Off-label use of misoprostol for labor induction: a nation-wide survey in Switzerland

Twice-Weekly Versus Once-Weekly Membrane Sweeping in the Prevention of Post-Term Pregnancy: a Systematic Review and Meta-Analysis of Randomized Controlled Trials

Membrane sweeping is considered a simple and effective method for initiating spontaneous onset of labor. Despite the widely accepted membrane sweeping use to prevent post-term birth, the optimal frequency has not been estimated. We aimed to assess the effectiveness and safety of twice-weekly versus once-weekly membrane sweeping in post-term pregnancy prevention. Four different databases were searched for available clinical trials from inception to October 2022. We selected randomized controlled trials (RCTs) that compared twice-weekly membrane sweeping in intervention group versus once-weekly membrane sweeping in control group among pregnant women with singleton pregnancy at ≥ 39 gestational weeks. Our primary outcomes were the rate of spontaneous onset of labor and the requirement for formal methods of labor induction. Our secondary outcomes were sweeping to delivery interval in days, gestational age at delivery in weeks, Bishop score at admission, chorioamnionitis, and premature rupture of membranes. Three RCTs (596 patients) were included. Twice-weekly membrane sweeping was associated with significant increase in the rate of spontaneous onset of labor and significant decline in labor induction rate in comparison with once-weekly group. Duration from sweeping to delivery was significantly shorter among the twice-weekly group (p<0.001). Furthermore, gestational age at delivery was significantly earlier in the twice-weekly group. A significantly higher Bishop score at admission was observed in the twice-weekly group (p=0.02). There were no significant differences across both groups in chorioamnionitis and premature rupture of membranes. In conclusion, twice-weekly membrane sweeping is more effective in preventing post-maturity pregnancy than once-weekly sweeping without added adverse events.

Safety and Efficacy of Cervical Ripening and Induction of Labor Using Prostaglandin E1 in Primiparas, Multiparas and Grand Multiparas

Objective

To compare the efficacy and safety of cervical ripening and induction of labor with prostaglandin E1 among primiparas, multiparas and grand multiparas.

Study design

This was a retrospective cohort study.

Results

Between January and December 2017, 1713 women underwent cervical ripening and induction of labor with prostaglandin E1: 523 were primiparas, 656 were multiparas, and 534 were grand multiparas. Four hundred and seventy-nine (91.6%) primiparas delivered vaginally as did 640 (97.6%) multiparas and 521 (97.6%) grand multiparas. Forty-four (8.4%) primiparas underwent cesarean delivery compared to 16 (2.4%) multiparas and 13(2.4%) grand multiparas. Induction to delivery interval was significantly longer in primiparas (29.7 ± 22.8 h). There were no cases of uterine rupture, and the rates of postpartum hemorrhage and endometritis were similar among the three groups. Neonatal outcomes including Apgar score < 7 and umbilical artery pH < 7.1 were not significantly different between the groups.

Conclusion

Using prostaglandin E1 for cervical ripening and labor induction is efficient and safe in primiparas, multiparas and grand multiparas.

Trends and regional variations in prescriptions dispensed to stimulate uterine contractions at the end of pregnancy in Belgium: A community-based study from 2003 to 2018

PURPOSE

To investigate trends and regional variations in uterotonics dispensed around birth between 2003 and 2018 in Belgium.

METHODS

Data, including outpatient and inpatient prescriptions were extracted from a nationally representative prescription database. The prevalence of uterotonics dispensed during a period including the 7 days before birth, the delivery day and the 7 days after birth was computed over three 4-year-long study periods from 2003 to 2018. The trends between periods and associations between the use of at least one uterotonic and maternal age, region of residence, delivery type and social status were assessed using logistic regression.

RESULTS

In total, 31 675 pregnancies were included in the study. The proportion of pregnancies exposed to at least one uterotonic decreased significantly from 92.9% (95%CI, 92.3-93.4) in 2003-2006 to 91.4% (95%CI, 90.7-92.0) in 2015-2018 for vaginal births and from 95.5% (95%CI, 94.5-96.4) to 93.7% (95%CI, 92.6-94.7) for caesarean sections. However, for vaginal births, the proportion of oxytocin increased from 84.5% (95%CI, 83.7-85.2) to 89% (95%CI 88.3-89.7). A significant association was found between uterotonic agent use and maternal age, region of residence, and delivery type. The dispensation of some uterotonic agents differed significantly between the regions.

CONCLUSIONS

The proportion of pregnancies exposed to at least one uterotonic was high across the study period but decreased slightly between 2003 and 2018. Important variations in uterotonic use between regions highlight the need for improved national guidance.

Cervical change times during induction in nulliparas using vaginal or buccal misoprostol

AIM

To determine if the time to cervical change and time to active labor were different when misoprostol was administered by a vaginal or buccal route for cervical ripening in nulliparas undergoing labor induction at term.

METHODS

This was a secondary analysis of nulliparous participants in the IMPROVE Study-A comparison of vaginal versus buccal misoprostol for cervical ripening for labor induction at term: a triple-masked randomized controlled trial (NCT02408315). The parent study was a non-inferiority randomized controlled trial in which patients beginning induction with a modified Bishop score ≤6 received either vaginal or buccal misoprostol and simultaneous placebo via the opposite route. The primary outcome of the parent study was time to delivery. Primary outcomes for this secondary analysis were the time to active labor (at least 6 cm dilated) and time to change in cervical dilation. Kaplan-Meier analysis was used to compare routes for time to active labor and multistate Markov modeling was used to compare sojourn times at each cervical dilation.

RESULTS

Of the 300 participants enrolled in the parent trial, 124 (41.3%) were nulliparous; 59 (47.6%) nulliparous participants underwent induction with vaginal misoprostol and 65 (52.4%) received buccal dosing. Nulliparas receiving vaginal dosing required fewer doses of misoprostol to reach active labor (median 2 vs 3, p = .003). However, this did not result in shorter time to active labor (median vaginal 23.1 h, 95% CI = [21.6, 27.2 h]; buccal 25.6 h [21.5, 29.3 h], p = .45) or higher rate of vaginal delivery within 24 h; (33.9% vs 35.4%, p = .86). There was also no significant difference in time to active labor after adjusting for covariates (adjusted HR for dose route (buccal vs vaginal) = 0.91 [0.61, 1.36], p = .649). Among people that delivered vaginally, the mean sojourn times, measuring cervical dilation state change, were not significantly different, with mean duration to active labor of 20.5 [17.6, 24.5] h for buccal and 21.8 [17.7, 28.2] h for vaginal dosing (p = .092). Satisfaction and preference for dosing routes were not different between groups.

CONCLUSION

Buccal and vaginal dosing of misoprostol for cervical ripening in nulliparas appear to have similar times to active labor and progression of cervical change during ripening.

Health Related Quality of Life Post Labour Induction with Misoprostol Versus Dinoprostone At Muhimbili National Hospital in Dar Es Salaam, Tanzania: A cross Sectional Study

BACKGROUND

Labour induction using Misoprostol or Dinoprostone results to similar maternal and foetal clinical outcomes. However, the clinical outcome measures have rarely been combined with effects of interventions on patients' health related quality of life. This study aimed to assess postpartum health related quality of life of parturient after labour induction with vaginal administration of misoprostol versus dinoprostone.

METHODS

This was a comparative cross sectional study in which pregnant women who underwent labour induction with misoprostol and dinoprostone during the study period were included. Data were collected within 24 hours post-delivery using the 36 item short form health survey questionnaire which consists of 24 attributes distributed in five domains including bodily pains and physical performance three attributes each, mental health seven attributes, general health two attributes, social functioning six attributes and three attributes for labour induction satisfaction. We first estimated scores of all attributes in each domain using Likert scales and then the domain scores were converted into a 0 to 100 scales to express in percentage of total scores. Quality of life was compared in the two study groups using the independent samples T Test. Multivariate regression analysis was performed to control for marital status, gravidity, parity, baseline cervical status, time interval from induction to delivery and mode of delivery.

RESULTS

Women who received misoprostol reported better health related quality of life compared to those who received dinoprostone (mean score 92.89 vs. 87.25;P<.00). Misoprostol group had significantly higher scores in all domains of health related quality of life; reduced bodily pain (93.76 vs. 84.19;P<.00), physical performance (83.64 vs. 73.58;P<.00), mental health (96.40 vs. 93.55; P<.00), general health (93.78 vs. 90.23;P=.01), social functioning (94.81 vs. 91.25;P<.00) and satisfaction perceptions (94.96 vs. 90.71;P<.00).

CONCLUSION

Health related quality of life information is of particular value in routine care of natal and postnatal mothers. Current and updated guidelines should address the impacts of labour induction interventions on maternal health related quality of life, and encourage the use of quality of life information in provision of holistic natal and postnatal care services. Clinical trials are recommended to determine the effectiveness of labour induction with either of the two methods and address the historical adverse outcomes associated to the use of misoprostol.

A comparison of vaginal versus buccal misoprostol for cervical ripening in women for labor induction at term (the IMPROVE trial): a triple-masked randomized controlled trial

BACKGROUND

Cervical ripening is commonly needed for labor induction. Finding an optimal route of misoprostol dosing for efficacy, safety, and patient satisfaction is important and not well studied for the buccal route.

OBJECTIVE

To compare the efficacy and safety of vaginal and buccal misoprostol for women undergoing labor induction at term.

STUDY DESIGN

The IMPROVE trial was an institutional review board-approved, triple-masked, placebo-controlled randomized noninferiority trial for women undergoing labor induction at term with a Bishop score ≤6. Enrolled women received 25 mcg (first dose), then 50 mcg (subsequent doses) of misoprostol by assigned route (vaginal or buccal) and a matching placebo tablet by the opposite route. The primary outcomes were time to delivery and the rate of cesarean delivery performed urgently for fetal nonreassurance. A sample size of 300 was planned to test the noninferiority hypothesis.

RESULTS

The trial enrolled 319 women, with 300 available for analysis, 152 in the vaginal misoprostol group and 148 in the buccal. Groups had similar baseline characteristics. We were unable to demonstrate noninferiority. The time to vaginal delivery was lower for the vaginal misoprostol group (median [95% confidence interval] in hours: vaginal: 20.1 [18.2, 22.8] vs buccal: 28.1 [24.1, 31.4], log-rank test P = .006, P_{noninferiority} = .663). The rate of cesarean deliveries for nonreassuring fetal status was 3.3% for the vaginal misoprostol group and 9.5% for the buccal misoprostol group (P = .033). The rate of vaginal delivery in <24 hours was higher in the vaginal group (58.6% vs 39.2%, P = .001).

CONCLUSION

We were unable to demonstrate noninferiority. In leading to a higher rate of vaginal deliveries, more rapid vaginal delivery, and fewer cesareans for fetal issues, vaginal misoprostol may be superior to buccal misoprostol for cervical ripening at term.

Misoprostol vaginal insert versus misoprostol vaginal tablets for the induction of labour: a cohort study

Background

Misoprostol vaginal insert for induction of labor has been recently reported to be superior to dinoprostone vaginal insert in a phase III trial, but has never been compared to vaginal misoprostol in another galenic form. The aim of this study was to compare misoprostol vaginal insert (MVI) with misoprostol vaginal tablets (MVT) for induction of labor in term pregnancies.

Methods

In this retrospective cohort study we compared 200 consecutive women induced with 200-μg misoprostol 24-h vaginal insert (Misodel®) with a historical control of 200 women induced with Misoprostol 25-μg vaginal tablets (Cytotec®) every 4-6 h. Main outcomes variables included induction-to-delivery interval, vaginal delivery within 24-h, incidence of tachysystole, mode of delivery, and neonatal outcome. A subanalysis in the MVI group was performed in order to identify predictive factors for tachysistole and vaginal delivery within 24 h.

Results

The time from induction to vaginal delivery was 1048 ± 814 min in the MVI group and 1510 ± 1043 min in the MVT group (p < 0.001). Vaginal delivery within 24-h occurred in 127 (63.5%) patients of the MVI group and in 110 (55%) patients of the MVT group (p < 0.001). Tachysystole was more common in the MVI group (36% vs. 18%; p < 0.001). However, no significant predictors of uterine tachysystole in MVI group have been identified in crude and fully adjusted logistic regression models. Bishop score was the only predictor for vaginal delivery within 24 h (p < 0.001) in MVI group. Caesarean delivery rate (27% vs. 20%) and vaginal-operative deliveries (15.5% vs. 15.5%) did not differ significantly between the two groups. Neonatal outcomes were similar in both groups.

Conclusions

MVI achieves a more vaginal delivery rate within 24 h and Tachysystole events compared to MVT. However, no differences in caesarean section, operative vaginal delivery, and neonatal outcomes are reported. No predictors of tachysistole after MVI administration have been identified. Bishop score and parity are the only predictors of vaginal delivery within 24 h after MVI administration.

The misoprostol vaginal insert compared with oral misoprostol for labor induction in term pregnancies: a pair-matched case-control study

AIM

To compare the efficacy and safety of the misoprostol vaginal insert (MVI) with an off-label use of oral misoprostol (OM).

METHODS

Pair-matched case-control study comparing the induction of labor with a retrievable MVI to OM. The primary outcomes were the time from induction to delivery and the cesarean section rate. Secondary outcomes included uterine tachysystole, tocolysis, fetal scalp blood testing, meconium-stained amniotic fluid, umbilical arterial pH, and Apgar score.

RESULTS

One hundred and thirty eight women ≥37/0 weeks pregnant undergoing labor induction with misoprostol were included. The mean time from application to delivery was significantly shorter and the caesarean section rate significantly higher in the MVI group (P<0.01) with an odds ratio of 2.75 (95% CI: 1.21-6.25) in favor of vaginal delivery in the OM group. The mean 5-min Apgar scores and arterial cord pH values were significantly lower in the MVI group. An arterial pH value of 7.10-7.19 was found in 26.1% and 15.9%, and a value <7.10 was found in 4.3% and 0% of MVI and OM cases, respectively.

CONCLUSION

The MVI compared with OM significantly shortened the time from application to delivery at the expense of a higher cesarean section rate and negative effects on neonatal outcomes.

Off-label prescriptions in intensive care unit: the Chinese experience

Background and purpose

Off-label prescriptions for critically ill patients pose several ethical and legal dilemmas for intensive care unit (ICU) clinicians. Yet, few data are available on the prevalence of this practice in critical care environment in China. This nationwide survey was performed to evaluate the conditions of off-label prescriptions in ICU within China.

Methods

The survey was performed at the scene of the national ICU conferences in 2016. ICU clinicians attending the congress from 23 provinces across the country were invited. The features of the clinician's off-label prescription practice were investigated and analyzed.

Results

A total of 1,318 ICU clinicians completed the anonymous questionnaire. Of these, 76.2% prescribed off-label in clinical practice. A significant difference (p<0.005) was observed between the ICU clinicians with different years of working experience and professional levels, respectively. For 69.2% of the ICU clinicians, the proportion of off-label prescriptions did not exceed 10%, while for fewer prescribers (2.9%), the proportion exceeded 25%. The main reasons for off-label prescriptions were life-threatening or terminal medical condition without other substitutes (48.3%), new treatments with strong scientific evidence (38.1%), and limited indications of drug labels (22.7%). Of the ICU clinicians surveyed, 87.5% worried about causing medical disputes, and 26.5% encountered medical disputes caused by off-label prescriptions. The risk of medical disputes was positively associated with the proportion of off-label prescriptions (p=0.009). Among the ICU clinicians, 92.5% expected the national policy for off-label prescriptions in future. Gastrointestinal and respiratory drug classes were noted to have the highest prevalence of off-label use.

Conclusion

Off-label prescriptions have been commonly practiced by ICU clinicians in China. A concerted effort should be made to develop a practical and explicit guidance for off-label prescriptions.

Survey of Provider Preferences Regarding the Route of Misoprostol for Induction of Labor at Term

Objective  To survey obstetrical provider preferences regarding use of misoprostol for induction of labor (IOL). Methods  An anonymous 25-question survey was distributed at an American College of Obstetricians and Gynecologists (ACOG) joint District V and VII Meeting in 2014 to obstetrics providers. The same survey was sent electronically to local providers. A separate survey was emailed to the labor and delivery nurses at two of the teaching hospitals in Indianapolis. The surveys queried provider demographics, dosing practice for misoprostol, opinions regarding different dosing strategies, and instructions on buccal administration. Results  A total of 113 (46.5%) providers responded. Of these, 92.9% used misoprostol for IOL, 73% preferred the vaginal route, 20% preferred buccal administration, and 7% oral administration. Only resident physician and midwife providers endorsed buccal route preference. Being a midwife independently predicted a preference for using buccal misoprostol (odds ratio [OR]: 125.8, 95% confidence interval [CI]: 7.9-1992.3). Additionally, 44 nurses completed the survey regarding administration techniques of buccal misoprostol. Also, 54.5% of nurses correctly instructed their patients on buccal administration techniques. Conclusion  Although not extensively studied, one-fifth of providers, particularly nurse midwives, prefer buccal administration of misoprostol for IOL. The majority of nurses correctly administered buccal misoprostol. There may be a need for further study and education about buccal administration of misoprostol for IOL.

Challenges to the validity of using medicine labels to categorize clinical behavior: An empirical and normative critique of "off-label" prescribing

This study aimed to determine whether the label status of a medicine penetrates into the clinical reasoning of Australian medical practitioners and to explore the possible reasons for our findings using semistructured interviews with 14 Australian physicians. The interviews revealed 3 broad catalysts for off-label prescribing. The first of these was lack of awareness or understanding of the regulatory process in general and labels more specifically. The second was the perception that labels are not meaningful guides for clinical practice. The third was the recognition of alternative mechanisms for ensuring safe, rational, and evidence-based prescribing occurs. This research suggests that Australian physicians do not consider whether a medicine is off-label to be a reliable measure of the appropriateness of their prescribing practices. Rather, the legitimacy of prescribing practices is determined by the abilities, skills, and knowledge base of particular prescribers by a culture that encourages and supports evidence-based practice, and safe prescribing. Although labels are of minimal clinical significance, there are real conceptual, practical, and moral problems associated with conflating "good" or "better" practice with "on-label" practice, and "bad" or "worse" practice with off-label prescribing as often occurs. To ascribe greater meaning to the term "off-label" than is warranted can have the unintended consequence of casting suspicion on and making it more difficult for physicians to provide appropriate clinical care. We conclude that labeling can, in some cases, provide assurances to both clinicians and patients that their medications have been demonstrated to be safe and effective, but that clinicians should be able to continue to prescribe responsibly off-label without having any stigma attached to their practice.

[Induction of labour at term with misoprostol: the experience of a Tunisian maternity ward]

To evaluate the efficacy and safety of vaginal misoprostol for term labour induction. A prospective study conducted at the Department of Obstetrics and Gynecology B of hospital Charles Nicolle, Tunis, over a period of 4 months. The group of subjects, selected to represent the population of interest, were pregnant patients at term undergoing cervical ripening. Patients received 50 mcg vaginal misoprostol every 12 hours. The parameters studied were: contractile abnormalities, abnormalities of fetal heart rate (FHR), mode of delivery, delayed delivery and neonatal status. 44 patients underwent cervical ripening with misoprostol. The average term was 40 WA. Nulliparous rate was 23/44 (52%). Vaginal birth rate was 31/44 (70.4%). 84% of patients received a single dose of misoprostol. FHR abnormalities were observed in 14/44 (32%). The rates of meconium-stained amniotic fluid was 12/44 (27%). Apgar score of less than 7 at 5 minutes was found in 7/44 (16%). A case of uterine rupture occurred in a primipara after a single dose of misoprostol. Our results are disappointing due to the occurrence of 1 uterine rupture and of 1 significant neonatal morbidity. Other multicentre prospective studies will be useful to better ensure the effectiveness but primarily the safety of low-dose misoprostol for induction of labour at term.

What is the optimal duration of oral misoprostol treatment for cervical ripening?

OBJECTIVES

To evaluate the number of misoprostol tablets needed to obtain a Bishop score (BS) ≥ 6 or a significant cervical change (≥2 points in BS) during cervical ripening.

METHODS

Retrospective study of women with term singleton pregnancies and a BS < 6 taking oral misoprostol (20 μg first 2 doses followed by 40 μg every 2 h) for cervical ripening.

RESULTS

We included 400 women, 72% nulliparous, mean age of 31.3 ± 5.9 years and 70% with a baseline BS ≤ 2. During cervical ripening, 61 (15.3%) achieved a BS ≥ 6 and 205 (51.3%) a significant change in BS. The incremental risk to achieve a BS ≥ 6 after 4 tablets was low (+3.25%) with an incremental probability of +12.75% for painful uterine contractions and +0.5% for abnormal fetal tracing (AFT). The incremental probability to achieve a significant change in BS after 7 tablets was low (+2.0%). 24.3% women delivered by cesarean section which likelihood significantly increased with maternal age <35 years, BMI ≥ 30, nulliparity, AFT, and baseline BS ≤ 2.

CONCLUSIONS

The marginal benefit of giving more than 7 misoprostol tablets (14 h) during cervical ripening is very low.

Induction of Labor in Post-Term Nulliparous and Parous Women - Potential Advantages of Misoprostol over Dinoprostone

INTRODUCTION

We undertook a prospective cohort study to compare the effectiveness and safety of 50 µg misoprostol versus 3 mg dinoprostone in two vaginal doses 6 hours apart, followed if necessary by oxytocin for labor induction in low-risk post-term (> 40 weeks) pregnancies with unfavorable cervix (Bishop score ≤ 6).

METHODS

Labor induction and subsequent management were conducted using a standardized protocol. The primary outcome of the study was labor induction rate. Secondary outcomes included mode of delivery, time interval from induction to delivery, maternal complications and neonatal outcome.

RESULTS

107 patients received misoprostol (Group A) and 99 patients received dinoprostone (Group B). Compared with group A, more women in Group B needed a second vaginal dose of prostaglandin or oxytocin infusion in order to proceed to labor (21.5 vs. 43.4 %; p = 0.01). Misoprostol alone as a single or double vaginal dose was more effective than dinoprostone alone in inducing labor without oxytocin administration (85.0 vs. 50.4 %; p = 0.04). Overall, the rate of successful induction of labor did not differ between groups (91.6 vs. 85.8 %; p = 0.75). Vaginal delivery, operative vaginal delivery and Caesarean section rates were not significantly different. Time interval from induction to delivery however, was shorter for Group A (median 11 hours vs. 14.1 hours; p < 0.001). Though emergency Caesarean section due to fetal distress was more frequent in Group A (16.8 vs. 4.0 %; p = 0.007), low Apgar scores < 7 and NICU admissions did not differ significantly. Maternal complications, mostly not serious, were higher in Group A (31.8 vs. 2.0, p < 0.001).

CONCLUSION

Misoprostol is a more effective agent than dinoprost in post-term pregnancy for labor induction with few maternal adverse effects.

Misoprostol for Labour Induction after Previous Caesarean Section - Forever a "No Go"?

Misoprostol in oral or vaginal form is an established method of labour induction worldwide. Its use after previous caesarean section is associated with a high rate of uterine rupture; according to international guidelines it is therefore contraindicated in this setting. However the evidence base for this recommendation comprises case reports, one randomised trial that was discontinued prematurely, and numerous low quality retrospective data analyses published between 1997 and 2004. New insights into e.g. resorption kinetics, dosage and application intervals, dose dependant uterine hyperstimulation rates, as well as increasing clinical experience with misoprostol have lead to a critical reappraisal of these "historical" studies. Accordingly the evidence supporting a ban on vaginal and particularly oral misoprostol for labour induction in the context of a scarred uterus is currently insufficient for a convincing guideline recommendation. In view of the clear advantages of misoprostol over prostaglandin E₂ (cheaper, more effective) a retrospective review of registry data should be conducted to determine the incidence of uterine rupture following misoprostol and the circumstances in which it occurs. A prospective, randomised trial could then be conducted on the basis of these findings (e.g. oral misoprostol vs. vaginal prostaglandin E₂); known risk factors for uterine rupture including the type of uterine scar would need to be taken into account when selecting patients for vaginal delivery. Until new data from well-designed studies are available, misoprostol will continue to be contraindicated in clinical guidelines for use in labour induction after previous caesarean section.