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Ben-David C, Bachar G, Shbita D, Justman N, Vitner D, Khatib N, Ginsberg Y, Beloosesky R, Weiner Z, Zipori Y. Pre-labour Rupture of Membranes at Term in Women With Gestational Diabetes and the Risk of Neonatal Hypoglycemia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102234. [PMID: 37820928 DOI: 10.1016/j.jogc.2023.102234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES The management for improving maternal and neonatal outcomes of women with gestational diabetes mellitus (GDM) arriving at the delivery ward with pre-labour rupture of membranes (PROM) has not been elucidated. We tested the hypothesis that prolonged PROM in women with GDM would result in higher rates of neonatal hypoglycemia. METHODS We retrospectively enrolled women with diet or insulin-controlled GDM who presented with spontaneous clear PROM. Each woman was allocated into one of two groups based on the PROM-delivery time: <18 hours (group 1) and ≥18 hours (group 2). The primary outcome was the incidence of neonatal hypoglycemia, defined as glucose <40 mg/dL (2.2 mmol/L) within 24 hours of birth. RESULTS We ultimately analyzed 631 cases of GDM (6.7%), 371 with PROM-delivery <18 hours, and 260 with PROM-delivery ≥18 hours. The incidence of neonatal hypoglycemia did not differ between the two groups, reaching 7.3%. Women in group 2 were at increased risk of both cesarean delivery (20% vs. 12.4%, P < 0.01) and maternal chorioamnionitis morbidity (6.5% vs. 1.3%, P < 0.001). CONCLUSIONS In a sub-group of women with GDM, a PROM-delivery time ≥18 hours is not associated with higher rates of neonatal hypoglycemia, but higher rates of chorioamnionitis and cesarean delivery were noted. Therefore, we suggest consideration for early delivery when managing women with GDM and PROM.
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Affiliation(s)
- Chen Ben-David
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.
| | - Gal Bachar
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Dima Shbita
- Ruth and Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Naphtali Justman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine-Technion Institute of Technology, Haifa, Israel
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Awkadigwe FI, Ezugwu FO, Eleje GU, Nweze SO, Odugu BU, Dinwoke VO, Olu EA, Ortuanya KE, Ezenwaeze MN, Eze OC, Onyekpa JI, Ofor IJ, Onah OO, Omeje CU, Ezike AU, Enyinna PK, Malachy DE, Okafor CG. Active versus expectant management for premature rupture of membranes at term: A randomized, controlled study. J Int Med Res 2023; 51:3000605231195451. [PMID: 37656970 PMCID: PMC10478565 DOI: 10.1177/03000605231195451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVE To compare the effects on feto-maternal outcomes of expectant versus active management for premature rupture of membranes (PROM) at term. METHODS This was a prospective randomized (1:1) controlled study involving 86 pregnant-women who received either expectant management (n = 43) or active management with misoprostol (n = 43) for PROM at term. Primary outcome was route of delivery. Secondary outcomes were: PROM to presentation interval; latency period; PROM to delivery interval; recruitment to delivery interval; labour and delivery complications. RESULTS Baseline-characteristics were similar between groups. There was no significant difference between active and expectant groups in mean PROM to presentation/admission, or PROM to delivery. However, mean latency period (11.1 ± 7.3 hours vs 8.8 ± 5.5 hours) and mean recruitment to delivery intervals after PROM (14.7 ± 5.2 hours vs 11.8 ± 5.0 hours) were significantly shorter for the active group compared with the expectant group. Although the rate of caesarean section was less in expectant management group (21%) compared with the active management group (30%), the difference was not statistically significant. There were no significant differences between groups in delivery or perinatal complications. CONCLUSION Active and expectant management for PROM at term gave comparable outcomes in terms of methods of delivery and complications. However, active management significantly shortened the latency period and induction to delivery intervals compared with expectant management.Trial-Registration: Pan-African-trial-registry-(PACTR)-approval-number PACTR202206797734088.
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Affiliation(s)
- Fredrick I. Awkadigwe
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Frank O. Ezugwu
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - George U. Eleje
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra State, Nigeria
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Nnewi Campus, Nigeria
| | - Sylvester O. Nweze
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Boniface U. Odugu
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Victor O. Dinwoke
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Ephraim A. Olu
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Kelvin E. Ortuanya
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Malachy N. Ezenwaeze
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Obiechina C. Eze
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Johnson I. Onyekpa
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Ifeanyichukwu J. Ofor
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Osmond O. Onah
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Chimdalu U. Omeje
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Andre U. Ezike
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Perpetua K. Enyinna
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology (ESUT) Teaching Hospital, Parklane, Enugu, Nigeria
| | - Divinefavour E. Malachy
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University, Nnewi Campus, Nigeria
| | - Chigozie G. Okafor
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra State, Nigeria
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Misoprostol use in obstetrics. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:356-368. [PMID: 37494579 PMCID: PMC10621739 DOI: 10.1055/s-0043-1770931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
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Prelabor rupture of membranes at term: A possible hematological triage in addition to vagino-rectal beta-hemolytic streptococcus screening for early labor induction. PLoS One 2022; 17:e0261906. [PMID: 35025890 PMCID: PMC8757946 DOI: 10.1371/journal.pone.0261906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 12/13/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction A potential complication of term prelabor rupture of membranes (term PROM) is chorioamnionitis with an increased burden on neonatal outcomes of chronic lung disease and cerebral palsy. The purpose of the study was to analyze the efficacy of a standing clinical protocol designed to identify women with term PROM at low risk for chorioamnionitis, who may benefit from expectant management, and those at a higher risk for chorioamnionitis, who may benefit from early induction. Material and methods This retrospective study enrolled all consecutive singleton pregnant women with term PROM. Subjects included women with at least one of the following factors: white blood cell count ≥ 15×100/μL, C-reactive protein ≥ 1.5 mg/dL, or positive vaginal swab for beta-hemolytic streptococcus. These women comprised the high risk (HR) group and underwent immediate induction of labor by the administration of intravaginal dinoprostone. Women with none of the above factors and those with a low risk for chorioamnionitis waited for up to 24 hours for spontaneous onset of labor and comprised the low-risk (LR) group. Results Of the 884 consecutive patients recruited, 65 fulfilled the criteria for HR chorioamnionitis and underwent immediate induction, while 819 were admitted for expectant management. Chorioamnionitis and Cesarean section rates were not significantly different between the HR and LR groups. However, the prevalence of maternal fever (7.7% vs. 2.9%; p = 0.04) and meconium-stained amniotic fluid was significantly higher in the HR group than in LR group (6.1% vs. 2.2%; p = 0.04). This study found an overall incidence of 4.2% for chorioamnionitis, 10.9% for Cesarean section, 0.5% for umbilical artery blood pH < 7.10, and 1.9% for admission to the neonatal intensive care unit. Furthermore, no confirmed cases of neonatal sepsis were encountered. Conclusions A clinical protocol designed to manage, by immediate induction, only those women with term PROM who presented with High Risk factors for infection/inflammation achieved similar maternal and perinatal outcomes between such women and women without any risks who received expectant management. This reduced the need for universal induction of term PROM patients, thereby reducing the incidence of maternal and fetal complications without increasing the rate of Cesarean sections.
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Delorme P, Lorthe E, Sibiude J, Kayem G. Preterm and term prelabour rupture of membranes: A review of timing and methods of labour induction. Best Pract Res Clin Obstet Gynaecol 2021; 77:27-41. [PMID: 34538740 DOI: 10.1016/j.bpobgyn.2021.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 01/07/2023]
Abstract
Prelabour rupture of membranes (PROM) exposes both foetuses and mothers to the risk of infection. Induction of labour has been proposed to reduce this risk, but its neonatal and maternal risks and benefits must be balanced against those of expectant management (EM). Recent randomized studies of preterm PROM show that EM until 37 weeks of gestation is associated with lower overall neonatal morbidity. In term PROM, active management is associated with a shorter birth interval but not with lower rates of neonatal infection. Similar maternal and neonatal outcomes are reported regardless of whether induction uses oxytocin, PGE2, or oral misoprostol.
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Affiliation(s)
- Pierre Delorme
- Sorbonne Université, AP-HP, Department of Gynaecology and Obstetrics, Trousseau Hospital, Paris, France; INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), FHU PREMA, Paris Descartes University, Paris, France
| | - Elsa Lorthe
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), FHU PREMA, Paris Descartes University, Paris, France; Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Jeanne Sibiude
- Université de Paris, IAME, INSERM, F-75018, Paris, France; AP-HP, Hôpital Louis Mourier, Service de Gynécologie-Obstétrique, F-92700, Colombes, France
| | - Gilles Kayem
- Sorbonne Université, AP-HP, Department of Gynaecology and Obstetrics, Trousseau Hospital, Paris, France; INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), FHU PREMA, Paris Descartes University, Paris, France.
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Coates D, Makris A, Catling C, Henry A, Scarf V, Watts N, Fox D, Thirukumar P, Wong V, Russell H, Homer C. A systematic scoping review of clinical indications for induction of labour. PLoS One 2020; 15:e0228196. [PMID: 31995603 PMCID: PMC6988952 DOI: 10.1371/journal.pone.0228196] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The proportion of women undergoing induction of labour (IOL) has risen in recent decades, with significant variation within countries and between hospitals. The aim of this study was to review research supporting indications for IOL and determine which indications are supported by evidence and where knowledge gaps exist. METHODS A systematic scoping review of quantitative studies of common indications for IOL. For each indication, we included systematic reviews/meta-analyses, randomised controlled trials (RCTs), cohort studies and case control studies that compared maternal and neonatal outcomes for different modes or timing of birth. Studies were identified via the databases PubMed, Maternity and Infant Care, CINAHL, EMBASE, and ClinicalTrials.gov from between April 2008 and November 2019, and also from reference lists of included studies. We identified 2554 abstracts and reviewed 300 full text articles. The quality of included studies was assessed using the RoB 2.0, the ROBINS-I and the ROBIN tool. RESULTS 68 studies were included which related to post-term pregnancy (15), hypertension/pre-eclampsia (15), diabetes (9), prelabour rupture of membranes (5), twin pregnancy (5), suspected fetal compromise (4), maternal elevated body mass index (BMI) (4), intrahepatic cholestasis of pregnancy (3), suspected macrosomia (3), fetal gastroschisis (2), maternal age (2), and maternal cardiac disease (1). Available evidence supports IOL for women with post-term pregnancy, although the evidence is weak regarding the timing (41 versus 42 weeks), and for women with hypertension/preeclampsia in terms of improved maternal outcomes. For women with preterm premature rupture of membranes (24-37 weeks), high-quality evidence supports expectant management rather than IOL/early birth. Evidence is weakly supportive for IOL in women with term rupture of membranes. For all other indications, there were conflicting findings and/or insufficient power to provide definitive evidence. CONCLUSIONS While for some indications, IOL is clearly recommended, a number of common indications for IOL do not have strong supporting evidence. Overall, few RCTs have evaluated the various indications for IOL. For conditions where clinical equipoise regarding timing of birth may still exist, such as suspected macrosomia and elevated BMI, researchers and funding agencies should prioritise studies of sufficient power that can provide quality evidence to guide care in these situations.
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Affiliation(s)
- Dominiek Coates
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Angela Makris
- Department of Medicine, Western Sydney University, Sydney, Australia
- Women’s Health Initiative Translational Unit (WHITU), Liverpool Hospital, Liverpool, Australia
| | - Christine Catling
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Amanda Henry
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
- Department of Women’s and Children’s Health, St George Hospital, Sydney, Australia
- The George Institute for Global Health, UNSW Medicine, Sydney, Australia
| | - Vanessa Scarf
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Nicole Watts
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Deborah Fox
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
| | - Purshaiyna Thirukumar
- School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Vincent Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute of Applied Research Science, University of New South Wales, Liverpool, Australia
| | - Hamish Russell
- South Western Sydney Local Health District, Sydney, Australia
| | - Caroline Homer
- Centre for Midwifery and Child and Family Health, Faculty of Health, University of Technology Sydney, Australia
- Maternal and Child Health Program, Burnet Institute, Victoria, Australia
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Sibiude J. [Term Prelabor Rupture of Membranes: CNGOF Guidelines for Clinical Practice - Timing of Labor Induction]. ACTA ACUST UNITED AC 2019; 48:35-47. [PMID: 31669525 DOI: 10.1016/j.gofs.2019.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect of immediate induction versus expectant management on maternal and neonatal outcomes in case of term prelabor rupture of membranes. METHODS We searched Medline Database, Cochrane Library and consulted international guidelines. RESULTS In case of term prelabor rupture of membranes, induction of labor is associated with shorter rupture of membranes to delivery intervals when compared to expectant management, if induction is conducted with oxytocin (LE2), prostaglandin E2 (LE2) or misoprostol (LE2), but not when induction is conducted with Foley® catheter (LE2), osmotic dilatator (LE2) or acupuncture (LE2). The strongest evidence to date comes from a large international randomized study, the TERMPROM study, which included over 5000 women between 1992 and 1995. This study compared immediate induction with oxytocin or prostaglandin E2 to expectant management up to 96hours, followed by induction by oxytocin or prostaglandin E2. Immediate induction was not associated with a decreased neonatal infection rate (LE1), even among women with a positive streptococcus B vaginal swab (LE2). Thus, expectant management can be offered without increasing the neonatal infection risk (Grade B). Induction with oxytocin was associated with a decreased risk of intra-uterine infection and postpartum fever in the TERMPROM study (LE2), however, this study had significant limitations concerning this outcome (unknown streptococcus B status and low rate of prophylactic antibiotics), and this association was not found in other smaller studies. This decrease was not observed with induction by prostaglandin E2. In the TERMPROM study, induction was not associated with an increase or decrease in the rate of cesarean section (LE2), whatever the parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the cesarean section risk (Grade B). There is no study evaluating expectant management over 4 days. CONCLUSION In case of term prelabor rupture of membranes, induction can be offered without increasing the cesarean section risk (Grade B). Expectant management can be offered without increasing the neonatal infection risk (Grade B), even among women with a positive streptococcus B vaginal swab (Professional consensus). The optimal moment of induction will therefore be guided by the maternity wards organization and women's preference after having informed them of the risks and benefits associated with induction and expectant management (Professional consensus). In case of meconial fluid or term prelabor rupture of membranes>4 days, induction must be offered (Professional consensus).
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Affiliation(s)
- J Sibiude
- Service de gynécologie-obstétrique, université de Paris, hôpital Louis-Mourier, DHU risque et grossesse, 92700 Colombes, France; IAME, Inserm, 75018 Paris, France.
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Alfirevic Z, Keeney E, Dowswell T, Welton NJ, Medley N, Dias S, Jones LV, Gyte G, Caldwell DM. Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2018; 20:1-584. [PMID: 27587290 DOI: 10.3310/hta20650] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND More than 150,000 pregnant women in England and Wales have their labour induced each year. Multiple pharmacological, mechanical and complementary methods are available to induce labour. OBJECTIVE To assess the relative effectiveness, safety and cost-effectiveness of labour induction methods and, data permitting, effects in different clinical subgroups. METHODS We carried out a systematic review using Cochrane methods. The Cochrane Pregnancy and Childbirth Group's Trials Register was searched (March 2014). This contains over 22,000 reports of controlled trials (published from 1923 onwards) retrieved from weekly searches of OVID MEDLINE (1966 to current); Cochrane Central Register of Controlled Trials (The Cochrane Library); EMBASE (1982 to current); Cumulative Index to Nursing and Allied Health Literature (1984 to current); ClinicalTrials.gov; the World Health Organization International Clinical Trials Registry Portal; and hand-searching of relevant conference proceedings and journals. We included randomised controlled trials examining interventions to induce labour compared with placebo, no treatment or other interventions in women eligible for third-trimester induction. We included outcomes relating to efficacy, safety and acceptability to women. In addition, for the economic analysis we searched the Database of Abstracts of Reviews of Effects, and Economic Evaluations Databases, NHS Economic Evaluation Database and the Health Technology Assessment database. We carried out a network meta-analysis (NMA) using all of the available evidence, both direct and indirect, to produce estimates of the relative effects of each treatment compared with others in a network. We developed a de novo decision tree model to estimate the cost-effectiveness of various methods. The costs included were the intervention and other hospital costs incurred (price year 2012-13). We reviewed the literature to identify preference-based utilities for the health-related outcomes in the model. We calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit. We represent uncertainty in the optimal intervention using cost-effectiveness acceptability curves. RESULTS We identified 1190 studies; 611 were eligible for inclusion. The interventions most likely to achieve vaginal delivery (VD) within 24 hours were intravenous oxytocin with amniotomy [posterior rank 2; 95% credible intervals (CrIs) 1 to 9] and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CrI 1 to 6). Compared with placebo, several treatments reduced the odds of caesarean section, but we observed considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best three treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity. For other safety outcomes there were insufficient data or there was too much uncertainty to identify which treatments performed 'best'. Few studies collected information on women's views. Owing to incomplete reporting of the VD within 24 hours outcome, the cost-effectiveness analysis could compare only 20 interventions. The analysis suggested that most interventions have similar utility and differ mainly in cost. With a caveat of considerable uncertainty, titrated (low-dose) misoprostol solution and buccal/sublingual misoprostol had the highest likelihood of being cost-effective. LIMITATIONS There was considerable uncertainty in findings and there were insufficient data for some planned subgroup analyses. CONCLUSIONS Overall, misoprostol and oxytocin with amniotomy (for women with favourable cervix) is more successful than other agents in achieving VD within 24 hours. The ranking according to safety of different methods was less clear. The cost-effectiveness analysis suggested that titrated (low-dose) oral misoprostol solution resulted in the highest utility, whereas buccal/sublingual misoprostol had the lowest cost. There was a high degree of uncertainty as to the most cost-effective intervention. FUTURE WORK Future trials should be powered to detect a method that is more cost-effective than misoprostol solution and report outcomes included in this NMA. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005116. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Zarko Alfirevic
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Edna Keeney
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Therese Dowswell
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nancy Medley
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Sofia Dias
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Leanne V Jones
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Gillian Gyte
- Centre for Women's Health Research, University of Liverpool and Liverpool Women's Hospital, Liverpool, UK
| | - Deborah M Caldwell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Middleton P, Shepherd E, Flenady V, McBain RD, Crowther CA. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2017; 1:CD005302. [PMID: 28050900 PMCID: PMC6464808 DOI: 10.1002/14651858.cd005302.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Prelabour rupture of membranes (PROM) at term is managed expectantly or by planned early birth. It is not clear if waiting for birth to occur spontaneously is better than intervening, e.g. by inducing labour. OBJECTIVES The objective of this review is to assess the effects of planned early birth (immediate intervention or intervention within 24 hours) when compared with expectant management (no planned intervention within 24 hours) for women with term PROM on maternal, fetal and neonatal outcomes. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (9 September 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials of planned early birth compared with expectant management (either in hospital or at home) in women with PROM at 37 weeks' gestation or later. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted the data, and assessed risk of bias of the included studies. Data were checked for accuracy. MAIN RESULTS Twenty-three trials involving 8615 women and their babies were included in the update of this review. Ten trials assessed intravenous oxytocin; 12 trials assessed prostaglandins (six trials in the form of vaginal prostaglandin E2 and six as oral, sublingual or vaginal misoprostol); and one trial each assessed Caulophyllum and acupuncture. Overall, three trials were judged to be at low risk of bias, while the other 20 were at unclear or high risk of bias.Primary outcomes: women who had planned early birth were at a reduced risk of maternal infectious morbidity (chorioamnionitis and/or endometritis) than women who had expectant management following term prelabour rupture of membranes (average risk ratio (RR) 0.49; 95% confidence interval (CI) 0.33 to 0.72; eight trials, 6864 women; Tau² = 0.19; I² = 72%; low-quality evidence), and their neonates were less likely to have definite or probable early-onset neonatal sepsis (RR 0.73; 95% CI 0.58 to 0.92; 16 trials, 7314 infants;low-quality evidence). No clear differences between the planned early birth and expectant management groups were seen for the risk of caesarean section (average RR 0.84; 95% CI 0.69 to 1.04; 23 trials, 8576 women; Tau² = 0.10; I² = 55%; low-quality evidence); serious maternal morbidity or mortality (no events; three trials; 425 women; very low-quality evidence); definite early-onset neonatal sepsis (RR 0.57; 95% CI 0.24 to 1.33; six trials, 1303 infants; very low-quality evidence); or perinatal mortality (RR 0.47; 95% CI 0.13 to 1.66; eight trials, 6392 infants; moderate-quality evidence). SECONDARY OUTCOMES women who had a planned early birth were at a reduced risk of chorioamnionitis (average RR 0.55; 95% CI 0.37 to 0.82; eight trials, 6874 women; Tau² = 0.19; I² = 73%), and postpartum septicaemia (RR 0.26; 95% CI 0.07 to 0.96; three trials, 263 women), and their neonates were less likely to receive antibiotics (average RR 0.61; 95% CI 0.44 to 0.84; 10 trials, 6427 infants; Tau² = 0.06; I² = 32%). Women in the planned early birth group were more likely to have their labour induced (average RR 3.41; 95% CI 2.87 to 4.06; 12 trials, 6945 women; Tau² = 0.05; I² = 71%), had a shorter time from rupture of membranes to birth (mean difference (MD) -10.10 hours; 95% CI -12.15 to -8.06; nine trials, 1484 women; Tau² = 5.81; I² = 60%), and their neonates had lower birthweights (MD -79.25 g; 95% CI -124.96 to -33.55; five trials, 1043 infants). Women who had a planned early birth had a shorter length of hospitalisation (MD -0.79 days; 95% CI -1.20 to -0.38; two trials, 748 women; Tau² = 0.05; I² = 59%), and their neonates were less likely to be admitted to the neonatal special or intensive care unit (RR 0.75; 95% CI 0.66 to 0.85; eight trials, 6179 infants), and had a shorter duration of hospital (-11.00 hours; 95% CI -21.96 to -0.04; one trial, 182 infants) or special or intensive care unit stay (RR 0.72; 95% CI 0.61 to 0.85; four trials, 5691 infants). Women in the planned early birth group had more positive experiences compared with women in the expectant management group.No clear differences between groups were observed for endometritis; postpartum pyrexia; postpartum antibiotic usage; caesarean for fetal distress; operative vaginal birth; uterine rupture; epidural analgesia; postpartum haemorrhage; adverse effects; cord prolapse; stillbirth; neonatal mortality; pneumonia; Apgar score less than seven at five minutes; use of mechanical ventilation; or abnormality on cerebral ultrasound (no events).None of the trials reported on breastfeeding; postnatal depression; gestational age at birth; meningitis; respiratory distress syndrome; necrotising enterocolitis; neonatal encephalopathy; or disability at childhood follow-up.In subgroup analyses, there were no clear patterns of differential effects for method of induction, parity, use of maternal antibiotic prophylaxis, or digital vaginal examination. Results of the sensitivity analyses based on trial quality were consistent with those of the main analysis, except for definite or probable early-onset neonatal sepsis where no clear difference was observed. AUTHORS' CONCLUSIONS There is low quality evidence to suggest that planned early birth (with induction methods such as oxytocin or prostaglandins) reduces the risk of maternal infectious morbidity compared with expectant management for PROM at 37 weeks' gestation or later, without an apparent increased risk of caesarean section. Evidence was mainly downgraded due to the majority of studies contributing data having some serious design limitations, and for most outcomes estimates were imprecise.Although the 23 included trials in this review involved a large number of women and babies, the quality of the trials and evidence was not high overall, and there was limited reporting for a number of important outcomes. Thus further evidence assessing the benefits or harms of planned early birth compared with expectant management, considering maternal, fetal, neonatal and longer-term childhood outcomes, and the use of health services, would be valuable. Any future trials should be adequately designed and powered to evaluate the effects on short- and long-term outcomes. Standardisation of outcomes and their definitions, including for the assessment of maternal and neonatal infection, would be beneficial.
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Affiliation(s)
- Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
| | - Vicki Flenady
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)Stillbirth Research TeamLevel 2 Aubigny PlaceMater Health ServicesBrisbaneQueenslandAustralia4101
| | - Rosemary D McBain
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
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Zhang Y, Zhu HP, Fan JX, Yu H, Sun LZ, Chen L, Chang Q, Zhao NQ, Di W. Intravaginal Misoprostol for Cervical Ripening and Labor Induction in Nulliparous Women: A Double-blinded, Prospective Randomized Controlled Study. Chin Med J (Engl) 2016; 128:2736-42. [PMID: 26481739 PMCID: PMC4736884 DOI: 10.4103/0366-6999.167299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: In China, no multicenter double-blinded prospective randomized controlled study on labor induction has been conducted till now. This study is to evaluate the efficacy and safety of intravaginal accurate 25-μg misoprostol tablets for cervical ripening and labor induction in term pregnancy in nulliparous women. Methods: This was a double-blinded, prospective randomized controlled study including nulliparous women from 6 university hospitals across China. Subjects were randomized into misoprostol or placebo group with the sample size ratio set to 7:2. Intravaginal 25-μg misoprostol or placebo was applied at an interval of 4 h (repeated up to 3 times) for labor induction. Primary outcome measures were the incidence of cumulative Bishop score increases ≥3 within 12 h or vaginal delivery within 24 h. Safety assessments included the incidences of maternal morbidity and adverse fetal/neonatal outcomes. Results: A total of 173 women for misoprostol group and 49 women for placebo were analyzed. The incidence of cumulative Bishop score increases ≥3 within 12 h or vaginal delivery within 24 h was higher in the misoprostol group than in the placebo (64.2% vs. 22.5%, relative risk [RR]: 2.9, 95% confidence interval [CI]: 1.4–6.0). The incidence of onset of labor within 24 h was significantly higher in the misoprostol group than in the placebo group (48.0% vs. 18.4%, RR: 2.6, 95% CI: 1.2–5.7); and the induction-onset of labor interval was significantly shorter in the misoprostol group (P = 0.0003). However, there were no significant differences in the median process time of vaginal labor (6.4 vs. 6.8 h; P = 0.695), incidence (39.3% vs. 49.0%, RR: 0.8, 95% CI: 0.4–1.5) and indications (P = 0.683) of cesarean section deliveries, and frequencies of maternal, fetal/neonatal adverse events between the groups. Conclusion: Intravaginal misoprostol 25 μg every 4 h is efficacious and safe in labor induction and cervical ripening.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Wen Di
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
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Mishanina E, Rogozinska E, Thatthi T, Uddin-Khan R, Khan KS, Meads C. Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis. CMAJ 2014; 186:665-73. [PMID: 24778358 DOI: 10.1503/cmaj.130925] [Citation(s) in RCA: 173] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Induction of labour is common, and cesarean delivery is regarded as its major complication. We conducted a systematic review and meta-analysis to investigate whether the risk of cesarean delivery is higher or lower following labour induction compared with expectant management. METHODS We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery. RESULTS We identified 157 eligible RCTs (n = 31,085). Overall, the risk of cesarean delivery was 12% lower with labour induction than with expectant management (pooled relative risk [RR] 0.88, 95% confidence interval [CI] 0.84-0.93; I(2) = 0%). The effect was significant in term and post-term gestations but not in preterm gestations. Meta-regression analysis showed that initial cervical score, indication for induction and method of induction did not alter the main result. There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25-0.99; I(2) = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79-0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10-9.57; I(2) = 0%) with labour induction. INTERPRETATION The risk of cesarean delivery was lower among women whose labour was induced than among those managed expectantly in term and post-term gestations. There were benefits for the fetus and no increased risk of maternal death.
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Affiliation(s)
- Ekaterina Mishanina
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Ewelina Rogozinska
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Tej Thatthi
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Rehan Uddin-Khan
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Khalid S Khan
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
| | - Catherine Meads
- Homerton Hospital University Trust (Mishanina); Centre for Primary Care and Public Health (Rogozinska, Khan), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; School of Medicine (Thatthi), University of Nairobi, Nairobi, Kenya; Barts Health NHS Trust (Uddin-Khan), London, UK; Health Economics Research Group (Meads), Brunel University, Uxbridge, UK
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Abstract
OBJECTIVE To review the most current literature in order to provide evidence-based recommendations to obstetrical care providers on induction of labour. OPTIONS Intervention in a pregnancy with induction of labour. OUTCOMES Appropriate timing and method of induction, appropriate mode of delivery, and optimal maternal and perinatal outcomes. EVIDENCE Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in 2010 using appropriate controlled vocabulary (e.g., labour, induced, labour induction, cervical ripening) and key words (e.g., induce, induction, augmentation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to the end of 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence in this document was rated using criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). SUMMARY STATEMENTS: 1. Prostaglandins E(2) (cervical and vaginal) are effective agents of cervical ripening and induction of labour for an unfavourable cervix. (I) 2. Intravaginal prostaglandins E(2) are preferred to intracervical prostaglandins E(2) because they results in more timely vaginal deliveries. (I).
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Daneva Markova A, Hadži-Lega M, Stefanović M. COMPARISON OF FOLEY CATHETER AND PROSTAGLANDIN E2 TABLETS FOR THE INDUCTION OF LABOR AT TERM. ACTA MEDICA MEDIANAE 2013. [DOI: 10.5633/amm.2013.0404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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[Premature rupture of membranes at term on unfavourable cervix: immediate or delayed induction?]. ACTA ACUST UNITED AC 2013; 42:671-7. [PMID: 23764228 DOI: 10.1016/j.jgyn.2013.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 02/14/2013] [Accepted: 03/04/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To define the optimal delay before inducing labor in the management of premature rupture of the membranes (PRM) at term with unfavourable cervix in order to reduce the risk of caesarean section as well as the risk of maternal and foetal infection. MATERIALS AND METHODS Retrospective study of three homogeneous groups carried out over on a period of 4years in two centres. All the patients were included after premature rupture of membranes at term with unfavourable cervix (Bishop score<6). We defined three expected delays after PRM at term: less than 7h (group 1), between 7 and 12h (group 2) and more than 12h (group 3). We have assessed the obstetrical, maternal and foetal consequences for each group. RESULTS Sixty patients were allocated in group 1, 49 in group 2 and 46 in group 3. There was no significant difference in the rate of caesarean between the three groups but it was lower in group 2: 6.1% versus 18.3% in group 1 and 21.7% in group 3. No statistical difference was observed concerning maternal or foetal infections. CONCLUSION In PRM at term, neither our study nor literature data allow us to conclude about the optimal delay before inducing labor.
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Shah K, Doshi H. Premature rupture of membrane at term: early induction versus expectant management. J Obstet Gynaecol India 2012; 62:172-5. [PMID: 23543046 DOI: 10.1007/s13224-012-0172-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 04/02/2012] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Premature rupture of membrane is managed either expectantly or actively. The purpose of the study was to assess the effectiveness of early labor induction with cervical prostaglandin E2 versus expectant management in women with term premature rupture of membrane. MATERIAL AND METHODS Singleton pregnancy cases with cephalic presentation reported between 37 and 41 weeks of pregnancy with PROM of <6 h and cervical dilatation <3 cm were studied over a period of 2 years. Out of 100 patients studied, half of them were managed by expectant protocol and the other half by early induction within 6 h of PROM with intracervical gel. Main outcomes measured were PROM-delivery interval, mode of delivery, neonatal and maternal morbidity, and period of maternal and/or neonatal hospitalization. Chi-square test was used to compare frequencies between two groups. Differences between means of other measurement were compared by independent t test. RESULTS PROM-delivery interval was 22 h in expectant group, while in early induction group, it was 13 h (p value < 0.001). Rate of cesarean section remained almost same in both groups. Increases in maternal-neonatal infection rate and hospital stay were noted in expectant group; however, this was not statistically significant. CONCLUSION Immediate labor induction with prostaglandin in cases of term PROM shortens delivery interval and maternal hospital stay with reduction in maternal-neonatal sepsis.
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Affiliation(s)
- Krupa Shah
- Department of Obstetrics and Gynecology, B J Medical College, Ahmedabad, 380016 India ; 238, B Type Quarters, Kasturba Medical College Campus, Manipal, Udupi District, Karnataka 576104 India
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Chaudhuri S, Mitra SN, Banerjee PK, Biswas PK, Bhattacharyya S. Comparison of vaginal misoprostol tablets and prostaglandin E2 gel for the induction of labor in premature rupture of membranes at term: A randomized comparative trial. J Obstet Gynaecol Res 2011; 37:1564-71. [DOI: 10.1111/j.1447-0756.2011.01575.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Hofmeyr GJ, Gülmezoglu AM, Pileggi C. Vaginal misoprostol for cervical ripening and induction of labour. Cochrane Database Syst Rev 2010; 2010:CD000941. [PMID: 20927722 PMCID: PMC7061246 DOI: 10.1002/14651858.cd000941.pub2] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- G Justus Hofmeyr
- University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of HealthDepartment of Obstetrics and Gynaecology, East London Hospital ComplexFrere and Cecilia Makiwane HospitalsPrivate Bag X 9047East LondonEastern CapeSouth Africa5200
| | - A Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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Darmstadt GL, Yakoob MY, Haws RA, Menezes EV, Soomro T, Bhutta ZA. Reducing stillbirths: interventions during labour. BMC Pregnancy Childbirth 2009; 9 Suppl 1:S6. [PMID: 19426469 PMCID: PMC2679412 DOI: 10.1186/1471-2393-9-s1-s6] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Approximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined. METHODS We undertook a systematic review of the published literature, searching PubMed and the Cochrane Library, of trials and reviews (N = 230) that reported stillbirth or perinatal mortality outcomes for eight interventions delivered during labour. Where eligible randomised controlled trials had been published after the most recent Cochrane review on any given intervention, we incorporated these new trial findings into a new meta-analysis with the Cochrane included studies. RESULTS We found a paucity of studies reporting statistically significant evidence of impact on perinatal mortality, especially on stillbirths. Available evidence suggests that operative delivery, especially Caesarean section, contributes to decreased stillbirth rates. Induction of labour rather than expectant management in post-term pregnancies showed strong evidence of impact, though there was not enough evidence to suggest superior safety for the fetus of any given drug or drugs for induction of labour. Planned Caesarean section for term breech presentation has been shown in a large randomised trial to reduce stillbirths, but the feasibility and consequences of implementing this intervention routinely in low-/middle-income countries add caveats to recommending its use. Magnesium sulphate for pre-eclampsia and eclampsia is effective in preventing eclamptic seizures, but studies have not demonstrated impact on perinatal mortality. There was limited evidence of impact for maternal hyperoxygenation, and concerns remain about maternal safety. Transcervical amnioinfusion for meconium staining appears promising for low/middle income-country application according to the findings of many small studies, but a large randomised trial of the intervention had no significant impact on perinatal mortality, suggesting that further studies are needed. CONCLUSION Although the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.
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Affiliation(s)
- Gary L Darmstadt
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Rachel A Haws
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Esme V Menezes
- Division of Maternal and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Tanya Soomro
- Division of Maternal and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Maternal and Child Health, The Aga Khan University, Karachi, Pakistan
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Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King VJ. Indications for induction of labour: a best-evidence review. BJOG 2009; 116:626-36. [PMID: 19191776 DOI: 10.1111/j.1471-0528.2008.02065.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Rates of labour induction are increasing. OBJECTIVES To review the evidence supporting indications for induction. SEARCH STRATEGY We listed indications for labour induction and then reviewed the evidence. We searched MEDLINE and the Cochrane Library between 1980 and April 2008 using several terms and combinations, including induction of labour, premature rupture of membranes, post-term pregnancy, preterm prelabour rupture of membranes (PROM), multiple gestation, suspected macrosomia, diabetes, gestational diabetes mellitus, cardiac disease, fetal anomalies, systemic lupus erythematosis, oligohydramnios, alloimmunization, rhesus disease, intrahepatic cholestasis of pregnancy (IHCP), and intrauterine growth restriction (IUGR). We performed a review of the literature supporting each indication. SELECTION CRITERIA We identified 1387 abstracts and reviewed 418 full text articles. We preferentially included high-quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised trials and observational studies. MAIN RESULTS We included 34 full text articles. For each indication, we assigned levels of evidence and grades of recommendation based upon the GRADE system. Recommendations for induction of labour for post-term gestation, PROM at term, and premature rupture of membranes near term with pulmonary maturity are supported by the evidence. Induction for IUGR before term reduces intrauterine fetal death, but increases caesarean deliveries and neonatal deaths. Evidence is insufficient to support induction for women with insulin-requiring diabetes, twin gestation, fetal macrosomia, oligohydramnios, cholestasis of pregnancy, maternal cardiac disease and fetal gastroschisis. AUTHORS' CONCLUSIONS Research is needed to determine risks and benefits of induction for many commonly advocated clinical indications.
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Affiliation(s)
- E Mozurkewich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
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Zakariah AY, Alexander S. [Immediate induction or expectant management in term PROM? Do not falter, do not wait!]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2008; 36:1248-1250. [PMID: 19010706 DOI: 10.1016/j.gyobfe.2008.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- A-Y Zakariah
- Unité PERU (Perinatal Epidemiology and Reproductive health Unit), école de Santé publique, campus Erasme, université Libre de Bruxelles, CP 597, route de Lennik, 808, 1070 Bruxelles, Belgique.
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Wing DA, Gaffaney CAL. Vaginal Misoprostol Administration for Cervical Ripening and Labor Induction. Clin Obstet Gynecol 2006; 49:627-41. [PMID: 16885668 DOI: 10.1097/00003081-200609000-00021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intravaginal misoprostol has been shown to be an effective agent for cervical ripening and induction of labor. Vaginal application of misoprostol has been reported in over 9000 women worldwide and seems to have safety profile similar to that of endocervically and intravaginally administered dinoprostone. Concern arises with the use of higher doses of intravaginal misoprostol (50 mcg or more) and the association with uterine contractile abnormalities and for this reason, use of low-dose misoprostol regimen has been recommended by the American College of Obstetricians and Gynecologists. The recommendation is use of a 25-mcg dose of misoprostol inserted into the posterior vaginal fornix and repeated every 3 to 6 hours as needed. Misoprostol administration to women with prior cesarean births seems to increase the likelihood of uterine scar disruption and should not be used in these women. There are reports of uterine rupture in women with unscarred uteri treated with vaginally applied misoprostol. Therefore, all patients need to be monitored adequately after misoprostol administration. Although there is a growing body of data regarding the ambulatory use of intravaginal misoprostol for cervical ripening, its use for this purpose cannot be recommended outside of investigational protocols at this time because of concerns for maternal and neonatal safety.
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Affiliation(s)
- Deborah A Wing
- Division of Maternal-Fetal Medicine, Department of Obstetrics-Gynecology, University of California, Irvine, School of Medicine, Irvine, California, USA.
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Dare MR, Middleton P, Crowther CA, Flenady VJ, Varatharaju B. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2006:CD005302. [PMID: 16437525 DOI: 10.1002/14651858.cd005302.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prelabour rupture of membranes at term is managed expectantly or by elective birth, but it is not clear if waiting for birth to occur spontaneously is better than intervening. OBJECTIVES To assess the effects of planned early birth versus expectant management for women with term prelabour rupture of membranes on fetal, infant and maternal wellbeing. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966 to November 2004) and EMBASE (1974 to November 2004). SELECTION CRITERIA Randomised or quasi-randomised trials of planned early birth compared with expectant management in women with prelabour rupture of membranes at 37 weeks' gestation or more. DATA COLLECTION AND ANALYSIS Two review authors independently applied eligibility criteria, assessed trial quality and extracted data. A random-effects model was used. MAIN RESULTS Twelve trials (total of 6814 women) were included. Planned management was generally induction with oxytocin or prostaglandin, with one trial using homoeopathic caulophyllum. Overall, no differences were detected for mode of birth between planned and expectant groups: relative risk (RR) of caesarean section 0.94, 95% confidence interval (CI) 0.82 to 1.08 (12 trials, 6814 women); RR of operative vaginal birth 0.98, 95% 0.84 to 1.16 (7 trials, 5511 women). Significantly fewer women in the planned compared with expectant management groups had chorioamnionitis (RR 0.74, 95% CI 0.56 to 0.97; 9 trials, 6611 women) or endometritis (RR 0.30, 95% CI 0.12 to 0.74; 4 trials, 445 women). No difference was seen for neonatal infection (RR 0.83, 95% CI 0.61 to 1.12; 9 trials, 6406 infants). However, fewer infants under planned management went to neonatal intensive or special care compared with expectant management (RR 0.72, 95% CI 0.57 to 0.92, number needed to treat 20; 5 trials, 5679 infants). In a single trial, significantly more women with planned management viewed their care more positively than those expectantly managed (RR of "nothing liked" 0.45, 95% CI 0.37 to 0.54; 5031 women). AUTHORS' CONCLUSIONS Planned management (with methods such as oxytocin or prostaglandin) reduces the risk of some maternal infectious morbidity without increasing caesarean sections and operative vaginal births. Fewer infants went to neonatal intensive care under planned management although no differences were seen in neonatal infection rates. Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices.
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