Comparison of oral and vaginal misoprostol for cervical ripening before evacuation of first trimester missed miscarriage

To assess the effectiveness of misoprostol in cervical ripening before evacuation of conception in the first trimester missed miscarriages, and to compare between oral and vaginal routes of administration. A randomized controlled study was carried out in Baghdad Teaching Hospital, Baghdad, Iraq in 2006. One hundred and twenty women with first trimester missed miscarriages were divided into 2 study groups, randomized for oral and vaginal 400 mcg misoprostol priming of cervix, and 2 control groups randomized for oral and vaginal placebo, before undergoing surgical evacuation of conception after 3 hours. Measured outcomes were: post medication cervical dilatation, time needed to dilate the cervix surgically, blood loss, and development of the side effects of misoprostol. Post medication cervical dilatation was higher in the misoprostol group 7.07 +/- 1.36 mm for oral misoprostol, 7.77 +/- 1.22 mm for vaginal misoprostol, versus the control groups 2.43 +/- 0.5 mm. Post medication cervical dilatation was significantly higher in the vaginal misoprostol group, compared to the oral group p = 0.04. The time required to dilate the cervix in the misoprostol group was shorter, compared with placebo. There were no significant differences in the amount of blood loss between oral p = 0.74, and vaginal misoprostol groups p = 0.62, and gastrointestinal side effects were significantly more in the oral misoprostol group p = 0.014. Misoprostol is an effective cervical priming agent when administered either orally or vaginally before evacuation of conception in the termination of the first trimester missed miscarriage

Maternal mortality ratio [MMR] in Baghdad Health Directorate-Risafa [BHD-R] hospitals: 2002-2004

The aim of this paper is to report the MMR in Risafa district hospitals during 3-year period. Data were collected from questionnaires completed and sent voluntarily to the Maternal and child [MCH] department by the attending obstetricians. Data were analyzed regarding the possible cause of death, type and place of delivery, age group and state of antenatal care attendance. 31 maternal deaths in hospitals were reported among 107605 hospital live births during the study period. MMR was estimated to be 28.8/ 100 000 live births. The leading direct cause of death was hemorrhage accounting for 65%, thromboembolism accounting for 13%, hypertensive disorders and early pregnancy complications. The low MMR in this study is probably due to under-reporting and lower attendance rates. Priorities should be set towards a more accurate documentation and reporting of deaths in hospitals. Policies to reduce avoidable causes of death in terms of system support, training; and the adoption of international guidelines while formulating national guidelines

Obstetrics in Iraq between reality and hopes for the future

The science of obstetrics had far advanced during the 20[th] century in terms of decreasing maternal mortality rates [MMR] and perintatal mortality rates [PN MR]. This was at the expense of increasing cesarean section rates. Nevertheless when cesarean section rates exceeded 25% during the eighties of last century people started to think why and started working to decrease this level. In Iraq we have increasing rates of C.S [C.S.R] in addition to high maternal and perinatal mortality rates. We have to ask ourselves why and what is wrong with our obstetric practice.To summarize: 1- Labor rooms in major obstetric hospitals lack facilities for observation and follow up of high risk pregnancies and deliveries like cardiotochographs and fetal PH estimation devices rendering these rooms similar to what a home birth attendant has gloves, 20[th] century sonicaid. 2- The Ex-system that used to pay the obstetrician for cesarean section and not for vaginal birth, that led many obstetricians to harvest cesarean section from labor rooms. 3- Senior house officers spend their first year of training in rural hospitals, which have no facilities to learn scientific obstetrics. 4- Lack of evaluation of residents in obstetrics and poor economic states that led many of them to seek other jobs to improve their income. 5- Lack of training programs in obstetric emergencies and neonatal resuscitation and many residents are faced with these emergencies [Live] in the labor room for the first time. 6- Home birth attendants interfere and exceed their limitation like early rupturing of membranes before labor and oxytocin injection. 7- Private hospitals again have the same facilities of government hospitals [gloves, sonicaid and cesarean section]. Now what are the suggested solutions? 1-Improve labor room facilities in major central hospitals in Baghdad and governorates and until then senior house officers should not waste their first year of training residency in rural hospitals. One can benefit from services of doctors serving their obligatory rural areas to run these labor rooms until improvement of these rural hospitals. 2- Allow a system of overlap between first and second year residents in obstetrics in central hospitals so as not leave a gap where no resident is present in hospitals. 3-Try to decrease cesarean section rates by first counting the total rate then correct the rate against non- preventable sections point out cases where one can decrease the rate through them and discuss these cases through peer review. Count cesarean section rates for every senior obstetrician. 4-Establish training programs for obstetric risk assessment and emergency management which should be obligatory to all those training and practicing obstetrics and put these programs under testing in terms of decreasing PN MR and MMR. 5- Rules should be put and strictly applied to manage home- birth- attendants who exceed their limitations and make complications in terms of morbidity and mortality