Slow-release vaginal insert of misoprostol versus orally administrated solution of misoprostol for the induction of labour in primiparous term pregnant women: a randomised controlled trial

OBJECTIVE

To compare the World Health Organization (WHO) recommended orally administrated dosage of misoprostol (25 μg) with a vaginal slow-release (7 μg/hour) insert of misoprostol regarding time from induction to delivery and safety of the method.

DESIGN

Open label, Randomised controlled trial (RCT).

SETTING

Delivery ward at a secondary referral hospital in Stockholm, Sweden, from 1 October 2016 to 21 February 2018.

POPULATION

One hundred and ninety-six primiparous women with singletons in cephalic presentation at ≥37 weeks of gestation and with a Bishop score of ≤4.

METHODS

Women were randomised to an oral solution of misoprostol (Cytotec^® n = 99) or vaginal slow-release misoprostol (Misodel^® [MVI] n = 97).

MAIN OUTCOME MEASURES

Primary outcome: time from induction to vaginal delivery.

SECONDARY OUTCOMES

mode of delivery; proportion of vaginal deliveries within 24 hours (VD24); neonates with an Apgar score of <7 at 5 minutes; pH < 7.10; postpartum haemorrhage (PPH) of >1000 ml; hyperstimulation; and women's delivery experience (VAS).

RESULTS

There was no difference in the time to delivery [corrected] (median 21.1 hours in the MVI group and 23.2 hours in the oral group; Kaplan-Mayer log rank P = 0.31). There was no difference regarding the proportion of VD24 (50.5 versus 55.7%, P = 0.16). Hyperstimulation with non-reassuring cardiotocography (CTG) was more common in the MVI group (14.4 versus 3.0%, P < 0.01). Terbutaline (Bricanyl^® ) was used more often for hyperstimulation in the MVI group (22.7 versus 4.0%, P < 0.01). There was no difference in the numbers of children admitted to the neonatal intensive care unit (NICU).

CONCLUSIONS

Vaginal delivery after induction of labour (IOL) with slow-release misoprostol did not result in a shorter time from induction to vaginal delivery, compared with oral misoprostol solution, but was associated with a higher risk for hyperstimulation and fetal distress. There were no differences in mode of delivery or neonatal outcome.

TWEETABLE ABSTRACT

IOL with MVI was similar to oral solution of misoprostol but hyperstimulation and fetal distress were more common.

Epidemiology, chronobiology and taxonomic updates of Rhinoestrus spp. infestation in horses of Sardinia Isle, Western Mediterranean (Italy)

From January to December 2008, 265 horses slaughtered in Sardinia (Italy) were examined for the presence of Rhinoestrus spp. (Diptera: Oestridae) through the examination of the nasal cavities and pharynges. Larvae were detected in 49% of the horses, with a mean intensity of infestation of 16.09 and abundance of 7.95. A total of 2108 larvae were collected, 66% of which were classified in first instar (L1), 22% in second instar (L2) and 12% in third instar (L3). The most frequent localization of larvae was the ethmoid, while the less one the larynx. According to the dynamics of Rhinoestrus larval stages, three periods in the chronobiology can be considered, the diapause (September-February) characterized by an absolute prevalence of first larval stage; the active phase of the endogenous phase (February-September) with an increase in the percentages of L2 and L3, and the exit phase (May-September), pointed by a further increase of L1. Morphological examination of L3 larvae revealed the presence of the Rhinoestrus purpureus features in 8% of the examined larvae, of 8% of the Rhinoestrus usbekistanicus features, while in 84% of the larvae were evidenced intermediate features. Contrastingly biomolecular analysis of the COI gene of the larvae evidenced uniformity at genetic level, confirming the presence of a unique species in the Mediterranean area. The results of the present paper, reveal the wide diffusion of rhinoestrosis among Sardinian horses, and suggest the need for applying appropriate control measures. Chemotherapy should be very useful if administered during the diapause period, for reducing the presence of L1 stages and interrupting thus the life cycle of this myiasis.

Strongylus vulgaris (Looss, 1900) in horses in Italy: is it still a problem?

A post-mortem survey was carried out on 46 Sardinian horses to evaluate the presence of Strongylus vulgaris and associated pathology. Horses were from local farms and had been treated with broad-spectrum anthelmintics at least 3 times a year. Examination of the cranial mesenteric arterial system (CMAS) showed parasite-induced lesions in all horses. S. vulgaris larvae were found in 39% of examined arteries, while their detection rate in coprocultures was 4%. Histology, carried out on 26 horses, showed mainly chronic and chronic-active lesions. Histometry showed a significant increase in thickness of the arterial wall, in particular of the intima tunic and adventitia tunic of the ileocolic artery and its colic branch. MCV, MCHC and alpha2, beta and gamma globulins were increased in horses with S. vulgaris larvae in the arteries, while the albumin/globulin ratio was decreased. Horses that were positive on faecal examination showed decreased values for RBC, PCV and the albumin/globulin ratio. Although several studies have shown a dramatic decrease of S. vulgaris infection worldwide, our data show that this parasite continues to exert its pathogenic role, even when its detection rate is quite low within the strongyle population infecting horses.

Childhood cardiac function after twin-to-twin transfusion syndrome--a 10-year follow up

AIM

To perform a 10-year follow up of cardiac structure and function after twin-to-twin transfusion syndrome (TTTS)--a severe foetal circulatory complication associated with myocardial hypertrophy in the recipient twin.

METHODS

Cardiac dimensions, systolic and diastolic function as assessed by echocardiography including flow and tissue Doppler velocimetry in 22 healthy survivors of TTTS with a mean age of 9.6 (7.2-11.8) years.

RESULTS

The donor and recipient twin did not show any differences in end-diastolic ventricular size, interventricular septum thickness, diameter of right ventricular outflow tract, cardiac valves, coronary arteries or in systolic blood flow velocities. However, compared with the donors, the recipients had significantly lower E/A ratios because of lower E-waves in both mitral (-0.15 +/- 0.10, p < 0.01) and tricuspid (-0.09 +/- 0.07, p < 0.01) valves, indicating reduced early diastolic ventricular fillings compared with donors.

CONCLUSION

At school age, twins surviving TTTS had a cardiac structure and function within normal range. There were no differences in heart structure or systolic ventricular function between twins but, compared with the donor twin, we found a reduced early diastolic function in the recipient.

Discordant twin growth in utero and differences in blood pressure and endothelial function at 8 years of age

OBJECTIVE

Low birth weight is associated with increased prevalence of hypertension and cardiovascular disease in adults. The aim of this study was to evaluate genetic and intrauterine environmental contributions to blood pressure (BP) and vascular functions in twins with discordant growth in utero.

SUBJECTS

We studied 31 twin pairs (21 monozygous and nine dizygous), mean age 8 years) with large within-pair differences in birth weight. Among the monozygous pairs, nine had suffered from twin-to-twin-transfusion syndrome (TTTS).

METHODS

Apart from BP, we determined diameters and elasticity of the carotid artery and abdominal aorta with ultrasonography, and endothelial function in skin vessels with a laser Doppler technique, before and after transdermal delivery of acetylcholine and nitroglycerin.

RESULTS

Eight of 62 twin subjects had a systolic BP above the 90th percentile in a North-American reference population. Among these, seven/eight were monozygous with a history of poor fetal growth and/or TTTS. In monozygous twin pairs without TTTS, systolic BP and pulse pressure were higher and vascular endothelial function was impaired in the lower birth weight twin. In the TTTS group, the lighter twin had a narrower carotid artery but there was no within-pair difference in arterial elasticity. Pre-eclampsia during the index pregnancy enhanced within-pair differences in BP but abolished within-pair differences in endothelial function.

CONCLUSIONS

Severe fetal growth retardation contributes to higher BP, arterial narrowing and endothelial dysfunction in childhood. Pre-eclampsia may act both as an effect modifier and confounder of these associations.

Antenatal renal pelvis dilatation emphasizing vesicoureteric reflux: two-year follow-up of minor postnatal dilatation

AIM

To describe the occurrence of foetal renal pelvis dilatation in an unselected population of pregnancies and to describe the clinical course in a subgroup of infants with minor renal pelvis dilatation (RPD).

METHODS

During 1996-1999 the foetuses of 17850 consecutive pregnant women were scanned with ultrasonography (USG) in the 16th-19th gestational week and later in the pregnancy when indicated. RPD was defined as anterior-posterior pelvic diameter > or = 5 mm. After birth all infants were examined with USG twice. If any postnatal USG showed RPD > or = 10 mm, extended radiological investigation was performed. Infants with pelvis dilatation < 10 mm and no calyceal or ureteric dilatation were not investigated further and antibiotic prophylaxis was discontinued. The children were followed up at 2 y of age.

RESULTS

109 foetuses (0.6%) with RPD were identified. Postnatally, 94/109 were available for follow-up: 43 had postnatal dilatation > or = 10 mm and were investigated and treated according to clinical routine, while 51 had dilatation < 10 mm and were followed up after they had reached at least 2 y of age. No case of pyelonephritis was recorded. USG in 48/51 children was normal.

CONCLUSION

The data indicate that infants with minor RPD do not constitute a risk group for renal morbidity and thus do not need antibiotic prophylaxis and extensive radiological examination.

Back pain in women post-partum is not a unitary concept

BACKGROUND AND PURPOSE

At least half of all pregnant women experience back pain at some time during pregnancy and some of them also have persisting back pain post-partum. The aim of the present study was to identify and classify back problems in women post-partum by use of different pain provocation tests and define their relationship to spinal sagittal configuration and mobility.

METHOD

One hundred and nineteen women with back pain persisting two months after delivery were interviewed and examined, on average 7.2 months post-partum. Ten clinical pain provocation tests were performed. The first was performed to identify hip pain, the second to identify radiating pain and the other eight tests were performed to provoke pain in the areas of the posterior pelvic/sacroiliac joints, the symphysis pubis and the lumbar spine. The spinal sagittal configuration and mobility were measured in the thoracic and lumbar spine, respectively, with Debrunner's kyphometer (Protek AG, Berne, Switzerland).

RESULTS

Twenty-seven per cent of women had pain in the area of the posterior pelvic/sacroiliac joints, 18% in the area of the lumbar spine, 39% both in the area of the posterior pelvic/sacroiliac joints and in the lumbar spine, and in 16% no pain could be provoked. There were no statistically significant differences between the four groups with respect to the spinal sagittal configuration or the mobility in the thoracic or lumbar spine.

CONCLUSIONS

Back pain post-partum is not a unitary concept. Based on the clinical tests, women with back pain post-partum can be separated into groups with different pain localizations. The measuring of the spinal sagittal configuration and mobility did not help to further identify or classify post-partum back pain.