Hofmeyr, G J

Jager, M de

Milos, D

Nikodem, V C

English

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Short ReportLimb reduction anomalyafter failed misoprostolabortionG J Hofmeyr, 0 Milos, V C Nikodem, M de JagerCase reportA 42-year-old woman, para 5, gravida 6, was admitted toCoronation Hospital on 2 June 1997. She reported vaginalbleeding for the past month and draining of amniotic fluidfor 2 days. She had had 5 normal deliveries, the last havingbeen of twins, and her 6 children ranged in age from 8 yearsto 18 years. Her last menstrual period had been on 25November 1996. She, her husband and 3 of her children hadbeen born with an extra digit on one or both hands. Thepast medical history waS otherwise non-contributory.The patient gave the following history relevant to thecurrent pregnancy. In March 1997 pregnancy had beendiagnosed by a general practitioner, and she had gone toher local hospital to request termination of pregnancy interms of the newly promulgated Act. An ultrasound scanconfirmed pregnancy of about 13 weeks' duration.Termination of the pregnancy was attempted withmisoprostol tablets, one inserted vaginally on 4 consecutivedays. On the 4th day some vaginal bleeding occurred. Oneweek later she was admitted to the hospital for sterilisation.A minilaparotomy was performed under general anaesthesia,and after the operation she was informed that thesterilisation had not been performed because she had beenfound to still be pregnant. She had decided not to make anyfurther attempt at termination of the pregnancy.On the patient's admission to Coronation Hospital on2 June, her general condition was found to be good. Theuterus was soft and non-tender and the symphysis-fundusmeasurement was 24 cm. Vaginal examination with aspeculum confirmed drainage of non-offensive amniotic fluidand slight bleeding. Ultrasound examination revealed abreech presentation with measurements corresponding to26 weeks' gestation, an estimated fetal weight of 970 g andgreatly reduced amniotic fluid volume, which made detailedassessment for fetal anomalies difficult.The patient was counselled about the risks of rupturedmembranes at this gestational age, and the option ofinduction of labour, but she requested conservativemanagement. She was treated with prophylactic antibioticsand steroid therapy to promote fetal lung maturity. HerDepartment of Obstetrics and Gynaecology, Coronation Hospital andUniversity of the Witwatersrand, JohannesburgG J Hofmeyr. MACOGo Milos.MDV C Nikodem. MCurM de Jager. MCurcondition was monitored with temperature charting, dailycardiotocography and alternate-day leucocyte counts andC-reactive protein estimations. No clinical or laboratoryevidence of amnionitis was detected. Ultrasoundexaminations on 15 June and 24 June showed persistentsevere oligohydramnios and estimated fetal weights of 1 100and 1 135 g, respectively.On 26 June the patient reported reduced fetalmovements. Cardiotocography showed reduced fetal heartrate variability and repetitive fetal heart rate decelerations.Because of suspected fetal compromise, caesarean sectionwas performed under spinal analgesia. A female infant wasdelivered as a breech, with good Apgar scores. She had anextra digit on each hand, and the right lower limb wasabsent below the knee (Fig. 1). Mother and infant weredischarged from the hospital in good condition. The childwas to return for orthopaedic care.Fig. 1. Radiograph of the infant described in this report, showingbelow-knee limb reduction anomaly of the right leg after a failedattempt at abortion with misoprostol.CommentaryThis is to our knowledge the first reported case in SouthAfrica of limb reduction anomaly in a surviving infantfollowing failed abortion. Limb reduction has been welldescribed as a teratogenic effect of misoprostoladministration. Although we do not have documentation ofthe sequence of events in early pregnancy, which werebased on the history given by the patient, the typical natureof this unusual anomaly is highly suggestive of misoprostolteratogenicity.Misoprostol (Cytotec; Searle) is a methyl ester ofprostaglandin E, and is marketed for use in the preventionand/or treatment of peptic ulcer disease caused byprostaglandin synthetase inhibitors. It is also an effectiveabortifacient, both alone and following pretreatment withRU-486.' Its widespread use in Brazil2•5 resulted in theidentification of teratogenic effects," particularly limbreduction defects' such as was seen in our case, followingunsuccessful attempts to terminate pregnancies.It is vital that health workers using misoprostol fortermination of pregnancy be aware of these risks, andVolume 88 No. 5 May 1998 SAMJArt c I e 5counsel their clients in detail about the teratogenic effectsand the need to complete the termination of pregnancy onceit is embarked upon.Misoprostol has become an integral part of the primarycare pregnancy termination services in South Africa. There isan urgent need for the health authorities to issue guidelineson its use regarding dosage, complications and counselling,and indemnity for doctors and nurses who use it accordingto these guidelines for unregistered indications such aspregnancy termination.REFERENCES1. Norman JE, Thong KJ, Baird DT. Uterine contractility and inductIon of abortion inearly pregnancy by misoprostol and mifeprlstone. Lancet 1991; 338: , 233-1236.2. Schonhofer PS. MIsuse of mlsoprostol as an abortifacient may inducemalformations. Lancet 1991; 337: 1534-1535.3. Coelho HLL, MIsago C. da Fonseca WVC, Sousa DSC, de ArauJo JML. Sellingabortlfacients over the counter in pharmacies in Fortaleza. Brazil. Lancet 1991:338: 247.4. Costa SH, Vessey MP. Misoprostol and illegal abortion in Rio de Janeiro, Brazil.Lancet 1993; 341: 1258-1261.5. Coelho HLL, Teixelra AC, Santes AP. ee al. Mlsoprostol and illegal abortion inFortaJeza, Brazil. Lancet 1993: 341: 1261-1263.6. Fonseca W. Alencar AJC, Mata FSB, Coelha HLL. Misoprostol and congenitalmalformatlons. Lancet 1991; 338: 56.7. Gonzatez CH, Vargas FR, Perez AB, et al. Limb deficiency with or without Mobiussequence In seven BraZIlian children associated with misoprostol use in the firsttrimester of pregnancy. Am J Med Genet 1993; 47: 59-64.Accepted 27 Feb 1998.Total Intravenous Anaesthesialan Smith & Paul WhiteFebruary 1998, paper-back, 234 x 156 mm,168 pp, R242This is a straightforwardand accessible introductionto the basic concepts oftotal intravenousanaesthesia, providingdefinitions, historicalperspectives, basicprinciples, and an overviewof the drugs, their interactions, and theequipment used.Amply illustrated with clear black and white linediagrams and photographs, this text shows theapplications of intravenous anaesthesia in avariety of situations. Subjects covered include:types of intravenous anaesthesia, pharmaco-kinetics and pharmacodynamics of drugs usedin total intravenous anaesthesia, use ofintravenous anaesthesia techniques in specialpatient populations, and the future ofintravenous anaesthesia.MASA Multimedia, Private Bag X1, Pinelands7430. Tel: (021) 531-3081, Fax: (021) 531-4126.STUDENT PAPERA peripheral hospital canbe fulfilling - for staff andpatients alikeTeboho LekhanyaSS Gida Hospital, Keiskammahoek, Eastern Cape, is amodern 220-bed hospital. It serves a map radius of 7 kmand about 120 000 people. There are currently 5 doctorswho, in addition to outpatient department (OPO), ward andtheatre duties, make monthly visits to the hospital's 20community clinics.The OPO serves an average of 76 patients per weekday(range 33 - 112 for 19 February to 6 March 1996). Thepatients are seen by nursing sisters, UCT student internsand the doctors. Over the past few years, all of the doctorsand most of the UCT students have been non-Xhosaspeakers.Aim of the surveyS S Gida is, in many respects, strategically placed to meetthe South African government's primary health care initiative.However, because of its very remote location it is shunnedby South African doctors. The aim of the survey was: (I) toexplore patients' perceptions of the service being offered atS S Gida and the factors that contribute thereto; (il) todetermine the extent to which S S Gida is treating patientsholistically, based on the patients' own opinions; and (iil) tomake recommendations on how S S Gida (and otherperipheral hospitals) can improve services so as to meet theprimary health care initiative.MethodologyA total of 30 adult patients seen in the OPO over 2successive days were interviewed according to aquestionnaire (Table I) via an interpreter who had rehearsedthe questionnaire with the researchers.Findings and discussionAlthough the sample of patients was very small for statisticalsignificance, certain points on the patient profile are worthcommenting on:1. There is a predominance of female patients. This isconsistent with a survey done in the Western Cape byDepartment of Medicine, University of Cape TownTeboho Lekhanya. BSc. 6th-year medical studentThis is a report of a survey conducted at S S Gida Hospital,Keiskammahoek, Eastern Cape, by T Lekhanya, F Mohideen andS Mullajee - all 6th-year medical students at UCT at the time.SAMJ Volume 88 No. 5 May /998 __

Limb reduction anomaly after failed misoprostol abortion

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Limb reduction anomaly after failed misoprostol abortion

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