Pretreatment with laminaria tents before mid-trimester abortion with intra-amniotic prostaglandin F2α

284 Communications in brief

Douglas and often presents as a pelvic tumor which obstructs labor. In 1899, Gemmell 4 described a freely mobile mass which could be moved out of the pelvis. After delivery, this was found to be an omental hydatid cyst. In 1902, Franta 5 reported 36 cases associated with complications of labor and delivery Embrey 6 reported 2 patients in 1938. More recent reports are rare. 1 The pelvic mass usually is considered to be secondary to a leak in a liver cyst. Surgical excision is the main therapy, although chemotherapy may be of some value. 8 Prophylaxis by avoidance of contaminated foodstuffs is important. Appreciation is expressed to Dr. C. Luttor for permission to report this case. REFERENCES

J. F., Lopez Adaros, H., and Trejos, A.: Am. J. Trop. Med. Hyg. 20: 224, 1971. Schwartz, S. 1.: Principles of Surgery, New York, 1969, McGraw-Hill Book Company, Inc., p. 1043. Cameron, T. W. M.: Parassitologia 2: 381, 1960. Gemmell, J. E.: Br. Med. J. 2: 1603, 1899. Franta, J.: Ann. Gynecol. Obstet. 57: 165, 1902. Embrey, M. P.: Br. Med. J. 2: 1201, 1938. Guz, A., and Lea, P. A. W.: Br. Med. J. 1: 385, 1956. Baltzly, R., Burrows, R. B., Harfenist, M., et a!.: Nature 206: 408, 1965.

l. Williams,

2. 3. 4. 5. 6. 7. 8.

Pretreatment with laminaria tents before mid-trimester abortion with intra-amniotic prostaglandin F2, PHILLIP G. STUBBLEFIELD, M.D. FREDERICK NAFTOLIN, M.D., PH.D. FREDRIC D. FRIGOLETTO, M.D. KENNETH J. RYAN, M.D. Department of Obstetrics and Gynecology, Harvard Medical School, and the Boston Hospital for Women, Lying·ln Division, Boston, Massachusetts.

T H E u s E oF tents of Laminaria digitata as an adjunct to abortion has recently been reSupported by a grant from the Rockefeller Foundation. Reprint requests: Dr. Frederick Naftolin, Department of Obstetrics and Gynecology, Han•ard Medical School, 45 Shattuck St.., Boston, Massachusetts 02115.

Januaty 15. 1974 Am. ]. Obstet. Gynecol.

discovered in the United States. The use of laminaria tents inserted at the same time as saline infusion is performed has been reported with a definite shortening of the time of ahortion. 1 Wf' have used laminaria tents for pretreatment prior to intra-amniotic injection of prostaglandin in 11 patients, 16 to 20 weeks pregnant. Our method was as follows: Patients were admitted to the hospital in the late afternoon. After exposure with a sterile speculum, the cervix was washed with benzalkonium chloride.* The cervix was grasped with a large Allis clamp, and the endocervical canal was prepared with small sterile swabs dipped in povidone-iodinet solution. A sterile sound was inserted just through the internal os which was then swabbed for a bacterial culture. One to three sterile laminaria tents, 1 to 5 mm. in diametert were coated with lubricating jelly§ and inserted until 5 mm. projected beyond the external cervical os. Two opened 4 by 4 gauze sponges soaked in benzalkonium chloride were draped over the cervix with their edges tucked into the fornices to prevent expulsion of the laminaria. Two more 4 by 4 gau~e sponges were also packed into the vagina to hold the tents in place until they began expanding. The following morning, 14 to 19 hours later, the laminaria tents were removed, the endocervix was recultured, and 40 mg. of prostaglandin F 2 a was then instilled by abdominal amniocentesis as previously described." The mean time from instillation of prostaglandin to abortion was 9.6 ± 6. 7 hours, a dramatic improvement over our results with either intra-ammotiC prostaglandin alone or intraamniotic saline (Fig. I and Table I). None of our 11 patients had any fever or other clinical evidence of infection. The rate of operative removal of the placenta in pretreated patients ( 4/11) was the same as in the non pretreated prostaglandin patients ( 7/20) . The cervical dilatation before intra-amniotic infusion obviated the possibility of lower segment tears caused by lack of cervical dilatation. Although our patients were hospitalized for laminaria insertion, there is no reason why this could not be done as an outpatient procedure

*Zephiran chloridr, Winthrop Labs., Div. of Sterling Drug Inc., New York, New York. tBetadine, Purdue Frederick Co., Yonkers, New York. tPurchased from Milex Products, Chicago, Illinois, or Eshmann-USA. §Sterile Lubricating Jelly, Holland-Rantos Co., Inc., Piscataway, New Jersey.

Communications in brief 285

Volume 118 Number 2

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REFERENCES

1. Hale, R. W., and Pion, R. J.: Clin. Obstet. Gynecol. 15: 829, 1972 . 2. Naftolin, F., Kirshen, E. J., and Ryan, K. J.: In Southern, E. M., editor: The Prostaglandins, Clinical Applications in Human Reproduction, Mt. Kisco, New York, 1972, Futura, p. 423.

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Fig. 1. Cumulative percentage of patients aborted versus the time to abortion.

S E R r o u s F E T A L complications occurring in association with diagnostic amniocentesis have been previously discussed and reviewed. 1 - 3 The present case appears to be unique in that a viable-size fetus died within minutes after failed amniocentesis.

with the patients admitted the following morning. This would considerably shorten the time of hospitalization for mid-trimester abortion. Based on this small study, we feel laminaria pretreatment with subsequent intra-ammot1c prostaglandin F 2,. to be a promising method for mid-trimester abortion and plan a larger series to evaluate further the safety and efficacy of this combined method.

A 34-year-old, para 4-0-1-4, white woman with no recall of the last menstrual period, was hospitalized in the apparently twenty-ninth week of pregnancy for a combination of medical and obstetric problems. She had reported painless vaginal bleeding and both the radioisotope placental scan and Doppler4 ultrasound suggested a central placenta previa. She was a known heroin addict and was on the methadone program; she had active syphilis and was being treated with oral erythromycin because of a penicillin allergy; she was also severely asthmatic. In addition, she had severe iron deficiency anemia and demonstrated evidence of moderate malnutrition. The patient responded well to a high-protein diet and bed rest, but after 2 weeks implied that she might sign out against advice. Because of uncertainty as to the gestational period (fetal weight estimates varied from 2 to 4 pounds) and in hope that the pregnancy could be terminated before her disappearance, diagnostic amniocentesis was attempted to determine fetal lung maturity, but no amniotic fluid could be obtained. Some 26 hours later, the membranes spontaneously ruptured with only minimal subsequent vaginal bleeding. She was then observed for a period of 24 hours with no evidence of labor and was again prepared for diagnostic amniocentesis. The site for the amniocentesis

We acknowledge Dr. E. M. Southern of The Upjohn Co., Kalamazoo, Michigan, for supplying the prostaglandin F,. used in this study.

Reprint requests: Dr. Robert C. Goodlin, Santa Clara Valley Medical Center, 751 S. Bascom Ave., San Jose, California 95128.

Table I. Time from intra-amniotic infusion to abortion Hours±S.D.

Treatment

Sodium chloride (20%) Prostaglandin F,. Prostaglandin F,.

Laminaria

106 20 11

30.6 ± 19.2 29.4 ± 16.2 9.6 ± 6.7