Misoprostol and the debate over off-label drug use

Effect of acidic vaginal pH on the efficacy of dinoprostone (PGE2) vaginal tablet for labor induction in full term pregnant women: a randomized controlled trial

OBJECTIVES

There is controversial evidence that acidification of vaginal pH may increase the efficacy of vaginal prostaglandins in labor induction, with research being mainly focused on misoprostol. This study aims to evaluate the impact of this intervention on the progress of labor induction with dinoprostone (PGE2) vaginal tablet.

METHODS

This double-blind, parallel-group, randomized study was conducted between October 2021 and December 2022 at Alexandra General Hospital, Athens, Greece. A total of 230 women with singleton, full term pregnancy that were scheduled for labor induction were randomly divided into two groups: Group A, who received acidic vaginal wash (5 % acetic acid) and Group B, who received a normal saline vaginal wash. Afterwards, participants received a vaginal tablet of 3 mg dinoprostone every 6 h (maximum two doses).

RESULTS

There were no statistically significant differences in mode of delivery, duration of different labor stages, Bishop score changes and possible complications. Participants in the acidification group needed less often labor augmentation with oxytocin and epidural anesthesia (p=0.03).

CONCLUSIONS

Vaginal acidification seems to have no effect on the efficacy of the dinoprostone vaginal tablet. Even though it may reduce the need for oxytocin augmentation, there is no apparent benefit on clinical outcomes, such as reduction in cesarean section rates or shorter labor duration. Future research is necessary in order to validate these findings.

Comparison of fetal safety of vaginal Misoprostol tablet and Dinoprostone gel for induction of labor: An open-label randomized control trial

AIM

In modern obstetrics, need of labor induction is increasing along with increased caesarean deliveries. Major contributions for these operative deliveries are due to induction failure. This demands a potent labor-inducing agent. Dinoprostone gel is an established method but having some drawbacks. Misoprostol could be an effective alternative to Dinoprostone, but its fetal safety is not yet well established. This study aimed to evaluate the fetal safety of vaginal Misoprostol tablet by measuring fetal heart rate changes during induction of labor.

METHODS

This was a single-center randomized controlled trial incorporating 140 term women, equally randomized to get either tablet Misoprostol or Dinoprostone gel. Fetal heart rate patterns were compared in both the groups by continuous cardiotocographic tracing. All the data were analyzed on an intention-to-treat basis.

RESULTS

There were no statistically significant changes in fetal heart rate pattern in both Misoprostol and Dinoprostone groups. Vaginal deliveries were statistically higher in Misoprostol group. Neonatal parameters like 1 min Appearance, Pulse, Grimace, Activity, and Respiration score and neonatal intensive care unit admission were comparable, and there was no significant difference in terms of major adverse events and side effects.

CONCLUSIONS

Misoprostol is a safe alternative to Dinoprostone gel for induction of labor and found to be more effective labor-inducing agent. In the background of higher caesarean rate, vaginal Misoprostol can be a potential labor-inducing agent especially in a resource poor setting.

Trends and regional variations in prescriptions dispensed to stimulate uterine contractions at the end of pregnancy in Belgium: A community-based study from 2003 to 2018

PURPOSE

To investigate trends and regional variations in uterotonics dispensed around birth between 2003 and 2018 in Belgium.

METHODS

Data, including outpatient and inpatient prescriptions were extracted from a nationally representative prescription database. The prevalence of uterotonics dispensed during a period including the 7 days before birth, the delivery day and the 7 days after birth was computed over three 4-year-long study periods from 2003 to 2018. The trends between periods and associations between the use of at least one uterotonic and maternal age, region of residence, delivery type and social status were assessed using logistic regression.

RESULTS

In total, 31 675 pregnancies were included in the study. The proportion of pregnancies exposed to at least one uterotonic decreased significantly from 92.9% (95%CI, 92.3-93.4) in 2003-2006 to 91.4% (95%CI, 90.7-92.0) in 2015-2018 for vaginal births and from 95.5% (95%CI, 94.5-96.4) to 93.7% (95%CI, 92.6-94.7) for caesarean sections. However, for vaginal births, the proportion of oxytocin increased from 84.5% (95%CI, 83.7-85.2) to 89% (95%CI 88.3-89.7). A significant association was found between uterotonic agent use and maternal age, region of residence, and delivery type. The dispensation of some uterotonic agents differed significantly between the regions.

CONCLUSIONS

The proportion of pregnancies exposed to at least one uterotonic was high across the study period but decreased slightly between 2003 and 2018. Important variations in uterotonic use between regions highlight the need for improved national guidance.

The Duogynon controversy and ignorance production in post-thalidomide West Germany

This article examines the West German controversy over Duogynon, a 'hormone pregnancy test' and the drug at the centre of the first major, international debate over iatrogenic birth defects in the post-thalidomide era. It recovers an asymmetrical power struggle over the uneven distribution of biomedical knowledge and ignorance (about teratogenic risk) that pitted parent-activists, whistleblowers and investigative journalists against industrialists, scientific experts and government officials. It sheds new light on the nexus of reproduction, disability, epidemiology and health activism in West Germany. In addition, it begins to recover an internationally influential discourse that, in the post-thalidomide world, seems to have resuscitated antenatal drug use as safe until proven harmful.

Misoprostol for labour induction

Oral and vaginal misoprostol are effective induction methods, but there is a delicate balance between a quicker labour and avoiding side effects. In randomised comparisons with balloon catheters, oral misoprostol resulted in more vaginal births in the first 24 h as well as fewer caesarean sections without an increase in hyperstimulation events. Vaginal misoprostol was most effective when used concurrently with a balloon catheter. In comparison with dinoprostone, oral misoprostol had lower rates of caesarean section and uterine hyperstimulation with foetal heart rate changes, but fewer babies were born vaginally within 24 h. In contrast, vaginal misoprostol resulted in more vaginal births within 24 h, with no significant differences in caesarean section rates. There were no differences in perinatal adverse events with either route. When oral and vaginal misoprostol were compared, vaginal misoprostol resulted in more vaginal births in the first 24 h, but with more maternal and neonatal complications.

A Stalled Revolution? Misoprostol and the Pharmaceuticalization of Reproductive Health in Francophone Africa

Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment of gastric ulcers. Decades of research have since demonstrated the safety and effectiveness of off-label use of misoprostol as a uterotonic in pregnant women to prevent and treat post-partum hemorrhage, treat incomplete abortion, or terminate first-trimester pregnancy. Global health experts emphasize misoprostol's potential to revolutionize access to reproductive health care in developing countries. Misoprostol does not require refrigeration, can be self-administered or with the aid of a non-physician, and is relatively inexpensive. It holds particular promise for improving reproductive health in sub-Saharan Africa, where most global maternal mortality related to post-partum hemorrhage and unsafe abortion occurs. Although misoprostol has been widely recognized as an essential obstetric medication, its application remains highly contested precisely because it disrupts medical and legal authority over pregnancy, delivery, and abortion. I draw on fieldwork in Francophone Africa to explore how global health organizations have negotiated misoprostol's abortifacient qualities in their reproductive health work. I focus on this region not only because it has some of the world's highest rates of maternal mortality, but also fertility, thereby situating misoprostol in a longer history of family planning programs in a region designated as a zone of overpopulation since the 1980s. Findings suggest that stakeholders adopt strategies that directly address safe abortion on the one hand, and integrate misoprostol into existing clinical protocols and pharmaceutical supply systems for legal obstetric indications on the other. Although misoprostol has generated important partnerships among regional stakeholders invested in reducing fertility and maternal mortality, the stigma of abortion stalls its integration into routine obstetric care and availability to the public. I demonstrate the promises and pitfalls of pharmaceuticalizing reproductive health: despite the availability of misoprostol in some health facilities and pharmacies, low-income and rural women continue to lack access not only to the drug, but to quality reproductive health care more generally.

Clinical experience with misoprostol vaginal insert for induction of labor: a prospective clinical observational study

Purpose

To provide real-world evidence using misoprostol vaginal insert (MVI) for induction of labor in nulliparous and parous women at two German Level I Centers in a prospective observational study.

Methods

Between 1 August 2014 and 1 October 2015, eligible pregnant women (≥ 36 + 0 weeks of gestation) requiring labor induction were treated with MVI. Endpoints included time to and mode of delivery rates of tocolysis use, tachysystole, uterine hypertonus or uterine hyperstimulation syndrome and newborn outcomes.

Results

Of the 354 women enrolled, 68.9% (244/354) achieved vaginal delivery (nulliparous, 139/232 [59.9%]; parous 105/122 [86.1%]; p < 0.001). Median time from MVI administration to vaginal delivery was 14.0 h (nulliparous, 14.5 h; parous, 11.9 h; p < 0.001). A total of 205/244 (84.0%) and 228/244 (93.4%) women achieved a vaginal delivery within 24 h and 30 h, respectively. The most common indications for cesarean delivery were pathologic cardiotocography (nulliparous, 41/232 [17.4%]; parous, 13/122 [10.7%]; p = 0.081) and arrested labor (dilation or descent; nulliparous, 45/232 [19.4%], parous, 3/122 [2.5%]; p ≤ 0.001). A total of 24.3% of women experienced uterine tachysystole and 9.6% experienced uterine tachysystole with fetal heart rate involvement, neither of which were significantly different for nulliparous and parous women. In total, 42/345 (12.2%) of the neonates had an arterial pH < 7.15 and 12/345 3.5% had a 5-min Apgar score ≤ 7.

Conclusion

When clinically indicated, MVI was efficient and safe for induction of labor in women with an unfavorable cervix. Women, however, should be counseled regarding the risk of uterine tachysystole prior to labor induction with MVI.

Abortion in two francophone African countries: a study of whether women have begun to use misoprostol in Benin and Burkina Faso

OBJECTIVES

This study aimed to document the means women use to obtain abortions in the capital cities of Benin and Burkina Faso, and to learn whether or not use of misoprostol has become an alternative to other methods of abortion, and the implications for future practice.

STUDY DESIGN

We conducted in-depth, qualitative interviews between 2014 and 2015 with 34 women - 21 women in Cotonou (Benin) and 13 women in Ouagadougou (Burkina Faso) - about their pathways to abortion. To obtain a diverse sample in terms of socio-demographic characteristics, we recruited the women through our own knowledge networks, in health facilities where women are treated for unsafe abortion complications, and in schools in Benin.

RESULTS

The 34 women had had 69 abortions between them. Twenty-five of the women had had 37 abortions in the previous 5 years; the other abortions were 5-20 years before. Pathways to abortion were very different in the two cities. Lengthy and difficult pathways with unsafe methods often led to complications in Ougadougou, whereas most Cotonou women went to small, private health centers. Six of the 37 abortions in the previous 5 years involved misoprostol use, and were all among educated women with significant social and economic capital and personal contact with clinicians.

CONCLUSIONS

Use of misoprostol for abortion has appeared in both Cotonou and Ougadougou in the past 5 years. Evidence that the use of misoprostol for abortion occurred among women with the most access to information and resources in this study suggests that increased awareness of and use of misoprostol in both countries is likely in the coming years.

IMPLICATIONS

Although no pharmaceutical company that produces misoprostol has as yet tried to obtain marketing authorization in either Burkina Faso or Benin for gynecological-obstetric indications, making its use more potential than actual for the time being, international advocacy for access to medical abortion is growing rapidly and is likely to lead to many changes in this picture in the coming years.

Induction of Labor in Post-Term Nulliparous and Parous Women - Potential Advantages of Misoprostol over Dinoprostone

INTRODUCTION

We undertook a prospective cohort study to compare the effectiveness and safety of 50 µg misoprostol versus 3 mg dinoprostone in two vaginal doses 6 hours apart, followed if necessary by oxytocin for labor induction in low-risk post-term (> 40 weeks) pregnancies with unfavorable cervix (Bishop score ≤ 6).

METHODS

Labor induction and subsequent management were conducted using a standardized protocol. The primary outcome of the study was labor induction rate. Secondary outcomes included mode of delivery, time interval from induction to delivery, maternal complications and neonatal outcome.

RESULTS

107 patients received misoprostol (Group A) and 99 patients received dinoprostone (Group B). Compared with group A, more women in Group B needed a second vaginal dose of prostaglandin or oxytocin infusion in order to proceed to labor (21.5 vs. 43.4 %; p = 0.01). Misoprostol alone as a single or double vaginal dose was more effective than dinoprostone alone in inducing labor without oxytocin administration (85.0 vs. 50.4 %; p = 0.04). Overall, the rate of successful induction of labor did not differ between groups (91.6 vs. 85.8 %; p = 0.75). Vaginal delivery, operative vaginal delivery and Caesarean section rates were not significantly different. Time interval from induction to delivery however, was shorter for Group A (median 11 hours vs. 14.1 hours; p < 0.001). Though emergency Caesarean section due to fetal distress was more frequent in Group A (16.8 vs. 4.0 %; p = 0.007), low Apgar scores < 7 and NICU admissions did not differ significantly. Maternal complications, mostly not serious, were higher in Group A (31.8 vs. 2.0, p < 0.001).

CONCLUSION

Misoprostol is a more effective agent than dinoprost in post-term pregnancy for labor induction with few maternal adverse effects.

The biomedicalisation of illegal abortion: the double life of misoprostol in Brazil

This paper examines the double life of misoprostol in Brazil, where it is illegally used by women as an abortifacient and legally used in obstetric hospital wards. Based on my doctoral and post-doctoral anthropological research on contraception and abortion in Salvador, Bahia, this paper initially traces the "conversion" of misoprostol from a drug to treat ulcers to a self-administered abortifacient in Latin America, and its later conversion to aneclectic global obstetric tool. It then shows how, while reducing maternal mortality, its use as an illegal abortifacient has reinforced the double reproductive citizenship regime existing in countries with restrictive abortion laws and poor post-abortion care services, where poor women using it illegally are stigmatised, discriminated against and exposed to potentially severe health risks.

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 Between Sublingual and Vaginal Administration of Misoprostol in Management of Missed Abortion

AIM

The aim of the present study is to compare between sublingual administration of misoprostol and vaginal administration in the management of missed abortion.

MATERIALS AND METHODS

The study was conducted in El-Shatby Maternity Hospital on 160 patients diagnosed as missed abortion by ultrasonographic examination. Cases were divided into two groups according to the methods of misoprostol administration, whether sublingual or vaginal. Patients of the two groups were observed for the times of uterine colic starting, cervical dilation, and conceptus expulsion, along with recording of any side effects.

RESULT

During the follow-up of our cases we found that sublingual route is more effective than vaginal route in the management of missed abortion. The difference between the two groups in percentage of conceptus expulsion was statistically significant. The most common side effects were nausea which was present in 55 % of cases in group I (sublingual) and in 40 % of cases in group II (vaginal) then severe pain in 25 % of cases in group I (sublingual) and in 20 % of cases in group II (vaginal) and hyperpyrexia in 15 % of cases in group I (sublingual) and in 5 % of cases in group II (vaginal).

CONCLUSION

Sublingual administration of misoprostol is more effective than its vaginal administration in missed abortion management. Side effect of misoprostol as nausea, vomiting, fever is more common with sublingual administration in comparison with its vaginal administration.

Oral misoprostol for induction of labour

BACKGROUND

Misoprostol is an orally active prostaglandin. In most countries misoprostol is not licensed for labour induction, but its use is common because it is cheap and heat stable.

OBJECTIVES

To assess the use of oral misoprostol for labour induction in women with a viable fetus.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 January 2014).

SELECTION CRITERIA

Randomised trials comparing oral misoprostol versus placebo or other methods, given to women with a viable fetus for labour induction.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial data, using centrally-designed data sheets.

MAIN RESULTS

Overall there were 76 trials (14,412) women) which were of mixed quality.In nine trials comparing oral misoprostol with placebo (1109 women), women using oral misoprostol were more likely to give birth vaginally within 24 hours (risk ratio (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49; one trial; 96 women), need less oxytocin (RR 0.42, 95% CI 0.37 to 0.49; seven trials; 933 women) and have a lower caesarean section rate (RR 0.72, 95% CI 0.54 to 0.95; eight trials; 1029 women).In 12 trials comparing oral misoprostol with vaginal dinoprostone (3859 women), women given oral misoprostol were less likely to need a caesarean section (RR 0.88, 95% CI 0.78 to 0.99; 11 trials; 3592 women). There was some evidence that they had slower inductions, but there were no other statistically significant differences.Nine trials (1282 women) compared oral misoprostol with intravenous oxytocin. The caesarean section rate was significantly lower in women who received oral misoprostol (RR 0.77, 95% CI 0.60 to 0.98; nine trials; 1282 women), but they had increased rates of meconium-stained liquor (RR 1.65, 95% CI 1.04 to 2.60; seven trials; 1172 women).Thirty-seven trials (6417 women) compared oral and vaginal misoprostol and found no statistically significant difference in the primary outcomes of serious neonatal morbidity/death or serious maternal morbidity or death. The results for vaginal birth not achieved in 24 hours, uterine hyperstimulation with fetal heart rate (FHR) changes, and caesarean section were highly heterogenous - for uterine hyperstimulation with FHR changes this was related to dosage with lower rates in those with lower doses of oral misoprostol. However, there were fewer babies born with a low Apgar score in the oral group (RR 0.60, 95% CI 0.44 to 0.82; 19 trials; 4009 babies) and a decrease in postpartum haemorrhage (RR 0.57, 95% CI 0.34 to 0.95; 10 trials; 1478 women). However, the oral misoprostol group had an increase in meconium-stained liquor (RR 1.22, 95% CI 1.03 to 1.44; 24 trials; 3634 women).

AUTHORS' CONCLUSIONS

Oral misoprostol as an induction agent is effective at achieving vaginal birth. It is more effective than placebo, as effective as vaginal misoprostol and results in fewer caesarean sections than vaginal dinoprostone or oxytocin.Where misoprostol remains unlicensed for the induction of labour, many practitioners will prefer to use a licensed product like dinoprostone. If using oral misoprostol, the evidence suggests that the dose should be 20 to 25 mcg in solution. Given that safety is the primary concern, the evidence supports the use of oral regimens over vaginal regimens. This is especially important in situations where the risk of ascending infection is high and the lack of staff means that women cannot be intensely monitored.

The pharmacology of prostaglandins for induction of labor

Prostaglandin medications are frequently used in the process of induction of labor. Understanding the history and research that supports prostaglandin use for induction of labor is crucial for safe practice. Dinoprostone has been the standard of care for cervical ripening in term pregnancies. Misoprostol administration via various routes has been shown to be efficacious. Oral misoprostol in particular is effective and associated with reassuring maternal and fetal outcomes. In addition, cost has become a variable in decision making regarding best practice. More research is necessary to determine the safest medication, route, dose, and interval of administration. This article reviews cervical physiology and endogenous prostaglandin activity in relation to labor, and the pharmacologic profiles of synthetic prostaglandins currently used for induction of labor.

Misoprostol and the politics of abortion in Sri Lanka

Misoprostol, a WHO essential medicine indicated for labour induction, management of miscarriage and post-partum haemorrhage, as well as for induced abortion and treatment of post-abortion complications, came up for registration in Sri Lanka in December 2010. The decision on registration was postponed, indefinitely. This has wide-ranging implications, as misoprostol is widely available and used, including by health professionals in Sri Lanka, without guidance or training in its use. This paper attempts to situate the failure to register misoprostol within the broader context of unsafe abortion, drawing on data from interviews with physicians and health policymakers in Sri Lanka. It demonstrates how personal opposition to abortion infiltrates policy decisions and prevents the issue of unsafe abortion being resolved. Any move to reform abortion law and policy in Sri Lanka will require a concerted effort, spearheaded by civil society. Women and communities affected by the consequences of unsafe abortion need to be involved in these efforts. Regardless of the law, women will access abortion services if they need them, and providers will provide them. Decriminalizing abortion and registering abortion medications will make provision of abortion services safer, less expensive and more equitable.

The expression of glycosaminoglycans and proteoglycans in the uterine cervix of albino rats after local hyaluronidase infusion

OBJECTIVE

To assess the local effect of hyaluronidase injection on the expression of glycosaminoglycans (GAGs) and proteoglycans (PGs) in the extracellular matrix of the uterine cervix from pregnant albino rats.

METHODS

Ten pregnant rats were divided into two groups on day 18 of pregnancy. The experimental group (Gexp) of rats received an intracervical infusion of 0.02 mL of hyaluronidase diluted to 1 mL with distilled water, whereas the control group (Gc) received 1 mL of distilled water. On day 20 of pregnancy, the pregnant rats were sacrificed and the uterine cervixes from all rats were then dissected. The qualitative expression of hyaluronic acid (HA) was assessed by immunohistochemistry and quantified by sandwich ELISA. To compare the quantitative GAG values between groups, a Student's t-test for independent samples was performed. PGs were also assessed by immunohistochemical analysis.

RESULTS

The electrophoretic profile of newly synthesized radioactively labeled GAGs degraded by specific enzymes showed that there were two predominant GAGs in both Gc and Gexp, i.e. heparan sulfate (HS) and a mixture of hondroitin sulfate (CS) and dermatan sulfate (DS). The concentrations of GAGs showed a significant reduction of CS/DS (p < 0.004) and HS (p < 0.005) relative to Gc. HA staining was less intense in the lamina propria and area surrounding the blood vessels in Gexp compared to Gc. The HA contents were also significantly reduced (p < 0.012).

CONCLUSIONS

Intracervical hyaluronidase infusion promoted a significant reduction in the concentration of sulfated GAGs as assessed by both qualitative (histochemical) and quantitative (fluorometric) measurements of HA.

Titrated oral misoprostol for augmenting labour to improve maternal and neonatal outcomes

BACKGROUND

Labour dystocia is associated with a number of adverse maternal and neonatal outcomes. Augmentation of labour is a commonly used intervention in cases of labour dystocia. Misoprostol is an inexpensive and stable prostaglandin E1 analogue that can be administered orally, vaginally, sublingually or rectally. Misoprostol has proven to be effective at stimulating uterine contractions although it can have serious, and even life-threatening side-effects. Titration refers to the process of adjusting the dose, frequency, or both, of a medication on the basis of frequent review to achieve optimal outcomes. Studies have reported on a range of misoprostol titration regimens used for labour induction and titrated misoprostol may potentially be effective and safe for augmentation of labour.

OBJECTIVES

To examine the effects and safety of titrated oral misoprostol compared with placebo, oxytocin, other interventions, or no active treatment, in women with labour dystocia.

SEARCH METHODS

The Trials Search Co-ordinator of the Cochrane Pregnancy and Childbirth Group searched the Cochrane Pregnancy and Childbirth Group's Trials Register; date of search: 29 May 2013. We also searched the reference lists of retrieved studies

SELECTION CRITERIA

Randomised trials (including quasi-randomised and cluster-randomised trials) comparing titrated oral misoprostol with placebo, other interventions (e.g. oxytocin, other prostaglandins), or no treatment in women requiring augmentation of labour were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility for inclusion, carried out data extraction and assessed risk of bias in included studies. Data were entered by one author and checked for accuracy.

MAIN RESULTS

We included two randomised trials with a total of 581 women each comparing different regimens of titrated oral misoprostol with intravenous oxytocin. One study compared 20 mcg doses of misoprostol dissolved in water (repeated every hour up to four hours, after which the dose was increased to 40 mcg per hour up to a maximum total dose of 1600 mcg), while the second study gave women 75 mcg doses (repeated after four hours provided there were no adverse effects observed).Neither trial reported maternal death, severe maternal morbidity, or fetal/neonatal mortality outcomes, and only a few fetal/neonatal morbidity outcomes were considered, none of which were significantly different between groups. For several outcomes (such as maternal side-effects, instrumental birth, maternal blood transfusion for hypovolaemia and epidural analgesia), the number of events was generally too low for sufficient statistical power to be achieved. Maternal satisfaction was not reported in either trial. One trial reported a slight reduction in the median duration of labour from the start of augmentation to vaginal delivery in the oxytocin group.Neither trial reported significantly higher rates of caesarean section (CS) in the oral misoprostol group. Rates of vaginal delivery within 12 and 24 hours of commencing augmentation were not significantly different in the trial using a 20 mcg misoprostol dose. Neither trial had significantly higher rates of uterine hyperstimulation with fetal heart rate changes in the titrated oral misoprostol group. However, the rates of this outcome varied so greatly between the two studies as to suggest that other factors were at play. The only significant differences between groups related to uterine hyperstimulation (without fetal heart rate changes), and results were not consistent in the two trials. In the trial examining the higher dose of misoprostol, more women in the misoprostol group experienced hyperstimulation of labour measured over a 10-minute period compared with those receiving oxytocin (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.02 to 1.35, 350 women). In the study examining the lower titrated dose of misoprostol, there was a lower incidence of tachysystole when labour was augmented with titrated oral misoprostol than with oxytocin (RR 0.39, 95% CI 0.17 to 0.91, 231 women) with no occurrences of hypertonus in either group of women.

AUTHORS' CONCLUSIONS

Important uncertainties still exist on the safety and acceptability of titrated oral misoprostol compared with intravenous oxytocin regimens in women with dystocia following spontaneous onset of labour. Although in facilities where electronic oxytocin infusion is not available, low-dose titrated misoprostol may offer a better alternative to an uncontrolled oxytocin infusion to avoid hyperstimulation. Further research is needed in both high- and low-resource settings More trials should be conducted to evaluate the effect of a standard titration oral misoprostol regimen, both following spontaneous labour and labour induction. Comparisons with other augmentation methods are also warranted, as are any effects on women's birth experiences.

Laminaria tent versus Misoprostol for cervical ripening before surgical process in missed abortion

OBJECTIVE

To compare the efficacy of Laminaria tents with Misoprostol for cervical ripening before surgical process in missed abortion.

METHOD

In a prospective study, 70 women with missed abortion were assigned to have either insertion of a 3 mm intracervical Laminaria tent (n = 35) or vaginal Misoprostol 400 μg (n = 35) on the day prior to suction dilation and curettage (D/C). The women were interviewed just prior to the D/C with regard to pain, vaginal bleeding, and cervical dilator preference.

RESULT

Cervical dilation was greater in the Laminaria group but not significantly different from that in the Misoprostol group. However, additional cervical dilation before D/C was required in more patients in the Misoprostol group (45.7 vs 14.3%, P = 0.001). Women who received Laminaria reported significantly more pain at the time of insertion (62.8% in Laminaria group vs 22.8% in Misoprostol group) compared with women who received Misoprostol. Conversely, Misoprostol was associated with more nausea, vomiting, diarrhea and vaginal bleeding.

CONCLUSIONS

Laminaria tents are more effective cervical dilators than vaginal Misoprostol when inserted the day prior to suction D and C. Vaginal Misoprostol insertion is more comfortable, although it is associated with an increased risk of vaginal bleeding.

Off-label use of misoprostol for labor induction: a nation-wide survey in Switzerland

OBJECTIVE

Off-label use of drugs is frequent in obstetrical practice. No data however are available about nation-wide off-label use in obstetrics regarding frequency and patient information. The objective of our study was to assess the clinical practice of off-label use of misoprostol for labor induction.

STUDY DESIGN

We performed a prospective nation-wide survey study by means of a validated questionnaire in three languages in Switzerland. All registered obstetricians/gynaecologists in Switzerland were included. Of 1100 subjects, 725 (66%) answered the questionnaire; 69 subjects were excluded because they were not actively practicing OB/GYN, resulting in a total of 656 questionnaires included in the analysis.

RESULTS

A total of 512 out of 656 obstetricians/gynaecologists (78%) use misoprostol for labor induction. The most frequent administration route of misoprostol is intravaginal (86%), in a single dose of 50μg (94%), at a dose interval range from 4 to 6h (85%). Among the users of misoprostol, 314 (61%) answered that they do not inform their patients about the off-label use of the medication. Among the non-users of misoprostol, the main reason for non-use is absent license for obstetric indications (48%) and non-availability (14%). If misoprostol were to be licensed for this indication, and commercially available, 69% of current non-users would use it. Non-users of misoprotol use prostaglandin E2 vaginal gel, ovules or slow-release vaginal insert, and oxytocin for labor induction.

CONCLUSION

Misoprostol is the single most commonly used drug for labor induction in Switzerland, although it is not licensed and although there are effective, licensed alternative drugs available. A minority of practitioners inform the patients about the off-label use.

Medical methods for mid-trimester termination of pregnancy

BACKGROUND

With the improvement of ultrasound technology, the likelihood of detection of major fetal structural anomalies in mid-pregnancy has increased considerably. Upon the detection of serious anomalies, women typically are offered the option of pregnancy termination. Additionally, there are still many reasons other than fetal anomalies why women seek abortion in the mid-trimester.

OBJECTIVES

To compare different methods of second trimester medical termination of pregnancy for their efficacy and side-effects.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, Popline and reference lists of retrieved papers and other sources.

SELECTION CRITERIA

All randomised controlled trials (RCTs) examining medical regimens for termination of pregnancy of a singleton living fetus between 12-28 weeks' gestation were analysed. The outcome measures were the induction to abortion interval, abortion rate within 24 hours, need for surgical evacuation, blood loss, uterine rupture, pain, and side-effects.Trials including >20% fetal death, multiple pregnancies, previous uterine scars and regimens which involved cervical preparation were excluded.

DATA COLLECTION AND ANALYSIS

Two authors selected the trials and three authors extracted data.

MAIN RESULTS

Fourty RCTs were included, addressing various agents for pregnancy termination and methods of administration. When used alone, misoprostol was an effective inductive agent, though it appeared to be more effective in combination with mifepristone. However, the evidence from RCTs is limited.Misoprostol was preferably administered vaginally, although among multiparous women sublingual administration appeared equally effective. A range of doses of vaginally administered misoprostol has been used. No randomised trials comparing doses of misoprostol were identified; however low doses of misoprostol appear to be associated with fewer side-effects while moderate doses appear to be more efficient in completing abortion. Four RCTs showed that the induction to abortion interval with 3-hourly vaginal administration of prostaglandins is shorter than 6-hourly administration without an increase in side-effects.Many studies reported the need for surgical evacuation. Indications for surgical evacuation include retained products of the placenta and heavy vaginal bleeding. Fewer women required surgical evacuation when misoprostol was administrated vaginally compared with women receiving intra-amniotical PGF(2a) . Mild, self-limiting diarrhoea was more common among women who received misoprostol compared to other agents.

AUTHORS' CONCLUSIONS

Medical abortion in the second trimester using the combination of mifepristone and misoprostol appeared to have the highest efficacy and shortest abortion time interval. Where mifepristone is not available, misoprostol alone is a reasonable alternative. The optimal route for administering misoprostol is vaginally, preferably using tablets at 3-hourly intervals. Apart from pain, the side-effects of vaginal misoprostol are usually mild and self limiting. Conclusions from this review are limited by the gestational age ranges and variable medical regimens, including dosing, administrative routes and intervals of medication, of the included trials.

Assessing the global availability of misoprostol

OBJECTIVE

To assess the worldwide availability of misoprostol. Documenting the extent of misoprostol use in obstetrics-gynecology is difficult because the drug typically is unregistered for such indications.

METHODS

Data for 2002-2007 on annual sales (measured in weight) to hospitals and retail pharmacies, plus manufacturer prices per 200-microg misoprostol, were analyzed for medications containing misoprostol alone or combined with a nonsteroidal anti-inflammatory drug (NSAID); regional and country-specific trends were identified. Consumer prices per pill are documented for all formulations of registered medications.

RESULTS

Of the misoprostol sold worldwide, 70% was misoprostol-NSAID-combination drugs; of this, 91% was sold in North America and Western Europe. Asia sold the most misoprostol-only drugs; sales increased dramatically in Bangladesh (by 128%) and India (646%), where various low-price brands are sold. Misoprostol sales decreased in Latin America but increased in the Middle East-North Africa and Sub-Saharan Africa; these regions generally had low amounts sold per population.

CONCLUSION

Availability is improving in some low-income regions where misoprostol could significantly reduce maternal deaths due to postpartum hemorrhage and unsafe abortion.

Low-dose oral misoprostol for induction of labor: a systematic review

OBJECTIVE

To estimate the efficacy and safety of low-dose oral misoprostol compared with dinoprostone (PGE2), vaginal misoprostol, and oxytocin for labor induction in women with a viable fetus.

DATA SOURCES

We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published before January 2008 using the keywords misoprostol, labor, induction, randomized controlled trials, dinoprostone, oxytocin, pregnancy, and maternal and fetal side effects.

METHODS OF STUDY SELECTION

We included randomized controlled trials comparing 20-25 micrograms oral misoprostol with vaginal misoprostol, dinoprostone or oxytocin given to women at 32-42 weeks of gestation for labor induction. From 401 citations identified, results from nine studies were finally analyzed using the Review Manager software. Relative risk (RR) and 95% confidence intervals (CIs) were calculated using fixed and random-effects models.

TABULATION, INTEGRATION, AND RESULTS

Nine articles with 2,937 women met the inclusion criteria. The five trials comparing oral misoprostol and dinoprostone showed significantly fewer women requiring cesarean delivery in the misoprostol group (20% compared with 26%; RR 0.82, 95% CI 0.71-0.96). There were no statistically significant differences in risks of uterine hyperstimulation or need for oxytocin augmentation. Two trials compared oral with vaginal low-dose misoprostol. Women using oral misoprostol were significantly less likely to experience uterine hyperstimulation with fetal heart rate changes (2% compared with 13%; RR 0.19, 95% CI 0.08-0.46), but there were no significant differences in other outcomes.

CONCLUSION

Low-dose oral misoprostol solution (20 micrograms) administered every 2 hours seems at least as effective as both vaginal dinoprostone and vaginal misoprostol, with lower rates of cesarean delivery and uterine hyperstimulation, respectively.

Off-label promotion, on-target sales

Adriane Fugh-Berman and Douglas Melnick describe techniques by which pharmaceutical companies covertly promote off-label drug use even where such promotion is illegal.

Reducing postpartum hemorrhage in Vietnam: Assessing the effectiveness of active management of third-stage labor

AIM

The study was undertaken to meet the need of the Ministry of Health to have local evidence on the effectiveness of active management of third-stage labor (AMTSL) in reducing the incidence of postpartum hemorrhage (PPH) > or = 500 mL and the need for PPH treatment.

METHODS

Using a quasi-experimental design, AMTSL was introduced for all births attended by government midwives (at home, community, and district levels) in one district while standard practice without AMTSL was continued in three neighboring districts (with a 1:2 ratio of participants). Oxytocin (10 IU) was administered either by standard disposable syringe and needle or by a prefilled, single-use injection device. Postpartum blood loss was estimated using standard containers; other outcome measures included the duration of third stage, the need for additional treatments, and final maternal condition. A total of 3607 women participated (1236 in the intervention district and 2371 in the comparison districts). Multivariate logistic regression was used to control for age, parity, place of delivery, and first-stage oxytocin augmentation.

RESULTS

AMTSL was associated with reduced risks for prolonged third stage beyond 30 min (odds ratio [OR] = 0.20, 95%; confidence interval [CI]: 0.11, 0.35), supplemental oxytocin (OR = 0.68, 95% CI: 0.49, 0.94), and bimanual compression (OR = 0.63, 95%; CI: 0.41, 0.98). When cases with first-stage oxytocin augmentation were excluded, AMTSL was associated with a 34% reduction in PPH incidence (OR = 0.66, 95%; CI: 0.45, 0.98).

CONCLUSION

This study supports the value of AMTSL in reducing the incidence of PPH, shortening the third stage of labor, and reducing the need for additional treatments.

Oral Misoprostol Administration for Labor Induction

Using oral agents for induction of labor would reduce the need for repeated vaginal examinations; this is more acceptable to women and could reduce infection rates. A systematic review was conducted of 41 randomized trials comparing oral misoprostol to other induction agents. Oral misoprostol is effective at achieving vaginal delivery, and may have benefits over both vaginal and intracervical dinoprostone. Although it does not achieve vaginal delivery as quickly as vaginal misoprostol, the rates of hyperstimulation are lower when using comparable doses. As the primary consideration should be safety rather than speed, an oral regimen using a maximum of 50 mcg 4 hourly is recommended.

Review of medical abortion using mifepristone in combination with a prostaglandin analogue

Induced abortion is still a major health problem in the world and the most frequently performed intervention in obstetrics and gynecology with an estimated total of 46 million worldwide each year. Medical abortion with mifepristone and prostaglandin was first introduced in 1988 and is now approved in 31 countries. This combination of drugs has recently been included in the List of Essential Medicines by the World Health Organisation. The present review summarizes the development, physiology and the development of the currently used regimens.

Oral misoprostol for induction of labour

BACKGROUND

Misoprostol is a synthetic prostaglandin that can be given orally or vaginally. In most countries misoprostol has not been licensed for use in pregnancy, but its unlicensed use is common because misoprostol is cheap, stable at room temperature and effective in causing uterine contractions. Oral use of misoprostol may be convenient, but high doses could cause uterine hyperstimulation and uterine rupture which may be life-threatening for both mother and fetus.

OBJECTIVES

To assess the effectiveness and safety of oral misoprostol used for labour induction in women with a viable fetus in the third trimester of pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (January 2005).

SELECTION CRITERIA

Randomised trials comparing oral misoprostol versus other methods, placebo or no treatment, given to women with a viable fetus for labour induction.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data, using centrally-designed data sheets.

MAIN RESULTS

Forty-one trials (8606 participants) were included. In four trials comparing oral misoprostol with placebo (474 participants), women using oral misoprostol were less likely to have long labours (relative risk (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49), needed less oxytocin (RR 0.32, 95% CI 0.24 to 0.43) and had a lower caesarean section rate (RR 0.62, 95% CI 0.40 to 0.96). In nine trials comparing oral misoprostol with vaginal dinoprostone (2627 participants), women given oral misoprostol were less likely to need a caesarean section, but this reduction reached statistical significance only in the subgroup with intact membranes (RR 0.78, 95% CI 0.66 to 0.94). Uterine hyperstimulation was more common after oral misoprostol (RR 1.63, 95% CI 1.09 to 2.44) although this was not associated with any adverse fetal events. Seven trials (1017 participants) compared oral misoprostol with intravenous oxytocin. The only difference between the groups was an increase in meconium-stained liquor in women with ruptured membranes following administration of oral misoprostol (RR 1.72, 95% 1.08 to 2.74). Sixteen trials (3645 participants) compared oral and vaginal misoprostol and found no difference in the primary outcomes. There was less uterine hyperstimulation without fetal heart rate changes in those given oral misoprostol (RR 0.37, 95% 0.23 to 0.59). Oral misoprsotol was associated with increased need for oxytocin augmentation (RR 1.28, 95% 1.11 to 1.48) and more meconium-stained liquor (RR 1.27, 1.01 to 1.60).

AUTHORS' CONCLUSIONS

Oral misoprostol appears to be more effective than placebo and at least as effective as vaginal dinoprostone. However, there remain questions about its safety because of a relatively high rate of uterine hyperstimulation and the lack of appropriate dose ranging studies. In countries where misoprostol remains unlicenced for the induction of labour, many practitioners will prefer the legal protection of using a licenced product like dinoprostone. There is no evidence that misoprostol given orally is inferior to the vaginal route and has lower rates of hyperstimulation. If misoprostol is used orally, the dose should not exceed 50 mcg.

Oral misoprostol for induction of labour at term: randomised controlled trial

OBJECTIVE

To compare oral misoprostol solution with vaginal prostaglandin gel (dinoprostone) for induction of labour at term to determine whether misoprostol is superior.

DESIGN

Randomised double blind placebo controlled trial.

SETTING

Maternity departments in three hospitals in Australia. Population Pregnant women with a singleton cephalic presentation at > or = 36+6 weeks' gestation, with an indication for prostaglandin induction of labour.

INTERVENTIONS

20 mug oral misoprostol solution at ourly intervals and placebo vaginal gel or vaginal dinoprostone gel at six hourly intervals and placebo oral solution.

MAIN OUTCOME MEASURES

Vaginal birth within 24 hours; uterine hyperstimulation with associated changes in fetal heart rate; caesarean section (all); and caesarean section for fetal distress.

RESULTS

741 women were randomised, 365 to the misoprostol group and 376 to the vaginal dinoprostone group. There were no significant differences between the two treatment groups in the primary outcomes: vaginal birth not achieved in 24 hours (misoprostol 168/365 (46.0%) v dinoprostone 155/376 (41.2%); relative risk 1.12, 95% confidence interval 0.95 to 1.32; P = 0.134), caesarean section (83/365 (22.7%) v 100/376 (26.6%); 0.82, 0.64 to 1.06; P = 0.127), caesarean section for fetal distress (32/365 (8.8%) v 35/376 (9.3%); 0.91, 0.57 to 1.44; P = 0.679), or uterine hyperstimulation with changes in fetal heart rate (3/365 (0.8%) v 6/376 (1.6%); 0.55, 0.14 to 2.21; P = 0.401). Although there were differences in the process of labour induction, there were no significant differences in adverse maternal or neonatal outcomes.

CONCLUSIONS

This trial shows no evidence that oral misoprostol is superior to vaginal dinoprostone for induction of labour. However, it does not lead to poorer health outcomes for women or their infants, and oral treatment is preferred by women.

TRIAL REGISTRATION

National Health and Medical Research Council, Perinatal Trials, PT0361.

Pharmacokinetics of a novel oral slow-release form of misoprostol

BACKGROUND

The pharmacokinetics of a novel slow-release (SR) misoprostol was studied and compared to conventional misoprostol.

METHODS

Thirty-one women, pregnant between 8 and 12 weeks, requesting surgical abortion were randomly allocated to receive orally 400 microg conventional misoprostol, 400 microg SR misoprostol or 800 microg SR misoprostol. Venous blood samples were taken at 0, 30, 60, 120, 240 and 360 min after the administration of misoprostol. Misoprostol acid (MPA) was determined in serum samples using liquid chromatography/tandem mass spectrometry.

RESULTS

Serum peak concentration (Cmax) was highest for conventional oral misoprostol. The time to peak concentration (Tmax) was similar for all groups. The area under the curve up to 360 min was similar for conventional and for 800 microg SR misoprostol and significantly greater for these groups compared to 400 microg SR misoprostol (P = 0.013).

CONCLUSION

The new SR form of misoprostol demonstrated lower peak levels but longer-lasting elevation in plasma levels compared to conventional oral misoprostol. The AUC for 800 microg SR misoprostol was similar to that of 400 microg of conventional oral misoprostol. SR misoprostol may offer an alternative to repeated administration of oral misoprostol or to vaginal administration.