We conducted a health technology assessment of the care of women with high-risk pregnancies in the South Wales valleys. Women in the control arm were intended to receive conventional care with standard midwifery visits. Women in the intervention arm received additional or longer visits and domiciliary fetal heart rate telemonitoring. Eighty-one mothers were randomized. There were significant differences in midwifery intervention resources between domiciliary and control groups, with the former receiving a mean of 3.7 visits lasting 33.5 min, compared with 1.4 visits lasting 12.8 min for the latter. There were slightly more spontaneous labours and fewer Caesarean sections in the domiciliary group. Maternal satisfaction and anxiety were high in both groups. Domiciliary care increased the service costs by 21.02 Pounds per woman in terms of extra midwife travel and visiting time, and by a further 18.38 Pounds per woman in home monitoring equipment costs. This, however, was more than offset by health service savings from fewer clinic visits (35.60 Pounds) and fewer clinic ultrasound scans (9.01 Pounds). Adding the reductions in lost productivity to women and their partners (34.51 Pounds) suggests that domiciliary care was cheaper than conventional care, even if it did not greatly reduce inpatient days (a reduction nonetheless saving 184.24 Pounds). While clinical processes were similar in both groups, there were useful practical advantages and savings for patients and the health service from the domiciliary intervention.
The Chinese policy of limiting family size is well known worldwide. We report the case of a patient who required hysterotomy for removal of an intrauterine contraceptive device inserted in China following termination of pregnancy. Case reportA 35-year-old Chinese woman was referred to the gynaecology outpatient clinic for removal of an intrauterine contraceptive device (IUD) that had been inserted following a termination of pregnancy in China in 1990. Prior to this pregnancy the woman had had an ectopic pregnancy. As a result of this she had undergone a left salpingectomy and evacuation of retained products of conception. She had a regular menstrual cycle with no intermenstrual or postcoital bleeding.At her outpatient appointment in August 2001 no coil threads were visible, but an ultrasound scan confirmed the presence of a normal sized uterus with an IUD within the uterine cavity.The patient underwent a hysteroscopy under general anaesthesia to remove the IUD. At hysteroscopy it was not possible to enter the uterine cavity because of the presence of a fibrous band of adhesions across the cavity of the uterus. These adhesions were probably secondary to an infection following insertion of the IUD. The patient and her husband were advised of the findings at hysteroscopy, however they were both insistent that the IUD be removed. It was decided to perform hysteroscopy with attempted removal of IUD under ultrasound guidance. The patient insisted that if the IUD could not be retrieved vaginally she wanted a laparotomy and hysterotomy for its removal.At hysteroscopy, fluid could be seen outlining the endometrial cavity with the IUD within it. There was a band of adhesions across the lower part of the body of the uterus. Attempted hysteroscopic division of the adhesions was unsuccessful, and a laparotomy and hysterotomy were performed. A longitudinal incision was made in the anterior wall of the uterus and the IUD identified within the cavity and removed.The IUD was a small, circular, spring-like device. The endometrium within the cavity appeared normal. The patient had an uncomplicated postoperative course. She and her partner were advised that as fluid could pass through the adhesions into the cavity there was a small chance that she may now become pregnant. In view of her past history the patient was advised to attend for an early viability ultrasound scan should she have a positive pregnancy test.In July 2002 the patient had a positive pregnancy test. An ultrasound scan confirmed a single, viable, intrauterine fetus. She had an uncomplicated pregnancy and was booked for an elective Caesarean section at 39 weeks' gestation. She presented to the delivery suite at 36 weeks' gestation with a sudden, painless, vaginal bleed. She had ruptured her membranes and was in early labour. She underwent emergency Caesarean section and was delivered of a healthy baby boy weighing 3.04 kg. She made an excellent postoperative recovery. DiscussionA literature search has failed to reveal any published case reports of hysterotom...
achieved with implants because of the unclear relation between postmenopausal use of oestrogen and risk of breast cancer, which has been reported to depend on dose and duration when conjugated equine oestrogens are given.34 At present, though, there are no data linking oestradiol implants with an increased risk of breast cancer.'Drs J H Tobias and T J Chambers have observed that in vitro supraphysiological oestradiol concentrations increased bone resorption in the rat.6 A cross sectional study suggests that in vivo oestradiol implants increase bone mass in humans.7Drs Jean Ginsburg and Paul Hardiman dispute that the phenomenon of decreasing efficacy with
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