misoprostol and Respiratory-Distress-Syndrome

This study compared prophylactic administration of either intragastric misoprostol (200 micrograms four times a day), a prostaglandin E1 analog, or bolus intravenous cimetidine (300 mg every 6 hours) in preventing stress lesions and stress bleeding in 127 adult postoperative patients who required mechanical ventilation and also had developed hypotension or sepsis. Both drug treatments were equally effective in preventing the development of diffuse gastritis (greater than 10 gastric hemorrhagic lesions) and in preventing upper gastrointestinal hemorrhage (UGIH). The combined data from both groups showed that for the 44 (35%) patients who died, death was significantly associated with the presence at study entry of renal failure (64% of 25 patients with renal failure died), hepatic failure (57% of 23 patients) or coagulopathy (62% of 29 patients) (p less than 0.02 for each), and with the number of organ system failures at study entry (48% of 69 patients with multiple organ system failures died, p less than 0.001). Death was also significantly associated with the presence of adult respiratory distress syndrome (ARDS) at study entry or the development of ARDS (63% of 24 patients with ARDS died, p less than 0.001), and the development of UGIH (5% of 93 patients with known bleeding outcome died, p less than 0.05). The number of stress lesions that developed was significantly associated with subsequent UGIH (p less than 0.001). Additional organ system failure developed during the study in 31% of the 127 patients, as did diffuse gastritis in 20% of 111 patients who had a follow-up endoscopy. These results demonstrate that postoperative patients who require mechanical ventilation and have hypotension or sepsis are at significant risk for the development of stress gastric lesions and multiple organ system failure even when prophylaxis for stress ulcers is provided. Furthermore, the presence of ARDS, renal failure, hepatic failure, coagulopathy, and UGIH are significantly associated with death.

Topics: Cause of Death; Cimetidine; Critical Care; Double-Blind Method; Female; Follow-Up Studies; Gastroscopy; Humans; Male; Middle Aged; Misoprostol; Multiple Organ Failure; Peptic Ulcer; Peptic Ulcer Hemorrhage; Placebos; Pneumonia; Postoperative Complications; Prospective Studies; Respiratory Distress Syndrome; Stress, Physiological; Surgical Procedures, Operative; Survival Rate; Treatment Outcome; Wound Healing

A 31-year-old G3P2002 with history of two prior caesarean sections presented with influenza-like illness, requiring intubation secondary to acute respiratory distress syndrome. Investigations revealed intrauterine fetal demise at 30-week gestation.She soon deteriorated with sepsis and multiple organs impacted. Risks of the gravid uterus impairing cardiopulmonary function appeared greater than risks of delivery, including that of uterine rupture. Vaginal birth after caesarean was achieved with misoprostol and critical care status rapidly improved.Current guidelines for management of fetal demise in patients with prior hysterotomies are mixed: although the American College of Obstetricians and Gynecologists recommends standard obstetric protocols rather than misoprostol administration for labour augmentation, there is limited published data citing severe maternal morbidity associated with misoprostol use. This case report argues misoprostol-augmented induction of labour can be a reasonable option in a medically complex patient with fetal demise and prior hysterotomies.

Topics: Administration, Intravaginal; Adult; Delivery, Obstetric; Female; Fetal Death; Humans; Hysterotomy; Intubation, Intratracheal; Labor, Induced; Labor, Obstetric; Misoprostol; Multiple Organ Failure; Oxytocics; Pregnancy; Pregnancy Complications, Infectious; Pregnancy Trimester, Third; Respiratory Distress Syndrome; Treatment Outcome; Uterine Rupture

Topics: Abortifacient Agents, Nonsteroidal; Adult; Delivery, Obstetric; Female; Fetal Death; Humans; Influenza A Virus, H7N9 Subtype; Influenza, Human; Misoprostol; Pneumonia, Viral; Pregnancy; Respiratory Distress Syndrome; Stillbirth