Antonio Bugalho

A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique

Objective To evaluate the outcome of caesarean delivery performed by assistant medical officers and specialists in obstetrics and gynaecology with particular attention to post‐operative complications.

The Effectiveness of Intravaginal Misoprostol (Cytotec) in Inducing Abortion after Eleven Weeks of Pregnancy

At Maputo Central Hospital in Mozambique, intravaginal misoprostol, a PGE2 methyl-analogue, was used by 169 women whose request for interruption of pregnancy had been approved. The drug was used by women who had completed between 12 and 23 weeks of gestation. The initial dose was 800 micrograms, repeated 24 hours later if abortion had not occurred or was not in progress. The treatment was considered a failure when abortion was not advanced by 48 hours after the initial dose, and curettage was performed in all but one of such cases. During the course of the study, the dosage was successively reduced to 600, 400, and 200 micrograms. Abortion was successfully induced in 154 women (91.1 percent); there were 10 failures (5.9 percent), and five women (3.0 percent) dropped out of the study. The mean time from initial dose to abortion was 14.3 hours. No significant association of success rate and time from dosage to expulsion was found with age, parity, previous abortion, or gestational age. Preventive vacuum aspiration of the uterine cavity was carried out on all subjects.

Induction of labor with intravaginal misoprostol in intrauterine fetal death

OBJECTIVE Our purpose was to evaluate the effectiveness and safety of intravaginal misoprostol for the induction of labor in intrauterine fetal death. STUDY DESIGN Seventy-two women at 18 to 40 weeks of pregnancy with intrauterine fetal death, without abdominal scars, were treated with 100 micrograms of intravaginal misoprostol. The dose was repeated every 12 hours until effective uterine contractions and cervical dilatation were obtained, for up to 48 hours. RESULTS The mean time from induction to delivery was 12.6 hours, and only six patients (8%) required between 24 and 48 hours, at the end of which all patients had been delivered. Only the Bishops score was significantly associated with time from first dose to expulsion. No surgical procedure was required. Hypercontractility, sweating, fever, diarrhea, or other gastrointestinal effects were not detected. There was no need for analgesics. CONCLUSIONS Intravaginal misoprostol at the dose of 100 micrograms every 12 hours appears to be a safe, effective, practical, and inexpensive new method for induction of labor in intrauterine fetal death.

Misoprostol for prevention of postpartum hemorrhage.

Objective: To compare the effectiveness of 400 μg rectal misoprostol in 5 cm3 of saline with oxytocin 10 IU, i.m., in reducing bleeding during the third stage of labor. Design: A double blind, randomized, clinical trial including 663 women with uncomplicated vaginal delivery who received misoprostol (n=324) or oxytocin (n=339). Main outcome measures: Changes in hemoglobin and hematocrit from before to 72 h postpartum; blood loss during the third stage; duration of the third stage of labor; need for additional oxytocic drug; frequency of requisition and of administration of blood; changes in blood pressure; and occurrence of side effects. Results: No significant differences were observed between groups, before and 72 h postpartum, in mean hemoglobin and hematocrit, on volume of blood loss and duration of third stage of labor. The incidence of shivering and mean temperature (P<0.01) was significantly greater among women receiving misoprostol than oxytocin. Conclusions: Misoprostol administered as a micro‐enema, 400 μg in 5 ml of saline during the third stage of labor, appears to be as effective as oxytocin 10 IU, i.m., but misoprostol produced more side effects than oxytocin.

Outcome of teenage pregnancy in Maputo, Mozambique

OBJECTIVE: To evaluate the perinatal outcome of teenage pregnancies in comparison with a population of older, high‐risk women. METHOD: Data about 15 207 high‐risk women delivered during 1989 at the Central Hospital of Maputo, Mozambique, were collected retrospectively from the clinical records. Of these women 2185 were less than 19 years old. Frequencies were compared through the χ2‐test or, when required, Fishers exact test. Odds ratios and 95% confidence intervals were computed. RESULT: Frequency of operative vaginal deliveries (forceps and/or vacuum extraction), cesarean section rate and low birth rate were significantly higher among women under 19 than in the older ones. Also, maternal mortality and stillbirth rates were greater among teenagers, although the differences were not statistically significant. CONCLUSION: Among the selected, high‐risk hospital population of a developing country young maternal age, both by itself and in association with other risk factors, represents an important predictor of adverse perinatal outcome for mothers and babies. Implications for family planning and reproductive education programs are discussed.

Pregnancy Interruption by Vaginal Misoprostol

A total of 132 pregnant women with average gestational age of 14.2 weeks (range 11-22 weeks) undergoing legal abortion volunteered for a trial utilizing vaginal administration of misoprostol. In 106 women a dose of 800 micrograms was utilized, whilst in 26 women 1,200-1,600 micrograms were given. Nonsurgical expulsion of the fetus was successful in 117 cases (88.6%). Four cases had to be excluded for various social reasons. A total of 11 did not achieve fetal expulsion within 56 h after application of misoprostol. These cases (11/132; 8.3%) were considered failures. Previous reports in the literature of toxicity trials on animals reporting no fetotoxic nor teratogenic effects of misoprostol at doses up to 10,000 micrograms/kg body weight seem to be of no validity in the human since we could demonstrate that almost 80% of pregnancies were interrupted at a dose of 10-15 micrograms/kg body weight. The conclusion is that vaginal administration of this prostaglandin analogue, not requiring cool temperature for storage, is remarkably effective in achieving safe interruption of pregnancy without any significant complications.

Vaginal misoprostol as an alternative to oxytocin for induction of labor in women with late fetal death

Background. Induction of labor in women with late fetal death is often difficult in settings with scarce resources. The purpose of this study was to assess the value of vaginal misoprostol for induction of labor in women with such fetal death.

Prevalence of syphilis infection in Mozambican women with second trimester miscarriage and women attending antenatal care in second trimester.

OBJECTIVES--To elucidate whether recent syphilis infection is significantly more prevalent among women with mid-trimester miscarriage than among antenatal care attenders in midtrimester pregnancy. DESIGN--Two categories of pregnant women were compared regarding serological signs of syphilis. Rapid Plasma Reagin (RPR) analyses were done in Mozambique and Veneral Disease Research Laboratory (VDRL) tests in Sweden. In case of RPR and/or VDRL positivity, Treponema pallidum haemagglutination (TPHA) and Captia Syphilis-M were performed. SETTING--A suburban antenatal care clinic and the emergency ward at the Department of Obstetrics and Gynecology at the Central Hospital in Maputo, Mozambique, were studied June-August 1991. SUBJECTS--Randomly selected women seeking antenatal care in midtrimester pregnancy (N = 202) were compared with 114 women consecutively entering with clinical signs of midtrimester miscarriage. RESULTS--Among antenatal care attenders, 37/202 (18.3%), and among women with midtrimester miscarriage, 37/114 (32.5%), had syphilis confirmed with the Treponema pallidum haemagglutination test (p < 0.01). Significant titres of IgM antibodies tended to be more prevalent among women with miscarriage (7.0%) than among women attending antenatal care (4.5%), though the difference only approached statistical significance. CONCLUSION--The findings suggest a potential association between syphilis seropositivity and midtrimester miscarriage. Present findings justify more extensive studies to establish whether or not recent syphilis infection is a risk factor for midtrimester miscarriage.

Low-dose vaginal misoprostol for induction of labor with a live fetus

Objective: To test the effectiveness and safety of low‐dose vaginal misoprostol for induction of labor with a live fetus. Methods: Labor was induced in 666 pregnant women with a live fetus in the cephalic position, who had no medical complications and no history of uterine surgery. One‐fourth of a 200‐μg tablet of misoprostol (50 μg) was placed in the posterior vaginal fornix every 12 h for a maximum of four doses or until active labor commenced. Time from induction to delivery, side effects and neonatal outcome were evaluated. Results: Labor was successfully induced in all cases. The mean time from induction to delivery was 10.4 h. The cesarean section rate was 7.8%. There were eight perinatal deaths, six of which occurred in low birth weight fetuses. There was one case of abruptio placenta, which was less than that expected in the study population. Conclusion: Vaginal misoprostol, in very low doses, was a remarkably efficient and safe method for induction of labor with a live fetus.

Labor induction by vaginal misoprostol in grand multiparous women

BACKGROUND Grand multiparous women in poor and under-privileged settings run a high risk of uterine rupture at labor induction. The purpose was to elucidate whether vaginal misoprostol medication is a safe and cost-effective alternative induction method in grand multiparous women, in whom, under prevailing circumstances, induction by oxytocin is associated with high risk of adverse maternal outcome of pregnancy. METHOD One hundred and sixty-five grand multiparous parturient women with five or more previous deliveries were divided into two groups. The first group (n=134) had the fetus alive and the second (n=31) had late intrauterine fetal death. Both groups were subject to induction of labor by use of vaginal misoprostol in a dose of 50 microg (live fetus) and 100 microg (intrauterine fetal death). No additional oxytocin was utilised. RESULTS Labor induction by vaginal misoprostol was successful in grand multiparous women. The proportion of women requiring a Cesarean section was 6.0%, which is less than one third of the average Cesarean section rate in the setting studied. Women with fetus alive had significantly shorter application-to-expulsion interval (AEI) than women with fetal death (10.1 versus 15.4 hours; p=0.039). Significantly shorter AEI was recorded in women with prelabor rupture of membranes (9.1 hours) than in women with intact membranes (12.9 hours) (p=0.01). With Bishops score > or = 5 and < 5 AEI was 8.7 hours and 14.4 hours, respectively (p=0.001). No significantly adverse neonatal or maternal outcomes of pregnancy were registered and it was specifically noted that no uterine rupture occurred among the 165 grand multiparous women induced. CONCLUSIONS Induction of under-privileged grand multiparous women with live fetus or with fetal death can be performed safely and cost-effectively by vaginal misoprostol.