Midtrimester medical termination of pregnancy: a review of 1002 consecutive cases.

We assessed the effectiveness, safety and factors that affected the outcome of midtrimester medical termination of pregnancy at 13-21 weeks gestation. Of the 1002 women, 3 took mifepristone and decided to continue with the pregnancy, with 999 women being compliant with the regimen. Of these, 2 women aborted prior to administration of misoprostol and 970 (97.1%) aborted successfully within five doses of misoprostol. Surgical intervention was necessary to complete the abortion process in 81 (8.1%) women. Women with no previous pregnancy (p = 0.02), no previous live birth (p = 0.0001) and gestations 17-21 weeks (p = 0.001) required more prostaglandin. Younger women (p = 0.0001) and women with a previous live birth (p = 0.001) were more likely to have a successful abortion. The induction abortion interval was significantly longer with increasing gestation [95% confidence interval (CI) difference in means: -2.52 to -0.89, p = 0.0001], increasing age (p = 0.0001) and no previous live birth (95% CI difference in means: -0.25 to -1.01, p = 0.0001). Surgical intervention was more likely to be required with increasing age (p = 0.008). Mifepristone in combination with misoprostol is a safe and effective regimen for midtrimester medical abortion with younger women and those with a previous live birth more likely to have a successful abortion.

Medical management of early fetal demise using a combination of mifepristone and misoprostol.

BACKGROUND: This study aims to assess the efficacy of a combination of mifepristone and misoprostol in the management of missed miscarriage and anembryonic pregnancy. METHODS: Data of 220 consecutive women with miscarriage, undergoing medical evacuation of the uterus were collected prospectively at an early pregnancy assessment unit in a tertiary referral hospital. Each woman received a single oral dose of mifepristone 200 mg and 36-48 h later vaginal misoprostol 800 microg. Three hours following the first dose, two further doses of misoprostol, 400 microg each, were administered vaginally or orally at 3 h intervals. Women who failed to pass products of conception were offered repeat medical regime with misoprostol. Success was defined as complete uterine evacuation within 3 days, without the need for surgical evacuation. RESULTS: The overall success rate of medical management was 84.1%. Mifepristone alone induced natural expulsion of products of conception in 18.1% of women. The median dose of misoprostol required was 1600 microg and the median induction miscarriage interval after first prostaglandin administration was 8.04 h (range: 0.58-50.54 h). Of the 142 women who were symptomatic at presentation the medical regime failed in 30 (21.1%), compared with five (6.4%) failures of the 78 who were asymptomatic (P = 0.007). Of the 35 women who had surgical evacuation, eight required an emergency curettage for bleeding. CONCLUSIONS: The combination of oral mifepristone 200 mg with vaginal or oral misoprostol is an alternative to surgical management of early fetal demise, although it is not as effective as surgery.

Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries.

The objective of the study described is to assess the feasibility and effectiveness of using a criterion-based clinical audit to measure and improve the quality of obstetric care at the district hospital level in developing countries. The focus is on the management of five life-threatening obstetric complications--hemorrhage, eclampsia, genital tract infection, obstructed labor and uterine rupture was audited using a "before and after" design. The five steps of the audit cycle were followed: establish criteria of good quality care; measure current practice (Review I); feedback findings and set targets; take action to change practice; and re-evaluate practice (Review II). Systematic literature review, panel discussions and pilot work led to the development of 31 audit criteria. Review I included 555 life-threatening complications occurring over 66 hospital-months; Review II included 342 complications over 42 hospital-months. Many common areas for improvement were identified across the four hospitals. Agreed mechanisms for achieving these improvements included clinical protocols, reviews of staffing, and training workshops. Some aspects of clinical monitoring, drug use and record keeping improved significantly between Reviews I and II. Criterion-based clinical audit in four typical district hospitals in Ghana and Jamaica is a feasible and acceptable method for quality assurance and appears to have improved the management of life-threatening obstetric complications.

Mifepristone as a late post-coital contraceptive.

This study was undertaken to assess the efficacy of mifepristone as a post-coital contraceptive beyond 72 h and up to 5 days in women who found the intrauterine contraceptive device (IUCD) unacceptable. During a 2 year period 219 consecutive women fulfilling the inclusion criteria and presenting late for emergency contraception were approached and offered a choice of methods. Fifteen (6.8%) women wished to have the IUCD fitted, but 204 (93.2%) who found this unacceptable were offered and accepted mifepristone 200 mg. In one woman there was a technical problem fitting the IUCD and mifepristone was administered. Women who had mifepristone were younger (mean age 21.4 versus 26.9 years, P = 0.004) and more likely to be nulliparous (81 versus 25 %, P < 0.001) than the IUCD group. A total of 155 (75.6%) women who had mifepristone and all 14 who had the coil fitted were followed up. There were no true failures in either group. There was one user failure in the mifepristone group, where pregnancy occurred from an act of intercourse subsequent to treatment, giving a crude pregnancy rate of 0.65%. Mifepristone prevented 85% of expected pregnancies. Most women find the IUCD an unacceptable method of post-coital contraception. Mifepristone is an effective late post-coital contraceptive, which can be offered to women who decline the IUCD.

Screening based on risk factors for gestational diabetes in an Asian population.

The results of glucose tolerance testing (OGTT) in 1004 consecutive women were examined with respect to risk factors for gestational diabetes mellitus (GDM). GDM was diagnosed in 41 of 1004 (4.08%) women. GDM was present in 7.8% of women aged over 35 years (compared to 3.1% if less than 35 years), in 8.1% women with a body mass index (BMI) >/=30 (compared to 3.6% if BMI <30) and in 5.2% of women with a family history of diabetes (compared to 3.9% in the absence of family history of diabetes). Past history of macrosomic babies (over 4 kg) was present in 12.1% of GDMs compared to 8.4% of non-diabetic pregnancies (NDP). A history of unexplained perinatal loss was present in 4.8% of GDMs compared to 2.2% of non-diabetic pregnancies (NDP). Thirteen per cent of grandmultiprous women had GDM compared to 3.9% in women with low parity. The proportion of women who had more than one risk factor was 16.7%. A combination of one or all of these risk factors predicted GDM in only 24 of 41 (58.5%) cases. Selective testing on the basis of risk factors using WHO criteria for diagnosis of GDM would miss over 40% of all cases in our population. Hence, this study supports the policy of universal screening for GDM in populations similar to ours.

Fertility following ligation of internal iliac arteries for life-threatening obstetric haemorrhage: case report.

Bilateral ligation of internal iliac (hypogastric) arteries (BIL) is a life-saving operation in cases of massive obstetric haemorrhage. This operation preserves reproductive function as opposed to the more commonly performed emergency hysterectomy in such situations. We report on effectiveness and future fertility in 12 women who had internal iliac ligation to control severe obstetric haemorrhage: in 10 out of the 12 women, BIL was successful. Of the two women who subsequently needed emergency hysterectomy, one woman died of disseminated intravascular coagulation. Of the eight women we were able to follow-up to assess reproductive performance, two did not desire future fertility. Three had subsequent pregnancies (50%), of whom two proceeded to term. We conclude that BIL is a safe and effective procedure for treating life-threatening obstetric haemorrhage with preservation of future fertility. This technique should be performed more often when indicated.

Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries.

Improving the quality of obstetric care is an urgent priority in developing countries, where maternal mortality remains high. The feasibility of criterion-based clinical audit of the assessment and management of five major obstetric complications is being studied in Ghana and Jamaica. In order to establish case definitions and clinical audit criteria, a systematic review of the literature was followed by three expert panel meetings. A modified nominal group technique was used to develop consensus among experts on a final set of case definitions and criteria. Five main obstetric complications were selected and definitions were agreed. The literature review led to the identification of 67 criteria, and the panel meetings resulted in the modification and approval of 37 of these for the next stage of audit. Criterion-based audit, which has been devised and tested primarily in industrialized countries, can be adapted and applied where resources are poorer. The selection of audit criteria for such settings requires local expert opinion to be considered in addition to research evidence, so as to ensure that the criteria are realistic in relation to conditions in the field. Practical methods for achieving this are described in the present paper.