Vaginal misoprostol in the management of first trimester non-viable pregnancy

To study the effectiveness of a regimen of repeated doses of vaginal misoprostol in the management of first trimester missed abortion, one hundred and four pregnant women with first trimester non-viable pregnancies were treated with an initial dose of 800 ! g of vaginal misoprostol followed after four hours by further doses of 400 ! g four-hourly for a maximum of three doses. The complete expulsion rate was 85.6%. Fifty of the 104 [48.1%] women underwent surgical evacuation. In 14 [13.5%] women, gestational products were obtained and confirmed by histopathological examination. In 36 [34.6%] there were minimal or no products obtained and these were considered to be complete miscarriages. The cervical os was found open in all [13.5%] the incomplete miscarriages. Severe abdominal pain was experienced by 10.6% of the patients and excessive vaginal bleeding occurred in 13.5% of them. A fall in hemoglobin of more than one gram/dl occurred in 5.8% of the women and another 5.8% of them had fever >38°C. The stay in hospital was two days for 87 [83.7%] women and three days for 15 [14.4%] women. One [1%] woman stayed four days and another stayed less than one day. None of the women had any complications. This study demonstrated the efficacy and safety of vaginal misoprostol as a medical treatment for first trimester non-viable pregnancies using an initial dose of 800 ! g, followed after four hours by further doses of 400 ! g four-hourly for a maximum of three doses. This management also provided adequate cervical dilatation for surgical evacuation when complete expulsion did not occur

Ultrasound prediction fo fetal macrosomia in diabetic women and its effect on the route of delivery and the outcome of pregnancy

The purpose of this study is to review the maternal and neonatal outcome in pregnant diabetic women given a trial of labor and delivered macrosomic infants [>/= 4000 grams] and to assess the accuracy of birth weight prediction by ultrasound examination at term. One hundred and twenty-nine charts of pregnant diabetic women were reviewed, sixty eight women were given a trial of labor and delivered macrosomic fetuses [>/= 4000 grams], fifty of them had vaginal delivery and the other eighteen had caesarean delivery. In the other group, 61 patients delivered by elective caesarean section, for 41 of them the indication was fetal macrosomia [>/= 4000 grams] as estimated by ultrasound examination and in the other 20, it was due to clinical estimation of big baby. Maternal and neonatal complications were reviewed in each group. Maternal complications included lacerations, hemorrhage and infection and the neonatal complications evaluated were shoulder dystocia and associated birth trauma, asphyxia, and mortality. The accuracy of ultrasound in estimating fetal weight was also evaluated. Sixty eight [52.7%] women attempted a trial of labor, 73.5% delivered vaginally and 26.5% had a caesarean delivery. All, except two, had macrosomic fetuses [>/= 4000 grams]. Only one woman, of those who delivered vaginally, had postpartum hemorrhage due to atonic uterus. The incidence of shoulder dystocia for infants weighing 4000-4499 grams was 6.3% and those infants had the same incidence [6.3%] of brachial plexus injury. There was no perinatal asphyxia or perinatal mortality among those infants who were delivered vaginally. There were no maternal complications for women who had caesarean delivery after labor [18 patients] but there was perinatal asphyxia in two infants who were treated properly without any neurological sequele. Elective caesarean delivery was performed in 47.3% of the study population. There were no neonatal complications or perinatal mortality in this group of patients and only one woman had wound infection. The sonographic prediction fetal weight was accurate in 52.4% of the cases. The overestimation was in 50.8% of the estimated fetal weights and 49.2% of them were underestimated when compared to actual birth weights. Caution should be taken in the use of sonographic estimations of fetal weight to guide obstetric decisions concerning labor and delivery. Special consideration should be given to diabetic patients having fetuses with estimated fetal weights between 4000 and 4500 grams. Flexibility in the management of these patients is best, taking in consideration their previous obstetric performance and if the estimated fetal weight is closer to 4500 grams than to 4000 grams, it is perhaps, better to proceed to a primary caesarean delivery