[The practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology]

The Dutch College of General Practitioners (NHG) revised their practice guideline on vaginal discharge. From a gynaecological point of view, relocation of cervix problems from this guideline to the NHG guideline 'The STD consultation' is not practical. Moreover, the role of simple, but effective diagnosis with a microscope in the primary-care setting cannot be overemphasized. The reluctance to oral treatment is rather inopportune, because once-only ingestion has the advantage of promoting compliance. As physical examination is not always necessary in a recurrent Candida infection, treatment performed by the patient with imidazole compounds is a possibility that does not always result in abuse or increased resistance.

Controlled comparison of induction versus expectant care for prelabor rupture of the membranes at term

This randomized clinical trial compared oxytocin induction of labor with expectant care for 48 hours after prelabor rupture of the membranes at term. Women at term with prelabor rupture of the membranes for at least 8 hours were assigned at random to induction with oxytocin or to expectant management for 48 hours followed by induction if necessary. Of 168 eligible women, 123 (73%) agreed to participate. More women in the induction group (23%) than in the expectant group (10%) had operative delivery, either cesarean section or instrumental vaginal delivery. In the induction group 41% received analgesia versus 24% in the expectant group (p < 0.005). There was no difference in the rate of maternal and neonatal infection between groups and sepsis was not observed. The active policy of oxytocin induction exposed the mother to a higher risk of operative delivery and a less comfortable labor than the 48 hours expectant care option.

Controversies: prelabor rupture of the membranes at term: the case for expectant management

Review of the controlled comparisons between induction of labor and expectant care after prelabor rupture of the membranes (PROM) at term indicates that they are not unhelpful for deciding which of the two options is best. This is, first, because there is a large potential for bias in the studies reported thus far. Second, the trials are rather heterogeneous and they are comparisons more between early and late induction than between induction and expectant care. Third, it is difficult to weigh an increased risk of operative delivery with the induction policy against an apparently clear, but almost certainly biased, reduction of neonatal infection. With expectant care about 70% of women will give birth within 24 hours and 85% within 48 hours. The majority of these women will derive little, if any, benefit from induction and a routine policy of induction of labor after PROM cannot be justified on the basis of the data that are available.

[A patient with a vesico-uterine fistula]

In a 20-year-old woman with a uterus didelphys a vesicouterine fistula was diagnosed after caesarean section. The symptoms suggested a vesico-vaginal fistula but no abnormalities could be detected vaginally and the methylene-blue test was negative. The fistula was visualised by instillation of radiopaque contrast fluid into the vesical fistula opening, using a ureter catheter. The patient was operated via a transperitoneal route with interposition of peritoneum between the urinary bladder and the uterus.

Case of lethal multiple pterygium syndrome with special reference to the origin of pterygia

A case of lethal multiple pterygium syndrome is presented. Besides the anomalies usually associated with this syndrome, cardiac hypertrophy and connective tissue abnormalities were observed. On the basis of these observations, we suggest that an abnormally fragile collagen constitution is the principal disorder in the lethal multiple pterygium syndrome, which is responsible for the pathogenesis of fetal immobility, pterygia, and many of the associated anomalies.