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Taliento C, Manservigi M, Tormen M, Cappadona R, Piccolotti I, Salvioli S, Scutiero G, Greco P. Safety of misoprostol vs dinoprostone for induction of labor: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 289:108-128. [PMID: 37660506 DOI: 10.1016/j.ejogrb.2023.08.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/20/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Pharmacological agents such as prostaglandins (dinoprostone and misoprostol) are commonly used to reduce the duration of labor and promote vaginal delivery. However, key safety considerations with its use include an increased risk of uterine rupture, tachysystole and hyperstimulation of pregnant women, which could potentially lead to a non-reassuring fetal heart rate and to fetal hypoxemia. The aim of this systematic review was to assess maternal and fetal outcomes between misoprostol group (PGE1) and dinoprostone group (PGE2) STUDY DESIGN: We search on MEDLINE (PubMed), CINHAL (EBSCOhost), EMBASE, Scopus (Ovid), CENTRAL (January 1, 1998, to December 31, 2022). Patients were eligible if they presented at greater than 36 weeks gestation with an indication for induction of labor and a single live cephalic fetus. We conducted a meta-analysis of data for both primary (cesarean section rate, instrumental deliveries rate, tachysystole, uterine rupture, post-partum haemorrage; chorionamiositis) and secondary outcomes (Apgar at 5 min <7, meconium-stained liquor, NICU admission, infant death) using odds-ratio (OR) as a measure of effect-size. Risk of bias assessment was performed with RoB-I. We performed statistical analyses using Cochrane RevMan version 5.4 software. RESULTS We found 39 RCTs comparing the outcomes of interest between misoprostol and dinoprostone. The pooled effect showed no statistically significant difference between the two groups in terms of cesarean section rate [OR: 0.94; 95% CI 0.84-1.05], instrumental deliveries rate [OR: 1.04; 95% CI: 0.90-1.19; p = 0.62], tachysystole [OR: 1.21; 95% CI: 0.91-1.60; p = 0.19], post-partum hemorrhage [OR: 0.85; 95% CI: 0.62-1.15p = 0.30], chorioamnionitis [OR: 0.94; 95% CI: 0.76-1.17p = 0.59], Apgar at 5 min < 7 [OR: 0.83; 95% CI: 0.61-1.12, p = 0.21], meconium-stained liquor [OR: 1.11; 95% CI: 0.97-1.27p = 0.59], NICU admission group [OR: 0.91; 95% CI: 0.77-1.09], infant death [OR: 0.57; 95% CI: 0.22-1.44]. After performing a sub-group analysis based on the type of prostaglandins administrations (oral, vaginal gel, vaginal pessary), results did not change substantially. CONCLUSIONS This systematic review and meta-analysis demonstrate that misoprostol and dinoprostone appear to have a similar safety profile.
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Affiliation(s)
- Cristina Taliento
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Ferrara, Italy.
| | - Margherita Manservigi
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Mara Tormen
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Rosaria Cappadona
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Irene Piccolotti
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Stefano Salvioli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa - Campus of Savona, Italy; Department of Neuroscience and Rehabilitation, University of Ferrara, Italy
| | - Gennaro Scutiero
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Pantaleo Greco
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Donatsch L, Friker B, Sieme H, Kaeser R, Burger D. No increase in pregnancy rate of mares after preovulatory deep uterine horn application of misoprostol. Theriogenology 2022; 184:132-139. [DOI: 10.1016/j.theriogenology.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/09/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
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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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Monteiro S, Imramovský A, Pauk K, Pavlík J. Novel synthetic approach to alfaprostol key intermediates via Stille coupling with an alkyne. Tetrahedron Lett 2017. [DOI: 10.1016/j.tetlet.2017.04.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Beloosesky R, Khatib N, Ganem N, Matanes E, Ginsberg Y, Divon M, Weiner Z. Cervical length measured before delivery and the success rate of vaginal birth after cesarean (VBAC). J Matern Fetal Neonatal Med 2017; 31:464-468. [PMID: 28139951 DOI: 10.1080/14767058.2017.1288206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To test the hypothesis that measuring cervical length (CL) close to the time of delivery is a predictor of successful vaginal birth following a cesarean. METHODS A prospective longitudinal study included women with singleton pregnancies at 38-41 weeks, who previously underwent a cesarean, and who were interested in trial of labor. Patients who did not have a spontaneous onset of labor were induced at 41 weeks' gestation. CL measurements were performed prior to labor by transvaginal ultrasound, recorded, and blinded from the caring physicians. RESULTS Vaginal birth was achieved in 63/105 (60%) of patients participating in the study. The mode of delivery significantly correlated with CL, Bishop score, and previous obstetrical history. When multivariate analysis was performed, only CL and previous obstetrical history correlated significantly with mode of delivery. In the subgroup of patients with no previous vaginal delivery, only CL had a significant correlation with mode of delivery. The ROC curve demonstrated a high prediction of vaginal delivery by CL for the entire study group and for the subgroup of patients with no previous vaginal delivery (AUC = 0.8, p < .0001). CONCLUSIONS CL measurement after 36 weeks has a high predictive accuracy for a successful vaginal birth after cesarean.
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Affiliation(s)
- Ron Beloosesky
- a Department of Obstetrics and Gynecology , Rambam Medical Center , Haifa , Israel
| | - Nizar Khatib
- a Department of Obstetrics and Gynecology , Rambam Medical Center , Haifa , Israel
| | - Nadir Ganem
- a Department of Obstetrics and Gynecology , Rambam Medical Center , Haifa , Israel
| | - Emad Matanes
- a Department of Obstetrics and Gynecology , Rambam Medical Center , Haifa , Israel
| | - Yuval Ginsberg
- a Department of Obstetrics and Gynecology , Rambam Medical Center , Haifa , Israel
| | - Mike Divon
- a Department of Obstetrics and Gynecology , Rambam Medical Center , Haifa , Israel
| | - Zeev Weiner
- a Department of Obstetrics and Gynecology , Rambam Medical Center , Haifa , Israel
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Verhoeven CJM, Opmeer BC, Oei SG, Latour V, van der Post JAM, Mol BWJ. Transvaginal sonographic assessment of cervical length and wedging for predicting outcome of labor induction at term: a systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:500-8. [PMID: 23533137 DOI: 10.1002/uog.12467] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 03/02/2013] [Accepted: 03/14/2013] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis to assess the predictive capacity of transvaginal sonographic assessment of the cervix for the outcome of induction of labor. METHODS We searched MEDLINE, EMBASE and the Cochrane Library, and manually searched reference lists of review articles and eligible primary articles. Studies in all languages were eligible if published in full. Two reviewers independently selected studies and extracted data on study characteristics, quality and test accuracy. We then calculated pooled sensitivities and specificities (with 95% CIs) and summary receiver-operating characteristics (sROC) curves. Outcome measures were test accuracy of sonographically measured cervical length and cervical wedging for Cesarean section, not achieving vaginal delivery within 24 h and not achieving active labor. RESULTS We included 31 studies reporting on both cervical length and outcome of delivery. The quality of the included studies was mediocre. Sensitivity of cervical length in the prediction of Cesarean delivery ranged from 0.14 to 0.92 and specificity ranged from 0.35 to 1.00. The estimated sROC curve for cervical length indicated a limited predictive capacity in the prediction of Cesarean delivery. Summary estimates of sensitivity/specificity combinations of cervical length at different cut-offs for Cesarean delivery were 0.82/0.34, 0.64/0.74 and 0.13/0.95 for 20, 30 and 40 mm, respectively. For cervical wedging in the prediction of failed induction of labor summary point estimates of sensitivity/specificity were 0.37/0.80. CONCLUSIONS Cervical length and cervical wedging as measured sonographically at or near term have moderate capacity to predict the outcome of delivery after induction of labor.
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Affiliation(s)
- C J M Verhoeven
- Department of Obstetrics & Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
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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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Calder AA, Loughney AD, Weir CJ, Barber JW. Induction of labour in nulliparous and multiparous women: a UK, multicentre, open-label study of intravaginal misoprostol in comparison with dinoprostone. BJOG 2008; 115:1279-88. [DOI: 10.1111/j.1471-0528.2008.01829.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Prager M, Eneroth-Grimfors E, Edlund M, Marions L. A randomised controlled trial of intravaginal dinoprostone, intravaginal misoprostol and transcervical balloon catheter for labour induction. BJOG 2008; 115:1443-50. [PMID: 18715244 DOI: 10.1111/j.1471-0528.2008.01843.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of induction of labour by vaginal application of dinoprostone or misoprostol or transcervical insertion of a balloon (Bard) catheter. DESIGN A non-blinded, randomised, controlled trial. SETTING A tertiary level Swedish hospital. POPULATION A total of 592 women who had undergone full-term pregnancies, not previously been subjected to a caesarean section, and required induction of labour for common, routine indications. METHODS Women were randomly assigned to induction of labour using intravaginal dinoprostone (2 mg once every 6 hours) or misoprostol (25 micrograms once every 4 hours) or a transcervical balloon catheter. MAIN OUTCOME MEASURES The time interval between induction to delivery in general and vaginal delivery in particular, the mode of delivery, maternal and neonatal parameters of outcome. RESULTS Of the 588 subjects included in the final intention-to-treat analysis, 191 were assigned to treatment with dinoprostone, 199 with misoprostol and 198 with the balloon catheter. The shortest mean induction-to-delivery interval was obtained with the catheter (12.9 hours versus 16.8 and 17.3 hours for dinoprostone and misoprostol, respectively). The efficacies of the two prostaglandins were similar. The maternal and neonatal outcomes associated with each of the three procedures were similar. CONCLUSIONS Induction of labour with a transcervical balloon catheter is effective and safe and can be recommended as the first choice. The two prostaglandins, dinoprostone and misoprostol, were shown to be equally effective and safe, while misoprostol costs significantly less and is easier to store.
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Affiliation(s)
- M Prager
- Division of Obstetrics and Gynaecology, Department of Woman and Child Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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Hatfield AS, Sanchez-Ramos L, Kaunitz AM. Reply. Am J Obstet Gynecol 2008. [DOI: 10.1016/j.ajog.2008.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Metaanalysis of diagnostic and prognostic studies: the challenge continues. Am J Obstet Gynecol 2008; 199:e16; author reply e16-7. [PMID: 18455139 DOI: 10.1016/j.ajog.2008.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Accepted: 02/21/2008] [Indexed: 11/20/2022]
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Hatfield AS, Sanchez-Ramos L, Kaunitz AM. Sonographic cervical assessment to predict the success of labor induction: a systematic review with metaanalysis. Am J Obstet Gynecol 2007; 197:186-92. [PMID: 17689645 DOI: 10.1016/j.ajog.2007.04.050] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Revised: 03/13/2007] [Accepted: 04/26/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this investigation was to review the literature that evaluates sonographic cervical assessment to predict successful induction of labor. STUDY DESIGN Published prospective trials that measured sonographic cervical length before labor induction was initiated were evaluated. Trials were excluded if they contained data presented in later articles or did not contain extractable data. The total analysis included 20 trials with 3101 aggregate participants. RESULTS Cervical length predicted successful induction (likelihood ratio of positive test, 1.66; 95% confidence interval [CI], 1.20-2.31) and failed induction (likelihood ratio of negative test, 0.51; 95% CI, 0.39-0.67). Cervical length did not predict any specific outcome (eg, mode of delivery). The assessment of cervical wedging proved to be a useful diagnostic test, with a likelihood ratio of a positive test result of 2.64 and a likelihood ratio of a negative test result of 0.64. CONCLUSION Sonographic cervical length was not an effective predictor of successful labor induction. Further evaluation of cervical wedging in the prediction of labor induction appears warranted.
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Affiliation(s)
- Ann S Hatfield
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA.
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Prostaglandin E1, E2 and oxytocin in labor induction. Open Med (Wars) 2006. [DOI: 10.2478/s11536-006-0038-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractThe risks of induction must be carefully weighed against the risks of allowing the pregnancy to continue and not inducing labor. The aim of the study was to show labor and neonatal outcome of 335 deliveries inducted in 2004 at Institute of gynecology and obstetrics Clinical Center of Serbia. Inductions were performed with PGE2, PGE1 and Oxytocin. The best ripening effect was noted in PGE2 group. The average duration of labor was 8.6h in PGE1group, 5.9h in PGE2 group and 10.4h in OT group. Sixty eight labors finished with cesarean section (20%). Comparing duration of labor, percentage of emergency cesarean sections, incidence of fetal distress during the labor we suggest Dinoprostone, placed intracervically, as an agent of choice for induction of labor.
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Crane JMG, Butler B, Young DC, Hannah ME. Misoprostol compared with prostaglandin E2 for labour induction in women at term with intact membranes and unfavourable cervix: a systematic review*. BJOG 2006; 113:1366-76. [PMID: 17081181 DOI: 10.1111/j.1471-0528.2006.01111.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Misoprostol is a commonly used prostaglandin to induce labour. A potential risk of induction, however, is caesarean delivery, especially in women with an unfavourable cervix. OBJECTIVES To evaluate the use of misoprostol, compared with prostaglandin E2 (PgE2), for labour induction in women at term with an unfavourable cervix and intact membranes. SEARCH STRATEGY PubMed, Medline, EMBASE and the Cochrane Library were searched for articles published in any language from January 1987 to December 2005, using the keywords 'misoprostol', 'labour/labor' and 'induction'. SELECTION CRITERIA We identified randomised trials of women at term (> or =37 weeks of gestation) with intact membranes and unfavourable cervix, undergoing labour induction with misoprostol, orally, vaginally, sublingually or buccally, compared with PgE2 vaginally or intracervically. DATA COLLECTION AND ANALYSIS Caesarean delivery was the primary outcome, with tachysystole and hyperstimulation as secondary outcomes. The primary analysis compared any misoprostol with any PgE2 for all women, with a subgroup analysis for nulliparous women. Secondary analyses compared different routes and doses of misoprostol (oral or vaginal and 25 microgram or >25 microgram) and PgE2 (intracervical or vaginal). Relative risks (RR) and 95% confidence intervals (CI) were calculated using random effects models. Main results Fourteen of 611 articles identified met the criteria for systematic review, with three providing information for nulliparous women. There was no difference in the risk of caesarean delivery between misoprostol and PgE2 groups (RR = 0.99, 95% CI = 0.83-1.17). Any misoprostol was associated with higher risks of tachysystole and hyperstimulation compared with any PgE2 (RR = 1.86, 95% CI = 1.01-3.43 and RR = 3.71, 95% CI = 2.00-6.88, respectively). There was a higher rate of vaginal delivery within 24 hours among all vaginal deliveries with any misoprostol compared with any PgE2 (RR = 1.14, 95% CI = 1.00-1.31), and among all deliveries, a lower rate of oxytocin use (RR = 0.71, 95% CI = 0.60-0.85) but a trend towards increased meconium staining was observed (RR = 1.22, 95% CI = 0.96-1.55). The use of misoprostol at starting dosages >25 microgram had similar findings to the primary analysis. Studies of lower misoprostol dosing (starting dose of 25 microgram) did not show any differences in the outcomes of interest, but the sample size of this secondary analysis was small (304 women, 155 receiving misoprostol). AUTHOR'S CONCLUSIONS Although misoprostol in women at term with an unfavourable cervix and intact membranes was more effective than PgE2 in achieving vaginal delivery within 24 hours, misoprostol does not reduce the rate of caesarean delivery either in all women or in the subgroup of nulliparous women, and it increases the rates of tachysystole and hyperstimulation. Further studies of misoprostol using a starting dose of 25 microgram may be warranted.
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Affiliation(s)
- J M G Crane
- Department of Obstetrics and Gynecology, Eastern Health, Memorial University of Newfoundland, St John's, Newfoundland, Canada.
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Lee HY, Zhao S, Fields PA, Sherwood OD. Clinical Use of Relaxin to Facilitate Birth: Reasons for Investigating the Premise. Ann N Y Acad Sci 2006; 1041:351-66. [PMID: 15956733 DOI: 10.1196/annals.1282.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In the United States, both medical and nonmedical factors have driven the cesarean section rate to over 26% of all deliveries. In addition to questions of increased cost associated with operative delivery, some have questioned the ethics of performing cesarean section for nonmedical reasons. Reduction of both the duration and the pain associated with vaginal delivery would likely bring about a decline in the rate of both medical and nonmedical cesarean sections. This chapter summarizes recent findings that support the premise that through its growth-promoting and softening effects on the cervix, short-term subcutaneous administration of pharmacologic amounts of relaxin to women at term holds promise as a means of reducing the duration and discomfort associated with delivery. Two recent studies conducted in pregnant rats demonstrated that the cervix is highly responsive to relaxin during the antepartum period and that short-term subcutaneous administration of the hormone to relaxin-deficient animals not only promotes growth and softening of the cervix, but also reduces the duration of labor and delivery. Moreover, recent human clinical trials examining the influence of 24 weeks of continuous subcutaneous administration of recombinant human relaxin for the treatment of scleroderma provided evidence not only that the human reproductive tract is responsive to relaxin, but also that the administration of the hormone does not cause serious adverse side effects. It is concluded that recent findings provide an impetus for an investigation into relaxin's potential for cervical remodeling and facilitating birth in women.
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Affiliation(s)
- Hyung-Yul Lee
- Department of Molecular and Integrative Physiology, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
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Abstract
BACKGROUND Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue marketed for use in the prevention and treatment of peptic ulcer disease. It is inexpensive, easily stored at room temperature and has few systemic side effects. It is rapidly absorbed orally and vaginally. Although not registered for such use, misoprostol has been widely used for obstetric and gynaecological 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 trials register (October 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002) and bibliographies of relevant papers. SELECTION CRITERIA The criteria for inclusion included the following: (1) 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; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. To avoid duplication of data in the primary reviews, the labour induction methods have been listed in a specific order, from one to 25. Each primary review includes comparisons between one of the methods (from two to 25) with only those methods above it on the list. MAIN RESULTS Sixty-two trials have been included. Compared to placebo, misoprostol was associated with increased cervical ripening (relative risk of unfavourable or unchanged cervix after 12 to 24 hours with misoprostol 0.09, 95% confidence interval (CI) 0.03 to 0.24). It was also associated with reduced failure to achieve vaginal delivery within 24 hours (relative risk (RR) 0.36, 95% CI 0.19 to 0.68). Uterine hyperstimulation, without fetal heart rate changes, was increased (RR 11.7 95% CI 2.78 to 49). Compared with vaginal prostaglandin E2, intracervical prostaglandin E2 and oxytocin, vaginal misoprostol labour induction 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. Compared with intracervical prostaglandin E2, unchanged or unfavourable cervix after 12 to 24 hours was less common with misoprostol. Lower doses of misoprostol compared to higher doses were associated with more need for oxytocin augmentation, less uterine hyperstimulation, with and without fetal heart rate changes, and a non-significant trend to fewer admissions to neonatal intensive care unit. Use of a gel preparation of misoprostol versus tablet was associated with less hyperstimulation and more use of oxytocin and epidural analgesia. Information on women's views is conspicuously lacking. REVIEWER'S CONCLUSIONS Vaginal misoprostol appears to be more effective than conventional methods of cervical ripening and labour induction. The apparent increase in uterine hyperstimulation is of concern. Doses not exceeding 25 mcg four-hourly of concern. Doses not exceeding 25 mcg four-hourly appeared to have similar effectiveness and risk of uterine hyperstimulation to conventional labour inducing methods. The studies reviewed were not large enough to exclude the possibility of rare but serious adverse events, particularly uterine rupture, which has been reported anecdotally following misoprostol use in women with and without previous caesarean section. The authors request information on cases of uterine rupture known to readers. Further research is needed to establish the ideal route of administration and dosage, and safety. 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 J Hofmeyr
- (Director, Effective Care Research Unit, University of the Witwatersrand), Frere/Cecilia Makiwane Hospitals, Private Bag 9047, East London 5200, Eastern Cape, South Africa.
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