A double-blind randomized trial of two dose regimens of misoprostol for cervical ripening and labor induction.

OBJECTIVES: The objective of this study was to compare the efficacy and safety of two dosing regimens of misoprostol for cervical ripening and labor induction. METHODS: Patients who fulfilled the study criteria were randomized to received misoprostol 25 microg or 50 microg intravaginally every 3 h for a total of eight doses for cervical ripening or until labor was established. Endpoints for successful cervical ripening was achievement of Bishop score of nine or greater, and for labor induction reaching the active phase of labor in the first 24 h. The rates of success, duration of first and second stages of labor, type of delivery, significant side effects, and neonatal outcome were measured and compared between the two study groups. Two hundred and fifty-one patients were randomized in two groups--126 received 50 microg and 125 received 25 microg misoprostol. Demographics of the two study groups were similar. RESULTS: Patients in the 50 microg group had a shorter first stage (848 min vs. 1,122 min, P < 0.007), shorter induction-to-vaginal delivery interval (933 min vs. 1,194 min, P < 0.013), decreased incidence of oxytocin augmentation (53.9% vs. 68%, P < 0.015), and decreased total units of oxytocin (2,763 mU vs. 5,236 mU, P < 0.023), but there was a higher hyperstimulation rate (19% vs. 7.2%, P < 0.005). CONCLUSIONS: Successful induction rate, delivery types, and fetal outcome were similar in both groups. Although the rate of vaginal delivery and neonatal outcome were similar in both groups, the 50 microg regimen had shorter first and second stages of labor, and a higher hyperstimulation rate that was easily manageable, allowing for flexibility in using the higher dose in low-risk pregnancies.

Prenatal care in cocaine-exposed pregnancies.

OBJECTIVE: To examine the effect of prenatal care with and without drug rehabilitation on perinatal outcome in cocaine-using women. METHODS: Cocaine-exposed pregnancies of 905 human immunodeficiency virus (HIV)-negative women were frequency matched (ratio 6:1) and compared with 150 nonusers. Cocaine subgroups consisted of 278 women who received prenatal care and drug rehabilitation ("comprehensive care"), 206 women who received prenatal care only, and 421 who received neither. Maternal and fetal complications, drug screening, and attendance were recorded. Pregnancy rates and HIV seroconversion were determined over the year following delivery. RESULTS: The groups were similar in age, race, education and poverty level. Linear trends of increasing incidence of maternal complications were seen across the four groups. Comparing nonusers with cocaine users, the odds ratios, with 95% confidence intervals were: 28.0 (4.2, 103.2) for both anemia and weight under 100 lb; 2.4 (1.8, 5.0) for urinary tract infections; 15 (4.6, 36.1) for syphilis; and 11.2 (4.0, 35.8) for other sexually transmitted diseases. Perinatal outcome measures were similar for nonusers and "comprehensive care" groups but significantly worse for the other two groups. Four maternal deaths and two myocardial infarctions occurred with no care. Positive toxicology at delivery was 1.5 and 4.3 times more likely for the two groups without drug treatment, than for "comprehensive care." Congenital anomalies and HIV seroconversion increased in cocaine users. Repeat pregnancy was less likely and more often drug free with "comprehensive care." CONCLUSION: "Comprehensive care" of the cocaine-using gravida increases the likelihood of carrying to term, having fewer complications, being drug free at delivery, and having fewer exposed repeat pregnancies.

Patterns of cocaine binging: effect on pregnancy.

OBJECTIVE: The purpose of this study was to determine how cocaine and crack binging affected perinatal complications. STUDY DESIGN: Between Jan. 1 and Dec. 31, 1989, patterns of cocaine-crack binging and perinatal consequences in 905 pregnant women from multiethnic, multiracial, inner-city populations were studied. Binging cycles reflect the chaotic lifestyle of drug abuse and multiple obstetric at-risk cofactors as integral parts of binging and are more accurately defined than amount of drugs consumed. RESULTS: Binging patterns in 905 pregnant women who use cocaine-crack as their primary drug were as follows: group 1, 78 women with "erratic" binging that is variable in intervals, duration, and amounts but who are very aggressive drug seekers; group 2, 67 women who binged daily; group 3, 760 women who binged in cycles at 3-, 5-, 7-, or > 7-day intervals. Binges ranged from 26.4 to 34.4 hours. Complications were proportional to the frequency of binging, (linear association p < 0.0007). The prematurity rate in group 1 was unexpectedly as high as that in group 2 (35.9% vs 34.3%). Acute problems (vaginal bleeding 21.8%, abruptio placentae 14.3%, stillbirths 20.5%) were most significant in group 1, while chronic problems (small-for-gestational-age infants 32.8%, systemic infections 31.3%, anemia 35.6%, and low maternal weight [< 100 pounds] 32.8%) were more significant in groups 2 and 3. Odds ratios show that prematurity, abruptio placentae, and vaginal bleeding were two to three times more likely to occur if test results for cocaine were positive at delivery. However, in group 1 the likelihood of abruptio placentae was unchanged whether toxicologic test results were positive (14.3%) or negative (14.0%), reflecting the role of cofactors in binging. CONCLUSION: Erratic use of cocaine-crack results in perinatal complications that are as severe as those occurring with daily binging but the patterns differ. Cofactors play a significant role in outcomes.

Pregnancy outcome at greater than or equal to 20 weeks' gestation in women in their 40s. A case-control study.

The obstetric performance of 166 women in their 40s who delivered during a one-year period at greater than or equal to 20 weeks' gestation was compared to that of a cohort of controls younger than 40. Medical complications--diabetes, chronic hypertension and antepartum bleeding--occurred more frequently in the older patients. They had a threefold increase in antepartum hospital admissions over the controls (23.5% vs. 7.8%). Both groups had the same perinatal mortality rate, 18/1,000, and their newborns had similar incidences of neonatal complications except for a higher frequency of major and minor congenital anomalies in the study group (16% vs. 8.4%). The older patients had a longer second stage of labor. Older nulliparas had a higher incidence of premature deliveries and cesarean sections than did their controls. The outcome of pregnancy in this age group is affected by multiple confounding variables; medical complications, parity and age play major roles.

Premature rupture of the membranes before 28 weeks: conservative management.

The maternal and fetal outcomes of 70 consecutive singleton pregnancies with prolonged premature rupture of the membranes before 28 weeks, which were managed expectantly, were evaluated; 58.6% of the mothers developed chorioamnionitis and 13% postpartum endomyometritis. No long-term maternal sequelae were noted. None of the 22 infants born before 25 weeks survived the neonatal period. The weights of the 35 surviving infants ranged between 800 and 4100 gm. Only 29.4% of the 17 infants with long-term follow-up were both physically and developmentally normal at 6 months of age or more.