A randomised controlled trial of low-dose misoprostol and dinoprostone vaginal pessaries for cervical priming.

OBJECTIVE: We studied the efficacy of 25-microg misoprostol pessaries as either single or double dose compared with a 3-mg dinoprostone pessary for cervical priming. DESIGN AND SETTING: A randomised controlled trial in Singapore. POPULATION: One hundred and seventy-one women with term pregnancies and modified Bishop scores (mBS) < or =6 from 2003 to 2004. METHOD: Patients were randomised to single misoprostol dose, double misoprostol dose or the current dinoprostone regimen. MAIN OUTCOME MEASURES: Primary outcome was number of women who achieved favourable mBS >6 or active labour by day 2. Secondary outcomes were time interval from insertion to delivery, cardiotocographic abnormalities, delivery and neonatal outcome. RESULTS: More women in the misoprostol double-dose group (96.6%) and dinoprostone group (93%) achieved the primary outcome compared with the single-dose group (77.8%) (P = 0.003 and P = 0.03, respectively). There was no difference in secondary outcomes. More multiparous women achieve primary outcome compared with nulliparous women (odds ratio 0.21, 95% confidence interval 0.06-0.77). CONCLUSION: Double-dose misoprostol 25 microg is as effective as dinoprostone 3 mg inserts for cervical priming; both are more efficacious than a single-dose misoprostol pessary. Parity prognosticates the success of induction.

Induction policy and missed post-term pregnancies: a mathematical model.

The aim of this study was to compare the clinical performance of ultrasound dates and ultrasound dates combined with menstrual dates for the detection of post-maturity. A computer model was designed which uses the statistical distributions of the duration of normal pregnancy, day of ovulation in relation to the menstrual cycle and ultrasound error for estimating gestational age. The clinical performance of the different dating methods was then analysed from these variables, on simulations of 30,000 cases. The efficacy of different dating methods for detecting post-maturity was determined by generating receiver-operator characteristics (ROC) curves. The proportion of post-term pregnancies (294 days and over) predicted by the model (3.5%) agrees with published values. There is a steep rise in missed cases if induction is delayed beyond 10 days from the expected date of delivery, reaching 20% on day 294. Elective delivery on day 290 will detect 98.9% of cases destined to deliver post-term, with an induction rate of 10%; the respective figures for induction on day 294 are 79% and 3.8%. The ROC curves for the detection of post-maturity suggest that use of the mid-trimester biparietal diameter (BPD) is better than a 7-day or 10-day rule. Timing of elective delivery is the most important variable affecting the detection rate for post-maturity There is no advantage in using menstrual dates when ultrasound biometry is available.

Direct intrauterine fetal therapy in a case of bronchopulmonary sequestration associated with non-immune hydrops fetalis.

Bronchopulmonary sequestration associated with non-immune hydrops fetalis is generally recognized as a uniformly fatal fetal condition without fetal surgical intervention. We describe here the first case of such a condition treated successfully with direct intrauterine fetal therapy using digoxin and frusemide.

Analysis of cystic hygroma, ascitic, and pleural fluids by conventional lymphocyte culture and fluorescent in situ hybridization.

Serous fluids from cystic hygromas, pleural effusions, and ascites are an easily accessible and plentiful source of lymphocytes. The feasibility and reliability of using these as alternative sources to conventional amniotic fluid or fetal blood cultures have been studied here. In some cases of prenatal diagnosis, especially in pregnancies complicated by the presence of cystic hygromas and fetal hydrops, obtaining amniotic fluid or fetal blood can be difficult due to obstruction by the cyst or oligohydramnios. A total of 14 cases with fetal hydrops detected ultrasonigraphically between 15 and 33 weeks of pregnancy over a period of 1 year have been subjected to conventional amniotic fluid or fetal blood karyotyping, along with samples of fluids from cystic hygromas, ascites or pleural effusions as obtained. Pleural fluids (n = 4), cystic hygroma fluids (n = 5), and ascitic fluids (n = 6) were obtained. The culture failure rate was low, 2/14. Karyotypically, two of the fluids, both from cystic hygromas, were 45,X; the rest were normal. A rapid 1-day additional test of fluorescent in situ hybridization (FISH) was carried out on uncultured cells of the alternative fluids using probes for the most commonly occurring aneuploidies, 13, 18, 21, X and Y, with good results.

Uterine activity in dysfunctional labour and target uterine activity to be aimed with oxytocin titration.

Uterine activity was quantified using a transducer tipped intrauterine catheter in 75 nulliparous women with dysfunctional labour. The active contraction area profiles in these women were below the median levels reported for those who had normal progress of labour from our institution. When uterine activity was augmented with oxytocin, 90.7% progressed in labour and delivered vaginally. Six patients (8%) showed poor progress despite good uterine activity and had to be delivered by caesarean section (CS) for failure to progress and signs of cephalopelvic disproportion. The pre- and post-augmentation uterine activity were similar in those who delivered vaginally or by CS and was not helpful in identifying those who had cephalopelvic disproportion. Of the 75 women who had slow progress of labour, 50 had a contraction frequency of less than 1 in 3 min whilst 25 had a minimum frequency of 1 in 3 min or more. All except one in the latter group delivered vaginally when oxytocin was titrated to achieve a contraction frequency of 1 in 2 to 2 1/2 min which were clinically judged to be adequate based on a duration greater than 40 sec. Oxytocin should be titrated to achieve a target contraction frequency of 1 in 2 to 2 1/2 min lasting greater than 40 sec to achieve good obstetric outcome in those with dysfunctional labour.