Home subcutaneous metoclopramide therapy for hyperemesis gravidarum.

OBJECTIVE: To describe the use of subcutaneous (s.c.) metoclopramide in the outpatient treatment of hyperemesis gravidarum. STUDY DESIGN: In a retrospective design, women who received continuous s.c. metoclopramide for treatment of hyperemesis gravidarum were identified from a national database. Data analysis included weight at start and stop of treatment, frequency of resolution of symptoms, and side effects of medication. In addition, data were collected on adjuvant therapies. RESULTS: Between January and December of 1997, there were 646 women with hyperemesis gravidarum who received continuous s.c. metoclopramide on an outpatient basis. A total of 413 patients (63.9%) had complete resolution of symptoms. Seventy-five percent of patients had received one or more antiemetic medications before initiation of s.c. metoclopramide. A total of 192 patients (30.5%) reported at least one side effect related to treatment. The majority of reported side effects were considered mild and did not require discontinuation of s.c. metoclopramide. CONCLUSION: S.c. metoclopramide appears to be a safe, effective treatment for hyperemesis gravidarum. Outpatient treatment may result in decreased costs compared with inpatient hospitalization.

Home subcutaneous metochlopramide therapy for hyperemesis gravidarum.

Objective: To evaluate the efficacy, safety, and economics of home subcutaneous metochlopramide (Reglan) therapy for hyperemesis gravidarum.Methods: All charts of patients who underwent home therapy via a standard protocol utilizing a pump to administer metochlopramide subcutaneously between January 1994 and December 1995 were reviewed. Data were collected on the resolution of symptoms, reason for discontinuance of therapy, additional antiemetic therapy before, during, and after subcutaneous metochlopramide therapy, and side effects.Results: A total of 301 patients received home subcutaneous therapy with metochlopramide: 195 (64.8%) patients had complete resolution of symptoms, 32 (10.6%) patients discontinued therapy because of side effects, and 43 (14.3%) discontinued therapy because of worsening symptoms. A total of 16 (5.2%) patients discontinued therapy for other/nonspecific reasons. Two hundred twenty-two (73.8%) patients received one or more antiemetics prior to subcutaneous metochlopramide therapy. This number decreased to 6 (3%) of the group successfully treated who required any maintenance antiemetic after therapy was completed. One hundred sixty-four (54.5%) patients experienced some side effects. The vast majority of these were mild and did not require discontinuation of therapy. Eleven patients experienced extra pyramidal symptoms, 9 of which were discontinued therapy. The average daily costs for each home therapy patient was $265.00/day. This compares to the average daily costs of $1,370.00 for inpatient therapy for the same Diagnosis Related Group (DRG) in a Midwest five-hospital system.Conclusion: Home subcutaneous metochlopramide therapy appears to be a safe and effective treatment for hyperemesis gravidarum. The home setting results in decreased costs compared to inpatient hospitalization and may constitute a therapeutic, less stressful environment.

Prostaglandin E2 gel for cervical ripening in patients with an indication for delivery.

OBJECTIVE: To determine if labor can be induced safely and efficiently in patients with a medical or obstetric indication for delivery before 41 completed weeks of gestation by pre-induction cervical ripening with prostaglandin (PG) E2 gel. METHODS: One hundred eighteen women with confirmed indication for induction of labor before 41 completed weeks were randomized in a double-blind fashion to either intracervical PGE2 gel or placebo before induction by a standard oxytocin protocol. Data regarding the change in Bishop score, interval to complete dilation, maximal oxytocin dose required to establish labor, and route of delivery were collected. Apgar scores and umbilical artery pH were also recorded. RESULTS: The maximum oxytocin dose required to establish progressive labor was significantly lower in the PGE2 group (10.06 +/- 8.50 versus 13.35 +/- 9.27 mU/minute, P = .014). The cesarean rate was also significantly lower in the PGE2 group (13.1 versus 31.6%, P = .016). CONCLUSION: Pre-induction intracervical deposition of 1 mg PGE2 gel decreased the amount of oxytocin required to induce progressive labor and decreased the cesarean rate in patients who had medical or obstetric indications for delivery before 41 completed weeks. This was accomplished without negative effect on Apgar score or umbilical artery pH.

Trisomy 16 fetus surviving into the second trimester.

A 27-year-old gravida 4, para 3 was found to have anhydramnios at 14 weeks' gestation following a size/date discrepancy noted at her routine prenatal visit. A detailed ultrasound revealed multiple fetal anomalies including congenital heart defect, chest hypoplasia, and bilateral dysplastic kidneys. Karyotype revealed trisomy 16 in 15/15 cells from a tissue specimen obtained from the fetal cord insertion site following elective pregnancy termination.

Femoral-facial syndrome--prenatal diagnosis--autosomal dominant inheritance.

Fetal micrognathia and short, bowed femora were found on a routine prenatal ultrasonogram. At birth, a cleft palate and the characteristic facial appearance confirmed the diagnosis of the femoral-facial syndrome. (The femoral-facial syndrome [McKusick 137840] was first delineated by Daentl et al. [1975: J Pediatr 86:197-211] and called the "femoral hypoplasia-unusual facies syndrome." We prefer the "femoral-facial syndrome" because it is shorter, more easily translated, and because the McKusick catalog is the most widely recognized standard of nomenclature.) A paternal great uncle, deceased at age 4 years, seems to have had the same condition.

Effects of ultraviolet radiation on contact lens parameters.

Ultraviolet (UV) radiation has been proposed as an alternative method for contact lens disinfection. In order for UV radiation to be considered a viable contact lens disinfection method, its effects on lens polymers and parameters must be minimal. To evaluate this, soft contact lenses from each of the four FDA categories, soft lenses with handling tints, and rigid gas permeable (RGP) lenses were exposed to UV radiation in a controlled laboratory setting and their parameters measured. After 20 h of UV exposure, we found statistically significant changes in at least one parameter for each lens type evaluated. Most of these changes were small and within the error of measurement and, therefore, were not considered clinically significant. However, the group 2 soft lenses showed an increase in all four measured parameters--power, center thickness, diameter, and water content. These changes may have an impact on lens fitting characteristics and performance. Other than these changes for group 2 soft lenses, 20 h of UV exposure appeared to have little clinical effect on the contact lenses evaluated. This suggests that UV radiation may prove to be a feasible alternative method of disinfection for most types of contact lenses.

Intracervical prostaglandin in postdate pregnancy. A randomized trial.

A study was designed to see if incorporating intracervical administration of prostaglandin could affect the outcome of postdate pregnancies. All patients with verified dates, at least 41 6/7 weeks pregnant and enrolled in an antepartum testing schedule were randomized in a double-blind fashion to receive either 0.5 mg of prostaglandin E2 (PGE2) suspended in methylcellulose or a placebo of the gel alone. The gel was inserted directly into the cervical canal after the patient had a reactive/negative contraction stress test. The patient was then observed on an external fetal monitor for an hour before going home. A total of 23 patients received PGE2, and 20 received the placebo. Results were analyzed for the following: change in the Bishop score, lag time from dosage to delivery, spontaneous versus induced labor, cesarean section rate, length of labor and neonatal outcome. There were no significant differences between the groups except in the incidence of patients going into labor within 72 hours. The results indicate that, in general, 0.5 mg of intracervical PGE administered at greater than or equal to 41 6/7 weeks without subsequent oxytocin induction of labor did not appear to significantly alter the obstetric outcome.

Vaginal birth after cesarean: a comparison of maternal and neonatal morbidity to elective repeat cesarean section.

A retrospective study of vaginal birth after cesarean (VBAC) was conducted over 24 months. Of 152 women who had a previous cesarean, 141 were offered VBAC. Sixty-eight had an elective repeat cesarean, and 73 agreed to VBAC. These groups were similar with respect to age, race, parity, and weight. Fifty-nine of the VBAC patients delivered vaginally (80.8%). The two groups were compared for the incidence of febrile morbidity, endomyometritis, uterine dehiscence and estimated blood loss at delivery. There were no significant differences between the two groups or when each was compared with a control group of 69 routine vaginal deliveries except for the estimated blood loss and the number of days hospitalized (p less than 0.05). Neonatal morbidity was examined between the two groups by comparing the incidence of transient tachypnea and the number of newborns with suspected sepsis, as well as those requiring antibiotics or admission to the Neonatal Intensive Care Unit. The repeat cesarean group had a higher overall incidence of neonatal morbidity than the VBAC group, but this was not statistically significant. However, there was statistical significance (p less than 0.05) when comparing the number of days hospitalized between the infants in the VBAC group versus the repeat cesarean group. This study supports VBAC as a safe alternative to elective repeat cesarean for the patient and neonate. Data analysis was performed using Student's t test or chi-square analysis with a p less than 0.05 regarded as being statistically significant.

Congenital pulmonary atresia with intact ventricular septum, tricuspid insufficiency, and patent ductus arteriosus in two sibs.

Pulmonary atresia comprises only 1% of all congenital heart defects. Counseling the parents on recurrence risks is difficult. We present a rare case of pulmonary atresia in two sibs, along with a review of the literature.

The use of 15 methyl F2 alpha prostaglandin (Prostin 15M) for the control of postpartum hemorrhage.

Postpartum hemorrhage is a potentially life-threatening obstetric complication. A 22-month experience treating postpartum hemorrhage with Prostin 15M patients who had not responded to conventional therapy is presented. A total of 26 patients were treated. There were 22 successes and 4 failures (84.6% success rate). Two failures were documented placenta accreta. Side effects occurred in 13 of the 26 patients and were generally mild. This group of patients is at risk for significant blood loss as well as blood replacement. The treatment of postpartum hemorrhage with intramuscular Prostin 15M was found to be safe and effective.