Midtrimester cervical ripening and labor induction

High-dose vaginal misoprostol versus concentrated oxytocin plus low-dose vaginal misoprostol for midtrimester labor induction: a randomized trial

OBJECTIVE

This study was undertaken to compare the efficacy and side effects of a high-dose vaginal misoprostol regimen to concentrated intravenous oxytocin plus low-dose vaginal misoprostol for midtrimester labor induction.

STUDY DESIGN

Women at 14 to 24 weeks, with obstetric or fetal indications for delivery and no prior cesarean, were randomly assigned to receive either vaginal misoprostol 600 microg x 1, then 400 microg every 4 hours x 5 (group 1) or escalating dose-concentrated oxytocin infusions (277-1667 mU/min) plus vaginal misoprostol 400 microg x 1, then 200 microg every 6 hours x 2, then 100 microg x 1 (group 2). Analysis was by intent to treat. Primary outcomes were live birth rate and induction-to-delivery interval.

RESULTS

The intended sample size was 70 women per group; however, the trial was terminated at the initial interim analysis because of a highly significant difference in 1 of the primary study outcomes. Twenty women were assigned to group 1 and 18 were assigned to group 2. Median induction-to-delivery interval was significantly shorter in group 1 (12 hours, range 4-44 hours) versus group 2 (18 hours, range 7-36 hours; P = .01). Induction success rate at 12 hours was significantly higher in group 1 (60%) compared with group 2 (22%, P = .02). No significant difference was noted in the live birth rate between groups 1 and 2 (13%, 0%, P = .16). The incidence of retained placenta requiring curettage, chorioamnionitis, intrapartum fever, nausea, emesis, and diarrhea were similar between both groups.

CONCLUSION

Compared with concentrated oxytocin plus low-dose vaginal misoprostol, high-dose vaginal misoprostol significantly shortens midtrimester labor inductions.

Vaginal misoprostol versus concentrated oxytocin and vaginal PGE2 for second-trimester labor induction

OBJECTIVE

To compare the efficacy, side effects, and complications of high-dose vaginal misoprostol with concentrated intravenous oxytocin plus low-dose vaginal prostaglandin (PGE(2)) for second-trimester labor induction.

METHODS

One hundred twenty-six consenting women with maternal or fetal indications for pregnancy termination and no prior cesarean delivery were randomly assigned to receive either vaginal misoprostol 600 microg 1x, 400 microg every 4 hours 5x (misoprostol group, n = 60) or escalating-dose concentrated oxytocin infusions (277-1,667 mU/min) plus vaginal PGE(2) 10 mg every 6 hours 4x (oxytocin group, n = 66). Both groups received concurrent extra-amniotic saline infusion for cervical ripening. Women who failed their assigned regimen received 20 mg of PGE(2) suppositories every 4 hours until delivery. Analysis was by intent to treat.

RESULTS

Demographic characteristics were similar between study groups. Median induction-to-delivery interval was significantly shorter in the misoprostol group (12 hours) than in the oxytocin group (17 hours; P <.001). There was a higher induction success rate at 24 hours in the misoprostol group (95%) than in the oxytocin group (85%; P =.06), although this difference did not reach statistical significance. The incidence of live birth (25% versus 17%), chorioamnionitis (5% versus 2%), and postpartum hemorrhage greater than 500 mL (3% versus 3%) were similar between the misoprostol and oxytocin groups, respectively. Diarrhea (2% versus 11%; P =.04), nausea/emesis (25% versus 42%; P =.04), and retained placenta requiring curettage (2% versus 15%; P =.008) were significantly less common in the misoprostol group when compared with the oxytocin group, respectively. Isolated intrapartum fever, however, was more frequent in the misoprostol group (67%) than in the oxytocin group (21%; P <.001).

CONCLUSION

Compared with concentrated oxytocin plus low-dose vaginal PGE(2), high-dose vaginal misoprostol is associated with significantly shorter induction-to-delivery intervals, fewer side effects, a lower incidence of retained placenta, and comparable incidence of live birth.

Reproductive Performance following Midtrimester Termination of Pregnancy

The aim of the study was to determine the impact of midtrimester abortion with extra-amniotic PGE(2) on future fertility and reproduction. Two hundred and fifteen women were enrolled. The mean induction-to-abortion interval was 21.3 h. The complication rate was 11.7%. Twenty women (9.3%) were lost to follow-up, 82 patients (38.1%) used contraception. Spontaneous pregnancy occurred in 110 out of 113 women who desired fertility (97%). Three patients were defined as infertile but conceived following treatment. The average time between the abortion and the next conception was 15.9 months (range 1-77 months). Seventy patients (63.7%) delivered at term. Premature delivery occurred in 18 patients (16.4%). Eighteen women aborted spontaneously in the first and 3 in the second trimester. One extrauterine pregnancy occurred. Second-trimester abortion with extra-amniotic PGE(2) is a safe procedure with a low rate of complication. Apparently it does not affect future fertility, but may be associated with an increased rate of premature deliveries in future gestations.

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.

High-dose oral misoprostol for mid-trimester pregnancy interruption

OBJECTIVE

To evaluate the efficacy of high-dose oral misoprostol for mid-trimester pregnancy interruption.

METHODS

We reviewed our experience with high-dose oral misoprostol for mid-trimester pregnancy interruption from November 1995 to May 1999. Patients undergoing labor induction for intrauterine fetal demise or medically indicated pregnancy termination at 13-32 weeks of gestation with a non-dilated cervix were evaluated. Patients received 400 microg misoprostol orally every 4 h. Women undelivered within 24 h were considered failures and were treated with high-dose oxytocin as previously described. For comparison, a group of women treated with high-dose oxytocin were evaluated.

RESULTS

Forty-seven pregnancies were managed with misoprostol (n = 23) or high-dose oxytocin regimen (n = 24). Both groups were similar with respect to induction indication, gestational age, maternal age/parity, laminaria use, and initial cervical dilation. Induction-to-delivery interval (mean +/- SD) was significantly shorter in the misoprostol cohort (15.2 +/- 6.7 h) compared with those treated with oxytocin (21.7 +/- 11.0 h; p = 0.02). Additionally, a significantly greater percentage of women treated with misoprostol delivered within 24 h (91.0%) compared with the oxytocin group (62.0%; p = 0.04). Adverse outcomes and side effects were not significantly different between the study groups.

CONCLUSION

High-dose oral misoprostol is more effective than concentrated oxytocin infusion for mid-trimester pregnancy interruption.

Labor induction

Labor induction has become commonplace in modern obstetrics. The increasing rate of labor induction has probably played a role in the increased rate of cesarean delivery observed in the United States during the past few decades. Clearly, the favorability of the cervix has a substantial impact on the potential success of any labor induction. Induction in the setting of an unfavorable cervix can result in prolonged induction, prolonged hospitalization, failed induction, and an increased cesarean delivery rate. In this modern era of healthcare reform and cost containment, the identification of therapeutic strategies to enhance the success and cost-effectiveness of labor induction are of great interest. Ongoing research is needed to advance our knowledge of the mechanisms of parturition and cervical ripening in order to direct interventions for labor induction more effectively.

Cardiovascular effects of intravaginal misoprostol in the mid trimester of pregnancy

OBJECTIVE

Our aim was to evaluate the cardiovascular effects of high-dose intravaginal misoprostol administration by means of transthoracic electrical bioimpedance monitoring.

STUDY DESIGN

Healthy women undergoing mid trimester pregnancy interruption with intravaginal misoprostol were eligible for this prospective observational study. Baseline blood pressure was obtained for 1 hour and transthoracic electrical bioimpedance monitoring was performed before misoprostol administration, 600 microg vaginally. Posttreatment assessments were made every 15 minutes for a total of 4 hours, with patients in a left lateral recumbent position. Heart rate, mean arterial pressure, cardiac index, stroke index, systemic vascular resistance index, and end-diastolic volume index were determined. Measurements were averaged for 30-minute intervals and reported as mean +/- SD. Statistical analyses included the paired t test and repeated-measures analysis of variance.

RESULTS

Nine women consented to have transthoracic electrical bioimpedance monitoring, and no statistically significant changes in any of the measured cardiac parameters for the 4-hour monitoring interval were noted. Direct comparisons between the pretreatment and 2-hour posttreatment intervals (reported time peak of blood misoprostol levels) also revealed no significant differences in the cardiovascular index values.

CONCLUSION

High-dose intravaginal misoprostol in the mid trimester does not alter maternal cardiac function as measured by transthoracic electrical bioimpedance.