Twice-Weekly Versus Once-Weekly Membrane Sweeping in the Prevention of Post-Term Pregnancy: a Systematic Review and Meta-Analysis of Randomized Controlled Trials

Membrane sweeping is considered a simple and effective method for initiating spontaneous onset of labor. Despite the widely accepted membrane sweeping use to prevent post-term birth, the optimal frequency has not been estimated. We aimed to assess the effectiveness and safety of twice-weekly versus once-weekly membrane sweeping in post-term pregnancy prevention. Four different databases were searched for available clinical trials from inception to October 2022. We selected randomized controlled trials (RCTs) that compared twice-weekly membrane sweeping in intervention group versus once-weekly membrane sweeping in control group among pregnant women with singleton pregnancy at ≥ 39 gestational weeks. Our primary outcomes were the rate of spontaneous onset of labor and the requirement for formal methods of labor induction. Our secondary outcomes were sweeping to delivery interval in days, gestational age at delivery in weeks, Bishop score at admission, chorioamnionitis, and premature rupture of membranes. Three RCTs (596 patients) were included. Twice-weekly membrane sweeping was associated with significant increase in the rate of spontaneous onset of labor and significant decline in labor induction rate in comparison with once-weekly group. Duration from sweeping to delivery was significantly shorter among the twice-weekly group (p<0.001). Furthermore, gestational age at delivery was significantly earlier in the twice-weekly group. A significantly higher Bishop score at admission was observed in the twice-weekly group (p=0.02). There were no significant differences across both groups in chorioamnionitis and premature rupture of membranes. In conclusion, twice-weekly membrane sweeping is more effective in preventing post-maturity pregnancy than once-weekly sweeping without added adverse events.

A Comparative Study of the Efficacy and Safety of Oral Misoprostol, Intravenous Oxytocin, and Intravaginal Dinoprostone for Labor Induction in Pakistani Women

INTRODUCTION

A frequent medical procedure to accelerate labor is the induction of labor. There are different methods of labor induction, including the use of medications such as misoprostol, oxytocin, and dinoprostone.

OBJECTIVE

This research compared the effectiveness and safety of oral misoprostol, intravenous oxytocin, and intravaginal dinoprostone for labor induction in Pakistani women.

METHODOLOGY

A study was conducted in the Department of Obstetrics and Gynaecology, Hayatabad Medical Complex-Medical Teaching Institute (MTI) and Lady Reading Hospital-MTI, Peshawar, Pakistan, over two years. It included 378 women between 38 and 42 gestational weeks, divided into three groups of 126 women each. The oral misoprostol group was given a maximum of six doses of a 25 μg oral misoprostol solution (oral misoprostol tablet of 200 μg dissolved in 200 ml) at intervals of two hours. The drip rate for the intravenous oxytocin group ranged from 6 mIU/minute to 37 mIU/minute. The intravaginal dinoprostone group received a controlled-release vaginal insert containing 10mg of intravaginal dinoprostone, which was left in place for 12 hours.

RESULTS

More women in the oral misoprostol group (n=94; 74.6%) had successful inductions when compared to the intravaginal dinoprostone (n=83; 65.9%) and intravenous oxytocin (n = 77; 64.71%) groups. Oral misoprostol had the greatest proportion of normal vaginal deliveries (n=62; 65.95%), followed by intravaginal dinoprostone (n=47; 56.63%), and intravenous oxytocin had the lowest rate (n=33; 42.85%). Cesarean section rates were greatest in the intravenous oxytocin group (n=31; 40.26%), followed by the intravaginal dinoprostone group (n=29; 34.94%), and lowest in the oral misoprostol group (n=24; 25.53%).

CONCLUSION

Oral misoprostol induces labor in women safely and effectively, resulting in the lowest percentage of cesarean deliveries and the highest percentage of normal vaginal deliveries, respectively. Intravaginal dinoprostone showed the lowest rate of side effects, followed by oral misoprostol while intravenous oxytocin had the highest rate of side effects.

Oxytocin versus prostaglandins for labour Induction of women with an unfavourable cervix after 24 hours of cervical ripening (OPIC): protocol for an open multicentre randomised non-inferiority trial

INTRODUCTION

It remains uncertain whether the most appropriate management for women with an unfavourable cervix after 24 hours of cervical ripening is repeating the ripening procedure or proceeding directly to induction by oxytocin. No adequately powered trial has compared these strategies. We hypothesise that induction of labour with oxytocin among women who have just undergone an ineffective first ripening procedure is not associated with a higher risk of caesarean delivery than a repeated cervical ripening with prostaglandins.

METHODS AND ANALYSIS

We will conduct a multicentre, non-inferiority, open-label, randomised controlled trial aimed at comparing labour induction by oxytocin with a second cervical ripening that uses prostaglandins (slow-release vaginal dinoprostone; oral misoprostol 25 µg; dinoprostone vaginal gel 2 mg). Women (n=1494) randomised in a 1:1 ratio in 10 French maternity units must be ≥18 years with a singleton fetus in vertex presentation, at a term from ≥37+0 weeks of gestation, and have just completed a 24-hour cervical ripening procedure by any method (pharmacological or mechanical) with a Bishop score ≤6. Exclusion criteria comprise being in labour, having more than 3 contractions per 10 min, or a prior caesarean delivery or a history of uterine surgery, or a fetus with antenatally suspected severe congenital abnormalities or a non-reassuring fetal heart rate. The primary endpoint will be the caesarean delivery rate, regardless of indication. Secondary outcomes concern delivery, perinatal morbidity, maternal satisfaction and health economic evaluations. The nature of the assessed procedures prevents masking the study investigators and patients to group assignment.

ETHICS AND DISSEMINATION

All participants will provide written informed consent. The ethics committee 'Comité de Protection des Personnes Ile de France VII' approved this study on 2 April 2021 (No 2021-000989-15). Study findings will be submitted for publication and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

NCT04949633.

Cervical ripening and labour induction: A critical review of the available methods

Induction of labour is one of the most common interventions experienced by pregnant women. There are two overlapping components to labour induction, which include cervical ripening and the initiation of regular contractions. A large number of clinical studies have been conducted for evaluating the methods used for induction of labour, their effectiveness and safety, and pregnancy outcomes. Randomised controlled trials (RCTs) provide the strongest form of evidence for clinical practice. These data are brought together in systematic reviews and have been incorporated into national and international guidelines. Despite this, there is considerable variation in the recommendations between guidelines. Heterogeneity between studies, inconsistency in the definitions of trial outcomes, and underpowered sample size contribute to the difficulty in making robust recommendations. There are pharmacological and non-pharmacological approaches that can be compared with each other and with placebo or no treatment. There are also complementary therapies that may appeal to women but lack evidence of their effectiveness. These issues have been addressed in the current chapter, with a critical review of the research evidence presented in clinical trials and systematic reviews.

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

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

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Single versus double application of vaginal dinoprostone: maternal factors affecting responsiveness

Purpose: The aim of our study was to identify maternal characteristics of women who are responsive to the second application of vaginal dinoprostone in a cohort of patients with a low Bishop Score. Secondarily, we compared the outcome of the patients' response to a single application to that of the women's response to a double application. Materials and methods: This was a retrospective observational cohort study. Patients undergoing preinduction of labor with dinoprostone 10mg controlled-release vaginal device were included. Results: Among 216 included patients, 192 women (88.9%) achieved a cervical ripening after a single application of dinoprostone, while 24 (11.1%) required a second application. Patients notresponding to the first application of dinoprostone had a significantly higher body mass index (27.4 ± 6.7 kg/m² vs 24.9 ± 5.2 kg/m²; p < 0.05) and a significant increase in gestational weight gain (14 ± 5.2 kg vs 11.6 ± 6.1; p < 0.005). Double application of dinoprostone resulted in spontaneousdelivery in 58.4% of cases, but it was related to poorer neonatal outcome, compared to a single application. Conclusions: Obese women, not responding to the first application of dinoprostone could respond to the second application of this vaginal prostaglandin. However, data related to the use of a double application are still very limited to recommend its use as a standardized procedurefor not responsive patients.

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

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

Is there an interest in repeating the vaginal administration of dinoprostone (Propess®), to promote induction of labor of pregnant women at term? (RE-DINO): study protocol for a randomized controlled trial

BACKGROUND

Labor is induced in over 20% of women in France. Prostaglandins, especially intravaginal dinoprostone (Propess®), are widely used to initiate cervical ripening. If labor does not start within 24 h, there is uncertainty about whether to administer a second dinoprostone pessary or to use oxytocin to induce labor in order to achieve a vaginal delivery.

METHODS

RE-DINO is a prospective, open-label, multicenter, randomized superiority trial with two parallel arms running in six French hospitals. A total of 360 patients ≥ 18 years of age at > 37 weeks of gestation who exhibit unfavorable cervical conditions (Bishop score < 6) 24 h after placement of the first Propess®, with fetuses in cephalic presentation, will be included. Patients with premature membrane rupture, uterine scars, or multiple pregnancies will be excluded. Our principal objective is to determine whether placement of a second Propess® (followed by oxytocin [Syntocinon®], if necessary) in women for whom the first Propess® failed to induce cervical ripening increases the vaginal delivery rate compared to direct oxytocin injection. The vaginal delivery rate is therefore the primary outcome. The secondary outcomes are the induction failure rates and maternofetal morbidity and mortality.

DISCUSSION

This study may help in determining the optimal way to induce labor after failure of a first Propess®, an unresolved problem to date. This trial explores the effectiveness and safety of placing a second Propess® and may contribute to development of an obstetric consensus.

TRIAL REGISTRATION

Registered on 2 September 2016 at clinicaltrials.gov (identification number NCT02888041).

Comparison of Dinoprostone and Oxytocin for the Induction of Labor in Late-Term Pregnancy and the Rate of Cesarean Section: A Retrospective Study in Ten Centers in South China

Background

Dinoprostone is the recommended primary option for induction of labor (IOL) in late-term pregnancies (LTPs). However, oxytocin is used in developing and rural areas, and studies have supported similar effectiveness for oxytocin and dinoprostone in reducing the rate of cesarean delivery of LTPs with a Bishop’s score of between 4–6. This study aimed to compare dinoprostone and oxytocin for IOL in LTPs and the rate of cesarean section in ten centers in South China.

Material/Methods

A retrospective study included 1,408 women with LTP, with subgroups including a Bishop’s score of 0–3 and 4–6. Rates of cesarean delivery were compared between women given vaginal dinoprostone and intravenous oxytocin for IOL. Secondary outcomes included the duration of labor, and maternal and fetal complications.

Results

Comparison between women who received oxytocin (N=365) and dinoprostone (N=1,043) showed significantly lower rates of cesarean delivery with dinoprostone, but no significant difference between the subgroups with Bishop’s scores of 0–3 and 4–6. The interval between induction to labor and duration of the active phase of labor were significantly reduced in the dinoprostone group with a Bishop’s score of between 4–6.

Conclusions

For LTPs with a Bishop’s score of 0–3, dinoprostone was superior to oxytocin for IOL with a lower rate of cesarean delivery, but both agents had a similar outcome for women with a Bishop’s score of 4–6. These findings may have implications for the choice of agent used in IOL when dinoprostone is unavailable.

Use of labor induction with dinoprostone vaginal suppositories in pregnant women with gestational hypertension

AIM

Gestational hypertension is a common disorder of pregnancy. This study aims to evaluate the effect of labor induction with dinoprostone vaginal suppositories (Propess) on pregnancy outcomes in pregnant women with gestational hypertension.

METHODS

The retrospective study included 375 patients with gestational hypertension. All patients were included into three groups according to the characteristics at admission. Women who had initiated labor spontaneously at admission were enrolled in Spontaneous labor group. According to Bishop score, other patients underwent labor induction with Propess or oxytocin were enrolled in Propess group or Oxytocin group. Demographic information and perinatal outcome data were collected.

RESULTS

The vaginal delivery rate of the women with gestational hypertension was respectively 93.5% (Spontaneous labor group), 77.0% (Propess group), and 52.5% (Oxytocin group) in three groups with significant difference (P < 0.001). The duration of labor was 8.29 ± 3.70 h (Spontaneous labor group), 8.45 ± 5.21 h (Propess group) and 12.37 ± 11.47 h (Oxytocin group) in three groups, respectively. No differences were found in the intrapartum fever (P = 0.588), intrapartum hemorrhage (P = 0.953), intrapartum maximum blood pressure (P = 0.301 and P = 0.535) and post-partum hemorrhage (P = 0.075) among three groups. Neonatal outcomes were similar among three groups (Neonatal hospitalization rate, P = 0.437; 1-min Apgar score, P = 0.304; 5-min Apgar score, P = 0.340; Birth weight, P = 0.089). No poor maternal and neonatal outcomes occurred.

CONCLUSION

Pregnant women with gestational hypertension could have favorable pregnancy outcomes. Using Propess as a mode of labor induction in gestational hypertension is safe and effective, without increasing intrapartum blood pressure and inducing poor pregnancy outcomes.

Single versus double-balloon catheters for the induction of labor of singleton pregnancies: a meta-analysis of randomized and quasi-randomized controlled trials

OBJECTIVE

To compare the efficacy of single- versus double-balloon catheter (SBC vs. DBC) for cervical ripening and labor induction with an unfavorable cervix.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) or quasi-RCTs (qRCT) regarding the use of SBC or DBC for labor induction of live singleton cephalic pregnancies (≥ 35 weeks) of any parity with an unripe cervix (Bishop score ≤ 6). Nine research databases were searched for original articles published in all languages up to November 2017 comparing both devices for labor induction. Five RCTs and one qRCT were included. Primary outcome measures were time from intervention (device placement) to birth time, vaginal delivery and cesarean section rates, and maternal satisfaction with the procedure. Risk of bias was evaluated with the Cochrane tool. Random effects models were used to combine data for meta-analyses. Summary measures were reported as mean differences and risk ratios (RR) with 95% confidence intervals.

RESULTS

Regardless of parity, pooled analyses of the six trials (n = 1060 women) found that mean intervention to birth time, vaginal delivery and cesarean section rates, and maternal satisfaction to the procedure were similar for both studied groups (SBC vs. DBC).

CONCLUSION

Measured primary outcome measures were similar regardless of the type of device used for labor induction of singleton pregnancies.