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We evaluated repeat cerclage in women with prolapsed membranes. Twenty-two women with bulging membranes after primary cerclage were offered repeat cerclage; 11 chose a repeat cerclage and 11 chose bed rest. The median gestational age at delivery, birthweight and survival rates were significantly higher in the repeat cerclage group compared to the bed rest group (mean 26.8 weeks vs. 21.7 weeks, p= 0.04, mean birthweight 1180 g vs. 491 g, p= 0.01 odds ratio for survival 22.0, 95% CI, 2.1-236). Early repeat cerclage under antibiotic cover may be beneficial in women with bulging membranes after a prior failing cerclage attempt.

In September 2005, a 44-year-old woman was admitted to the hospital for a therapeutic abortion. She was at 18 weeks gestation. She had undergone hemodialysis for five years, and had taken carvedilol, nifedipine and valsartan for hypertension. She had no history of smoking or hormonal replacement therapy. The induction of abortion was attempted using a total of five vaginal prostaglandin E (PGE) pessaries (synthetic PGE 1 analogue misoprostol 200 mg, 400 mg and 400 mg) during a 20 h period. On vaginal examination, the cervix was unchanged. Subsequently, she was given intravenous PGE (synthetic PGE 2 analogue sulprostone, maximum dose 42 μg/h). Approximately 8 h after administration, she complained of acute left-sided chest pain and nausea. Her blood pressure was 120/80 mmHg. A physical examination produced normal results. An electrocardiogram (ECG) showed a regular sinus rhythm at 82 beats/min. ST elevation was seen in leads II, III and aVF, with reciprocal depression in the anterior leads ( Figure 1A). Serum creatine kinase MB isoenzyme (CK-MB) was 2.9 ng/mL (normal less than 5 ng/mL). The patient was diagnosed with acute inferior myocardial infarction. The pain was subsided slightly by administering sublingual nitroglycerin and an ECG indicated an accelerated idioventricular rhythm ( Figure 1B).A right coronary angiogram showed multiple luminal narrowing lesions ( Figure 2A). A total of 400 μg of intracoronary nitroglycerin was administered. Repeat angiography after administration of nitroglycerin revealed a disappearance of the lesions ( Figure 2B). Left coronary angiography showed normal findings. An ECG showed complete resolution of ST elevation. The patient was given nitrates, nifedipine and diltiazem. Ten hours after the incident, a fetus with no signs of life was delivered. Within 24 h, CK-MB reached a maximum concentration of 267.5 ng/mL and CK-MB was normalized three days later. She recovered without complications and was discharged. When last seen in July 2008, the patient reported no complaints. DisCussionVasospastic (also known as Prinzmetal's or variant) angina may be associated with acute myocardial infarction and severe cardiac arrhythmias, including ventricular tachycardia and fibrillation, as well as sudden death. Although responses to various vasoconstrictor substances, including catecholamines, serotonin, endothelin, thromboxane A 2 and arginine vasopressin, are greater in spastic segments of the coronary arteries, hypersensitivity to vasoconstrictor stimuli also occurs throughout the entire coronary trees in patients with vasospastic angina. PGE 2 and its analogues have been used therapeutically for their stimulant actions on the pregnant uterus for approximately 40 years (1). PGE 2 is the preferred agent for second trimester pregnancy termination and severe cardiovascular complications associated with PGE 2 cAse report ©2009 Pulsus Group Inc. All rights reserved Prostaglandin E (PGE) is the preferred agent for second-trimester pregnancy termination. Hypotension, bradycardia, ventricular arrh...