Jebmh.

com Original Article

STUDY OF SINGLE DOSE CARBOPROST IN TERMINATING PREGNANCY

Sudhavani1, J. Rajeshwari2
1Consultant Gynaecologist.
2Associate Professor, Department of Obstetrics and Gynaecology, GMC/GGH, Nizamabad, Telangana.

ABSTRACT
INTRODUCTION
Medical termination of pregnancy. It also called induced abortion. It is the medical way of getting rid of unwanted pregnancy.
Efficacy of the methods in achieving complete abortion is needed.
The aim of the study is to evaluate induction abortion interval when intracervical prostaglandin-E2 gel was followed by
carboprost IM injections.

MATERIALS AND METHODS

This was a prospective study for a period of 2 years. 50 cases were randomly selected from the patients attending the
Gynaecology Outpatient Department seeking termination of pregnancy between 10-14 weeks of gestation. Patients are divided
into 3 groups, Group - I: (25) intracervical application of 500 μg PGE2 gel, Group - II: Study group (25) 500 μg PGE2 gel was
instilled intracervically. After 12 hours, carboprost injections were given intramuscularly at 3rd hourly intervals.

RESULTS
Results were analysed in both the groups according to age, parity, reason for seeking abortion, preinduction cervical status,
cervical dilatation after 12 hours in group I and in group II induction abortion interval, incidence of incomplete abortion and
incidence of side effects.

CONCLUSION
Carboprost intramuscular injections 3rd hourly found to be an effective and safe method of terminating pregnancy with
induction abortion interval 19.8 hours in primi and 19.3 hours in multi with a success rate of 100%.

KEYWORDS
Carboprost Injections, Hegar’s Dilator, Laminaria Tent.

HOW TO CITE THIS ARTICLE: Sudhavani, Rajeshwari J. Study of single dose carboprost in terminating pregnancy. J. Evid.
Based Med. Healthc. 2016; 3(91), 4987-4990. DOI: 10.18410/jebmh/2016/1048
BACKGROUND abortions in rural areas conducted by ICMR (Indian Council
Induced abortion signifies voluntary or wilful termination of of Medical Research) revealed that the extent of illegal
pregnancy, whether permitted by law or not before viability. abortions (13.5 per 1000 pregnancies) in comparison with
The number of pregnancies terminated yearly by induced legal abortions (6.1 per 100 pregnancies) was still quite high
abortion throughout the world is not definitely known and the trend in the past 12 years could not show a tendency
because of inadequate data under registration of abortion for illegal abortions to decline (ICMR 1989).
and generally unreliable estimates of illegal abortion. It is 1) The conditions under which a pregnancy can be
estimated that 40-60 million abortions are performed in the terminated under the MTP act, 1972. There are 5
world each year including 33 million legal abortions. This conditions that have been identified in the act.
implies a worldwide abortion rate of 37-55 per 1000 women a) Medical - when continuation of pregnancy might
aged between 15-44 years and a rate of 24-32 abortions per endanger the mother’s life or cause grave injury to her
100 known pregnancies.1 physical or mental health.
In India, the Medical Termination of Pregnancy (MTP) bill b) Eugenic - where there is substantial risk of the child
was enacted in 1971 and came into force on 1st April, 1972. being born with serious handicaps due to physical or
Since then, over 6.38 million termination were effected up mental abnormalities.
to March 1989 under the MTP act. A study on illegal c) Humanitarian - where the pregnancy is the result of
Financial or Other, Competing Interest: None. rape.
Submission 16-09-2016, Peer Review 29-09-2016, d) Socioeconomic - where actual or reasonably forcible
Acceptance 20-10-2016, Published 14-11-2016. environment whether social or economic could lead to
Corresponding Author:
Dr. J. Rajeshwari, risk of injury to the health of the mother.
Associate Professor,
Department of Obstetrics and Gynaecology, The act provides safeguards to the mothers by
GMC/ GGH, Nizamabad, Telangana.
E-mail: [email protected] authorising only a registered medical practitioner having
DOI: 10.18410/jebmh/2016/1048 gynaecological and obstetric experience to perform abortion
where the gestation period does not exceed 12 weeks.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 3/Issue 91/Nov. 14, 2016 Page 4987
Jebmh.com Original Article
However, when pregnancy exceeds 12 weeks and not more Group - II: (Gestational age 10-12 weeks)
than 20 weeks, the opinion of two registered medical Patients in study group 500 μg PGE2 gel was instilled
practitioners is necessary to terminate the pregnancy.2 intracervically. In both the groups, pregnancy was
The study is aimed to evaluate induction abortion terminated by intramuscular injection of carboprost. These
interval when intracervical PGE2 gel was followed by injections were started 12 hours after intracervical
carboprost IM injections, efficacy of the methods in instillation of PGE2 gel/laminaria tent insertion and were
achieving complete abortion, cost effectiveness and given at 3rd hourly intervals till the patient aborted up to a
acceptability of the method by the patient. maximum of 5 injections. Injection Metoclopramide 10 mg
IM and 2 tabs of Lomotil were given 1 hour before the first
MATERIALS AND METHODS injection of carboprost. Initially, a tent of 0.4 mL (100 ug)
Study has been conducted at Gandhi Medical College, was given to check for hypersensitivity. If the patient did not
Gandhi Hospital, Secunderabad, for a period of 2 years. 100 abort within 15 hours of starting the carboprost injection,
cases were randomly selected from the patients attending the treatment was declared as failure and the patient was
the Gynaecology OP (outpatient) seeking termination of managed with alternative methods.
pregnancy between 10-14 weeks of gestation. Ultrasonography was done after abortion to know the
A careful clinical history was taken particularly about age, completeness of abortion. Check curettage was done only if
previous obstetric history, last menstrual period and necessary. Local examinations was done to exclude cervical
previous menstrual cycles. History of allergy or bronchial tears.
asthma was enquired and if present were excluded from the
study. Patients with known cardiac, pulmonary, renal, RESULTS
hepatic disease or epilepsy. Patients with uterine anomaly Results were analysed in both the groups according to age,
were excluded from study. parity, reason for seeking abortion, preinduction cervical
Group - I: Study group (25) intracervical application of status, cervical dilatation after 12 hours in group I and in
500 μg PGE2 gel was done. group II induction abortion interval, incidence of incomplete
Group - II: Study group (25) 500 μg PGE2 gel was abortion and incidence of side effects.
instilled intracervically. After 12 hours, carboprost injections
were given at 3rd hourly interval. Age in Years Group - I Group - II
A general examination was done. Per speculum <20 8 (32%) 6 (24%)
examination followed by bimanual examination was done to 20-30 16 (64%) 17 (68%)
know the size of the uterus, presence of adnexal masses, >35 1 (4%) 2 (8%)
length of the cervix, consistency, condition of external os Gravidity
and internal os, haemoglobin estimation, complete urine Primi 8 (32%) 7 (28%)
examination, blood grouping and Rh typing were done. G2 4 (16%) 4 (16%)
Ultrasonography was done for confirmation of gestational G3 9 (36%) 12 (48%)
age. Patients with lower genital tract infections were treated G4 and above 4 (16%) 2 (8%)
with antibiotics prior to MTP. Table 1. Demographic Distribution in Study
Patients were admitted and complete case record
prepared. Written consent was taken. Tetanus toxoid was 20-30 yrs. is the most common age group for Medical
given. Patient shifted to MTP room and placed in dorsal Termination of Pregnancy in our study.
position. External genitalia and perineum cleaned with Majority of the women were 3rd gravida desiring Medical
antiseptic solution and draped. Sterile Sims speculum Termination of pregnancy and sterilisation.
introduced and anterior lip of cervix held with a sponge
holder. Reasons Number of Patients
Unmarried 25
Group I - (Gestational age 10-12 weeks)
Divorce 4
Study group- Syringe containing 500 μg of dinoprostone gel
Failure of contraception 11
attached to its catheter. The catheter is introduced into the
Not used any contraceptive 60
cervical canal until the internal os is felt. It is slightly
withdrawn and contents of the syringe emptied while slowly Total number of cases 100
withdrawing the catheter. After instillation of the gel, patient Table 2. Reason for Seeking Abortion
is asked to remain supine for at least 30 minutes. Oral
antibiotics cap. ampicillin 500 mg 8th hourly is started. Onset Married couples not using any contraception in the most
of symptoms like lower abdominal cramps, bleeding per common reason for unwanted pregnancy.
vaginum noted. After 12 hours, suction evacuation was
done. The maximum number of Hegar’s dilator that could be
passed without resistance prior to suction evacuation was
noted. Further dilatation using Hegar’s dilator was done only
if necessary.

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Jebmh.com Original Article
Moderately DISCUSSION
Favourable Unfavourable
Favourable In this study, 50 cases were randomly selected from the
Group-I 10 (40%) 7 (28%) 8 (32%) patients seeking Medical Termination of Pregnancy. Criteria
Group-II 12 (48%) 7 (28%) 6 (24%) for selection was gestational age between 10-14 weeks
Table 3. Cervical Condition Before assessed from the last menstrual period. Bimanual
Inducing Abortion examination confirmed by ultrasonography. Cases were
In primigravida, cervix was firm, long and internal os divided into 2 groups depending on the gestational age.
tightly closed. In multipara, cervix was soft, short and Patients subjected for suction evacuation after 12 hrs. The
internal os closed. maximum number of Hegar’s dilator that could be passed
without resistance prior to suction evacuation noted. There
Gravidity Group-I Group-II is only one trial reported on maternal views with three
Induction Abortion Interval patients not satisfied in the intravaginal group (61 women)
Primi 26.5 hours (5) 19.8 hours (7) versus two patients in the intracervical group.
G2 24.45 hours (5) 18.85 hours (4) In study group, half of the patients have experienced
G3 24.50 hours (13) 19.5 hours (12) lower abdominal cramping within 30 mts. to one hour and
G4 and above 24.4 hours (2) 19.5 hours (2) bleeding per vaginum 1-2 hours after instillation of the drug.
Time taken for inducing abortion from the time of Four patients have aborted within 12 hours of PGE2
carboprost injection instillation. In 2 patients, it was incomplete abortion and
Primi 14.5 hours (5) 7.8 hours (7) check curettage was done. Mean number of Hegar’s dilator
G2 12.45 hours (5) 6.85 hours (4) that could be passed without resistance was 9-1 (9.4) in
G3 12.5 hours (13) 7.5 hours (12) primigravida, 10-11 (10.6) in multi.
G4 and above 12.4 hours (2) 7.5 hours (2) In control group, mean number of Hegar’s dilator that
Table 4. Inducing Abortion in Groups could be passed without resistance was 6-7 (6.8) in
primigravida 8-9 (8.4) in multi. Cervical resistance to further
Induction interval is less in study group than in control dilatation is significantly more in control group. In study
group. group, cervix was soft, supple and easily yielding.
Time taken for inducing abortion from the time of While doing suction evacuation in study group, products
carboprost injection is significantly less in group-II. (Mean were found to be already separated and time taken for
7.8 hours in Primi, 7.25 hours in Multi. It is less in study suction evacuation was shorter and the amount of blood loss
group). less in the study group.
Amount of carboprost required to induce abortion is less Other studies have described no reduced risk of
in group-II. caesarean section3. Similar to previous studies,2,3,4,5 FHR
changes, which resulted in foetal blood sampling were not
Incomplete Cervical GIT Side different between the two methods of PGE2 administration.
Fever Rath W, Kuhn W et al6 studied the effect of intracervical
Abortion Tear Effects
Group-I 8 (32%) Nil 5 (20%) 7 (28%) application of 500 μg PGE2 gel in primigravida undergoing
Group-II 6 (24%) Nil - 4 (16%) first trimester medical termination of pregnancy. After 6
Table 5. Incidence of Complications hours, the mean dilatation was 7.8±2 mm. Ulmsten U.,
Ekman G. et al7 studied the effect of 1 mg PGE2 gel applied
In complete abortion, rate is more in Group-II than in intracervically in 40 primigravida undergoing first trimester
study group. Incidence of fever and GIT side effects like medical termination of pregnancy. They noted mean Hegar
vomiting and diarrhoea are more in Group-I. dilatation of 11.18 mm in their study. In the present study,
mean Hegar’s dilator that could be passed without resistance
in primigravida is 9-10 (9.4). This value is slightly higher
Group-I Group-II
than the dilatation seen in Rath W, Kuhn W study and is
Success Rate 21 (84%) 25 (100%)
lower compared to Ulmsten U, Ekman G study.6,7
Failure Rate 4 (16%) -
Group-II: In study group, intracervical instillation of
Table 6. Success Rate and Failure Rate of the
PGE2 gel was done under aseptic precautions and in control
Method in Inducing Abortion
group Laminaria tent inserted under aseptic precaution 12
hours after instillation of PGE2 gel/Laminaria tent insertion
Success rate is 100% in group-II, while it is only 84% in
carboprost (250 μg) was given intramuscularly at third
Group-I.
hourly interval until the patient aborts up to a maximum of
5 injections. Patients who do not abort within 15 hours of
Rewrite the whole of the result part in relation to the
starting the carboprost injection, treatment was declared as
groups, i.e. one and two.
failure and managed by alternative methods.
You should be very clear about your objectives.
Mean induction abortion interval is 19.8 hours in primi
and 19.3 hours in multi in study group. Mean induction
abortion interval is longer in control group.

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Jebmh.com Original Article
Success rate in inducing abortion is 100% in study group. 6. Rath W, Kuhn W. Cervical ripening and induction of
All patients induced with this method have aborted. Success labor by intracervical and extra-amniotic prostaglandin
rate in control group is 84%. 4 patients in control group have gel application in cases of intrauterine fetal death. Int
not aborted and pregnancies were terminated by suction J Gynaecol Obstet 1985;23(5):387-394.
evacuation. Success rate is more in study group. Our study 7. Ulmsten U, Ekman G, Belfrage P, et al. Intracervical
correlates with other studies in literature.8,9,10,11,12 versus intravaginal PGE2 for induction of labor at term
in patients with an unfavorable cervix. Arch Gynecol
1985;236(4):243-248.
REFERENCES 8. Vukelić J. Second trimester pregnancy termination in
1. World Health Organization. WHO recommendations for primigravidas by double application of dinoprostone
the prevention and treatment of postpartum gel and intramuscular administration of carboprost
haemorrhage. Geneva, Switzerland: World Health tromethamine. Med Pregl 2001:54(1-2):11-16.
Organisation 2007. 9. Ottinger WS, Menard MK, Brost BC, et al. A randomized
2. Strobelt N, Meregalli V, Ratti M, et al. Randomized clinical trial of prostaglandin E2 intracervical gel and a
study on removable PGE2 vaginal insert versus PGE2 slow release vaginal pessary for preinduction cervical
cervical gel for cervical priming and labor induction in ripening. American Journal of Obstetrics & Gynecology
low-Bishop-score pregnancy. Acta Obstetriciaet 1998;179(2):349-353.
Gynecologica Scandinavica 2006;85(3):302-305. 10. Thiery M, Decoster JM, Parewijck W, et al. Endocervical
3. Keirse MJNC, de Koning Gans HJ. Randomized prostaglandin E2 gel for preinduction cervical
comparison of the effects of endocervical and vaginal softening. Prostaglandins 1984;27(3):429-439.
prostaglandin E2 gel in women with various degrees of 11. Zanini A, Norchi S, Beretta E, et al. Cervical ripening
cervical ripeness. American Journal of Obstetrics and and induction of labor in term pregnancy using
Gynecology 1995;173(6):1859-1864. prostaglandin E2. Controlled clinical study comparing
4. Ramsey PS, Harris DY, Ogburn PL, et al. Comparative the intracervical and intravaginal routes. Ann Ostet
efficacy and cost of the prostaglandin analogs Ginecol Med Perinat 1989;110(5):209-216.
dinoprostone and misoprostol as labor preinduction 12. Rath W, Kemp B, Heyl W. Prostaglandin-E2-vaginalgel
agents. American Journal of Obstetrics and versus intrazervikalgel und vaginaltablette in
Gynecology 2003;188(2):560-565. abhängigkeit vom zervixstatus - ergebnisse einer
5. Chyu JK, Strassner HT. Prostaglandin E2 for cervical prospektiven randomisierten multizenter-studie zur
ripening: a randomized comparison of cervidil versus geburtseinleitung. Geburtshilfe Frauenheilkd
prepidil. Am J Obstet Gynecol 1997;177(3):606-611. 1999;59(7):323-329.

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