A critique of current practice of transvaginal pudendal nerve blocks: a prospective audit of understanding and clinical practice.

Pudendal nerve blocks are a pre-requisite to forceps delivery without regional anaesthesia. Their efficacy is dependent on introducing local anaesthetic in close proximity to the pudendal nerve and allowing sufficient time for its onset of action. An audit of 57 obstetricians evaluated their clinical technique against standards using both a questionnaire and adapted model pelvis. The majority of participants were unable to describe correctly the point of infiltration and were unaware of the lag time required to effect adequate analgesia. We identify a deficiency in training and describe a method by which training can be facilitated and assessed.

Salmonella sepsis and miscarriage.

We present a case of a miscarriage at 16 weeks of gestation due to infection and transplacental passage of Salmonella group C. This was identified as being Salmonella Virchow from genital tract swab culture, and placental Gram-staining revealed numerous colonies of Gram-negative bacilli within the fibrin between the placental villi, confirming a true villitis associated with a hematogenous infection. Based on the patient's history, it was suggested that she had contracted the salmonella infection from eating undercooked eggs. Treatment of salmonella infection in pregnancy is controversial, and antibiotic therapy should be reserved for cases of invasive disease, using amoxicillin or a cephalosporin.

Social class and semen analysis.

It has often been postulated that certain occupations may be hazardous to semen counts, but there are many conflicting views, with others finding either no differences in sperm count or only subtle differences in semen variables. We studied the effect of occupation (in relation to social class) on 207 men attending the fertility clinic of a district general hospital. In our own population azoospermic men were more likely to be of social class 3 m (3 semi-skilled manual) and below. Men who failed to provide a sample were more likely to be of social class 3 m. There was no statistical occupation difference in men whose sperm counts were normal or low. It may not be occupation alone, but also lifestyle differences between social classes which affect semen parameters.

Medical management of first trimester incomplete miscarriage using misoprostol.

This prospective study looked at the effectiveness of 400 microg oral misoprostol in the management of women with a first trimester incomplete miscarriage with retained products of conception measuring between 15 mm and 50 mm on transvaginal ultrasound scan. Of 164 eligible women, 131 agreed to participate. Successful treatment, defined as an empty uterus on scan after 10 days with no bleeding, was achieved in 77.7% of women. Some women with retained products opted to have further misoprostol or conservative management instead of surgical evacuation and in total 92.4% of women completed their miscarriage without requiring surgery. Most bleeding was mild (31.3%) to moderate (38.9%), lasting on average 6.4 days. Forty-five per cent of women needed no pain relief, 51% received oral analgesia and 4% intramuscular opiates. Adverse effects included nausea (10.93%), diarrhoea (2.34%), vomiting (7.8%) and hypotension (4.68%). There were no infections. We concluded that a single dose of 400 microg of oral misoprostol was an effective treatment for women presenting with an incomplete miscarriage.

Medical management of first trimester miscarriage (blighted ovum and missed abortion): is it effective?

This prospective study of 104 women investigated the dose-related efficacy of mifepristone combined with oral misoprostol in the management of first trimester miscarriage (missed abortion and blighted ovum). Forty-four women (group A) received 600 mg of oral mifepristone and 60 women (group B) received 200 mg of mifepristone, followed after 48 hours by oral misoprostol. Successful treatment was an empty uterus on scan and no bleeding after 10 days. This was achieved in 70.5% of group A and 66.7% of group B. Also studied were amount and time to cessation of bleeding, pain scores, analgesic requirements, adverse effects and infections. Of group A, 54.5% had heavy bleeding and bleeding stopped on average by 8 days. Median pain scores were 5.5 on a linear scale and 18% of women received intramuscular opiate analgesia. Adverse effects were nausea in 25% of women and diarrhoea in 16%. Of group B, 38.3% had heavy bleeding and bleeding stopped on average by 7 days. Median pain scores were 4.5 with 25% of women receiving intramuscular opiates. Nausea occurred in 7% of women and diarrhoea in 7%. We concluded that 200 mg of mifepristone and oral misoprostol is as effective and better tolerated than 600 mg mifepristone with oral misoprostol. Medical management of miscarriage is a valid option for those women seeking an alternative to traditional surgical management.