Titrated low-dose vaginal and/or oral misoprostol to induce labour for prelabour membrane rupture: a randomised trial.

OBJECTIVE: To evaluate the clinical effectiveness and safety of titrated low-dose misoprostol for induction of labour (IOL) in the presence of prelabour rupture of membranes (PROM). DESIGN: Randomised controlled trial. SETTING: Maternity units in the UK (9) and Egypt (1). POPULATION: Women >34 weeks of gestation with PROM, singleton viable fetus and no previous caesarean section. METHODS: Subjects randomised to IOL with a titrated low-dose misoprostol regimen (oral except if unfavourable cervix, where initial dose vaginal) or a standard induction method, namely vaginal dinoprostone followed by intravenous oxytocin if the cervix was unfavourable or intravenous oxytocin alone if the cervix was favourable. MAIN OUTCOME MEASURES: Primary outcome measures were caesarean section and failure to achieve vaginal delivery within 24 hours. Analysis was by intention to treat. RESULTS: The trial did not achieve the planned sample size of 1890 due to failure in obtaining external funding. Seven hundred and fifty-eight women were randomised (375 misoprostol and 383 standard). There were less caesarean section (14 versus 18%, relative risk [RR] 0.79; 95% CI 0.57-1.09) and less women who failed to achieve vaginal delivery within 24 hours in the misoprostol group (24 versus 31%, RR 0.79; 95% CI 0.63-1.00), but the differences were not statistically significant. Subgroup analysis showed that with unfavourable cervix, misoprostol may be more effective than vaginal dinoprostone. There was no difference in hyperstimulation syndrome. There were more maternal adverse effects with misoprostol, but no significant differences in maternal and neonatal complications. CONCLUSIONS: Titrated low-dose misoprostol may be a reasonable alternative for IOL in the presence of PROM, particularly in women with an unfavourable cervix. Safety and rare serious adverse events could not be evaluated in a trial of this size.

A randomised controlled trial of insulin lispro given before or after meals in pregnant women with type 1 diabetes--the effect on glycaemic excursion.

In order to study the glucose excursion associated with pre- and postprandial administration a randomised controlled trial with patients randomised to receive insulin lispro (IL) immediately before or after a standardised meal was performed. Pregnant women with diabetes who were treated with IL as part of a basal bolus regime were asked to bring their own usual lunch and administer their own IL. Maternal glycaemia was monitored preprandially and then at 15-minute intervals for 3 hours following the first bite of lunch. Glucose excursions were calculated by subtracting the preprandial glucose level from the subsequent values at each time point. Each woman was invited to attend on four occasions. On two random occasions she was asked to administer her IL after completing her meal and on two occasions IL was administered immediately before her meal. Nine women completed a total of 27 meals (14 preprandial IL and 13 postprandial IL). There was no significant difference between the mean (SD) fasting values between the two groups, before 5.8 (2.8) and after 5.7 (2.0) mmol/l. At each time-point there was no significant difference between the mean blood glucose excursion in the two groups. No patient suffered a hypoglycaemic attack and there was no evidence of fetal compromise. In the two groups there was a marked similarity in the glycemic excursion following a standard meal, whether or not IL was given before or after eating. Postprandial administration of IL may increase the flexibility of IL usage in pregnant women with diabetes.

Preliminary experience with the use of insulin lispro in pregnant diabetic women.

Insulin lispro (IL) possesses characteristics (decreased hypoglycaemia, greater convenience in timing of administration and better post-prandial glucose control) which may favour its use in women with diabetes. We report pregnancy outcomes in seven women with Type I diabetes treated with IL. Mean age was 30 years (2241), duration of diabetes from 3 to 21 years. Two were using IL pre-conception; others transferred at various stages of pregnancy. Mean daily dose of IL within the last month of pregnancy ranged from 0.59 to 1.13 U/kg. Mean HbA1C from 4.4 to 8.5%. Babies were delivered at 3438 weeks' gestation, birth weights from 2900 to 4125 g (mean 3434 g). There were no congenital abnormalities. All patients elected to continue with IL after pregnancy. Our experience suggests that IL is convenient and practical therapy for women with Type I diabetes in pregnancy.

Vaginal dilator therapy-an outpatient gynaecological option in the management of dyspareunia.

The management of 18 women complaining of superficial dyspareunia is reviewed. Primary treatment consisted of self-vaginal dilatation using graduated glass dilators on an outpatient basis. All patients were given verbal explanation and written instructions. Treatment was considered successful with dilator therapy in 14 (77.8%) women. Three (16.7%) women required additional therapy in the form of surgery or psychotherapy. We conclude that in selected cases, self-vaginal dilator usage on an outpatient basis is effective primary therapy for superficial dyspareunia.

Survival of cornual (interstitial) pregnancy.

We report a case of a singleton cornual (interstitial) pregnancy following spontaneous conception in a primigravida with no risk factors for ectopic pregnancy. She presented at 30 weeks gestation with haemoperitoneum, due to a small rupture on the posterior surface of the cornual pregnancy. At laparotomy, an incision was made in the cornu, the baby was delivered and survived after spending 39 days in a special care baby unit.