M. Toppozada

Oral or vaginal misoprostol for induction of labor

Objective: To compare vaginal versus oral misoprostol for induction of labor. Method: Induction of labor was carried out in 40 women near term in two equal and randomized groups (according to a computer generated table) using misoprostol. Group I received vaginal misoprostol (100 μg) every 3 h while group II patients were given the same dose via the oral route. The dose was doubled if no response was detected under continuous cardiotocographic (CTG) tracings. Result: The vaginal route of administration induced a higher success rate in a shorter time interval using a lower dose but was associated with more abnormal FHR patterns and instances of uterine hyperstimulation. Conclusion: It is recommended to use the vaginal approach with cardiotocographic monitoring.

Response of the midpregnant human uterus to systemic administration of 15(S)-15-methyl-prostaglandin F2α

The contractile response of the midpregnant human uterus to a new (PG) prostaglandin analogue, 15(S)-methyl-PGF2alpha (15-me-PGF2alpha), was investigated and compared to the effect of natural PGF2alpha. It was found that the threshold dose of 15-me-PGF2alpha was around 10 mcg when given as a single intravenous injection, which is approximately 1/10 of the corresponding dose of PGF2alpha. It was also found that higher intravenous doses of 15-me-PGFalpha resulted in a uterine response of longer duration than that following PGF2alpha. Intramuscular injection of the analogue at doses of 1.0-1.5 mg induced a marked uterine stimulation sustained for 5-7 hours without causing local reaction. Intravenous infusion of 5 mcg/min of 15-me-PGF2alpha stimulated a level of uterine activity equivalent to that of 75 mcg/min of PGF1alpha. The incidence of gastrointestinal side effects was the same in the 2 treatment groups. However, there seemed to be a tendency toward a significantly higher abortion rate with the analogue.

Administration of 15-methyl-prostaglandin F2α as a pre-operative means of cervical dilatation

Abstract Pre-operative dilatation of the cervix prior to vacuum aspiration was accomplished in 67 volunteers by extra-amniotic or intra-muscular administration of 15(S)-15-methyl-PGF2α (15-me-PGF2α). Ninety-four per cent of the patients were in the 11th–13th week of gestation and 61% were nulliparae. A single extra-amniotic instillation (mean of 400 μg) or 3 intramuscular injections (300–800 μg per injection) of the compound induced a satisfactory outcome in terms of either abortion or sufficient dilatation of the cervix in 81% of the patients. In the remaining cases, the cervix was found at operation to be open for 7–9 mm which simplified the process of additional instrumental dilatation. In general the outcome of the trial turned the operation into an easy and safe procedure. Vacuum aspiration was performed in all cases after a mean time lag of 16 hours following the onset of the treatment. Extra-amniotic administration was associated with a low incidence of gastro-intestinal side-effects, but there was a transient and moderate degree of uterine pain reaction. The intramuscular route was technically more simple and caused less uterine pain but the high incidence of vomiting and diarrhoea constituted a clinical disadvantage. In late first trimester abortions, particularly cases where the uterus appears larger than expected, it is believed that dilatation of the cervix by PG prior to vacuum aspiration is a sound clinical indication. The method offers definite advantages that compensate for the price of some minor side-effects.

Intra-amniotic prostaglandin administration — A challenge to the currently used methods for induction of midtrimester abortion

Abstract The present investigation was undertaken to evaluate the degree of uterine stimulation and abortifacient efficacy of a single intra-amniotic injection of prostaglandin. A high dose of PGF 2a was compared with different dose levels of 15(s)-15-methyl-PGF 2a . 1. 1. Forty mg PGF 2a induced an initially high level of uterine activity followed by a gradual decline. Inefficient contractility, resulting from a transient response, was occasionally observed. The clinical trials resulted in a success rate of 76% and were associated with a comparatively high incidence of side-effects. 2. 2. Intra-amniotic administration of 15-me-PGF 2a induced a different type of response characterized by a gradual initiation of uterine stimulation but a sustained effect. One mg of the analogue proved to be too low as a single abortifacient dose whereas 2.5 and 5.0 mg induced abortion in nearly 100% of the cases. The intermediate dose (2.5 mg) resulted in a high level of uterine contractility, a high success rate and a low incidence of side-effects. These results were compared with available data on hypertonic saline abortions. The use of 15-me-PGF 2a seems to offer certain advantages of practical significance.

Induction Of Abortion by the Intravenous Administration of Prostaglandin F2xA Critical Evaluation

Prostaglandin F2x was administered intravenously to 166 women for induction of legal abortion. The patients were subdivided into different treatment groups to investigate the relative importance of the administered dose and the duration of infusion at various stages of pregnancy. The results of different parameters were analysed statistically. The details of the clinical outcome were analysed according to a defined scoring system describing the actual events following a certain treatment plan. Early pregnancies (7‐8 weeks) were more susceptible to induction by PGF2α infusion than later stages of gestation. The success rate in the 9th‐20th week of pregnancy was dose dependant as demonstrated by termination of pregnancy in 75% of the high dose (100 μg PC min) group and only 27% in the low dose group (50 μg per min). The duration of infusion was the second parameter of vital importance to achieve a satisfactory outcome. Infusion of a moderate dose (75 μg per min) for a period of 15 hours could induce a valuable clinical response in the form of cervical dilatation, yet the duration was too short to complete the abortion process. The frequency of vomiting and diarrhoea was an important complicating feature in the high dose group. The high dose necessary for an acceptable success rate is accompanied by a high incidence of distressing symptoms (an episode of vomiting or diarrhoea every second hour). This fact limits the routine clinical use of intravenous PGF2α prostaglandins for induction of abortion.

Prostaglandins and Fertility Regulation

A medical method for termination of early pregnancy would be an attractive alternative to vacuum aspiration, especially if the treatment could be administered by the woman herself. A prerequisite for such a procedure is that the treatment results in a complete abortion. Some of the naturally occurring Prostaglandins (PGs), PGE2 and PGF2alpha, as well as certain analogues have the unique capacity to effectively stimulate uterine contractility during all stages of pregnancy. If the treatment is applied during the 4th to 7th week of pregnancy experience indicates that it is possible to achieve a high proportion of complete abortion. As the pregnancy advances the frequency of incomplete abortion increases and a medical method becomes less useful (1).

Role of repeated stretching in the mechanism of timely rupture of the membranes

Abstract The uterine contractions were recorded before, at, and after spontaneous timely rupture of the membranes. The peculiarities of the rupturing contraction were studied and were compared with the prerupture pattern of uterine contractility. It was observed that the rupturing contraction was not the strongest one to which the membranes were subjected in 86.2 per cent of cases. To solve this topographic phenomenon, a new test, “the repeated stretching test,” was instituted. A new conception was then introduced to explain how timely rupture of the membranes takes place. During labor, nature utilizes uterine contractions to influence a repeated stretching action upon the membranes. This progressively and gradually weakens the membranes until, by the end of the first stage, their resistance is reduced to a degree that allows weaker uterine contractions to effect their rupture.

The relaxant property of local prostaglandin E2 on the non-pregnant uterus — A cyclic triphasic response

The response of the non-pregnant human uterus to intravenous (i.v.) injections and intra-uterine instillation of various doses of prostaglandin E-2 (PGE-2) was evaluated at the different phases of the menstrual cycle in 13 fertile regularly menstruating women who were neither lactating nor using any hormonal therapy. Uterine contractility was recorded by the microballoon technique in at least three sessions(proliferative, mid-cycle and secretory) in a single cycle with endometrial biopsy performed immediately following the last session to ascertain that the particular cycle was an ovulatory one. Single i.v. injections of PGE-I had a consistent stimulatory effect on the contractility throughout the cycle with a tendency towards a decreased uterine response at mid-cycle and luteal phase as compared to the proliferative part of the cycle. Intra-uterine instillation of the compound induced a peculiar and interesting type of response. In the proliferative and secretory phases of the cycle the response was one of stimulation; being more pronounced in the former period. However, around ovulation time, the local administration induced an evident uterine relaxation in most cases without any instance of stimulation. The possible implication of this triphasic response behaviour on the non-pregnant uterus within certain physiological events and pathological conditions is discussed.

Progesterone challenge test and estrogen assays in menopausal women with endometrial adenomatous hyperplasia

In an attempt to detect asymptomatic endometrial adenomatous hyperplasia in postmenopausal women, 40 cases were subjected to progesterone challenge test (PCT), measurement of serum estrogen and endometrial curettage. Group A (n = 30) included asymptomatic postmenopausal women, while group B (control group; n = 10) were cases with adenomatous hyperplasia (AH) diagnosed by biopsy. PCT showed a 100% sensitivity, 92% specificity, 71.4% predictive value of a positive test and 100% predictive value of a negative test in the detection of AH. Mean serum concentrations of E1 and E2 were significantly higher in patients with AH compared to cases with other endometrial histologies. Serum E1 and E2 and PCT can be used as screening tests to identify postmenopausal women with endometrial AH and thus at a greater risk of developing carcinoma.

Effect of heat on uterine contractions during normal labor

The effect of local application of heat on the abdominal wall on uterine activity was evaluated in 15 full‐term multiparous women early in the first stage of labor. Cardiotocographic monitoring showed that heat induces a significant increase in uterine activity without causing any abnormal fetal heart changes. The stimulated contractions return back to base line level following removal of heat. The application of heat on the abdominal wall of women in early labor appears to offer a new non‐pharmacological modality for the stimulation of uterine activity.