Low dose intravaginal misoprostol for induction of labor at term

Comparison of the Dinoprostone Vaginal Insert and Dinoprostone Tablet for the Induction of Labor in Primipara: A Retrospective Cohort Study

This retrospective study aimed to compare the safety and efficacy of Prostin E2 and Propess for the induction of labor (IOL) in nulliparous women between January 2018 and October 2021. The inclusion criteria were nulliparous, singleton, >37 weeks’ gestation, cephalic presentation with an unfavorable cervix (Bishop score ≤ 6), no signs of labor, and use of one form of dinoprostone (Prostin E2 or Propess) for IOL. The cesarean section (C/S) rate and induction-to-birth interval were the main outcome measures. In total, 120 women were recruited. Sixty (50%) patients received Propess and 60 (50%) received repeated doses of Prostin E2. The Prostin E2 and Propess groups had similar patient characteristics, but the Bishop score was significantly higher in the Propess group than in the Prostin E2 group; therefore, multivariate analysis was conducted, and the Bishop score was not associated with the induction-to-birth interval. The C/S rate was not significantly different between the two groups, but the Propess group achieved a shorter induction-to-birth interval, a higher rate of vaginal delivery in 24 h, and a lower number of vaginal examinations than the Prostin E2 group. Propess was effective and safe in IOL and could be an option for cervical ripening in nulliparous pregnancy.

Comparison of induction of labor with vaginal misoprostol plus oxytocin versus oxytocin alone in term primigravidae

OBJECTIVE

To compare the efficacy and complications of intravaginal misoprostol application before starting oxytocin infusion with oxytocin infusion alone for labor induction in term primigravidae pregnancies with low-Bishop score.

METHODS

This randomized study included 101 primigravidae women with singleton pregnancies >38 weeks and a Bishop score of <6. Group 1 (50 patients) received a 50-μg dose of intravaginal misoprostol, with an oxytocin infusion started 3 h later. Group 2 (51 patients) received only an oxytocin infusion for labor induction. The time from induction to delivery, the route of delivery and complications were analyzed.

RESULTS

The mean time from induction to delivery was 10.4 ± 2.1 h in Group 1 and 13.7 ± 3.4 in Group 2 (p < 0.001). The rates of vaginal delivery, Apgar scores at 1st and 5th min, placental abruption, and postpartum hemorrhage were similar between the two groups.

CONCLUSION

Intravaginal application of 50-μg misoprostol before starting oxytocin infusion is a more effective method of labor induction than oxytocin infusion alone in term primigravidae pregnant women with low-Bishop scores.

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.

Induction of labor with vaginal misoprostol plus oxytocin versus oxytocin alone

OBJECTIVE

To compare the effect of an oxytocin infusion alone or preceded by an intravaginal application of misoprostol for labor induction in women with term pregnancies and a low Bishop score.

METHODS

This study randomized 100 multiparous women with singleton pregnancies over 38 weeks and a Bishop score less than 6 to receive either a single 50-microg dose of misoprostol intravaginally 3 hours before initiation of the oxytocin infusion or only an oxytocin infusion. The time from induction to delivery, the route of delivery, and maternal and fetal outcomes were analyzed.

RESULTS

The mean time from induction to delivery was 9.36+/-1.97 hours in the misoprostol plus oxytocin group and 11.08+/-3.23 in the oxytocin alone group (P=0.002). The rates of vaginal delivery, 1- and 5-minute Agpar scores, placental abruption, and postpartum hemorrhage were similar between the 2 groups, as were the rates of admission to the neonatal intensive care unit. There were no cases of perinatal asphyxia.

CONCLUSION

A 50-microg intravaginal application of misoprostol before starting the oxytocin infusion is a more effective method of labor induction than an oxytocin infusion alone for our study population.

Pre-induction cervical ripening with 25 microg and 50 microg vaginal misoprostol in 181 nulliparous parturients

OBJECTIVE

To evaluate the effect of intravaginally misoprostol at start dosages of 25 microg and 50 microg when used for pre-induction cervical ripening among nulliparous parturients.

METHODS

Our observational study involves all cases of partus induction consecutively registered in a Norwegian hospital between September 2002 and August 2006, with the following inclusion criteria: nulliparous, singleton pregnancies >or=37 weeks, an unfavourable cervix (Bishop score <or=6), viable fetus >2499 g, received misoprostol vaginally every 6 h upto four times. Seventy-six women started with 25 microg (25 microg-group) and 105 started with 50 microg (50 microg-group). All continued with 25 microg. Primary outcome was vaginal delivery within 48 h after the first misoprostol dose. Secondary outcome was caesarean section performed within 96.

RESULTS

Vaginal delivery within 48 h after the initial dose occurred more often in the 25 microg-group than in the 50 microg-group (75 vs. 58%, p = 0.018). The rate of caesarean section was lower in the 25 microg-group than in the 50 microg-group (19 vs. 33%, p = 0.043). These differences remained significant after adjusting for confounders.

CONCLUSION

Our findings support the notion that the dose of 25 microg misoprostol is as at least as efficient as 50 microg in nulliparous parturients.