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severe early onset pre-eclampsia. Magnesium levels were used to add
a safety factor when the protocol was formulated in
our
unit, We find
that serum levels of magnesium provide objective data about
the therapy and now function more to assess undertreatment than
overdose with subsequent adjustment of the infusion rate. We do not
find a problem with the processing of the samples. The theoretical
problem for the clinician who uses lower limb reflexes to assess toxi-
city of magnesium still exists when the epidural block may obliterate
the tendon the reflexes and confound the diagnosis.
The patient was not eclamptic and therefore we do not feel that it is
necessary to provide evidence for serum monitoring of magnesium
therapy. In fact, since its inception in our unit we have observed
only
two
eclamptic fits in more than 20,000 deliveries. In addition,
ldama and Lindow are under the misconception that we performed
induction of labour in the reported case.
To
the contrary, this was a
case of induced abortion with synthetic prostaglandins, which do not
produce a physiological labour.
Toby
N.
Fay on behalf of the authors
Lack of analgesic effect of systemically
administered morphine or pethidine
on
labour pain
Sir,
We read with interest the recent article by Olofsson
et al.
(Vol
103,
October 1996)’, and would like to offer additional information that
suggests a conclusion less at odds with experience in the use of
opioids for analgesia. We have used the same visual analogue score
(VAS)
measure
of
pain in
two
large randomised
trials
of analgesia in
labour. In the first’, meperidine (pethidine) was given intravenously
to 437 women in
50
mg boluses at two-hour intervals with a mean
reduction in
VAS
score from
9
to
8.
However, when women were
queried within 24 hours of delivery, 22% subjectively rated their
satisfaction as excellent
or
very good while only
7%
of women
subjectively rated their satisfaction with analgesia as poor. In a sec-
ond trial (submitted for publication), patient controlled pumps
resulted in higher overall doses
of
meperidine during labour (up to
60 mgh). The associated change in
VAS
score was from 9 to
5,
and
postpartum rating of analgesia was excellent
or
good in
65%.
Seventy percent of the women expressed their desire for the same
type of analgesia during
a
future delivery. Our findings are consistent
with those of Olofsson
et al.
who used smaller doses of pethidine
than in either
of
our trials: pain relief is dose-dependent. We agree
that withholding analgesia from women in pain is unethical, and
women seem to be telling
us
that they want more than just a sedative.
Michael
J.
Lucas, Susan M. Ramin
&
Shiv Sharrna
Departments
of
Obstetrics and Gynecology
and
Anesthesiology,
University
of
Texas Southwestern Medical Center. Dallas, Texas, USA
References
1
Olofsson
C,
Ekblom
G,
Ekman-Ordeburg
G,
Hjelm
A,
Irestedt L.
Lack
of
analgesic effect of systemically administered morphine
or
pethidine
on
labour pain.
Br
J
Obstet Gynaecoll996;
103:
968-972.
2
Ramin
SM,
Gambling DR, Lucas MJ, Shma
SK,
Sidawi JE, Leveno
KJ.
Randomised trial
of
epidural
versus
intravenous analgesia during
labor.
Ohstet
Cynecoll995;
86:
783-789.
AUTHORS’
REPLY
Sir,
Thank you for allowing
us
to comment on the remarks by Lucas
et
al.
who suggest “a conclusion less at odds with experience in the
use
of
opioids
for
analgesia”. They refer to
two
studies from their own insti-
tution where they find that increased doses of meperidine during
labour (up to 60 mg/h) result in significant reductions in
VAS
scores
for labour pain. In their high meperidine dosage study they
also
find
postpartum rating of analgesia as excellent
or
good in
65%
of the
women. They claim, and we quote,
“our
findings are consistent with
those of Olofsson
el
al.
who used smaller doses of pethidine than in
either of
our
trials: pain relief is dose dependent”. On the basis of
our
own findings we strongly disagree with this statement.
Our median dose of pethidine was as high as
108
mg given intra-
venously within 20 to
25
minutes which induced heavy sedation but
no significant reduction in pain intensity measured by
VAS.
We
therefore claim that pethidine as well as morphine is devoid of true
analgesic properties in labour. On the other hand, maternal satisfac-
tion may well increase due to psychological effects such as increased
sedation, decreased tension and apprehension.
Lucas
et
al.
also refer to postpartum ratings of analgesia which we
consider to be rather unreliable since it is well known from several
studieslV2 that postpartum pain ratings tend to be significantly lower
than corresponding intrapartum pain ratings.
Our
point of view is that
opioids such
as
pethidine and morphine have little
or
no effect on
pain intensity during the course of labour as has been shown with
certain other types of visceral pain. On the other hand,
our
results as
well as those of Lucas
et
al.
emphasise that pethidine may well have
a significant effect on the ‘affective’ part of pain experience during
labour. In spite of this we still claim that the frequent use of systemic
meperidine as a regimen for labour pain relief to be scientifically
unfounded due to poor analgesic efficacy combined with well known
negative fetal and neonatal effects.
References
1
McKay
S,
Barrows
T.
Relieving birth: maternal response to viewing
videotape of their second stage labors.
J
Nur Scholarship
1992;
24:
2
Ranta
P,
Jouppila
R,
Spalding
M,
Kangas-Saarela
T,
Hollmen
A,
Jouppila
R.
Parturients assessment of water blocks, pethidine, nitrous
oxide, paracervical and epidural blocks in labour.
In?
J
Obstet Anesth
1994;
3:
193-198.
27-3
1.
Christina Olofsson on behalf of the authors
Department ofAnaesthesia and Intensive
Care,
Karolinska Hospital,
Stockholm,
Sweden
A
prospective cohort study of oxytocin plus
ergometrine compared with oxytocin alone for
prevention
of
postpartum haemorrhage
Sir,
I
read with great interest the article by Soriano
et al.
(Vol
103,
November 1996)l which reported that intravenous oxytocin alone
was as effective as intramuscular oxytocin-ergometrine in reducing
the risk of postpartum haemorrhage and had the benefits of a lower
rate of maternal side effects. They also reported no difference in the
frequency of prolonged third stage
(>
30
min) and manual removal of
placenta. This is in accord with the findings of McDonald
et
a/.?
but
in contrary to
our
findings3 that ergometrine increased the risk of
retained placenta and the need for manual removal (Table
1).
Table
1.
Comparison of the rate of prolonged third stage of labour
and manual removal of the placenta. Values are given as percentages.
McDonald Soriano Yuen
et et at.
‘
et al.
Prolonged 3rd stage
(>
30 min)
Oxytocin-ergometrine 2.5 5.3 2-6
Ox ytocin 2.7 5.2
I
.4
Manual removal of placenta
Ox ytocin-ergometrine 4.8 2.9 2.2
Oxytocin 4.9 3.0 0-6
0
RCOG
1997
Br
J
Obstet Gynaecol
104,
641-644
644
CORRESPONDENCE
In
Soriano
et
a1.k
study, manual removal of placenta was per-
formed only when the placenta was not completely expelled within
60
min. Their rate of manual removal of placenta was much higher
than
ours,
although we performed the procedure within
30
min of
retention of the placenta. It is interesting that the authors defined
prolonged third stage as longer than
30
min, yet they only performed
manual removal of the placenta only after
60
min of retention. Were
there any clinical reasons
for
not performing any intervention after
prolonged third stage was diagnosed, as in
our
study?
In
McDonald
et al.’s
study, the rate of manual removal of the placenta was almost
double that of the rate of prolonged third stage. This suggests that
some
2%
to
3%
of their women required manual removal of the
placenta before prolonged third stage of labour was diagnosed.
Unfortunately, the authors did not comment
on
this interesting find-
ing.
In
both studies, the incidence of nausea, vomiting and hyperten-
sion were also higher than in
our
own. As the management protocols
were the same, the discrepancy might be related to racial differences,
as suggested by Soriano
et
al.
It would be interesting to look into this
area to see whether Chinese women are less susceptible to the side
effects of ergometrine.
P.
M.
Yuen
Departnietit
of
Obstetrics and Gynaecology, Prince
of
Wales Hospital,
The Chinese University of’Hottg Kotig, Hong Kong
References
1
Soriano D, Dulitzki M, Schiff
E,
Barkai
G,
Mashiach
S,
Seidman DS.
A
prospective cohort study
of
oxytocin plus ergometrine compared
with oxytocin alone
for
prevention
of
postpartum haemorrhage.
Br
J
Obstet Gynaecoll996;
103:
1068-1073.
McDonald SJ, Prendiville
WJ,
Blair
E.
Randomised controlled trial of
oxytocin alone
versus
oxytocin and ergometrine in active manage-
ment
ofthirdstageofIabour.BMJ1993;307:
1167-1171.
Yuen PM, Chan
NST,
Yim
SF,
Chang
AMZ.
A
randomised double
blind comparison
of
Syntometrine@-’ and Syntocinon@ in the manage-
ment
of
the third stage of labour.
Br
J
Obstet Gynaecol 1995;
102:
2
3
337-380.
AUTH
OW’
REPLY
Sir,
We thank Dr Yuen for his comments.
Dr
Yuen questions
our
decision
to perform manual removal of the placenta after
60
min, while defin-
ing prolonged third stage as longer than 30 min. In addition, he is
concerned with the overall higher rate of manual removal of the
placenta reported in
our
study compared with his earlier report’. We
chose to drain the urinary bladder and allow
60
min of observation
for women who were
not
bleeding excessively, before manually
removing the placenta, since
our
clinical experience showed that
some
of
these women expelled their placenta during the additional
30-min interval.
In
regard to the rate of manual removal of the pla-
centa,
it
should be noted that the rates given in
our
results refer to
exploration of the uterine cavity and
nof
to manual removal of the
placenta. Exploration of the uterine cavity was performed not only in
cases requiring manual removal of the placenta, but also when
incomplete expulsion of
the
placenta was suspected, and when man-
aging severe postpartum haemorrhage.
David Soriano
&
Daniel
S.
Seidman
Departnietit
of
Obstetrics and Gvnecologv, Sheba Medical Center;
72l-Hushorner. Israel
Reference
1
Yuen PM, Chan
NST,
Yim
SF,
Chang AMAZ.
A
randomised double
blind comparison
of
Syntometrine% and Syntocinon@ in the manage-
ment
of
the third stage
of
labour.
Br
./
Obstet Gynaecol 1995;
102:
33
7-3
80.
Oral versus vaginal misoprostol
for
cervical priming
Sir,
We read with interest the article by Lawrie
el al.
(Vol
103, November
1996)’
again emphasising the use
of
misoprostol for cervical priming
before suction termination of pregnancy. We were concerned about
the timing of administration of oral misoprostol. This drug is rapidly
absorbed following oral administration with peak plasma levels of
the active metabolite (misoprostol acid) occurring after about
30
minutes. The plasma elimination half life of misoprostol acid is
20
to
40
minutes (ABPI Compendium
of
Data Sheets and Summaries
of Product Characteristics
1996/1997).
It is perhaps not surprising
therefore that
two
women
in
the oral treated group experienced an
incomplete abortion at home before their admission and
a
fiuther
woman required early admission because of heavy bleeding.
We would also wish to seek clarification regarding the decision to
allow the women to take the oral misoprostol at home
on
the day
prior to admission. Misoprostol has a well recognised abortifacient
effect? and in this trial it was prescribed specifically to achieve that
end. We would have thought that it therefore needed to be prescribed
and administered on licensed premises in order to comply with
the
1967
Abortion Act.
Rapid absorption of misoprostol should make oral administration
at the time of admission for day case suction termination
of
preg-
nancy realistic. We believe that the optimal route, dose and timing
has, however, yet to be established and warrants further study.
Sukumar Barik
&
Peter Stewart
Department
Of
Obstetrics and Gynaecology, Northern General Hospital
NHS Trust, Sheffeld
References
1
Lawrie A, Penny
G,
Templeton A. A randomised comparison of
oral
and vaginal misoprostol for cervical priming before suction termina-
tion
of
pregnancy.
Br
J
Obstet Gynaecoll996;
103:
1
l
17-1
119.
2
Costa
SH,
Vessey MP. Misoprostol and illegal abortion in
Rio
de
Janeiro,
Brazil.
Lancet 1993;
341:
1258-1261.
Aurnous’
REPLY
Sir,
Thank you for giving
us
the opportunity to comment on the letter
from Barik and Stewart regarding
our
paper.
Our
decision to admin-
ister oral misoprostol
12
hours prior
to
surgery was based on a pre-
liminary report from Ngai
et
al.
who obtained successfid results with
this schedule. Their further paper (in the same issue of the BJOG as
ow
own paper) again reports satisfactory results with this timing of
administration.
In
the
light
of
our
own experience however, we agree
with Barik and Stewart that studies of different dose and timing
schedules are warranted.
Barik and Stewart also comment
on
our decision to allow the
women to administer misoprostol at home.
As
discussed in
our
paper, self-administration at home was felt to be one of the major
advantages of this treatment approach. It avoids the need for an addi-
tional visit to hospital (as
is
required if mifepristone is used as
an
oral
priming agent) and avoids the need for arriving in hospital several
hours prior to daycase termination
(as
is required when vaginal pros-
taglandin is used).
In
our
view, the administration of an agent to soften the cervix
(rather than to achieve abortion) outwith licensed premises does not
contravene the
1967
Abortion Act.
Our
study obtained the approval
of
our
hospital ethical committee who, presumably, shared this view.
Thus, we agree that the use of oral misoprostol as a cervical priming
agent warrants further study, but feel that the requirement that
it
be
administered
on
hospital premises would negate the potential advan-
tages
of
self-administration in terms of streamlining procedures for
daycase termination.
Gillian
C.
Penney (on behalf of the authors)
Department
of
Obstetrics and Gynaecology, Utiiversity ofAberdeen,
Foresterhill. Aberdeen
0
RCOG
1997
Br
J
Obstet
Gynaecol
104,
641-644
