A randomised trial of prophylactic antibiotics for miscarriage surgery

Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection.

This trial was devised to throw some light on this issue. Three thousand four hundred and twelve patients from Malawi, Pakistan, Tanzania and Uganda were enrolled. Half of them received a single preoperative dose of 400mg of oral doxycycline and 400mg of oral metronidazole, and the other half received identical placebos. Pelvic infection was defined as two or more of four clinical features—purulent vaginal discharge, pyrexia, uterine tenderness and leucocytosis.

The conclusion reached was that antibiotic prophylaxis before miscarriage surgery did not result in a significantly lower risk of pelvic infection, as defined by pragmatic broad criteria, than placebo.

N Engl J Med 2019; 380:1012–21

Management of atrial fibrillation after cardiac surgery

Is atrial fibrillation (AF) that occurs after cardiac surgery best controlled by rhythm or rate control? This is questioned in this study.

After reviewing more than 2,000 relevant papers the authors of this study identified five reports that they considered to provide the best evidence—four were reports of randomised trials and one was a retrospective cohort study. Hospital length of stay were approximately equal in the two management protocols. Freedom from AF at follow-up was found to be similar. Minimal adverse effects were seen in both groups.

It appears that rate and rhythm control are equally good in the management of AF after cardiac surgery.

Internal Medicine Journal 2019; 49:656–658

Use of hormone replacement therapy and risk of venous thromboembolism

The aim of this nested case-control study was to assess the association between risk of venous thromboembolism and use of different types of hormone replacement therapy.

80,396 women with a diagnosis of venous thromboembolism were compared with 391,494 matched female controls. The researchers found a significantly increased risk of venous thromboembolism in those taking oral contraceptives compared with the subjects with no exposure. Equine oestrogen with medroxyprogesterone had the highest risk (2.10) and estradiol with dydrogesterone had the lowest risk (1.18). Transdermal preparations were not associated with risk of venous thromboembolism.

In the present study, transdermal treatment was the safest type of hormone replacement therapy when risk of venous thromboembolism was assessed. Transdermal treatment appears to be underused, with the overwhelming preference still for oral preparations.

BMJ 2019; 364:k4810

m was assessed. Transdermal treatment appears to be underused, with the overwhelming preference still for oral preparations.   BMJ 2019; 364:k4810