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Case report

  1. Top of page
  2. Case report
  3. Discussion
  4. References

A 35 year old woman with a previous history of two normal vaginal deliveries, presented at 37 weeks of gestation with moderate vaginal bleeding and mild lower abdominal pain. Her previous antenatal course had been uneventful.

On admission all her vital signs were normal. On speculum examination a minimal amount of blood was detected and the cervix was not dilated. Ultrasound scan confirmed the presentation and a high anterior placenta. She was managed expectantly. At this point, she requested to be induced for personal reasons.

Three days later, there was a spontaneous onset of hypertonic uterine contractions. The presentation was cephalic and vaginal examination showed a multip os. A white tablet was removed from the vagina. The patient denied any knowledge of its presence or source.

It was confirmed to be misoprostol on subsequent pharmacological analysis. Continuous cardiotocographic monitoring was advised and the patient was transferred to labour ward.

Uterine tachysystole was recorded throughout the labour but because the fetal heart remained reassuring, she was managed conservatively. She delivered vaginally a live male infant weighing 3.19 kg in good condition with normal Apgar scores following a 5-hour labour. The placenta delivered normally and a true knot of the cord was present. The postpartum period was uneventful.

Discussion

  1. Top of page
  2. Case report
  3. Discussion
  4. References

Various herbs, blue cohosh, castor oil and enema have been used by the patients for self-induction of labour, with resultant maternal and fetal side effects.1 Other methods that have been used for induction of labour are hyaluronidase, corticosteroids, homeopathy and sexual intercourse.2,3

Misoprostol is a prostaglandin E1 analogue. It was introduced as a treatment for peptic ulcer but was later used as an abortifacient in the first and second trimesters of pregnancy. Its usefulness for the prevention and treatment of postpartum haemorrhage is also established.4,5 Substantial evidence suggests that there are risks of hyperstimulation and uterine rupture that have not been fully evaluated and it is not currently licensed for induction of labour.6,7

It is much cheaper than prostaglandin E28 and is available legally in almost 87 countries. It is not surprising that the drug has become popular in the black market, especially where abortion is illegal. This unregulated access to misoprostol has been credited with reducing rates of complications from illegal abortions induced with herbal teas and inexpert surgery. Even in North America, misoprostol is popular on the streets as the Star Pill (due to the five sides of the tablet) and is available as a street drug in urban centres.

In this case, there is no doubt about an unqualified source for the tablet, which was retrieved from our patient's vagina, as misoprostol is not available on our unit drug formulary. Although a resident in the UK, this patient had family contacts in a country where misoprostol is easily available. During her antenatal stay, she was managed in a private room and received many visitors creating ample opportunity for an unqualified insertion of the tablet.

To our knowledge, this is the first reported case of unqualified self-induced labour using misoprostol leading to hyperstimulation in a hospital setting. It highlights important medico-legal and risk management issues. If we had not retrieved the tablet, we would have been at a loss in explaining her uterine hyperstimulation and in the face of an adverse outcome; it may have proved difficult to defend her management.

We believe that the possibility of unqualified self-induction of labour with misoprostol should be considered whenever faced with unexplained spontaneous hyperstimulation.

Documentation and confirmatory pharmacological analysis of the tablet are essential to complete the risk management process.

It is likely that misoprostol is already a ‘street’ drug in the UK and practitioners must be vigilant in this regard.

References

  1. Top of page
  2. Case report
  3. Discussion
  4. References
  • 1
    Kelly AJ, Kavanagh J, Thomas J. Castor oil, bath and or enema for cervical priming and induction of labour. The Cochrane Library, Issue 4, 2003.
  • 2
    Kavanagh J, Kelly AJ, Thomas J. Hyaluronidase for cervical priming and induction of labour; corticosteroids for induction of labour; sexual intercourse for induction of labour. The Cochrane Library, Issue 4, 2003.
  • 3
    Smith CA. Homeopathy for induction of labour. The Cochrane Library, Issue 4, 2003.
  • 4
    Turmen T. Safe motherhood: a global problem. Report from a symposium on the prevention and management of anaemia in pregnancy and postpartum hemorrhage. Zurich: World Health Organization, 1996: 113.
  • 5
    Walley RL, Wilson JB, Crane JMG, et al. A double-blind placebo controlled randomised trial of misoprostol and oxytocin in the management of the third stage of labour. Br J Obstet Gynaecol 2000;107: 11111115.
  • 6
    Thomas A, Jophy R, Maskhar A, Thomas RK. Uterine rupture in a primigravid woman with misoprostol use for induction of labour—case report. Br J Obstet Gynaecol 2003;110(2):217 (February).
  • 7
    Induction of labour: RCOG evidence based clinical guideline: number 9; June 2001.
  • 8
    British National Formulary. September 2003; 42, 381.

Accepted 9 March 2004