James R. Dingfelder

Reduction of cervical resistance by prostaglandin suppositories prior to dilatation for induced abortion

Several recent reports citing increased rates of prematurity among women who have had induced first-trimester abortion suggest that forceful cervical dilatation may result in cervical incompetence in future pregnancy. There appear to be conflicting clinical impressions regarding the effectiveness on cervical softening and the reduction of cervical resistance produced by various prostaglandins. The development of the Electronic Force Monitor which is capable of precise measurement of the forces encountered in overcoming resistance during dilatation provided objective evidence with which to evaluate the effects of vaginally administered prostaglandin E2 and F2alpha suppositories. Suppositories were administered 3 hours prior to cervical dilatation, after which suction curettage was performed. Compared to the nonmedicated control group, patients receiving PGF2alpha suppositories exhibited greatly reduced cervical resistance, in some cases permitting direct introduction of the suction curette without need for any preliminary dilatation. Those patients receiving PGE2 suppositories showed an intermediate degree of cervical softening.

Vaginally administered PGF2α for cervical dilatation in nulliparas prior to suction curettage

Because of the need for an atraumatic method to dilate the cervix when performing artificial abortion by suction curettage, cervical dilatation following vaginally administered PGF2alpha was studied. A 50 mg PGF2alpha vaginal suppository was administered to 40 (treated group) first trimester nulliparas 3 hours prior to progressive cervical dilatation from a 19 (circumference in mm) Pratt dilator to a 35 Pratt dialator. The smallest-sized dilator that met resistance was interpreted as being the amount of clinically significant cervical dilatation. The results were compared to 20 (control group) first trimester nulliparas who received no PGF2alpha studied in an identical manner. Independent of gestational age, treated patients were dilated significantly more than the control patients. When subjects of similar gestational age were compared, PGF2alpha treated subjects were more often dilated sufficiently to perform abortion (55%) by suction curettage than control group subjects (5%). Those PGF2alpha subjects needing further dilatation to accept an appropriate sized cannula for their gestational age needed less dilatation than did those subjects of similar gestational age in the control group. No serious complications of PGF2alpha per se were observed and the most frequent side effects, vomiting and diarrhea, did not appear severe enough to limit the clinical practicability of the method.

Primary dysmenorrhea treatment with prostaglandin inhibitors: A review

PRIMARY DYSMENORRHEA continues to be a common gynecologic disorder that is an etiologic and epidemiologic enigma, despite the well-deserved attention it has attracted in the most recent decade. A renewed interest in this often-disabling affliction undoubtedly was engendered by new information about the relationship of endometrial prostaglandins (PCs) and menstrual cramps and by the introduction of a wide variety of new, nonsteroidal, anti-inflammatory agents. These new drugs appear to work by inhibition of overall PG synthesis as well as by competition at PC receptor sites, and several have been tested clinically for their analgesic effects. This report is a review of the recent published evidence for their effectiveness. The frequency of the disorder remains speculative because of a lack of uniformity in defining its severity. Thus, percentages of affected women may vary from 6% to 7O%, depending on the population being surveyed and the definition used for the study. Numerous current review articles introduce the subject of dysmenorrhea by repeating an often-quoted statement: “Dysmenorrhea causes an estimated 140 million lost work hours annually.” This statement is usually attributed to Kistner’s current edition of his textbook Gynecology. A bit of medical reference detective work reveals the original source of this infamous quotation to be an article by John 0. Haman, M.D.,’ entitled “Exercises in dysmenorrhea,” published in 1945, in the AMERICANJOURNAL OF OBSTETRICS AND GYNECOLOGY. Table I outlines his calculations. Suffice it to say that 40-year-old estimates bear little relationship to the present problem, and we all realize that it is an extremely common problem of everyday practice. Dysmenorrhea is more than painful cramps; it is a

Intramuscular administration of 15(S)-15-methyl-prostaglandin E2-methyl ester for induction of abortion

An intramuscular dose schedule of 15(S)-15-methyl-prostaglandin E2-methyl ester (15-(S)-ME PGE2) was evaluated for its application as a midtrimester abortifacient route. 20 healthy gravidas aged 18-42 years and 8-22 menstrual weeks of gestation were aborted in the Clinical Research Unit of the University of North Carolina Memorial Hospital. The subjects were given 5 mcg of the PGE2 methyl ester every 4 hours. 85% (17/20) aborted within 48 hours, 65% (13/20) of these within 24 hours. Mean induction-abortion interval was 21 hours. Trials were defined as complete in 55%, incomplete in 30%, and failure in 15%. Shivering, fever, pain, vomiting, and diarrhea were the most common side effects. The transient shivering occurred in 13 (65%) of the subjects within 20 minutes of the first dose. Fever usually started after shivering, and both resolved spontaneously. 2 patients had estimated blood loss exceeding 500 ml, but they were not given transfusions. No clinically significant changes occurred in mean hemotocrit, platelet count, serum creatinine, bilirubin, alkaline phosphatase, electrolytes, serum glutamic oxalacetic transaminase, and serum glutamic pyruvic transaminase. Mean blood cell and neutrophil counts increased, but neither increase was statistically significant.

Laminaria augmentation of intra-amniotic prostaglandin F2α for the induction of mid-trimester abortion

Abstract From interpretation of 24-hour dose-response curves, it is improbable that mid-trimester abortion rates greater than about 80% can be accomplished with any one dose schedule of Prostaglandin F2α (PGF2α). To determine whether augmentation of intra-amniotic PGF2α with laminaria would improve the abortion rate, the results of a group of 22 gravidas treated with intra-amniotic PGF2α were compared to those of a group of 21 subjects treated with laminaria and an identical dose schedule of PGF2α. Patients with laminaria not only had a shorter mean abortion time (14.6 hours), but 95% aborted within 24 hours and all patients aborted within 24.5 hours of the initial PGF2α injection. Patients without laminaria had a longer mean abortion time (18.9 hours); only 68% aborted within 24 hours and one failed to abort within the 48-hour trial period. No significant differences in the frequency or severity of complications between the two groups were observed. Uterine contractility over the initial 6 hours of the induction was similar in the two groups. Therefore, augmenting the intra-amniotic PGF2α method with laminaria appears practicable.

Induction of therapeutic abortion with a single dose of intra-amniotically administered prostaglandin F2α*

Abstract To determine the abortifacient effectiveness and complications of a single intra-amniotic injection of 50 mg of Prostaglandin F2α (PGF2α), 40 gravidas were studied. While all subjects received a 50 mg dose of PGF2α at the initiation of the trial with no additional oxytocics or surgical intervention until they had aborted or until the end of the 48-hour trial period, they received intramuscularly administered prochlorperazine by one of two dose schedules. Twenty-five Group I subjects received 10 mg of prochlorperazine whenever they requested medication for alleviation of nausea or vomiting, while 15 Group II subjects received 10 mg one-half hour prior to the administration of PGF2α and at 6-hour intervals until they had aborted. Within the initial 24 hours, 77% of the subjects aborted while within the 48-hour trial period, 95% of the subjects aborted with a mean induction-to-abortion time of 19.1 hours for those aborting. Sixty-eight percent aborted completely, 28 percent aborted incompletely, and 5 percent failed to abort within the trial period. No serious complications were observed. The proportion of patients having no vomiting and the mean number of episodes of vomiting were significantly less in the Group II subjects than in the Group I subjects. No significant differences in the mean abortion times, cumulative abortion rates, or intra-amniotic pressures were noted between the two groups of subjects. It appears that the single intra-amniotic administration of 50 mg of PGF2α results in practicable rates of abortion and the associated vomiting can be significantly attenuated with prochlorperazine without significantly altering the abortifacient or oxytocic effect of PGF2α.

An evaluation of the sensitivity of five home pregnancy tests to known concentrations of human chorionic gonadotropin.

A study was conducted to evaluate the sensitivity of the five commercially available home pregnancy testing kits. Known amounts of human chorionic gonadotropin (hCG) were diluted in pooled, sterile male urine. Varying concentrations of hCG were randomly assigned to 100 kits of each of the five brands. The test results were read independently by three individuals who were blinded to the hCG concentrations. Statistical analysis were based on the majority vote of the readers. The rank-ordered sensitivity of the five home pregnancy tests, expressed as the proportion of positive results for the range of hCG concentrations studied, was as follows: (1) Predictor, (2) e.p.t., (3) Acu-Test, (4) Answer, and (5) Daisy 2. Overall, Predictor and e.p.t. appear to be more accurate than Acu-Test or Answer. Only Daisy 2 was found to be significantly different from the other brands. However, the currently marketed Daisy 2 pregnancy test is manufactured by a different company.

THE THERMOGENIC ACTIVITY OF EXOGENOUS E AND F PROSTAGLANDINS IN HUMANS

A basic understanding of the physiologic effects of the prostaglandins on the human reproductive system has been one of the diverse scientific interests of Professor Axel Ingelman‐Sundberg (19). Although the obvious clinical utility of these ubiqitous compounds directed early attention to their therapeutic aspects, more recently there has been renewed interest in the basic physiologic mechanisms of the prostaglandins in reproductive medicine. Undoubtedly, the work of Dr Ingelman‐Sundberg has stimulated many of his colleagues, students, and fellow scientists to pursue such basic studies in greater details.

Intra-amniotic administration of 15(S)-15-methyl-prostaglandin F2α for the induction of midtrimester abortion

To determine the practicability of administering 15(S)-15-methyl-prostaglandin F2alpha-tromethamine (15(S)-15-Me-PGF2alpha) intra-amniotically for the induction of midtrimester abortion, initially 2.5 mg. of 15(S)-15-Me-PGF2alpha was administered to 20 physically healthy gravid women, and was repeated after 24 hours in those patients who had not aborted. Within 24 hours, 65% aborted, and within 36 hours, 95% aborted. Although 67% experienced emesis, no serious complications occurred. This abortion rate is similar to that obtained with the recommended dose schedule of the dosage of prostaglandin F2alpha approved by the Food and Drug Administration and those reported with intra-amniotic administration of either hypertonic saline or urea when augmented with high, continuous, intravenous infusions of oxytocin. While the study intra-amniotic dose schedule appeared to be practicable, large, comparative studies will be necessary to determine the most satisfactory dose schedule and whether this method is more acceptable than other available methods.

Regional Training Program of Laparoscopy: Impact on Regional Care

In response to large numbers of requests for laparoscopic sterilization, the University of North Carolina began a training program to provide this service on a regional basis throughout the state. This report reviews the final distribution of centers providing these services: one within 50 miles of every person in the state. The clinical experience of 30 private physicians (excluding experience of residency training programs) was reviewed and found to parallel the national experience in provision of services, in complications, and in pregnancies. The brief but intense training program (2 days at the University of North Carolina and one morning at the physicians hospital) was found to result in rates of complications and failures similar to national levels of performance. Should the demand for laparoscopic sterilization increase in the coming years, the region has sufficient numbers of safely trained physicians to respond.