Hypoglycaemia with human and

Analysis of obstetric outcome at Coombe Lying-In Hospitalfor 1992. Figures are numbers (percentages) of women

Prolonged labour Epidural analgesia Episiotomy Forceps delivery Caesarean section

Primiparous women (n=2457)

Multiparous women (n=4029)

All women (n=6486)

244 (9 9) 1710 (69-6) 1077 (43 8) 608 (24-7) 378 (15 4)

83 (2 1) 1237 (30-7) 420 (10-4) 183 (4 5) 401 (10 0)

327 (5 0) 2947 (454) 1497 (23-1) 791 (12 2) 779 (12 0)

obstetric data should be analysed according to whether the patient is primiparous or multiparous. The importance of such analysis by parity has been highlighted in previous studies.24 Data from our hospital for last year also show that obstetric outcome differs dramatically between primiparous and multiparous women (table); this is not fully appreciated when the results of all parities are combined. Indeed, differences over time and differences among hospitals, regions, and populations may be due to the proportion of primiparous women in the study group rather than to other variables. Furthermore, separate analysis of first deliveries, especially for caesarean section, may be a useful and early predictor of future trends in obstetric care. We argue, therefore, that differentiation of first deliveries from subsequent deliveries is mandatory before further investigations into differences in obstetric outcome are

initiated. MICHAEL TURNER MARTHA FINN

Coombe Lying-In Hospital, Dublin 8, Republic of Ireland 1 Fleissig A. Prevalence of procedures in childbirth. BMJ 1993; 306:494-5. (20 February.) 2 Wingfield M, Tumer MJ, Rasmussen MJ, Stronge JM. Labour in twin pregnancy. An analysis of parity. Journal of Obstetrics and Gynaecology 1992;12:14-6. 3 Barton DPJ, Turner MJ, Boylan PC, Macdonald D, Stronge JM. Fetal acidosis in labour: a prospective study on the effect of

parity. EurJ Obstet Gynecol Reprod Biol 1991;39:93-8. 4 O'Driscoll K, Meagher D. Active management of labour. London: W B Saunders, 1982:9.

major insurers in the United States noticed a decrease in the cost of investigating menstrual abnormality? Unlikely. Where have all the patients gone? To the hysteroscopy clinic. JOHN GILES

Department of Gynaecology, East Somerset Trust, Somerset BA2 1 4AT I Coulter A, Klassen A, MacKenzie IZ, McPherson K, Diagnostic curettage: is it used appropriately? BMJ 1993;306:236-9. (23 January.) 2 Lewis BV. Diagnostic dilatation and curettage in young women. BMJ 1993;306:225-6. (23 January.)

EDITOR,-Having run an outpatient surgical service for some years, I welcome B V Lewis's editorial suggesting that diagnostic curettage should be replaced by outpatient endometrial biopsy.' The problems of providing this service are varied, and the view that procedures under local anaesthesia are less satisfactory than those under general anaesthesia is compounded by the current funding emphasis on day case surgery to the detriment of outpatient work. With the advent of contracts, business plans, consultant episodes, and performance audits, attendance for outpatient surgery (colposcopy, cone biopsy, hysteroscopy, curettage, etc) is classified as outpatient attendance. Obviously, as such procedures take longer than the usual consultation, activity seems to be reduced. Savings due to reduced admissions are dismissed by administrators because the saved places are readily used up from endless waiting lists. Perhaps the most disturbing factor I have so far encountered is that any savings from outpatient surgery are to the purchaser's benefit, not the provider's, and therefore outpatient surgery will effectively incur a financial penalty. With the current financial structuring of the service, even in trusts, until it is generally recognised that more than just a pen and speculum are required in gynaecological outpatient clinics the value of outpatient surgery will not be realised. J FOULKES

Department of Obstetrics and Gynaecology, Torbay Hospital, Torquay TQ2 7AA

Diagnostic dilatation and curettage

I Lewis BV. Diagnostic dilatation and curettage in young women.

EDITOR,-Angela Coulter and colleagues' implication that there are major savings to be made in the investigation of menstrual abnormality will doubtless delight district health authorities.' Gynaecologists, however, will be dismayed at the authors' apparent lack of understanding of the management of a common medical complaint. Certainly, considerable changes in the investigation of menstrual disorder have occurred not only in the United States but also in parts of the United Kingdom. The authors have shown that the traditional diagnostic curettage is becoming obsolete but have failed to identify the reason. Endometrial biopsy is cheap, safe, quick, easy, and useful for diagnosing endometrial carcinoma. As malignancy is one of the rarest causes of menstrual disturbance the procedure is not helpful in the management of most women referred to gynaecologists. Hysteroscopy and biopsy are more time consuming and expensive than the traditional dilatation and curettage. The accurate diagnosis achieved2 combined with the evolution of intrauterine surgery, however, is radically changing patients' management. Far from decreasing costs this change in management actually requires increased funding in the short term. Benefits to patients are obvious, but the theoretical long term savings in cost have yet to be confirmed. The idea that American gynaecologists have abandoned dilatation and curettage for a cheaper alternative is interesting but unfounded. Have the

EDITOR,-In response to Angela Coulter and colleagues' study of the use of diagnostic dilatation and curettage' Jane Weston and colleagues advocate that the procedure should be performed at the time of routine sterilisation procedures "to exclude early pregnancy."2 I disagree strongly. Firstly, termination of pregnancy should be performed only after proper counselling and the completion of a "blue form" by two medical practitioners in accordance with the Abortion Act. Secondly, the success rate of dilatation and curettage to terminate a pregnancy of under four weeks is poor. Add to this the small but unnecessary morbidity associated with dilatation and curettage, and most people would agree that this procedure is not indicated at the time of a routine sterilisation.

BMJ VOLUME 306

13 MARCH1993

BMJ 1993;306:225-6. (23 January.)

PHILLIP A SMITH Southmead Hospital, Bristol BS IO 5NB 1 Coulter A, Klassen A, MacKenzie IZ, McPherson K. Diagnostic dilatation and curettage: is it used appropriately? BMJ 1993;306:236-9. (23 January.) 2 Weston J, Gordon H, Price AB. Diagnostic dilatation and curettage. BMJ 1993;306:515-6. (20 February.)

EDITOR,-We agree that the use of diagnostic dilatation and curettage in young women should be nationalised.'2 Of 225 new patients attending our adolescent gynaecology clinic in 1992, 167 presented with menstrual disturbances. Only one was

admitted for diagnostic dilatation and curettage, which was performed as a day case procedure. The patient complained of continuous vaginal bleeding despite medical management with hormonal agents. Though a therapeutic response was reported, histological examination of the endometrial curettings did not show any disease. Of the remaining 166 patients, 136 were successfully treated pharmacologically. It has long been our practice to avoid performing diagnostic dilatation and curettage in young women if possible. In 1984 an audit in the hospital of 200 consecutive women aged under 40 who underwent diagnostic dilatation and curettage showed no cases of endometrial carcinoma and only 16 cases of endometrial hyperplasia. We therefore agree that the use of diagnostic dilatation and curettage in young women should be limited to those in whom important disease is suspected and that the procedure is necessary it should be accompanied by hysteroscopy. ORLA SHIEL

MICHAELTURNER

Coombe Lying-In Hospital, Dublin 8, Republic of Ireland 1 Lewis BV. Diagnostic dilatation and curettage in young women. BMJ 1993;306:225-6. (23 January.) 2 Coulter A, Klassen A, MacKenzie IZ, McPherson K. Diagnostic dilatation and curettage: is it used appropriately? BMJ 1993;306:236-9. (23 January.)

Hypoglycaemia with human and porcine insulins EDITOR,-Albert Maran and colleagues had already reported their randomised crossover study of hypoglycaemia with human and porcine insulin' in abstract form.2 In the abstract they stated that there were 88 episodes of hypoglycaemia with human and 132 with porcine insulin. In the article the figures are 136 and 149 respectively. The difference was marginally significant in the abstract (p= 009) and not significant in the article (p=0 63). This discrepancy is disturbing, and it is not obvious how it could have arisen, especially because the abstract and the full paper report on the same follow up period. Also, it is unclear whether the correct statistical tests were used. We observed a comparable difference in the occurrence of hypoglycaemic episodes (234 episodes with human insulin and 259 with porcine insulin), which was significant (p