Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas.

STUDY OBJECTIVE: To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure. DESIGN: Case series. SETTING: Single high-volume academic medical center. PATIENTS: Seven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023. INTERVENTION: Dilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics. CONCLUSION: In this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

Efficacy and safety of motherwort injection add-on therapy to carboprost tromethamine for prevention of post-partum blood loss: A meta-analysis of randomized controlled trials.

Motherwort (YiMuCao), a traditional Chinese herb, has been shown beneficial effects for women's diseases. This meta-analysis aimed to evaluate the efficacy and safety of motherwort injection add-on therapy to carboprost tromethamine for prevention of post-partum blood loss. A systematic literature search was conducted in PubMed, Embase, Cochrane Library, CNKI, VIP and Wanfang from their inception to December 2017. Randomized controlled trials that determined the add-on effects of motherwort injection to carboprost for prevention of post-partum blood loss were eligible. Pooled risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) were used to summarize the effect sizes. Eight trials including 1276 pregnant women fulfilled the inclusion criteria. Prophylactic use of motherwort injection add-on therapy significantly reduced the post-partum 2 h (MD -127.5 mL; 95% CI -149.13 to -105.88) and 24 h (MD -146.85 mL; 95% CI -179.77 to -113.94) blood loss and incidence of post-partum hemorrhage (RR 0.28; 95% CI 0.17-0.45) than carboprost. Moreover, adjunctive treatment with motherwort injection significantly decreased the length of the third stage of labor (MD -3.41 min; 95% CI -4.33 to -2.49) and duration of lochia (MD -7.13 days; 95% CI -8.49 to -5.76). There was no statistical significant difference in the incidence of adverse events (RR 0.76; 95% CI 0.50-1.16). Prophylactic use of motherwort injection add-on therapy to carboprost tromethamine could reduce post-partum blood loss. However, more well-designed trials are necessary to confirm the findings of this study due to the methodological flaws of the included trials.

[Clinical multicenter study of carboprost methylate suppository for cervical ripening prior to diagnostic hysteroscopy].

Objective: To evaluate the effectiveness of carboprost methylate suppository for cervical ripening before diagnostic hysteroscopy in premenopausal women. Methods: From July 2014 to July 2015, 1 614 women who were undergone diagnostic hysteroscopy in 12 hospitals were randomly assigned into study group (n=1 209) and control group (n=405) . The cases in study group were given 1 mg carboprost methylate suppository in vagina before hysteroscopy, the cases in control group were given 1 mg placebo. The extent of cervical ripening, the time of dilated cervix, pain scoring, incidence of drug side reactions after 24, 48, 72 hours, satisfaction degree of operators and patients, the time of hysteroscopy, incidence of complications between the two groups were observed and compared. Results: (1) Mean cervical widths in the study and control groups were 6.11±1.11 and 5.95±1.11, and showed a significant difference (P=0.034) ; the percentage of women requiring cervical dilatation in study group was lower than the percentage in control group significantly [28.3% (342/1 209) versus 34.6% (140/405) , P=0.020]. (2) The time of dilated cervix in study group was shorter than the time in control group significantly [ (34±25) versus (52±49) s, P=0.028] for the patients whose mean cervical widths≤4. (3) There was no significant difference in pain scores between the two groups (P>0.05) . (4) The incidence of side reactions 24, 48, 72 hours after operation were no significant difference between the two groups (P>0.05) . (5) The satisfaction degree of operators and patients, the time of hysteroscopy, incidence of complications between the two groups were no singnifcant difference between the two groups (all P>0.05) . Conclusion: Application of carboprost methylate suppository by vagina before hysteroscopy is an effective and safe method of cervical ripening.

Mifepristone in combination with prostaglandins for termination of 10-16 weeks' gestation: a systematic review.

OBJECTIVES: Medical regimens using mifepristone in combination with prostaglandins have been widely available for women undergoing termination of pregnancy (TOP) at 10-16 weeks' gestation in China. We undertook a systematic review to compare different regimens of mifepristone with prostaglandins for TOP at 10-16 weeks' gestation. METHODS: We searched multiple electronic databases for English and Chinese language reports (1990-2007) including MEDLINE, the Cochrane Library and the Chinese Biomedical Literature Database. Included were trials comparing mifepristone with prostaglandins (misoprostol, gemeprost or carboprost (PG05)) to each other for women at 10-16 weeks' gestation. Outcomes were successful abortion rates, induction-to-expulsion time, blood loss and side effects. Data were processed with RevMan 5 software. RESULTS: Nineteen trials comparing mifepristone with prostaglandin (misoprostol and PG05) were found of which 14 contributed to meta-analyses (4206 women). The quality of reports was poor. The effectiveness of vaginal mifepristone/misoprostol was super than mifepristone/PG05 (RR 1.14, 95%CI 1.05-1.22) as was induction-to-expulsion time, blood loss and side effects. When comparing misoprostol/mifepristone 150mg to misoprostol/mifepristone 200mg, no difference in TOP success rates were found (RR 0.98, 95%CI 0.96-1.01). Misoprostol vaginally compared to orally significantly increased the TOP success rate (RR 1.12, 95%CI 1.01-1.24). Gastrointestinal symptoms and fever occurred more often in misoprostol oral group (RR 1.67, 95%CI 1.46-1.91). CONCLUSIONS: Medical regimens of mifepristone/prostaglandins were effective and safe for TOP at 10-16 weeks' gestation. Misoprostol was super than PG05, and misoprostol vaginally was found to have better effectiveness than misoprostol orally. Further research should evaluate the relative effectiveness of medical methods compared to surgery.

[Some aspects of prostaglandin administration in obstetrics: preliminary report].

UNLABELLED: Prostaglandin preparations are widely used in the OB-GYN practice today. This is due to their high efficiency and their potency to prevent a surgical intervention and serious complications. The aim of this study is to share our experience in the prevention of hypo- and atonic, itra- and postoperative hemorrhage after Caesarian Section on multiple pregnancy. MATERIALS AND METHODS: 31 patients with multiple pregnancy for the period of Jan 2010 to June 2011, delivered by Cesarean Section due to unfavorable fetus presentation. Time of delivery- 34 to 38 weeks of gestation. 13 of them represented our work group, amongst them 11 with twin pregnancy and 2 with triplets. They were administered, in theatre, prostaglandin F2alpha as 1 ampule of Prostin 15M (Carboprost tromethamole 0.25 mg) in the uterus wall, as a prophylaxis. The control group consisted of 18 multiple pregnancy patients, chosen randomly and delivered again by C.S., 14 of them with twin pregnancy and 4 with triplets. RESULTS: In our work group the average maternal blood loss was 520 ml +/- 104 ml, compared to 760 +/- 80 ml in the control group. There were patients in the control group with average blood loss of 1500 ml leading to the need of urgent and lifesaving measures. CONCLUSIONS: Nevertheless the small number of cases we had, we dare to say the administration of Carboprost tromethamole - Prostin 15M, intramurally in the uterus during Cesarean section on multiple pregnancy, diminishes the risk of severe hypo- and atonic hemorrhage in theatre and postpartum.

[Induced termination of second and third trimester pregnancy in women with scarred uterus].

OBJECTIVE: To investigate the suitable mode of induced termination of pregnancy at second and third trimester for women with scarred uterus. METHODS: A retrospective study was performed in 90 cases of second and third trimester pregnant women with scarred uterus, who requested termination of pregnancy due to medical indications in Beijing Obstetrics and Gynecology Hospital from September 2002 to June 2009. The indications of termination of pregnancy were fetal anomaly, serious pregnant complication and intrauterine fetal deaths. 72 second trimester pregnant women and 18 third trimester pregnant women were included in this study. The interval time of previous operation to this pregnancy were recorded. And it was < 2 years in 20 cases and ≥ 2 years in 70 cases. The patients with normal Hepatic function began to take mifepristone and had an allergic test of Ethacridine Lactate. The method of mifepristone combined with Ethacridine Lactate were adopted when the allergic test was negative (group A, 54 cases). The method of mifepristone combined with carboprost methylate suppositories were used in the patients who had a positive reaction to the allergic test of Ethacridine Lactate, or who failed to amniotomy to inject Ethacridine Lactate because of oligohydramnios or small gestational age (group B, 36 cases). Record the detail information of every patient. (1) Age, gestational weeks, gravidity and parity. (2) The mode of previous operation (inducing the scar of uterus), previous operation time and indication. (3) The mode of induced labor in this pregnancy, the interval time from administration to uterine contraction, delivery or not and the interval time from induction to delivery. (4) Postpartum hemorrhage, the successful rate of induce labor, placental retention ratio and rupture of uterus or not. RESULTS: (1) It had no significant difference between group A and group B in age, gravidity, parity and the interval time of previous operation to this pregnancy (P > 0.05). But there was significant difference between two groups in gestational weeks of induction (16 weeks vs. 25 weeks, P < 0.01). (2) It had no significant difference between two groups in successful rate of induction and postpartum hemorrhage (P > 0.05), but the time from induction to regular uterine contraction and delivery in group B was significant shorter than that of group A (P < 0.01). The rate of delivery with 24 hours in group B was 94%. It was significant higher than that of group A (13%, P < 0.01). (3) The rate of retained placenta in group B (31%, 11/35) was significant higher than group A (10%, 5/52), but the ratio of residual of placenta and membranes in group A was significant higher than that of group B (54% vs. 34%). It was no significant difference in total rate of postpartum complication between two groups. Further analysis was done in relationship of complication and the time of previous operation. It was no significant difference between the over 2 years group and the less 2 years group in the incidence rate of complications including placental retention, residual of placenta and membranes, rupture of uterus, placental abruption and postpartum hemorrhage. (4) There was 1 case of uterine rupture in group B and 1 case of placental abruption in group A. CONCLUSIONS: Both of methods of mifepristone combined with carboprost methylate suppositories and the mifepristone combined with Ethacridine Lactate are feasible to induced second trimester and late trimester termination of pregnancy for women with scarred uterus. But sufficient preoperation preparation and the course of induction and labor careful monitoring must be done to prevent the uterine rupture.

A randomized controlled trial of prophylactic sublingual misoprostol versus intramuscular methyl-ergometrine versus intramuscular 15-methyl PGF2alpha in active management of third stage of labor.

OBJECTIVE: To compare the efficacy and side effects of 0.2 mg methyl-ergometrine IM, 400 microg misoprostol sublingual and 125 microg 15 methyl PGF2alpha IM in active management of third stage of labor. METHOD: Two hundred low risk pregnant women with induced or spontaneous labor were randomized to receive either 400 microg misoprostol sublingually or 0.2 mg methyl-ergometrine intramuscularly or 125 microg 15-methyl PGF2alpha intramuscularly, after the delivery of anterior shoulder of baby. The main outcome measures were: blood loss more than 500 ml, need for additional oxytoxic drug, change in hemoglobin level and side effects due to drugs. RESULTS: The median estimated blood loss, blood loss more than 500 ml, need for additional oxytocic drug and change in hemoglobin levels were similar in all three groups. The significant side effects in the misoprostol group were shivering, pyrexia (temperature > 38 degrees C) and vomiting, which were self-limiting. Diarrhea was significantly more in the 15 methyl PGF2alpha group. Three women in methyl-ergometrine group underwent manual removal of placenta. One woman in misoprostol group received blood transfusion. CONCLUSION: Sublingual misoprostol appears to be as effective as intramuscular methyl-ergometrine and intramuscular 15-methyl PGF2alpha in the prevention of postpartum hemorrhage. It can be a good alternative in resource poor setting.

Rectal misoprostol vs 15-methyl prostaglandin F2alpha for retained placenta after second-trimester delivery.

OBJECTIVE: The purpose of this study was to compare rectal misoprostol (RM) with 15-methyl prostaglandin F2alpha (PGF(2alpha)) for the management of retained placenta after second-trimester deliveries. STUDY DESIGN: A retrospective study of all second-trimester deliveries between the years 2000 and 2005 was performed. Women were divided into 2 groups, depending on whether they received RM or PGF(2alpha) after the delivery. RESULTS: Three hundred three second-trimester deliveries were analyzed. The time from the administration of medications to the placental delivery was significantly shorter in women who received PGF(2alpha), compared with the RM group (49.5 vs 89 minutes; P < .01). Women who received PGF(2alpha) had lower rates of retained placenta (4.9% vs 12.4%; P = .02). CONCLUSION: The use of PGF(2alpha) after second-trimester deliveries results in shorter third stage of labor and lower rates of retained placenta compared with RM.

[Clinical study on prevention of postpartum hemorrhage of cesarean section using hemabat in high risk pregnant women].

OBJECTIVE: To observe the effect and safety of hemabat (H) on prevention of postpartum hemorrhage in cesarean section and after cesarean section in high risk pregnant women. METHODS: Four hundred and sixty-nine pregnant women with high hemorrhagic risk factors including twin pregnancy, polyhydramnios, fetal macrosomia, placenta previa were planned cesarean section. A total of 457 pregnant women were divided into 3 groups by operation indications. There were 239 cases of fetal macrosomia, 145 cases of twin pregnancy and polyhydramnios, and 73 cases of placenta previa. Three kinds of hysterotonics were used randomly in each group. Group oxytocin (O): 20 U oxytocin injected into the uterine plus 20 U oxytocin intravascularly, 152 women; Group oxytocin + hemabate (O + H): 20 U oxytocin and 250 microg hemabat injected into the uterine, 192 women; group H: 250 microg hemabat, injected into the uterine, 125 women. The amount of bleeding during the operation and within 2-hour after delivery were measured. The side effect of each group was observed. RESULTS: The amount of bleeding during cesarean section in group O was (445 +/- 262) ml, in group O + H (332 +/- 218) ml, and in group H (375 +/- 265) ml. There was an extremely significant difference between group O and group O + H (P < 0.01). The amount of bleeding within 2 hours after delivery in group O was (176 +/- 193) ml, in group O + H was (110 +/- 114) ml, and in group H was (124 +/- 103) ml. There was a significant difference between groups O, O + H and H. Among the 469 women, 31 had total amount of bleeding more than 1000 ml during operation and within 2 hours after delivery. 48% (15 women) were in group O, 23% in group O + H and 29% in group H. The total amount of bleeding in group O was much more than group O + H and group H in the group of fetal macrosomia (P < 0.01, P < 0.01). Similar results were found in the group of twin pregnancy and polyhydramnios (P < 0.01, P < 0.01). The total amount bleeding in group O + H was much less than group O in the group of placenta previa (P < 0.05). There were 5% (12) pregnant women whose total amount of bleeding was >/= 1000 ml in the group of fetal macrosomia, 8% (11) in the group of twin pregnancy, 11% (8) in the group of placenta previa. No hysterectomy was done among the women. The incidence of side effects in the three groups was 2.6%, 11.5% and 7.0% respectively. Vomiting was frequently seen in the latter two groups, but recovered soon without treatment. CONCLUSION: Hemabat can significantly reduce the amount of bleeding during the cesarean section in pregnant women with high hemorrhagic risk factors and can be used with oxytocin as firstline medicine to prevent hemorrhage during and after delivery.

Method to determine stability and recovery of carboprost and misoprostol in infusion preparations.

The two synthetic prostaglandin analogues, carboprost and misoprostol, are used extensively in obstetric and gynaecological practice. Our recent research of these compounds' use for intra-umbilical injection to treat adherent placenta necessitated their storage in solution for 3-4 days. This raised concerns over the stability and applied dosage in the in-house infusion preparations. It requires various pharmacological preparations before administration in clinical practice. We used LCMS to develop a simultaneous, valid, fast and simple method to assess the stability and recovery of their in-house preparations in different conditions. The linearity between 0-40 microg/ml was above 0.995. The reproducibility (CV) was within 5.2%. The limit of quantitation of the method for both compounds is about 2 microg/ml. The accuracy of both compounds from 0.4-40 microg/ml is 96.4-104.3% while the precision is 0.4-7.4%. The recoveries of carboprost in the infusion were from 100.3+/-4.0 to 102.4+/-1.6% and that of misoprostol in Cytotec tablet was from 44.9+/-3.5 to 50.0+/-5.0% in water and saline at 4 degrees C and room temperature. No interference was found from the matrix and between the tested compounds. The compounds were basically stable for 6 days in water and in saline, whether they were stored at 4 degrees C or at room temperature. However, only half of the dosage of misoprostol was recovered in the solution. Therefore, misoprostol dosage should be adjusted before clinical application.

Treatment of early cervical pregnancy with cerclage, carboprost, curettage, and balloon tamponade.

BACKGROUND: Cervical pregnancy, an uncommon variety of ectopic gestation is associated with high morbidity and adverse consequences for future fertility. Currently there are no specific recommendations for the best treatment of this entity. CASE: A 35-year-old nullipara presented with 8 weeks of amenorrhea and painless brown discharge. The patient was diagnosed with cervical pregnancy with embryonic cardiac activity. A conservative surgical treatment under general anesthesia involved intracervical infiltration of carboprost, cerclage, suction curettage of cervix, and Foley balloon tamponade was performed. The Foley was removed on day 2 and the cerclage on day 7. CONCLUSION: Early cervical pregnancy was treated with combined cervical cerclage, intracervical infiltration of carboprost, curettage, and balloon tamponade. Severe hemorrhage during suction curettage and the adverse effects and complications of systemic methotrexate treatment were avoided.

[Some possibilities for application of "Pfizer" medicines--Prostin 15m, Prostin E2, Prepidil gel, Dostinex, Synarel--in the obstetrician practice].

The authors make a clinical and pharmacological overview of the possibilities of application in the obstetrician practice of part of the medicines of the company Pfiser. Some of these medicines have no analogue in Bulgaria--i.e. Prostin 15M. The authors outline the advantages of the Pfiser medicines in comparison with other medicines with similar action.

A prospective, randomized comparison of vaginal misoprostol versus intra-amniotic prostaglandins for midtrimester termination of pregnancy.

OBJECTIVE: The purpose of this study was to compare the efficacy and adverse effects of vaginal misoprostol and intra-amniotic PGF2alpha for midtrimester abortion. STUDY DESIGN: One hundred thirty-two women between 12 and 24 weeks' gestation, seeking abortion in a tertiary hospital, were randomized to receive vaginal misoprostol (400 microg every 3 hours) or intra-amniotic PGF2alpha (carboprost 1.5 mg). Main outcome measures were induction-to-abortion interval, success rates at 24 and 48 hours, and adverse effects. RESULTS: Successful abortion rates at 24 and 48 hours between intra-amniotic PGF2alpha and vaginal misoprostol were not statistically different. However, vaginal misoprostol results in a significantly shorter mean induction-to-abortion interval, compared with intra-amniotic PGF2alpha (misoprostol: 16.2 hours; intra-amniotic PGF2alpha: 20.8 hours; P = .006), particularly among multiparous women (misoprostol: 13.1 hours; intra-amniotic PGF2alpha 18.3 hours; P = .011) and for gestation below 130 days (misoprostol: 14.6 hours; intra-amniotic PGF2alpha: 20.2 hours; P = .015). Fever and shivering were commoner with vaginal misoprostol. CONCLUSION: Vaginal misoprostol should be the regimen of choice for midtrimester abortion, particularly for multiparous women and women in the early second trimester.

Cervical priming with sublingual misoprostol vs. 15-methyl-prostaglandin F2alpha prior to surgical abortion.

OBJECTIVE: To compare the efficacy and tolerability of sublingual misoprostol with those of intramuscular 15-methyl-prostaglandin F2alpha (15-M-PG F2alpha) for cervical dilation prior to vacuum aspiration (VA) in first-trimester pregnancy termination. METHODS: Sixty pregnant women requesting pregnancy termination between the 9th and 12th week were randomized to receive 400 microg of sublingual misoprostol or an intramuscular injection of 125 microg of 15-M-PG F2alpha 2 h prior to vacuum aspiration. Baseline cervical dilation prior to vacuum aspiration was measured using Hegar's dilators. Other variables assessed included procedure duration, intraoperative blood loss, and associated adverse effects. Patient acceptability was assessed by questionnaires completed at the time of discharge from the hospital. RESULTS: Mean cervical dilation at vacuum aspiration was significantly greater in the misoprostol group than in the 15-M-PG F2alpha group (8.8 vs. 7.6 mm; P<0.01), and preoperative adverse effects were significantly less frequent in the sublingual misoprostol group (P<0.05). However, procedure duration and intraoperative blood loss were similar in both groups. The acceptability rates were 93.3% in the sublingual misoprostol group and 76.6% in the 15-M-PG F2alpha group, respectively; however, 6.6% patients in the sublingual misoprostol group thought that the tablets had an unpleasant taste. CONCLUSION: Sublingual misoprostol appears to be an effective alternative to intramuscular 15-M-PG F2alpha for cervical dilation prior to vacuum aspiration in first trimester pregnancy. In addition, misoprostol is inexpensive and convenient to use and has higher patient acceptability rates.

Use of carboprost to facilitate hysteroscopic resection of submucous myomas.

Ten women with submucous myomas that could not be completely resected hysteroscopically were treated with intracervical carboprost. This caused uterine contraction and extrusion of the unresectable intramural component into the endometrial cavity. Eleven of 13 myomas in these patients could then be completely resected. One intramural myoma extruded into the endometrial cavity after injection of carboprost and was also completely resected.