932 co R R E S P O N D E NC E

6 Assdli NS, Vergon JM, Tada Y, Garber SD. Studies on autonomic blockade. VI. The mechanisms regulating the hemodynamic changes in the pregnant woman and their relation to the hypertension of tox- emia of pregnancy. Am J Obstet Gynecol1952; 63: 978-988.

Antenatal corticosteroid prescribing: setting standards of care Sir, The paper by Wallace et al. (Vol 104, November 1997)’ addresses an important issue regarding antenatal corticosteroid prescribing. We agree that each unit should audit not only what percentage of women who deliver at or before 34 weeks of gestation and receive antenatal corticosteroids, but also how many women received corticosteroids and deliver after 34 weeks.

We keep records of all patients receiving steroids antenatally with the date when the steroids are given, the gestation at which they are given and also the number of doses.

During the year 1996, 150 women in total received dexametha- sone. Sixty-five women delivered at or before 34 weeks in 1996. Out of these 65 patients, 40 received dexamethasone antenatally. There were 25 patients who had not received dexamethasone, out of these 25 patients there were three intrauterine deaths and the remaining 22 all delivered within 6 hours of admission.

The number of patients who had received dexamethasone but delivered after 34 weeks was 110. Of these, only 7 were delivered between 35 and 37 weeks. All the rest were delivered after 37 weeks.

It therefore should not be forgotten that in order to ensure that the maximum number of patients who deliver at or before 34 weeks receive dexamethasone, a large number of women have to be given antenatal dexamethasone who do not need it.

R. Chaudhry & M. S. Robson Department of Obstetrics and Gynaecology, Wycombe Hospital, High Wjlcombe

Reference 1 Wallace EM, Chapman J, Stenson B, Wright S. Antenatal corti-

costeroid prescribing: setting standards of care. Br J Obstet Gynaecol1997; 104: 1262-1266.

Blood splashes to the masks and goggles during caesarean section Sir, The short communication by Sharma et al. (Vol 104, December 1997)’ highlights the important issue of blood splashes during caesarean section. Health care professionals are at risk of occupa- tionally acquired blood borne infection including HIV, but rarely appreciate this risk or adhere to published guidelines. It was our impression that there was confusion as to what constituted a high risk injury. With this in mind we circulated a survey of the med- ical staff, including obstetricians, in our district general hospital. The results showed that the increased risk of blood splashed on to a mucous membrane compared with intact skin was not fully appreciated; neither was the increased risk from a percutaneous injury with a hollow bore blood contaminated needle compared with a suture needle. The Department of Health guidelines rec- ommend that post exposure prophylaxis against HIV should be commenced as soon as possible after injury, preferably within the h o d . From our survey, although advice would be sought by the majority, few would seek help within one hour. The reasons given for not reporting an injury included concerns over future career prospects, pressure of work and perceived lack of risk. Complacency increased with seniority and multiple previous needlestick injuries. Most obstetric consultants had sustained at least ten needlestick injuries in the preceding ten years; a greater number than consultants in other specialties.

It is not current practice to routinely test antenatal women for HIV infection. As blood splashes and needle stick injuries are more common in obstetrics than in other fields of medicine, strategies to reduce the risk of injury and appropriate manage- ment of any incidents should be made a priority.

Elizabeth Foley & V. Harindra Genitourinary Medicine Department, St Mary’s Hospital, Portsmouth

References 1 Sharma JB, Ekoh S, McMillan L, Hussain S, Annan H. Blood

splashes to the masks and goggles during caesarean section. Br J Obstet Gynaecol1997 104: 1405-1406.

2 Department of Health. Guidelines on post exposure prophylaxis for health care workers occupationally exposed to HIV. PL/CO (97) I ; June 1997. London: Department of Health.

Extra-amniotic saline infusion for induction of labour in antepartum fetal death: a cost effective method worthy of wider use Sir, With much interest I have read the article ‘Extra-amniotic saline infusion for induction of labour in antepartum fetal death: a cost effective method worthy of wider use’ (Vol 104, August 1997)’. However from a public health point of view T am puzzled by the policy of inducing labour in antepartum fetal death in a poor resource country and I would like to ask the following questions:

1. What is the definition of cost effectiveness? The health bene- fit compared to the costs is not clear. Probably the article is meant to describe a relatively ‘cheap’ way of inducing labour but how cost effective is not clear. Compared with the cheapest way of treating antepartum death -expectant policy - it is not clear why induction was necessary.

2. Although the risk of intrauterine infection in every invasive procedure is slight, the number of women in the study is too small to draw any firm conclusions concerning this point. In a country with limited resources of manpower, equipment used for induc- tion, and antibiotics, there should be a good reason for induction of labour.

3. How did recruiting take place? Did women ask for their labours to be induced?

Carla van der Wijden Weesperziju‘e 65,1091 EH Amsterdam. The Netherlands

Reference 1 Mahomed K, Jayaguru A. Extra amniotic saline infusion for

induction of labour: a cost effective method worthy of wider use. Br J Obstet Gynaecol1996; 104: 1058-1061.

AUTHOR’S REPLY Sir, Antepartum intrauterine fetal death is a very emotional event irre- spective of the type or the socioeconomic status of the population one is dealing with. There is no longer a place in our opinion to leave these women alone in the hope that they will eventually go into spontaneous labour. We would strongly discourage this practice. Since we believe therefore that induction of labour is the appropriate management we suggest that this method is materially less expensive than the conventional use of prostaglandins. We accept that infec- tion may be a risk. Our sample size was small, but in an unpublished study from the department, where this method was used to induce labour with a live fetus in 300 women, infection did not appear to be a problem either. We would however encourage documentation of adverse events during the time this method is in use

K. Mahomed

0 RCOG 1998 Br J Obstet Gynuecol 105, 931-932