Misoprostol for induction of labor with a live fetus

Outcome of induction and associated factors among induced labours in public Hospitals of Harari Regional State, Eastern Ethiopia: A two years' retrospective analysis

BACKGROUND

Induction of labor (IOL) is an essential intervention to reduce adverse maternal and neonatal outcomes. It is also improved pregnancy outcomes, especially in resource-limited countries, where maternal and perinatal mortality is unacceptably high. However, there is a scarcity of evidence regarding the outcome of induction of labor and its predictors in low-income countries like Sub-Saharan Africa. Therefore, this study was aimed at assessing the outcome of induction of labor and associated factors among mothers who underwent labor induction in public Hospitals of Harari Regional State, Estern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from 1 to 30 March, 2019 in Harari Regional State, Eastern Ethiopia. A total of 717 mothers who underwent induction of labor in public Hospitals of Harari Regional State, Eastern Ethiopia from January 2017 to December 2018 were enrolled in the study. Data were collected using a pretested structured questionnaire. The collected data were entered into Epi-data version 3.1 and exported to SPSS version 24 (IBM SPSS Statistics, 2016) for further analysis. A multivariable logistic regression analysis was performed to estimate the effects of each predictor variable on the outcome of induction of labor after controlling for potential confounders. Statistical significance was declared at p-value <0.05.

RESULTS

Overall, the prevalence of success of induction of labor was 65% [95% CI (61.5, 68.5)]. Pre-eclampsia/eclampsia was found to be the most common indication for induction of labor (46.70%) followed by pre-labor rupture of fetal membrane (33.5%). In the final model of multivariable analysis, predictors such as: maternal age < 24 years old [AOR = 1.93, 95%CI(1.14, 3.26)], nulliparity[AOR = 0.34, 95%CI(0.19, 0.59)], unfavorable Bishop score [AOR = 0.06, 95%CI(0.03, 0.12)], intermediate Bishop score [AOR = 0.08, 95%CI(0.04, 0.14)], misoprostol only method [AOR = 2.29, 95%CI(1.01, 5.19)], nonreassuring fetal heart beat pattern [AOR = 0.14, 95%CI (0.07, 0.25)] and Birth weight 3500 grams and above[AOR = 0.32, 95% CI (0.17, 0.59)] were statistically associated with the successful outcome of induction of labor.

CONCLUSION

The prevalence of successful of induction of labor was relatively low in this study area because only two-thirds of the mothers who underwent induction of labor had a successful of induction. Therefore, this result calls for all stakeholders to give more emphasis on locally available induction protocols and guidelines. In addition, pre-induction conditions must be taken into consideration to avoid unwanted effect of failed induction of labour.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

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.

A randomised double-blind placebo-controlled trial comparing stepwise oral misoprostol with vaginal misoprostol for induction of labour

A comparison of induction of labour (IOL) using three doses of 25 µg vaginal misoprostol inserted at intervals of 4 h or more with a stepwise oral regime starting with 50 µg followed by two doses of 100 µg was studied in a double-blind placebo-controlled trial in a tertiary centre in South India. Primary outcome was vaginal delivery in 24 h. Significantly more women in the first group required oxytocin augmentation and a third dose of the drug than women in the second group. Uterine tachysystole and other maternal and neonatal complications were similar. Thus it is concluded that women induced with oral, as compared to vaginal misoprostol are more likely to labour without oxytocin.

Spontaneous delivery through a cervical tear without cervical os dilatation

Spontaneous delivery through a cervical tear, provoked by prostaglandin-induced uterine contractions, was described in a G2P0 woman with a history of cervical dilatation and uterine curettage. This rare complication with potentially serious maternal–fetal consequences can be predicted by an aberrant cervical response to prostaglandins in parturients with previous cervical interventions.

Orally administered misoprostol for induction of labor with prelabor rupture of membranes at term

Prelabor rupture of membranes (PROM) occurs in approximately 8% to 10% of women with term pregnancies. The management of PROM continues to be controversial. Approaches include expectant management and immediate induction of labor. The use of orally administered misoprostol for the management of women with PROM may provide significant advantages when they choose immediate induction of labor. This literature review presents current evidence that supports the use of oral misoprostol for women with PROM, including the benefits of a decreased interval time from PROM to vaginal birth, good safety profile, and reductions in the use of oxytocin augmentation and epidural anesthesia. In addition to clinically proven benefits to women of oral misoprostol for PROM, it also has the potential to reduce chorioamnionitis by reducing the number of sterile vaginal examinations performed thereby reducing the risk of ascending bacteria. Women have also reported acceptability and satisfaction when using oral misoprostol for immediate induction of labor. This review of literature discusses what is known about the use of orally administered misoprostol for the management of term PROM and makes recommendations for clinical use.

Oral misoprostol versus vaginal dinoprostone for labor induction in nulliparous women at term

OBJECTIVE

To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women.

STUDY DESIGN

Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24 h, mode of delivery and maternal and fetal outcomes.

RESULT

A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9 h, P<0.0001) and were more likely to deliver vaginally in <24 h (47% vs 64%, P=0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes.

CONCLUSION

Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.

Unusual complication of vaginal delivery: is misoprostal the cause?

A 20-year-old primiparous woman who delivered vaginally in a private hospital 5 h ago was referred to our institute as a case of ruptured uterus. She was very pale and tachycardic with well-contracted uterus of 18-week size but had a cervical tear extending up to the left fornix. Examination under anaesthesia showed colporrhexis of posterior vaginal wall with intestines at the site of colporrhexis. Emergency laparotomy confirmed the above findings and also revealed intestinal gangrene involving more than 10 cm. Repair of colporrhexis, cervical tear and resection and anastomosis of small intestines was carried out. She gave a history of administration of five doses of vaginal misoprostal during labour and fundal pressure at the time of delivery. Literature review revealed that vaginal misoprostal can cause overgrowth of clostridial organisms by decreasing the macrophage function and thus can lead to developmental gangrene of reproductive tract and gastrointestinal tract.

Shortening the induction delivery interval with prostaglandins: a randomized controlled trial of solo or in combination

OBJECTIVE

To compare the efficacy and safety of misoprostol alone with dinoprostone followed by misoprostol, all inserted intravaginally in induction of labor at term and the obstetrical outcome.

MATERIAL AND METHODS

A pilot study comprising 111 primigravidae, >37 gestational weeks with singleton pregnancy in cephalic presentation having an unfavorable Bishop score admitted for labor induction, were considered and randomly allocated into two groups. In group I (n=55) with intravaginal 25mcg misoprostol 4 hourly (six doses at the most) and and group II (n=56), with dinoprostone 0.5mg followed eight hours later by 25mcg misoprostol induction to vaginal delivery time was found to be significantly different, being 14.8 h in group-I and shorter in group-II with a mean of 11.6 h. Vaginal delivery rates within 12 h (groups-I and -II: 47.2%, as compared to 60.7%, respectively) were found to be higher with dinoprostone-misoprostol induction, as well as vaginal delivery rates in 24 h, 80.0% and 91.1%. The need for oxytocin augmentation was more frequent in the misoprostol than in the dinoprostone-misoprostol group, (61.8%, and 39.3%), and all these observations were statistically significant. Abnormal foetal heart rate pattern occurred more frequently (18.2%) in group-I in contrast to 5.3% in group-II, as was the incidence rate of (18.2%) who had passage of meconium in group-I, this rate being significantly different from group-II having meconium passage in 3 cases, a rate of 5.3%.

CONCLUSION

Using dinoprostone followed by vaginal misoprostol is safe and effective for induction of labor with less need for oxytocin augmentation and shorter induction delivery interval.

Factors and outcomes associated with the induction of labour in Latin America

OBJECTIVE

To describe the prevalence of labour induction, together with its risk factors and outcomes in Latin America.

DESIGN

Analysis of the 2005 WHO global survey database.

SETTING

Eight selected Latin American countries.

POPULATION

All women who gave birth during the study period in 120 participating institutions.

METHODS

Bivariate and multivariate analyses.

MAIN OUTCOME MEASURES

Indications for labour induction per country, success rate per method, risk factors for induction, and maternal and perinatal outcomes.

RESULTS

Of the 97,095 deliveries included in the survey, 11,077 (11.4%) were induced, with 74.2% occurring in public institutions, 20.9% in social security hospitals and 4.9% in private institutions. Induction rates ranged from 5.1% in Peru to 20.1% in Cuba. The main indications were premature rupture of membranes (25.3%) and elective induction (28.9%). The success rate of vaginal delivery was very similar for oxytocin (69.9%) and misoprostol (74.8%), with an overall success rate of 70.4%. Induced labour was more common in women over 35 years of age. Maternal complications included higher rates of perineal laceration, need for uterotonic agents, hysterectomy, ICU admission, hospital stay>7 days and increased need for anaesthetic/analgesic procedures. Some adverse perinatal outcomes were also higher: low 5-minute Apgar score, very low birthweight, admission to neonatal ICU and delayed initiation of breastfeeding.

CONCLUSIONS

In Latin America, labour was induced in slightly more than 10% of deliveries; success rates were high irrespective of the method used. Induced labour is, however, associated with poorer maternal and perinatal outcomes than spontaneous labour.

Low-dose oral misoprostol for induction of labor: a systematic review

OBJECTIVE

To estimate the efficacy and safety of low-dose oral misoprostol compared with dinoprostone (PGE2), vaginal misoprostol, and oxytocin for labor induction in women with a viable fetus.

DATA SOURCES

We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published before January 2008 using the keywords misoprostol, labor, induction, randomized controlled trials, dinoprostone, oxytocin, pregnancy, and maternal and fetal side effects.

METHODS OF STUDY SELECTION

We included randomized controlled trials comparing 20-25 micrograms oral misoprostol with vaginal misoprostol, dinoprostone or oxytocin given to women at 32-42 weeks of gestation for labor induction. From 401 citations identified, results from nine studies were finally analyzed using the Review Manager software. Relative risk (RR) and 95% confidence intervals (CIs) were calculated using fixed and random-effects models.

TABULATION, INTEGRATION, AND RESULTS

Nine articles with 2,937 women met the inclusion criteria. The five trials comparing oral misoprostol and dinoprostone showed significantly fewer women requiring cesarean delivery in the misoprostol group (20% compared with 26%; RR 0.82, 95% CI 0.71-0.96). There were no statistically significant differences in risks of uterine hyperstimulation or need for oxytocin augmentation. Two trials compared oral with vaginal low-dose misoprostol. Women using oral misoprostol were significantly less likely to experience uterine hyperstimulation with fetal heart rate changes (2% compared with 13%; RR 0.19, 95% CI 0.08-0.46), but there were no significant differences in other outcomes.

CONCLUSION

Low-dose oral misoprostol solution (20 micrograms) administered every 2 hours seems at least as effective as both vaginal dinoprostone and vaginal misoprostol, with lower rates of cesarean delivery and uterine hyperstimulation, respectively.

Misoprostol: pharmacokinetic profiles, effects on the uterus and side-effects

Misoprostol, a synthetic prostaglandin E1 analogue, is commonly used for medical abortion, cervical priming, the management of miscarriage, induction of labor and the management of postpartum hemorrhage. It can be given orally, vaginally, sublingually, buccally or rectally. Studies of misoprostol's pharmacokinetics and effects on uterine activity have demonstrated the properties of the drug after various routes of administration. These studies can help to discover the optimal dose and route of administration of misoprostol for individual clinical applications. Misoprostol is a safe drug but serious complications and teratogenicity can occur with unsupervised use.