misoprostol and Heart-Arrest

To evaluate the clinical effectiveness and safety of titrated low-dose misoprostol for induction of labour (IOL) in the presence of prelabour rupture of membranes (PROM).. Randomised controlled trial.. Maternity units in the UK (9) and Egypt (1).. Women >34 weeks of gestation with PROM, singleton viable fetus and no previous caesarean section.. Subjects randomised to IOL with a titrated low-dose misoprostol regimen (oral except if unfavourable cervix, where initial dose vaginal) or a standard induction method, namely vaginal dinoprostone followed by intravenous oxytocin if the cervix was unfavourable or intravenous oxytocin alone if the cervix was favourable.. Primary outcome measures were caesarean section and failure to achieve vaginal delivery within 24 hours. Analysis was by intention to treat.. The trial did not achieve the planned sample size of 1890 due to failure in obtaining external funding. Seven hundred and fifty-eight women were randomised (375 misoprostol and 383 standard). There were less caesarean section (14 versus 18%, relative risk [RR] 0.79; 95% CI 0.57-1.09) and less women who failed to achieve vaginal delivery within 24 hours in the misoprostol group (24 versus 31%, RR 0.79; 95% CI 0.63-1.00), but the differences were not statistically significant. Subgroup analysis showed that with unfavourable cervix, misoprostol may be more effective than vaginal dinoprostone. There was no difference in hyperstimulation syndrome. There were more maternal adverse effects with misoprostol, but no significant differences in maternal and neonatal complications.. Titrated low-dose misoprostol may be a reasonable alternative for IOL in the presence of PROM, particularly in women with an unfavourable cervix. Safety and rare serious adverse events could not be evaluated in a trial of this size.

Topics: Administration, Intravaginal; Administration, Oral; Adolescent; Adult; Female; Fetal Membranes, Premature Rupture; Heart Arrest; Humans; Kaplan-Meier Estimate; Labor, Induced; Misoprostol; Oxytocics; Postpartum Hemorrhage; Pregnancy; Pregnancy Outcome; Young Adult

Amniotic fluid embolism is a rare but often catastrophic emergency. The non-specific clinical features and lack of diagnostic tests make it a diagnosis of exclusion. Point-of-care visco-elastometric testing is being increasingly used during obstetric haemorrhage. We present a case of amniotic fluid embolism, diagnosed and managed using rotational thromboelastography. During a precipitous labour, a 21-year-old multiparous woman became pale, distressed and disorientated. The fetus was delivered using forceps. Simultaneously maternal cardiac arrest occurred and advanced life support was commenced. As there was no obvious bleeding, pulmonary embolism was considered the most likely diagnosis and preparation was made to thrombolyse. During resuscitation, rotational thromboelastometry demonstrated haemostatic failure, supporting a diagnosis of amniotic fluid embolism. This reversed the decision to thrombolyse and focused the team on resuscitation and management of coagulopathy. Targeted blood products were given using a local protocol specific to obstetric bleeding. Return of cardiac output was achieved. The total measured blood loss was more than 3.6 L and transfusion was guided by point-of-care tests. Transfused blood products were six units of packed red blood cells, one pool of platelets, 12 units of fresh frozen plasma and 14 g of fibrinogen concentrate. This case demonstrates amniotic fluid embolism with haemostatic failure, without initial revealed blood loss. The high mortality of amniotic fluid embolism necessitates rapid diagnosis and aggressive management. Laboratory tests in this context are impractical in informing clinical decisions, showing the value of point-of-care testing in facilitating team work and timely administration of targeted blood products.

Topics: Adult; Carboprost; Cardiopulmonary Resuscitation; Coagulants; Embolism, Amniotic Fluid; Female; Fibrinogen; Heart Arrest; Humans; Infant, Newborn; Male; Misoprostol; Oxytocics; Plasma; Pregnancy; Thrombelastography; Young Adult

A 41-year-old woman developed cardiac arrest after administration of misoprostol in order to induce an abortion. She was successfully resuscitated. Coronary angiography revealed coronary artery spasm which responded to nitroglycerine. Misoprostol is first-line treatment for medically induced abortion. Reports have described cardiovascular adverse events in women with cardiovascular risk factors, and clinicians should be aware of this.

Topics: Abortion, Induced; Adult; Angina Pectoris; Coronary Vasospasm; Electrocardiography; Female; Heart Arrest; Humans; Misoprostol; Pregnancy