Methylene blue as a means of treatment for priapism caused by intracavernous injection to combat erectile dysfunction

OBJECTIVE

The authors observed priapism as a side effect occuring during the intracavernous treatment of erectile dysfunction. Earlier priapism had been treated with an intracavernous injection of sympatomimetics; unfortunately several complications and contraindications were found.

PATIENTS AND METHODS

Methylene blue was applied in the treatment of five patients. First a corpus cavernosum punction was performed and some blood was aspirated from the penis. Finally 100 mg of Methylthionin Chlorati was injected into the corpus cavernosum.

RESULTS

A sufficient detumescence was observed in all of these cases. There were no complications. The method was applied effectively in two cases after an unsuccessful punction.

CONCLUSION

The autors recommend intravenous methylene blue for the treatment of priapism. According to their experience this method is free of complications and as effective as a sympathomimetics treatment. As they think, it can be recommended in any manifestations of priapism because its force of action appears to be both chemically and biologically clear.

Vasoactive agents induce cytotoxicity in cultured human penile smooth muscle cells

OBJECTIVES

To evaluate the direct in vitro cytotoxicity of vasoactive agents (papaverine, phentolamine, and prostaglandin E(1) [PGE(1)]) to human penile cavernosal smooth muscle cells. Intracavernous pharmacotherapy with vasoactive agents for male erectile dysfunction has been associated with long-term complications such as a reduction in penile smooth muscle content and fibrosis.

METHODS

Human penile cavernosal tissue explants (1 to 2 mm(3) size) were obtained with proper institutional review board approval from patients undergoing penile prosthesis implantation. Primary culture was initiated in Dulbecco's modified Eagles medium containing 10% fetal bovine serum, and monolayer cavernosal cells were grown in 48-well tissue culture dishes. At 60% to 80% confluence, cells were labeled overnight with (51)Na(2)CrO(4) (1.5 microCi) and then incubated with therapeutic concentrations of papaverine (1.5 to 30 mg/mL), phentolamine (0.5 mg/mL), and PGE(1) (5 microg/mL) alone, as well as in combination, for 30 minutes at 37 degrees C. At the end of incubation, an aliquot of supernatant was collected in scintillation vials. The release of cell-free chromium in supernatants was determined in a liquid scintillation counter, and results were expressed as the percentage of cytotoxicity.

RESULTS

Papaverine induced a significant dose-dependent increase in chromium release from the cavernosal cells. At therapeutic concentrations, papaverine (30 mg/mL) produced up to 60% cytotoxicity; PGE(1) (5 microg/mL) resulted in 40% toxicity. The combination of papaverine with either PGE(1) or phentolamine had a cumulative toxic effect, and maximal toxicity (70%) was observed with the triple combination.

CONCLUSIONS

Papaverine-induced cytotoxicity to cavernosal smooth muscle cells may contribute to the fibrosis and loss of smooth muscle content associated with the intracavernous pharmacotherapy. Quantitative evaluation of in vitro cytotoxicity in human cavernosal smooth muscle cell culture may be important in the development of new intracavernosal vasoactive agents.

The incidence of pharmacologically induced priapism in the diagnostic and therapeutic management of 685 men with erectile dysfunction

OBJECTIVE

To evaluate the incidence of pharmacologically induced priapism in the diagnostic and therapeutic management of erectile dysfunction.

PATIENTS AND METHODS

Over a period of 7 years, 685 men were investigated for erectile failure. They underwent a simple test with vaso-active drugs, and the nonresponders were further investigated. Eventually, 83 men began autoinjections and 45 still continue.

RESULTS

Eight (1.2%) cases of priapism presented during the simple test with vaso-active drugs in these patients, while none occurred during self-injection treatment. Three were prolonged erections induced by prostaglandin E1 (PGE1) and 5 by papaverine (Pap). Six were treated safely with intracavernosal injection of etilephrine without blood aspiration.

CONCLUSION

Priapism is always a potential phenomenon where no individual, no particular drug and no specific dose are completely safe. It may be caused even with 5 microg of PGE1 or 7.5 mg of Pap. Auto-injection therapy however is a safe kind of treatment in well-experienced patients. Careful regulation of the doses and practice in the use of vaso-active drugs may reduce the priapism rate.

Idiopathic arterial calcification of infancy: effectiveness of prostaglandin infusion for treatment of secondary hypertension refractory to conventional therapy: case report

A premature baby had severe hypertension associated with idiopathic arterial calcification of infancy. Despite the fact that there was laboratory evidence of renin-mediated hypertension, the disease was refractory to specific renin antagonist and failed to respond to conventional medical treatment. Prostaglandin E1 (PGE1) infusion (dosage range 0.017-0.068 microgram/kg/min) promptly controlled hypertension on two occasions. The drug was given for a total of 65 days and then stopped after the appearance of severe thrombocytopenia; other side effects included sporadic hyperthermia and irritability. Blood pressure was then stabilized satisfactory by a multiple-antihypertensive regimen. In the light of these findings, we believe that PGE1 infusion is a possible therapeutic alternative for babies with idiopathic arterial calcification complicated by severe hypertension refractory to conventional treatment.

Second-trimester abortion by intramuscular 15-methyl-prostaglandin F2 alpha or intravaginal prostaglandin E2 suppositories: a randomized trial

OBJECTIVE

To compare intramuscular (IM) prostaglandin 15 methyl-F2 alpha (15M-PGF2 alpha) with prostaglandin E2 (PGE2) vaginal suppositories for second-trimester abortion in terms of efficacy and side effects.

METHODS

Fifty-one women were randomized to receive either 15M-PGF2 alpha IM injections or PGE2 intravaginal suppositories for second-trimester abortion. Efficacy and side effects of the two agents were analyzed by two-tailed t tests, chi 2 analysis with Fisher exact test, and survival analysis.

RESULTS

The mean times to rupture of membranes, delivery of fetus, and delivery of placenta were significantly less for women receiving PGE2 vaginal suppositories. The cumulative abortion rate after 24 hours for the PGE2 group was 96%, compared with 69% for the 15M-PGF2 alpha group. Although there were few differences in side effects, the 15M-PGF2 alpha group had significantly fewer headaches, fevers, and chills.

CONCLUSION

Intravaginal PGE2 is superior to IM 15M-PGF2 alpha for second-trimester abortion.

Prostaglandin-induced neonatal periostitis

Prostaglandins are being commonly used to maintain the patency of the ductus arteriosus in infants with congenital ductal-dependent heart disease. A significant and unusual side effect of this drug treatment is the symmetrical development of periostitis of the long bones. A review of neonates with congenital heart disease requiring prostaglandin treatment at the Children's Hospital of Eastern Ontario revealed five infants who developed periostitis, the earliest onset being after 14 days of prostaglandin infusion. The drug dosage varied in these infants from 0.02 to 0.10 micrograms/kg/min. The periostitis was associated with limb pain and considerable swelling of the extremities in all children. The periostitis improved on cessation of the prostaglandin infusion, and by 6 weeks after the cessation of the drug, the periostitis had decreased significantly. Periostitis seemed more dependent on the duration of administration of the prostaglandin than on the dosage of prostaglandin administered. Awareness of this entity is essential not only for the treatment team caring for these infants but also for consultant pediatric orthopaedists to avoid excessive investigation for infection, metabolic disease, or vitamin deficiencies that resemble prostaglandin-induced periostitis.

Toxic effects of intravenous and oral prostaglandin E therapy in patients with liver disease

BACKGROUND

Prostaglandins are cytoprotective agents that have been shown to benefit patients with a variety of acute and chronic liver diseases. Few data exist on the frequency of adverse effects of prostaglandins in these patients.

METHODS

We retrospectively studied 105 patients with liver disease who were treated with either intravenous (i.v.) or oral prostaglandin E (PGE). Forty-four patients with primary nonfunction after liver transplantation and 36 patients with fulminant hepatic failure received i.v. PGE1 for 4.5 +/- 2.6 and 12.6 +/- 10.9 days, respectively. Twenty-five patients with recurrent hepatitis B viral infection after liver transplantation received oral PGE1 for 105 +/- 94 days or PGE2 for 464 +/- 399 days.

RESULTS

Twenty-six of 80 patients (33%) receiving i.v. PGE1 developed gastrointestinal and/or cardiovascular side effects and 8% developed arthritis. Twenty-three of 25 patients (92%) who received high-dose oral PGE1 or PGE2 incurred arthritis and/or gastrointestinal adverse effects. Twenty-five patients received prolonged PGE therapy (oral > 60 days; i.v. > 28 days). Of this group, 23 (92%) developed clubbing and cortical hyperostosis resembling hypertrophic osteoarthropathy. All adverse effects were dose related and resolved with reduction or cessation of therapy.

CONCLUSION

PGE therapy resulted in a wide spectrum of multisystem adverse effects which were reversible with reduction or cessation of therapy. Although the administration of PGE was safe and generally well tolerated, close medical supervision is necessary to avoid serious side effects.

Reasons for high drop-out rate with self-injection therapy for impotence

One hundred and eighty patients, average age of 58 years (range 24-75) were evaluated for impotence and were advised to undergo pharmacologic self-injection therapy with either papaverine/Regitine (90%) or prostaglandin E1 (10%). Follow-up was available from 2 months to 3 years (average 11 months). The cause of impotence was determined by hormonal testing, Rigiscan and psychological testing. The etiology of impotence was organic (70%), psychogenic (20%), and mixed (10%). After the initial test injection 22% of patients did not enroll in the self-injection program or were lost to follow-up. The group with psychogenic impotence had the highest satisfaction/usage rate at 42%. Overall only 20% of patients were satisfied long-term and were actively using self-injection therapy. Of the 140 patients available for follow-up, 112 patients (80%) discontinued self-injection therapy. The reasons for discontinued usage were alternate treatment (prosthesis or vacuum device) 15%, return or improvement of erections 8%, partner dissatisfaction or loss of partner 10%, or complications of injection therapy 10%. Cost was not a factor for discontinued use. Loss of interest caused 57% of patients to stop using self-injection therapy. Although pharmacologic self-injection therapy is initially promising there is a high drop-out rate at long-term follow-up.

Study of low dosage prostaglandin--usages and complications

Low dosage intravenous (< 0.01 micrograms.kg-1.min-1) and oral prostaglandin E have been reported to produce fewer complications than higher intravenous doses in the ductal manipulation of congenital heart disease. Over a 3-year period 34 patients were treated with low dosage intravenous or oral prostaglandin. Eighteen (53%) had complications associated with this treatment with 14 having more than one complication. Major complications occurred in nine neonates: necrotising enterocolitis (7), apnoea/bradycardia (5), convulsions (1), haemorrhage (1), and resulted in a change of management. This study therefore concludes that the high incidence of complications is similar with both low and high dosages of intravenous and oral prostaglandin. The use of prostaglandin in any form deserves caution.

Third-trimester uterine rupture after prostaglandin E2 use for labor induction

Prostaglandin E2 is a powerful oxytoxic agent that reliably initiates labor, even in the presence of an unripened cervix. The very low incidence of obstetric and neonatal side effects contributes to its universal use. Only nine cases of uterine rupture during the third trimester of pregnancy after application of various prostaglandin E2 preparations have been reported in English. Although uterine rupture after prostaglandin administration is a very rare complication, no prostaglandin compound seems to be exempt from it.

Prostaglandins for the control of pulmonary hypertension in the postoperative cardiac surgery patient: nursing implications

Right ventricular failure associated with pulmonary hypertension is a potential complication in selected cardiac surgical patients following cardiopulmonary bypass. Treatment modalities are generally focused on reduction of right ventricular afterload. PGE1 infusion is one method of providing afterload reduction by its vasodilating action on the pulmonary vasculature. Nursing management of the patient receiving PGE1 requires a thorough knowledge of the hemodynamic alterations occurring in right ventricular failure and pulmonary hypertension, as well as the effect of PGE1 on these hemodynamic parameters. The nurse must understand the rationale for concomitant administration of a vasoconstrictor with the PGE1 as well as possible methods of administering these agents. Lastly, recognition and management of possible adverse effects associated with PGE1 infusion are essential components of nursing care.

Exogenous prostaglandin administration and pseudo-Bartter syndrome

Biological abnormalities simulating Bartter syndrome were observed in a preterm neonate with complex cyanotic congenital heart disease, for which ductus arteriosus was maintained open by high doses of prostaglandin (PG) until a Blalock shunt could be performed. These abnormalities spontaneously disappeared after cessation of PG administration. We postulate that the natriuretic effect of exogenous administered PG could further increase sodium wasting already induced by the cardiopathy thus leading to pseudo-Bartter syndrome.

Slow release delivery of rioprostil by an osmotic pump inhibits the formation of acute aspirin-induced gastric lesions in dogs and accelerates the healing of chronic lesions without incidence of side effects

Rioprostil, a primary alcohol prostaglandin E1 analog, inhibits gastric acid secretion and prevents gastric lesions induced by a variety of irritants in experimental animals. Because rioprostil is relatively short-acting, it would be of significant benefit clinically if its duration of action could be extended to allow once daily dosing. This investigation demonstrates that when administered via an osmotically driven pump (Osmet, Alza Corp.), rioprostil prevents the acute effects of aspirin on the gastric mucosa of dogs, accelerates the healing of aspirin-induced gastric lesions, and heals preexisting aspirin-induced gastric lesions during chronic administration of aspiring. The potency of rioprostil against acute gastric lesion formation was greatest when delivered from a 24-hr release pump (ED50 = 0.77 micrograms/kg/24 hr) and was 37 times greater than when administered as a single oral bolus. In addition, this activity occurred at doses which had little or no gastric antisecretory activity in betazole-stimulated Heidenhain pouch dogs. When delivered from a 24-hr pump, rioprostil (100 micrograms/kg/24 hr) healed preexisting aspirin-induced gastric lesions within 8 days after removal of aspirin, or after 15 days during continued daily aspirin administration. Additional studies determined that administration of rioprostil at doses of 720, 1440, or 2160 micrograms/kg/24 hr (935-2805 times the gastroprotective ED50 in 24 hr pumps) was well tolerated, with only slight, transient increases in body temperature, softening of the stools, and mild sedation at the highest dose. Administration of rioprostil daily for 5 days at 960 micrograms/kg/24 hr from 24-hr release pumps was also well tolerated by all dogs with no evidence of any accumulation of effect of rioprostil. In summary, administration of rioprostil via an osmotic pump increases its potency and duration of action against the gastric lesion-inducing effect of aspirin, and maintains a wide ratio of safety.

Drug safety of rioprostil in patients with active gastric or duodenal ulcer

Data from a large number of patients (1918) treated with rioprostil, H2-antagonists and placebo, are analysed to examine the safety profile of rioprostil in the treatment of active gastric ulcer or active duodenal ulcer. Rioprostil is administered to 1000 of those patients. Patients who dropped out of the studies and those with adverse drug reactions are classified and compared within different subgroups. The overall dropout rate for rioprostil patients is 8.8%: 2.3% of these because of adverse reactions. The incidence of adverse reactions during rioprostil treatment is 20.9%, with more than 60% of these having gastrointestinal symptoms, mainly appearing in the first week of therapy. Comparisons show a higher incidence of symptoms with rioprostil treatment than with ranitidine treatment because of the gastrointestinal symptoms. Possible differences are found between groups in sex, age, and drug dose. The analysis of laboratory variables does not show clinically important changes as a result of rioprostil treatment.

Side effects of anti-ulcer prostaglandins: an overview of the worldwide clinical experience

Anti-ulcer prostaglandins (PG)--misoprostol, enprostil and rioprostil--have been given to more than 5000 patients in short-term studies on gastric and duodenal ulcer. Analysis of these studies shows the drugs to be safe. Their side effects appear to be dose-dependent and mainly restricted to the gastrointestinal system, the major syndromes being diarrhoea and abdominal pain. The clinical relevance of PG-related unwanted effects, though in average exceeding that of H2-blockers, seems to be sufficiently low. In terms of safety efficacy, however, they appear inferior to H2-antagonists, so their routine use in preference to the latter compounds is still premature.

Bone formation induced in an infant by systemic prostaglandin-E2 administration

We report a case of long-term systemic administration of prostaglandin E2 (PGE2) to a newborn infant with ductus-dependent congenital heart disease. After 46 days of treatment, radiography showed cortical hyperostosis of the long bones. The child died 62 days after discontinuation of prostaglandin treatment. Histologic examination of tubular bones showed hyperostosis presumably due to prostaglandin-induced rapid formation of primitive bone. The additional finding of extensive resorption of the outer cortical surface and bone formation at the inner surface suggested a reversible phase after discontinuation of treatment.

Outpatient cervical ripening with prostaglandin E2 gel in uncomplicated postdate pregnancies

A double-blind, placebo-controlled, prospective investigation was undertaken to determine whether the outpatient administration of prostaglandin E2 gel was helpful for ripening the cervix in postdate pregnancies. One hundred eighteen women with an uncomplicated pregnancy at or beyond 42 weeks' gestation with an unripe cervix (Bishop score less than or equal to 5) were randomly administered a single dose of gel containing either 2.5 mg prostaglandin E2 (n = 55) or a placebo (n = 63) before induction of labor with Pitocin. No side effects were detected in these healthy mothers and fetuses. A distinct change in Bishop score after 12 hours occurred more often in the prostaglandin E2 than in the placebo group (42% versus 6%, p less than 0.0001). Forty-four women (80%) who had received prostaglandin E2 were admitted in early labor; they required little or no oxytocin for augmentation. The duration of labor and maximum dose of oxytocin infused were significantly decreased in the prostaglandin E2 group, and forceps delivery or primary cesarean sections were performed less often when prostaglandin E2 was used (24% versus 44%, p less than 0.05). The outpatient administration of a single dose of prostaglandin E2 gel is safe in the uncomplicated postdate pregnancy and was found to significantly change the unripe cervix, enhance the onset of labor, minimize the need for oxytocin administration, and encourage a spontaneous vaginal delivery.

[3 pregnancies carried to term following vaginal administration of 3 mg prostaglandin E 2 in the 1st trimester]

In the years 1985 and 1986 three women decided in the last minute not to undergo a planned abortion after vaginal application of prostaglandin E 2 twenty-four hours before the intended operation. These women came to our genetic clinic in order to obtain some information on the teratogenic risks of prostaglandins applied during early pregnancy. On the basis of these consultation and risk assessment, all three women decided to continue their pregnancy, resulting in the delivery of a healthy child in each case.

Pregnancy termination after detection of fetal chromosomal or metabolic abnormalities

In 3400 midtrimester amniocenteses, 68 fetuses had abnormal findings. Three women elected to continue their pregnancies and the remainder chose terminations. Of these, 29 were cared for in our hospitals. Pregnancy termination was carried out in gestations averaging 21.6 +/- 2.3 weeks and fetal weights averaging 531 +/- 351 g. Three prostaglandins techniques were used, two of which proved to be effective. Dosages employed were comparable to those used in early second trimester pregnancy terminations. Side effects were similar; one retained placenta occurred. We have used a multidisciplinary counseling approach for these couples and have restricted ourselves to the medical aspects of their problems. Techniques are described for the psychologic support of the couple during this stressful period.

[Current use of prostaglandins E2]

Prostaglandins E2 have been used since 1959 and introduced in France since 1966. Their main indication is to pre-induce labor in order to mature a cervix barely open (below 6) and induce labor. For the pre-inducement, the extra-amniotic route seems most interesting in a gel form at a dose of 0.500 microgram (Gelovect): the gain on the cervical opening is 1 to 2 points and labor is induced in 50 to 60 p. cent of the cases, without any other treatment, by artificial rupture of the membranes. For inducing labor, the venous route may be interesting when the condition of the cervix is less than optimum, especially in premature rupture of the membranes. The effectiveness is comparable to that of pitocin, but 10 times more potent resulting in a much more strict control of its prescription by intravenous route. The doses used are 0.15 to 0.25 microgram per minute to a maximum of 2 micrograms per minute. Intravenous prostaglandins E2 should not be used concomitantly with pitocin. Other local administration routes are less used in France. In the immediate post-partum, prostaglandins E2 are interesting parenterally (2 to 4 micrograms per minute) or in the myometrium in case of severe haemorrhages. In 2nd trimester miscarriages, maturation of the cervix may be used but prostaglandin-like substances, either PGE (Geneprost) or prostaglandins E2-like products are preferred, intramuscularly.

Prostaglandin E2 in tylose gel for cervical ripening before induction of labor

Two hundred seventeen women who received 3 mg of prostaglandin E2 (PGE2) gel applied to the cervix followed by adjunctive oxytocin were compared to 94 patients whose labor was induced with oxytocin alone (OA). Postdatism, pregnancy-induced hypertension and rupture of the membranes were the major indications for induction of labor, accounting for 70% of the PGE2 group and 88% of the OA group. Mean initial cervical scores were found to be significantly less favorable among PGE2 patients as compared with OA patients. Though PGE2 was associated with a significant improvement in mean cervical scores, responsiveness of the cervix to PGE2, as determined by clinical examination, was not necessary for a successful induction. Failed inductions were infrequent in both groups. Nulliparous PGE2 patients with unfavorable cervical scores had fewer cesarean sections (CSs) and shorter labors than did their OA counterparts. Complications were uncommon but largely due to the subsequent use of oxytocin. Patients with prior CSs were safely induced following PGE2 cervical ripening.

Management of uterine hyperstimulation after prostaglandin E2 administration

Recent literature suggests that intravaginal or intracervical application of prostaglandin E2 gel may be an effective agent for cervical ripening. One potentially disastrous reported side effect is uterine hyperstimulation. This case report represents the first description of the successful management of uterine hyperstimulation with intravenous ritodrine therapy after the intravaginal administration of prostaglandin E2.

Neonatal respiratory distress caused by aspiration of a vaginal tablet containing prostaglandin

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Delayed-onset synergism between leukotriene B4 and prostaglandin E2 in human skin

The time-course of cutaneous inflammatory responses to LTB4 and PGE2 both alone and in combination has been studied in 10 healthy volunteers. LTB4 induced a transient wheal and flare response in some subjects, maximal at 15 minutes and succeeded by an erythematous, indurated lesion at 2-4 hours. PGE2 elicited a wheal and erythema response which resolved within 1-2 hours. Combination of LTB4 and PGE2 produced acute wheal and erythema responses which did not differ significantly from the summation of responses to the individual constituents of the mixture or from responses to a two-fold increase in the concentration of either component. Wheal and erythema responses persisted, however, with significant potentiation of responses 4 hours after injection. As both leukotrienes and prostaglandins are generated in acute allergic reactions, the effects of these mediators in combination could contribute to persisting and late-onset responses to allergen, in both the skin and lung. In particular, sustained responses to the combination of LTB4 and PGE2 might be important in the pathogenesis of inflammatory skin diseases such as psoriasis.

Digital swelling following long-term administration of prostaglandin E1 in an infant

A premature infant with hypoplasia of the right heart and pulmonary arteries required treatment with prostaglandin E1 (PGE1) for 107 days prior to surgical intervention. Digital swelling was noted at 40 days of age. Swelling was measured by determining the ratio of the distal phalangeal depth to interphalangeal depth. The ratio declined from 1.16 to 0.94 in the first 64 days after treatment. We believe digital swelling is a reversible complication of PG therapy.

Nausea and vomiting after prostaglandins in day case termination of pregnancy. The efficacy of low dose droperidol

The antiemetic effects of low dose droperidol (0.25 and 0.5 mg) and a placebo were compared in patients who had received prostaglandin for day case termination of pregnancy. The incidence of nausea and vomiting was high. Low dose droperidol significantly reduced postoperative nausea and vomiting without any delay in immediate recovery or discharge home (p less than 0.05). Droperidol 0.25 mg was equally effective as an antiemetic, as 0.5 mg.

Uterine hyperstimulation resulting from intravaginal prostaglandin E2. A case report

Prostaglandin E2 administered intravaginally is an effective method of improving Bishop scores in patients requiring elective induction of labor. We treated a woman for hypertonic uterine contractions that occurred over a five-hour period after application of 5 mg of prostaglandin E2. Sedation and magnesium sulfate were not effective in decreasing the intensity of the contractions, but terbutaline, 0.25 mg subcutaneously, was.

Alcohol, pregnancy, and prostaglandins

Basic scientists and clinicians alike are in agreement that children of alcoholic mothers are at risk for a variety of birth defects. These defects have been labeled fetal alcohol syndrome or, in a milder form, fetal alcohol effects. Prevention or therapeutic intervention of this disorder requires an understanding of the mechanism of action of alcohol on the developing fetus. This paper addresses the possible role of prostaglandins as biochemical mediators of the teratogenic actions of alcohol.

Effect of rioprostil, a synthetic prostaglandin E1 on meal-stimulated gastric acid secretion and plasma gastrin levels in humans

The effects of rioprostil (a newly developed synthetic prostaglandin E1 analogue) on meal-stimulated gastric acid secretion was evaluated in 8 healthy human volunteers. Gastric acid output was measured by intragastric titration on 4 different occasions. The following procedure was invariably employed: after a basal period of 45 min, 5 peptone meals (8%, 500 ml each) were given intragastrically in 45-min intervals and gastric acid output was measured continuously. 45 min after the first meal, either placebo or 150, 300 or 600 micrograms of rioprostil were given intragastrically in a randomized order and on different days. 15 min later, the second meal was given and intragastric titration continued. Rioprostil caused a dose-dependent inhibition of the 3-hour integrated gastric acid response to the peptone meals. The percentage of inhibition was 41, 68 and 79%, respectively, for 150, 300 and 600 micrograms of rioprostil. Whereas the inhibition by the two highest doses was statistically significant, this was not the case for the lowest dose of rioprostil. The integrated 3-hour plasma gastrin response to the peptone meals was not significantly changed by any of the doses of rioprostil. No significant adverse effects were observed with rioprostil.

Preinduction cervical softening with endocervical PGE2 gel. A multi-center trial

In a prospective, randomized trial, a single dose of PGE2 gel, 0.5 mg (2.5 ml), was given to 416 low Bishop Score patients 12 h prior to indicated oxytocin induction and compared with 404 non-gel controls. Successful initial induction was achieved in 83% of the treated and 58% of the non-treated subjects. In addition the induction-delivery interval was shortened (median times 9.0 h vs. 11.3 h) and fewer cesarean sections were performed (16% vs. 21%) in the PGE2 gel series. The endocervical administration of PGE2 was well tolerated and, provided care is taken to avoid excess extra-amniotic placement, systemic PGE2 effects are minimal.

Absence of maternal side effects from prostaglandins used for cervical ripening

Prostaglandin E2 vaginal suppositories were found to have associated maternal and fetal side effects no different than those in women undergoing spontaneous labor or labor induced with oxytocin.

[Thrombocytopenia following intracervical prostaglandin priming]

Thrombocyte aggregation with normochromic anaemia occurred in a gravida III of 27 years of age with sonographically confirmed foetal hydrocephalus, after prostaglandin E2 cervical priming. The authors discuss the differential diagnostic possibilities, but the actual genesis of the changes remains unclear. Hence, it is recommended to check with particular care especially in induction of abortion, the coagulation system with the thrombocytes, over and above the well-known prostaglandin side effects. Special attention must be paid to the occurrence of allergic reactions, and it must always be borne in mind that induction of abortion after the 14th week of gestation is a risky matter (1).

Preinduction cervical ripening with prostaglandin E2 intracervical gel

A double-blind, placebo-controlled, dose-ranging study was undertaken to evaluate the efficacy of two doses of intracervical prostaglandin E2 gel in patients with unfavorable Bishop scores. Mean change in Bishop score, success of softening, time to labor, and time to delivery were all significantly different in the two treatment groups as compared with the placebo group. Twenty-three of 30 treated patients had uterine contractions lasting greater than four hours and eight patients delivered during the observation period. Moreover, one case of uterine hyperactivity and five cases of severe fetal heart rate decelerations were noted in the treatment groups. Although efficacious for cervical ripening, caution is warranted when using this technique in patients at risk for placental insufficiency.

[Hyperstimulation in elective labor induction with intravaginal PGE2 administration--recommendation on the procedure based on 2 case reports]

In about 0.5 per cent of elective inductions by means of intravaginal application of 3 mg PGE2 containing tablets hyperstimulation of the uterus with alterations of the foetal heart rate can occur. Amniotomy or the use of betamimetic drugs almost always lead to a normalisation of these alterations avoiding unnecessary Caesarean Sections. In unclear cases foetal blood gas analyses are required. This concept is exemplified by two case reports.

Pseudo-widening of cranial sutures as a feature of long-term prostaglandin E1 therapy

Disturbance of desmogenous ossification of the skull is an extremely rare complication of long-term prostaglandin treatment. This report describes a newborn with pulmonary atresia, ventricular septal defect and ductus-dependent pulmonary blood flow in whom administration of prostaglandin E1 (PGE1) over a period of 96 days produced uncommon clinical and radiologic findings.

Evaluation of oral and low dose intravenous prostaglandin E2 in management of ductus dependent congenital heart disease

Prostaglandin E2 was given orally to 59 infants with ductus dependent congenital heart disease, and intravenous infusions were substituted for varying periods in 27 of them. An additional three neonates received intravenous treatment alone. Mean oral maintenance dose was 27 micrograms/kg per hour and the mean intravenous dose was 0.005 micrograms/kg per minute. Mean duration of treatment was 49 days (range 16 hours to 272 days). Oral treatment was almost always effective and was especially suitable for long term use. Low dose intravenous treatment was readily substituted when indicated. Complications were usually 'minor'. Growth of the infants and of their pulmonary arteries facilitated later surgical management.

Preinduction cervical ripening with prostaglandin E2 (Prepidil) gel

The effect of preinduction cervical ripening with Prepidil, a commercially prepared prostaglandin E2 gel (0.5 mg), on the outcome of induction of labor with intravenous oxytocin was investigated. Fifty-nine pregnant women were randomized either to receive intracervical application of the gel or to undergo sham application. Compared to control subjects, patients in the group given Prepidil had significant increases in cervical Bishop scores, shorter induction-to-delivery intervals, lower maximum doses of oxytocin, and fewer days of induction. Systemic side effects were minimal, but 37% (11 of 30) of the gel-treated patients experienced labor prior to receiving oxytocin and 20% (six of 30) were actually delivered during the 12-hour ripening period. No differences in route of delivery or fetal outcome were found between the two groups.