On the mechanism of midtrimester abortions induced by the prostaglandin “impact”

Using Csapo's technique a single dose of 24.3±1.1mg PG F_2α had been delivered intraamniotically to 20 sedated 15.9±0.6 weeks pregnant patients, to provoke a “PG Impact” (PGI), a consequent progesterone (P) withdrawal and a conversion of the pharmacologically refractory normal pregnant uterus into a reactive organ. The side effects were occasional and acceptable and no further PG F_2α treatment was needed except in 4 cases (5–10mg). Only after the Oxytocin Test showed that the uterus is becoming reactive was 50mU/min oxytocin infused i.v., to facilitate the evolution of IUP to 93±3mm Hg and thus promote clinical progress. All the 20 patients aborted both the fetus and the placenta in 16.5±2.1 hours, but 8 women retained small placental residues to be removed by curettage. The Csapo Score was high, 92±2.As early as 3 hours after PGI, the plasma P levels already decreased significantly. They continued to decline throughout the IAT and reach a 72% withdrawal when the fetus was aborted. Fifteen patients, whose P-withdrawal was rapid aborted before the mean IAT, while those 5 women whose P-withdrawal was slow aborted after this time. Thus, the rate of P-withdrawal was directly, while parity and gestational age indirectly related to the IAT. Studies are in progress to elucidate further the abortifacient action of PG F_2α and through this knowledge promote predictable therapy.     

On the mechanism of midtrimester abortions induced by prostaglandin "impact"

Using Csapo's technique, a single dose of 24.3 +or- 1.1 mg prostaglandin F2alpha (PGF2alpha) had been delivered intraamniotically to 20 sedated pregnant patients (15.9 +or- 0.6 weeks pregnant) in order to provoke a PG impact (PGI), a consequent progesterone (P) withdrawal, and a conversion of the pharmacologically refractory normal pregnant uterus into a reactive organ. The side effects were occasional and acceptable and no further PGF2alpha treatment was needed except in 4 cases (5-10 mg). Only after the Oxytocin test showed that the uterus is becoming reactive, was 50 mU/minute oxytocin infused intravenously to facilitate the evolution of IUP to 93 +or- 3 mmHg and thus promote clinical progress. All the 20 patients aborted both the fetus and the placenta in 16.5 +or- 2.1 hours, but 8 women retained small placental residues to be removed by curettage. The Csapo score was a high 92 +or- 2. As early as 3 hours after PGI, the plasma P levels already decreased significantly. They continued to decline throughout the IAT and reached a 72% withdrawal when the fetus was aborted. 15 patients whose P withdrawal was rapid, aborted before the mean IAT, while those 5 women whose P withdrawal was slow aborted after this time. Thus, the rate of P withdrawal was direct while parity and gestational age indirectly related to the IAT. Studies are in progress to elucidate further the abortifacient action of PGF2alpha and through this knowledge promote predictable therapy.     

The effect of prostaglandin I on the contractility of the term pregnant human myometrium

Small myometrial strips were dissected from the upper and lower segments of the term pregnant human uterus. The specimens were superfused in organ chambers and contractile activity was recorded isometrically. In strips from the upper segment, prostacyclin (PGI2), induced an initial excitatory response followed in the majority of experiments by transient inhibition. In the lower segment the response was generally the same although direct inhibition without initial stimulation occurred in some cases. During the period of inhibition the specimens were refractory to iterated exposure to PGI2. Furthermore, during this period of PGI2-induced inhibition the muscle strip was also refractory to PGE2 but responded to PGF2 alpha and oxytocin by stimulation. After inhibition of spontaneous contractile activity induced by indomethacin PGI2 induced an excitatory response. The results do not indicate any critical change in the myometrial responsiveness of the upper uterine segment to PGI2 during labor. In strips from the lower segment obtained before labor there tended to be a dominance of non-responders and inhibition only as compared to the results during labor. Nevertheless, whether or not PGI2 under physiological or pharmacological conditions has any significant influence on the contractility of the term pregnant human uterus, still remains obscure. As judged from earlier reports from our laboratory and the present study it is evident that the uterine vessels are considerably more sensitive to the action of PGI2 than the myometrium.     

The efficacy and acceptability of the ″prostaglandin impact″ in inducing complete abortion during the second week after the missed menstrual period

Twenty-two pregnant patients were exposed, 12±1 days after their missed menstrual period, to a single intrauterine dose of 5mg PG F2_α, to provoke a PG ″Impact″ (PGI) and through it legal abortion. The PGI, delivered through the cervix during 10 minutes, induced 83±9mm Hg contracture in 20±3 minutes. Cyclic IUP reached 102±10mm Hg only in 116±14 minutes, it was then sustained for about 2 hours and subsequently declined.During the evolution of IUP uterine bleeding appeared, progesterone (P) and estradiol 17_β (E₂) started to decrease and continued decreasing. At 24 hours after PGI, P-withdrawal was 44% (P<0.05), bleeding continued and cervical dilatation approximated 1cm. Subsequently uterine bleeding (containing tissue fragments) continued and out of 22 women 20 aborted completely. After 3–5 days bleeding declined, the pregnancy tests became negative and normal menstrual periods one month after PGI provided the desired end points of the study. Complete abortions, simulating the symptoms of delayed menstrual periods, had a high Abortion Score of 95 and in the sedated patients the side effects were infrequent, mild and acceptable. This clinical outcome encourages extensive field trials.None of the patients aborted during the short lived period of exogenous PG stimulation. However, the continued steroid withdrawals indicated that PGI damaged the endocrine function of the ovum and the luteotrophic support of the corpus luteum. Therefore, if it was PG which completed abortion eventually, it had to be the endogenous compound, having become effective in physiological concentrations, due to the threshold-lowering action of P-withdrawal.     

Massive initial prostaglandin impact in postconceptional therapy

The abortifacient effect of an initial PGF2alpha impact was examined in 10 obstetrically normal first trimester pregnant patients. Sedated patients were given extraamniotically an average initial dose of 8.1 + or - 0.8 mg PGF2alpha during a 10 minute instillation. Side effects occurred occasionally but were minimal. Uterine contracture developed rapidly reaching an average pressure of 83.2 + or - 11.3mm Hg in about 20 minutes and then slightly declined in time. Superimposed on the contracture response were gradually increasing cyclic changes in intrauterine pressure which reached a magnitude of 129.8 + or - 12.2mm Hg by 10 hours after initial treatment. Initial therapy was augmented in some cases by an average of 4mg PGF2alpha; only 4 patients required oxytocin supportive therapy. The patients aborted in an average of 10.9 + or - 2.0 hours. 7 aborted completely, 2 left behind small placental residues, and 1 retained the placenta during a period of 11.5 hours. An (AbS) abortion score of 92 was obtained in the study which is the highest in 6 consecutive studies using various methods of PGF2alpha administration. Plasma estradiol-17beta and progesterone levels decreased continuously during the instillation abortion time in the complete aborters, while the incomplete aborters showed lesser changes. It is concluded that massive intrauterine PGF2alpha injection is a more efficacious and acceptable form of postconceptional therapy than protracted treatment. Such therapy appears to convert the refractory uterus into a spontaneously active and pharmacologiclly reactive organ by inducing vasoconstriction, myometrial stretch, and fetoplacental insufficiency.     

The efficacy of the extraovular “Prostaglandin-Impact” in provoking first trimester abortion

In good agreement with earlier findings (1–8) legal abortion had been induced successfully with Csapo's method of “Prostaglandin Impact” (PGI) in 44 out of 50 sedated patients. They were 25±1.1 years of age, 11.3±0.2 weeks pregnant, para 1.1±0.2. Only a PGI (10 mg PG F2α) was delivered into the extraovular space. In 44 women, this single PGI provoked 40% progesterone (P)-withdrawal in 3 hours (P < 0.001) and 64% P-withdrawal (P < 0.001) in 15.3±0.9 hours, when the patients aborted. The remaining 6 women, whose P-withdrawal was only 14% at 3 hours without continuation during 24 hours, failed to abort. Thus in PG-induced abortions the regulatory significance of rapid and continued P-withdrawal (1–8) had been verified.The side effects were mild, transient and acceptable. The “Abortion Score” was 86. There were no serious complaints or complications during the study and followup. Since even in the 6 cases of failure the cervix dilated sufficiently to allow curettage (without surgical dilatation), the therapeutic benefits of the single PGI technique should be further examined in those services, where constant medical supervision (for determining the necessity and timing of repeated PGI) is not available.     

The effects of ovariectomy and strech on the regulatory profile and activity of the uterus

Following ovariectomy of five New Zealand white rabbits at day 25 of pregnancy, the intrauterine pressure (IUP) and uterine progesterone (P) and prostaglandin (PG) levels were measured sequentially at days 25, 26 and 27. At day 25, when the uterine P and PGE and PGF were high, massive intrauterine treatment with 500 μg PGF2α provoked only a sustained contracture on which only low level oscillation in IUP was superimposed. At day 26, when the P levels had decreased significantly (P<0.001) and the PG levels had not changed significantly, 50 μg PGF2α significantly increased cyclic IUP as compared with the day 25 value (P<0.001). At day 27, when the P levels decreased further, as little as 5 μg PGF2α provoked still higher cyclic IUP, in spite of a significant reduction in PG levels (P<0.05).Stretching the uterus of six post partum and six 26 days pregnant rabbits (after removing the uterine contents) significantly increased the uterine PGF levels (P<0.001). However, stretch increased only cyclic IUP of the post partum uterus and was without effect on the pregnant uterus, which still had high P levels. These results indicate that the myometrium activated by exogenous PG or stretch, regardless of whether the uterine PG levels increase, remain unchanged or even moderately decrease, provided that the uterine P levels are reduced to a critical value.     

Menstrual induction with PGF2 alpha and PGE2.

The "prostaglandin impact" (PGI), a massive intrauterine dose of PG, converts the refractory pregnant uterus into a reactive organ by provoking a regulatory imbalance. This regulatory conversion releases the endogenous mechanism of menstruation or abortion. During initial studies, PGI successfully provoked menstrual induction (MI) in 22 and subsequently in 65 volunteers. These results were confirmed and complemented by 2 independent trials in 14 and 36 gravidas respectively. The best clinical outcome was obtained in 20 volunteers, when a "PG-Pellet" (a mini-suppositorium) was inserted in utero, containing only 2.5 mg PGF2alpha. These 157 trials in sedated volunteers had the common features of over 90% efficiency, transient and medically acceptable side effects and infrequent complications. The present study of 542 volunteers focused upon the collection of clinical data regarding efficacy, side effects and complications of MI. All patients had committee approval for legal abortion, during the 2nd week of their missed menstrual period. They volunteered to participate because of their preference for pharmacological rather than surgical pregnancy termination. The clinical outcome of the 542 MI with 5 mg PGF2alpha (428 cases) and 1.5 mg PGE2 (114 cases) was identical. On the average, 95% of the gravidas had complete evacuation of the uterus with the clinical symptoms of delayed menstruation rather than abortion; they experienced spontaneous menstruation in 34 days after having received a single dose of PG.     

The mechanism of prostaglandin action on the pregnant human uterus.

The concentrations of 15 methyl PGF2 alpha, progesterone and estradiol in the peripheral plasma were assayed sequentially and the resting and active pressures of the uterus were quantitated in 10 first trimester pregnant patients, treated with a vaginal suppository containing 3 mg U-36,384. The purpose of the study was to determine the sequence of the prostaglandin induced changes in regulatory profile and uterine function and thus expose further the mechanism of prostaglandin action. The temporal relationships of the changes revealed that the primary action of exogenous prostaglandin is the disruption of the normal endocrine function of the conceptus and that the delayed oxytocic effect of this compound is secondary, a consequence of the primary action. Apparently prostaglandins are only effective as postconceptional agents if they convert the refractory normal pregnant uterus into a reactive organ. The academic and therapeutic significance of this finding is discussed.     

The effect of prostaglandin I2 on the contractility of the term pregnant human myometrium

Small myometrial strips were dissected from the upper and lower segments of the term pregnant human uterus. The specimens were superfused in organ chambers and contractile activity was recorded isometrically.In strips from the upper segment, prostacyclin (PGI₂), induced an initial excitatory response followed in the majority of experiments by transient inhibition. In the lower segment the response was generally the same although direct inhibition without initial stimulation occurred in some cases.During the period of inhibition the specimens were refractory to iterated exposure to PGI₂. Furthermore, during this period of PGI₂-induced inhibition the muscle strip was also refractory to PGE₂ but responded to PGF_2α and oxytocin by stimulation.After inhibition of spontaneous contractile activity induced by indomethacin PGI₂ induced an excitatory response.The results do not indicate any critical change in the myometrial responsiveness of the upper uterine segment to PGI₂ during labor. In strips from the lower segment obtained before labor there tended to be a dominance of non-responders and inhibition only as compared to the results during labor. Nevertheless, whether or not PGI₂ under physiological or pharmacological conditions has any significant influence on the contractility of the term pregnant human uterus, still remains obscure.As judged from earlier reports from our laboratory and the present study it is evident that the uterine vessels are considerably more sensitive to the action of PGI₂ than the myometrium.     

Suppression of uterine activity and abortion by inhibition of prostaglandin synthesis

The premise has been examined that the evolution of uterine activity, provoked by progesterone(P)-deficiency and consequent prostaglandin(PG)-dominance, can be suppressed in patients by inhibiting PG-synthesis. In 20 midtrimester pregnant women P-deficiency, evolution of intrauterine pressure (IUP), oxytocin response (OR) and abortion had been induced by the hypertonic saline technique and the changes in P and E2 levels and in IUP and OR measured sequentially. According to a "double blind" protocol, 10 volunteers received placebo, while another 10 were treated during 14 hours with 1050 mg naproxen, an inhibitor of PG-synthesis. Significant decrease in plasma progesterone (P 0.001) and estradiol 17Beta (P 0.02) preceding clinical progress in abortion demonstrated that hypertonic saline suppressed the endocrine function of the fetoplacental unit in both groups of patients. In spite of a 40% reduction in the P-levels of the experimental group (at a time when the controls aborted) the evolution of IUP, OR and abortion in the naproxen treated had been delayed by about 30 hours. This significant delay in all the measured parameters (P 0.001) is evidence that inhibition of PG-synthesis prevents the endogenous activation of the uterus in patients, as it does in animal "models".     

The abortifacient action of the extraovular “Prostaglandin impact” during the first half of human pregnancy

In 30 volunteers, 7 to 22 weeks pregnant, legal abortion had been induced successfully with the extraovular “Prostaglandin Impact” (PGI) (1). The patients were 24.8±1.1 years old (Means ± S.E.), para 1.6±0.3. At the 14.8±0.7 weeks of pregnancy and under sedation an initial dose of 10.0±0.0 mg PG F2α had been delivered transcervically into their extraovular (E.O.) space. This dose had been increased if accidental rupture of their fetal membranes resulted in intraamniotic (I.A.) treatment. The initial PGI of 16.0±2.0 mg was supplemented by additional PG doses, up to 27.0±2.9 mg, if clinical progress was slow. The patients responded to the initial PGI with sustained uterine contracture; rapid and continued progesterone (P) withdrawal, from 59.9±3.0 ng/ml to 30.7±2.1 ng/ml (49%); and with the progress of time high level cyclic intrauterine pressure (IUP). The 26% P-withdrawal, measured 3 hours after PGI was already significant (P < 0.001). Abortion was complete in 25 and incomplete in 4 patients, while 1 gravida had been curetted at 2 cm cervical dilatation. The instillation-abortion time (IAT) was short, only 13.0±1.1 hours. No side effects were observed in 17 patients, while 8 gravidas vomited (usually once) and 5 had transient increase in blood pressure. Extensive laboratory tests revealed no significant deviations from normality, during and after PG treatment. Blood transfusion was given to 2 patients (partly detached placentae and hemorrhage), antibiotics resolved 2 cases of endometritis and curettage removed (2 weeks after abortion) a small placental residue.The fetal membranes were accidentally ruptured in 11 patients and in these women the slow contracture response of the uterus signaled I.A. (rather than E.O.) PGI. The initial PG dose was increased, therefore, from 10.0±0.0 mg to 25.9±3.9 mg (P < 0.001) and the total dose from 20.0±2.0 to 42.3±4.8 mg (P < 0.001), to compensate for the lesser efficacious I.A. administration. In spite of this massive increase in the initial and total doses of PG, the rate and degree of P-withdrawal, the IAT, the incidence of side effects and the “Abortion Score” (AbS) of these 11 patients were similar to those of the 19 gravidas who received E.O. PGI. This finding, the good clinical outcome of the earlier (1) and the present study suggests that the transcervical E.O. PGI (regardless of accidental I.A. treatment) is a recommendable procedure for the non-surgical termination of pregnancy during the 1st half of gestation.     

Fetal viability does not affect the onset of stretch-induced labor and the increase in amniotic fluid prostaglandin F2 alpha and plasma prostaglandin F2 alpha metabolite levels.

The role of the fetus in the onset and progress of stretch-induced labor and in the change in amniotic fluid prostaglandin F2 alpha and plasma prostaglandin F2 alpha metabolite levels was evaluated in six normal pregnant women (group 1) and six women whose fetuses had been dead for more than one week (group 2). The uterus was distended by a balloon inflated with physiologic saline. Regular uterine contractions occurred, and increased in all patients. Within 21 hours, all patients delivered a normal baby in group 1 and a macerated fetus in group 2. There was no significant difference in induction-delivery interval between the two groups. Both groups showed a significant and similar range of increases in the levels of amniotic fluid prostaglandin F2 alpha and plasma prostaglandin F2 alpha metabolite during treatment (P less than 0.001). Thus, the fetus has no functional role in the onset and progress of stretch-induced labor or in the rise of amniotic fluid prostaglandin F2 alpha and plasma prostaglandin F2 alpha metabolite levels.     

Enhanced excitability of the uterus of the pregnant rabbit by imidazole stimulation of cyclic AMP phosphodiesterase

Imidazole, at concentrations between 10(-3) and 10(-2) M, exerts a profound stimulatory effect on rabbit uterine strips obtained during pregnancy and studied isometrically in vitro. The action is not duplicated by N-alkylimidazoles which have greater potency as inhibitors of thromboxane synthetase but the effect of imidazole was antagonized by isoproterenol or theophylline. Biochemical analysis indicated that imidazole at concentrations greater than 5 x 10(-4) M stimulated both high and low affinity forms of cyclic AMP phosphodiesterase. The uterus of pregnant rabbits is profoundly refractory to any kind of pharmacological stimulation and the effects of imidazole, acting to stimulate phosphodiesterase, suggest that the integrity of the adenyl cyclase-cyclic AMP-protein kinase system is a necessary requirement for this organ to remain quiescent during pregnancy.     

The mechanism of prostaglandin action on the pregnant human uterus

The concentrations of 15 methyl PGF2α, progesterone and estradiol in the peripheral plasma were assayed sequentially and the resting and active pressures of the uterus were quantitated in 10 first trimester pregnant patients, treated with a vaginal suppository containing 3 mg U-36,384. The purpose of the study was to determine the sequence of the prostaglandin induced changes in regulatory profile and uterine function and thus expose further the mechanism of prostaglandin action.The temporal relationships of the changes revealed that the primary action of exogenous prostaglandin is the disruption of the normal endocrine function of the conceptus and that the delayed oxytocic effect of this compound is secondary, a consequence of the primary action. Apparently prostaglandins are only effective as postconceptional agents if they convert the refractory normal pregnant uterus into a reactive organ. The academic and therapeutic significance of this finding is discussed.     

Decrease of utero-placental blood flow during prostaglandin F2α induced abortion

Pregnancy had been terminated in 6 normal midtrimester pregnant patients by the extraovular injection of 10 mg prostaglandin F2α (PGF2α). In these 6 Experimental and 3 Control patients utero-placental blood flow had been measured, by changes in the density of radioactive Indium, distributed over the uterine area, as a function of time. In comparison with Controls utero-placental blood flow decreased in the Experimental patients already at 5 minutes after PG-treatment, long before advanced cyclic IUP evolved. This finding substantiates the conclusion (1–3), based on experiments in animal “models”, that decrease in utero-placental blood flow is an early step in the mechanism of PG action.     

Physiological studies on nonpregnant and pregnant uterus in experimentally diabetic rats]

Spontaneous intraluminal pressure waves of diabetic nonpregnant uterus and contractile responses to oxytocin and prostaglandin F2 alpha (PGF 2 alpha) of both diabetic nonpregnant and diabetic pregnant uterus were investigated in vitro. Diabetes was induced by streptozotocin (STZ), 60 mg/kg for nonpregnant and 50 mg/kg for pregnant rats. Frequency of spontaneous intraluminal pressure waves of nonpregnant uterus was reduced in diabetic rats when compared with normal, but amplitude was slightly larger in diabetic than in normal uterus. Pressure-volume curves revealed that the compliance of nonpregnant diabetic uterus was remarkably reduced. Normal tubal side-circular muscle was significantly more sensitive to oxytocin and PGF 2 alpha than cervical one in contractile responses. This tendency was lost in diabetic nonpregnant uterus. Contractile responses of both tubal and cervical circular muscles to oxytocin were lower in nonpregnant diabetic than in normal rats, but those of longitudinal muscles were higher in diabetic nonpregnant than in normal rats. Cervical circular muscle of pregnant diabetic rats was more sensitive to both agents than those of normal. However, contractile responses of diabetic longitudinal muscle to both agents were higher than those of normal as in the case of nonpregnant uterus. The mechanism of diabetic changes of the nonpregnant and pregnant uterus was discussed.     

Prostaglandins and the initiation of labor

A total of 96, dated pregnant, New Zealand white rabbits were studied. In 58 animals the intrauterine pressure (IUP) of the unstimulated and PGF2α-stimulated myometrium was recorded, by the extraovular microballoon technique, before, during and after parturition. In the remaining 38 the concentrations of PGE and PGF and progesterone (P) were measured by radioimmunoassays (RIA). The samples were collected individually or sequentially during the perinatal period from uterine tissue and uterine or peripheral vein blood.At the critical time, at around parturition, when the myometrium is converted from a suppressed and refractory muscle into a spontaneously active and reactive organ (quantitated by recording the IUP), the uterine PGE and PGF levels decreased rather than increased (quantitated by RIA). Thus, this critical regulatory and functional change of the myometrium cannot be accounted for by an increase in the intrinsic uterine stimulant: PG, but only by a decrease in the suppressor: P. These findings, 46 years after the discovery of P, demand the further exploration of Corner's legacy.     

The effect of epidermal growth factor (EGF) on progestin secretion and cyclic AMP synthesis in cultured luteal cells from pregnant rats

It is reported that steroid synthesis in ovarian cells is affected by epidermal growth factor (EGF). We cultured luteal cells from pregnant rats for 2 days with or without EGF, followed by incubation of the cells with or without stimulants (hCG, forskolin and dibutyryl cyclic AMP) for 5 hours. The levels of progesterone, 20 alpha-hydroxy-pregn-4-en-3-one (20 alpha-dihydroprogesterone) and cyclic AMP (cAMP) in the media were assayed. EGF had no effect on the basal levels of progesterone, 20 alpha-dihydroprogesterone and cAMP, but it suppressed these levels which were increased by the stimulants. We investigated binding capacity of [125I]-EGF to ovarian tissue of pregnant rats. Ovarian tissue had specific binding sites for EGF. The maximum number of binding sites was 2.38 fmol/mg tissue and the Kd value was 0.547 nM. It was indicated that EGF modified the reactivity of luteal cells to stimulants; counteracting the tropic effect of gonadotropins. It was shown that this effect of EGF might be exerted through its receptor in luteal cells.     

Alpha 2-plasmin inhibitor inactivation by human granulocyte elastase

Plasminogen-binding human alpha 2-plasmin inhibitor is converted by human granulocyte elastase into its non-plasminogen-binding and finally into the inactive form of the inhibitor. This degradation of the plasmin inhibitor, described earlier as "spontaneously" occurring conversion, is shown in dodecyl sulfate polyacrylamide gel electrophoresis, in two-dimensional immunoelectrophoresis and by measuring the kinetics of plasmin inhibition. Experiments in the presence of normal human plasma required unphysiologically high concentrations of elastase to inactivate alpha 2-plasmin inhibitor, suggesting a role of elastase in this type of indirect fibrinolysis in a microenvironment only and not in systemic events.