Erring on the side of life: the case of Terri Schiavo

In debates over life and death it is often said that one should err on the side of caution--that is, on the side of life. In the light of the recent case of Terri Schiavo, it is explained how the "err-on-the-side-of-life" argument proceeds, and an objection to it is offered.

Rectal misoprostol in the prevention of postpartum hemorrhage: a placebo-controlled trial

OBJECTIVE

This study investigated the effectiveness of rectal misoprostol in preventing postpartum hemorrhage.

STUDY DESIGN

In a randomized, placebo-controlled study, 550 women were randomly allocated to rectally receive 400 microg misoprostol or nonidentical placebo after normal vaginal delivery. Any excessive bleeding was actively managed with conventional oxytocic agents. Blood loss was measured directly.

RESULTS

The baseline variables were similar. Blood loss of > or = 1000 mL occurred in 4.8% (13/270) of the misoprostol group and 7% (19/272) of the placebo group. Additional oxytocic therapy was required by 3.3% and 4.7%, respectively. No predominance of side effects, particularly shivering, was noted in the misoprostol group.

CONCLUSIONS

Postpartum use of 400 microg rectal misoprostol was well tolerated and associated with a statistically nonsignificant trend toward less postpartum hemorrhage. The early active management of excessive bleeding with conventional oxytocic agents may have reduced the potential of the study to detect differences between the groups.

Randomized comparison of rectal misoprostol with Syntometrine for management of third stage of labor

BACKGROUND

The search for an effective, easily stored, affordable uterotonic agent in preventing postpartum hemorrhage is of importance, especially in the developing world. The objective of this study was to randomly compare the effectiveness of rectal misoprostol with Syntometrine in the management of the third stage of labor.

METHODS

Four hundred and ninety-one low risk women in labor were randomly allocated to receive either misoprostol 400 microgram rectally or Syntometrine 1 ampuole intramuscularly, and postpartum blood loss was estimated as the principal end point. Comparisons were by the chi-square test or Fisher's test and relative risks with 95% confidence intervals for categorical data, and the Mann-Whitney test for ranked continuous variables.

RESULTS

The baseline characteristics in terms of hemoglobin estimation in antenatal clinic, mean age, parity, and duration of labor in the 250 patients who received Syntometrine and 241 patients who received misoprostol were similar. However, there was a significant difference in the pre-delivery blood pressure of the two groups because of the non-protocol exclusion of women with elevated blood pressure allocated to receive Syntometrine. Duration of third stage of labor, blood loss postpartum and hemoglobin estimation post partum were all similar. Postpartum diastolic hypertension was more common in the Syntometrine group (p= 0.002). No other apparent side effect was noted in either group.

CONCLUSION

Misoprostol rectally for management of the third stage of labor merits further investigation.

Induction of labour with intravaginal misoprostol in the second and third trimesters of pregnancy

OBJECTIVE

To confirm the effectiveness of misoprostol as a labour-induction agent.

DESIGN AND SETTING

One hundred and ten consecutive second- and third-trimester hospital patients. Patients with intra-uterine deaths (group A) received 100 micrograms misoprostol 4-hourly and those with live fetuses (group B) 50 micrograms misoprostol 4-hourly until labour commenced.

SUBJECTS

Forty-eight patients in group A (group A1 second trimester 27, group A2 third trimester 21); 62 mainly hypertensive patients in group B.

OUTCOME MEASURES

These were the amount of misoprostol required to induce labour; duration of induction and labour; success and completeness of vaginal delivery; neonatal outcome; and cost.

RESULTS

In group A1, labour was successfully induced in 21/27 (77.8%) patients with 157.4 micrograms misoprostol; and in 19/21 (90.5%) patients in group A2 with 128.9 micrograms misoprostol. Cost per successful induction was R0.55 and R0.44 respectively. Mean induction times were 13.2 hours and 13.4 hours respectively. All patients delivered vaginally but incompletely in 7/21 group A1 and 1/19 group A2 patients. In group A2, the mean duration of labour was 5.97 hours. In group B induction was successful in 51/62 (82%) with 95.1 micrograms of misoprostol; the mean cost was R0,32. Twelve out of 51 (23%) received oxytocin and 44/51 delivered vaginally. Mean duration of induction was 11.4 hours and of labour 5.4 hours. Two babies had low Apgar scores. There were two stillbirths (perinatal mortality rate 39.2/1000), both apparently unrelated to misoprostol.

CONCLUSIONS

Misoprostol is an effective, easy to use, apparently safe and cheap drug for the induction of labour.

Primary hepatocellular carcinoma in pregnancy. A case report

A case of primary hepatocellular carcinoma (HCC) in a 17-year-old pregnant primigravida diagnosed during the 32nd week of pregnancy is presented. A live infant was delivered after induction of labour during the 33rd week. The mother, although still alive 3 months postpartum, had ongoing spread of the malignancy. Only 7 cases of primary liver cancer in pregnancy have been reported to date, with 100% maternal mortality and only 3 live infants. The literature and the diagnosis and management are discussed.

Non-immunological hydrops fetalis: report of 6 cases and a review

Six consecutive cases of non-immunological hydrops fetalis (NIHF) seen by the authors over a 3-year period are presented. Two cases were due to haematological causes and 3 to cardiac anomalies; in 1 case trisomy-21 with a possible associated cardiac anomaly was present. No infant survived. On the basis of this experience and a review of the literature the associated conditions, diagnosis and management of NIHF are discussed.

Obstetrics in the very young black South African teenager

A group of 200 14-16-year-old Black obstetric patients was compared with controls aged 20-23 years. We found a significantly higher incidence of occipitoposterior presentations in the former group, resulting in higher caesarean section and assisted delivery rates. Decreases i the incidence of pre-eclamptic toxaemia and in perinatal mortality are evident in comparison with a similar study 10 years age.

The use of a beta-sympathomimetic drug in locked twins. Case report

Locked twins were born vaginally after hexoprenaline sulphate, a beta-sympathomimetic drug, had been used to relax the uterus so that the fetal heads could be disimpacted.

Epidural anaesthesia as an anticonvulsant in the management of hypertensive and eclamptic patients in labour

Lumbar epidural anaesthesia was used as an anticonvulsant in a series of 1 106 patients with hypertension in labour, including 7 patients with eclampsia. Six of the 1 074 patients in whom epidural analgesia was successful subsequently had convulsions. Of these 4 had convulsions after delivery, which took place at least 2 1/2 hours after the last dose of local anaesthetic, and the 2 others within 5 minutes of receiving the first dose of bupivacaine. We conclude that before it wears off epidural anaesthesia is an effective way of preventing eclampsia and that other anticonvulsant therapy is not required, although the latter may be necessary before the procedure. The possible mechanism of the anticonvulsant action is discussed.