Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester.

BACKGROUND: Cesarean scar pregnancy (CSP) is a serious complication of pregnancy, which consists of implantation of the gestational sac in the hysterotomy scar. This condition is increasing in frequency and often poses a diagnostic challenge. Its diagnosis is dependent on visual assessment of the uterus on the longitudinal sagittal ultrasound plane. Misdiagnosing a low intrauterine chorionic sac as a CSP, or a true scar pregnancy as an intrauterine pregnancy (IUP), may lead to adverse outcomes including hysterectomy. OBJECTIVE: The objective of the study is to describe a sonographic method for the differential diagnosis of CSP vs IUP in early gestation. The current study tests the hypothesis that on a first-trimester ultrasound performed between 5-10 weeks of gestation, the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus can be used for early detection of CSPs. STUDY DESIGN: This is a retrospective review of electronically archived ultrasound images of IUP and CSP between 5-10 weeks of gestation. A total of 242 ultrasound images were analyzed: 185 cases of normal IUPs (including 128 in anteverted uteri, 31 in retroverted uteri, and 26 IUPs with history of cesarean delivery) and 57 cases of CSPs diagnosed from 2004 through 2015 in a single institution. The following measurements were made for each case: distance from the external cervical os to the uterine fundus, the midpoint axis of the uterus, the distance from the external cervical os to the center of gestational sacs, and the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix. RESULTS: The location of the center of the gestational sac relative to the midpoint axis of the uterus between 5-10 weeks of gestation differentiated between IUP and CSP (mean 17.8 vs -10.6 mm, respectively, P = .0001), indicating that most CSPs are located proximally to the midpoint axis of the uterus whereas most normal IUPs are located distally from the midpoint of the uterus. Using location of the center of the gestational sac as a marker of CSPs between 5-10 weeks of gestation yielded the following characteristics of diagnostic accuracy: sensitivity 93.0% and specificity 98.9%. The likelihood ratio of the positive test was 84.5. The likelihood ratio of the negative test was 0.07. CONCLUSION: The location of the center of the gestational sac relative to the midpoint axis of the uterus can be used as an easy method for sonographic differentiation of IUP and CSP between 5-10 weeks of gestation.

Evaluation and management of postpartum hemorrhage: consensus from an international expert panel.

BACKGROUND: Postpartum hemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide, although the lack of a precise definition precludes accurate data of the absolute prevalence of PPH. STUDY DESIGN AND METHODS: An international expert panel in obstetrics, gynecology, hematology, transfusion, and anesthesiology undertook a comprehensive review of the literature. At a meeting in November 2011, the panel agreed on a definition of severe PPH that would identify those women who were at a high risk of adverse clinical outcomes. RESULTS: The panel agreed on the following definition for severe persistent (ongoing) PPH: "Active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures including first-line uterotonic agents and uterine massage." A treatment algorithm for severe persistent PPH was subsequently developed. Initial evaluations include measurement of blood loss and clinical assessments of PPH severity. Coagulation screens should be performed as soon as persistent (ongoing) PPH is diagnosed, to guide subsequent therapy. If initial measures fail to stop bleeding and uterine atony persists, second- and third-line (if required) interventions should be instated. These include mechanical or surgical maneuvers, i.e., intrauterine balloon tamponade or hemostatic brace sutures with hysterectomy as the final surgical option for uncontrollable PPH. Pharmacologic options include hemostatic agents (tranexamic acid), with timely transfusion of blood and plasma products playing an important role in persistent and severe PPH. CONCLUSION: Early, aggressive, and coordinated intervention by health care professionals is critical in minimizing blood loss to ensure optimal clinical outcomes in management of women with severe, persistent PPH.

Mifepristone vaginally in an early medical abortion regimen: a pilot study.

OBJECTIVE: This prospective observational pilot study was undertaken to assess the efficacy of mifepristone and misoprostol, both administered vaginally. The ultimate goal is to investigate alternative means of reducing the time interval between the two treatments involved. The efficacy of the early medical abortion regimen utilizing mifepristone and misoprostol is beyond doubt. The regimen usually involves administering misoprostol 36 h following oral administration of mifepristone. The interval between the two treatment components might affect a woman's choice of the medical method. METHODS: Eighteen women undergoing abortion for nonmedical reasons were recruited. RESULTS: Seven women required further intervention to achieve complete abortion. Median induction-to-abortion interval was 7.66 h in the 11 women with complete abortion. CONCLUSION: The complete abortion rate of 61% in this study was lower than that with the standard medical regimen.

Vaginal azithromycin and misoprostol before surgical abortion.

Vaginally administered oral azithromycin tablets and specially formulated azithromycin and misoprostol vaginal pessaries achieved tissue levels significantly higher than those required to treat chlamydial infection.

Oral, rectal, and vaginal pharmacokinetics of misoprostol.

OBJECTIVE: To compare the pharmacokinetic profiles of orally, rectally, and vaginally administered misoprostol tablets in pregnant women. METHODS: Women between 7 and 14 completed weeks of gestation were recruited and randomly assigned to be given 400 microg misoprostol orally, rectally, or vaginally 3 hours before surgical termination of pregnancy. Blood samples were obtained at 0, 7.5, 15, 30, 45, 60, 90, 120, and 240 minutes and later analyzed for plasma concentrations of misoprostol free acid (the principle metabolite). RESULTS: Vaginal misoprostol was present in the circulation longer than oral misoprostol and had a greater area under curve at 240 minutes (P <.001). Rectal misoprostol had a similar pattern but a much lower area under curve at 240 minutes. Oral misoprostol had a significantly greater peak plasma concentration and a shorter duration to maximum concentration than either rectal or vaginal misoprostol (both P <.001). CONCLUSION: Oral misoprostol tablet is also absorbed by the rectal and vaginal routes. Misoprostol administered in early pregnancy has route-dependent pharmacokinetics and is absorbed best when administered vaginally. LEVEL OF EVIDENCE: I

Prostaglandins in the prevention and management of postpartum haemorrhage.

Myometrial contractility is integral to the delivery of the placenta and the arrest of potential subsequent haemorrhage. The details of this physiological process are patchy but it is clear that there is an important hormonal contribution. Oxytocin, with or without ergometrine, has thus been widely used with a recognized beneficial treatment effect. This practice, however, was never universal. The injectable nature of these agents restricted their wider use, even in societies with average medical services. The availability of the prostaglandin analogue misoprostol has renewed interest in the third stage of labour, has taken its pharmacological management to new frontiers, and has expanded the therapeutic options for the management of postpartum haemorrhage.

Pharmacokinetics and adverse-effect profile of rectally administered misoprostol in the third stage of labor.

OBJECTIVE: To characterize the pharmacokinetics and adverse-effect profile of rectally administered misoprostol. METHODS: To assess absorption of rectally administered misoprostol, 20 women were randomized to receive misoprostol 600 microg by either oral or rectal administration after delivery. Blood samples were obtained at 0, 7.5, 15, 30, 45, 60, 90, 120, and 240 minutes and analyzed for serum concentrations of misoprostol free acid by enzyme-linked immunosorbent assay. Additionally, 275 women were randomized to receive rectal 400 microg, rectal 600 microg, or oral 600 microg misoprostol after delivery. Self-assessment questionnaires were used to ascertain the adverse-effect profiles. RESULTS: Misoprostol tablets are absorbed rectally even though they are formulated for oral use. The area under the curve (integral of concentration and time graph) for rectal misoprostol was higher by 121 pg.h/mL (95% confidence interval [CI] -4.2, 246.2) than for oral misoprostol. The rectal route group had a mean maximum serum concentration 144 pg/mL lower than that for the oral route (95% CI 63, 225). This maximum was achieved on average 23 minutes later than in the oral group (95% CI 10, 35). Shivering was reported by 76% of the patients in the oral 600-microg arm, 56% of the patients in the rectal 400-microg arm, and 54% of the patients in the rectal 600-microg arm. The relative risk of shivering in the combined rectal groups is 73% that of the oral group (95% CI 61%, 86%). Severe shivering reported by patients was significantly reduced, by 72%, in rectal groups compared with the oral group (95% CI 60%, 81%). CONCLUSION: Misoprostol administered rectally is associated with lower peak levels and a reduction in adverse effects compared with the oral route. Increasing rectal doses may achieve higher efficacy without reducing the acceptability of the treatment.

Dinoprostone versus misoprostol: a randomized study of nulliparous women undergoing induction of labor.

BACKGROUND: The objectives of the study were to compare the efficacy and safety of intravaginal misoprostol and intravaginal dinoprostone for induction of labor and to quantify the clinical response to suspicious cardiotocographic (CTG) readings. METHODS: One hundred and ninety-one patients were randomized to receive either 50 micro g misoprostol initially then a further identical dose 6 h later or 2 mg dinoprostone initially followed by 1 mg 6 h later, over a period of 24 h. If not in labor after 24 h, then both arms of the study would thereafter receive dinoprostone alone as per hospital protocol. RESULTS: The induction to delivery interval (1047 vs. 1355 min, p = 0.01), delivery within 12 h (35.4% vs. 18.9%, p = 0.02) and delivery within 24 h (83.3% vs. 63.3%, p = 0.01) were all shorter in the misoprostol arm. There were no differences in rates of oxytocin augmentation (p = 0.47), tachysystole (p = 0.32) and hyperstimulation syndrome (p = 0.82). There was an increase in the median number of times a doctor was called to advise on a suspicious CTG in the misoprostol group (1 vs. 2 occasions, p = 0.052), but there was no difference in neonatal outcome. CONCLUSIONS: Intravaginal misoprostol led to a shorter, more efficient labor, and although there was more anxiety related to the CTG, there was no increase in neonatal adverse effects.

Randomized trial in multiparous patients: investigating a single vs. two-dose regimen of intravaginal misoprostol for induction of labor.

BACKGROUND: Multiparous patients have a higher risk of hyperstimulation and uterine rupture than nulliparous patients. The minimum possible dose of uterotonic drug should be used in induction of labor for multiparous patients to avoid excessive uterine activity, which could increase both maternal and fetal risks. METHODS: One hundred and four women were randomized to either a single dose of 50 micro g of intravaginal misoprostol in 24 h, or two consecutive doses of intravaginal 50 micro g misoprostol 6 h apart. RESULTS: The mean induction to delivery interval (789 min [95% CI: 637-941] vs. 576 min [95% CI: 484-667], p = 0.018) and delivery rate within 12 h (63% vs. 83%, p = 0.035) were higher in the two-dose group. The oxytocin augmentation rate (14% vs. 2%, p = 0.03) was higher in the single-dose group. There was a higher rate of clinician input related to suspicious cardiotocographic readings in the single-dose arm (p = 0.04). There was no statistical difference (p > 0.05) between the one- and two-dose regimens with respect to the rates of tachysystole (21% vs. 15%), hyperstimulation (3.9% vs. 0%), and meconium staining at delivery (9.8% vs. 13.2%). CONCLUSIONS: The two-dose regimen was most efficient, but both regimens were well tolerated by the fetuses.

Post-partum haemorrhage: definitions, medical and surgical management. A time for change.

Any woman who gives birth can have post-partum haemorrhage which may threaten her life. PPH is one of the leading causes of maternal mortality and an important cause for serious morbidity in the developing and developed world. We are at the threshold of major developments in its prevention and treatment due to changing ideas about its definition and medical and surgical management. The implementation of these changes is an essential part of a wider commitment towards saving mothers from complications of childbirth.