Limb reduction anomaly after failed misoprostol abortion

A 42-year-old woman, para 5, gravida 6, was admitted to Coronation Hospital on 2 June 1997. She reported vaginal bleeding for the past month and draining of amniotic fluid for 2 days. She had had 5 normal deliveries, the last having been of twins, and her 6 children ranged in age from 8 years to 18 years. Her last menstrual period had been on 25 November 1996. She, her husband and 3 of her children had been born with an extra digit on one or both hands. The past medical history waS otherwise non-contributory. The patient gave the following history relevant to the current pregnancy. In March 1997 pregnancy had been diagnosed by a general practitioner, and she had gone to her local hospital to request termination of pregnancy in terms of the newly promulgated Act. An ultrasound scan confirmed pregnancy of about 13 weeks' duration. Termination of the pregnancy was attempted with misoprostol tablets, one inserted vaginally on 4 consecutive days. On the 4th day some vaginal bleeding occurred. One week later she was admitted to the hospital for sterilisation. A minilaparotomy was performed under general anaesthesia, and after the operation she was informed that the sterilisation had not been performed because she had been found to still be pregnant. She had decided not to make any further attempt at termination of the pregnancy. On the patient's admission to Coronation Hospital on 2 June, her general condition was found to be good. The uterus was soft and non-tender and the symphysis-fundus measurement was 24 cm. Vaginal examination with a speculum confirmed drainage of non-offensive amniotic fluid and slight bleeding. Ultrasound examination revealed a breech presentation with measurements corresponding to 26 weeks' gestation, an estimated fetal weight of 970 g and greatly reduced amniotic fluid volume, which made detailed assessment for fetal anomalies difficult. The patient was counselled about the risks of ruptured membranes at this gestational age, and the option of induction of labour, but she requested conservative management. She was treated with prophylactic antibiotics and steroid therapy to promote fetal lung maturity. Her