Termination of pregnancy with fetal death in the second and third trimesters--the double balloon versus extra-amniotic prostaglandin.

OBJECTIVES: To evaluate the use of a double balloon catheter in the termination of pregnancy with fetal death in the second and third trimesters, in comparison with the administration of extra-amniotic PGF2-alpha. METHODS: Twenty cases with IUFD at > 20 weeks of gestation were divided into two groups. Group I was subjected to the double balloon alone, while in Group II extra-amniotic instillation of PGF2-alpha via a Foley's catheter was used. RESULTS: There were no significant differences between the two groups with regard to induction-expulsion time, induction-delivery time and failure rate. CONCLUSIONS: The double balloon catheter proved to be an effective non-pharmacological method. The technique was simple and well tolerated by the patients. The side-effects of the prostaglandin and the cost of the medication were avoided.

Treatment of severe pre-eclampsia by acetyl salicylic acid.

Low-dose Aspirin inhibits thromboxane A2 with minimal effects on prostacyclin and induces clinical improvements in pre-eclampsia. Two groups of pre-eclamptic women (10 in each) were treated either by low-dose acetyl salicylic acid (group I) or by conventional therapy (group II). Both groups showed a significant drop in systolic and diastolic blood pressure, a decrease in temperature, edema and albuminuria and an increase in urine volume. These effects were more significant in group I than in group II, except for the diastolic blood pressure. The obstetric progress and perinatal outcome were rather similar in both groups. These data offer a new potential therapeutic measure for the management of severe pre-eclampsia and call for further evaluation in a larger group of cases.

Cervical prostaglandin injection: a novel method of administration for ripening the cervix and induction of labor.

Twenty pregnant women with greater than or equal to 36 weeks gestation and Bishop score of less than or equal to 4 were subjected to either intracervical injection of PGE2 (0.25 mg) every 4 h to ripen the cervix and induce labor (study group n = 10) or injection of only the diluent (control group n = 10). PGE2 cases showed significant increase in Bishop score and were successfully induced. The mean induction-establishment and induction-delivery intervals were 4.3 +/- 0.1 min and 6.07 +/- 1.7 h, respectively. The control group showed no response. PGE2 cervical injection is a safe and effective method for cervical ripening and labor induction.

Induction of labor by oral prostaglandin E2 in protracted pregnancy.

Induction of labor was performed in 20 pregnant females with postmaturity (greater than 294 days) using either oral PGE2 tablets (0.5 mg) or i.v. oxytocin drip (each group n = 10). The induction-establishment interval was significantly shorter in the oxytocin group (P less than 0.005). Moreover, the uterine activity (in Alexandria units) at 3 h post-induction and at the end of the first stage of labor, was significantly higher with i.v. oxytocin (P less than 0.005). However, the induction-delivery interval did not differ in both groups. All cases delivered spontaneously with a satisfactory Apgar score.

Local effect of thromboxane B2 on the contractility of the human non pregnant uterus.

The effect of intra-uterine instillation of 100 micrograms thromboxane B2 [TXB2] on the contractility of the non-pregnant uterus was studied in 30 subjects during the different phases of the menstrual cycle [menstrual, proliferative, periovulatory and secretory]. Twenty control cases received a similar volume of diluted ethanol. The TXB2 proved to be a powerful uterine stimulant at all phases and the response [maximum elevation in tonus and duration] appeared to be most pronounced in the secretory phase. The implication of these findings in the control of uterine activity is discussed.

Effect of heat on uterine contractions during normal labor.

The effect of local application of heat on the abdominal wall on uterine activity was evaluated in 15 full-term multiparous women early in the first stage of labor. Cardiotocographic monitoring showed that heat induces a significant increase in uterine activity without causing any abnormal fetal heart changes. The stimulated contractions return back to base line level following removal of heat. The application of heat on the abdominal wall of women in early labor appears to offer a new non-pharmacological modality for the stimulation of uterine activity.

Therapeutic use of PGA1 infusions in severe pre-eclampsia - a major clinical potential.

Pilot studies showed that, i.v. infusions of the renal prostaglandin A1 (PGA1) induced a triad of beneficial clinical responses in severe pre-eclampsia; the blood pressure became normotensive, renal function was markedly improved and labour was successfully induced. The present study was an attempt to develop a therapeutic schedule of PGA1 administration in severe toxemia. Twenty one cases of severe pre-eclampsia (in 3 equal groups) received i.v. infusions of PGA1 in a dose range of 0.1-0.5 microgram/kgm/min for 12 - 24 hours and the B.P., uterine activity and FHR were continuously monitored during and for 12 hours following the infusion period. The 0.1 microgram/Kgm/min dose for 12 hours was inadequate while 0.5 microgram/Kgm/min for 12 hours induced a good hypotensive response and the cases delivered within 48 hours but a post-infusion rebound in hypertension was observed. The dose of 0.5 microgram/Kgm/min for 24 hours appeared to be optimal in clinical terms since a satisfactory effect on B.P. was recorded and all the subjects delivered normal babies during the infusion period with minimal or no post-infusion rebound rise in B.P. This approach holds a major potential in the treatment of severe pre-eclampsia.

Uterine response to PGE2 with IUDs: a possible mechanism of action and side effect.

PIP: 10 healthy nonpregnant women aged 20 to 35 years with at least 2 children and normal regular menstrual cycles participated in this study which was conducted to determine the effects of IUDs on uterine activity and to study uterine response to PGE2 (prostaglandin E2) before and after IUD insertion. The women were recruited on days 2 to 3 of the cycle. Uterine activity was recorded in 3 sessions (proliferative phase; midcycle; secretory phase) during the control cycle. Spontaneous contractility patterns were recorded in all cases followed by local PGE2 administration in 7 cases. A plain Lippes Loop size C was inserted in the next cycle and uterine contractility recorded during the same phases and on same days following same experimental design as control cycle. The results show that Lippes loop size C causes an increase in spontaneous contractility of the nonpregnant uterus, depending on phase of the cycle studied. Changes were minimal in the proliferative phase (3 out 7 cases) and more common in the other phases (all cases in luteal and menstrual phases). Excessive or irregular bleeding and cramps may be traced to the general tendency towards hypermotility due to the presence of IUDs. The contraceptive action of IUDs may be partly attributed to the uterine hyperactivity observed in the early or mid-luteal phase after IUD insertion. Increased uterine sensitivity to local instillation of PGE2 at the proliferative and luteal phases was observed following IUD insertion. Post-insertional changes in basal motility was also attributed in part to the increased or altered uterine reactivity to PGs as a result of IUD insertion.^ieng

The protective influence of progestogen only contraception against vaginal moniliasis.

The incidence of Candida albicans (C.A.) infection of the vagina was evaluated in vaginal discharges obtained from 85 subjects using a large battery of culture media and confirmatory tests. Twenty women using DMPA 150 mg i.m. contraceptive injections for more than one year (long-term users) were compared with forty 2nd trimester pregnant cases with respect to vaginal candidiasis. The basis of comparison was the presence of amenorrhea and high hormonal levels in both groups. However, pregnant subjects showed a 60% prevalence while none of the DMPA cases had a positive culture or smear. Another group of 25 cases was similarly studied once before DMPA injection and again three months following drug administration (short-term use). The pre-therapy samples demonstrated a 32% incidence which was reduced to 8% after three months of use. It therefore appears that progestogen only contraceptives have the advantage of some protective influence against monilial vaginitis. Moreover, the use of these drugs may carry the beneficial potential of use in resistant cases of monilial vaginitis, either as a single approach or better as a supplementary procedure to known antifungal agents.

PIP: The incidence of vaginal moniliasis in women accepting Depo-Provera (DMPA) as a contraceptive method was determined, and differences in incidence between long- and short-term users were investigated. 85 reproductive age women were divided into 3 groups: 1) 40 second-trimester pregnant women; 2) 20 DMPA users for more than 1 year (long-term users); and 3) 25 women accepting DMPA for the 1st time. Among the 85 cases studied, moniliasis was recovered from the vaginal smears of 34 (40%). The highest occurrence was among Group 1, where out of the 40 cases, 24 (60%) had Candidia in their vaginal secretions. On the other hand, from the 25 Group 3 cases, Candida was recovered from 8 (32%) before administration of DMPA. 3 months later, Candida was only recovered from 2 (8%) of the same Group 3 subjects. This occurrence in the follow-up examination (8%) was significantly lower than the control sample before drug administration (Z=2.12). Apparently, incidence of moniliasis decreased with short-term DMPA use. None of the 20 long-term users had Candida in their vaginal secretions. Culture technique was superior to smear technique for determining Candida; all cases diagnosed by smear were culture positive, whereas smear positive cases in Groups 1 and 3 composed only 83.3% of culture positive cases in both groups.

Reduced uterine response to PGF2alpha under oral contraceptives.

The effect of prostaglandin F2alpha (PGF2alpha) on the nonpregnant human uterus was evaluated in 35 patients. The compound was administered both by intra-uterine and intravenous routes. Two groups of volunteers were studied;fifteen cases who were under oral contraceptives and twenty women with normal ovulatory cycles. The uterus under the influence of oral contraceptives showed a reduced response to local and systemic administration of PGF2alpha at all phases of the menstrual cycle. The implications of these findings in certain physiological and pathological conditions related to reproduction are discussed.

Aberrant uterine response to prostaglandin E2 as a possible etiologic factor in functional infertility.

The clinical entity of functional infertility still remains unexplained and largely lacking a line of proper management. The uterine response to prostaglandin E2 (PGE2) and prostaglandin F2alpha (administered by intravenous and intrauterine routes) was evaluated during different phases of the menstrual cycle in five functionally infertile women. The results (quantitative and qualitative) were compared with those elicited among 20 fertile women. There were no apparent differences between the two groups with respect to either compound (systemic or local) when given during the proliferative or luteal phase of the cycle. However, at midcycle, about the time of ovulation (days 13 to 18), there was a salient deviation in the type of response following local instillation of PGE2; in the normal fertile group there was a definite inhibition of motility, while uteri in the functionally infertile group showed marked stimulation. The possible role of this aberrant uterine response in the etiology of functional infertility is discussed.

The relaxant property of local prostaglandin E-2 on the non-pregnant uterus - a cyclic triphasic response.

The response of the non-pregnant human uterus to intravenous (i.v.) injections and intra-uterine instillation of various doses of prostaglandin E-2 (PGE-2) was evaluated at the different phases of the menstrual cycle in 13 fertile regularly menstruating women who were neither lactating nor using any hormonal therapy. Uterine contractility was recorded by the microballoon technique in at least three sessions(proliferative, mid-cycle and secretory) in a single cycle with endometrial biopsy performed immediately following the last session to ascertain that the particular cycle was an ovulatory one. Single i.v. injections of PGE-I had a consistent stimulatory effect on the contractility throughout the cycle with a tendency towards a decreased uterine response at mid-cycle and luteal phase as compared to the proliferative part of the cycle. Intra-uterine instillation of the compound induced a peculiar and interesting type of response. In the proliferative and secretory phases of the cycle the response was one of stimulation; being more pronounced in the former period. However, around ovulation time, the local administration induced an evident uterine relaxation in most cases without any instance of stimulation. The possible implication of this triphasic response behaviour on the non-pregnant uterus within certain physiological events and pathological conditions is discussed.