Mifepristone for labour induction after previous caesarean section.

OBJECTIVE: To evaluate the efficacy and tolerance of mifepristone in women undergoing induction of labour at term after previous caesarean section. DESIGN: A prospective double blind placebo controlled trial. SUBJECTS: Thirty-two women at term (after 37.5 weeks' amenorrhea) who had had a previous caesarean delivery with a low transverse uterine incision. All women had a clear clinical indication for induction of labour with unfavourable cervical conditions (Bishop's score < 4). They were randomised to receive either 200 mg of mifepristone or placebo on days one and two of a four-day observation period. RESULTS: Thirteen women entered spontaneous labour: 11 were treated with mifepristone and two were in the control group (P < 0.01). Thirteen women, still with an unfavourable cervix on day four needed cervical ripening with vaginal tablets of prostaglandins. Of these, four had received mifepristone and nine the placebo. Mean oxytocin requirements were lower in the mifepristone group (P < 0.01) and the mean time interval between day one and start of labour was also significantly shorter in this group. Mode of delivery and neonatal outcome were similar in both groups. CONCLUSIONS: Induction of labour is facilitated in term women with prior caesarean section by the use of mifepristone. This induction agent appears safe and useful with no adverse events on the fetus or mother.

Methotrexate treatment of ectopic pregnancy: 100 cases treated by primary transvaginal injection under sonographic control.

OBJECTIVE: To evaluate safety and efficacy of intrasaccular methotrexate (MTX) for treatment of ectopic pregnancy (EP). DESIGN: Longitudinal nonrandomized trial of MTX treatment of EP. SETTING: Department of Obstetrics and Gynecology (A. Béclère Public Hospital, Clamart, France Paris-Sud University). PATIENTS: One hundred patients with an EP visualized by sonography. Patients were 31.4 +/- 4.8 years old, para 0 to 4, and gravida 0 to 7. Twelve patients had a past history of EP, and 18 had previously undergone tubal surgery. Inclusion score for proposed medical treatment used six criteria graded from 1 to 3: gestational age, initial hCG level, P level, existence of abdominal pain, size of hemoperitoneum, and diameter of hematosalpinx. Eleven patients had an EP with cardiac activity. Treatment consisted of MTX, 1 mg/kg, given locally under transvaginal sonographic control. RESULTS: Eighty-three of 100 patients were considered to be completely cured (return of hCG to < 10 mIU/mL). The success rate was 92.8% with an initial hCG level < 5,000 mIU/mL and 87% when the score was < or = 12. Seven of the 11 patients with an EP with cardiac activity were treated successfully, including 5 of 7 when the initial score was < or = 12, and all failures concerned cases with an initial score > 12. Twenty-eight of 83 patients treated successfully required more than one injection of MTX (additional doses being given intramuscularly) because of nonresolution of hCG levels. Follow-up hysterosalpingography was performed in 80 patients showing 90% tubal patency on the side of the treated EP. Of 58 patients wishing pregnancy, 34 pregnancies occurred, including 25 ongoing or delivered. We observed a low recurrence rate of EP (3 with 1 on the same side). CONCLUSION: Treatment by initial transvaginal injection of MTX under sonographic control appears to be simple and effective, with no demonstrable untoward effects. The tubal patency and subsequent fertility obtained appear satisfactory. The highest success rate is observed when hCG level is under 5,000 mIU/mL and/or a pretherapeutic score < or = 12 when EP is visualized by sonography.

[The value of RU-486 (mifepristone) in medical indications of the induction of labor at term. Results of a double-blind randomized prospective study (RU-486 versus placebo)]. / Intérêt du RU 486 (mifépristone) dans les indications médicales de déclenchement du travail à terme. Résultats d'une étude prospective randomisée en double aveugle (RU 486 versus placebo).

One hundred and twenty term women (> 37.5 weeks amenorrhea) with unripe cervixes (Bishop < 4) and with a clear clinical indication for labour induction were randomized to receive either mifepristone (RU 486) or placebo. The patients' regimens consisted of 200 mg of mifepristone on days 1 and 2 over an observation period of 4 days, with labour induction planned for day 4. Within 12 hours after taking the first tablet, fetal distress was diagnosed in 8 patients (3 in the Mifepristone group and 5 in the control group), who underwent immediate cesarean section. These 8 patients could not therefore participate in our survey and have been excluded from the final results. Forty one patients had spontaneous onset of labour, 31 in the mifepristone group and 10 in the control group (p < 0.001). Forty seven patients needed cervical maturation with prostaglandin, 32 from the control group and 13 from the mifepristone group (p < 0.001). Thirteen patients in each group had cervical maturation sufficient for classical labour induction. We noted that patients delivering vaginally needed significantly lower amount of oxytocin in the mefepristone group and that the mean time interval between day 1 and the onset of labour was also significantly shorter in this group. The high cesarean section rate (32%), which is equivalent in both the placebo and the treated groups, may be attributed to the fact most of the patients in this survey had high risk pregnancies. There was no difference in the occurrence of fetal distress during labour in the 2 groups. Neonatal parameters were similar in both groups. These results establish mifepristone as an induction agent for the initiation of labour in term women. Though more studies are needed, Mifepristone has shown itself to be safe and appropriate in situations where labor has to be induced in term women.

Return of reproductive performance after expectant management and local treatment for ectopic pregnancy.

The purpose of this study was to examine hysterosalpingographic findings and reproductive performance in patients previously managed non-surgically for ectopic pregnancy. Forty-nine patients with unruptured ectopic pregnancies were treated either by expectant management (n = 16) or medically (n = 33), using transvaginal methotrexate or sulprostone injection. The treatment was successful in 35 patients (71.5%), 12 out of 16 and 23 out of 33 in the two groups respectively. For all patients, follow-up currently varies from 3 to 52 months with a median follow-up of 16.6 +/- 11.2 months and 7.3 +/- 4.3 months in the two groups respectively. Hysterosalpingography was performed in 25 out of 26 patients who desired further pregnancy. We found evidence of tubal patency on the ectopic pregnancy treated side in 23 cases (92%). In this group, no recurrent ectopic pregnancy was observed. In the expectant management group, eight out of nine patients became pregnant, and the mean time to achieve pregnancy was 16.6 +/- 11.2 months. In the medical treatment group, eight out of 17 patients became pregnant and the mean time to achieve pregnancy was 8.6 +/- 4.2 months. In this last group, seven out of nine non-pregnant patients have had only a short follow-up, 4.5 +/- 3.2 months since treatment completion. No recurrent ectopic pregnancy was observed in this successfully treated group of patients who desired further pregnancy. We conclude that the medical approach to unruptured ectopic pregnancy is associated with a high rate of tubal patency and a reproductive performance similar to conservative surgical methods.

Conservative management of ectopic pregnancy: prospective randomized clinical trial of methotrexate versus prostaglandin sulprostone by combined transvaginal and systemic administration.

In a prospective randomized study, 21 patients with an unruptured tubal pregnancy were treated with local and systemic injection. On the day of diagnosis, methotrexate (MTX) (1 mg/kg) or sulprostone (500 micrograms) were injected into the gestational sac under transvaginal sonographic control. The systemic component consisted of an intramuscular injection of MTX (1 mg/kg) 3, 5, and 7 days after local injection or of sulprostone (500 micrograms) on the 1st 2 postlocal injection days. Methotrexate therapy was successful in 8 of 12 patients and sulprostone therapy in 6 of 9. Laparoscopy was then performed on the 7 unsuccessful patients: 3 of them had pain and hemoperitoneum and 4 of them had rising human choriogonadotropin (hCG) levels. One stomatitis after MTX and one cramping abdominal pain were observed. Thirteen of 14 successfully treated patients had initial hCG levels less than 5,000 mIU/mL. At subsequent hysterosalpinography, 13 of 14 patients had normal tubal configuration and patency. Three of 10 patients who desired another pregnancy had already achieved a normal intrauterine pregnancy. These results suggest that MTX and sulprostone were equally effective, and medical approach for the unruptured ectopic pregnancy may be restricted to patients with hCG less than 5,000 mIU/mL.

Prognostic value of cervical distensibility index measurement in the outcome of pregnancies with threatened premature labor.

Threatened premature labor remains a difficult diagnostic and therapeutic problem, and various clinical scores have been designed to evaluate its prognosis. This study presents the use of a cervicotonometer to measure cervical distensibility in 58 women hospitalized for threatened premature labor. This value will be used to determine whether preterm labor is preceded by preterm cervical maturation and thus to assess prognosis. The cervical distensibility index (CDI) obtained with the cervicotonometer was significantly elevated at the time of hospitalization in women who had a preterm delivery when compared to those who delivered at or after 37 weeks of amenorrhea, whereas clinical scores showed no difference between these two groups. No preterm deliveries occurred when the CDI was normal or low at the time of hospitalization. Therefore, CDI measurement, reflecting cervical maturation, seems to be a good prognostic indicator in premature labor.

[Simulation of ovulation using two types of LH-RH agonists]. / Stimulation de l'ovulation associée a deux modes d'utilisation des agonistes du LH-RH.

Luteinizing hormone-releasing hormone (LH-RH) agonists are being increasingly used in ovulation stimulation protocols in IVF programs. The results of two methods of utilization of LH-RH agonists are compared. There was difference in the ovarian response on the day of human chorionic gonadotropin (hCG) higher in the short protocol (69% vs 56%, P less than 0.001). The ongoing pregnancy rate per treatment cycle was similar in both groups (18% in the long protocol and 16% in the short protocol).

[Nul telediastolic flux. Prognostic value]. / Flux télédiastolique nul. Valeur pronostique.

42 fetuses over a period of 2 1/2 years have presented with absent end-diastolic velocity. In 6 of these cases the measurements that had been carried out before the 22nd week of pregnancy with later normalisation of the Doppler velocities did not constitute a poor prognostic sign. On the other hand, absent end-diastolic velocity after the 22nd week (36 fetuses) was a sign of chronic fetal distress. The fetal mortality was 33.2%. 19.45% of the infants had chromosome abnormalities and only 58% of these children were alive and healthy. 74% of the live infants were delivered by caesarean section. With these results we think that absent end-diastolic velocity is a simple diagnostic sign, but it warns us that we should carry out tests for the fetal karyotype.

[Celioscopy under local anesthesia for collecting oocytes for in vitro fertilization]. / Coelioscopie sous anesthésie locale pour recueil d'ovocyte en vue d'une fécondation in vitro.

Since 1960, laparoscopy under local anaesthesia has been gradually abandoned in France and until now oocytes for in vitro fertilization were collected under general anaesthesia, thus increasing the risk of allergic reactions to anaesthesia in these patients who usually undergo several operations. From February to May, 1983, at the Antoine Béclère Maternity, Paris, 50 laparoscopies were performed under local anaesthesia with lidocaine combined with neuroleptanalgesia with diazepam and fentanyl. The procedure was uneventful in 94% of the cases and only 3 women required general anaesthesia. At least one mature oocyte was collected in 46 of these 50 women and 4 pregnancies have already been recorded. Local anaesthesia enables the woman to participate fully in this first stage of in vitro fertilization, increases the out-patient activities of the hospital unit and reduces the cost of in vitro fertilization.