H. Van Kets

IMMEDIATE POSTPLACENTAL IUD INSERTION: THE EXPULSION PROBLEM

This paper reports an evaluation of immediate post-placental insertion of a non-copper (Lippes Loop D) and several copper-bearing IUD models (TCu200, TCu220C, MLCu375, MLCu250, Nova T-PP, DimélysR). Based on the analysis of a total of 2,646 insertions and 55,794 woman-months of experience, we conclude that placement of an IUD within ten minutes of delivery of the placenta is a valuable alternative to interval insertion, because this method is safe and effective. Effectiveness was significantly lower for the Lippes Loop D than for the T- and ML-IUD models tested, the latter showing roughly comparable pertinent event rates. Pertinent event rates for copper IUDs were influenced by the skill of the operator; age of the recipient only had a significant effect on effectiveness, whereas parity had no significant effect on pertinent event rates. The single and still unsolved problem associated with immediate postpartum insertion is the greater likelihood of expulsion compared with interval insertion, and this hazard is significantly much greater for the Loop than for the copper-bearing devices assessed. The evolution of the expulsion rates shows a constant time-relationship. This pattern makes it obvious why follow-up of recipients, at least during the first trimester following insertion, is mandatory if immediate post-placental IUD insertion is to be optimally effective.

Endocervical prostaglandin E2 gel for preinduction cervical softening

A single, endocervical application of a new commercial preparation of prostaglandin E2 (PGE2) gel, 0.5 mg of PGE2 in 2.5 ml (3 g), was evaluated for preinduction cervical softening. Safety and efficacy were assessed in a comparison with a 2.0 mg PGE2 vaginal tablet and placebo in normal nulliparous women at term, with low Bishop scores. Treatment was administered in randomized, double blind fashion. Overall success, defined as a progression in Bishop score of at least 3 points within 12 hours, was achieved in 22/40 (55%) of the gel group, 15/41 (37%) in the tablet treated women, and 8/40 (20%) in those receiving placebo. Of interest was the observation that of women with very unfavorable induction features (Bishop score 0-2), the cervical gel treatment resulted in a 6/8 (75%) success rate compared with 2/13 (15%) success for the vaginal tablet and 0/17 (0%) for placebo. In as much as a very low incidence of side effects accompanied this treatment scheme, expanded multi-center testing is recommended.

Effectiveness of extra-ovular injection of prostaglandin E2 in tyloseR gel to ripen the cervix prior to elective induction of labor at term

Ripening of the unfavorable cervix (Bishop score less than or equal to 4) was obtained in 92 clinically normal gravidae at term (68 nulliparae and 24 parous women), not in labor and with intact membranes, by injecting one or two doses (250 to 500 mug each) of prostaglandin (PG)E2 suspended in a viscous gel (5% Tylose) into the extra-ovular space. On average 7 to 8 hours after the injection the mean increase of the cervical score was 3.7 and 4.1 in the nulliparous and parous women, respectively. Complications associated with placement of the catheter were few. The method is simple, well tolerated and no untoward maternal or perinatal effects could be directly attributed to it. However, suitable criteria for predicting both the effect of the procedure and the optimal PG dose to be administered are still needed.

Perinatal hazards of chronic antenatal tocolysis with indomethacin

Indomethacin was administered from the 20th to the 34th week of gestation to 51 women (59 fetuses) in whom bed rest and a beta-mimetic compound (ritodrine) had failed to stop preterm labor. No serious maternal side effects were observed. Of the 8 perinatal deaths, 5 were not and 3 were possibly related to the prostaglandin synthesis inhibitor. The sole case of serious neonatal morbidity is not considered to have had a causal relationship with the indomethacin treatment.

IUD expulsion solved with implant technology

In an attempt to minimize the problem of IUD expulsion, implantation technology has been developed and tested. The trials have extended from 1985 until the present time for interval as well as for immediate postabortal and post-placental insertion and fixation of the CuFix IUD (Gyne-Fix). The present article reports on an ongoing study with GyneFix interval insertion, with an improved inserter, in 820 women, observed up to 3 years, of whom 213 (25.9%) are nulligravid/nulliparous. The cumulative expulsion rate is 0.6 per 100 women-years at 3 years and is not significantly higher in the nulligravid/nulliparous group. The cumulative pregnancy rate is 0.6 and the cumulative removal rate for medical reasons 3.2 at 3 years. The total experience in this multicenter study covers approximately 14,000 woman-months. It is concluded that the design characteristics of the GyneFix (fixed, frameless, and flexible) explain the low expulsion, high efficacy and high acceptability rates. The implantation technology is very effective and the improved inserter allows easy insertion and optimal anchoring.

Ultrasonic detection, localization and identification of intrauterine contraceptive devices

Abstract To assess the value of B-scan echography for the detection, localization, and identification of tailed IUDs, two studies were performed, each comprising 110 women. In the first the ultrasonographist was cognizant of the clinical context and the investigation was limited to the Lippes loop. The second was a blind study and concerned three types of IUDS : the Lippes loop, the Dalkon shield, and a copper device (Cu7TM). The diagnostic accuracy of the procedures for the detection and the localization of IUDs within the uterus was adequate in both series, although the best results were obtained with the Lippes loop, which-gives fairly typical sonographic patterns. With respect to IUD typing, the results were disappointing, especially for the Dalkon shield and the copper 7TM. The value of ultrasonic detection and localization of an IUD coexistent with an incipient pregnancy was analyzed in six women. That the diagnostic precision proved to be less satisfactory in these cases than in the entire series was apparently due to the disturbing effect of the pregnancy-ring. The genesis of the sonographic patterns derived from the various tailed IUDs was further analyzed in an in vitro investigation. This study provided corroborative evidence to explain the intrinsic failure rate of sonography for both the detection and typing of IUDs located within the uterus.

Fetal effects of cervical ripening with extra-amniotic prostaglandin E2 in gel

A gel containing 0.5 mg prostaglandin E2 (PGE2) was extra-amniotically instilled 90 clinically normal gravidae at term, for ripening of the cervix before elective induction of labor by amniotomy and intravenous PGE2. An acceptable increase in the Bishop score was noted to have occurred in 87/90 women, when assessed eight hours after administration of the gel; 14 of these women were then in established labor, which progressed uneventfully. Four of the 90 subjects required cesarean section for cephalopelvic disproportion. No adverse maternal or fetal effects of the procedure were detected under careful clinical, electronic and biochemical monitoring. However, epidural anesthesia adversely influenced the acid-base equilibrium of the fetus.

Intravenous prostaglandin F2α and amniotomy for the elective induction of labor at term

In an earlier trial [7, 11] with intravenously administered PGF2# for the elective induction of multiparae at term, amniotomy was delayed to comply with FD A regulations. As a consequence, the Start of the electronic supervision was also postponed and thus the refined assessment of the potential fetal ha2ards of PGF2& was prevented. The present study was tailored in accordance with the dual purpose of meeting our primary objective (to study the effects of PGF2# in the fetus and the newborn) by relying on a procedure actually used in clinical obstetrics, i. e. amniotomy followed by the intravenous infusion of an oxytocic drug.

A double blind comparative study of prostaglandin F2α and oxytocin for the elective induction of labor

Abstract Under monitoring control, term labor was induced electively in two groups of 25 women each, in one by an intravenous infusion of prostaglandin (PG) F 2α and in the other with an intravenous infusion of synthetic oxytocin (Pitocin ® ), according to a fixed dosage schedule. At birth, both the clinical and the biochemical state of the fetuses were evaluated. It is concluded that in the dosage used, PGF 2α is without adverse effects on the mother. Labor could be effectively induced with both PGF 2α and oxytocin. If hyperstimulation of the myometrium is avoided during the infusion, the fetal condition is not endangered by either of these compounds. It is, however, our impression that PGF 2α leads more easily to uterine hyperstimulation than does Pitocin ® . For this reason the clinical use of PGF 2α should be probably confined to well-equiped obstetrical units.

The value of fetal monitoring for the prediction of the biochemical and clinical status of the infant at birth. The “monitor-normal” case

Abstract The authors have sought an answer to the question: is it possible to predict the condition — clinical and biochemical — of the fetus at birth solely by continuous monitoring of the fetal heart rate (FHR) and the intrauterine pressure during the greater part of the first stage of labor and during the entire second stage? This report of the first part of their study is restricted to the statistical analysis of 88 “ monitor-normal ” cases characterized (a) by normal FHR and contractility patterns throughout labor and (b) by a smooth second stage. For the estimation of the fetal oxygen debt, a specific biochemical parameter was used, i.e. the fetal-maternal difference in excess lactate . The conclusion is reached that “ monitor-normal ” cases show a normal biochemical state of the infant at birth. The relationship between the physical parameters (FHR and intra-amniotic pressure) and the clinical state at birth (Apgar score), on the other hand, was found to be significantly less accurate.