Induction of labor utilizing vaginal vs. intracervical prostaglandin E2.

OBJECTIVE: To compare the efficacy of intracervical vs. vaginal prostaglandin E2 (PGE2) gel for induction of labor. METHOD: Sixty-eight women scheduled for elective induction of labor at term were randomized to receive either 0.5 mg intracervical PGE2 (I/C group, n = 37) or 2 mg vaginal PGE2 gel (Vag group, n = 31) on a 6-hourly basis for a maximum of three doses. RESULTS: Three participants who delivered by cesarean section soon after gel administration were excluded from further analysis. Twenty-nine of 30 (97%) in the Vag group were successfully induced compared with 23 of 35 (66%) in the I/C group (P < 0.01). The induction-active labor intervals were 8.0 +/- 5.4 h for the Vag group and 23.1 +/- 27.6 h for the I/C group (P = 0.002). The induction-delivery intervals were 12.4 +/- 6.3 h for the Vag group and 29.8 +/- 29.1 h for the I/C group (P = 0.001). Uterine hyperstimulation and perinatal outcome were similar in both groups. CONCLUSION: Vaginal PGE2 was more efficacious than intracervical PGE2 in inducing labor.

Breech delivery of infants weighing more than 2000 grams: a case controlled retrospective analysis of 751 patients.

This is a case controlled study of 385 women with breech presentation and 357 with cephalic presentation. Unlike many recent studies, vaginal breech delivery was associated with a significantly worse outcome for the infant. The reasons for these are discussed particularly in relation to developing countries and a protocol for management of these women is suggested to attempt to reduce the unacceptably poor outcome. Selective external cephalic version is advocated.

Evaluation of prophylactic use of tetracycline after evacuation in abortion in Harare Central Hospital.

A randomised controlled trial involving 140 non-septic incomplete abortions was performed to determine the efficacy of prophylactic tetracycline as practiced in these cases in Harare Central Hospital. The treatment group (62) received tetracycline (500 mg four times daily) for a week. The remainder acted as controls. No significant difference in sepsis rate between treatment and control groups was noted. The high sepsis recorded in the treatment group was thought to be due to poor compliance. A new prophylaxis regimen has been suggested.

PIP: The purpose of this randomized, controlled study was to determine the efficacy of tetracycline as a prophylactic antibiotic therapy in treating nonseptic, incomplete abortion patients in Zimbabwe. In 1984, the gynecology emergency unit of Harare Central Hospital admitted 3240 cases of incomplete abortion, of which 2891 were nonseptic on admission. For this prospective study, patients presenting with nonseptic, incomplete abortion (n = 140) from February through May 1985 were recruited at Harare Central. These patients were randomly divided into treatment and control groups, and all patients received aseptic evacuation procedures. Following evacuation, the treatment group (n = 62) was given tetracycline (500 mg 4 times daily to be taken for a week). The remainder (n = 78) acted as controls. Diagnosis for sepsis, based on defined parameters, was performed a week later by the author, who did not know the group to which the patient belonged. The majority of the patients in both groups were 15-24 years old and of parity 1-4. An overall sepsis rate of 35.6% was obtained in this study. No significant difference in sepsis rates between treatment and control groups was noted. The apparent higher proportion of sepsis recorded in the treatment group (25/62, or 40.32%) in comparison to the control group (23/78, or 29.5%) was not significant. Although all patients insisted they took their drugs as instructed, further questioning and counting of remaining capsules revealed that the majority (82.6%) had not taken any or part of the course; the patients who did complete the course had not followed the instructions properly. Thus, the lack of significant reduction in the sepsis rate with the use of prophylactic tetracycline was thought to be due to poor compliance. The author argued that this was due to the young age, low socioeconomic status, and lack of understanding of the regimen among the patients. Thus, it is suggested that tetracycline treatment be replaced with a cheap, single-dose, hospital-administered prophylaxis regimen, such as doxycycline, that covers a wide range of organisms.

Outcome of term breech presentation.

Three hundred and ninety five cases of breech presentation at Harare Maternity Hospital, Harare revealed that caesarean section either electively or in labour resulted in good fetal outcome. Vaginal breech delivery was associated with a perinatal mortality of 74 per 1,000. Fifty four (25%) out of 216 infants delivered vaginally required admission to the Neonatal Unit and thirteen of these had a five minute Apgar Score of 5 or less. Various reasons for this unacceptably high morbidity and mortality are discussed in order to develop a protocol for management of breech presentation in a developing country. The protocol includes the advocation of external cephalic version.

Induction of labor using prostaglandin E2 (PGE2) vaginal gel in triacetin base. An efficacy study comparing two dosage regimens.

OBJECTIVE: To compare two dosage regimens for the administration of vaginal prostaglandin gel in triacetin base for induction of labor. METHODS: Seventy subjects planned for elective induction of labor at term were randomized to treatment with PGE2 vaginal gel every 6 or 12 hours. The 6-hourly group received an initial dose of 1 mg, followed by 2 mg at 6 hour intervals for a maximum of two additional doses if not in active labor. The 12-hourly group had an initial dose of 2 mg followed by two additional doses at 12 hour intervals if not in active labor. RESULTS: Successful induction rate was higher in the 12-hourly as compared to 6-hourly gel regimen (100% vs. 91%, P > 0.05). Twelve hours after the initial dose, delivery occurred in 34% delivery had occurred in 57% and 37% respectively (P < 0.01). We found no difference in the induction-active labor interval (P > 0.05), and the induction-delivery interval (P > 0.05) between the two groups. Active labor followed a single dose of gel in 66% of the 12-hourly group compared to 40% of the 6-hourly group (P < 0.01). Syntocinon augmentation was needed in 6% of subjects in the 12-hourly group as compared to 26% in the 6-hourly group (P < 0.01). The cesarean section rate was similar in both groups. Uterine hyperstimulation occurred less frequently in the 12-hourly group (P < 0.05). The perinatal outcome was similar in both groups. CONCLUSIONS: The 12-hourly regimen was more effective than the 6-hourly regimen in initiating labor. The majority of the subjects in the 12 hourly group achieved labor following a single dose of gel. Induction delivery interval, however, was similar in both groups.

A case of post-partum toxic shock syndrome presenting in an African patient.

A classic case of post-partum toxic shock syndrome with a possible mother-infant pair involvement is presented. Its low incidence in Africa as well as a probable source of infection is discussed.

Ectopic tubal pregnancy in Zimbabwe.

A study of 441 ectopic tubal pregnancies treated at Harare Central Hospital between 1981-84 was carried out. During that time, there were 162,964 deliveries in the unit. The incidence of tubal pregnancy in this study was only 0.27%. Patients ranged in age from 13-46 years with the majority (67%) between ages 20-29. 88% of the patients were parous, the mean parity being 2.6 96% of the patients complained of abdominal pain, 78% of amenorrhea, and 64% of abnormal uterine bleeding. Abdominal tenderness (96%) and cervical excitation (91%) were the most significant signs. Paracentesis was positive in 78% of the cases. It was a little value in the diagnosis of chronic or unruptured tubal pregnancy. There was 1 maternal death.

External cephalic version at term. A randomized controlled trial using tocolysis.

OBJECTIVE: To assess the role of external cephalic version (ECV) at term, using tocolysis. DESIGN: A randomized controlled trial over a 12 month period. SETTING: Harare Maternity Hospital, Harare, Zimbabwe. SUBJECTS: 208 women with breech presentation at term were recruited after satisfying eligibility criteria. There were 103 women in the study group and 105 in the control group. At the end of the study a further 104 women were recruited for ECV. INTERVENTION: ECV attempted after intravenous injection of 10 micrograms of hexaprenaline, using either forward or backward somersault over a maximum period of 5 min. MAIN OUTCOME MEASURES: Success rate in terms of presentation during labour, need for caesarean section, and various variables related to fetal outcome. RESULTS: ECV reduced the frequency of breech presentation during labour from 83% to 17% and that of caesarean section from 33% to 13%. There were no troublesome complications from the procedure. CONCLUSION: In carefully selected women with breech presentation, ECV at term using tocolysis, safely reduced the rate of breech presentation in labour and also the caesarean section rate. Further research is needed to determine the role of ECV in early labour.

Resumption of menstruation after amenorrhea in women treated by endometrial ablation and myometrial resection.

STUDY OBJECTIVE: To evaluate the prevalence of resumption of menstruation after an interval of amenorrhea in women treated by endometrial ablation and myometrial resection. DESIGN: Retrospective analysis. SETTING: Tertiary care university-affiliated teaching hospital. PATIENTS: One hundred fifty-seven consecutive patients treated for menorrhagia refractory to medical therapy. INTERVENTIONS: Loop resection or rollerball ablation of the endometrium. MEASUREMENTS AND MAIN RESULTS: At 6 to 12 months postoperatively, 50. 6% of patients were amenorrheic and 35.1% had hypomenorrhea. Over follow-up of 13 to 30 months, 45.1% of women became amenorheic and 40.5% had satisfactory hypomenorrhea. Resumption of menstruation after any interval of amenorrhea occurred in 27.2% of amenorheic patients. We observed an increasing trend to resumption of menstruation after rollerball ablation (29.4%) compared with loop resection (26.7%) and after preoperative endometrial suppression with buserelin (37.5%) and leuprolide (27.1%) compared with danazol (12.5%) and goserelin (10.5%). Resumption of menstruation occurred in 44.4% of women who did not have preoperative endometrial suppression. CONCLUSIONS: Our results suggest that resumption of menstruation does occur after a variable interval of amenorrhea following endometrial ablation and myometrial resection. It could potentially be used as a marker of failure of endometrial destruction.