Sublingual versus oral misoprostol for induction of labour in prelabour rupture of membranes at term.

OBJECTIVE: To compare the efficacy of sublingual with oral misoprostol for induction of labour in primigravida with prelabour rupture of membranes at term. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology Unit-II, Sir Ganga Ram Hospital, Lahore, from June 2004 to January 2006. METHODOLOGY: The study included 100 primigravidas with singleton pregnancy at term, having pre-labour rupture of membranes and unfavourable Bishop score with no contraindication of induction of labour, vaginal delivery or misoprostol use. The cases were randomized into two equal groups, A and B. Women in the group A were given 100 microg of misoprostol orally at an interval of 4 hours to a maximum of 2 doses while patients in the group B were prescribed the medicine sublingually (50 microg, 4 hourly, maximum of 2 doses). Induction to delivery interval, mode of delivery and fetomaternal complications were main outcome measures of the study. RESULTS: In the sublingual misoprostol group (B), 92% women delivered within 12 hours of induction while 84% of subjects delivered in this time period in oral group (A, p < 0.05). There was no failed induction in either group. Regarding dosage, 64% of women delivered with single dose in group B while only 32% delivered with single dose in group A (p < 0.05). The frequency of vaginal delivery was 92% in group B versus 80% in group A, while rate of caesarean section was 8% in the group B and 20% in the group A, which is statistically insignificant. No significant fetomaternal complications were seen in both groups. CONCLUSION: The efficacy of sublingual misoprostol in the dosage of 50 microg was comparable to 100 microg oral dose for the induction of labour in the primigravidas at term with pre-labour rupture of membranes.

Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study.

OBJECTIVE: To evaluate the value of fetal scalp blood sampling (FBS) as an adjunct test to cardiotocography, to predict adverse neonatal outcomes. STUDY DESIGN: A multicentre service evaluation observational study in forty-four maternity units in the UK. We collected data retrospectively on pregnant women with singleton pregnancy who received FBS in labour using a standardised data collection tool. The primary outcome was prediction of neonatal acidaemia diagnosed as umbilical cord arterial pH < 7.05, the secondary outcomes were the prediction of Apgar scores<7 at 1st and 5th minutes and admission to the neonatal intensive care unit (NICU). We evaluated the correlation between the last FBS blood gas before birth and the umbilical cord blood and adjusted for time intervals. We constructed 2 × 2 tables to calculate the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and generated receiver operating curves to report on the Area Under the Curve (AUC). RESULTS: In total, 1422 samples were included in the analysis; pH values showed no correlation (r = 0.001, p = 0.9) in samples obtained within an hour (n = 314), or within half an hour from birth (n = 115) (r=-0.003, p = 0.9). A suboptimal FBS pH value (<7.25) had a poor sensitivity (22%) and PPV (4.9%) to predict neonatal acidaemia with high specificity (87.3%) and NPV (97.4%). Similar performance was noted to predict Apgar scores <7 at 1st (sensitivity 14.5%, specificity 87.5%, PPV 23.4%, NPV 79.6%) and 5th minute (sensitivity 20.3%, specificity 87.4%, PPV 7.6%, NPV 95.6%), and admission to NICU (sensitivity 20.3%, specificity 87.5%, PPV 13.3%, NPV 92.1%). The AUC for FBS pH to predict neonatal acidaemia was 0.59 (95%CI 0.59-0.68, p = 0.3) with similar performance to predict Apgar scores<7 at 1st minute (AUC 0.55, 95%CI 0.51-0.59, p = 0.004), 5th minute (AUC 0.55, 95%CI 0.48-0.62, p = 0.13), and admission to NICU (AUC 0.58, 95%CI 0.52-0.64, p = 0.002). Forty-one neonates had acidaemia (2.8%, 41/1422) at birth. There was no significant correlation in pH values between the FBS and the umbilical cord blood in this subgroup adjusted for sampling time intervals (r = 0.03, p = 0.83). CONCLUSIONS: As an adjunct tool to cardiotocography, FBS offered limited value to predict neonatal acidaemia, low Apgar Scores and admission to NICU.

Knowledge and attitude towards menopause and hormone replacement therapy (HRT) among postmenopausal women.

INTRODUCTION: To determine the knowledge and attitude towards menopause and Hormone Replacement Therapy (HRT) among postmenopausal women. METHOD: A descriptive cross sectional study based on sample of convenience was conducted at outpatient services of Jinnah Medical College Hospital Karachi from 1st January 2005 to 30th April 2005. One hundred and two postmenopausal women who came to outpatient department of Jinnah Medical College Hospital Karachi as a patient or as an attendant were interviewed after taking verbal consent. Sociodemographic characteristics, knowledge and attitude towards menopause and HRT were collected through a structured pretested questionnaire. RESULTS: The mean age of respondents was 55.1 +/- 10 years (range 40 - 75 years). The mean age at menopause was 47.4 +/- 3.3 years. Majority of respondents belonged to poor socioeconomic class (75.5%) and 62 (60.8%) had received no formal education. Ninety seven percent of women had heard about menopause and 29.4% were aware of the symptoms. Four (3.92%) knew the long term implications of menopause. Out of 102, only 02 (1.96%) respondents were aware of HRT. Most of respondents (94%) did not consider menopause to be a medical condition but a normal transition. Majority of respondents had positive (47%) or Neutral (39.2%) attitude towards menopause. Thirty six (35.29%) respondents were not sexually active. Decrease libido and frequency was reported by 33 (32.3%) respondents while 25(24.5%) reported no change. CONCLUSION: Majority of women lacked sufficient knowledge on menopause and HRT. Women's attitude towards menopause showed that majority considered it a natural event and not a medical condition.

Frequency, predisposing factors and fetomaternal outcome in uterine rupture.

OBJECTIVE: To determine the frequency and to analyze the predisposing factors, maternal and fetal outcome of uterine rupture. DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: The Department of Gynaecology and Obstetrics, Jinnah Postgraduate Medical Centre, Karachi from February 1997 to January 2000. PATIENTS AND METHODS: All cases of ruptured uterus, who were either admitted with or who developed this complication in the hospital, were included in the study. Demographic data, details regarding the most probable predisposing factor, type of rupture, the management and maternal and fetal outcome were taken into consideration for analysis. RESULTS: During three years, total number of deliveries was 18668, and there were 103 cases of uterine rupture (0.55%). Out of these, only 13 (12.62%) patients were booked. Most of the patients presented between the ages of 26-30 years (42.71%). Majority of ruptures occurred in para 2-4 (44.66%). Fifty-five cases (53.39%) had a previous caesarean section scar. In 68 (66.01%) cases, the tear was located in lower uterine segment. In 93 (90.29%) cases, anterior uterine wall was involved. Rupture was complete in 79 (76.69%) cases. Repair of uterus was done in 79 (76.69%) cases. Hysterectomy was performed in 24 (23.30%) cases. There were 8 (7.76% or 77.66/1000) maternal deaths and 85 (81.73% or 825 / 1000) perinatal deaths. CONCLUSION: This study confirms high frequency of such serious preventable obstetrical problem which can lead to high fetomaternal mortality. Rupture of caesarean section scar was the most common cause of uterine rupture found in this series.

Somatostatin receptor profiling in hepatic metastases from small intestinal and pancreatic neuroendocrine neoplasms: immunohistochemical approach with potential clinical utility.

BACKGROUND: The expression of somatostatin receptors (SSTRs) on endocrine tumor (ET) cells forms the basis for somatostatin analog treatment of patients with SSTR-positive, hormonally active ETs. In patients with SSTR-negative ETs, the clinical response is generally absent or suboptimal, while nonfunctioning ETs with SSTR positivity show a variable response to such therapy. METHODS: We retrospectively studied SSTR subtype expression in hepatic metastases from 14 adult patients with primary endocrine carcinomas (ECAs) of the small intestine and pancreas and compared SSTR subtype expression among the primary and metastatic ECAs. Polyclonal antibodies against the 5 SSTR subtypes were used on formalin-fixed, paraffin sections from each primary and metastatic ECA. Both qualitative and semiquantitative evaluation of the stained ECA sections was carried out. RESULTS: Eleven (61%) of 18 hepatic metastases from small intestinal and pancreatic ECAs were positive for SSTR-1, 15 (83%) for SSTR-2, 13 (72%) for SSTR-3, 10 (56%) for SSTR-4, and 15 (83%) for SSTR-5. Among 11 hepatic ECA metastases from small intestinal ECAs (carcinoids), 7 (63%) expressed SSTR-1, 9 (81%) expressed SSTR-2, 8 (72%) expressed SSTR-3, 6 (54%) expressed SSTR-4, and 10 (91%) expressed SSTR-5. Of 7 hepatic ECA metastases from pancreatic ECAs, 4 expressed SSTR-1, 6 expressed SSTR-2, and 5 expressed SSTR-3 and SSTR-5 each. We also observed the immunohistochemical evidence of heterogeneity of expression of various SSTR subtypes in the primary enteropancreatic ECAs and their hepatic metastases. CONCLUSIONS: SSTR subtype expression needs to be correlated to somatostatin analog therapy. Immunohistochemical profiling of various SSTR subtypes as a part of routine surgical pathologic analysis of enteropancreatic ETs may become a useful predictor of responsiveness of ETs to various SSTR analogs.