No benefit, but increased harm from high dose (100 microg) misoprostol for induction of labour: a randomised trial of high vs. low (50 microg) dose misoprostol

New Classification for the Reporting of Complications in Retinal Detachment Surgical Trials

IMPORTANCE

Quantifying severity of complications in rhegmatogenous retinal detachment (RRD) surgical trials is needed. A consensus classification system will help surgeons to more effectively compare harms of different surgical techniques.

OBJECTIVE

To develop a new consensus-based classification to quantify severity of complications of RRD surgery.

DESIGN, SETTING, AND PARTICIPANTS

A comprehensive list of complications was developed followed by a Delphi consensus survey of international vitreoretinal surgeons. The survey was conducted in 17 countries in mainland Europe, the United Kingdom, the United States, Asia, South Africa, and Australia. Seventy vitreoretinal surgeons were invited to take part in the Delphi survey; 45 agreed to participate. Participants were selected through boards/members lists of retinal societies. Data were analyzed between April 2019 and August 2019.

MAIN OUTCOMES AND MEASURES

Consensus-derived classification of complications of RRD surgery, according to their severity.

RESULTS

Forty-three of 45 vitreoretinal surgeons who agreed to participate in the Delphi survey completed round 1 (96%); all but 1 (98%) completed round 2. Consensus was reached for 96% of the 84 complications assessed. Examples of complications classified as least severe (graded 1) included subconjunctival hemorrhage and chemosis while those classified as most severe included endophthalmitis and sympathetic ophthalmia (graded 9) and phthisis (graded 10).

CONCLUSIONS AND RELEVANCE

We propose a new classification for quantifying severity of surgical complications based on an international consensus of vitreoretinal surgeons to quantify harm and improve the reporting of complications of RRD surgery.

Vaginal misoprostol for cervical ripening and induction of labour

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.

Safety and efficacy of misoprostol for induction of labour in a semi-urban hospital setting

Most studies on the use of misoprostol for induction of labour have been carried out in well-endowed hospitals in developed countries with state-of-the-art monitoring equipment. There is need for more studies to be conducted in facilities with limited resources, if more patients are to benefit from the low cost and effectiveness of the drug. Following Ethical Committee approval, 152 women had labour induced in our maternity unit using intravaginal misoprostol. The patients were monitored clinically using the WHO model partograph with digital palpation of uterine contractions and intermittent auscultation of fetal heart with a pinard stethoscope. One hundred and thirty-five (88.8%) of the women had a vaginal delivery, while nine (5.9%) had a caesarean section for various obstetric indications. Eight cases of uterine hyperstimulation were noted but none of uterine rupture. We conclude that misoprostol can be used safely for induction of labour in less endowed hospital settings such as in developing countries, using basic clinical tools for monitoring.

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.

[Efficacy and safety of misoprostol in obstetrics]

OBJECTIVE

To review the efficacy and safety of misoprostol for indications not included in the prescription information given for the product, including abortion, labor induction, treatment and prevention of postpartum bleeding, and hysteroscopy preparation.

METHOD

Pubmed was searched for controlled, randomized, blinded clinical trials of misoprostol in obstetrics from 1999 through 2004.

RESULTS

Nineteen clinical trials were found. The efficacy for abortion in association with mifepristone at a dosage of 400 microg/6 h is superior versus both placebo and gemeprost, but misoprostol is more painful and less effective than dilation and subsequent evacuation. Regarding the administration route, trials show similar efficacy for the vaginal and oral approaches. In the prevention and treatment of postpartum hemorrhage, misoprostol was not any better than oxytocin. When used as a labor inducing agent, results are best with doses of 50 microg/3-8 h, but no controlled clinical trials were found. Although its use for hysteroscopy facilitates the procedure versus placebo, it entails a higher frequency of adverse events. No controlled clinical trials were found for other options.

CONCLUSIONS

The efficacy of misoprostol for indications reviewed in this paper is controversial, and studies found are heterogeneous. Designing and conducting further clinical trials to investigate appropriate dosage and administration routes, as well as the drug s adverse effect profile under such circumstances is essential, and would potentially allow an application for approval to be filed with health authorities regarding its use in obstetric practice.

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.

Drugs that affect the fetus and newborn infant via the placenta or breast milk

In general, drugs that are taken by a mother during pregnancy or after birth may be transferred to the fetus or the infant (through breast milk). Many factors are involved that determine the amount of drugs that are transferred and their potential effects on the fetus or infant. A careful assessment of the risk versus benefit is necessary and should be individualized. In the breastfed infant, many measures can be undertaken further so that the amount of drug transferred to the infant is minimized.

Vaginal misoprostol for cervical ripening and induction of labour

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.