Are we complying with NICE guidelines on the use of prostaglandin E2 for induction of labour? A survey of obstetric units in the UK

To determine whether obstetric units in the UK comply with the recommendations by the National Institute for Clinical Excellence (NICE) on the maximum doses of intravaginal prostaglandin for induction of labour, a cross-sectional telephone survey of all obstetric units in the UK listed on Dr Foster's website was undertaken. The maximum doses recommended by NICE were exceeded by 86.4% (76/88) and 61.1% (55/90) of units that use intravaginal prostaglandin tablet and intravaginal prostaglandin gel, respectively. Units that use prostaglandin tablets were four times more likely to exceed the recommended maximum dose (OR = 4.03, 95% CI, 1.9 - 8.4), six times more likely to use 50% or more of the recommended maximum dose for nulliparous women (OR = 5.9, 95% CI, 3.1 - 11.0), and six times more likely to use 50% or more of the recommended maximum dose for multiparous women (OR = 6.5, 95% CI, 3.0 - 13.9). A majority of obstetric units in the UK exceed the maximum doses of intravaginal prostaglandin recommended by NICE for induction of labour.

High perinatal survival in monoamniotic twins managed by prophylactic sulindac, intensive ultrasound surveillance, and Cesarean delivery at 32 weeks' gestation

OBJECTIVES

Increased perinatal mortality in monoamniotic twin pregnancies is attributed to cord accidents in utero and at delivery. We evaluated the following parameters in monoamniotic pregnancies: (1) the incidence of cord entanglement; (2) the effect of sulindac on amniotic fluid volume and stability of fetal lie; and (3) the perinatal outcome with our current management paradigm.

METHODS

This is a retrospective review of monoamniotic pregnancies of >or=20 weeks' gestation managed with serial ultrasound surveillance, medical amnioreduction and elective Cesarean delivery at 32 weeks' gestation. Mean amniotic fluid index (AFI) and change in AFI in monoamniotic pregnancies managed with oral sulindac was compared with 40 gestation-matched monochorionic-diamniotic controls.

RESULTS

Among 44 monoamniotic pregnancies, 20 with two live structurally normal twins at 20 weeks' gestation satisfied the inclusion criteria. All fetuses survived to 28 days postnatally despite early prenatal cord entanglement in all but one case. Whereas AFI remained stable throughout gestation in the controls, the AFI fell in those patients on sulindac from a mean value of 21.0 cm (95% CI, 18.5-23.6 cm) at 20 weeks to a mean of 12.4 cm (95% CI, 10.1-14.6 cm) at 32 weeks (ANOVA P across gestation = 0.001) but mainly remained within normal limits. Fetal lie was stabilized in 11/20 cases in the monoamniotic group compared with 13/40 in the control group (P < 0.0001).

CONCLUSIONS

Cord entanglement appears unpreventable, as it typically occurs in early pregnancy. Sulindac therapy reduces AFI, leads to more stable fetal lie, and may prevent intrauterine death by diminishing the risk of constricting cords that are already entangled. Perinatal survival in monoamniotic pregnancies managed by a regime of sulindac from 20 weeks' gestation, close ultrasound surveillance and elective abdominal delivery at 32 weeks' gestation seems empirically higher than that in the literature.