Comparison of misoprostol with dinoprostone for induction of labor in postdated pregnancy

To compare the efficacy of misoprostol with dinoprostone in induction of labor in nulliparous women at and beyond 41 weeks of gestation. Experimental comparative study. Department of Obstetrics and Gynecology Unit-II, Jinnah Post Graduate Medical Center, Karachi, from September 2007 to October 2010. A total of 105 women with more than 287 days [41weeks] gestation with unfavorable cervix and intact membranes were selected for induction of labor. Dinoprostone was inserted in 41 patients while 64 patients were induced with intravaginal misoprostol. The primary outcome measures were induction-delivery interval, number of doses required for induction, rate of spontaneous vaginal delivery, C-section and instrumental delivery. Secondary outcomes were the incidence of meconium stained amniotic fluid, fetal weight at the time of delivery, fetal distress and need for admission to NICU. Out of 63 patients in the misoprostol group, 43 [67.1%] women had spontaneous vaginal delivery [SVD] while 26 [63.4%] patients out of 41 in dinoprostone group had SVD. The induction to delivery interval was 13.03 +/- 3.52 hours in misoprostol group while it was 14.12 +/- 3.31 hours in dinoprostone group. With misoprostol, induction of labor started in 18, 33 and 13 women with 1, 2 and 3 doses respectively within 24 hours but in dinoprostone group 16 women were successfully induced with 1 tablet only, while 21 patients required 2 doses for induction. The need for oxytocin infusion was the same in both the groups. The neonatal weight was 3.54 +/- 3.38 kg in misoprostol group as compared to 3.10 +/- 0.26 kg in dinoprostone group [p=0.41, t=1.57]. Four neonatal deaths were reported in the misoprostol group as compared to two with dinoprostone. Sixteen neonates were admitted to NICU in misoprostol group as compared to five patients in dinoprostone group. Twenty-eight [44.4%] patients in misoprostol group had meconium stained liquor as compared to 14 [34%] patients in dinoprostone group. Dinoprostone was most effective in comparison with misoprostol in gravida with 41 weeks and above gestation. Misoprostol though showed comparable results, but is not the drug of first choice

Hysterectomy as a management option for morbidly adherent placenta

To determine the outcome of interval [delayed] hysterectomy as compared to cesarean [immediate] hysterectomy in cases of placental invasion in previous cesarean sections. Comparative study. Department of Obstetrics and Gynecology, Unit II, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from January 2008 to June 2011. The study subjects included 28 women with history of previous cesarean section who had low lying as well as morbidly adherent placenta [MAP] of variable degree. Patients were classified into two groups [group A and B] according to whether cesarean or interval hysterectomy was needed at time of delivery. Demographic data, obstetrical risk factors such as parity and number of previous cesarean sections were compared as well as radiological and histopathological findings, and details of the management. Chi-square, Fisher's exact and t-tests were used to compare proportions and mean values. The frequency of MAP in previous cesarean sections turned out to be 1.83/1000 [28/15,340] deliveries. Mean maternal age [26.54 vs. 29.13 years, p=0.05], mean gestational age [33.8 vs. 36 weeks, p=0.05], estimated blood loss [2615.38 vs. 1506.6 ml, p=0.001], volume of blood transfused [9.76 vs. 2.9 pints, p=0.001] and the duration of hospital stay [10.69 vs. 32.86 days, p=0.001] differed significantly between group A and group B. One maternal death occurred in each group. Eight patients had other complications in group A compared to 3 patients in group B. Three neonatal deaths occurred in group A compared to nil in group B. The frequency of morbidly adherent placenta was 1.83/1000 deliveries. The management and outcome differed markedly according to emergency and scheduled antenatal diagnosis. Counselling and antenatal radiological screening can reduce the high morbidity and mortality associated with it

Spontaneous rupture of primigravid uterus due to morbidly adherent placenta

Morbidly adherent placenta in a nulliparous woman is a rare phenomenon. An unusual case of a 20 years old primigravida presented in emergency with unstable haemodynamics and abdominal pain at 17 weeks of gestation is reported. She was found to have complete placental invasion and heamoperitoneum on laparotomy. Although there is an increased risk of placental invasion [increta and percreta] causing uterine rupture in previous caesareans but morbid adhesion resulting in placenta percreta without previous uterine surgery is a rarity. Exact pathogenesis is still unknown. Prenatal diagnosis with the help of Doppler ultrasound and MRI is important to reduce both fetal and maternal morbidity and mortality

Primary PPH; Role of uterine packing in control of haemorrhage

To determine the effectiveness and safety of uterine packing in selected cases of primary postpartum haemorrhage. Cross-sectional study. The study was conducted at Jinnah Postgraduate Medical Centre, Karachi, From September 2003 to April 2008. Women developing primary PPH due to uterine atony, placenta previa and coagulation failure were selected for uterine packing. Firm packing was done with enormous length of sterile ribbon gauze, using 'layering technique' under prophylactic antibiotic cover. Vagina was also packed to give additional pressure. Pack was removed after 12 - 36 hours or early in case of failure to control haemorrhage. Pulse, blood pressure, soakage of pads, height of uterine fundus and temperature were monitored to assess effectiveness and safety. 39 women were included in the study. Cause of PPH was uterine atony in 30 [76.9%], coagulation failure in 5 [12.8%] and placenta previa in 4 [10.3%] cases. Packing was successful in arresting haemorrhage in 32 [82.1%] and failed in 7 [17.9%] cases; 95% Confidence Interval 67-91. There was no case of concealed haemorrhage, four patients developed emdometritis and none had delayed haemorrhage. 13 laparotomies were prevented. The difference between the causes of haemorrhage in successful and failed cases did not show a definite trend. If employed early, uterine packing is a quick, effective and safe method for controlling primary PPH in carefully selected cases

Therapeutic termination of second trimester pregnancies with low dose misoprostol

To determine the effectiveness of 50micro g misoprostol for midtrimester termination of pregnancies. Experimental, cross-sectional study. Department of Gynaecology and Obstetrics, Unit II, Jinnah Postgraduate Medical Centre, Karachi, a tertiary care centre, from 1st Jan 2003 to 30th June 2005. The study subjects were 54 pregnant women admitted during the 2nd trimester [14-26 weeks] of gestation, willing or requiring termination of pregnancy. Those patients were included in the study who were admitted with closed cervical os, either had intrauterine death, fetal anomaly, medical disorder [hypertension or diabetes] or history of previous ceasrean section. Cases of placenta previa, acute asthma, glaucoma, cardiac diseases and allergy to prostaglandins were excluded. Each patient received 50micro g misoprostol intravaginally. Maximum 4 doses were given at 4 hours interval and state of cervical os was assessed by vaginal examination before insertion of next dose or at the onset of uterine contractions. After 4 doses of misoprostol, patients were kept under observation and watched for uterine contractions to start or for expulsion of products. Syntocinon infusion was started to augment labour where products of conception failed to expel out inspite of open os. Outcome measures include success rate of termination within 12, 24, 36 and 48 hours, mean induction - abortion time interval and maternal side effects. The success rate of termination within 12, 24, 36 and 48 hours were 27.7%, 83.3%, 94.4% and 96.3% respectively. Mean induction to abortion time interval, in case of abortion within 48 hours, was found to be 18.9 +/- 11.58 [range 4-48 hours]. Dead fetuses were aborted earlier than alive fetuses. The mean induction abortion time interval was 17.01 +/- 8.7 hours in dead and 23.4 +/- 15.9 hours in alive fetuses [t -value:1.9, p: 0.05]. Two patients failed to deliver within 48 hours of induction. Two patients suffered from febrile illness. Vaginal administration of 50 micro g misoprostol every 4 hourly is an effective and safe agent for ripening of cervix and convenient way of inducing abortion during 2nd trimester of pregnancy in a women either with alive or dead fetus. It is associated with a low frequency of side effect