Mifepristone combined with ethacridine lactate for third-trimester stillbirth induction: a 5-year experience from Shanghai.

OBJECTIVE: To review and analyze the efficacy and safety of mifepristone combined with ethacridine lactate for induction of stillbirth in the third trimester. METHODS: All patients with stillbirth in late pregnancy (≥ 28 weeks) in a university-affiliated maternity center from October 2016 to September 2021 were included in this study. After exclusion, patients were divided into ethacridine lactate and non-ethacridine lactate groups according to induction methods. Logistic regression was conducted to identify the risks of complications. RESULTS: We identified 122 patients that experienced stillbirth (5' Apgar score = 0) in third-trimester from the 5-year total deliveries in the hospital, among whom 39 stillbirths that resulted from termination of pregnancy for severe fetal anomalies and 1 stillbirth that was in twin pregnancy were excluded. Thus, 82 cases with stillbirths (dead before induction) were included in the analyses. In the 82 cases, 49 (59.76%) accepted intra-amniotic ethacridine lactate induction with 47 (95.92%, 47/49) successfully induced. No statistical difference was observed in induction failure rate between ethacridine dosage groups of < 75mg and ≥ 75mg (0/25, vs. 2/24, respectively; P > 0.05). The ethacridine lactate induction group showed no increased risks in complications (6.12%, 3/49), compared with non-ethacridine lactate group (12.12%, 4/33) (P = 0.35, OR, 0.47, 95%CI, 0.10 to 2.27). CONCLUSION: Mifepristone combined with ethacridine lactate is a safe and low-risk induction method for patients with stillbirth in the third trimester.

Influence of topically applied antimicrobial agents on muscular microcirculation.

Bacterial infections cause major complications in wound healing. Local antiseptics are used for daily wound care; however, their potential toxic effects on the vasculature have not yet been thoroughly investigated. The aim of this study was to assess the effects of antiseptics on microcirculation. Investigations were performed on a standardized cremaster muscle model on rats (n = 60). The arteriolar diameter and functional capillary density (FCD) were investigated using transillumination microscopy before and 60 and 120 minutes after application of each of the following antimicrobial agents: alcohol, hydrogen peroxide, imipenem, octenidine dihydrochloride, polyhexanide, and ethacridine lactate. Although polyhexanide caused a significant arteriolar dilatation (106.25 ± 3.23 vs. 88.54 ± 6.74 µm [baseline value]) and increase of FCD compared with baseline value (12.65 ± 0.82 vs. 9.10 ± 0.50 n/0.22 mm), alcohol led to a significant decrease of both parameters (90.63 ± 10.80 vs. 52.09 ± 7.69 and 5.35 ± 0.54 vs. 1.68 ± 0.48) and was the only agent that caused arteriolar thrombosis. The FCD also increased significantly after treatment with hydrogen peroxide (10.55 ± 0.33 vs. 12.30 ± 0.48) and octenidine (6.82 ± 0.63 vs. 12.32 ± 0.63). However, no positive effect on arteriolar diameter could be found. Ethacridine lactate and imipenem did not impact either parameter. In addition to reducing bacteria, an antiseptic should be nontoxic, especially to the microcirculation. Polyhexanide seems to have a positive influence on vessel diameter and capillary density, whereas alcohol reduces both parameters. If the antimicrobial efficacy is comparable, the antiseptic with less toxic effects should be chosen, especially in critically perfused wounds.

Misoprostol preferable to ethacridine lactate for abortions at 13-20 weeks of pregnancy: Cuban experience.

Outdated second trimester abortion methods are still being used in some countries, and very few studies have compared them to currently recommended methods. To this end, we studied the efficacy and safety of vaginal misoprostol used alone for abortions in 189 women at 13-20 weeks gestation, in 2004-2006. We also retrospectively collated similar data from an historical cohort of 189 women drawn consecutively and chronologically from hospital records from 2003-2006, also at 13-20 weeks gestation, who had had abortions with a combination of extra-amniotic 0.1% ethacridine lactate solution, oxytocin and sharp curettage. At 24 hours, misoprostol was 92.6% effective in inducing abortion versus 76.2% with the ethacridine lactate regimen (OR 4.2, 95% CI 2.3-8.0). The misoprostol cohort experienced fewer complications than the ethacridine cohort (4 vs. 38 cases, OR 0.086, 95% CI 0.03-0.23). We conclude that in the absence of mifepristone, misoprostol alone is preferable to the ethacridine regimen for the termination of pregnancy in the second trimester, because it works faster, has a higher success rate in a shorter period of time, and fewer complications.

Silent rupture of unscarred uterus: an unusual presentation at second trimester abortion.

Rupture of unscarred uterus during the second trimester is rare. A case of ruptured uterus in a multiparous woman is presented. To our knowledge, this might be the first reported case in the English literature of uterine rupture during second trimester termination of pregnancy using ethacridine lactate. This case is also rare as uterine rupture is presented with an insidious course rather than acute, thus delaying the diagnosis.

Bacterial contamination of commercially available ethacridine lactate (acrinol) products.

Bacterial contamination of commercially available ethacridine lactate (acrinol) solutions and cotton gauze soaked in ethacridine lactate solution was investigated. Of 56 samples from ethacridine lactate solutions (eight products, seven manufacturers), seven samples (12.5%) of two products (two manufacturers) were contaminated with 10(1)-10(4) colony forming units (cfu)/mL of Burkholderia pickettii. Of 67 samples obtained from gauze soaked in ethacridine lactate solution (seven products, seven manufacturers), 41 (61.2%) of six products (six manufacturers) were contaminated with 10(2)-10(6) cfu/mL of bacteria. The major bacteria detected were Burkholderia cepacia and Burkholderia pickettii. This relatively high incidence of bacterial contamination in commercially available cotton gauze soaked in ethacridine lactate solution may be due to the presence of gauze in ethacridine lactate solution.

Microbiological studies in mid-trimester abortion with Emcredil versus normal saline.

In 40 mid-trimester abortion seekers, in whom abortion was induced by extra-amniotic normal saline or Emcredil, microbiological studies were carried out before induction and at 24 hours. It was observed that there was no difference in the isolation of organisms from vagina and cervix of these subjects between 0 hours and 24 hours. Thus, this study shows that leaving the catheter in the extra-amniotic space until it is expelled spontaneously does not increase the risk of ascending infection. At the same time, leaving the catheter in-situ until it is expelled spontaneously reduces the induction-abortion interval appreciably.

PIP: This study examined the microbiological flora before the insertion of a catheter into the extra-amniotic space for induction of mid-trimester abortion. A total of 40 subjects were included in the study. Subjects were divided into two groups. In the first group, abortion was induced by extra-amniotic instillation of 150 ml of 0.1% Emcredil, while group II was given 150 ml of normal saline. A success rate of 90% was reported in both study groups with no complications. The mean induction-to-abortion interval was 18.43 hours in Group I and 18.53 hours in Group II. The interval between expulsion of the catheter and the products of conception ranged from 15 minutes to 4 hours (average, 1 hour). Mycoplasma was found in 20% and 25% of subjects in Group I and Group II, respectively. In both study groups, about 70-75% of subjects showed presence of ureaplasma. It was concluded that there were no significant differences in the genital tract flora. In addition, there is no increase in risk of infection if the catheter is left in-situ until expelled spontaneously.

Mid-trimester pregnancy termination with ethacridine lactate.

PIP: A study was conducted in Kamla Raja Hospital, G.R. Medical College, Gwalior, India to evaluate the efficacy of 1% ethacridine lactate and to compare the results with 20% hypertonic saline as abortifacients in midtrimester abortions. The abortions were performed using 1% ethacridine lactate in 65 patients with pregnancies between 12-20 weeks (group A). The patients were admitted to the hospital 1 day before the abortion. In a 2nd group of 65 patients (group B,), the abortion was done using 20% hypertonic saline. In this group oxytocin also was used as it had been with group A patients if the abortion did not occur with 24 hours. The mean induction abortion interval was lower with ethacridine lactate (37.82 hours) than with hypertonic saline (44.40 hours). This interval continued decreasing as the pregnancy advanced -- 12-14 weeks, 42.45 hours; 15-16 weeks, 36.05 hours; 17-20 weeks, 34.96 hours. In the hypertonic saline series, the induction abortion interval continued increasing as the pregnancy advanced -- 12-14 weeks, 44.30 hours; 15-16 weeks, 45.68 hours; and 17-20 weeks, 45.61 hours. With ethacridine lactate the abortion rate (24.62%) was significantly higher within the first 24 hours than with saline (9.23%), although the overall success rate was more with saline (96.92%) than with ethacridine lactate (90.77%). If reinstillation cases were included, the success rate with ethacridine lactate (95.39%) became almost similar to that of hypertonic saline. The complete expulsion rate with ethacridine lactate was only 35.38%, but it was 66.48% with hypertonic saline. The incidence of various side effects, such as headache, rigor, and vomiting, was more with hypertonic saline than with ethacridine lactate. Another advantage of ethacridine lactate was the fact that it can be used safely in patients with cardiovascular and renal diseases. The changes in the maternal coagulation system following intra-amniotic instillation of hyptonic saline, considered to be almost universal, were never encountered in ethacridine lactate induced abortions. Simplicity of technique and equipment required to perform ethacridine lactate instillation is a significant asset for India. Dangers of amniocentesis-like accidental injury to bowel and bladder are never encountered with ethacridine lactate instillation.^ieng

Termination of midtrimester pregnancies with extraovular 0.1% ethacridine lactate. Accurate method for estimation of blood loss. Role of spartein sulfate.

PIP: This study evaluated the effectiveness of extraovular .1% ethacridine lactate alone and edacridine lactate plus spartein sulfate in midtrimester pregnancy termination. In the 60 cases where ethacridine lactate alone was administered, 50 cases aborted within 48 hours of instillation (83.3% success rate). Of these 50, 25 aborted within 24 hours (41.7%). Abortion was complete in 45 cases. The time of onset of uterine contractions ranged from 1 hour to 16.5 hours, with a mean 21-1/4 hours. The mean time of membrane rupture in the series was 23 hours and the induction-abortion interval averaged 27-1/4 hours. Side effects included vomiting (18.3%), shivering (16.6%), fever (3.3%), cervical injuries (6.6%), and excessive blood loss (1.7%). Blood loss until expulsion of the fetus averaged 54.1 ml, and blood loss up to 4 hours after abortion averaged 115.1 ml in cases of complete abortion and 219 ml in cases of incomplete abortion. In the 90 cases where both ethacridine lactate and spartein sulfate were used, 76 aborted within 48 hours (success rate 84.6%) and 40 aborted within 24 hours (44.4%). Abortion was complete in 75% of cases. The abortion-induction interval ranged from 4 hours to 47-3/4 hours, with a mean of 28-1/2 hours. These results, which are comparable to those obtained in other studies, indicate that extraovular ethacridine lactate alone appears to be a safe, efficient, and relatively inexpensive method of midtrimester abortion. Although there were fewer reports of side effects in the group that received spartein sulfate, use of this compound does not reduce the induction-abortion interval. The relatively low incidence of side effects such as vomiting and diarrhea, the antiseptic properties of ethacridine lactate, and the absence of serious complications such as rupture of the uterus and cervicovaginal fistula are advantages of the ethacridine lactate method that nullify the disadvantage of its slightly prolonged induction-abortion interval.^ieng

Intraamniotic injection of ethacridine for second-trimester induction of labor.

In the People's Republic of China one of the most widely used methods of second-trimester abortion is the intraamniotic injection of ethacridine (Rivanol). Intraamniotic ethacridine produces fetal death, a fall in maternal urinary estriol excretion, and a rise in prostaglandin levels. Although the induction time is longer than that usually seen with prostaglandins, the method is not ordinarily associated with vomiting, cervical injury, or the delivery of a live fetus. In a series of 10,302 cases, the success rate was 96.4% and the incidence of associated complications was low.

Abortion during mid-pregnancy by rivanol-catheter supplemented with PGF2 alpha drip-infusion or quinine hydrocholoride.

Abortion during mid-pregnancy was performed in 200 patients by extra-amniotic insertion of Nelaton catheters and instillation of 0.1% rivanol solution. To shorten the abortion time, quinine hydrochloride was given orally in one group (n=100), and intravenous infusion of prostaglandin F2 alpha (PGF2 alpha) was undertaken in the other group (n=100). The abortion rate after 72 hours was higher in the PGF2 alpha group (96%) than that in the quinine group (91%), but the difference was not statistically significant. The abortion time was significantly shorter in the PGF2 alpha group than in the quinine group (p less than 0.01). This method, together with supplementary treatment with oxytocic substances, proved to be an effective mid-pregnancy abortion method. The risks of endometritis, gastro-intestinal complications, and/or heavy bleeding either during or post-abortive were minimal.

Comparison of extra-amniotic instillation of rivanol and PGF2alpha either separately or in combination followed by oxytocin for second trimester abortion.

Second trimester abortion was induced in 92 women by extra-amniotic instillation of Rivanol and/or PGF2alpha followed by intravenous oxytocin after 24 hours. All instillations were made via a catheter with a balloon filled with 30 ml and left in place until abortion, but never for more than 24 hours. Induction was started by Rivanol alone (n = 23), PGF2alpha alone (n = 23), Rivanol combined with PGF2alpha (n = 23), or Rivanol combined with half dose PGF2alpha (n = 23) and the patients were allotted to the different groups in a random manner. The Rivanol solution was instilled as a single dose but PGF2alpha was instilled every 2nd hour for 24 hours. The mean induction-abortion time was similar in all 4 groups but a number of patients given PGF2alpha alone or in combination with Rivanol aborted earlier than patients induced by Rivanol alone, during the period before intravenous oxytocin was administered. Gastrointestinal side effects were equally common after Rivanol as after PGF2alpha. With the methods and doses used in the present investigation PGF2alpha alone or combined with Rivanol with subsequent oxytocin had no over-all advantage over Rivanol.

PIP: Groups of 23 patients in second trimester pregnancy were given either Rivanol, prostaglandin F2a (PGF2a), Rivanol plus PGF2a, or Rivanol plus 1/2 the dose of PGF2a instilled in the previous group. Medication was instilled via catheter into the extraovular space of the internal cervical orifice. There were no significant differences between groups with respect to cumulative abortion rate, mean abortion time, or side effects. It is concluded that PGF2a does not have a significant advantage over Rivanol for induction of abortion.

[The advantages of the extra-amniotic transcervical instillation of rivanol in therapeutic abortions (author's transl)]. / Vorzüge der transzervikalen extraamnialen Rivanol-Instillation bei der Interruptio.

Our experience with the transcervical extra-amniotic instillation of 70 ml 0.1% Rivanol solution in 154 cases of first trimestre, second trimestre abortions and intra-uterine fetal deaths is reported. This simple and safe method has several advantages which render it suitable for out-patient usage should the rate of therapeutic abortions increase even more. The gentle dilatatory effect on the cervix is remarkable and is noticeable after 24 hours. Dilatation with the Hegar-dilators becomes unnecessary. There were no major complications. The stress on the patient is minimized.