A CAJM clinical report on medically induced pregnancies in a rural hospital in KwaZulu Natal, South Africa.The need for termination of pregnancy, particularly for intra-uterine death, is a common problem facing doctors working in rural hospitals. It is probable that the spread of infection with the Human Immune Deficiency Virus will increase the numbers of pregnancies complicated by intra-uterine death and increase the demand for a safe and effective method of termination of pregnancy which can be used by general practitioners where the services of obstetricians are not available.
The purpose of this study was to evaluate whether extra-amniotic injections of Prostaglandin F2a is such a method

Janowski, K.A.

Krolikowski, A.

Larsen, J.V.

Central African Journal of Medicine

English

IDS OpenDocs

Vol. 40, No. 8
ORIGINAL ARTICLES
CONTENTS
Neoplasms involving the spinal cord in 
Zimbabweans: an analysis of 262 cases..............
Termination of pregnancy using extra-amniotic 
prostaglandin F2a-  experience in a peripheral 
hospital..................................................................
Epidemiological study of drug use in urban and 
rural secondary schools in Zimbabwe..................
A comparison of three types of “M” traps for 
sampling tsetse fly (Diptera: Glossinidae) popu­
lations at South Luangwa Game Management 
Area, Zambia..........................................................
Increased susceptibility of erythrocyte membrane 
lipids to peroxidation in sickle cell disease..........
CASE REPORTS
Intracranial Burkitt’s lymphoma with extension 
into orbital spaces resulting in bilateral blindness
Munchausen syndrome by proxy -  a case report 
and review of literature..........................................
Hypothyroxinemia in Acquired Immune 
Deficiency Syndrome (AIDS)...............................
REVIEW ARTICLES
Advances in electrodiagnosis in Zimbabwe. 
Part II:. “Evoked Potentials” .................................
August, 1994
PI Garrido, S Laher-Mooncey, NL Murphree,
N Jonker, LF Levy, S Makarawo..........................201
A Krolikowski, KA Janowski, JV Larsen............ 204
SW Acuda, AH E ide............................................. 207
MM Ziba, M Mukunyandela, S Siziya, JS Chipipa,
L Mwanza...............................................................212
EU Essien...............................................................217
K Ramesh, LD Gahukamble, DB Gahukamble ...220
OA Oyelami, AM Alhaj, IK Airede.....................222
CC Ezeala, E Chukwurah..................................... 226
O Parry, LF Levy, J M ielke................................. 229
SUPPORTED BY CIMAS MEDICAL AID SOCIETY
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 40, No. 8, 1994
Termination of pregnancy 
using extra-amniotic 
prostaglandin F2a -  
experience in a peripheral 
hospital
*A KROLIKOWSKI, *KA JANOWSKI, *JV LARSEN 
SUMMARY
Extra-amniotic injection of prostaglandin F2a has 
proved to be an effective method of termination of 
pregnancy, although its use has been associated with 
serious complications including rupture of the uterus 
and maternal death.2,4
*Eshowe Hospital 
Private Bag 504 
Eshowe 5815, RSA 
Correspondence to:
Dr A Krolikowski 
Provincial Hospital 
P O  Box 504 
Eshowe 3815, RSA.
204
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 40, No.8,1994
In this retrospective study of 45 patients who re­
quired termination of pregnancy in Eshowe Hospital 
for intra-uterine death or missed abortion two patients 
developed minor complications of this method. Forty 
four patients aborted between four hours 30 minutes 
and 18 hours 15 minutes after the injection. There was 
one patient who had a failed induction and who devel­
oped serious sepsis. It is not clear whether the sepsis 
was a result of the method used to induce labour or 
whether it was the primary pathology causing the intra­
uterine death and failed induction.
INTRODUCTION
The need for termination of pregnancy, particularly for 
intra-uterine death, is a common problem facing doc­
tors working in rural hospitals. It is probable that the 
spread of infection with the Human Immune Defi­
ciency Virus will increase the numbers of pregnancies 
complicated by intra-uterine death and increase the 
demand for a safe and effective method of termination 
of pregnancy which can be used by general practitio­
ners where the services of obstetricians are not avail­
able.
The purpose of this study was to evaluate whether 
extra-amniotic injections of Prostaglandin F2a is such 
a method.
MATERIALS AND METHODS
The case notes of 45 consecutive women who agreed to 
termination of pregnancy using extra-amniotic pros­
taglandin F2a in Eshowe hospital were analyzed retro­
spectively.
The period of study extended from November 1992
to September 1993.
All these patients required termination of pregnancy 
because of missed abortion or intra-uterine death. Their 
ages ranged from 16 to 40 years and the length of the 
period of gestation from 13 to 40 weeks. A coagulation 
profile which included a platelet count, partial throm­
bin time, prothrombin index and estimation of fibrino­
gen degradation products (XDP) was done on all women 
before the procedure.
The technique we employed was as follows. The 
cervix was exposed with a Cuscoe speculum with the 
patient in the lithotomy position. A Foley catheter was 
then introduced through the cervix into the extra- 
amniotic space. The size of the catheter used depended 
on the dilatation of the cervix. The balloon of the
catheter was then inflated and pulled down against the 
internal os to prevent leakage of the prostaglandin 
solution. Five mg of prostaglandin F2a solution was 
then diluted in 40 ml 0,9 pc saline solution and injected 
slowly through the catheter. The catheter was then 
clamped and the patient asked to remain supine for one 
hour.
If induction failed, we repeated the procedure the 
next day using 10 mg prostaglandin in 40 ml of 0,9 pc 
saline solution and adding oxytocin augmentation if 
contractions were inadequate. Antibiotics were used 
only when indicated. The uterus was evacuated if the 
placenta was incomplete.
RESULTS
The characteristics of the patients are shown in Table I. 
It will be noted that there is a large age range, a large 
range of gestational ages and that some of the women 
had had previous caesarean sections. No grande 
multipara were included in this study.
Table I: Patient characteristics.
Maternal age (yrs) 1 6 -2 0 2 1 -3 0 3 1 -4 0
7(16 pc) 29  (64 pc) 9 (20  pc)
Gravida I II _UL_
13 (28 pc) 2 5  (56 pc) 7  (16 pc)
Gestational age (wks) 1 4 -2 0 2 1 -2 8 2 9 -4 0
7 (1 6  pc) 2 0  (44 pc) 18 (40  pc)
Previous c/section 0 1 2
3 6  (80 pc) 7  (16  pc) 2  (p c )
There were two minor complications. Two women 
developed nausea, vomiting, skin rash and transient 
dyspnoea. Nopatient had hyperstimulation of the uterus 
or excessive haemorrhage before or after abortion.
There was one major complication in a patient in 
whom induction failed. This was a 32 year old gravida 
5 para 4 patient who was induced for an intra-uterine 
death. She was given two extra-amniotic injections 
with prostaglandin F2a and failed to get any contrac­
tions. Signs of intra-uterine infection then developed, 
so a hysterectomy was done under antibiotic cover to 
empty the uterus. A macerated foetus was removed. 
There was such severe myometrial infection that hys­
terectomy was required. The patient made an unevent­
ful recovery on antibiotic therapy and was discharged 
on day 10. Other outcomes of management are 
summarised in Table II.
205
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 40, No. 8,1994
Table II: Outcome o f management.
Oxytocin augmentation: 5 (1 1  pc)
Analgesia: 7  (16 pc)
Retained placenta: 2 (  4  pc)
Failed induction: 1 ( 2  pc)
Average time to delivery: 9 hours 20 minutes.
Two patients with retained placenta required manual 
removal. Seven patients needed analgesics and five 
augmentation of labour with oxytocin. The average 
time from induction to delivery was nine hours 20 mins 
which is shorter than that described by other authors,12
DISCUSSION
The ideal method of termination of pregnancy should 
be easy to perform without sophisticated equipment 
and should give a short induction/delivery interval with 
minimal risk to the patient. The existence of many 
methods of induction shows that none is ideal.3,5'6-7 
There is no doubt that the introduction of prostaglan­
dins was a milestone in the management of termination 
of pregnancy and that it allows medical staff to avoid 
many of the complications associated with surgical 
methods.
In our small study, termination of pregnancy with 
extra-amniotic prostaglandin F2a proved to be an effi­
cient method of management which is easy and rela­
tively safe to use. We consider that it is a suitable 
method for terminating pregnancies complicated by 
intra-uterine death in the second and third trimesters in 
patients in rural hospitals.
However, the patient who developed serious sepsis 
after two failed attempts to induce labour illustrates the 
need for great care with aseptic techniques and for close 
monitoring for signs of infection at all stages of the 
procedure. Prophylactic antibiotics should be given 
when the first attempt at induction fails.
We do not consider that induction of labour with this 
method should ever be attempted where immediate 
recourse to laparotomy is not possible. Because of 
previous experience, we also do not consider that 
induction of labour with prostaglandins is safe in grande 
multipara.* Our experience since that paper in 1984 has 
confirmed that these agents are very dangerous in this 
group of women.
REFERENCES
1. Guidozzi F, van der Griendt M, Israelstam D. 
Major complications associated with extra-am­
niotic prostaglandin F2a termination of the mid 
trimester pregnancy. S AfrMed 1992;82:102-4.
2. Steyn DW, Pienaar MR. Mid trimester termina­
tion of pregnancy -  a randomised controlled 
trial of the prostaglandin regimes. S Afr Med J  
1992;83:737-8.
3. Segal SJ, La Guardia KP. Termination of preg­
nancy -  a global view. Bailliere’s Clin Obstet 
Gynaecol 1990;4:235-47.
4. Cates W Jnr, Jordaan HVF. Sudden collapse 
and death of women obtaining abortions in­
duced with prostaglandin F2a. Am J  Obstet 
Gynaecol 1979;133:398-400.
5. BygdcmanM. Non invasive methods for termi­
nation of second trimester pregnancy. Baillieres ’ 
Clin Obstet Gynaecol 1990;4:351-9.
6. Hill NC W, MacKenzie IZ. 2 308 second trimes­
ter terminations using extra-amniotic and intra- 
amniotic prostaglandin E2: an analysis of effi­
cacy and complications. Br J  Obstet Gynaecol 
1989;96:1429-31.
7. Toppozada M, Ismail AAA. Intra-uterine ad­
ministration of drugs for termination of preg­
nancy in the second trimester. Bailliere’s Clin 
Obstet Gynaecol 1990;4:327-49.
8. Larsen JV, Brits CU, Whittal D. Uterine hyper- 
stimulation and rupture after induction of labour 
with prostaglandin E2. S Afr M edJ 1984;65:615- 
6 .
206
This work is licensed under a 
Creative Commons
Attribution -  Noncommercial - NoDerivs 3.0 License.
To view a copy of the license please see: 
http://creativecommons.org/licenses/by-nc-nd/3.0/
This is a download from the BLDS Digital Library on OpenDocs
http://opendocs.ids.ac.uk/opendocs/
Institute o f 
Development Studies


Termination of pregnancy using extra-amniotic prostaglandin F2a - experience in a peripheral hospital.

https://opendocs.ids.ac.uk/opendocs/bitstream/20.500.12413/7218/1/Krolikowski%2cA%2c%20Janowski%2cKA%20%26%20Larsen%2c%20JV%20%20The%20CAJM%20%20vol.%2040%2cno.8.pdf

Termination of pregnancy using extra-amniotic prostaglandin F2a - experience in a peripheral hospital.

Abstract

Similar works

Full text

Available Versions

IDS OpenDocs