Anders Ölund

The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones.

In a prospective study, pelvic floor muscle strength was investigated pre‐ and post partum in 87 women with uncomplicated pregnancies. Those vaginally delivered were 71 primiparas, while 16 underwent an elective cesarean section. The objective was to evaluate the effect of the delivery procedure on the pelvic floor muscle strength with the aid of vaginal cones. In the group of women with vaginal delivery three subgroups were identified: episiotomy, spontaneous laceration and intact perineum. Pelvic floor muscle strength was weakest in the episiotomy subgroup, the difference in values between this subgroup and each of the other subgroups and the elective cesarean section group being significant. No significant difference was evident between the spontaneous lacerations and intact perineum subgroups.

Prostaglandins and thromboxanes in amniotic fluid during rivanol-induced abortion and labour

Abortion or delivery were induced by extra-amniotic instillation of Rivanol during the second trimester in twelve patients and during the third trimester in two patients with fetal death and one patient with fetal acrania. Serial sampling of amniotic fluid was performed through a transabdominal catheter and the levels of free arachidonic acid (AA), prostaglandin F2 alpha (PGF2 alpha), prostaglandin E2 (PGE2), 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha) and thromboxane B2 (TXB2) were determined. The levels of AA, PGF2 alpha, PGE2, 6-keto-PGF1 alpha and TXB2 in amniotic fluid increased significantly during induction with the exception of AA in fetal death which was high and remained constant during induction. Furthermore, PGF2 alpha, 6-keto-PGF1 alpha and TXB2 were all significantly correlated to AA. These observations suggested that free AA is released during Rivanol-induction of abortion and labour giving an increased synthesis of PGF2 alpha, PGE2 prostacyclin and thromboxane A2 in the fetal membranes and the decidua but not in the fetus. This increase might be relevant for the initiation and progress of abortion and labour in these patients.

Bacterial Vaginosis Is Not a Simple Ecological Disorder

Eighty-four patients with bacterial vaginosis were examined in an open randomized trial, the aim of which was to define clinical results and the microbiological panorama after topical treatment for 1 week with either an acetic acid jelly (A), an estrogen cream (B), a fermented milk product (C) or metronidazole (D). After exclusion because of chlamydia infection (15 cases) or for other reasons, 61 cases remained for complete evaluation 4 weeks after the start of treatment. Clinical cure was obtained in 3 cases out of 17 on regimen A, in 1 out of 16 on regimen B, in 1 of 14 on regimen C, and in 13 out of 14 on regimen D. The patients were conclusively either symptomless or symptomatic when examined on 113 occasions. Statistically significant reduction after treatment resulting in relief of symptoms was observed in the numbers of corynebacteria and anaerobic cocci, whereas lactobacilli increased in numbers. The instillation of high numbers of Lactobacillus acidophilus (C) into the vagina cured only 1 patient and did not influence the predominance of lactobacilli in the vagina at the follow-up examination. The difference in microbiological profile of women in symptomatic and asymptomatic conditions becomes still more apparent when the results of the present and previously published studies on the subject by the present group of investigators are combined. The symptomatic woman is significantly more often harboring corynebacteria, Gardnerella vaginalis, peptostreptococci, peptococci, eubacteria and Bacteroides species. Lactobacilli are significantly reduced in numbers. However, only 51 % of our previously symptomatic, but now symptomless women show predominant growth of lactobacilli, which is less than expected for healthy women. Therefore, lactobacilli may not be the specific factor that protects against bacterial vaginosis.

The effect of cervical dilatation by laminaria on the plasma levels of 15-keto-13,14-dihydro-PGF2α

Laminaria tents were inserted to induce cervical dilatation prior to suction abortion in 42 primigravidae. The plasma level of 15-keto-13,14-dihydro-PGF2 alpha, the principal metabolite of prostaglandin F 2 alpha, increased during the dilatation period. The gentle dilatation by laminaria tents probably induces an endogenous synthesis of prostaglandins causing a softening of the cervix.

The use of episiotomy in primiparas in Sweden: A descriptive study with particular focus on two hospitals

This study has examined the use of episiotomy (Ep) in primiparas on all labor wards (65) in Sweden, focusing on two hospitals in particular. The information was obtained by means of a questionnaire and from original medical records at the two hospitals. Whereas the mean incidence of Ep for the whole country was 30%, we found a wide variation (9–77%) from hospital to hospital. When delivery positions were compared, the lowest Ep rate was reported from those hospitals where women frequently used “alternative positions”. The results suggest that efforts should be directed to a more restrictive use of Ep in normal delivery.

Termination of early human pregnancy with Epostane

Fifty-six healthy women, with a gestational length of less than 49 days from the last menstrual period, who requested termination of pregnancy were treated with Epostane, a progesterone synthesis inhibitor. Epostane, which competitively inhibits the 3 beta-hydroxy steroid dehydrogenase enzyme system, was given in the dose 200 mg X 4 for seven days. Physical examination, routine laboratory screening and determination of hCG, progesterone, estradiol and cortisol was performed on days 0, 7 and 14. The treatment resulted in 84% complete abortions (90% among women completing therapy). Two women experienced vaginal bleeding only, while 7 were non-responders. Among subjective side effects nausea dominated totally and was also the reason for discontinuation in 4 cases. The average length of bleeding among women with complete abortions was 10.7 days and the decrease in hemoglobin and hematocrit was very slight. Routine laboratory values remained within the normal range. Cortisol levels were elevated on day 7 compared to days 0 and 14, but all single values were within the normal limits.

Reproductive hormones during termination of early pregnancy with mifepristone.

Thirteen women received a single oral dose of 600 mg mifepristone (RU486; Roussel-Uclaf, Paris, France) on day 0 to induce first-trimester abortion. Eleven women had a complete abortion, and 2 had a continuing pregnancy and were considered as failures. Plasma levels of human chorionic gonadotropin (hCG) increased from day 0 in all women, but dropped sharply after day 3 in women with successfully induced abortion. In these women, the levels of progesterone, 17 alpha-hydroxyprogesterone and estradiol-17 beta increased from day 0 to day 1 and then dropped. In the 2 failed inductions, the steroid levels remained virtually unchanged. In the complete abortions, the main prostaglandin F2 alpha metabolite, 15-keto-13,14-dihydro-PGF2 alpha, increased to a significant peak at day 6 followed by a significant fall to day 14. These findings supports a direct effect of mifepristone on the decidua, initiating prostaglandin synthesis. It is also suggested that there is a luteolytic effect of prostaglandin F2 alpha, as the levels of corpus luteum steroids started to fall before the drop in hCG.

Does the Hygroscopic Property of the Laminaria Tent Imply a Risk for Ascending Infection in Legal Abortions?: A microbiological study

In 53 women admitted for first‐trimester abortion, the cervical canal was dilated with laminaria tents prior to vacuum aspiration. Before insertion of the tents, endocervical specimens were taken for microbiological investigations, including Chlamydia trachomatis, and both aerobic and anaerobic microorganisms. The laminaria tents, widened by their hygroscopic properties, were removed just before the vacuum aspiration and sent for cultivation of aerobic and anaerobic microorganisms. The Grampositive aerobic cocci, Staph. epidermidis, Strept. faecalis and Strept. agalactiae as well as Escherichia coli and Klebsiella/Enterobacter were the most frequent microorganism among the aerobic isolates from the endocervices as well as from the laminaria tents. These microorganisms were identified on the tents in greater numbers than in the cervices. Staph. aureus was isolated from three laminaria tents, but only one of these 3 women was proved to be primarily colonized endocervically. Among the anaerobes, Bacteroidaceae followed by peptococci and peptostreptococci were the predominant genera found in the cervix as well as on the removed laminaria tents. These three groups of anaerobic microorganisms were found markedly less frequently on the laminaria tents than in the endocervix. On the other hand, Strept. intermedius, another anaerobe of possible enteric origin, was recovered from 9 laminaria tents but not in the cervices. Since no cases of clinically verified endometritis/salpingitis were registered in the present study it is concluded that the risk of a pelvic inflammatory disease (PID) due to the laminaria tent is negligible as long as the laminaria treatment does not exceed 24 hours.

Infiltration of morphine into an abdominal wound; effects on pain relief and endocrine/immune response

&NA; We wanted to evaluate pain relief and endocrine /immune response after local administration of morphine into an abdominal wound. In a randomised double blind design 29 patients undergoing hysterectomy received two blinded injections of morphine and saline. Before surgery the patients in the control group (n=15) got 10 mg of subcutaneous morphine into an arm and at skin incision 30 ml of saline was infiltrated directly into the wound. The patients in the wound group (n=14) received 1 ml of saline into an arm before surgery and 10 mg of morphine in 30 ml of saline into the wound at skin incision. Patient controlled analgesia (PCA) with i.v. morphine was used after surgery. Repeated blood samples were obtained from the day before the surgery until 3 days later and analysed for cortisol and interleukin‐6 (IL‐6). There were no differences between the groups either in pain relief or in the consumption of PCA morphine. The wound group used 47±15 mg of i.v. morphine and the control group used 50±16 mg. Peak values for IL‐6 and cortisol appeared at 4 h. The area under the curve (AUC) of cortisol at 0–6, 0–10 and 0–20 h was significantly lower in the control group than in the wound group (P<0.05). High doses of i.v. morphine reduced cortisol and IL‐6 levels in the early hours after surgery. The injection of morphine into the wound did not improve pain relief or reduce the consumption of i.v. morphine after surgery. The endocrine stress response to trauma was modified by preoperative administration of morphine.

The effect of indomethacin on the instillation‐abortion interval in rivanol‐induced mid‐trimester abortion

During 1975-1977, 20 women undergoing mid-trimester (mean 16.1 weeks) abortions induced by Rivanol were treated with oral doses of 50 mg indomethacin every 6 hours starting immediately prior to the instillation of Rivanol. A group of 55 women undergoing Rivanol abortions (mean gestational age 15.6 weeks) during the same period acted as a control. It was found that administration of indomethacin, a strong inhibitor of prostaglandin synthesis, prolonged the induction-abortion interval significantly from a mean of 32.3 hours in the control group to a mean of 46.9 hours in the indomethacin group. This result adds support to the theory that the mechanism by which Rivanol induces abortion involves the stimulation of the endogenous production of prostaglandins. Extra-amniotic instillation of Rivanol for the induction of mid-trimester abortion is a safe and effective method and its clinical value has been described in several reports (for ref. see (5)). The mechanism by which Rivanol induces abortion is, however, still obscure. It has been proposed that hypertonic saline induces abortion by stimulating the release of endogenous PGF2a (1). The fact that prostaglandin synthetase inhibitors prolong the inductionabortion interval in saline-induced abortion lends further support to this theory (4). The purpose of the present study was to examine possible effects of indomethacin, a strong prostaglandin synthetase inhibitor, on mid-trimester abortion induced by Rivanol.