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Socha MW, Flis W, Wartęga M, Stankiewicz M, Kunicka A. The Efficacy of Misoprostol Vaginal Inserts for Induction of Labor in Women with Very Unfavorable Cervices. J Clin Med 2023; 12:4106. [PMID: 37373798 DOI: 10.3390/jcm12124106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The purpose of the present study was to evaluate the effectiveness of a misoprostol vaginal insert as an induction-of-labor (IOL) agent in women with an unfavorable cervix (Bishop score < 2) in achieving vaginal delivery (VD) within 48 h, depending on the gestational week, with particular emphasis on the cesarean section (CS) percentage, intrapartum analgesia application and possible side effects, such as tachysystole ratio. METHODS In this retrospective observational study involving 6000 screened pregnant patients, 190 women (3%) fulfilled the study inclusion criteria and underwent vaginal misoprostol IOL. The pregnant women were collected into three groups: patients who delivered at up to 37 weeks of gestation (<37 Group)-42 patients; patients who delivered between 37 and 41 weeks of gestation (37-41 Group)-76 patients; and patients who delivered after 41 weeks of gestation (41+ Group)-72 patients. The outcomes included time to delivery and mode of delivery, rate of tachysystole, need for intrapartum analgesia, and need for oxytocin augmentation. RESULTS Most of the patients delivered vaginally (54.8% in <37 Group vs. 57.9% in 37-41 Group vs. 61.1% in 41+ Group). A total of 89.5% (170/190) of patients delivered within 48 h (<37 Group-78.6% vs. 37-41 Group-89.5% vs. 41+ Group-95.8%). Statistical significance was demonstrated for the increased rate of vaginal deliveries and shortened time to delivery in the 41+ weeks group (p = 0.0026 and p = 0.0038). The indications for cesarean section were as follows: abnormal CTG pattern vs. lack of labor progression: 42.1% vs. 57.9% in <37 Group, 59.4% vs. 40.6% in 37-41 Group and 71.4% vs. 28.6% in 41+ Group. Statistical significance was demonstrated for the increased rate of abnormal CTG patterns as cesarean section indications in the 41+ Group (p = 0.0019). The need for oxytocin augmentation in each group was: 35.7% in <37 Group vs. 19.7% in 37-41 Group vs. 11.1% in 41+ Group. Statistical significance was shown for decreased need for oxytocin augmentation in +41 Group (p = 0.0016). The need for intrapartum anesthesia, depending on the group, was: 78.6% in <37 Group vs. 82.9% in 37-41 Group vs. 83.3% in 41+ Group. Statistical significance was demonstrated for increased need for intrapartum anesthesia application during labor in +41 Group (p = 0.0018). The prevalence of hyperstimulation was similar in all three groups (4.8% vs. 7.9% vs. 5.6% p > 0.05). CONCLUSIONS The misoprostol vaginal regimen for IOL used in our study is effective in achieving vaginal delivery within 48 h. In post-term women, the use of this regimen is characterized by an increased rate of vaginal deliveries, a shorter time to delivery and a lower need for oxytocin.
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Affiliation(s)
- Maciej W Socha
- Department of Perinatology, Gynecology and Gynecologic Oncology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Łukasiewicza 1, 85-821 Bydgoszcz, Poland
- Department of Obstetrics and Gynecology, St. Adalbert's Hospital in Gdańsk, Copernicus Healthcare Entity, Jana Pawła II 50, 80-462 Gdańsk, Poland
| | - Wojciech Flis
- Department of Perinatology, Gynecology and Gynecologic Oncology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Łukasiewicza 1, 85-821 Bydgoszcz, Poland
- Department of Obstetrics and Gynecology, St. Adalbert's Hospital in Gdańsk, Copernicus Healthcare Entity, Jana Pawła II 50, 80-462 Gdańsk, Poland
| | - Mateusz Wartęga
- Department of Pathophysiology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie-Skłodowskiej 9, 85-094 Bydgoszcz, Poland
| | - Martyna Stankiewicz
- Department of Perinatology, Gynecology and Gynecologic Oncology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Łukasiewicza 1, 85-821 Bydgoszcz, Poland
| | - Aleksandra Kunicka
- Department of Perinatology, Gynecology and Gynecologic Oncology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Łukasiewicza 1, 85-821 Bydgoszcz, Poland
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Kagwisage J, Balandya BS, Pembe AB, Mujinja PGM. 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. East Afr Health Res J 2020; 4:58-64. [PMID: 34308221 PMCID: PMC8279179 DOI: 10.24248/eahrj.v4i1.622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 05/26/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Jonas Kagwisage
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Belinda S Balandya
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Phares GM Mujinja
- Department of Behavioral Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Dorr ML, Pierson RC, Daggy J, Quinney SK, Haas DM. Buccal versus Vaginal Misoprostol for Term Induction of Labor: A Retrospective Cohort Study. Am J Perinatol 2019; 36:765-772. [PMID: 30380580 PMCID: PMC7692025 DOI: 10.1055/s-0038-1675219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To compare the efficacy of similar buccal and vaginal misoprostol doses for induction of labor. STUDY DESIGN Retrospective chart review of 207 consecutive women undergoing term induction of labor with misoprostol. Misoprostol route and dosing were collected. Time to delivery and other labor outcomes (e.g., vaginal delivery less than 24 hours) were compared between women receiving buccal and vaginal misoprostol. RESULTS There was no significant difference in time to delivery for women receiving buccal (median 18.2 hour, 95% confidence interval [CI] = [14.9, 21.5]) versus vaginal (median 18.3 hour, 95% CI = [15.0, 20.4]) misoprostol (p = 0.428); even after adjusting for covariates (p = 0.381). Women who presented with premature rupture of membranes were more likely to receive buccal misoprostol (92.7% received buccal vs. 7.3% received vaginal, p < 0.001). A similar number of women delivered vaginally in the buccal group (88.2%) and vaginal misoprostol group (86.8%, p = 0.835). The proportion of women who experienced uterine tachysystole or chorioamnionitis did not significantly differ by route of administration. CONCLUSION We found no significant differences in time to delivery or other labor outcomes between buccal or vaginal dosing of misoprostol in women undergoing labor induction at term.
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Affiliation(s)
- Meredith L. Dorr
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rebecca C. Pierson
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana,Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joanne Daggy
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sara K. Quinney
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana,Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - David M. Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana,Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
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Viteri OA, Sibai BM. Challenges and Limitations of Clinical Trials on Labor Induction: A Review of the Literature. AJP Rep 2018; 8:e365-e378. [PMID: 30591843 PMCID: PMC6306280 DOI: 10.1055/s-0038-1676577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/12/2018] [Indexed: 11/03/2022] Open
Abstract
Induction of labor is a common obstetric procedure performed in nearly a quarter of all deliveries in the United States. Pharmacological (prostaglandins, oxytocin) and/or mechanical methods (balloon catheters) are commonly used for labor induction; however, there is ongoing debate as to which method is the safest and most effective. This narrative review discusses key limitations of published trials on labor induction, including the lack of well-designed randomized controlled trials directly comparing specific methods of induction, heterogeneous trial populations, and wide variation in the protocols used and outcomes reported. Furthermore, the majority of published trials were underpowered to detect significant differences in the most clinically relevant efficacy and safety outcomes (e.g., cesarean delivery, neonatal mortality). By identifying the limitations of labor induction trials, we hope to highlight the importance of quality published data to better inform guidelines and drive evidence-based treatment decisions.
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Affiliation(s)
- Oscar A Viteri
- Avera Medical Group Maternal Fetal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth McGovern Medical School, Houston, Texas
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Alfirevic Z, Keeney E, Dowswell T, Welton NJ, Medley N, Dias S, Jones LV, Gyte G, Caldwell DM. Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2018; 20:1-584. [PMID: 27587290 DOI: 10.3310/hta20650] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Zarko Alfirevic
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Edna Keeney
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Therese Dowswell
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nancy Medley
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Sofia Dias
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Leanne V Jones
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Gillian Gyte
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Deborah M Caldwell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Deshmukh VL, Rajamanya AV, Yelikar KA. Oral Misoprostol Solution for Induction of Labour. J Obstet Gynaecol India 2017; 67:98-103. [PMID: 28405116 PMCID: PMC5371524 DOI: 10.1007/s13224-016-0937-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/12/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the effects of oral misoprostol solution for induction of labour. STUDY DESIGN This is a prospective observational study. SETTING This study was conducted in Government Medical College, Aurangabad. METHOD Patients undergoing induction of labour after 36 weeks of pregnancy were allocated by randomization to induction of labour with oral misoprostol solution administered 2 h apart. Delivery within 24 h after induction with oral misoprostol solution was the primary outcome on which the sample size was based. The data were analysed by Statistical Software for Social Sciences software. RESULT Two hundred patients were randomly selected for induction with oral misoprostol solution. There were no significant differences in substantive outcomes. Vaginal delivery within 24 h was achieved in 80.5 % of patients. The caesarean section rate was 19.5 %. Uterine hyperactivity occurred in 4 % of patients. The response to induction of labour in women with unfavourable cervices (modified Bishop's score <2) was somewhat slower with misoprostol, induction to delivery interval was more, oxytocin requirement was more, and vaginal delivery rate was less. CONCLUSION This new approach to oral misoprostol solution administration was successful in achieving vaginal delivery rate in 24 h in 80.5 % of patients; rate of LSCS was less 19.5 %.
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Affiliation(s)
- Varsha L. Deshmukh
- Department of Obstetrics and Gynaecology, Government Medical College, Aurangabad, India
| | - Apurva V. Rajamanya
- Department of Obstetrics and Gynaecology, Government Medical College, Aurangabad, India
| | - K. A. Yelikar
- Department of Obstetrics and Gynaecology, Government Medical College, Aurangabad, India
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Wang L, Zheng J, Wang W, Fu J, Hou L. Efficacy and safety of misoprostol compared with the dinoprostone for labor induction at term: a meta-analysis. J Matern Fetal Neonatal Med 2015; 29:1297-307. [DOI: 10.3109/14767058.2015.1046828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tsui KH, Lin LT, Yu KJ, Chen SF, Chang WH, Yu S, Cheng JT, Wang PH. Double-balloon cervical ripening catheter works well as an intrauterine balloon tamponade in post-abortion massive hemorrhage. Taiwan J Obstet Gynecol 2012; 51:426-9. [DOI: 10.1016/j.tjog.2012.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2012] [Indexed: 10/27/2022] Open
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Hofmeyr GJ, Gülmezoglu AM, Pileggi C. Vaginal misoprostol for cervical ripening and induction of labour. Cochrane Database Syst Rev 2010; 2010:CD000941. [PMID: 20927722 PMCID: PMC7061246 DOI: 10.1002/14651858.cd000941.pub2] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- G Justus Hofmeyr
- University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of HealthDepartment of Obstetrics and Gynaecology, East London Hospital ComplexFrere and Cecilia Makiwane HospitalsPrivate Bag X 9047East LondonEastern CapeSouth Africa5200
| | - A Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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