The experience with prostaglandin E2 vaginal tablets for induction of labour in grand and great grand multiparae. A two year review in Saudi Arabia

Methods for the induction of labor: efficacy and safety

This review assessed the efficacy and safety of pharmacologic agents (prostaglandins, oxytocin, mifepristone, hyaluronidase, and nitric oxide donors) and mechanical methods (single- and double-balloon catheters, laminaria, membrane stripping, and amniotomy) and those generally considered under the rubric of complementary medicine (castor oil, nipple stimulation, sexual intercourse, herbal medicine, and acupuncture). A substantial body of published reports, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PGE1) when used for cervical ripening and labor induction. Misoprostol administered vaginally at doses of 50 μg has the highest probability of achieving vaginal delivery within 24 hours. Regardless of dosing, route, and schedule of administration, when used for cervical ripening and labor induction, prostaglandin E2 seems to have similar efficacy in decreasing cesarean delivery rates. Globally, although oxytocin represents the most widely used pharmacologic agent for labor induction, its effectiveness is highly dependent on parity and cervical status. Oxytocin is more effective than expectant management in inducing labor, and the efficacy of oxytocin is enhanced when combined with amniotomy. However, prostaglandins administered vaginally or intracervically are more effective in inducing labor than oxytocin. A single 200-mg oral tablet of mifepristone seems to represent the lowest effective dose for cervical ripening. The bulk of the literature assessing relaxin suggests this agent has limited benefit when used for this indication. Although intracervical injection of hyaluronidase may cause cervical ripening, the need for intracervical administration has limited the use of this agent. Concerning the vaginal administration of nitric oxide donors, including isosorbide mononitrate, isosorbide, nitroglycerin, and sodium nitroprusside, the higher incidence of side effects with these agents has limited their use. A synthetic hygroscopic cervical dilator has been found to be effective for preinduction cervical ripening. Although a pharmacologic agent may be administered after the use of the synthetic hygroscopic dilator, in an attempt to reduce the interval to vaginal delivery, concomitant use of mechanical and pharmacologic methods is being explored. Combining the use of a single-balloon catheter with dinoprostone, misoprostol, or oxytocin enhances the efficacy of these pharmacologic agents in cervical ripening and labor induction. The efficacy of single- and double-balloon catheters in cervical ripening and labor induction seems similar. To date, the combination of misoprostol with an intracervical catheter seems to be the best approach when balancing delivery times with safety. Although complementary methods are occasionally used by patients, given the lack of data documenting their efficacy and safety, these methods are rarely used in hospital settings.

Safety of low-dose prostaglandin E2 induction in grandmultiparous women with previous cesarean delivery

OBJECTIVE

To determine the safety and efficacy of labor induction with low-dose vaginal prostaglandin E2 (PGE2) in grandmultiparous women with a previous cesarean delivery.

METHODS

We conducted a retrospective cohort study of 219 grandmultiparous women with a previous cesarean delivery (study group) who underwent induction of labor with low dose PGE2. These patients were compared to 1376 grandmultiparous women without a previous cesarean section (control group) who underwent induction of labor with low dose PGE2. The primary outcome was uterine rupture and secondary outcomes included mode of delivery, post-partum hemorrhage (PPH) and a low 5-min Apgar score (≤7).

RESULTS

One patient in the study group as well as one patient in the control group were diagnosed with uterine rupture (0.4% versus 0.07%). In the study group, vaginal delivery was achieved in 204 (93.16%) patients, whereas 15 (6.84%) patients had emergent cesarean delivery. Five minutes Apgar score ≤7 was recorded in two cases (0.9%) in the study group. Patients in the study group had a significantly higher rate of cesarean delivery (6.84%, versus 3.4%, respectively, p < 0.001) as well as operative vaginal delivery (4.56% versus 2% respectively, p < 0.05) compared to the control group. There were no significant differences between the groups regarding the rate of PPH (0.91% versus 0.90%, p = 0.2) or 5-min Apgar score ≤7 (0.91% versus 0.22%, p = 0.28).

CONCLUSIONS

Low dose PGE2 is a relative safe method for induction of labor in grandmultiparous women with a previous cesarean section.

Safety of labor induction with prostaglandin E2 in grandmultiparous women

OBJECTIVE

The aim of this study was to assess the safety of labor induction with vaginal prostaglandin E2 (PGE2) in grandmultiparous women.

METHODS

We conducted a retrospective cohort study of 1376 grandmultiparous women who underwent induction of labor with low dose PGE2. The primary outcome was uterine rupture and secondary outcomes included mode of delivery, postpartum hemorrhage and five minutes Apgar score.

RESULTS

One case was diagnosed with uterine rupture (0.07%). Vaginal delivery was achieved in 1329 (96.6%) patients, whereas 47 (3.4%) patients had emergent cesarean delivery. Five minutes Apgar score ≤7 was recorded in three cases (0.2%). There was no correlation between parity and cesarean delivery rate or low Apgar score. There were no significant differences between the grandmultiparous and great-grandmultiparous patients regarding cesarean delivery rate (3.1 vs. 5%, P = 0.12), operative vaginal delivery rate (2 vs. 2.3%, P = 0.74) or postpartum hemorrhage rate (0.8 vs. 1.1%, P = 0.6).

CONCLUSIONS

Low dose PGE2 is a safe and efficient method for induction of labor in grandmultiparous and great-grandmultiparous women.

A comparison of induction with vaginal prostaglandin E2 versus spontaneous of labor in grand multiparous women

OBJECTIVE

To compare the outcome of labor in grand multiparous women (para 6 or more) who had induction of labor with vaginal prostaglandin E2 with grand multiparous women in spontaneous labor.

METHODS

A retrospective case-control study was performed, 202 grand multiparous women were induced labor with vaginal prostaglandin E2 and compared with outcomes with grand multiparous women who entered in spontaneous labor and delivered during the same study period and served as control group.

RESULTS

There were no statistically significant differences in the duration of labor, fetal birth weight, use of oxytocin augmentation, and Apgar scores in the two groups. Fourteen women (6.9%) in the induction group delivered by cesarean section compared to six woman (3.0%) in the control group. This was a statistically significant difference (P = 0.01). In the induction group, the mean duration of the hospital stay was longer (P = 0.003) and there was one neonatal fetal death and one uterus rupture.

CONCLUSION

Induction of labor with vaginal prostaglandin E2 in grand multiparous women is still relatively safe.

Our Experience with Vaginal Prostaglandin-E2 for Induction of Labor in Qatar: Six Months Review

In order to review our experience with prostaglandin-E2 for the induction of labour and to evaluate its safety and outcomesa retrospective study was carried out at the Women's Hospital, Hamad Medical Corporation, over a six-month period. Three hundred and thirty four patients (7% of total deliveries) were induced by PGE2 (Dinoprostone), including 105 (30%) nulliparae and 229 (70%) multiparae. Patients with a history of one previous lower segment caesarean section were also included. Post date pregnancy and diabetes were the most common indications for induction.

There were significant differences in the two groups regarding the number of doses and the mean total dose of PGE2 used. The need for syntocinon augmentation was more in the nulliparae (41% vs 22%). Failed induction occurred only in nulliparae. The rate of caesarean section in induced labour remained significantly low compared with a spontaneous labour (11.6% vs 10.7%). The caesarean section rate was higher in the nulliparae (16.0% vs 9.6%) but this was not statistically significant. The caesarean section rate was higher when Bishop score 0-4 (76% vs 24%). Only two of the babies in the study group had an Apgar score less than 7 at 5 minutes. There was one caesarean hysterectomy because of postpartum hemorrhage associated with the PGE2 induction.

Conclusion: The calculated induction rate with PGE2 was 7% of total deliveries. Induction of labour with PGE2 in a grandmultiparae and previous caesarean section is relatively safe but further multicentre studies are needed to confirm our findings.