OBGYN Column Two

I’m just back from holiday which as all OBGYN’s know is never a complete break. The usual scenario at the beach/bar/restaurant; Interested person "Oh so you’re an OBGYN, I know you’re on holiday but what do you think about my/our periods/fertility problems/pelvic pain?" . Just what should we do in such circumstances ? I was discussing this point with a lawyer friend of mine at a party who said that he was always asked for advice, but when he sent the person a bill the following morning and he wasn’t troubled again. "What a good idea" I replied, only to find the following morning a bill from my lawyer friend "For professional services…"

Our management of miscarriage is undergoing fundamental changes which challenges all of us who try to practice evidence based medicine. It used to be thought that any woman who miscarried should undergo uterine evacuation to prevent further bleeding or infection which may affect her future fertility. Such women often had to wait to get into the operating theater, then have a general anaesthetic and a surgical procedure before leaving hospital, physical discomfort compounding emotional agony.

Against such a background medical management of miscarriage was slowly developed. Give the patient drugs to cause the uterus to contract expelling any retained products of conception and thereby avoiding surgery. But do we even need to give drugs, can we just watch the patient expectantly?

To my mind a most important paper randomizing women to either expectant or medical management of first trimester miscarriage has just been published (BJOG, 1999,106, 804-807). Women were either randomized to oral mifepristone followed by vaginal misoprostol or followed expectantly. Guess what, there was no difference in pain, bleeding, complications or convalescence in both groups. I think this paper should prompt all OBGYN’s to discuss with their patients who have been unfortunate to have a miscarriage which management options : surgical, medical or conservative, the woman and her partner most favor.

How long are we going to use obstetric forceps ? I pose this question, reflecting on a delivery I conducted at the weekend, why are these always as such an uncivilized hour ? The patient, a primip at term, labored well and reached full dilation without difficulty. As she started pushing, there was a profound fetal bradycardia, as I examined her I considered my options, fully dilated, just at the spines with caput in the ROA position. Should I do a caesarean section, or attempt a ventouse or forceps delivery ? I applied the Neville-Barnes Forceps and the baby was delivered easily the next contraction in good condition.

How do obstetricians translate evidence-based-medicine into sound clinical practice ? Maybe I should have used a ventouse ? However I am not as quick with the ventouse as the forceps. I’m fortunate in my training in having good experience of forceps deliveries, our younger trainees often have little exposure to them and the ventouse is being increasingly used. Many studies will point to reduced fetal and maternal morbidity with the ventouse compared to the obstetric forceps, but controversy still reins in the labour ward as to which instrument is better.

Chronic pelvic pain is one of the most miserable conditions for women to cope with, and incredibly challenging for their gynaecologists. Most of these women will eventually end up with a diagnostic laparoscopy to see whether they have any obvious pathology to explain their symptoms.

When I discharge these women post-operatively and discuss the operative finding with them, I am constantly amazed at the feedback I get. Some women are pleased that something has been found which may legitimate their symptoms, some of them were not treated seriously by their family and friends so a positive finding is important for them.

The laparoscopically negative women are often difficult to counsel. Their symptoms are very real, and it’s hard for some women and their doctors to accept no cause has been found this far. Many women of course are delighted that no serious gynaecological cause had been found, and their symptoms rapidly disappear. I do find that it’s extremely difficult to predict which response a laparoscopically negative women will give – despondency or delight. Hopefully some of the newer emerging investigations of pelvic pain will give us more diagnostic options in the future.

©Ellis Downes, MD,
OBGYN.net Editorial Advisor, Hysterectomy & Alternatives