Extra-amniotic mannitol for pregnancy termination - (preliminary report)Malini A Deshmukh, Sushila Shah, S Shah, Shobha J Joglekar
Department of Obstetrics and Gynecology, K.E.M. Hospital, Parel, Bombay-400012., India
To induce termination of pregnancy, during 11 to 20 , weeks' period of gestation, extra-amniotic 20% Mannitol solution was used, in 40 patients. The amount of Mannitol varied from 350 ml. to 1290 ml. over a period o f 24 to 48 hours, through a Foley's catheter. After the patient started aborting, Pitocin 2 units were given I.M., every half hourly for 4 injections. The success rate was 95%. Mean induction time for abortion was 33.8 hrs. No adverse effects were noted. This is only a preliminary report and further studies in progress will be reported later.
There is no doubt that termination of pregnancy is associated with some risk which is minimal before 12 weeks, but is considerably increased later. The reason is that we have still not found a safe and cheap method which can be universally used.
Prostaglandins and urea, though safe, are still expensive and yet not available on a large scale to be freely used for the masses.
In this study, we have used by extraamniotic method, 20% Mannitol, which is universally available and fairly cheap. Since it can be given intravenously, it can safely be injected in the extraamniotic space.
Total number of 40 patients were studied. The period of gestation varied from 11 to 20 weeks. Patients were instructed to use antiseptic vaginal tablets twice a day for 5 days before admission. An antibiotic cover was given during the trial till their delivery.
Method of Injection: After vaginal toilet, a 14 gauge Foley's Catheter was introduced through the cervix into the space between the amniotic membrane and the uterine wall. The bulb was inflated to prevent the catheter and the injected fluid from escaping out. The fluid was injected by drip method. Temperature, pulse, respiration, B.P. and urine output were noted at the time of injection and two hourly till delivery. Second dose was not injected if the patient had not passed at least 60 ml. of urine per hour.
After the patient had started aborting, Pitocin 2 units were given I.M. every half hourly for 4 doses. Most of the patients had completed the abortion by the time 1 or 2 injections were given.
This practice was started to minimise operative interference.
[Table 1] shows the doses of mannitol used in this study.
[Table 2] shows the results.
[Table 3] shows the time taken for abortion to occur after the injection.
The longest induction abortion internal was 72 hours. 86.8% of the patients aborted in 48 hours, and 63.1% in 36 hours.
The induction-onset interval varied from 2 hours to 60 hours but in the majority of patients labour started within 24 hours. The mean induction onset interval was 23.2 hours and the pains were extremely mild. Although 13 cases have been shown as incomplete abortions, only 1 case had retained placenta. In the remaining 12 cases when P.V. examination was done to confirm the completion of abortion, few bits of products were felt and D & C was done as a safety measure. No patients required blood transfusion.
[Table 4] shows the effective doses of mannitol in this study.
Patients were encouraged to drink plenty of water to ensure good diuresis. Urine output of the patients varied from 75 to 180 ml. per hour.
When more than 350 ml. of mannitol were injected, patients were given a mixture of potassium citrate two times a day. No patient had any fever or suffered from any side effects.
In this small series, success rate with Mannitol was 95%. This is less than that obtained with hypertonic saline, or prostaglandin. This may be so because correct dosage needed had to be found out by trials. In two cases which failed to respond, the labour had started, and the catheter was expelled due to dilatation of cervix. Further dose of Mannitol could not be given, and both the patients aborted within 48 hours with Pitocin drip.
Mannitol is a polyhydric alcohol which is not metabolised. in
We thank Dr. V. N. Purandare, Head of the Department of Obstetrics and Gynaecology, K.E.M. Hospital, and Dr. C. K. Deshpande, Dean, K.E.M. Hospital and Seth G. S. Medical College, for allowing us to report the Hospital data.
[Table 1], [Table 2], [Table 3], [Table 4]