Donna Hutchens

Transvaginal ultrasound and digital examination in predicting successful labor induction

OBJECTIVE To compare transvaginal ultrasound and digital cervical examination in predicting successful induction in post‐term pregnancy. METHODS Transvaginal ultrasound and digital vaginal examinations were performed on 122 women at 41 or more weeks gestation, immediately before labor induction. Ultrasound assessments of cervical length, dilatation, and presence of funneling were compared with the components of the Bishop score. The primary outcome was the rate of vaginal delivery. Secondary outcomes assessed included the rates of active labor in 12 hours, vaginal delivery in 12 and 24 hours, mean duration of latent phase, and induction to vaginal delivery interval. Linear and multiple logistic regression models were generated to identify factors independently associated with successful induction. RESULTS No ultrasound characteristic predicted primary or secondary outcomes. Bishop score (odds ratio [OR] 2.98, 95% confidence interval [CI] 1.71, 5.20), cervical position (OR 4.35, 95% CI 1.41, 12.50), and maternal age (OR 1.15, 95% CI 1.01, 1.30) independently predicted vaginal delivery. Maternal weight (OR 0.96, 95% CI 0.94, 0.98), cervical dilatation (OR 6.08, 95% CI 1.70, 21.68), and effacement (OR 2.34, 95% CI 1.16, 4.73) independently predicted active labor in 12 hours. Independent predictors of vaginal delivery in 12 hours were induction method (P < .001), cervical dilatation (OR 11.16, 95% CI 3.17, 39.29), gravidity (OR 2.06, 95% CI 1.13, 3.77), and maternal weight (OR 0.96, 95% CI 0.93, 0.99). Cervical effacement (OR 2.70, 95% CI 1.59, 4.57) and parity (OR 7.10, 95% CI 2.22, 22.72) independently predicted vaginal delivery in 24 hours. Maternal weight, cervical position, and cervical dilatation were independently associated with latent phase labor duration. Factors independently associated with length of induction to delivery interval were parity, cervical effacement, and maternal weight. CONCLUSION Transvaginal ultrasound does not predict successful labor induction in post‐term pregnancy as well as digital cervical examination.

A double-blind placebo controlled randomised trial of misoprostol and oxytocin in the management of the third stage of labour.

Objective To compare oral misoprostol 400 μg with intramuscular oxytocin 10 IU in the routine management of the third stage.

Oral misoprostol for premature rupture of membranes at term

OBJECTIVEnThe study was undertaken to compare the efficacy, safety, and maternal satisfaction of oral misoprostol and intravenous oxytocin for labor induction in women with premature rupture of membranes at term.nnnSTUDY DESIGNnOne hundred five women were stratified by parity and randomly assigned to oral misoprostol 75 microg every 4 hours as needed to establish labor or to intravenous oxytocin.nnnRESULTSnThe induction to vaginal delivery time with oral misoprostol was 737 (+/-426) minutes compared with 573 (+/-318) minutes with oxytocin (P=.04). The incidence of hyperstimulation was lower in the misoprostol group (6.0% vs 27.1%, P=.005). Women were more likely to be very satisfied with their care in the misoprostol group (86.0% vs 63.4%, P=.02).nnnCONCLUSIONnIn women at term with premature rupture of membranes, oral misoprostol resulted in a longer induction to vaginal delivery interval but increased maternal satisfaction and less hyperstimulation compared with intravenous oxytocin. Further research is needed to assess uncommon neonatal and maternal outcomes.

A Randomized Trial of Oral Misoprostol in Premenopausal Women Before Hysteroscopy

OBJECTIVEnTo determine if the use of oral misoprostol in premenopausal women undergoing diagnostic hysteroscopy produces a clinically important difference in pre-procedural cervical dilatation.nnnMETHODSnAt a tertiary care hospital, premenopausal women undergoing diagnostic hysteroscopy were randomized to receive either 400 microg of misoprostol or a vitamin B6 placebo orally 12 hours before the procedure. Patients were stratified on the basis of parity. The primary outcome was the pre-procedural dilatation of the cervix. Secondary outcomes included the need to further dilate the cervix, the time required to further dilate the cervix, and side effects.nnnRESULTSnSixty-four women (11 nulliparous and 53 parous) undergoing diagnostic hysteroscopy consented to participate in the study. Thirty-three women received misoprostol and 31 received placebo. Baseline demographics showed no difference in age and parity between the two groups. There were no significant differences in pre-procedural dilatation (5.0 mm vs. 4.7 mm, P = 0.52), need to further dilate the cervix (56.7% vs. 63.0%, P = 0.63), and time required to further dilate the cervix (12.7 seconds vs. 25.7 seconds, P = 0.27). Significantly more women in the misoprostol group experienced menstrual-like cramping (24.2% vs. 3.3%, P = 0.03) and vaginal spotting (21.2% vs. 3.3%, P = 0.05).nnnCONCLUSIONnIn premenopausal women, there is no improvement in pre-procedural cervical dilatation with administration of oral misoprostol 12 hours before diagnostic hysteroscopy. Further research is required in both nulliparous and parous premenopausal women to determine whether oral misoprostol improves cervical dilatation and, if so, the ideal dose, route and timing.

Oral Misoprostol Versus Oxytocin in the Management of the Third Stage of Labour

OBJECTIVEnTo compare the effects of oral misoprostol 800 mug with intramuscular oxytocin 10 IU in routine management of the third stage of labour.nnnMETHODSnThis randomized controlled trial was performed in a rural district hospital in Ghana, West Africa, and enrolled women in labour with anticipated vaginal delivery and no known medical contraindication to prostaglandin administration. Women were randomized to receive oral misoprostol 800 mug or intramuscular oxytocin 10 IU. Blood samples were taken to determine hemoglobin concentration before delivery and at 12 hours post partum. Treatment was administered at delivery of the anterior shoulder. The primary outcome was the change in hemoglobin concentration from before to after delivery. Secondary outcomes included other measures of blood loss and presumed medication side effects.nnnRESULTSnIn total, 450 women were enrolled in the study. Their baseline characteristics were similar. There was no significant difference between the groups in the change in hemoglobin concentration (misoprostol 1.07 g/dL and oxytocin 1.00 g/dL). The only significant secondary outcomes were shivering (80.7% with misoprostol vs. 3.6% with oxytocin) and pyrexia (11.4% with misoprostol, none with oxytocin).nnnCONCLUSIONnRoutine use of oral misoprostol 800 microg appears to be as effective as 10 IU parenteral oxytocin in minimizing blood loss during the third stage of labour, as determined by change in hemoglobin concentration. Misoprostol appears to be a safe, inexpensive, and effective uterotonic for use in rural and remote areas, where intravenous oxytocin may be unavailable.

The Maternal Benefits of Corticosteroids with HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelet Count) Syndrome

OBJECTIVESnTo determine the more effective regime in improving hematologic abnormalities associated with HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, by comparing two different antenatal dosing protocols for dexamethasone (given primarily for fetal lung maturity).nnnSTUDY DESIGNnA retrospective cohort study of 30 women between 24 and 34 weeks gestation, diagnosed with HELLP syndrome prior to delivery, who received 2 doses of dexa-methasone 12 mg intramuscularly, given either 24 hours apart or 12 hours apart.nnnRESULTSnThere was a shorter time from the first corticosteroid dose to the beginning of improvement with the 12-hour regime for platelet count (11 hours [9, 25 hours] versus 69 hours [41, 112 hours], median [quartiles], P = 0.003) and for alkaline phosphatase (25 hours [5, 44 hours] versus 59 hours [31, 69 hours], median [quartiles], P = 0.02). Worsening recurred from 11 hours, for alanine aminotransferase (ALT) and aspartate transaminase (AST), to 32 hours, for uric acid, after initial improvement. Hematologic improvement occurred in 37% (for ALT) to 67% (for alkaline phosphatase) of women overall.nnnCONCLUSIONnA temporary improvement in the hematologic parameters of HELLP syndrome can occur with antenatal dexa-methasone administration, with the 12-hour regime having quicker onset to improvement in platelet count and alkaline phosphatase.

Rectal Misoprostol Versus Oxytocin in the Management of the Third Stage of Labour

OBJECTIVEnTo compare the effect of rectal misoprostol with intramuscular oxytocin in the routine management of the third stage in a rural developing country.nnnMETHODSnA randomized controlled trial was performed at two district hospitals in Ghana, West Africa. Four hundred fifty women in advanced labour were enrolled. The only exclusion criterion was a known medical contraindication to prostaglandin administration. Women were randomized to receive rectal misoprostol 800 microg or intramuscular oxytocin 10 IU with delivery of the anterior shoulder. The main outcome measure was change in hemoglobin concentration from before to after delivery. Secondary outcomes included the need for additional uterotonics, estimated blood loss, transfusion, and medication side effects.nnnRESULTSnDemographic characteristics were similar in each treatment group. There was no significant difference between treatment groups in change in hemoglobin (misoprostol 1.19 g/dL and oxytocin 1.16 g/dL; relative difference 2.6%; 95% confidence intervals [CI]-16.8% to 19.4%; P = 0.80). The only significant secondary outcome was shivering, which was more common in the misoprostol group (misoprostol 7.5% vs. oxytocin 0.9%; relative risk 8.0; 95% CI 1.86-34.36; P = 0.001).nnnCONCLUSIONnRectal misoprostol 800 microg is as effective as 10 IU intramuscular oxytocin in minimizing blood loss in the third stage of labour. Rectal misoprostol has a lower incidence of side effects than the equivalent oral dose. This confirms the utility of misoprostol as a safe and effective uterotonic for use in the rural and remote areas of developing nations where other pharmacologic agents may be less feasible.

Maternal Serum Screening: Practice Patterns of Physicians in Newfoundland

OBJECTIVEnTo compare the utilization of the second trimester maternal serum screen (MSS) of a-fetoprotein, human chorionic gonadotrophin, and unconjugated estriol, in Newfoundland, by practice location, training, and gender.nnnMETHODSnFour hundred eighteen anonymous self-reported questionnaires were mailed out to all practising family physicians, general practitioners, and obstetricians in Newfoundland, who were identified through the provincial medical board. The survey included questions on demographic characteristics, provision of antenatal care, gestational age at which MSS is ordered, reasons for offering or not offering MSS, and the use of routine antenatal ultrasound. Categorical data were analyzed using chi-square and Fisher exact tests, as appropriate.nnnRESULTSnOverall, 63% of physicians responded to the survey. Forty percent of respondents had an urban practice. Female physicians, regardless of specialty, were more likely to offer MSS to their patients (89% vs. 78%; P = 0.04), whereas family physicians and obstetricians were more likely to offer screening than general practitioners (85% vs. 83% vs. 25%; P = 0.02). Among physicians offering MSS, 54% offered it only to women 35 years and older. Practice location did not affect whether a woman was offered MSS (P = 0.41). Twenty-five percent of family physicians offering MSS did not offer it at the appropriate gestational age of 15 to 20 weeks. Ninety-four percent of pregnant women were routinely offered an ultrasound during pregnancy.nnnCONCLUSIONnThe utilization of MSS in Newfoundland is affected by physician training and gender, but not by practice location. Further education of physicians is required to ensure appropriate use and timing of this screening test.

Misoprostol Use in Pregnancy — An Update

Abstract Misoprostol is an inexpensive prostaglandin E 1 analogue marketed for oral prophylaxis and management of upper gastro-intestinal disorders, particularly those associated with nonsteroidal anti-inflammatory drugs. Vaginally administered misoprostol is a cost-effective medical agent for second trimester termination of pregnancy. In the first trimester, it is effective only after use of an antiprogesterone (mifepristone or methotrexate). Its use in first trimester pregnancy has been associated with newborn facial nerve paralysis if termination of the pregnancy failed to occur. In a much lower dose, vaginal misoprostol has been studied for labour induction at term. Numerous clinical trials have found vaginal misoprostol no less effective than existing approaches, but much less expensive than other prostaglandins. Though it appears to be safe for mother and newborn, there is still concern that it might provoke uterine hyperstimulation. No national body or consensus group has yet endorsed its use in clinical practice for induction of labour. The limited research with oral misoprostol suggests effectiveness with fewer problems of excessive uterine activity. Research into its use for the management of the third stage of labour and post-partum bleeding has now begun.

Randomized Comparison of Oral Misoprostol and Oxytocin in the Third Stage of Labour

Abstract Objective: To compare oral misoprostol 200 µg with intravenous oxytocin 5 or 10 lU in minimizing blood loss in the third stage of labour. Design: Randomized controlled trial. Setting: Tertiary care hospital in St. Johns, Newfoundland, Canada. Population: 173 women at low risk for postpartum hemorrhage in the second stage of labour in whom vaginal delivery was anticipated. Methods: Women were randomly assigned to receive either misoprostol 200 µg orally after delivery of the anterior shoulder, or oxytocin 5 or 10 IU intravenous bolus, after delivery of the placenta (the standard of care at our institution). Main outcome measure: Change in pre-delivery to 24-hour postpartum hematocrit was the primary outcome measure. Secondary outcome measures included the frequency of use of additional uterotonic agents, blood transfusion, operative intervention for postpartum hemorrhage, side effects including nausea and vomiting, clinical estimate of blood loss greater than 500 mL, and patient satisfaction. Results: Demographic characteristics were similar between groups. There was no significant difference in the change in hematocrit between the misoprostol group of 0.046 Percent packed cell volume (PCV) and the oxytocin group of 0.048 Percent PCV (p = 0.82, relative difference=- 4.2%, 95% Cl [-26.6, 18.2%]). Maternal satisfaction was not different except that 83 percent of the women in the misoprostol group preferred to have medication in the form of a pill rather than an injection, versus 42 percent of the oxytocin group (P Conclusions: Oral misoprostol is not less effective than oxytocin in minimizing postpartum blood loss in low-risk parturients.