Oral Misoprostol Administration for Labor Induction

Titrated oral misoprostol versus static regimen of oral misoprostol for induction of labour: a systematic review and meta-analysis

We aimed to conduct a systematic review and meta-analysis to compare the efficacy and safety of titrated oral misoprostol versus static oral misoprostol for labour induction. We searched for the available randomised clinical trials (RCTs) in the Cochrane Library, PubMed, ISI web of science, Scopus, and ClinicalTrials.gov. We included RCTs compared titrated oral misoprostol versus static regimen of oral misoprostol during labour induction. Our main outcomes were vaginal and caesarean delivery rates, uterine tachysystole, misoprostol side effects, and neonatal adverse events. Three RCTs met our inclusion criteria with a total number of 360 patients. The vaginal delivery rate did not significantly differ between both groups (p = 0.49). Titrated oral misoprostol was associated with significant increase in the caesarean delivery rate compared to static oral misoprostol (p = 0.04). Moreover, titrated oral misoprostol led to significant increase in the uterine tachysystole and misoprostol side effects (p = 0.01 & p = 0.003, respectively). There were no differences among both groups regarding different neonatal adverse events. In conclusion, titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol. Thus, static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. Impact StatementWhat is already known on this subject? Different studies have evaluated titrated oral misoprostol administration for induction of labour and proved their efficacy in comparison with other induction methods. However, there is controversy among the published studies between titrated oral misoprostol and static oral misoprostol during induction of labour. A recent study concluded that hourly titrated misoprostol and static oral misoprostol are equally safe and effective when utilised for induction of labour with no fear of any adverse events. However, another study recommended static oral misoprostol administration for labour induction as it was linked to a lower caesarean section incidence, fewer drug side effects, and decline in complication rates in comparison with titrated oral misoprostol.What the results of this study add? Titrated oral misoprostol increases the incidence of caesarean delivery, uterine tachysystole, and misoprostol side effects with a similar vaginal delivery rate compared to static dose misoprostol.What the implications are of these findings for clinical practice and/or further research? Static oral misoprostol should be used instead of titrated oral misoprostol during labour induction. More future trials are required to confirm our findings.

Oral Misoprostol Versus Vaginal Prostaglandin E2 Labor Induction Efficiency, Safety, and Labor Outcomes

BACKGROUND

Prostaglandin E1 (oral misoprostol) and the other Prostaglandin E2 (Dinoprostone gel) are promising agents for cervical ripening and induction of labor.

AIMS OF STUDY

To compare the efficiency and safety on maternal-fetal outcomes using 25 micrograms oral misoprostol PGE1 with 50 micrograms of intra-vaginal PGE2 for induction of labor.

METHODS

This was a retrospective study design reviewing medical records of induced labor at Al Shifa hospital in Gaza Strip.

RESULTS

In general, the results showed that women who used oral misoprostol with an age less than 30 years and parity less than 3 was effective for delivery and safe outcomes with an odds ratio (OR) of 15.8 (CI 6.9–39.8) and OR 29.2 (CI 10.7–80.3) respectively. The most common indication for labor induction in both methods was reputure of the membrane (ROM) more than 24 hours, postdates, and a medical disorder. However, the total interval hours for both methods was 8.4 hours. The mode of delivery was similar in both groups as vaginal delivery outcome was 73.6% for oral misoprostol E1 and 75% for prostaglandin E2 cases. However, PGE2 induction showed a higher cesarean delivery 25% rate versus 18.4%. Clinically the use of oral misoprostol showed a higher percentage of birth canal injury, failed induction, uterine rupture by 9.3%, 8%, 1.3% respectively. Fetal distress was found as the most common fetal complication and the most common cause for cesarean section.

CONCLUSION

The study recommended more research is needed as present evidence does not support use of oral misoprostol versus Prostaglandin E2.

Misoprostol for Labour Induction after Previous Caesarean Section - Forever a "No Go"?

Misoprostol in oral or vaginal form is an established method of labour induction worldwide. Its use after previous caesarean section is associated with a high rate of uterine rupture; according to international guidelines it is therefore contraindicated in this setting. However the evidence base for this recommendation comprises case reports, one randomised trial that was discontinued prematurely, and numerous low quality retrospective data analyses published between 1997 and 2004. New insights into e.g. resorption kinetics, dosage and application intervals, dose dependant uterine hyperstimulation rates, as well as increasing clinical experience with misoprostol have lead to a critical reappraisal of these "historical" studies. Accordingly the evidence supporting a ban on vaginal and particularly oral misoprostol for labour induction in the context of a scarred uterus is currently insufficient for a convincing guideline recommendation. In view of the clear advantages of misoprostol over prostaglandin E₂ (cheaper, more effective) a retrospective review of registry data should be conducted to determine the incidence of uterine rupture following misoprostol and the circumstances in which it occurs. A prospective, randomised trial could then be conducted on the basis of these findings (e.g. oral misoprostol vs. vaginal prostaglandin E₂); known risk factors for uterine rupture including the type of uterine scar would need to be taken into account when selecting patients for vaginal delivery. Until new data from well-designed studies are available, misoprostol will continue to be contraindicated in clinical guidelines for use in labour induction after previous caesarean section.

Comparison of the efficacy and safety of titrated oral misoprostol and a conventional oral regimen for cervical ripening and labor induction

OBJECTIVE

To compare the efficacy and safety of titrated oral misoprostol and a conventional oral regimen for cervical ripening and labor induction.

METHODS

A randomized double-blind trial of women with term singleton pregnancies with indications for labor induction. Participants were allocated to receive 20 mL of misoprostol solution (1 μg/mL) orally every 1 hour for 4 doses then titrated to 40 μg every 1 hour (titrated group) or 50 μg of misoprostol orally every 4 hours up to 12 hours (conventional group). Primary outcomes were success rate of cervical ripening within 12 hours, interval from first dose until more favorable cervix or active labor occurred, and total dose of misoprostol.

RESULTS

Sixty-four participants were included. Mean total dose of misoprostol and incidence of tachysystole were significantly higher in the titrated compared with the conventional group (236.2±110.1 μg vs 103.1 ± 35.7 μg; P=0.001 and 25.0% vs 6.3%; P=0.03), whereas success rate, interval from drug administration to more favorable cervix and delivery, proportion of patients delivered vaginally within 12 hours and 24 hours, need for oxytocin augmentation, cesarean delivery rate, maternal adverse effects and complications, and neonatal outcome were not significantly different (P>0.05).

CONCLUSION

Conventional oral misoprostol is as effective as titrated misoprostol for cervical ripening and labor induction, but has a lower incidence of tachysystole and a lower total dose of misoprostol is required. ClinicalTrial.gov: NCT00886860.

Comparison of labor induction with titrated oral misoprostol solution between nulliparous and multiparous women

AIM

To compare the outcomes of labor induction with oral misoprostol solution between nulliparous and multiparous women.

METHODS

We retrospectively reviewed the medical records of all patients between 37 and 42 weeks of gestation with a Bishop score <or=6 who underwent labor induction with titrated oral misoprostol solution. The women were allocated into two groups: nulliparous and multiparous. The women received one basal unit of misoprostol solution (20 mL, 1 microg/mL) every hour for four doses; additional doses were titrated against individual uterine response. The interval of latent and active phase and vaginal delivery within 12 h were the primary outcomes.

RESULTS

Of the 112 women included in the study, 49 (43.8%) mulliparae and 63 (56.2%) multiparae underwent labor induction with titrated oral misoprostol solution. Complete vaginal delivery occurred within 12 h in 21 (42.9%) nulliparae and 54 (85.7%) multiparae (RR, 0.54; 95% CI, 0.39-0.76). All induction intervals, including the latent and active phases, were significantly shorter in the multiparous group (P < 0.01). Induction failure did not occur in any patient in either of the groups. There were no instances of hyperstimulation, which was defined as tachysystole or hypertonus with nonreassuring fetal heart rate pattern, although tachysystole, defined as the presence of at least six contractions in 10 min over at least two 10-min windows, occurred in four (8.2%) nulliparous women and in four (6.3%) multiparous women. Hypertonus, defined as a single contraction lasting more than 2 min, did not occur in either group. None of the neonates in either group had an Apgar score of <7 at 1 min.

CONCLUSION

Titrated oral misoprostol solution is a promising method of labor induction for both nulliparous and multiparous women.

Titrated oral compared with vaginal misoprostol for labor induction: a randomized controlled trial

OBJECTIVE

To compare the efficacy and safety of titrated oral misoprostol and vaginal misoprostol for labor induction.

METHODS

Women between 34 and 42 weeks of gestation with an unfavorable cervix (Bishop score less than or equal to 6) and an indication for labor induction were randomLy assigned to receive titrated oral or vaginal misoprostol. The titrated oral misoprostol group received a basal unit of 20 mL misoprostol solution (1 mcg/mL) every 1 hour for four doses and then were titrated against individual uterine response. The vaginal group received 25 mcg every 4 hours until attaining a more favorable cervix. Vaginal delivery within 12 hours was the primary outcome. The data were analyzed by intention-to-treat.

RESULTS

Titrated oral misoprostol was given to 101 (48.8%) women and vaginal misoprostol to 106 (51.2%) women. Completed vaginal delivery occurred within 12 hours in 75 (74.3%) women in the titrated oral group and 27 (25.5%) women in the vaginal group (relative risk [RR] 8.44, 95% confidence interval [CI] 4.52-15.76). The incidence of hyperstimulation was 0.0% in the titrated oral group compared with 11.3% in the vaginal group (RR 0.08, 95% CI 0.01-0.61). Although more women experienced nausea (10.9%) in the titrated oral group (RR 27.07, 95% CI 1.57-465.70), fewer infants had Apgar scores of less than 7 at 1 minute in the titrated oral group than in the vaginal group (RR 0.10, 95% CI 0.01-0.76).

CONCLUSION

Titrated oral misoprostol is associated with a lower incidence of uterine hyperstimulation and a lower cesarean delivery rate than vaginal misoprostol for labor induction in patients with unfavorable cervix.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00529295

LEVEL OF EVIDENCE

I.

Prescribing in maternity care in Russia: The legacy of Soviet medicine

Remarkably, there has been very little detailed research on clinical practice in Russia and its neighbours in what was the USSR, even though it is known that the USSR was isolated from many international developments, in particular evidence-based medicine. In this study we examine obstetric practice, an area of practice where there is an extensive body of evidence on the appropriateness of many interventions. The study is undertaken in Tula, a region 200 km south of Moscow. Building on earlier detailed analyses of data from the facilities in the region, it reports a series of structured interviews with 52 obstetricians from all 19 facilities in the region, designed to identify patterns of prescribing, supplemented by 36 more detailed re-interviews to explore reasons for the differing practices. The study demonstrates a widespread divergence from internationally accepted practice. Maternity care is extremely medicalised but many non-evidence based medicines are used. Some are heavily marketed by large pharmaceutical companies, some were widely used during the Soviet period but never evaluated, and a few are not known to be used anywhere else in the world. For several conditions, the most widely used drugs are clearly inferior to alternative products and some are used for indications quite different from those in other countries. This study contributes to the growing evidence that much of the care provided in Russian maternity units is ineffective or potentially dangerous but also begins to offer some explanations for why this is, including a lack of access to information and a lack of awareness of the concept of evidence-based practice.

Tailoring systematic reviews to meet critical priorities in maternal health in the intrapartum period

Health care practitioners and researchers commonly call for greater reliance on evidence as a means to achieve improvement in quality of care. Systematic reviews provide a means to accelerate the use of evidence-based clinical interventions and public health practices. The extent to which these time- and resource-intensive systematic reviews currently address critical maternal health priorities in the intrapartum period is unclear. This analysis summarises key maternal health and research priorities, maps these priorities to existing reviews, identifies gaps in the literature that can be addressed with systematic reviews, and highlights key methodological concerns in conducting systematic reviews. The analysis draws on published data on maternal morbidities and an overview of 108 systematic reviews in Medline in the past 5 years using the MeSH terms 'Delivery, Obstetric,' to draw the links between health priorities, research priorities, existing evidence and missing evidence. Key causes of morbidity during labour and delivery in the United States include haemorrhage, pre-eclampsia and eclampsia, obstetric trauma and infection. Analyses of maternal morbidity and mortality suggest that key concerns include racial and ethnic disparities in health outcomes and the prevention of adverse events. Systematic reviews, however, generally tend to focus on the reduction of harms associated with interventions, are frequently limited to randomised designs, and do not address issues of health disparities. The results suggest that advances in evidence-based care in maternal health require that systematic reviews address issues of prevention of adverse events, include a larger variety of study designs when necessary and pay closer attention to health disparities.