Oral misoprostol or vaginal dinoprostone for labor induction: a randomized controlled trial

Comparing labour induction outcomes using misoprostol and dinoprostone in term pregnancies: A retrospective study at Kiambu Level 5 Hospital between 2018 and 2020

BACKGROUND

The Maternal and Perinatal Death Surveillance and Response (MPDSR) was introduced in Kenya in 2016 and implemented at Kiambu Level 5 Hospital (KL5H) three years later in 2019. During a routine MPDSR meeting at KL5H, committee members identified a possible link between the off-label use of 200mcg misoprostol tablets divided eight times to achieve the necessary dose for labour induction (25mcg) and maternal deaths. Following this, an administrative decision was made to switch from misoprostol to dinoprostone for the induction of labour in June of 2019. This study aimed to assess the overall impact of MPDSR as well as the effect of replacing misoprostol with dinoprostone on uterine rupture, maternal and neonatal deaths at KL5H.

METHODS

We conducted a retrospective cohort study of women who gave birth at KL5H between January 2018 and December 2020. We defined the pre-intervention period as January 2018-June 2019, and the intervention period as July 2019-December 2020. We randomly selected the records of 411 mothers, 167 from the pre-intervention period and 208 from the intervention period, all of whom were induced. We used Bayes-Poisson Generalised Linear Models to fit the risk of uterine rupture, maternal and perinatal death. 12 semi-structured key person questionnaires was used to describe staff perspectives regarding the switch from misoprostol to dinoprostone. Inductive and deductive data analysis was done to capture the salient emerging themes.

RESULTS

We reviewed 411 patient records and carried out 12 key informant interviews. Mothers induced with misoprostol (IRR = 3.89; CI = 0.21-71.6) had an increased risk of death while mothers were less likely to die if they were induced with dinoprostone (IRR = 0.23; CI = 0.01-7.12) or had uterine rupture (IRR = 0.56; CI = 0.02-18.2). The risk of dying during childbearing increased during Jul 2019-Dec 2020 (IRR = 5.43, CI = 0.68-43.2) when the MPDSR activities were strengthened. Induction of labour (IRR = 1.01; CI = 0.06-17.1) had no effect on the risk of dying from childbirth in our setting. The qualitative results exposed that maternity unit staff preferred dinoprostone to misoprostol as it was thought to be more effective (fewer failed inductions) and safer, regardless of being more expensive compared to misoprostol.

CONCLUSION

While the period immediately following the implementation of MPDSR at KL5H was associated with an increased risk of death, the switch to dinoprostone for labour induction was associated with a lower risk of maternal and perinatal death. The use of dinoprostone, however, was linked to an increased risk of uterine rupture, possibly attributed to reduced labour monitoring given that staff held the belief that it is inherently safer than misoprostol. Consequently, even though the changeover was warranted, further investigation is needed to determine the reasons behind the rise in maternal mortalities, even though the MPDSR framework appeared to have been put in place to quell such an increase.

An Externally Validated Model to Predict Prolonged Induction of Labor with an Unfavorable Cervix

OBJECTIVE

 To develop and externally validate a prediction model to calculate the likelihood of prolonged induction of labor (induction start to delivery time > 36 hours).

STUDY DESIGN

 This was a retrospective cohort study of all nulliparous women with singleton pregnancies and vertex presentation at term who underwent induction of labor and had a vaginal delivery at a single academic center. Women with contraindications for vaginal delivery were excluded. Analyses were limited to women with unfavorable cervix (both simplified Bishop score [dilation, station, and effacement: range 0-9] <6 and cervical dilation <3 cm). Prolonged induction of labor was defined as the duration of induction (induction start time to delivery) longer than 36 hours. A backward stepwise logistic regression analysis was used to identify the factors associated with prolonged induction of labor by considering maternal characteristics and comorbidities as well as fetal conditions. The final model was validated using an external dataset of the Consortium on Safe Labor after applying the same inclusion and exclusion criteria. We developed a receiver observer characteristic curve with area under the curve (AUC) in validation cohorts.

RESULTS

 Of 2,118 women, 364 (17%) had prolonged induction of labor. Factors associated with prolonged induction of labor included body mass index at admission, hypertension, fetal conditions, and epidural. Factors including younger maternal age, prelabor rupture of membranes, and a more favorable simplified Bishop score were associated with a decreased likelihood of prolonged induction of labor. In the external validation cohort, 4,418 women were analyzed, of whom 188 (4%) had prolonged induction of labor. The AUC of the final model was 0.76 (95% confidence interval: 0.73-0.80) for the external validation cohort. The online calculator was created and is available at: https://medstarapps.org/obstetricriskcalculator.

CONCLUSION

 Our externally validated model was efficient in predicting prolonged induction of labor with an unfavorable cervix.

KEY POINTS

· The number of inductions of labor at 39 weeks' gestation and beyond has been increasing.. · Our model had a good prediction of prolonged induction of labor.. · An online calculator has been created and available..

Safety of misoprostol vs dinoprostone for induction of labor: A systematic review and meta-analysis

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.

Association between the cervical sliding sign and successful induction of labor in women with an unfavorable cervix: A prospective observational study

OBJECTIVES

To evaluate the role of the cervical sliding sign (CSS) in the prediction of the outcome of induction of labor (IOL).

STUDY DESIGN

Two-center prospective observational cohort study involving a non-consecutive series of uncomplicated singleton term pregnancies, planned for IOL, with a fetus in cephalic presentation and unfavorable cervix as defined by a Bishop score ≤ 6. The Bishop score was evaluated by transvaginal digital examination and the cervical length and CSS by transvaginal ultrasound. The presence of CSS was defined as the sliding of the anterior cervical lip on the posterior one under gentle pressure of the transvaginal probe. The primary outcome of the study was successful vaginal delivery within 24 h. The secondary outcome was the induction-to-active-labor time. The interobserver agreement for the CSS was also evaluated.

RESULTS

Over a period of 12 months, 179 women were included. The CSS was found in 86 (48.0 %) patients and was associated with an increased likelihood of vaginal delivery within 24 h (60/86 or 69.8 % vs 27/93 or 29.0 %, P < 0.001) and a shorter induction-to-active-labor time (954 ± 618 min vs 1416 ± 660 min, P < 0.001). Multivariable regression analysis showed that the CSS was an independent predictor of vaginal delivery within 24 h (aOR 5.37, 95 % CI 2.26-12.75) and shorter induction-to-active-labor time interval (HR 1.81, 95 % CI 1.19-2.74). The interobserver variability based on intraclass correlation coefficient for the CSS was excellent (ICC = 0.90).

CONCLUSION

In women undergoing IOL with an unfavorable cervix, the CSS is associated with a higher frequency of vaginal delivery within 24 h and a shorter induction-to-active-labor time.

[Efficacy and safety of oral misoprostol 25μg vs. vaginal dinoprostone in induction of labor at term]

OBJECTIVE

To compare the efficacy and safety of oral misoprostol 25μg compared to vaginal dinoprostone in the induction of labor at term.

METHODS

Analytic, retrospective study of patients induced at term by prostaglandins with an unfavorable cervix, over two consecutive periods from 01/01/2019 to 19/02/2020 and from 20/02/2020 to 07/04/2021, within a regional level III university hospital center. We compared the safety and the efficacy between the oral misoprostol Angusta® used since 20/02/2020 and the vaginal dinoprostone previously used in gel or diffuser. The primary endpoint was the rate of vaginal deliveries within 24h. Secondary endpoints were cesarean section rate, indications for cesarean section, uterine contractility abnormalities and neonatal outcomes.

RESULTS

Our study found no difference in terms of efficacy with similar rates of vaginal deliveries within 24h (51.88% vs. 51.25%; P=0.87) and caesarean sections (misoprostol group: 19.42% vs. dinoprostone group: 16.62%; P=0.33). However, the tolerance criteria revealed in the dinoprostone group an increase in tachysystole (misoprostol group: 9.28% vs. dinoprostone group: 16.90%; P=0.003) and acidosis (arterial pH<7.10, misoprostol group: 3.83% vs. dinoprostone group: 9.29%; P=0.006).

CONCLUSION

No difference in efficacy was found between the two induction techniques. Oral misoprostol 25μg seems to be better tolerated from a maternal and fetal point of view.

Oral Misoprostol alone versus oral misoprostol followed by oxytocin for labour induction in women with hypertension in pregnancy (MOLI): protocol for a randomised controlled trial

BACKGROUND

Every year approximately 30,000 women die from hypertensive disease in pregnancy. Magnesium sulphate and anti-hypertensives reduce morbidity, but delivery is the only cure. Low dose oral misoprostol, a prostaglandin E1 analogue, is a highly effective method for labour induction. Usually, once active labour has commenced, the misoprostol is replaced with an intravenous oxytocin infusion if ongoing stimulation is required. However, some studies have shown that oral misoprostol can be continued into active labour, a simpler and potentially more acceptable protocol for women. To date, these two protocols have never been directly compared.

METHODS

This pragmatic, open-label, randomised trial will compare a misoprostol alone labour induction protocol with the standard misoprostol plus oxytocin protocol in three Indian hospitals. The study will recruit 520 pregnant women being induced for hypertensive disease in pregnancy and requiring augmentation after membrane rupture. Participants will be randomised to receive either further oral misoprostol 25mcg every 2 h, or titrated intravenous oxytocin. The primary outcome will be caesarean birth. Secondary outcomes will assess the efficacy of the induction process, maternal and fetal/neonatal complications and patient acceptability. This protocol (version 1.04) adheres to the SPIRIT checklist. A cost-effectiveness analysis, situational analysis and formal qualitative assessment of women's experience are also planned.

DISCUSSION

Avoiding oxytocin and continuing low dose misoprostol into active labour may have a number of benefits for both women and the health care system. Misoprostol is heat stable, oral medication and thus easy to store, transport and administer; qualities particularly desirable in low resource settings. An oral medication protocol requires less equipment (e.g. electronic infusion pumps) and may free up health care providers to assist with other aspects of the woman's care. The simplicity of the protocol may also help to reduce human errors associated with the delivery of intravenous infusions. Finally, women may prefer to be mobile during labour and not restricted by an intravenous infusion. There is a need, therefore, to assess whether augmentation using oral misoprostol is superior clinically and economically to the standard protocol of intravenous oxytocin.

TRIAL REGISTRATION

Clinical Trials.gov, NCT03749902 , registered on 21^st Nov 2018.

Low-dose oral misoprostol for induction of labour

BACKGROUND

Misoprostol given orally is a commonly used labour induction method. Our Cochrane Review is restricted to studies with low-dose misoprostol (initially ≤ 50 µg), as higher doses pose unacceptably high risks of uterine hyperstimulation.

OBJECTIVES

To assess the efficacy and safety of low-dose oral misoprostol for labour induction in women with a viable fetus in the third trimester of pregnancy.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov,  the WHO International Clinical Trials Registry Platform (14 February 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials comparing low-dose oral misoprostol (initial dose ≤ 50 µg) versus placebo, vaginal dinoprostone, vaginal misoprostol, oxytocin, or mechanical methods; or comparing oral misoprostol protocols (one- to two-hourly versus four- to six-hourly; 20 µg to 25 µg versus 50 µg; or 20 µg hourly titrated versus 25 µg two-hourly static).

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened reports, extracted trial data, and performed quality assessments. Our primary outcomes were vaginal birth within 24 hours, caesarean section, and hyperstimulation with foetal heart changes.

MAIN RESULTS

We included 61 trials involving 20,026 women. GRADE assessments ranged from moderate- to very low-certainty evidence, with downgrading decisions based on imprecision, inconsistency, and study limitations. Oral misoprostol versus placebo/no treatment (four trials; 594 women) Oral misoprostol may make little to no difference in the rate of caesarean section (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.11; 4 trials; 594 women; moderate-certainty evidence), while its effect on uterine hyperstimulation with foetal heart rate changes is uncertain (RR 5.15, 95% CI 0.25 to 105.31; 3 trials; 495 women; very low-certainty evidence). Vaginal births within 24 hours was not reported. In all trials, oxytocin could be commenced after 12 to 24 hours and all women had pre-labour ruptured membranes. Oral misoprostol versus vaginal dinoprostone (13 trials; 9676 women) Oral misoprostol probably results in fewer caesarean sections (RR 0.84, 95% CI 0.78 to 0.90; 13 trials, 9676 women; moderate-certainty evidence). Subgroup analysis indicated that 10 µg to 25 µg (RR 0.80, 95% CI 0.74 to 0.87; 9 trials; 8652 women) may differ from 50 µg (RR 1.10, 95% CI 0.91 to 1.34; 4 trials; 1024 women) for caesarean section. Oral misoprostol may decrease vaginal births within 24 hours (RR 0.93, 95% CI 0.87 to 1.00; 10 trials; 8983 women; low-certainty evidence) and hyperstimulation with foetal heart rate changes (RR 0.49, 95% CI 0.40 to 0.59; 11 trials; 9084 women; low-certainty evidence). Oral misoprostol versus vaginal misoprostol (33 trials; 6110 women) Oral use may result in fewer vaginal births within 24 hours (average RR 0.81, 95% CI 0.68 to 0.95; 16 trials, 3451 women; low-certainty evidence), and less hyperstimulation with foetal heart rate changes (RR 0.69, 95% CI 0.53 to 0.92, 25 trials, 4857 women, low-certainty evidence), with subgroup analysis suggesting that 10 µg to 25 µg orally (RR 0.28, 95% CI 0.14 to 0.57; 6 trials, 957 women) may be superior to 50 µg orally (RR 0.82, 95% CI 0.61 to 1.11; 19 trials; 3900 women). Oral misoprostol probably does not increase caesarean sections overall (average RR 1.00, 95% CI 0.86 to 1.16; 32 trials; 5914 women; low-certainty evidence) but likely results in fewer caesareans for foetal distress (RR 0.74, 95% CI 0.55 to 0.99; 24 trials, 4775 women). Oral misoprostol versus intravenous oxytocin (6 trials; 737 women, 200 with ruptured membranes) Misoprostol may make little or no difference to vaginal births within 24 hours (RR 1.12, 95% CI 0.95 to 1.33; 3 trials; 466 women; low-certainty evidence), but probably results in fewer caesarean sections (RR 0.67, 95% CI 0.50 to 0.90; 6 trials; 737 women; moderate-certainty evidence). The effect on hyperstimulation with foetal heart rate changes is uncertain (RR 0.66, 95% CI 0.19 to 2.26; 3 trials, 331 women; very low-certainty evidence). Oral misoprostol versus mechanical methods (6 trials; 2993 women) Six trials compared oral misoprostol to transcervical Foley catheter. Misoprostol may increase vaginal birth within 24 hours (RR 1.32, 95% CI 0.98 to 1.79; 4 trials; 1044 women; low-certainty evidence), and probably reduces the risk of caesarean section (RR 0.84, 95% CI 0.75 to 0.95; 6 trials; 2993 women; moderate-certainty evidence). There may be little or no difference in hyperstimulation with foetal heart rate changes (RR 1.31, 95% CI 0.78 to 2.21; 4 trials; 2828 women; low-certainty evidence). Oral misoprostol one- to two-hourly versus four- to six-hourly (1 trial; 64 women) The evidence on hourly titration was very uncertain due to the low numbers reported. Oral misoprostol 20 µg hourly titrated versus 25 µg two-hourly static (2 trials; 296 women) The difference in regimen may have little or no effect on the rate of vaginal births in 24 hours (RR 0.97, 95% CI 0.80 to 1.16; low-certainty evidence). The evidence is of very low certainty for all other reported outcomes.

AUTHORS' CONCLUSIONS

Low-dose oral misoprostol is probably associated with fewer caesarean sections (and therefore more vaginal births) than vaginal dinoprostone, and lower rates of hyperstimulation with foetal heart rate changes. However, time to birth may be increased, as seen by a reduced number of vaginal births within 24 hours. Compared to transcervical Foley catheter, low-dose oral misoprostol is associated with fewer caesarean sections, but equivalent rates of hyperstimulation. Low-dose misoprostol given orally rather than vaginally is probably associated with similar rates of vaginal birth, although rates may be lower within the first 24 hours. However, there is likely less hyperstimulation with foetal heart changes, and fewer caesarean sections performed due to foetal distress. The best available evidence suggests that low-dose oral misoprostol probably has many benefits over other methods for labour induction. This review supports the use of low-dose oral misoprostol for induction of labour, and demonstrates the lower risks of hyperstimulation than when misoprostol is given vaginally. More trials are needed to establish the optimum oral misoprostol regimen, but these findings suggest that a starting dose of 25 µg may offer a good balance of efficacy and safety.

Labor induction with prostaglandin E1 versus E2: a comparison of outcomes

OBJECTIVE

To compare the peripartum outcomes when labor is induced with prostaglandins E₁ versus E₂.

METHODOLOGY

The Consortium of Safe Labor database was utilized. Women with non-anomalous singletons >24 weeks gestation undergoing induction were analyzed. The primary endpoint was a composite adverse maternal outcome with a composite adverse neonatal outcome as our secondary outcome.

RESULTS

Of the 228,438 births within the database, 8229 (10.8%) met inclusion criteria with 4703 (55.7%) receiving PGE₁, and 3741 (44.3%), PGE₂. The rate of vaginal delivery was similar between both. Composite adverse maternal outcome, was more likely among the prostaglandin E₁: 7.2% vs. 1.5% (aOR 4.20; 95% CI 3.02-5.85); similar trend observed with composite adverse neonatal outcome rates: 4.6% vs. 1.4% (aOR 1.69; 95% CI 1.14-2.50).

CONCLUSION

Utilization of prostaglandin E₁, compared to E_2, was associated with an increased likelihood of adverse maternal and neonatal outcomes.

Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis

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.

Randomized clinical trial between hourly titrated and 2 hourly static oral misoprostol solution for induction of labor

BACKGROUND

Misoprostol is an effective agent for the induction of labor. Existing guidelines recommend oral misoprostol solution 25 μg every 2 hours. However, more research is required to optimize the use of oral misoprostol solution for the induction of labor.

OBJECTIVE

The purpose of this study was to compare efficacy and safety of hourly titrated-dose oral misoprostol solution with static-dose oral misoprostol solution every 2 hours for labor induction.

STUDY DESIGN

In this randomized controlled study, oral misoprostol solution was administered as (1) 20 μg hourly (≤4 doses) that was increased in the absence of regular uterine contractions to 40 μg hourly (≤4 doses) and then to 60 μg hourly (≤16 doses) or (2) 25 μg every 2 hours until active labor began (≤12 doses). A sample size of 146 women was planned with the use of a projected 95% rate for the primary endpoint (vaginal delivery within 24 hours) for hourly titrated-dose misoprostol and 80% rate for static-dose misoprostol every 2 hours. Safety outcomes included maternal morbidity and adverse neonatal outcomes.

RESULTS

From December 2013 to July 2015, 146 women were assigned randomly to treatment. Demographic and clinical factors were similar between groups, except for age. Vaginal delivery was achieved within 24 hours in 47 women (64.4%) who received hourly titrated-doses of misoprostol solution and 48 women (65.8%) who received 2-hourly static-dose misoprostol solution (P=1.00). Rates of vaginal delivery within 24 hours did not differ significantly between treatment groups for women who were nulliparous (P=1.00) or who had postterm pregnancies (P=.66), a Bishop score of ≤3 (P=.84), or oxytocin augmentation (P=.83). Cesarean deliveries were performed within 24 hours in 9 women who received hourly titrated-dose misoprostol solution and 2 women who received 2-hourly static-dose misoprostol solution (P=.056). Pyrexia and meconium-stained liquor occurred more frequently with the hourly titrated-dose regimen.

CONCLUSION

The static-dose oral misoprostol solution every 2 hours has similar efficacy as hourly titrated-dose misoprostol solution but with fewer side-effects and lower complication rates.

Outcome of misoprostol and oxytocin in induction of labour

BACKGROUND

Induction of labour is the process of initiating the labour by artificial means from 24 weeks of gestation. The main aim of this study is to find out the maternal and foetal outcomes after induction of labour with misoprostol and oxytocin beyond 37 weeks of gestation.

METHODS

This was a hospital-based observational study carried out at Paropakar Maternity and Women's Hospital, Nepal. Misoprostol of 25 µg was inserted in posterior fornix of vagina or oxytocin infusion was started from 2.5 units on whom induction was decided. Maternal and foetal/neonatal outcomes were observed. Collected data were analysed using SPSS and MS Excel.

RESULTS

General induction rate was found to be 7.2%. In this study, post-term pregnancy was found to be the most common reason for induction of labour. Analysis of onset of labour led to the finding that mean onset of labour was much rapid in oxytocin (6.6 h) than misoprostol (13.6 h). However, there is similarity in induction-delivery interval in both groups. Overall, the rate of normal delivery and caesarean section was found to be 64.9% and 33.2%, respectively. Similarly, normal delivery within 12 h was seen in 18.4% of the patients given with misoprostol and 43.5% in oxytocin group. Foetal distress was found as the most common reason for caesarean section. The overall occurrence of maternal complication was found to be similar in misoprostol and oxytocin groups, nausea/vomiting being the most common (36.7%) complication followed by fever (24.1%). Besides this, the most common neonatal complication found in overall cases was meconium stained liquor (49.2%).

CONCLUSION

It was found that misoprostol was used most frequently for induction of labour compared to oxytocin. The onset of labour was found to be rapid in oxytocin than misoprostol. However, the occurrence of side effects was found to be similar in both misoprostol and oxytocin groups.

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.

Oral misoprostol for induction of labour

BACKGROUND

Misoprostol is an orally active prostaglandin. In most countries misoprostol is not licensed for labour induction, but its use is common because it is cheap and heat stable.

OBJECTIVES

To assess the use of oral misoprostol for labour induction in women with a viable fetus.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 January 2014).

SELECTION CRITERIA

Randomised trials comparing oral misoprostol versus placebo or other methods, given to women with a viable fetus for labour induction.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial data, using centrally-designed data sheets.

MAIN RESULTS

Overall there were 76 trials (14,412) women) which were of mixed quality.In nine trials comparing oral misoprostol with placebo (1109 women), women using oral misoprostol were more likely to give birth vaginally within 24 hours (risk ratio (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49; one trial; 96 women), need less oxytocin (RR 0.42, 95% CI 0.37 to 0.49; seven trials; 933 women) and have a lower caesarean section rate (RR 0.72, 95% CI 0.54 to 0.95; eight trials; 1029 women).In 12 trials comparing oral misoprostol with vaginal dinoprostone (3859 women), women given oral misoprostol were less likely to need a caesarean section (RR 0.88, 95% CI 0.78 to 0.99; 11 trials; 3592 women). There was some evidence that they had slower inductions, but there were no other statistically significant differences.Nine trials (1282 women) compared oral misoprostol with intravenous oxytocin. The caesarean section rate was significantly lower in women who received oral misoprostol (RR 0.77, 95% CI 0.60 to 0.98; nine trials; 1282 women), but they had increased rates of meconium-stained liquor (RR 1.65, 95% CI 1.04 to 2.60; seven trials; 1172 women).Thirty-seven trials (6417 women) compared oral and vaginal misoprostol and found no statistically significant difference in the primary outcomes of serious neonatal morbidity/death or serious maternal morbidity or death. The results for vaginal birth not achieved in 24 hours, uterine hyperstimulation with fetal heart rate (FHR) changes, and caesarean section were highly heterogenous - for uterine hyperstimulation with FHR changes this was related to dosage with lower rates in those with lower doses of oral misoprostol. However, there were fewer babies born with a low Apgar score in the oral group (RR 0.60, 95% CI 0.44 to 0.82; 19 trials; 4009 babies) and a decrease in postpartum haemorrhage (RR 0.57, 95% CI 0.34 to 0.95; 10 trials; 1478 women). However, the oral misoprostol group had an increase in meconium-stained liquor (RR 1.22, 95% CI 1.03 to 1.44; 24 trials; 3634 women).

AUTHORS' CONCLUSIONS

Oral misoprostol as an induction agent is effective at achieving vaginal birth. It is more effective than placebo, as effective as vaginal misoprostol and results in fewer caesarean sections than vaginal dinoprostone or oxytocin.Where misoprostol remains unlicensed for the induction of labour, many practitioners will prefer to use a licensed product like dinoprostone. If using oral misoprostol, the evidence suggests that the dose should be 20 to 25 mcg in solution. Given that safety is the primary concern, the evidence supports the use of oral regimens over vaginal regimens. This is especially important in situations where the risk of ascending infection is high and the lack of staff means that women cannot be intensely monitored.

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.

Randomized clinical trial between hourly titrated oral misoprostol and vaginal dinoprostone for induction of labor

OBJECTIVE

The objective of the study was to compare the efficacy and safety of hourly titrated oral misoprostol with vaginal dinoprostone insert.

STUDY DESIGN

Subjects were randomized into hourly titrated oral misoprostol or dinoprostone 10 mg vaginal insert. Misoprostol was given as 20 μg hourly for 2 doses. In the absence of regular uterine contractions, the dose was increased to 30 μg hourly for 3 doses and then 40 μg for 1 dose, 50 μg for 1 dose, and 60 μg hourly for 4 doses. Before the 40 and 50 μg doses, 1 more hour of observation was given. The primary outcome variable was vaginal delivery within 24 hours. Safety assessments included the incidence of maternal morbidity and adverse neonatal outcomes.

RESULTS

A total of 160 women was enrolled in the study. The groups were similar for demographic and clinical factors. Vaginal delivery was achieved within 24 hours in 100 women (62.5%): 44 in the dinoprostone group (55.0%) and 56 in the misoprostol group (70.0%) (P = .05). The proportion of women who achieved vaginal delivery within 24 hours was significantly greater for nulliparous women in the misoprostol group (24 of 51, 58.5%) compared with the dinoprostone group (12 of 36, 33.3%; P = .0270). Significantly more women with baseline Bishop score of 3 or less in the misoprostol group had successful induction (43 of 59, 72.9%) compared with the dinoprostone group (27 of 60, 45.0%; P = .002). Frequencies of maternal adverse events were similar between groups.

CONCLUSION

Hourly titrated oral misoprostol can provide an efficacious and safe substitute for the expensive dinoprostone vaginal insert.

Safety of induction of labor with vaginal prostaglandins (e2) in grandmultipara

OBJECTIVES

The aim of this study is to determine safety of induction of labor with vaginal Prostaglandins (E2) in Grand Multipara.

METHODS

Prostaglandin E2 was used in the form of vaginal tablets or gel in post fornix for induction as per protocol. Maternal and fetal data collected included age, parity, and indication of induction, bishops score, total dose of PGE2 used & complications of induction of labor. The data was collected and analyzed using Epi info - 6.

RESULTS

50% cases were induced for past dates, the ceasarean rate was high in the induction group (19.5%) compared to the control (12.5%) OR 1.69 RR 1.37(95% CI-1.07-1.75) difference was statistically significant. Adverse neonatal outcome was found to be similar in both groups. Special Care Baby Unit (SCBU) admissions were 19 in the induction group and 21 in the control group, which was not statistically significant. No severe maternal complications were observed such as infection or uterine rupture.

CONCLUSION

As there were no adverse events in the study, it may be safe to use vaginal PGE2 as method of choice for induction of labour in grand mutipara. However, RCT for further validation of these findings is recommended.

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.

Comparative efficacy and safety of vaginal misoprostol versus dinoprostone vaginal insert in labor induction at term: a randomized trial

OBJECTIVE

To compare efficacy and safety of vaginal misoprostol (PGE(1) analog) with dinoprostone (PGE(2) analog) vaginal insert for labor induction in term pregnancies.

STUDY DESIGN

A total of 112 women with singleton pregnancies of > or =37 weeks of gestation, and low Bishop scores underwent labor induction. The subjects were randomized to receive either 50 mug misoprostol intravaginally every 4 h to a maximum of five doses or a 10 mg dinoprostone vaginal insert for a maximum of 12 h. Time interval from induction to vaginal delivery, vaginal delivery rates within 12 and 24 h, requirement of oxytocin augmentation, incidence of tachysystole and uterine hyperstimulation, mode of delivery, rate of cesarean section due to fetal distress and neonatal outcome were outcome measures. Student's t test, Chi square test, Fischer's exact test were used for statistical analysis.

RESULTS

Time interval from induction to vaginal delivery was found to be significantly shorter in misoprostol group when compared to dinoprostone subjects (680 +/- 329 min vs. 1070 +/- 435 min, P < 0.001). Vaginal delivery rates within 12 h were found to be significantly higher with misoprostol induction [n = 37 (66%) vs. n = 25 (44.6%); P = 0.02], whereas vaginal delivery rates in 24 h did not differ significantly between groups [n = 41 (73.2%) vs. n = 36 (64.2%); P = 0.3]. More subjects required oxytocin augmentation in dinoprostone group [n = 35 (62.5%) vs. n = 20 (35.7%), P = 0.005] and cardiotocography tracings revealed early decelerations occurring more frequently with misoprostol induction (10.7 vs. 0%, P = 0.03). Tachysystole and uterine hyperstimulation, mode of delivery, rate of cesarean sections due to fetal distress and adverse neonatal outcome were not demonstrated to be significantly different between groups (P = 1, P = 0.5, P = 0.4, P = 0.22, P = 0.5).

CONCLUSION

Using vaginal misoprostol is an effective way of labor induction in term pregnant women with unfavorable cervices, since it is associated with a shorter duration of labor induction and higher rates of vaginal delivery within 12 h. Misoprostol and dinoprostone are equally safe, since misoprostol did not result in a rise in maternal and neonatal morbidity, namely, tachysystole, uterine hyperstimulation, cesarean section rates and admission to neonatal intensive care units as reported previously in literature.

Misoprostol to induce labour: a review of its use in a NSW hospital

BACKGROUND

Induction of labour (IOL) is a common procedure in maternity care. Misoprostol is a prostaglandin E(1) analogue that is effective, cheap and easily stored but not licensed for this use in Australia. Despite evidence supporting the use of misoprostol for IOL, few Australian maternity units use it.

AIMS

To review the outcomes of women who received vaginal misoprostol for IOL.

METHODS

A retrospective review of all births induced with vaginal misoprostol from July 1998 to October 2005 at one hospital in New South Wales. Women who had an IOL for multiple pregnancy, known fetal death or congenital abnormality were excluded.

RESULTS

In total, 1998 women with a normal, viable, single fetus received vaginal misoprostol for IOL. More than half (57%) of women did not require augmentation during labour. More than one third (37%) had epidural analgesia, 25% had an emergency Caesarean section, 7% had a post-partum haemorrhage and 16% of babies were admitted to the special care nursery. Uterine rupture occurred in two women, one of whom had a history of uterine surgery. There were two neonatal deaths, both because of Group B Streptococcus infection.

CONCLUSIONS

In this cohort of women, misoprostol was an effective and safe agent to induce labour. Recent legal concerns at this hospital make its future use in normal clinical practice unlikely.

Misoprostol compared with prostaglandin E2 for labour induction in women at term with intact membranes and unfavourable cervix: a systematic review*

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.

A randomized comparison between intravaginal misoprostol and prostaglandin E2 for labor induction

OBJECTIVE

The aim of this randomized study was to compare the effectiveness, safety, and side effects of 6 h vaginal misoprostol versus vaginal prostaglandin E(2) (PGE(2)) for labor induction.

STUDY DESIGN

Fifty microgram of misoprostol was given intravaginally in the misoprostol group (204 women), and 3 mg PGE(2) was given intravaginally in the PGE(2) group (211 women). In both groups, the dose was repeated every 6 h for a maximum of three doses, until active labor was achieved. Artificial rupture of membranes and oxytocin infusion was used during labor in both groups where it was indicated.

RESULTS

The mean interval from the institution of labor induction to delivery was 11.3 +/- 8.6 h for the misoprostol group, and 15.7 +/- 9.3 h for PGE(2 )group (P < 0.05). In the misoprostol group, oxytocin was used less frequently, but there was a higher prevalence of tachysystole. No statistically significant differences were observed between the two groups as regard abnormal patterns of fetal heart rate, the mode of delivery, and the need for neonatal intervention.

CONCLUSION

In conclusion, the intravaginal administration of 50 mug misoprostol at 6 h interval (maximum three doses) is comparable in safety, but more effective for induction of labor than 3 mg intravaginal PGE(2).

Oral Misoprostol Administration for Labor Induction

Using oral agents for induction of labor would reduce the need for repeated vaginal examinations; this is more acceptable to women and could reduce infection rates. A systematic review was conducted of 41 randomized trials comparing oral misoprostol to other induction agents. Oral misoprostol is effective at achieving vaginal delivery, and may have benefits over both vaginal and intracervical dinoprostone. Although it does not achieve vaginal delivery as quickly as vaginal misoprostol, the rates of hyperstimulation are lower when using comparable doses. As the primary consideration should be safety rather than speed, an oral regimen using a maximum of 50 mcg 4 hourly is recommended.

The routine use of oxytocin after oral misoprostol for labour induction in women with an unfavourable cervix is not of benefit

BACKGROUND

Induction of labour with misoprostol is often augmented with oxytocin with the possible consequence of uterine hypercontractility. It is important to determine whether the use of oxytocin in this circumstance has benefit as well as risk.

AIM

To compare two regimens for labour induction in women with an unfavourable cervix: oral misoprostol vs. oral misoprostol routinely followed by oxytocin.

METHODS

A prospective randomised trial in which 200 women with an unfavourable cervix received either oral misoprostol 25 microg every 3 h (group 1, n = 100) or two such doses routinely followed by oxytocin (group 2, n = 100). Outcomes included change in Bishop score, induction delivery interval, oxytocin requirement, contraction abnormalities, mode of delivery and neonatal outcome.

RESULT

The improvement in Bishop score with two misoprostol doses in all 200 women was highly significant (2.9 +/- 1.5 to 6.6 +/- 1.9, P < 0.0001). The induction delivery interval, Caesarean delivery rate, vaginal delivery rate within 24 h, contraction abnormalities and neonatal outcome were similar in both groups. Contraction abnormalities were remarkably low with either regimen (1%). Routine addition of oxytocin 3 h after the second misoprostol dose (group 2) resulted in the maximum oxytocin dose (64 mU/min) being given to more women (66% in group 2; 36% in group 1).

CONCLUSION

There was no benefit of routine addition of oxytocin after two doses of misoprostol. Reduced oxytocin requirement was observed when it was added only if needed. Both regimens achieved 85-87% vaginal deliveries with low incidence of hypercontractility.

Oral misoprostol for induction of labour

BACKGROUND

Misoprostol is a synthetic prostaglandin that can be given orally or vaginally. In most countries misoprostol has not been licensed for use in pregnancy, but its unlicensed use is common because misoprostol is cheap, stable at room temperature and effective in causing uterine contractions. Oral use of misoprostol may be convenient, but high doses could cause uterine hyperstimulation and uterine rupture which may be life-threatening for both mother and fetus.

OBJECTIVES

To assess the effectiveness and safety of oral misoprostol used for labour induction in women with a viable fetus in the third trimester of pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (January 2005).

SELECTION CRITERIA

Randomised trials comparing oral misoprostol versus other methods, placebo or no treatment, given to women with a viable fetus for labour induction.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data, using centrally-designed data sheets.

MAIN RESULTS

Forty-one trials (8606 participants) were included. In four trials comparing oral misoprostol with placebo (474 participants), women using oral misoprostol were less likely to have long labours (relative risk (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49), needed less oxytocin (RR 0.32, 95% CI 0.24 to 0.43) and had a lower caesarean section rate (RR 0.62, 95% CI 0.40 to 0.96). In nine trials comparing oral misoprostol with vaginal dinoprostone (2627 participants), women given oral misoprostol were less likely to need a caesarean section, but this reduction reached statistical significance only in the subgroup with intact membranes (RR 0.78, 95% CI 0.66 to 0.94). Uterine hyperstimulation was more common after oral misoprostol (RR 1.63, 95% CI 1.09 to 2.44) although this was not associated with any adverse fetal events. Seven trials (1017 participants) compared oral misoprostol with intravenous oxytocin. The only difference between the groups was an increase in meconium-stained liquor in women with ruptured membranes following administration of oral misoprostol (RR 1.72, 95% 1.08 to 2.74). Sixteen trials (3645 participants) compared oral and vaginal misoprostol and found no difference in the primary outcomes. There was less uterine hyperstimulation without fetal heart rate changes in those given oral misoprostol (RR 0.37, 95% 0.23 to 0.59). Oral misoprsotol was associated with increased need for oxytocin augmentation (RR 1.28, 95% 1.11 to 1.48) and more meconium-stained liquor (RR 1.27, 1.01 to 1.60).

AUTHORS' CONCLUSIONS

Oral misoprostol appears to be more effective than placebo and at least as effective as vaginal dinoprostone. However, there remain questions about its safety because of a relatively high rate of uterine hyperstimulation and the lack of appropriate dose ranging studies. In countries where misoprostol remains unlicenced for the induction of labour, many practitioners will prefer the legal protection of using a licenced product like dinoprostone. There is no evidence that misoprostol given orally is inferior to the vaginal route and has lower rates of hyperstimulation. If misoprostol is used orally, the dose should not exceed 50 mcg.

Oral misoprostol for induction of labour at term: randomised controlled trial

OBJECTIVE

To compare oral misoprostol solution with vaginal prostaglandin gel (dinoprostone) for induction of labour at term to determine whether misoprostol is superior.

DESIGN

Randomised double blind placebo controlled trial.

SETTING

Maternity departments in three hospitals in Australia. Population Pregnant women with a singleton cephalic presentation at > or = 36+6 weeks' gestation, with an indication for prostaglandin induction of labour.

INTERVENTIONS

20 mug oral misoprostol solution at ourly intervals and placebo vaginal gel or vaginal dinoprostone gel at six hourly intervals and placebo oral solution.

MAIN OUTCOME MEASURES

Vaginal birth within 24 hours; uterine hyperstimulation with associated changes in fetal heart rate; caesarean section (all); and caesarean section for fetal distress.

RESULTS

741 women were randomised, 365 to the misoprostol group and 376 to the vaginal dinoprostone group. There were no significant differences between the two treatment groups in the primary outcomes: vaginal birth not achieved in 24 hours (misoprostol 168/365 (46.0%) v dinoprostone 155/376 (41.2%); relative risk 1.12, 95% confidence interval 0.95 to 1.32; P = 0.134), caesarean section (83/365 (22.7%) v 100/376 (26.6%); 0.82, 0.64 to 1.06; P = 0.127), caesarean section for fetal distress (32/365 (8.8%) v 35/376 (9.3%); 0.91, 0.57 to 1.44; P = 0.679), or uterine hyperstimulation with changes in fetal heart rate (3/365 (0.8%) v 6/376 (1.6%); 0.55, 0.14 to 2.21; P = 0.401). Although there were differences in the process of labour induction, there were no significant differences in adverse maternal or neonatal outcomes.

CONCLUSIONS

This trial shows no evidence that oral misoprostol is superior to vaginal dinoprostone for induction of labour. However, it does not lead to poorer health outcomes for women or their infants, and oral treatment is preferred by women.

TRIAL REGISTRATION

National Health and Medical Research Council, Perinatal Trials, PT0361.

Prospective randomized clinical trial of inpatient cervical ripening with stepwise oral misoprostol vs vaginal misoprostol

OBJECTIVE

The purpose of this study was to compare the efficacy and safety of stepwise oral misoprostol vs vaginal misoprostol for cervical ripening before induction of labor.

STUDY DESIGN

Two hundred and four women between 32 to 42 weeks of gestation with an unfavorable cervix (Bishop score < or = 6) and an indication for labor induction were randomized to receive oral or vaginal misoprostol every 4 hours up to 4 doses. The oral misoprostol group received 50 microg initially followed by 100 microg in each subsequent dose. The vaginal group received 25 microg in each dose. The primary outcome was the interval from first misoprostol dose to delivery. Patient satisfaction and side effects were assessed by surveys completed after delivery.

RESULTS

Ninety-three (45.6%) women received oral misoprostol; 111 (54.4%) received vaginal misoprostol. There was no difference in the average interval from the first dose of misoprostol to delivery in the oral (21.1 + 7.9 hrs) and vaginal (21.5 + 11.0 hrs, P = NS) misoprostol groups. The incidence of hyperstimulation in the oral group was 2.2% vs 5.4% in the vaginal group, P = NS. Eighteen patients in the oral group (19.4%) and 36 (32.4%) in the vaginal group underwent cesarean section (P < .05). This difference was attributed to better tolerance of more doses of misoprostol by the women in the oral group. There was no difference in side effects (nausea, vomiting, diarrhea, shivering) between groups. Fourteen percent of women in the vaginal group versus 7.5% in the oral group were dissatisfied with the use of misoprostol (P = NS).

CONCLUSION

Stepwise oral misoprostol (50 microg followed by 100 microg) appears to be as effective as vaginal misoprostol (25 microg) for cervical ripening with a low incidence of hyperstimulation, no increase in side effects, a high rate of patient satisfaction, and is associated with a lower cesarean section rate.

Misoprostol and pregnancy: ever-increasing indications of effective usage

PURPOSE OF REVIEW

The subject of misoprostol in the field of reproductive health care has courted much controversy. The aim of this review is to survey the literature published in this field over the past year, and to evaluate developments in this area. This article will cover termination of pregnancy, induction of labor and the issue of postpartum hemorrhage.

RECENT FINDINGS

The use of misoprostol as a single agent remains of clinical value when mifepristone is unavailable. The sublingual and rectal routes are alternative modes of administration. For induction of labor, the optimum dose and route of misoprostol is still undetermined. Lower doses of between 20 microg to 40 microg may increase the safety profile for labor induction. Misoprostol may be a useful adjunct to the therapeutic options available for the prevention and treatment of postpartum hemorrhage.

SUMMARY

There are many potential uses for misoprostol in pregnancy. However clinicians must judge the evidence and the emotive debate surrounding this field and decide how it will influence their clinical practice depending on the priorities of their own clinical circumstances.

A comparison of orally administered misoprostol to intravenous oxytocin for labor induction in women with favorable cervical examinations

OBJECTIVE

The purpose of this study was to compare orally administered misoprostol with intravenous oxytocin infusion for labor induction in women with favorable cervical examinations (defined as a Bishop score of 6 or more).

STUDY DESIGN

One hundred ninety-eight women with indications for labor induction and favorable cervical examinations were assigned randomly to receive oral misoprostol or oxytocin induction. Misoprostol, 100 mg, was administered every 4 hours up to 6 doses, or intravenous oxytocin was administered by standardized protocol.

RESULTS

One hundred ten (55.6%) women received misoprostol; 88 (44.4%) received intravenous oxytocin. There was no statistically significant difference in the average interval from start of induction to vaginal delivery, being longer in the misoprostol group (789.4 +/- 510.2 minutes) than in the oxytocin group (654.0 +/- 338.2 minutes, P=.19, log-transformed data). Two women had tachysystole develop in each treatment group. More women in the misoprostol group experienced hyperstimulation (7/110, 6.4%) than in the oxytocin group (0/88, P=.02, Fisher exact test). Nine (8.1%) misoprostol-treated women and 8 (9.1%) oxytocin-treated women underwent cesarean deliveries (P=.82). There was a presumed uterine rupture in a misoprostol-treated multipara women. There were no statistically significant differences in neonatal outcomes between the groups.

CONCLUSION

Oral misoprostol offers no benefit over intravenous oxytocin for labor induction in women with favorable cervical examinations. It is associated with a higher likelihood of uterine hyperstimulation and may increase the risk of uterine rupture.