A comparison of oral and vaginal misoprostol tablets in induction of labour at term

A Comparison of Vaginal vs. Oral Misoprostol for Induction of Labor-Double Blind Randomized Trial

OBJECTIVE

To compare efficacy and safety of 50 μgm misoprostol vaginal with oral for labor induction.

METHODS

110 women at term gestation, Bishop score ≤4, with various indications for labor induction were randomized and double blinded. After decoding 51 women had received misoprostol orally and 52 vaginally, four hourly (maximum six doses) or till woman went into active labor.

RESULTS

Statistical analysis was done with SPSS 11.0. In vaginal misoprostol group induction delivery interval was significantly less (9.79 vs. 16.47 h) and successful induction was significantly higher (90.38 vs. 74.51%) than oral group, with in 24 h of induction. As for as dose required is concerned in vaginal group 40.38% women needed two doses for delivery, in contrast 35.29% in oral group maximum six doses were required.

CONCLUSION

Vaginal route of misoprostol is more effective labor inducing agent than oral.

Vaginal misoprostol induction of labour: a Nigerian hospital experience

We reviewed our experience with vaginal misoprostol induction of labour in 339 consecutive women with a live fetus and intact fetal membrane using 100 mcg 12-hourly until labour was established. The labours were monitored using the WHO partograph protocol. Two hundred and sixty-five women had a successful induction while 74 had an emergency caesarean section because of cephalopelvic disproportion (63.5%), fetal distress (14.9%), prolonged labour (12.2%), antepartum haemorrhage (6.8%) and other indications (2.8%). The induction delivery interval among the women who had successful induction ranged from 3 hours 42 minutes to 26 hours 15 minutes with a mean of 9 hours 23 minutes (SD 2 hours 41 minutes). Most (73.6%) of these patients delivered within 12 hours of starting induction, the majority (95.3%) requiring only 100 mcg to go into established labour. Complications recorded in this series include fetal distress in 32 (9.4%), postpartum haemorrhage in 23 (6.8%), hyperstimulation in six (1.8%), uterine rupture in one (0.3%), birth asphyxia in eight (2.5%), admission in neonatal intensive care ward in five (1.5%), neonatal death in one (0.3%) and maternal death in one (0.3%) patient. In conclusion, misoprostol was found not only to be efficacious but relatively safe in comparison to other methods of induction in use in our hospital.

Labor induction in preeclampsia: is misoprostol more effective than dinoprostone?

OBJECTIVE

To compare the efficacy of vaginal misoprostol versus dinoprostone for induction of labor (IOL) in patients with preeclampsia according to the WHO criteria.

STUDY DESIGN

Ninety-eight patients were retrospectively analyzed. A total of 47 patients received 3 mg dinoprostone suppositories every 6 h (max. 6 mg/24 h) whereas 51 patients in the misoprostol group received either 50 mug misoprostol vaginally every 12 h, or 25 mug every 6 h (max. 100 mug/24 h). Primary outcomes were vaginal delivery within 24 and 48 h, respectively.

RESULTS

The probability of delivering within 48 h was more than three-fold higher in the misoprostol than in the dinoprostone group: odds ratio (OR)=3.48; 95% confidence interval (CI) 1.24, 10.30, whereas no significant difference was observed within 24 h (P=0.34). No correlation was seen between a ripe cervix prior to IOL and delivery within 24/48 h (P=0.33 and P=1.0, respectively). More cesarean sections were performed in the dinoprostone group due to failed IOL (P=0.0009). No significant differences in adverse maternal outcome were observed between both study groups, whereas more neonates (12 vs. 6) of the dinoprostone group were admitted to the NICU (P=0.068).

CONCLUSION

This study suggests that misoprostol may have some advantages compared to dinoprostone, including improved efficacy and lower cost of the drug, even in cases of preeclampsia.

Pilot study of labor induction with titrated oral misoprostol

OBJECTIVE

To evaluate the safety and efficacy of titrated oral misoprostol for labor induction at term.

MATERIALS AND METHODS

Seventy-seven pregnant women (37 nullipara and 40 multipara), with medical or obstetric indications for labor induction after 37 weeks of gestation and unfavorable cervices (Bishop's score < 7), were induced according to the principles of titrated oral doses of misoprostol against uterine response. Our primary outcome measurements were the percentage of patients who had a vaginal delivery within 24 hours of induction and the interval from induction to vaginal delivery. Secondary measurements included oxytocin requirement, total misoprostol dosage, number of cesarean deliveries, induction failure, uterine hyperstimulation rates and neonatal outcomes.

RESULTS

Seventy-five women (97.4%) experienced active labor within 24 hours, with 72 (93.5%) completing vaginal delivery within 24 hours. The mean interval from induction to vaginal delivery for all the women was 9.7 hours, with a 2.3-hour active phase. The mean misoprostol dosage was 206 microg, with eight women (10.4%) requiring oxytocin augmentation. There was no uterine hyperstimulation or induction failure, except for seven cases of uterine tachysystole (9.1%).

CONCLUSION

Titrated oral misoprostol is a safe and effective method of labor induction because the dosage can be adjusted according to individual response.

Women's perceptions, expectations and satisfaction with induced labour—A questionnaire-based study

OBJECTIVES

To evaluate the understanding and expectations of women undergoing labour induction, to assess their actual experience of the process and to compare their satisfaction with labour to those labouring spontaneously.

STUDY DESIGN

Four hundred and fifty women at term undergoing induction of labour and cervical ripening with prostaglandinE2 vaginal tablets and 450 women labouring spontaneously were recruited into the study. The induction group were requested to complete a questionnaire prior to the start of their induction process and another questionnaire post-delivery. The post-delivery questionnaire contained two sections, one pertaining to issues to do with the induction and the second with the actual labour process. The spontaneously labouring group was requested to complete a questionnaire post-delivery, which only contained the section pertaining to the actual labour process. The main outcome measures were satisfaction with labour, perception of pain and length of labour between the induced and spontaneous labour groups, and issues that the women might wish changed about their induction.

RESULTS

In the induction group, 34.7% were not satisfied with the information they received about the induction prior to the procedure and 27.2% expected to deliver within 12h of the administration of the inducing agent. Post-induction, 40% of the women felt the most important aspect they would like to change about their induction were they to have another one, would be the speed of the induction, 13.6% felt they might wish to take the inducing agent orally, 7% to have fewer vaginal examinations and 9% to have fewer complications. Among the women who returned questionnaires, 26.3% had a caesarean delivery in the induction group and 21.4% in the spontaneous labour group. Significantly more women were satisfied with their labour in the spontaneous labour group 79.5% versus 70.4%, RR 0.89, 95% CI 0.8-0.96, P=0.006).

CONCLUSIONS

Labour that is artificially induced does result in lower satisfaction rates as compared to that following spontaneous onset. The longer time delay between the start of the induction and the delivery plays a significant part in this, with the mode of administration of the inducing agent, more vaginal examinations and the increase in caesarean deliveries being perceived as secondary issues. There is a need to improve the information provided to women undergoing labour induction, to counter unrealistic expectations and thereby improve satisfaction.

A comparison of oral and vaginal misoprostol for induction of labor

OBJECTIVE

The aim of the study is to compare the efficacy and safety of oral (100 microg) and vaginal (50 microg) misoprostol for labor induction.

STUDY DESIGN

Ninety-nine patients with indications for labor induction randomly received 100 microg oral misoprostol every 4 h or 50 microg vaginal misoprostol every 4 h, using maximum six doses. Mean induction to delivery interval, mode of delivery, rates of tachysystole, hypertonus and hyperstimulation syndrome, oxytocin use, number of doses used, failed induction rate and neonatal outcomes were compared for the two groups.

RESULTS

Mean dose of misoprostol used for oral and vaginal misoprostol groups were 2.17+/-1.35 and 1.91+/-0.94, respectively (p=0.65). There were two failed inductions in the oral (4%) and one failed induction (2.5%) in the vaginal group after a total of six doses of misoprostol (p=0.58). There was no significant difference for the mean induction to delivery interval, to the beginning of active phase interval, active phase duration, second stage duration and the number of women who received oxytocin for induction or augmentation between the two groups (p>0.05). There were also no significant differences for intrapartum complications and neonatal outcomes between the oral and vaginal misoprostol groups (p>0.05).

CONCLUSION

Our findings indicate that, in a closely supervised hospital setting with adequate monitoring, 100 microg oral misoprostol has the potential to induce labor as safely and effectively as its 50 microg vaginal analogue. As oral use of the drug is easier for both the patient and the doctor, oral misoprostol will probably be more preferable than the vaginal route.

Induction of labour with a favourable cervix and/or pre-labour rupture of membranes

Premature rupture of membranes (PROM) occurs in 8% of term deliveries. In this situation labour induction with prostaglandins, compared with expectant management, results in a reduced risk of chorioamnionitis, neonatal antibiotic therapy, neonatal intensive care (NICU) admission, and increased maternal satisfaction. The use of prostaglandin is associated with an increased rate of diarrhoea and use of analgesia/anaesthesia. Compared with oxytocin, prostaglandin induction results in a lower rate of epidural use and internal fetal heart rate monitoring but a greater risk of chorioamnionitis, nausea, vomiting, more vaginal examinations, neonatal antibiotic therapy, NICU admission and neonatal infection. Women should be informed of the risks and benefits of each method of induction.Misoprostol is gaining increasing interest as an alternative induction agent. It appears to be an effective method of labour induction with term PROM. Further research is needed to identify the preferred dosage, route and interval of administration, and to assess uncommon maternal and neonatal outcomes. There has been limited research on the use of prostaglandins, including misoprostol, for induction of labour with a favourable cervix and intact membranes. Compared with intravenous oxytocin (with and without amniotomy), labour induction using vaginal prostaglandins in women with a favourable cervix (with and without PROM) results in a higher rate of vaginal delivery within 24 hours and increased maternal satisfaction. In women with a favourable cervix, artificial rupture of membranes followed by oral misoprostol has similar time to vaginal delivery compared with artificial rupture of membranes followed by oxytocin. Further research with prostaglandins, including misoprostol, is needed to evaluate other maternal and neonatal outcomes in women being induced with a favourable cervix. No form of prostaglandin induction in women with PROM or favourable cervix has proven clearly superior to oxytocin infusion.

A randomized controlled trial comparing two protocols for the use of misoprostol in midtrimester pregnancy termination

OBJECTIVE

Our purpose was to compare the efficacy of oral misoprostol with that of vaginal misoprostol for midtrimester termination of pregnancy.

STUDY DESIGN

Women seen for midtrimester pregnancy termination were randomly assigned to receive either misoprostol orally in a dose of 200 microg every hour for 3 hours followed by 400 microg every 4 hours or vaginally in a dose of 400 microg every 4 hours. The protocol was followed for 24 hours, after which time further management was at the discretion of the attending physician. The primary outcome measure was the induction-to-delivery interval. Sample size was calculated a priori. Statistical analysis was performed with the t test for continuous variables and the chi(2) test for categorical variables. P <.05 was considered significant.

RESULTS

One hundred fourteen women were randomized, with 49 receiving vaginal misoprostol and 65 receiving oral misoprostol. The two groups were comparable with respect to maternal age, parity, indication for pregnancy termination, gestational age, and maternal weight. The mean induction-to-delivery interval was significantly shorter for the vaginal group (19.6 +/- 17.5 hours vs 34.5 +/- 28.2 hours, P <.01). Length of stay was also shorter in the vaginal group (32.3 +/- 17.3 hours vs 50.9 +/- 27.9 hours, P <.01). Significantly more patients in the vaginal group were delivered within 24 hours (85.1% vs 39.5%, P <.01), and more patients in the oral group required changes in the method of induction when they were undelivered after 24 hours (38.2% vs 7%, P <.01). The only complication was an increase in febrile morbidity in the vaginal group (25% vs 6.7%, P =.046). This did not result in an increased use of antibiotics, and all the fevers resolved post partum without further complications.

CONCLUSIONS

Vaginal administration of misoprostol resulted in a shorter induction-to-delivery interval. The shorter length of stay should result in improved patient care.

Induction of labour with misoprostol

Misoprostol, an orally active prostaglandin E1 analogue, has been used widely by the vaginal and oral routes for labour induction at or near term. Several recent trials have confirmed that it is highly effective. Overall caesarean section rates appear to be reduced, despite a relative increase in caesarean sections for fetal heart rate abnormalities. Concern remains regarding increased rates of uterine hyperstimulation and meconium-stained amniotic fluid, although data on perinatal outcomes have been reassuring. Recent reports reviewed here have raised the possibility that postpartum haemorrhage may be increased after the induction of labour with misoprostol, and isolated reports of uterine rupture with or without previous caesarean section, continue to appear. Using small dosages appears to reduce adverse outcomes. Very large trials are needed to evaluate rare adverse outcomes.