Second dose of PGE2 vaginal insert versus Foley transcervical balloon for induction of labor after failure of cervical ripening with PGE2 vaginal insert

The efficacy and safety of second dinoprostone pessary or balloon catheter after unsuccessful primary ripening with dinoprostone pessary

We investigated which treatment should be applied if primary cervical ripening with a dinoprostone pessary is unsuccessful. We included 281 women who experienced unsuccessful cervical ripening with a dinoprostone pessary and continued on induction of labour (IOL). Of the 281 women recruited, 177 were given a second dose of dinoprostone; 104 women received a balloon catheter. The second dinoprostone pessary was successful in achieving vaginal delivery in 88 of the 177 (48.6%) women, while the balloon catheter was successful in 42 of the 104 women (40.4%); there was no significant difference between the two treatments with regards to successful vaginal delivery. However, of the women who experienced successful vaginal delivery, the delivery rate in the dinoprostone group was significantly higher than that in the balloon catheter group 12, 24, 36, or 48 h after insertion (p = .0094, .0005, .0258, .0483, respectively). The neonatal outcomes, the proportion of maternal infection and postpartum haemorrhage were similar between the two groups.IMPACT STATEMENTWhat is already known on this subject? Labour induction is a common procedure in obstetrics in a bid to achieve vaginal delivery in China, because vaginal delivery is more beneficial and associated with a better quality of life as compared to a Caesarean delivery. There is consensus relating to the preferred method of IOL after unsuccessful IOL with a dinoprostone pessary.What do the results of this study add? This is the first study in a Chinese population to compare the dinoprostone pessary and balloon catheter for women with no response to dinoprostone for cervical ripening with a sample size greater than 100. We found that a second dose of dinoprostone can reduce the time from the re-initiation of IOL to vaginal delivery compared with the balloon catheter. Our data also indicated that all other outcomes relating to the mother and infant were similar.What are the implications of these findings for clinical practice and/or future research? A second dose of dinoprostone is a superior choice for women who experience unsuccessful IOL with dinoprostone to further accelerate vaginal delivery.

Repeated dose of prostaglandin E2 vaginal insert when the first dose fails

Objective

To compare the obstetric and neonatal outcomes of patients treated with repeated-dose prostaglandin E2 (dinoprostone) vaginal insert when the first dose fails.

Materials and Methods

This retrospective study included 1.043 pregnant women who received dinoprostone for labor induction between November 2012 and August 2015. Pregnant women were divided into two groups according to the number of dinoprostone administrations: group 1, single-dose dinoprostone (n=1.000), and group 2, repeated-dose dinoprostone (n=43). Intrapartum, postpartum, and neonatal outcomes of the pregnant women were compared.

Results

Vaginal delivery rate was 65% in group 1 and 30.2% in group 2 (p=0.001). The need for the neonatal intensive care unit was found in 44 pregnant women (4.4%) in group 1 and 6 pregnant women (13.6%) in group 2 (p=0.006).

Conclusion

When obstetric and neonatal data were evaluated in our study, we observed that dinoprostone administration was associated with increased cesarean rates and adverse neonatal outcomes with repeated-dose dinoprostone when the first dose failed.

Comparison of two management options for labor induction following unsuccessful prostaglandin E2 ripening

Objective: We sought to compare the likelihood of a vaginal delivery (VD) using oxytocin, with and without a cervical ripening balloon, in nulliparous women who did not respond to initial ripening with prostaglandin E2 (PGE2).Methods: We a performed a retrospective cohort study of nulliparous women with a singleton pregnancy at term who underwent cervical ripening with vaginal PGE2 between October 2015 and March 2019. Patients who did not respond to PGE2 ripening (bishop score (BS) of 6 or less with cervical dilation less than 3 cm) were stratified into two groups based on management: sequential ripening with a cervical ripening balloon in addition to oxytocin versus oxytocin alone. Patients who had PGE2 for less than 6 h, a BS greater than 6 after ripening, rupture of membranes or missing data were excluded. The primary outcome was VD. Secondary outcomes included VD within 24 h of induction, time from induction to delivery, rates of chorioamnionitis and postpartum hemorrhage, presence of meconium, neonatal birthweight, NICU admission, 5 min apgar < 5, and umbilical cord pH < 7. Statistical analysis included Chi-squared, Fisher's exact and Mann-Whitney U tests, as well as logistic regression. Odds ratios (ORs) were calculated and adjusted for significant confounders using backwards-stepwise logistic regression. For time to delivery, a Cox proportional hazard regression was used to determine the hazard ratio (HR) and adjusted HR.Results: 840 patients underwent cervical ripening with PGE2 during the study period. After the exclusion criteria were applied, 272 cases comprised the study cohort. Of those, 123 (45%) continued labor induction with a cervical ripening balloon and oxytocin and 149 (55%) continued labor induction with oxytocin alone. Baseline characteristics such as age, BMI, ethnicity, gestational age at induction and number of women undergoing elective induction were similar between both groups. There was no statistically significant difference in the likelihood of VD (oxytocin and cervical ripening balloon: 62.6% vs. oxytocin alone: 50.3%; a OR 1.61, p = .07) or rate of secondary outcomes between the two groups. Patients in the oxytocin alone group had a higher BS after PGE2 ripening, although both were very low (3 vs. 2, p < .0001).". Additionally, there were significantly more patients undergoing full PGE2 ripening for 12 h in the cervical ripening balloon and oxytocin group compared to oxytocin alone (65.9% vs. 49.7%, p = .02).Conclusion: Our data did not show a difference in VD rate in nulliparous women unresponsive to PGE2 ripening who underwent continued induction with oxytocin and cervical ripening balloon compared to oxytocin alone. Larger studies investigating the utility of sequential ripening and determining the optimal induction method following unsuccessful ripening are needed.