Filshie clip sterilization between 1983 and 2002. They completed follow-up questionnaires that were analyzed for the following outcomes: failed sterilization, regret after the operation, and sterilization reversal. RESULTS: Two hundred thirty-three of 968 (24%) eligible women sent the questionnaire had moved from their last known address. Of the remaining 735 women, 573 (78%) completed the questionnaire: 223 (39%) 5-6 years after the operation, 175 (30%) after 7-9 years, and 175 (30%) after 10-15 years. One pregnancy occurred 10 months after surgery, and one woman had the procedure repeated when unilateral tubal patency was identified by hysterosalpingography 3 weeks after surgery. Twenty-four (4%) women regretted having the operation; 7 (1.2%) women had a reversal operation, and all subsequently conceived. CONCLUSION: Failure after tubal sterilization using Filshie clips is less than 1:500 operations. Patient selection and surgeons' experience may have influenced these results. Regret occurred in a small proportion. LEVEL OF EVIDENCE: III.

Why remove all cervical polyps and examine them histologically?

A retrospective analysis of 1366 cervical polyps showed that none had malignant features and 67% were removed from asymptomatic women. A policy removing only cervical polyps from symptomatic women or those with abnormal cervical cytology and limiting histological examination to these polyps would result in significant savings and reduce the small risk of morbidity associated with polypectomy.

Delivery after caesarean section: consultant obstetricians' professional advice and personal preferences.

The objective of this study was to determine how obstetricians would wish to be managed in their own pregnancy and their advice to patients delivering after a caesarean section. A questionnaire was sent to 219 consultant obstetricians in two large UK medical deaneries investigating their personal preferences for delivery and management of spontaneous, augmented and induced labour after a caesarean section and how they advise their patients related to the indication for the previous caesarean section. Responses were analysed according to age and gender. The questionnaire yielded a 68% response rate. None would counsel against labour unless there were contraindications. The majority would recommend labour for all indications for the previous caesarean section, although personal preferences were lower (p<0.04): 56% would recommend labour to their patients after a failed instrumental delivery, but only 36% would personally choose that option (p<0.002). Female obstetricians would contemplate and recommend labour more readily than males. Labour augmentation and induction was more frequently recommended (66% and 57%, respectively) than opted for personally (57% and 52%). Reluctance for labour augmentation and induction was greatest among younger consultants. While the majority of consultants favour labour for themselves and recommend this for their patients, it was reassuring to note that patients are encouraged to make the final decision. Informed patient choice is paramount and it is therefore important that full information about risks and benefits is available.

Clinical validation of routine antenatal anti-D prophylaxis questions the modelling predictions adopted by NICE for Rhesus D sensitisation rates: results of a longitudinal study.

OBJECTIVE: To compare the rates of Rh(D) sensitisations with a policy of restricted routine antenatal anti-D prophylaxis (first pregnancy only) with the rates predicted with universal routine antenatal anti-D prophylaxis (all pregnancies). STUDY DESIGN: A retrospective longitudinal observational study involving 15,500 confinements in Rhesus D negative (Rh(D)-ve) women between 1990 and 2003 in a single health district was conducted. All Rh(D) sensitised pregnancies were identified and evidence for routine antenatal anti-D prophylaxis administration during the first pregnancy was investigated. The rate of Rh(D) sensitisations following a policy of restricted prophylaxis was compared with that predicted with mathematical modelling following universal prophylaxis. RESULTS: There were 50 newly sensitised and 37 previously sensitised pregnancies among 15,596 Rh(D)-ve women. For the calculated 13,575 Rh(D)-ve women whose first confinement was in Oxford and who were eligible for restricted prophylaxis, there were 30 new and 26 previously sensitised pregnancies. Of these 30 new sensitisations, 10 were nulliparae, 12 parity 1, and eight parity 2 or greater (third or later continuing pregnancy); only one of these latter eight women had received routine prophylaxis, four had delivered their first baby before the programme was introduced, and in three documentary evidence could not be confirmed that prophylaxis had been given. There was no difference between a policy of restricted and universal routine antenatal anti-D prophylaxis in the sensitisation rates for women during their third or subsequent pregnancy. CONCLUSIONS: This study has shown that restricted routine antenatal prophylaxis provides continuing protection for subsequent pregnancies although the mechanism for this is unclear. These results challenge the wisdom and expense of a policy of universal prophylaxis and prompt a need for further similar analyses to test the appropriateness of the NICE guideline.

Impact of the severity of fetal distress on decision-to-delivery intervals for assisted vaginal delivery.

To correlate the severity of fetal distress assessed retrospectively using the Dublin intrapartum fetal monitoring classification, with decision-to-delivery intervals (DDI) and neonatal outcome, a prospective 3-month study of 78 consecutive instrumental deliveries was conducted. There were 66 cardiotocographs (CTGs) with an 83% majority agreement on classification: it was agreed 95% of deliveries should be expedited for the 58 interpretable CTGs. Although the more abnormal CTG patterns resulted in shorter DDIs and greater neonatal acidaemia, there were no significant correlations. Acidosis was present in 14% with a suspicious, or 22% an ominous CTG pattern. Delivery as a trial in theatre doubled the DDI at 41.5 +/- 22.7 (mean +/- SD) min, compared with 18.1 +/- 8.1 min in the labour room (p < 0.0001), with one case of severe acidosis in the former group. The prolonged DDI with a trial of delivery in theatre could adversely compromise the already 'distressed' fetus and should be used only when clearly indicated.

Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy?

This is a retrospective analysis of post-myomectomy pregnancies beyond 20 weeks' gestation in a teaching hospital for a 16-year period. There were 117 pregnancies, with complete data available for 112 pregnancies, in 81 women. A total of 92 deliveries followed myomectomy at laparotomy, 1 at laparoscopy and 19 at hysteroscopy. Of 72 labours, 22 were induced and 33 were augmented. Ten of those who laboured were delivered by caesarean section. The most common indication for intra-partum caesarean section was poor labour progress. There were no significant differences in neonatal outcome for babies delivered after labour compared with elective caesarean section. Maternal blood loss was however significantly higher with elective caesarean section (OR 2.01; 95% CI 1.96 - 2.06, p < 0.001). We report one uterine rupture at 36 weeks' gestation that followed laparoscopic myomectomy. These data do not support the view that myomectomy performed at laparotomy or hysteroscopy warrant avoiding labour or oxytocic administration. Laparoscopic myomectomy may be associated with a greater risk of scar rupture.

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.

The impact of a trial of instrumental delivery in theatre on neonatal outcome.

OBJECTIVE: To observe the effect of a trial of instrumental delivery in theatre on outcome for mother and baby. DESIGN: A prospective observational study. METHODS: Relevant maternal and neonatal data were collected for all instrumental deliveries of singleton viable pregnancies delivered over a three month period. POPULATION: Two hundred and twenty nine consecutive deliveries conducted by ventouse or forceps because of fetal distress or dystocia. SETTING: The maternity unit of a teaching hospital delivering around 6000 women annually. MAIN OUTCOME MEASURES: The decision-to-delivery intervals (DDI), mode of delivery and neonatal condition at birth. RESULTS: Sixty (26%) deliveries were managed as a trial in theatre, 46 (77%) because of prolonged second stage, with malposition being a factor in 39, and 14 (23%) because of fetal distress. The mean +/- SD DDI for these 60 deliveries was 59.2 +/- 20.4 minutes (median 58 minutes) compared with 21.2 +/- 9.0 minutes (median 20 minutes) for 169 delivered in the labour room (P < 0.0001). Of these 169 deliveries, 168 were delivered within 46 minutes and 1 delivered by caesarean section at 60 minutes. Nine women (13%) ultimately delivered by caesarean section, eight following a trial in theatre; in seven, there was malposition. Deliveries following a trial had slightly less favourable cord blood gas results. CONCLUSIONS: Trial of instrumental delivery takes two to three times longer than delivery in the labour room; fetal malposition was the major indication for the trial of instrumental delivery and reason for failed delivery. Adopting the recent guidelines of the Royal College of Obstetricians and Gynaecologists, at least 107 (47%) should have been managed as a trial in theatre. The added delay in delivery could be damaging to an already hypoxic fetus, and the use of a trial should be individually assessed.

Retrospective study to investigate the possible relationship between excess blood loss at caesarean section and reduced intra-operative oxytocin dose.

OBJECTIVE: To investigate a possible relationship between the oxytocin dose at caesarean section and blood loss. STUDY DESIGN: Retrospective analysis of computerised data for all caesarean sections in a UK maternity unit delivering 6000 women annually during 1995-2009 and thus for seven years before and after the 2001 recommended change in oxytocin dose. Validation of computerised and hand-checked clinical data for 1996 and 2006 was performed and annual frequency of blood loss >1000 ml was observed. RESULTS: Validation showed most variables recorded were similar for both acquisition methods. For 17,405 (98.9%) caesarean sections with blood loss recorded, excess or severe loss occurred in 127 (1.6%) of 7177 cases during 1995-2001 compared with 362 (4.0%) of 9035 during 2003-2009 (OR 2.317, CI 1.888-2.843). It was significantly more frequent with multiple than singleton pregnancies (OR 1.946, CI 1.417-2.673), with general than neuraxial anaesthesia (OR 4.296, CI 3.479-5.305) and with non-longitudinal than longitudinal fetal lie (OR 1.942, CI 1.501-2.512). Excluding these three groups, excess blood loss was still more frequent during 2003-2009 than 1995-2001 (OR 3.181, CI 2.374-4.263). Oxytocin given during labour did not influence the frequency of excess blood loss. CONCLUSIONS: The increased rate of excess blood loss at caesarean section during the latter period could be the result of the reduced oxytocin dose. If similar observations are made by others, this possible relationship should be investigated with appropriate objective randomised studies.

Expression of the hypoxically regulated angiogenic factor adrenomedullin correlates with uterine leiomyoma vascular density.

Uterine leiomyomas are the most prevalent benign tumor type in women of reproductive age and are one of the most common indications for hysterectomy. The expression of five angiogenic factors, adrenomedullin (ADM), vascular endothelial growth factor (VEGF), acidic fibroblast growth factor, basic fibroblast growth factor, and platelet-derived endothelial cell growth factor/thymidine phosphorylase, were examined in 91 uteri collected throughout the menstrual cycle; 52 of which contained leiomyomata, and the remainder were normal controls. The microvascular density and endothelial proliferative indices were then determined for each of the uterine sections. ADM and VEGF were the most widely expressed angiogenic factors in the leiomyomas. Furthermore, the expression of ADM and VEGF in the endometrium and myometrium was up-regulated in leiomyoma-bearing uteri compared with controls. Although acidic fibroblast growth factor and basic fibroblast growth factor were expressed in leiomyomas and endometrium in all of the uterine samples examined, they were only expressed in the myometrium of leiomyomata-bearing uteri. Endothelial proliferation in leiomyomas was statistically greater than that of the myometrium and endometrium, both within and between uteri (P < 0.05). The vascular density in the myometrium but not the endometrium was significantly increased in leiomyoma-containing uteri (P < 0.05). Expression of ADM alone correlated directly with vascular density and endothelial cell proliferation index in leiomyomas and myometrium and may account for the high vascularity found in leiomyomas and the myometrium of leiomyoma-bearing uteri. As such, ADM is identified as a novel target for antiangiogenic therapy of these benign, clinically problematic uterine tumors.

Regulation of the expression of the angiogenic enzyme platelet-derived endothelial cell growth factor/thymidine phosphorylase in endometrial isolates by ovarian steroids and cytokines.

The angiogenic enzyme platelet-derived endothelial cell growth factor/thymidine phosphorylase (PD-ECGF/TP) was strongly expressed in the endometrial glands in the luteal and menstrual, but not the proliferative, phases of the cycle. The converse was seen in the stroma, where expression was strong in the proliferative, but not the luteal or menstrual, phases. Inflammatory cytokines induced PD-ECGF/TP expression in primary cultures of human normal endometrial epithelial (NEE) and normal endometrial stromal cells. The profile of cytokine induction of PD-ECGF/TP was cell dependent. Thus, in NEE cells, PD-ECGF/TP expression was strongly induced by the combination tumor necrosis factor-a and interferon-gamma. In contrast, in normal endometrial stromal cells, interferon-gamma gave, by far, the strongest induction of PD-ECGF/TP. Expression of the enzyme was not regulated by ovarian hormones alone. Although treatment of NEE cells with a physiological concentration of progesterone (5 X 10[-8] M) or transforming growth factor-beta1 (10 ng/ml) alone had no effect on PD-ECGF/TP expression, when delivered together at the same dose they induced a 48-fold increase in expression. This expression correlates with cyclic changes in progesterone and transforming growth factor-beta1 levels in the uterus.

The steroid hormonal milieu of the undisturbed human fetus and mother at 16-20 weeks gestation.

The interrelations of steroid hormone levels in plasma and amniotic fluid from mothers and their undisturbed fetuses at early midgestation of human pregnancy have not been defined previously. We, therefore, studied 12 healthy mothers and their fetuses undergoing termination of pregnancy for social reasons at 16-20 weeks gestation. Fetal arterial and venous blood was obtained by direct vessel puncture through a fetoscope in the conscious sedated mothers immediately before termination of pregnancy. Simultaneously, maternal peripheral venous blood and amniotic fluid were collected. Aldosterone (Aldo), corticosterone (B), 11-deoxycorticosterone, progesterone (P), 17-hydroxyprogesterone (17OHP), 11-deoxycortisol, cortisol (F), and cortisone were simultaneously determined by specific RIA after extraction and chromatography. Positive fetal arterio-venous differences were found for F, B, and Aldo, whereas arteriovenous differences were negative for P and 17OHP. In amniotic fluid, six of the eight corticosteroids showed significantly lower levels during fetoscopy than during routine amniocentesis, as reported previously using the same analytical methods. The present study demonstrates that the undisturbed human fetus at 16-20 weeks gestation actively secretes the most important gluco- and mineralocorticoids, F, B, and Aldo, independent of the mother. P and 17OHP were shown to be primarily derived from placental production and supplied to the fetus as a source of F and Aldo biosynthesis. The fetoscopy procedure with premedication seemed to give rise to less stress to the fetus than routine amniocentesis without sedation. Fetoscopy is, therefore, an ideal method to study feto-maternal steroid interrelations in human pregnancy.

Wnt-7a is upregulated by norethisterone in human endometrial epithelial cells: a possible mechanism by which progestogens reduce the risk of estrogen-induced endometrial neoplasia.

Progestogens are added to oestrogen in hormone replacement therapy regimens to reduce the risk of endometrial cancer. We have performed in vitro studies analysing gene expression of isolated normal endometrial epithelia cells (NEE) treated with estradiol and the progestogen norethisterone acetate (NETA). We report here for the first time upregulation of the Wnt-7a gene by NETA in estrogen treated NEE. Wnt genes are a large family of developmental genes associated with cellular responses such as oncogenesis. We therefore suggest that upregulation of Wnt-7a may be associated with the antineoplastic effects of progestogens on the endometrium.

Oxytocin-stimulated phosphoinositide hydrolysis in human myometrial cells: involvement of pertussis toxin-sensitive and -insensitive G-proteins.

Phosphoinositide hydrolysis is important in mediating the actions of oxytocin and prostaglandin (PG) F2 alpha on uterine contractions during labour. We have measured the effect of oxytocin, PGF2 alpha and other agents on the formation of inositol phosphates (IPs) in cultured human myometrial cells labelled with [3H]inositol and on changes in intracellular free Ca2+ concentration ([Ca2+]i) in cells loaded with Fura-2. Oxytocin induced the formation of [3H]IPs in a concentration-dependent manner with an EC50 (concentration of agonist producing 50% of the maximal response) of 1.4 +/- 0.5 nmol/l (mean +/- S.E.M.). The maximal response was obtained with 1 mumol oxytocin/l and represented a stimulation of 670% over basal. PGF2 alpha also stimulated the formation of [3H]IPs and the response at 1 mumol/l was a 204% stimulation over basal. The effects of PGF2 alpha were independent of extracellular Ca2+ but the effect of oxytocin was reduced with low extracellular Ca2+. Cyclic AMP formation, induced by forskolin or PGE2, had no effect on the stimulated levels of [3H]IPs. Pertussis toxin (PT) reduced the oxytocin-stimulated formation of [3H]IPs in a concentration-dependent manner. The maximal effect of PT resulted in an 80% reduction in the formation of [3H]IPs. However, PGF2 alpha stimulation was not affected by PT treatment. To analyse the action of PT further, we studied its effect on oxytocin-induced changes in [Ca2+]i. The basal [Ca2+]i was 112 +/- 4 nmol/l (n = 225 cells) and was not affected by PT treatment (109 +/- 3 nmol/l; n = 200 cells). In the absence of PT, 1 mumol oxytocin/l increased [Ca2+]i to a peak of 522 +/- 26 nmol/l, and in PT-treated cells, the [Ca2+]i peak was reduced to 348 +/- 16 nmol/l. Similar inhibitory effects of PT were obtained at oxytocin concentrations ranging from 1 to 100 nmol/l. Our data suggest that in human myometrial cells, the oxytocin-induced production of [3H]IPs and increase in [Ca2+]i are mediated by a PT-sensitive G-protein. However, a significant fraction of the oxytocin response appears to be mediated by a PT-insensitive G-protein, possibly a member of the Gq family.

Production of prostaglandins E and Falpha by corpora lutea, corpora albicantes and stroma from the human ovary.

This study has shown that corpora lutea, stromal tissue and corpora albicantes from human ovaries contain prostaglandin E (PGE) and PGFalpha, and that the two former tissues can synthesize these prostaglandins during incubation. Enhanced syntheses, especially of PGE, occurred on adding arachidonic acid to the incubation medium, and the presence of prostaglandin synthetase activity was conclusively demonstrated. In corpora lutea obtained during the early and mid-luteal phase, the mean concentrations of PGE and PGFalpha were 34.3 and 9l9 ng/g respectively (mean ratio PGE:PGFalpha = 3.7); similar values were found in three corpora lutea from women at 10-12 weeks of pregnancy. All these corpora lutea contained appreciable amounts of progesterone and oestradiol-17beta. Prostaglandin levels were generally lower in corpora lutea obtained during the late luteal phase, although the PGE:PGFalpha ratio had increased to a mean value of 8.4. In corpora albicantes, the concentrations of both PGE and PGFalpha were significantly higher than the levels found in corpora lutea (P less than 0.01), whilst the mean ratio of PGE:PGFalpha had fallen significantly to 1.8 (P less than 0.01). Prostaglandin levels in stromal tissue varied considerably between individuals. The mean values were significantly lower than those of the corpora albicantes (P less than 0.01) but not significantly different to corpora lutea at any stage. These findings are discussed in relation to the possible role of prostaglandins in ovarian steroidogenesis and corpus luteum regression in man.

Prostaglandins. Has the initial promise been realised?

PIP: This review of prostaglandins (PGs) covers the following: PGs in obstetrics and gynecology (induction of labor, cervical priming, termination of pregnancies complicated by fetal death, use in 1st and 2nd trimester abortions, and potential contraceptive use); and PGs in other areas of medicine. The original work on the use of PGs in the induction of labor indicated that of the naturally occurring PGs only PGE2 and PGF2alpha are clinically important in reproduction. Ensuing clinical trials confirmed this observation but lead to the conclusion that intravenous PGs for routine labor induction provided no real benefit over intravenous oxytocin, and, in contrast to oxytocin, were associated with frequent gastrointestinal side effects and a pyrexia which could lead to confusion. A recent modification using a cross linked polymer pessary has been designed in an effort to provide a constant sustained release of the incorporated PGE2 for absorption by the vaginal surface. Further studies to assess this innovation are necessary. There was renewed interest in PGs in the mid 1970s when it was observed that they possibly enhanced the outcome of induced labor in patients with an unfavorable cervix. Recent research has established PGE2 as possibly the most efficient cervical priming agent available at this time. A cervical effect may be the reason why PGs are successful in evacuating pregnancies complicated by fetal death. The vaginal route has gained preference as a simple, nontraumatic means of stimulating uterine activity without increasing the chances of intrauterine infection. It seems unlikely that PGs will ever supersede routine aspiration termination of 1st trimester pregnancy. Longterm studies have not been reported yet to indicate that occult cervical damage will be avoided with preoperative PG treatment. Considerable research has been conducted into the safety of PGs for late abortion. Initial concerns of possible coagulopathy, encephalopathy and cardiopulmonary system disturbances have now been largely dismissed; the drugs have been confirmed as safe. The possibility of PGs becoming fertility controlling agents was initially explored in the early 1970s. Although abortion has been successfully induced in 80-90% of treated cases, in many reported series the observed side effects, particularly severe uterine effects, have thus far made the method untenable for routine management. Other uses of PGs include the treatment of spasmodic dysmenorrhea and dysfunctional uterine bleeding and the treatment of gastric ulcers.^ieng

Prenatal determination of fetal rhesus D status by DNA amplification of peripheral blood of rhesus-negative mothers.

We have developed a sensitive PCR-based assay for the RhD gene and used it to detect circulating fetal cells from RhD-positive fetuses from peripheral blood of RhD-negative mothers. With further improvement in diagnostic accuracy, this assay may have implications in the management of RhD-sensitized pregnancies in women whose partners are heterozygous for the RhD gene. Further studies are required to determine the relationship between maternal anti-D levels and circulating fetal cell numbers.

Cesarean section on demand.

The safety of cesarean section has improved dramatically over the past 50 years. During the past 20 years a greater awareness of and discussion about the symptomatic morbidity that can result for women following vaginal delivery has occurred and women's expectations for the outcome of pregnancy for them and their babies has increased. A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by cesarean section rather than the reverse. With the balance in favor of benefit for the baby from delivery by cesarean section, it is now difficult to sustain the argument favoring vaginal delivery rather than planned cesarean section, using maternal morbidity and mortality statistics. A critical evaluation of the costs indicates that there are probably few grounds for denying women their request for cesarean section for economic reasons. It seems likely, therefore, that in the near future those advising women on the options for delivery will need to ensure that the risks of vaginal delivery are explained as well as those for planned cesarean section.

Early termination of pregnancy: medical induction with prostaglandins versus surgical aspiration under local anesthetic.

Termination of pregnancy at 4-8 weeks gestation in 1085 patients using either local prostaglandin instillation (n = 820) or uterine aspiration under local anesthetic (n = 265) have been analyzed. Morbidity for both methods was similar although the incidence of side-effects (0.4%) and the transfusion rate (0%) were lower after aspiration than the respective rates of 59% and 1.3% after prostaglandin treatment. However the rates of genital tract trauma (0.75%) and uterine sepsis (1.8%) after aspiration were higher than the respective rates of 0.3% and 0.9% after prostaglandin treatment. The major disadvantage of prostaglandin treatment was the rate of re-admission for evacuation (8.5%) compared with (0.9%) after aspiration, although patient acceptability for both techniques was similar. In view of the advantages, more widespread use of both methods of termination is indicated.