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Continuous extraovular prostaglandin F2 alpha instillation for late pregnancy termination in patients with previous cesarean section delivery
315
Inr. J, Gynaecol. Obsret., 1986,24: 315-319 International Federation of Gynaecology & Obstetrics
CONTINUOUS EXTRAOVULAR PROSTAGLANDIN F2 ALPHA INSTILLATION FOR LATE PREGNANCY TERMINATION IN PATIENTS WITH PREVIOUS CESAREAN SECTION DELIVERY
J. ATAD, A. LISSAK, I. CALDERON, T. SOROKIN and H. ABRAMOVICI Department
of Obstetrics and Gynecology,
Carmel Hospital, Haifa (Israel)
(Received November 25th, 1985) (Accepted May 2nd, 1986)
Abstract Atad J, Lissak A, Calderon I, Sorokin Y, Abramovici H (Department of Obstetrics and Gynecology, Carmel Hospital, Haifa, Israel). Continuous extraovular prostaglandin FzDLinstillation for late pregnancy termination in patients with previous cesarean section delivery. Int J Gynaecol Obstet 24: 31.5-319,19&j Late pregnancy termination by continuous extraovular instillation of prostaglandin Fzo, (PGF,,) was successfully performed in I3 patients with previous cesarian section (C’S) The indications for pregnancy delivery. termination were intrauterine fetal demise in nine patients, social indications in two patients, Down’s Syndrome in one patient and quadruplets pregnancy in one patient. One patient had a previous classical vertical cesarian section, two had two previous and one three previous low segment transverse (LST) cesarian sections. The other nine patients had one previous low segment transverse cesarian section. The instillation of prostaglandin solution was obtained by using a new double balloon catheter designed for extraovular pregnancy terminations. All patients aborted following the procedure The instillation with no complications. abortion time ranged from SK to 20 h (mean 13.3 h). 0020-7292/86/$03.50
0 1986 International Federation of Gynaecology L Obstetrics Published and Printed in Ireland
Keywords: Late pregnancy Atad double balloon catheter; monitoring of contractions.
termination; Extraovular
Introduction Induction of midtrimester abortion in patients with a scarred uterus {previous cesarian section or myomectomy) has received little or no mention in the medical literature and textbooks. In these cases, one would anticipate rupture of the uterus as a result of the induced uterine contractions and increased intrauterine tonicity [ 21. The use ofjudicious doses of prostaglandins with careful monitoring of the uterine contractions may prove useful in preventing this serious complication. This method was successfully used in 13 patients with previous CS deliveries. The termination was performed by continuous extraovular instillation of Fzcu PGFsa. Twelve patients had previous LST CS and one had a classical CS. Among the patients with LST CS, two had two previous CS (patients 2 and 9), and one had three previous CS (patient 4). In nine of the patients, the indication for pregnancy termination was intrauterine fetal demise, in two social indication, in one patient a quadruplet pregnancy was diagnosed by ultrasound examination (patient 12) and in one patient a chromosomal abnorInT J Gynaecol Obstet 24
3 16
Atad et al.
Cervico Vaginal Balloon Fig. 1. The double balloon catheter designed for continuous extraovular instillation of prostaglandins. Atad Double Balloon Catheter (No. 37.106.18), manufactured by: Porges Instruments de Chirurgie, 9-15 Rue Leon Blum Z.1, 91120 Palaisseau, France.
Fig. 2. Position of the double balloon catheter after inflation of both balloons: the uterine balloon at the internal OS and the cervicovaginal balloon at the external OSof the cervix. Int J Gynaecol Obstet 24
Continuous extraovular prostaglandinFzDL instillation
mality (Trisomy 2 1) was diagnosed by amniocentesis (patient 13). The instillation was performed using a double balloon catheter designed for this procedure. All 13 patients aborted with no complications. The instillation abortion time (IAT) ranged between 5.5 and 20 h (mean 13.3 h). Catheter The catheter used for the procedure is 18 French gauge double balloon catheter (Fig. 1). There are three demarcation lines that identify the balloon locations. The distal balloon is marked UB (uterine balloon) and the proximal balloon is marked CVB (cervicovaginal balloon). The proximal end of the catheter has three connections. The solution is infused through a three-way valve (TWV). The uterine balloon is inflated through the uterine valve (marked U). The cervico-vaginal balloon is inflated through the cervicovaginal valve (marked CV). Preparation of the solution for extraovular ins tilla tio n The contents of an ampule containing 20 mg of PGF2& is aspirated into a syringe and added to 1000 ml of normal saline. Each milliliter contains 0.02 mg of PGFZa. This solution is connected to an infusion set with 20 drops/ml. Infusion of 16 drops/min of this solution is calculated to administer 50 ml/h which make 1 mg of PGF,,/h. Procedure With the patient in the lithotomy position and after cleaning the vulva and vagina with an antiseptic solution, the cervix was exposed with a bivalve speculum. With a suitable forceps, the double balloon catheter is introduced through the cervix into the extraovular space up to the third demarcation line. At this position, both of the flat balloons are inside the uterus. The distal balloon (valve indicating the letter U - uterine) is inflated with 10 cc of normal saline. The catheter is pulled out slightly until the inflated balloon is adherent to the cervical internal OS. The
317
proximal balloon (valve indicating CV cervicovaginal) is inflated with 20 cc of normal saline. This balloon occludes the cervical external OS. Normal saline (30 ml) is added to the distal balloon (U valve) until a total of 40 ml is reached, and then 20 ml to the proximal balloon (CV valve) for a total of 40 ml (Fig. 2). The catheter is taped to the patient’s leg and ready for instillation of the abortifacient solution. The procedure of catheter placement is very simple and is usually performed by resident physicians. The catheter is connected through the TWV to the infusion set connected to the prepared PGFza solution. The continuous infusion of 16 drops/min instils 1 mg/h of PGF2& into the extraovular space. The continuous infusion of PGFZa through the catheter is maintained at the same infusion rate until the patient aborts. Intrauterine pressure and uterine activity can be recorded by connection of the catheter TWV point to a tocodynamometer (Fig. 3). Additional inflation of the balloons is occasionally necessary to prevent leakage of the instilled solution. Active contractions dilate the cervix and the catheter is spontaneously expelled during the abortion. The patients are kept under continuous nursing supervision. Analgesia is given as needed: i.m. injections of 75 mg meperidine with 25 mg phenergan. No other medications were used, in order to minimize side effects of prostaglandins, which are negligible using small doses by continuous instillation, as presented in this procedure. After abortion occurred, the patients underwent gentle curettage with a large curet, under general anesthesia. The curettage is done routinely in the department in all midtrimester terminations. Integrity of the uterine scar was not examined by palpation in any of the patients. Patients The details of the 13 patients reported are summarized in Table I. As can be seen from the table, 12 patients had previous LST CS and one had a classical Int J Gynaecol Obstet 24
318
Fig. 3.
Atad et al.
Recording of uterine contractions
during the process of abortion by connection of the catheter to a tocodynamometer.
vertical cesarian section. In 9 patients, the pregnancy was interrupted due to intrauterine fetal demise (IUFD), in two patients (patients 1 and 3), the reason for interruption was social, one patient had a quadruplet preg-
nancy (patient 12) and one fetal chromosomal abnormality In 11 patients, the gestational 22 weeks, and in two patients was more advanced (weeks
patient had a (patient 13). age was below the pregnancy 23 and 27).
Table I. Details of patients, type of previous CS. LST or classical, reasons for termination of pregnancy (TOP), and instillation abortion, instillation delivery interval (IAI, IDI). No.
Name
Age
Obstetrical history
Type of previous CS
Gestational age
Reason for TOP
IAI, ID1 (h)
1 2 3 4 5 6 7 8 9 10 11 12 13
A.J. S.M. C.E. B.R. G.G. E.D. T.N. H.S. F.A. M.E. R.N. F.T. Z.E.
31 31 36 26 35 26 30 32 21 41 28 34 34
G,P, G,P, G,,P, G4P3 G,P, G,P, G,P, G,P, G,P, G,P, G,P, G,P, GsP2
LST LST (x2) LST LST (x3) Classical LST LST LST LST(X2) LST LST LST LST
16 16 17 17 18 23 27 20 21 20 15 15 21
Divorced IUFD Divorced IUFD IUFD IUFD IUFD IUFD IUFD IUFD IUFD Quadruplets Down’s Syndrome
15.5 10 13.5 14.5 5.5 10.5 8.5 20 19 16 20 9.5 11
Int J Gynaecol Obstet 24
-
Continuous extraovular prostaglandin Fza instillation
Results All 12 patients aborted within 20 h following the procedure. The instillation abortion or delivery interval was short in all patients, ranging from 5.5 to 20 h (mean 13.3 h). The instillation to contractions interval ranged from 1 h to 3.5 h (mean 2.3 h). No side effects or complications were recorded. The procedure was easy to perform and well tolerated by the patients. Intrauterine monitoring of contractions intensity and frequency was possible by connection of the TWV of the catheter to a tocodynamometer (Fig. 3). This pattern of monitor strip was seen in all patients with a similar type of frequency of contractions and intensity. Estimated blood loss was invariably less than 500 ml. No transfusion was necessary, and no significant drops in hemoglobin were observed. Comment Extraovular continuous instillation of small doses of PGFzQ using the double balloon catheter, which allows careful control and monitoring of the uterine contractions, may be proven to be one of the optimal procedures to be used for second trimester pregnancy termination [ 11, including patients with previous CS delivery.
319
At curettage, most of the patients had little or no placental tissue in the uterine cavity. However, since curettage was done routinely in all patients, it is not possible to estimate how many patients had a “complete abortion” not requiring curettage. There were no cervical lacerations and there were no lesions requiring sutures. There were no cervicovaginal fistulas. Patients were hospitalized for an average of 2 days, range 1-4. None of the patients required readmission for any complications. References Atad J, Lissak A, Sorokin Y, Bornstein J, Auslender R, Rofe A, Abramovici H; Continuous extraovular prostag landin F,, instillation for second trimester pregnancy termination. Isr J Med Sci 935: 21, 1985. Atienza MF, Burkman RT, King TM: Midtrimester abortion induced by hyperosmolar urea and prostaglandin FZa in patients with previous cesarean section: clinical course and potential for uterine rupture. Am J Obstet Gynecol138: 55, 1980.
Address for reprints: J. Atad, M.D. Department of Obstetrics and Gynecology Lady Davis Carmel Hospital 7 Michal Street Haifa 34362 Israel
Znt J Gynaecol Obstet 24
Inr. J, Gynaecol. Obsret., 1986,24: 315-319 International Federation of Gynaecology & Obstetrics
CONTINUOUS EXTRAOVULAR PROSTAGLANDIN F2 ALPHA INSTILLATION FOR LATE PREGNANCY TERMINATION IN PATIENTS WITH PREVIOUS CESAREAN SECTION DELIVERY
J. ATAD, A. LISSAK, I. CALDERON, T. SOROKIN and H. ABRAMOVICI Department
of Obstetrics and Gynecology,
Carmel Hospital, Haifa (Israel)
(Received November 25th, 1985) (Accepted May 2nd, 1986)
Abstract Atad J, Lissak A, Calderon I, Sorokin Y, Abramovici H (Department of Obstetrics and Gynecology, Carmel Hospital, Haifa, Israel). Continuous extraovular prostaglandin FzDLinstillation for late pregnancy termination in patients with previous cesarean section delivery. Int J Gynaecol Obstet 24: 31.5-319,19&j Late pregnancy termination by continuous extraovular instillation of prostaglandin Fzo, (PGF,,) was successfully performed in I3 patients with previous cesarian section (C’S) The indications for pregnancy delivery. termination were intrauterine fetal demise in nine patients, social indications in two patients, Down’s Syndrome in one patient and quadruplets pregnancy in one patient. One patient had a previous classical vertical cesarian section, two had two previous and one three previous low segment transverse (LST) cesarian sections. The other nine patients had one previous low segment transverse cesarian section. The instillation of prostaglandin solution was obtained by using a new double balloon catheter designed for extraovular pregnancy terminations. All patients aborted following the procedure The instillation with no complications. abortion time ranged from SK to 20 h (mean 13.3 h). 0020-7292/86/$03.50
0 1986 International Federation of Gynaecology L Obstetrics Published and Printed in Ireland
Keywords: Late pregnancy Atad double balloon catheter; monitoring of contractions.
termination; Extraovular
Introduction Induction of midtrimester abortion in patients with a scarred uterus {previous cesarian section or myomectomy) has received little or no mention in the medical literature and textbooks. In these cases, one would anticipate rupture of the uterus as a result of the induced uterine contractions and increased intrauterine tonicity [ 21. The use ofjudicious doses of prostaglandins with careful monitoring of the uterine contractions may prove useful in preventing this serious complication. This method was successfully used in 13 patients with previous CS deliveries. The termination was performed by continuous extraovular instillation of Fzcu PGFsa. Twelve patients had previous LST CS and one had a classical CS. Among the patients with LST CS, two had two previous CS (patients 2 and 9), and one had three previous CS (patient 4). In nine of the patients, the indication for pregnancy termination was intrauterine fetal demise, in two social indication, in one patient a quadruplet pregnancy was diagnosed by ultrasound examination (patient 12) and in one patient a chromosomal abnorInT J Gynaecol Obstet 24
3 16
Atad et al.
Cervico Vaginal Balloon Fig. 1. The double balloon catheter designed for continuous extraovular instillation of prostaglandins. Atad Double Balloon Catheter (No. 37.106.18), manufactured by: Porges Instruments de Chirurgie, 9-15 Rue Leon Blum Z.1, 91120 Palaisseau, France.
Fig. 2. Position of the double balloon catheter after inflation of both balloons: the uterine balloon at the internal OS and the cervicovaginal balloon at the external OSof the cervix. Int J Gynaecol Obstet 24
Continuous extraovular prostaglandinFzDL instillation
mality (Trisomy 2 1) was diagnosed by amniocentesis (patient 13). The instillation was performed using a double balloon catheter designed for this procedure. All 13 patients aborted with no complications. The instillation abortion time (IAT) ranged between 5.5 and 20 h (mean 13.3 h). Catheter The catheter used for the procedure is 18 French gauge double balloon catheter (Fig. 1). There are three demarcation lines that identify the balloon locations. The distal balloon is marked UB (uterine balloon) and the proximal balloon is marked CVB (cervicovaginal balloon). The proximal end of the catheter has three connections. The solution is infused through a three-way valve (TWV). The uterine balloon is inflated through the uterine valve (marked U). The cervico-vaginal balloon is inflated through the cervicovaginal valve (marked CV). Preparation of the solution for extraovular ins tilla tio n The contents of an ampule containing 20 mg of PGF2& is aspirated into a syringe and added to 1000 ml of normal saline. Each milliliter contains 0.02 mg of PGFZa. This solution is connected to an infusion set with 20 drops/ml. Infusion of 16 drops/min of this solution is calculated to administer 50 ml/h which make 1 mg of PGF,,/h. Procedure With the patient in the lithotomy position and after cleaning the vulva and vagina with an antiseptic solution, the cervix was exposed with a bivalve speculum. With a suitable forceps, the double balloon catheter is introduced through the cervix into the extraovular space up to the third demarcation line. At this position, both of the flat balloons are inside the uterus. The distal balloon (valve indicating the letter U - uterine) is inflated with 10 cc of normal saline. The catheter is pulled out slightly until the inflated balloon is adherent to the cervical internal OS. The
317
proximal balloon (valve indicating CV cervicovaginal) is inflated with 20 cc of normal saline. This balloon occludes the cervical external OS. Normal saline (30 ml) is added to the distal balloon (U valve) until a total of 40 ml is reached, and then 20 ml to the proximal balloon (CV valve) for a total of 40 ml (Fig. 2). The catheter is taped to the patient’s leg and ready for instillation of the abortifacient solution. The procedure of catheter placement is very simple and is usually performed by resident physicians. The catheter is connected through the TWV to the infusion set connected to the prepared PGFza solution. The continuous infusion of 16 drops/min instils 1 mg/h of PGF2& into the extraovular space. The continuous infusion of PGFZa through the catheter is maintained at the same infusion rate until the patient aborts. Intrauterine pressure and uterine activity can be recorded by connection of the catheter TWV point to a tocodynamometer (Fig. 3). Additional inflation of the balloons is occasionally necessary to prevent leakage of the instilled solution. Active contractions dilate the cervix and the catheter is spontaneously expelled during the abortion. The patients are kept under continuous nursing supervision. Analgesia is given as needed: i.m. injections of 75 mg meperidine with 25 mg phenergan. No other medications were used, in order to minimize side effects of prostaglandins, which are negligible using small doses by continuous instillation, as presented in this procedure. After abortion occurred, the patients underwent gentle curettage with a large curet, under general anesthesia. The curettage is done routinely in the department in all midtrimester terminations. Integrity of the uterine scar was not examined by palpation in any of the patients. Patients The details of the 13 patients reported are summarized in Table I. As can be seen from the table, 12 patients had previous LST CS and one had a classical Int J Gynaecol Obstet 24
318
Fig. 3.
Atad et al.
Recording of uterine contractions
during the process of abortion by connection of the catheter to a tocodynamometer.
vertical cesarian section. In 9 patients, the pregnancy was interrupted due to intrauterine fetal demise (IUFD), in two patients (patients 1 and 3), the reason for interruption was social, one patient had a quadruplet preg-
nancy (patient 12) and one fetal chromosomal abnormality In 11 patients, the gestational 22 weeks, and in two patients was more advanced (weeks
patient had a (patient 13). age was below the pregnancy 23 and 27).
Table I. Details of patients, type of previous CS. LST or classical, reasons for termination of pregnancy (TOP), and instillation abortion, instillation delivery interval (IAI, IDI). No.
Name
Age
Obstetrical history
Type of previous CS
Gestational age
Reason for TOP
IAI, ID1 (h)
1 2 3 4 5 6 7 8 9 10 11 12 13
A.J. S.M. C.E. B.R. G.G. E.D. T.N. H.S. F.A. M.E. R.N. F.T. Z.E.
31 31 36 26 35 26 30 32 21 41 28 34 34
G,P, G,P, G,,P, G4P3 G,P, G,P, G,P, G,P, G,P, G,P, G,P, G,P, GsP2
LST LST (x2) LST LST (x3) Classical LST LST LST LST(X2) LST LST LST LST
16 16 17 17 18 23 27 20 21 20 15 15 21
Divorced IUFD Divorced IUFD IUFD IUFD IUFD IUFD IUFD IUFD IUFD Quadruplets Down’s Syndrome
15.5 10 13.5 14.5 5.5 10.5 8.5 20 19 16 20 9.5 11
Int J Gynaecol Obstet 24
-
Continuous extraovular prostaglandin Fza instillation
Results All 12 patients aborted within 20 h following the procedure. The instillation abortion or delivery interval was short in all patients, ranging from 5.5 to 20 h (mean 13.3 h). The instillation to contractions interval ranged from 1 h to 3.5 h (mean 2.3 h). No side effects or complications were recorded. The procedure was easy to perform and well tolerated by the patients. Intrauterine monitoring of contractions intensity and frequency was possible by connection of the TWV of the catheter to a tocodynamometer (Fig. 3). This pattern of monitor strip was seen in all patients with a similar type of frequency of contractions and intensity. Estimated blood loss was invariably less than 500 ml. No transfusion was necessary, and no significant drops in hemoglobin were observed. Comment Extraovular continuous instillation of small doses of PGFzQ using the double balloon catheter, which allows careful control and monitoring of the uterine contractions, may be proven to be one of the optimal procedures to be used for second trimester pregnancy termination [ 11, including patients with previous CS delivery.
319
At curettage, most of the patients had little or no placental tissue in the uterine cavity. However, since curettage was done routinely in all patients, it is not possible to estimate how many patients had a “complete abortion” not requiring curettage. There were no cervical lacerations and there were no lesions requiring sutures. There were no cervicovaginal fistulas. Patients were hospitalized for an average of 2 days, range 1-4. None of the patients required readmission for any complications. References Atad J, Lissak A, Sorokin Y, Bornstein J, Auslender R, Rofe A, Abramovici H; Continuous extraovular prostag landin F,, instillation for second trimester pregnancy termination. Isr J Med Sci 935: 21, 1985. Atienza MF, Burkman RT, King TM: Midtrimester abortion induced by hyperosmolar urea and prostaglandin FZa in patients with previous cesarean section: clinical course and potential for uterine rupture. Am J Obstet Gynecol138: 55, 1980.
Address for reprints: J. Atad, M.D. Department of Obstetrics and Gynecology Lady Davis Carmel Hospital 7 Michal Street Haifa 34362 Israel
Znt J Gynaecol Obstet 24