[Termination of pregnancy in the 2nd trimester using intra-amniotic administration of prostaglandins]

INTRODUCTION

The method used to terminate pregnancy on medical grounds during the second trimester must be safe, rapid, psychologically feasible and associated with a minimal risk of long-term sequelae. The objective of the present work was a critical analysis of the author's standard protocol of termination of pregnancy during the second trimester.

MATERIAL AND METHODS

For induction of abortion during the second trimester the authors used a synthetic prostaglandin analogue (PG) F2 alpha-Dinoprost which was administered in a single dose of 30 mg by the intraamniotic route. At the time of onset of uterine contractions the authors administered peridural anaesthesia. The authors investigated indications, mean period of induction, correlation between the period of induction of abortion and the indications for termination of pregnancy, the week of pregnancy and parity of the mother. They recorded also the type and number of complications.

RESULTS

From January 1991 till June 1997 179 pregnancies were terminated by intraamniotic PG administration. After a single intraamniotic PG administration 72% women aborted within 24 hours. In 26% women the intraamniotic administration was repeated twice and in 2% women three times. The mean induction period, i.e. the interval between the administration and abortion of the foetus was 22.6 hours. The interval was significantly longer (28 hours) in foetuses where pregnancy was terminated because of a neural tube defect (p < 0.01). The authors did not detect a correlation between the period of induction and the indication, week of gestation and parity of the mother.

COMPLICATIONS

once a general reaction to intraamniotic administration, in three patients a major blood loss replaced by transfusion of erythrocyte mass, no uterine rupture.

CONCLUSION

In all instances the therapeutic effect was achieved and there was no need to perform section minor. The disadvantage of the method is the high price of the preparation and need of repeated intraamniotic administration of PG in 29% of the patients.

A randomised double-blind study of vaginal misoprostol vs dinoprostone for cervical ripening and labour induction in prolonged pregnancy

BACKGROUND

Dinoprostone, is presently used in our standard protocol for cervical ripening and labour induction. In search for a cheaper alternative, misoprostol has been found to be a good substitute. In view of the potential saving it might offer, we set out to test its efficacy against the standard dinoprostone.

METHODS

A randomised double-blind study involving 50 pregnant women with prolonged pregnancy, treated at a government hospital in Malaysia, was carried out. Two hundred micrograms of intravaginal misoprostol were compared with 3 mg of dinoprostone in each treatment arm.

RESULTS

In the misoprostol group, labour was successfully established in 92% of cases compared to 64% in the dinoprostone group (p = 0.04). The induction-delivery interval was shorter with more women delivering within 12 hours (72% vs 28%, p = 0.047). Maternal and neonatal complications, mode of delivery, the need for oxytocin and pethidine were quite similar statistically. Polysystole was more frequent (28% vs 12%, p = 0.28) in the misoprostol group but it was not associated with fetal distress.

CONCLUSION

The study showed that misoprostol was a more effective drug in labour induction.

Induction of second trimester abortion with mifepristone and gemeprost

OBJECTIVE

To determine the efficacy of a new regimen of the antiprogestogen mifepristone and gemeprost for midtrimester abortion.

DESIGN

Prospective study.

SETTING

Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh.

SUBJECTS

One hundred women undergoing midtrimester abortion.

INTERVENTIONS

Women were pretreated with 200 mg mifepristone 36 h before prostaglandin; 1 mg gemeprost was administered every 6 h for the first 24 h. If abortion had not occurred, 1 mg gemeprost was administered 3 hourly over the next 12 h.

MEASUREMENT AND MAIN RESULTS

Ninety-six percent and 99% women aborted within 24 h and 48 h, respectively. The median prostaglandin-abortion interval was significantly shorter in multigravidae compared to primigravida (6.6 vs 8.2 h, P < 0.01). The median number of gemeprost pessaries to induce abortion was only two and 47% of women required one pessary. The incidence of vomiting and diarrhoea was 31% and 5%, respectively. Eighty-four percent of women required intramuscular diamorphine for analgesia. Thirty-three percent of women required an evacuation of the uterus following abortion.

CONCLUSIONS

The shortened induction-delivery interval following pretreatment with mifepristone makes it possible to conduct midtrimester abortion on a daycare basis.

Low-dose sulprostone for pregnancy termination in cases of fetal abnormality

Thirty-two pregnancies (11 primi- and 21 multi-gravid) with an abnormal fetus were terminated between 16 and 35 weeks (mean 22 weeks; median 20 weeks) and a continuous intravenous infusion of 1 microgram of the prostaglandin analogue sulprostone. All pregnancies were terminated vaginally, 31 of them with this regimen in a median induction-expulsion interval of 23 h (range 8-52 h). Complete expulsion of the placenta occurred in 72 per cent of cases. Median blood loss was 100 ml (range 20-2000 ml). There were only a few side-effects. We conclude that this induction regimen is both appropriate and safe for pregnancy termination in cases of fetal anomaly.

[The effect of Enzaprost-F (PGF2) cervical tablets on the corpus luteum in the human body]

Authors removed dextro-ovary of a patient having 7-9th week of gestation for ovarian cyst during abortion. Preoperative cervical dilation was performed by Enzaprost-F cervical tablet containing 20 mg PGF2 agent. Before and 2, 4 and 6 hours after treatment, serum-progesterone and 17-beta-estradiol level was determined. Drug cervical dilation enabled instrumental termination of pregnancy within 4 hours. Histological finding of yellow body showed initial signs of colloid-cystic degeneration, which was followed by minimal decrease of values of serum-steroid concentrations. Authors presume that change in histological picture of yellow body was caused by effect of cervical tablet containing PGF2 agent.

Pretreatment with mifepristone (RU 486) reduces interval between prostaglandin administration and expulsion in second trimester abortion

The effect of pretreatment with mifepristone on prostaglandin-induced abortion was investigated in a double-blind randomized trial involving 100 women in the second trimester of pregnancy. The women were randomly allocated to receive either 600 mg oral mifepristone or placebo tablets 36 h before the administration of gemeprost pessaries. The median interval between administration of prostaglandin and abortion was significantly shorter in the mifepristone group (6.8 h) compared with the placebo group (15.8 h). The women pretreated with mifepristone required significantly fewer gemeprost pessaries to induce abortion and experienced significantly less pain than the women who had received placebo.

Second-trimester termination with 16,16 dimethyl-PGE1-methyl ester (gemeprost), compared with a regimen that included intra-amniotic PGF2 alpha and hypertonic saline

The use of gemeprost (16,16 dimethyl-PGE1-methyl ester) pessaries was compared in an open, randomized single-centre trial with the intra-amniotic injection of PGF2 alpha combined with hypertonic saline, intravenous oxytocin and a hygroscopic cervical dilator (Dilapan) for the termination of pregnancy between 14 and 20 weeks. There was no significant difference in the induction-delivery interval for the two groups. With the exception of an increased incidence of diarrhoea in the gemeprost group, there was no significant difference in other side effects, analgesic requirements or retained placentae. Gemeprost pessaries are an effective alternative to the more invasive methods previously used for the induction of second-trimester termination.

Controlled study of 16,16-dimethyl-trans-delta 2 prostaglandin E1 methyl ester vaginal pessaries prior to suction termination of first trimester pregnancies

A pessary containing the prostaglandin analogue, 16,16-dimethyl-trans-delta 2 prostaglandin E1 methyl ester (Cervagem) was inserted into the vagina of primigravid women 2 h before suction termination of pregnancy. The cervix was softer, easier to dilate and more widely dilated at the start of the procedure than in a control group of women who received placebo pessaries containing the vehicle alone. Intra-operative blood loss was diminished. The incidence of pre- and post-operative abdominal cramps was increased in the Cervagem-treated group. No gastrointestinal side-effects were noted.

Dilatation of the cervix by oral PGE2 before first-trimester termination of pregnancy

Twenty-four patients--all primigravidae with an especially narrow, rigid cervix--were given PGE2 tablets or placebo tablets in order to prime the cervix before first trimester termination of pregnancy. 1.5 mg PGE2 or placebo tablets were administered hourly for 12 hours on the day before vacuum aspiration. The diameter of the cervix was measured by means of a Hegar dilator prior to administering the tablets and also before the vacuum aspiration the following day. The plasma level of 15-keto-13,14-dihydro-PGF2 alpha was determined before the treatment and again before the vacuum aspiration. All the 12 patients treated with PGE2 tablets had an average change in cervix diameter of 2 mm, whereas in the placebo group the average change was 0.58 mm.

Prostaglandin-oxytocin induction of mid-trimester abortion complicated by grand mal-like seizures

Mid-trimester therapeutic abortion is performed routinely in several clinics by using a combination of intra-amniotic instillation of prostaglandin F2 alpha, followed by intravenous infusion of oxytocin in 5% glucose. In doses as low as 10 mU/min, oxytocin has an antidiuretic action. Two cases of grand mal-like seizure in connection with this procedure of therapeutic abortion are reported and the background discussed.