Maternal mortality and morbidity of unsafe abortion in a university teaching hospital of Karachi, Pakistan.

OBJECTIVE: To study the mortality and morbidity of unsafe abortion in a University Teaching Hospital. METHODS: A cross-sectional, descriptive study was conducted in Department of Obstetrics and Gynaecology, Unit III, Dow Medical College and Civil Hospital Karachi from January 2005 to December 2009. Data regarding the sociodemographic characteristics, reasons and methods of abortion, nature of provider, complications and treatment were collected for 43 women, who were admitted with complications of unsafe abortion, and an analysis was done. RESULTS: The frequency of unsafe abortion was 1.35% and the case fatality rate was 34.9%. Most of the women belonged to a very poor socioeconomic group (22/43; 51.2%) and were illiterate (27/43; 62.8%). Unsafe abortion followed an induced abortion in 29 women and other miscarriages in 14 women. The majority of women who had an induced abortion were married (19/29, 65.5%). A completed family was the main reason for induced abortion (14/29; 48.2%) followed by being unmarried (8/29, 27.5%) and domestic violence in 5/29 cases (17.2%). Instruments were the commonest method used for unsafe abortion (26/43; 68.4%).The most frequent complication was septicaemia (34; 79%) followed by uterine perforation with or without bowel perforation (13, 30.2%) and haemorrhage (9; 20.9%). Majority of induced abortions were performed by untrained providers (22/26; 84.6%) compared to only 3/14 cases (21.4%) of other miscarriages (p = 0.0001). CONCLUSION: The high maternal mortality and morbidity of unsafe abortion in our study highlights the need for improving contraceptive and safe abortion services in Pakistan.

Effects of leonurine hydrochloride on medically induced incomplete abortion in early pregnancy rats.

OBJECTIVES: To determine the effect of leonurine hydrochloride (LH) on abnormal bleeding induced by medical abortion. STUDY DESIGN: Rats had incomplete abortions induced in early pregnancy using mifepristone in combination with misoprostol. After abortion, rats were treated with LH for 7 days, and the duration and volume of uterine bleeding were observed. Approximately 30min after the last treatment, the animals were killed and the uterine shape was observed. The sinistro-uteri were suspended in organ baths to record the contraction curves, including the frequency and tension for 10min; the dextro-uteri were fixed with formaldehyde for pathologic evaluation. In addition, blood samples were collected from the femoral artery for the measurement of estradiol (E2) and progesterone (P) levels by radioimmunoassay. RESULTS: In in vivo experiments, compared with the model group, LH treatment markedly reduced the volume of bleeding and intrauterine residual, and significantly shortened the duration of bleeding. From the contraction curve, LH notably reinforced the frequency and tension of uterine contractions. LH remarkably elevated the serum estradiol level in rats, but had no obvious effect on progesterone level. CONCLUSIONS: LH has an inhibitory effect on bleeding caused by incomplete abortion; the mechanism may be related to up-regulation of the E2 level, leading to an increase in uterine contractions and evacuation of intrauterine residuum.

A trial of expectant management in incomplete miscarriage.

INTRODUCTION: Incomplete miscarriage is often treated with surgical evacuation in Sri Lanka. Expectant management, which is an alternative treatment, was assessed for efficacy and safety in a local setting. METHODS: Randomised clinical trial of two treatment groups of expectant and surgical management with 71 and 69 participants, respectively, was done at the University Gynaecology Unit of the Colombo North Teaching Hospital, Ragama, from December 2007 to July 2009. Women with incomplete miscarriage at a period of amenorrhoea of < 14 weeks and retained products of conception of < 50mm were included. Expectant management involved in-ward treatment till resolution of heavy bleeding and pain and follow up for two weeks. In surgical treatment, evacuation was undertaken and the patient sent home from hospital after bleeding settled with follow up. The maximum anteroposterior diameter of the endometrial cavity was measured with transvaginal ultrasonography and a diameter < 15mm was considered as complete miscarriage. RESULTS: Expectant management had a treatment success of 90.1% at one week and 94.4% at two weeks. For surgical treatment this was 95.7%. Infection was noted in one subject from the surgical group and none in the expectant group. Fall in the haemoglobin concentration in the two groups was clinically not significant. The expectantly managed group had a shorter hospital stay than the surgically managed group (1.58 vs 2.57 days, p = 0.008). CONCLUSIONS: Expectant management is an effective and safe alternative to surgical evacuation in management of incomplete miscarriage in the local setting. It relieves the burden on the healthcare provider by shortening the hospital stay and avoiding the need for evacuation of retained products of conception under anaesthesia.

Morbidity and mortality due to unsafe abortion in Pakistan.

OBJECTIVES: To determine the frequency of women who had undergone an unsafe abortion and attended a tertiary care hospital in Pakistan with complications. METHODS: Patients with a history of termination at a gestational age of less than or equal to 22 weeks were included in the study. RESULTS: Of 230 women who met the inclusion criteria, 50 (21.7%) patients had undergone an unsafe abortion and attended the hospital with associated complications. Unintended pregnancy was the reason for the abortion in 82% of women (n=41). Eighteen (36%) underwent terminations performed by doctors, 18 (36%) by Lady Health Visitors (n=18), 10 (20%) by an untrained birth attendant (Dai), and 4 (8.0%) by nurses. Dilatation and evacuation procedures were performed in 28 (56.0%) women, while a Laminaria tent prior to evacuation was used in 18 (36.0%). Major complications included uterine perforation and gastrointestinal injury, observed in 27 (54.0%) women. Hemorrhage was observed in 13 (26.0%) women with retained products of conception after incomplete abortion. Six (12.0%) women died. CONCLUSION: Healthcare providers performed the majority of terminations. To prevent maternal mortality, improved skills through refresher courses and workshops on safer methods are needed.

Uso do Misoprostol em ginecologia e obstetrícia / Misoprostol use in ginecology and obstetrics

Revisäo prática e atualizada sobre o uso do misoprostol em ginecologia e obstetrícia.

Very early pregnancy wastage in in vitro fertilization and embryo transfer (IVF-ET).

The occurrence and incidence of early pregnancy wastage in an in vitro fertilization and embryo transfer (IVF-ET) program have been studied in 750 patients. In 297 (39.6%) a pregnancy was diagnosed; of these, 14.8% were biochemical and 24.8% clinical pregnancies. In the latter group 23.6% aborted, while 75.8% had clinical ongoing pregnancies. The mean embryo quality score of the biochemical pregnancy group was similar to that of the clinical ongoing pregnancy group but statistically different from that of the clinical abortion group (P less than 0.005). Furthermore, the clinical ongoing pregnancy rate in women with previous biochemical pregnancy was 24.7%, a significantly higher percentage compared to clinical ongoing pregnancies achieved in IVF-ET cycles (P less than 0.05). It is possible that biochemical pregnancy does not represent an index for infertility but rather an intact stage of reproduction leading toward implantation. The high clinical pregnancy rate in subsequent cycles may probably serve as an encouraging sign or a marker for future clinical pregnancy.

HLA or HLA-linked genes reduce birthweight in families affected by idiopathic recurrent abortion.

HLA typing was performed in 49 families, each containing at least one woman with a history of unexplained recurrent spontaneous abortion (RSA), and reproductive histories were recorded for the siblings. Abortion rate in sisters sharing two HLA haplotypes with the proband was significantly (p less than 0.01) increased, whereas abortion rates of brothers' wives seemed independent of the brothers' degree of HLA sharing with the proband. Birthweights of offspring of both the sisters and the brothers decreased with increasing HLA haplotype identity between the sibling and the proband (p = 0.05). The mean birthweight of infants of siblings sharing both parental haplotypes with the proband was 3158 g which was significantly (p less than 0.02) less than the average birthweight in Denmark (3417 g). Significantly (p less than 0.05) decreased mean birthweight in infants of brothers who were HLA-identical with the proband suggested that the disposition to growth retardation could be inherited with HLA also through the male gametes. It has been shown that, in their few successful pregnancies, women with RSA bear infants with a birthweight which is approximately 300 g less than normal. The present study demonstrated that the two obstetrical conditions, RSA and retarded fetal growth, share common genetic markers: HLA. It is suggested that HLA or HLA-linked genes causing growth retardation in fetuses are part of the putative complex of genes involved in the pathogenesis of recurrent abortion.

Endometrial biopsy during a cycle of conception.

Endometrial biopsies obtained from 18 infertile women during early intrauterine pregnancy were examined histologically. The cycle date on which the biopsies were obtained was determined from the day of ovulation by basal body temperature charts and prior menstrual history. The average cycle dates of the biopsies were similar for the women who delivered at term or who had first-trimester spontaneous abortions. Among the women who delivered at term, the average histologic date assigned to the specimens was significantly earlier than the average cycle date. In contrast, among the women who had early pregnancy loss, the specimens had an average histologic date significantly later than the average cycle date. A histologic date of later than 25 days or later than the cycle date of the biopsy was associated with a poor prognosis for the pregnancy.

PIP: 18 infertile women from the Milton S. Hershey Medical Center in Pennsylvania underwent endometrial biopsy during the cycle of conception. The endometrial biopsies were examined histologically and dated by 4 different examiners within 2-day interval rates. Average cycle date on which biopsies were obtained was day 25 (range 21 to 28). 13 of the 18 women delivered at term, 4 had histologically documented 1st-trimester spontaneous abortions, and 1 was lost to follow up in the 2nd trimester. Pregnancy outcome did not correlate with day of cycle on which biopsy was taken. Overall incidence of obtaining endometrial biopsy during the cycle of conception in this group of patients was 6.2%, an incidence similar to that by Wentz but greater than that observed by others (0.05% to 4.2%). Average histologic date assigned to specimens was earlier than the average cycle date on which the biopsy was taken. Pregnancy outcome correlated with the histologic dates of the endometrium, with the number of 1st trimester abortion significantly increased among those whose endometrium was dated histologically later than the cycle date of biopsy or later than day 25.