Fatal uterine rupture during oxytocin-augmented, saline-induced abortion

In light of the knowledge of the association between oxytocin administration and uterine rupture in late pregnancy, supraphysiologic doses of intravenous oxytocin are used by physicians to augment second trimester saline-induced abortions. According to the Center for Disease Control, this practice causing uterine rupturing is not unique to higher parities and can be fatal if not recognized. 2 case studies are reported. The 1st case, a 23-year-old woman (gravida 3, para 2), underwent saline instilled elective abortion at 18 menstrual weeks' gestation. Following removal of 200 cc of clear amniotic fluid from the uterus, an equal volume of 20% saline was instilled. 2 hours later, intravenous oxytocin was begun and an additional 400 mg of oxytocin was administered in the next 32 hours. 35 hours after instillation the patient had a thready pulse and blood pressure of 88/60, followed by stupor and cardiopulmonary arrest. After resuscitation a laparotomy disclosed an anterior paramedian laceration of the uterus. A hysterectomy was performed, the subsequent course was complicated, and the patient died on the 5th hospital day. In Case 2 a 29-year-old obese women (gravida 4, para 3) had an elective saline-instilled abortion at 20 menstrual weeks' gestation. After saline instillation the patient received intravenous oxytocin in the following amounts: 1) 60 mg; 2) 40 mg, with mild bleeding noted, and 3) 60 mg, followed by profuse vaginal bleeding. The fetus and the placenta were removed, and no detection of uterine rupture was made. The patient was transferred to another hospital, and died 5 hours later following multiple cardiopulmonary arrests. Rupture of the gravida uterus is defined as disruption of the uterine wall, occurring predominantly in the lower uterine segment. Uterine rupture and rupture during a term birth are probably analogous. The death-to-case rate for saline-induced abortions in the U.S. from 1972 to 1975 is .08 deaths/100,000, however, this rate would be higher if only saline-induced abortions receiving oxytocin were considered.     

Design and evaluation of interventions promoting periconceptional multivitamin use

BACKGROUND: Periconceptional folic acid use reduces the risk of neural tube defects and possibly other birth defects. The effectiveness of two interventions to increase the use of multivitamins among women of childbearing ages was evaluated. METHODS: Quasi-experimental interrupted time series design with a nonequivalent control group. Participants included female members of Kaiser Foundation Health Plan aged 18 to 39 years residing in the three geographic service areas of California under study from 1998 through 2000. The central component of the direct mail/pharmacy information intervention was the mailing of "starter kits" of 100 multivitamins, while the provider education intervention used primary care providers to deliver the study message. Main outcomes included the use of multivitamins containing folic acid at least four times per week ("regularly"), intention to use multivitamins regularly, and knowledge and attitudes about multivitamins. Outcomes were measured via telephone interviews of nonpregnant women of childbearing age. RESULTS: A total of 3438 women were interviewed. There was a small but significant increase in the percentage of women using multivitamins in the direct mail/pharmacy information intervention group at the beginning of the intervention period (p =0.006), but this increase was not sustained after the interventions ended. No other significant change was observed. CONCLUSIONS: Despite our ability to reach many women of childbearing age with multiple messages about regularly using multivitamins, only a small temporary increase was found in the percentage of women using multivitamins who received the messages in the mail. Other interventions and further evaluation of the impact of food fortification with folic acid should be considered.     

Incidence of dementia in long-term hormone users

Results from epidemiologic studies of postmenopausal hormone use and dementia have been conflicting. Investigators from the Women's Health Initiative Memory Study reported that the incidence of dementia in women aged >/=65 years assigned to hormone use was increased. Here the authors report results from a prospective cohort study of 2,906 dementia-free women (1,519 hormone users and 1,387 hormone nonusers) aged > or =75 years who were recruited from a Southern California health plan in 1999 and followed through 2003. Cognitive status was assessed annually using the Telephone Interview of Cognitive Status-modified, supplemented by the Telephone Dementia Questionnaire and medical record review. The mean self-reported age at initiation of hormone use was 48.3 years for users of estrogen alone (n = 1,072) and 54.9 years for users of estrogen plus progestin (n = 447); self-reported mean durations of hormone use were 30.5 years and 23.2 years, respectively. There were 283 incident dementia cases identified during follow-up. After adjustment for age, education, and medical history, hazard ratios for incident dementia were 1.34 (95% confidence interval: 0.95, 1.89) in estrogen/progestin users and 1.23 (95% confidence interval: 0.94, 1.59) in estrogen users. These findings do not provide support for an effect of estrogen or estrogen/progestin use in preventing dementia.