Horace M Fletcher

Intravaginal misoprostol as a cervical ripening agent.

Objective To determine if misoprostol (exogenous prostaglandin E1 PGE1) used vaginally was of value in improving the Bishop score, leading to an early safe vaginal delivery in women in whom the cervix is unripe and delivery is indicated.

A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy

Objective To assess the comparative efficacy of perivascular vasopressin and tourniquet in minimizing bleeding and its sequelae at myomectomy. Methods Between March 1994 and February 1995, 52 women with symptomatic uterine leiomyomas scheduled for myomectomy were entered into a randomized trial comparing vasopressin (26 patients) and tourniquet (26 patients) for hemostasis. Myomectomy was performed after either the perivascular injection of 20 U of vasopressin diluted to 20 mL with normal saline or with the use of a Foley catheter tourniquet around both uterine vessels. The efficacy of each method was measured by comparing differences in pre- and postoperative hemoglobin levels, intraoperative blood pressure, measured blood loss, need for blood transfusion, evidence of postoperative febrile morbidity, complications, and length of hospital stay. Results Vasopressin resulted in less blood loss (mean 287.3 mL [standard deviation (SD) 1951 versus 512.7 mL [SD 4001 for tourniquet [P = .0361). Six of 26 patients in the tourniquet group lost more than 1000 mL of blood, whereas all of the vasopressin subjects lost less than this amount (P = .023). However, there were no significant differences between the two groups in the fall in the hemoglobin level, number of blood transfusions given, intraoperative blood pressure, highest postoperative pulse and temperature, or other complications. Conclusion Vasopressin prevents blood loss better than using the tourniquet during myomectomy.

Intramyometrial vasopressin as a haemostatic agent during myomectomy

Objective To assess the efficacy of intramyometrial vasopressin for minimising bleeding and its sequelae at myomectomy.

Misoprostol use in obstetrics and gynecology in Brazil, Jamaica, and the United States

Objectives: To investigate current clinical use of misoprostol for the treatment of a range of reproductive health indications by providers in Brazil, Jamaica, and the United States. Methods: Using a ‘snowball’ sampling technique, we surveyed 228 gynecologists and obstetricians in Brazil (n=123), Jamaica (n=52), and the United States (n=53). Results: Providers use misoprostol for labor induction (46%), postpartum hemorrhage (8%), intra‐uterine fetal death (61%), cervical priming (21%), missed abortion (57%), and incomplete abortion (16%) as well as first and second trimester abortion induction (27% and 13%, respectively). Conclusions: There is considerable variation in the regimens used; moreover, the regimens commonly used in clinical practice often differ from those recommended in the medical literature. While misoprostol is an appealing alternative for many reproductive health indications in developing countries, the varied regimens and lack of registration raise critical medical and policy questions.

Caesarean myomectomy--a safe procedure. A retrospective case controlled study.

Sixteen women, with uterine fibroids in pregnancy, who were treated by caesarean myomectomy, were compared retrospectively with 16 women, without uterine fibroids who had caesarean section during the same period. Myomectomy was performed at caesarean section after delivery of the baby and the placenta, with the administration of intravenous oxytocin. The fibroid defects were occluded with continuous interlocking and fixed sutures. Routine caesarean section was performed on the subjects in the control group. The comparative efficacy of the procedure was measured by comparing pre- and post-operative haemoglobin levels, measured blood loss, need for blood transfusion, post-operative febrile morbidity and length of hospital stay in both groups. Caesarean myomectomy resulted in a mean blood loss of 495 ml (range 200-1000 ml) compared with 355 ml (range 150-900 ml) in the control group (P =0.907). The caesarean myomectomy group had a mean fall in haemoglobin level of 1.7 g/dl compared with a fall of 1.4 g/dl in the control group. There were no significant differences between the groups in the need for blood transfusion, post-operative febrile morbidity or length of hospital stay. The results indicate that caesarean myomectomy is safe and offers no significant increased risk to the patient over caesarean section alone. This is beneficial to the health sector by the avoidance of an interval myomectomy hence justifying the cost effectiveness of the procedure.

Dietary intake of choline and plasma choline concentrations in pregnant women in Jamaica

Choline is an essential nutrient for humans and its availability during pregnancy is important for optimal fetal development. The Food and Nutrition Board of the Institute of Medicine in the United States of America has set the adequate choline intake during pregnancy at 450 mg/day. There is limited data available on normal plasma choline concentrations in pregnancy. Moreover, there are neither documented studies of choline intake among pregnant women in the Jamaican population nor of free plasma choline concentrations during pregnancy. Sixteen women presenting to the antenatal clinic of the University Hospital of the West Indies (UHWI) at 10-15 weeks of gestation were selected for this pilot study. A food frequency questionnaire was administered to estimate frequency of consumption of foods rich in choline. Fasting blood samples were collected by venepuncture and plasma assayed for choline using liquid chromatography electrospray ionization isotopic dilution mass spectrometry. Most of the women reported consumption of diets that delivered less than the recommended choline intake (mean +/- SEM, 278.5 +/- 28.9 mg). Mean plasma choline concentration was 8.4 +/- 0.4 micromol/L. This falls below the normal concentration (10 micromol/L) reported for individuals that are not pregnant and pregnant (14.5 micromol/L). The results of this study may be an indication that the choline included in the diet of pregnant women in Jamaica may not be adequate to meet both the needs of the mother and fetus and that further studies are warranted to determine clinical implications.

The effect of hyoscine butylbromide on the first stage of labour in term pregnancies

Objective  To determine whether hyoscine butylbromide shortens the first stage of labour, without an increase in maternal or neonatal complications.

Prevention of striae gravidarum with cocoa butter cream

To determine whether cocoa butter cream is effective in preventing striae gravidarum.

Body composition in pregnancies of adolescents and mature women and the relationship to birth anthropometry

Objective:To investigate differences in body composition between adolescent girls and mature women during pregnancy and the relationship to newborn anthropometry.Design:A prospective study.Setting:The antenatal clinic at the University Hospital of the West Indies, Kingston, Jamaica.Subjects:Four hundred and twenty-five women were invited to join the study. Three hundred and sixty-one women (84.9%) completed the study.Interventions:Study participants were divided into two groups: adolescents and mature women, who were all less than 15 weeks pregnant and had no systemic illness at the time of entry into the study. A questionnaire was administered which retrieved information on demographics, age, marital status, menstrual history, parity, socio-economic status, medical history and smoking/drinking habits. Anthropometric measurements including weight, height, triceps, biceps, subscapular and suprailiac skinfolds, as well as blood pressure measurements and urine analysis were performed at the first antenatal visit and repeated at 15, 25 and 35 weeks gestation. Anthropometric measurements of the newborn were performed at birth.Results:There were significant differences between anthropometry and skinfold thickness at the first antenatal visit between the adolescents and the mature women where the adolescents had lower measurements compared to the mature women. In the newborn anthropometry, the only significant difference seen was in the triceps skinfold thickness and the mid-upper arm circumference where the newborn of the adolescents had significantly smaller values (P=0.04; P=0.02, respectively). The percentage fat, fat mass and lean body mass were significantly lower in the adolescent compared to the mature women (P<0.0001), both at the first antenatal visit and at 35 weeks gestation. A greater gain was seen in these measurements throughout the pregnancy in the adolescents (P<0.0001). Linear regression analyses showed that the gain in lean body mass was the most important predictor of birth anthropometry.Conclusion:Body composition differs in pregnancy between adolescents and mature woman, and if adequate weight and lean body mass are attained, it impacts positively on birth size irrespective of age.Sponsorship:This study was supported by a grant from the Caribbean Health Research Council, 25A Warner Street, St Augustine, Trinidad, West Indies.

The impact of induced labour on postpartum blood loss.

It is generally believed that postpartum blood loss is less in patients whose labour is induced with prostaglandins than in patients delivered without induction. However, postpartum blood loss is known to be greater with precipitate labour and labours induced with oxytocin and prostaglandins, unless an oxytocic agent is continued after delivery. A retrospective study was undertaken at the University Hospital of the West Indies to look at the outcome of induced labour during 3 months, October – December 1998. Misoprostol induction was compared to the outcome after oxytocin induction, misoprostol induction plus oxytocin augmentation and those patients who delivered without oxytocics during this same time period. During that period, 524 patients were delivered and 51 (9.7%) were induced with misoprostol, 174 (33.2%) with oxytocin, 21 (4%) misoprostol plus oxytocin and 271 (51.7%) without oxytocic. Seven patients were eliminated from further analysis, as we were unsure of their induction status. Results showed no significant differences between the groups for variables such as maternal age, parity and fetal birth weight. There was a significantly greater mean blood loss at delivery with all induced labour compared with those not induced. For misoprostol 162.5(SD 190) ml, oxytocin (150 (SD 100) ml and for oxytocin plus misoprostol 150 (SD 150) ml, while controls had the lowest mean blood loss 100 (SD 130) ml occurring where no predelivery oxytocic was needed (P < 0.03). Postpartum haemorrhage was highest with misoprostol 5.8% versus 4.4% for no oxytocic, 1.1% for oxytocin and 0% for misoprostol plus oxytocin. However, none of these values reached statistical significance. The misoprostol group also had the shortest first stage, 333 minutes versus 557 minutes for oxytocin, 576 minutes when both misoprostol and oxytocin was used and 344 minutes with no oxytocic. Blood loss was also independently directly associated with placental weight (P = 0.01) and fetal birth weight (P = 0.03), as well as the length of the third stage of labour (P = 0.01), but not the length of the first stage of labour. Induction of labour with oxytocic agents is associated with greater blood loss. However, increased blood loss is not due to precipitate labour alone.