Cardiotocographic abnormalities associated with misoprostol and dinoprostone cervical ripening and labor induction

Comparison of fetal safety of vaginal Misoprostol tablet and Dinoprostone gel for induction of labor: An open-label randomized control trial

AIM

In modern obstetrics, need of labor induction is increasing along with increased caesarean deliveries. Major contributions for these operative deliveries are due to induction failure. This demands a potent labor-inducing agent. Dinoprostone gel is an established method but having some drawbacks. Misoprostol could be an effective alternative to Dinoprostone, but its fetal safety is not yet well established. This study aimed to evaluate the fetal safety of vaginal Misoprostol tablet by measuring fetal heart rate changes during induction of labor.

METHODS

This was a single-center randomized controlled trial incorporating 140 term women, equally randomized to get either tablet Misoprostol or Dinoprostone gel. Fetal heart rate patterns were compared in both the groups by continuous cardiotocographic tracing. All the data were analyzed on an intention-to-treat basis.

RESULTS

There were no statistically significant changes in fetal heart rate pattern in both Misoprostol and Dinoprostone groups. Vaginal deliveries were statistically higher in Misoprostol group. Neonatal parameters like 1 min Appearance, Pulse, Grimace, Activity, and Respiration score and neonatal intensive care unit admission were comparable, and there was no significant difference in terms of major adverse events and side effects.

CONCLUSIONS

Misoprostol is a safe alternative to Dinoprostone gel for induction of labor and found to be more effective labor-inducing agent. In the background of higher caesarean rate, vaginal Misoprostol can be a potential labor-inducing agent especially in a resource poor setting.

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour.

OBJECTIVE

To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups.

METHODS

We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves.

RESULTS

We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective.

LIMITATIONS

There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses.

CONCLUSIONS

Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention.

FUTURE WORK

Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005116.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

[Cervical ripening after previous cesarean section with dinoprostone vaginal insert]

OBJECTIVES

Because, to date in France, 20 % of pregnant women had a scared uterus and because the best mean of cervical ripening is unknown and controversial, we want to evaluate efficacy and safety of dinoprostone for cervical ripening in women with previous cesarean.

MATERIALS AND METHODS

We conducted a retrospective unicentric study, from 2010 to 2014, at Limoges regional university hospitals. Two hundred and sixty nine patients, with medical indication for induction of labor and scared uterus, were included and ripened with dinoprostone (Propess^® and/or Prostine^®). Women had unfavorable cervix with Bishop score inferior to 6.

RESULTS

Overall rate of vaginal delivery was 62 %. Patients have had more of one prostaglandin in 19 % of cases; the cesarean rate was significantly higher in this case (cesarean: 55.6 % vs. vaginal delivery: 44.4 %; P=0.0043). Overall, there were respectively 4 % and 0.7 % of post-partum hemorrhage and uterine rupture. One percent of newborns had a severe acidosis (pH<7 in umbilical artery) and 1 % was admitted to the Intensive Neonatal Care Unit.

CONCLUSION

Dinoprostone is an effective procedure in patients with previous cesarean section requiring labor induction, with a morbidity comparable to other methods of induction of labor.

Women's perceptions of induction of labour outcomes: Results of an online-survey in Germany

OBJECTIVE

induction of labour (IOL) is a common procedure in high income countries. It may be conducted for medical as well as non-medical reasons. Women's views on induction of labour have not extensively been evaluated as yet. Also, women's preferences for certain methods of induction including alternative and complementary methods need further exploration in order to meet their expectations and needs.

DESIGN AND SETTING

we published a short online questionnaire on women'views and experiences with IOL.

MEASUREMENTS AND FINDINGS

we asked for indication and gestational age at induction; method of induction, duration of labour and mode of birth. We also asked for the extent of desired, and experienced support and participation in decision-making. Within four weeks of being online, 698 women answered the questionnaire. Most frequent reasons for induction were postmaturity (51.7%), doctor's recommendation (31.6%) and medical complications (25.6%). Most women were induced with misoprostol or dinoprostone, but nearly half of the respondents were also offered, or asked for, complementary and alternative methods (CAM). 50% or more women would have preferred more information on alternatives to IOL, methods of IOL, side effects of the drugs, information on alternatives (59.2%) and on the medication (55.3%). Many would have wished for more support (49.9%) with decision-making (55.2%), and more time (54.1%).

KEY CONCLUSION

women' expectations and needs regarding IOL are widely unmet in current clinical practice.

IMPLICATIONS FOR PRACTICE

there is a need for evidence-based information and decisional support for pregnant women who need to decide how to proceed once term is reached.

A critical appraisal of the misoprostol removable, controlled-release vaginal delivery system of labor induction

BACKGROUND

Induction of labor is a major issue in pregnancy management. Finding strategies to increase rate and decrease time to vaginal delivery is an important goal, but maternal or neonatal safety must remain the primary objective. Misoprostol is a synthetic analogue of prostaglandin used off label to ripen the cervix and induce labor. The misoprostol vaginal insert (MVI) was designed to allow a controlled-release delivery of misoprostol (from 50 to 200 μg) with a removal tape. The objective of this review was to make a critical appraisal of this device referring to the literature.

METHODS

A literature search was performed in the PubMed and Cochrane databases using the keywords "vaginal misoprostol insert".

RESULTS

Several studies compared different doses of MVI (50, 100, 150, and 200 μg) with the 10 mg dinoprostone insert. The 100 μg MVI compared with the dinoprostone vaginal insert (DVI) showed similar efficacy and no significant differences in cesarean delivery rate. MVI 200 μg compared with DVI showed a reduced time to vaginal delivery and oxytocin need but had an increased risk of uterine hyperstimulation. The rate of hyperstimulation syndrome was two to three times more frequent with the 200 μg MVI than the 100 μg.

CONCLUSION

Current data suggest that the 100 μg MVI would provide the best balance between efficacy and safety. Further studies should be performed to evaluate this dose, especially in high-risk situations needing induction of labor.

Misoprostol for induction of labor

Labor-induction rates have increased considerably in the United States as well as around the world. With up to half of all induced labors requiring cervical ripening, prostaglandins have been utilized to increase induction success and achieve vaginal delivery. Misoprostol, a synthetic prostaglandin E1 analog has the ability to mimic the changes of spontaneous labor and has been used off label for over 30 years as a labor-induction agent. In the following article, cervical ripening and induction of labor with misoprostol will be discussed. The risks and benefits of misoprostol for ripening and induction and routes of administration will be reviewed, as well as future directions and new developments for its use.

A novel misoprostol delivery system for induction of labor: clinical utility and patient considerations

Induction of labor is one of the most commonly performed obstetric procedures and will likely become more common as the reproductive population in developed nations changes. As the proportion of women undergoing induction grows, there is a constant search for more efficacious ways to induce labor while maintaining fetal and maternal safety as well as patient satisfaction. With almost half of induced labors requiring cervical ripening, methods for achieving active labor and vaginal delivery are constantly being investigated. Prostaglandins have been shown to be effective induction agents, and specifically vaginal misoprostol, used off-label, have been widely utilized to initiate cervical ripening and active labor. The challenge is to administer this medication accurately while maintaining the ability to discontinue the medication when needed. The misoprostol vaginal insert initiates cervical ripening utilizing a delivery system that controls medication release and can be rapidly removed. This paper reviews the design, development, and clinical utility of the misoprostol vaginal insert for induction of labor as well as patient considerations related to the delivery system.

Misoprostol vaginal insert for induction of labor: a delivery system with accurate dosing and rapid discontinuation

Labor induction and cervical ripening are widely utilized and new methods are constantly being investigated. Prostaglandins have been shown to be effective labor induction agents and, in particular, were compared with other prostaglandin preparations; vaginal misoprostol used off-label was associated with reduced failure to achieve vaginal delivery. The challenge is to provide this medication with the correct dosing for this indication and with the ability to discontinue the medication if needed, all while ensuring essential maternal and neonatal safety. The misoprostol vaginal insert initiates cervical ripening using a delivery system that controls misoprostol release and can be rapidly removed. This article reviews the development, safety and efficacy of the misoprostol vaginal insert for induction of labor and cervical ripening, and will focus on vaginally administered prostaglandins.

Induction of labor in twin pregnancies with oral misoprostol versus vaginal dinoprostone--is it effective and safe?

OBJECTIVE

To compare the effectiveness and safety of oral misoprostol versus vaginal dinoprostone for the induction of labor in twin pregnancies.

METHODS

All twin pregnancies ≥ 34 weeks 0 days that were induced with either misoprostol or dinoprostone in St. Hedwig Hospital between 2002 and 2013 were included in this retrospective study. Length of induction, mode of delivery, maternal and neonatal outcomes were compared between the two groups.

RESULTS

After identifying 186 twin mothers matching the inclusion criteria, 154 women were induced with misoprostol (group A) and 32 with dinoprostone (group B). There were no differences in demographic data between the groups. Rates of successful vaginal delivery (53.9% versus 56.3%) and length of induction to delivery (30.2 h versus 26.9 h) were also similar. There were slightly higher rates of postpartum hemorrhage in group B (16.6% versus 10.8%), but without reaching statistical significance. Neonatal outcomes regarding umbilical artery pH <7.20 and one minute Apgar also were without significant differences.

CONCLUSIONS

Study data indicate that oral misoprostol and vaginal dinoprostone are similarly effective and safe for the induction of labor in twin gestations. Further trials with larger series are needed to confirm these results.

The effect of extending dinoprostone pessary placement from 12 to 24 h on the need for further mechanical cervical ripening

Dinoprostone pessaries (DP) are widely used for cervical ripening, and while licensed for 12-h administration in Australia, 24-h use is also reported. We examined 396 consecutive women before and after a protocol change from 12-h to 24-h DP use to determine whether extended DP use decreases the need for additional mechanical cervical ripening. No significant difference in cervical ripening balloon (CRB) requirement or vaginal birth rates was detected, showing that prolonged DP use does not reduce subsequent use of CRB.

The pharmacology of prostaglandins for induction of labor

Prostaglandin medications are frequently used in the process of induction of labor. Understanding the history and research that supports prostaglandin use for induction of labor is crucial for safe practice. Dinoprostone has been the standard of care for cervical ripening in term pregnancies. Misoprostol administration via various routes has been shown to be efficacious. Oral misoprostol in particular is effective and associated with reassuring maternal and fetal outcomes. In addition, cost has become a variable in decision making regarding best practice. More research is necessary to determine the safest medication, route, dose, and interval of administration. This article reviews cervical physiology and endogenous prostaglandin activity in relation to labor, and the pharmacologic profiles of synthetic prostaglandins currently used for induction of labor.

Current pharmacotherapy options for labor induction

INTRODUCTION

Labor induction is now reported to occur in up to 30 - 40% of obstetrical patients. There are a number of pharmacological options available to facilitate labor induction, including oxytocin and analogues of prostaglandins E1 and E2, which have particular utility when labor induction necessitates cervical ripening, as when labor induction occurs in the context of an unfavorable cervix.

AREAS COVERED

This paper reviews acceptable pharmacological options for labor induction, especially when cervical ripening is required. These options include oxytocin and a number of prostaglandin formulations using dinoprostone and misoprostol. It also covers several analyses of published clinical trials (Phase-III) describing evidence of effectiveness.

EXPERT OPINION

Oxytocin is best used when labor needs to be induced in the context of a favorable cervix. When the cervix is not favorable, cervical ripening using prostaglandins should precede labor induction. Either dinoprostone or misoprostol are superior to oxytocin alone for cervical ripening. However, judicious, careful considerations need to be made at the outset of labor induction so as to balance maternal and fetal risks, and these should be guided by institutional policies that reflect the evidence-base.

Vaginal misoprostol for cervical ripening and induction of labour

BACKGROUND

Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue widely used for off-label indications such as induction of abortion and of labour. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of vaginal misoprostol for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008) and bibliographies of relevant papers. We updated this search on 30 April 2010 and added the results to the awaiting classification section.

SELECTION CRITERIA

Clinical trials comparing vaginal misoprostol used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

We developed a strategy to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.We used fixed-effect Mantel-Haenszel meta-analysis for combining dichotomous data.If we identified substantial heterogeneity (I² greater than 50%), we used a random-effects method.

MAIN RESULTS

We included 121 trials. The risk of bias must be kept in mind as only 13 trials were double blind.Compared to placebo, misoprostol was associated with reduced failure to achieve vaginal delivery within 24 hours (average relative risk (RR) 0.51, 95% confidence interval (CI) 0.37 to 0.71). Uterine hyperstimulation, without fetal heart rate (FHR) changes, was increased (RR 3.52 95% CI 1.78 to 6.99).Compared with vaginal prostaglandin E2, intracervical prostaglandin E2 and oxytocin, vaginal misoprostol was associated with less epidural analgesia use, fewer failures to achieve vaginal delivery within 24 hours and more uterine hyperstimulation. Compared with vaginal or intracervical prostaglandin E2, oxytocin augmentation was less common with misoprostol and meconium-stained liquor more common.Lower doses of misoprostol compared to higher doses were associated with more need for oxytocin augmentation and less uterine hyperstimulation, with and without FHR changes.We found no information on women's views.

AUTHORS' CONCLUSIONS

Vaginal misoprostol in doses above 25 mcg four-hourly was more effective than conventional methods of labour induction, but with more uterine hyperstimulation. Lower doses were similar to conventional methods in effectiveness and risks. The authors request information on cases of uterine rupture known to readers. The vaginal route should not be researched further as another Cochrane review has shown that the oral route of administration is preferable to the vaginal route. Professional and governmental bodies should agree guidelines for the use of misoprostol, based on the best available evidence and local circumstances.