Uterine rupture at term pregnancy with the use of intracervical prostaglandin E2 gel for induction of labor

Nitric oxide donor isosorbide mononitrate for pre-induction cervical ripening at 41 weeks' gestation: A randomized controlled trial

OBJECTIVE

Nitric oxide donors have been shown to cause cervical ripening. The aim of this study was to determine whether sustained release isosorbide mononitrate (ISMN-SR) 60 mg administered vaginally is effective for pre induction cervical ripening at 41 weeks' gestation.

METHODS

A double-blind randomised controlled trial was carried out at the University Obstetric Unit, Galle, Sri Lanka for a period of 9 months, commencing 1st August 2003. One hundred and fifty-six consecutive women with uncomplicated singleton pregnancies at 41 weeks' gestation with a modified Bishop Score <5 were allocated by stratified (primip/multip) block randomization to receive either ISMN-SR 60 mg (n = 78) or vitamin C 100 mg (n = 78) vaginally. Modified Bishop Score at 41 weeks + 2 days' gestation and the proportions establishing spontaneous labor or becoming favorable for induction of labor (IOL) by 41 weeks + 2 days' gestation were evaluated in each group.

RESULTS

At the commencement of the study there were no differences between the mean age, parity or modified Bishop Score of the two groups. In the ISMN-SR group, there was a marked increase in the proportion establishing spontaneous labor (28% vs 7.5%, P < 0.01) and being favorable for IOL (40% vs 9% P < 0.001), 2 days after therapy. In the ISMN-SR group, there was a significantly higher increase in the mean modified Bishop Score (3.8, 95% CI 2.3-5.3 vs 1.3, 95% CI 0.3-2.2, P < 0.01) and a marked decrease in the proportion of subjects requiring further ripening of the cervix with a Foley catheter. (32% vs 79%, P < 0.001). The cesarean section rates were similar in both groups.

CONCLUSION

Sustained release ISMN administered vaginally is effective for preinduction cervical ripening.

Misoprostol for second trimester pregnancy termination in women with prior caesarean section

OBJECTIVE

To examine whether a previous caesarean section increases the risk for complications in women undergoing a mid-trimester pregnancy termination by labour induction.

DESIGN

Retrospective analysis of case records between 1997 and 2002.

SETTING

Fetal Medicine Unit of a large teaching hospital.

POPULATION

One hundred and eight women with a previous caesarean section (study group) and 216 women without such a history (controls), who underwent a second trimester termination of pregnancy.

METHODS

All the terminations were performed between 17 and 24 weeks of gestation by using 400 mug of oral administration of misoprostol in combination with 400 mug of intravaginal misoprostol. The same dose of intravaginal misoprostol was repeated every 6 hours for a maximum of five doses.

MAIN OUTCOME MEASURES

Severe haemorrhage requiring blood transfusion, post-abortal infection, retained placenta and uterine rupture.

RESULT

Complications occurred in 16 out of 108 women of the study group (15%) and in 26 out of 216 of the controls (12%), with only one ruptured uterus in the control group.

CONCLUSION

We found no evidence that a previous caesarean delivery affects the incidence of complications when women with such a history undergo a mid-trimester pregnancy termination with misoprostol.

A comparison of vaginally administered misoprostol with extra-amniotic saline solution infusion for cervical ripening and labor induction

OBJECTIVE

The purpose of this study was to compare intravaginal misoprostol with extra-amniotic saline solution infusion with concomitant oxytocin for cervical ripening and labor induction in viable pregnancies.

STUDY DESIGN

Two hundred women with indications for labor induction and unfavorable cervices were assigned randomly to vaginal misoprostol or extra-amniotic saline solution infusion. Twenty-five micrograms of misoprostol was administered every 4 hours up to six doses, followed by intravenous oxytocin administration. Patients who had received extra-amniotic saline solution infusion also received intravenous oxytocin along with a maximum 12-hour saline solution infusion through Foley catheters that were placed above the internal cervical os.

RESULTS

One hundred women were randomly assigned to misoprostol, and 100 women were assigned randomly to extra-amniotic saline solution infusion. The average interval from start of induction to vaginal delivery was longer in the misoprostol group (1323.3 +/- 700.3 minutes) than in the extra-amniotic saline solution infusion group (970.4 +/- 502.7 minutes; P =.006, log transformed data). Abnormal fetal heart rate tracings were found in 30% of the patients who received misoprostol and in 19% of the patients who received extra-amniotic saline solution infusion (relative risk, 1.6; 95% CI, 1.0-2.4; P =.05). There was more tachysystole in the misoprostol group (8%) than in the extra-amniotic saline solution infusion group (1%; P =.02). There were no differences in the routes of deliveries or neonatal outcomes between groups.

CONCLUSION

Extra-amniotic saline solution infusion with oxytocin administration appears more effective and is associated with fewer maternal complications than misoprostol for cervical ripening and labor induction.