Synthetic laminaria for cervical dilatation prior to vacuum aspiration in midtrimester pregnancy

Volume Number

14.7 4

Communications

in brief

475

Dellvery + _-E-o

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Fig. 1. MAP as a function of time after insertion of PGEB suppositories in the three patients described in the text. stable and dropped slightly after PGE2 administration in the second and third patients. The outcomes in these three cases suggest that PGEz suppositories can be used to terminate second-trimester pregnancy complicated by PIH or eclampsia when patients fail to respond to medical management or when fetal death occurs, although caution should be used since severe hypotension can occur with PGEz administration. REFERENCES

Novy, M., and Liggins, G. C.: Role of prostaglandins in reproduction, Semin. Perinatol. 4:45, 1980. 2. Keirse, M., Sokoiewixz, J., Frankena, A., et al.: Comparison of oral prostaglandin E2 and intravenous oxytocin for induction of labor in hypertensive pregnancies, Eur. J. Obstet. Gynaecol. Reprod. Biol. 10:231, 1980. 1.

Synthetic laminaria for cervical dilatation prior to vacuum aspiration in midtrimester pregnancy WILLIAM KATHY

E. BRENNER, ZUSPAN, M.D.

M.D.

Defartment of Obstetrics and Gynecology, University School of Medicine, Rena, Neruzda, and Department Obstetrics and Gynecology of the University of North School of Medicz’ne, Chapel Hill, North Carolina

of Nevada of Carolina

ONE OF THE practical uses for laminaria tents is cervical dilatation prior to vacuum extraction in patients

Supported in part by Cooper Medical Device Corp. Reprint requests: William E. Brenner, M.D., Department of Obstetrics and Gynecology, University of Nevada School of Medicine, 410 Mill St., Reno, Nevada 89502. 000%9378/82/120475+03$00.30/O

0

1982 The C. V. Mosby

Co.

undergoing midtrimester abortion. Potential benefits of a synthetic tent compared to the natural laminaria japonica would be: (1) uniformity of size and shape, (2) uniformity of dilatation characteristics, (3) assurance of sterility, (4) less expense, (5) ability to control predictably the rate of and amount of dilatation, and (6) ability to control shape. A polyvinyl alcohol foam sponge synthetic laminaria tent impregnated with magnesium sulfate (Lamicel), manufactured by Cooper Medical Device Corp., Newton, Pennsylvania 18940, was evaluated for practicability. The synthetic laminaria tents (Fig. 1) were made by compressing a 15 by 15 by 75 mm polyvinyl alcohol glycol polymer foam sponge (Merocel), manufactured by America1 Corp. of Mystic, Connecticut. under a pressure of 6,000 pounds per square inch to a rodshaped device of 5 by 75 mm after it was impregnated with 0.211 gm of magnesium sulfate and dried. Identification strings were placed through the intracervical portion of the synthetic laminaria tent. Laminaria tents were sterilized by cobalt irradiation. In the cervical canal, polyvinyl glycol expanded as Huid was translocated by the osmotic gradient resulting from the magnesium sulfate impregnation. Cervical dilatation resulted. Twenty healthy women from 13 to 17 menstrual weeks of gestation desiring elective abortion volunteered to be evaluated in a protocol approved by the Protection of Human Subjects Committee. One intracervical laminaria tent was placed in the cervix after cervical dilatation was determined. The following day the laminaria tent was removed and the amount of cervical dilatation was again determined. The amount of cervical dilatation was defined as the largest Pratt dilator that would pass without noticeable resistance. Abortion was accomplished with dilation and evacuation. All received oral tetracycline, 250 mg four times a day for four days. The laminaria tents were highly effective (Fig. 2).

476

Communications

June 15, 1982 Am. J. Obstet. Gynecol.

in brief

Fig.

A. Before Lominoria Mean 1.4 mm

8. After Mean

1.

Synthetic laminaria tent.

Laminaria 12.8 mm

16r

d6 Lbg4 oz

%2

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14

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MENSTRUAL

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tient. Another patient did not return for abortion. She had the laminaria tent removed elsewhere. Twentyfour hours thereafter the cervix was 12 mm dilated and she underwent a dilation and evacuation. -There were no cervical tears, false passages, uterine infections, or retained products of conception. Use ot’these synthetic laminaria tents appears practicable for inducing cervical dilatation in patients undergoing therapeutic abortion by dilation and evacuation. Clinically significant cervical dilatation and softening occurred with their overnight use, decreasing the need for acute mechanical dilatation dramatically. Side effects were minimal and no significant complications occurred. No visible tissue reaction occurred. The relatively short use (less than 24 hours) does not appear to cause significant rates of infection. The small dose of magnesium sulfate appears safe. Further evaluation of these laminaria tents is necessary. Larger studies will be necessary to determine the incidence of complications. Although their effectiveness seems similar to that of laminaria japonica’ and prostaglandin Fza vaginal suppositories,2 appropriate comparative studies are necessary to determine the best method. Pilot studies of their use in patients needing cervical dilatation for other purposes, such as before first-trimester abortion induced with intra-amniotic administration of drugs, and during induction of labor in the presence of a dead fetus and labor at term in women with an unfavorable cervix, are necessary. Important physiologic and pharmacologic characteristics of the cervix mav be revealed. Laminaria tents with other concentrations of magnesium sulfate and different amounts of compression should also be evaluated IO determine the best synthetic laminaria tent.

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Fig. 2. The mean cervical dilatation in millimeters diameter. A, Before insertion of the synthetic study laminaria tent (mean, 1.4 mm).B, 15 to 18 hours later, when the laminaria tents were removed among 20 pregnant women undergoing elective abortion from 13 to 17 weeks of gestation (mean, 12.8 mm). The mean cervical dilatation was 1.4 mm before insertion of the laminaria and 12.8 mm after the laminaria were removed. Between 1Y and 17 weeks’ gestation the mean cervical dilatation was similar. There were no apparent differences in dilatation among the eight nulliparous patients (mean, 12.9 mm) compared to the 12 multiparous patients (mean, 12.8 mm) even though dilatation among the nulliparolls group was slightly less than among the multiparous ones before the laminaria were placed (mean of 1.3 and 1.5 mm, respectively). No further dilatation was necessary in nine patients. The further dilatation with mechanical dilators in the other 11 patients was accomplished with minimal pressure. Several had mild discomfort during laminaria insertion. All attempts to place the larninaria tents were successful. No anesthesia was used. The laminaria tent came out of the cervix spontaneously in only one pa-

REFERENCES

1. Eaton, C. J., Cohn, F., and Bollinger, C. C.: Laminaria tent as a cervical dilator prior to aspiration-type therapeutic abortion, Obstet. Gynecol. 39:4, 1972.

Volume Number

143 4

Communications

in brief

477

2. Dingfelder, J., R., Brenner, W. E., Hendricks, C. H., et al.: Reduction of cervical resistance by prostaglandin suppositories prior to dilatation for induced abortion, AM. J. OBsmT. GYNECOL. 122:1, 1975.

lntrasphenoidal arachnoidocele with amenorrhea-galactorrhea and a pituitary apoplexy-like syndrome LUBOMIR

J.

ALAN

N.

VALENTA,

ELIAS,

Department of Medicine, Ink,

M.D.,

PH.D.

M.D. University

of California,

Iruine,

California

NONTUMOROLJS ENLARGEMENT and erosion of the sella turcica are most frequently due to the presence of a primary “empty” sella which is considered to be an acquired lesion. Typical patients suffering from primary empty sella have been described as middle-aged, hypertensive, obese women without endocrine abnormalities. However, both hypopituitarism and hyperprolactinemia with the syndrome of amenorrhea and galactorrhea can be associated with the primary empty sella. Also, at least one condition has been described where the empty sella is part of a familial syndrome, together with Rieger’s anomaly of the eye, and is probably congenital.’ Another condition anatomically resembling the empty sella is basal encephalocele.’ Here, an arachnoid invagination extends through the sella turcica into the sphenoid sinus, or through both the sella and the sphenoid sinus, into the nasopharynx. The basal encephalocele is associated with hypertelorism and midfacial defects as well as with a hypothalamic-pituitary dysfunction. Describer! here is a patient who seems to represent a transitional form between the primary empty sella and the basal encephalocele. The patient was a 40-year-old woman whose menses were always irregular and who suffered from infertility and amenorrhea-galactorrhea of at least 5 years’ duration. She was moderately obese. The blood pressure was 130/80 mm Hg. She demonstrated signs of hypertelorism with the intercanthal distance of 4.2 cm (normal, 2.9 to 3.8). No midfacial defects were present. Besides bilateral galactorrhea, physical

examination

including

pelvic and neurological

examination

was normal. The serum prolactin level was 150 rig/ml and over the period of 6 months increased progressively to 460 rig/ml. Further temporary increase to 690 ngiml occurred following intravenous administration of 500 w of thyrotropin-releasing hormone (TRH), 100 /.tg of gonadotropin-releasing hormone (GnRH), and 0.2 U of regular insulin per kilogram of body weight. Furthermore, this pituitary reserve test demonstrated normal response of cortisol, adrenocorticoReprint requests: Lubomir J. Valenta, 4137, Irvine, California 92716. OOOZ-9378/82/120477+02$00.20/O

M.D.,

P. 0.

0 1982 The C. V. Mosby Co.

BOX

Fig. 1. The upper tomogram demonstrates the region beyond the lesion, with the appearance of normal sella turcica. The lower tomogram demonstrates the “mass” lesion protruding through the floor of the sella into the sphenoidal sinus. tropin, and growth hormone. Both luteinizing hormone and follicle-stimulating hormone concentrations were depressed and their response to GnRH was severely blunted. Thyroid function tests were compatible with borderline hypothyroidism of the type seen in hypothalamic-pituitary dysfunction. Skull x-ray films demonstrated a questionably enlarged sella turcica with thinning of the floor. The patient was treated with bromocriptine, 5 mg twice a day, and the serum prolactin level decreased into the normal range. The galactorrhea disappeared but menstrual periods did not resume. Five months later the patient suddenly developed severe headaches, nausea and vomiting, dizziness. and blurred vision. She was admitted for suspected pituitary apoplexy. The blood pressure was elevated to between 180/105 and 230/130 mm Hg and required nitroprusside infusion to be controlled. Stiffness of the neck was present, but there was no papilledema. Cerebrospinal fluid was of normal pressure and composition. Sellar polytomograms were obtained and demonstrated a “mass” protruding through the floor of the sella into the sphenoidal sinus (Fig. 1). Transsphenoidal operation was performed. It demonstrated the presence of arachnoid invagination filled with cerebrospinal fluid of normal composition. No pituitary tumor was identified. Postoperatively, the blood pressure normalized without treatment,