Vaginal misoprostol versus vaginal dinoprostone for cervical ripening and induction of labour: An individual participant data meta-analysis of randomised controlled trials

BACKGROUND

Induction of labour (IOL) is common practice and different methods carry different effectiveness and safety profiles.

OBJECTIVES

To compare the effectiveness, and maternal and perinatal safety outcomes of IOL with vaginal misoprostol versus vaginal dinoprostone using individual participant data from randomised clinical trials.

SEARCH STRATEGY

The following databases were searched from inception to March 2023: CINAHL Plus, ClinicalTrials.gov, Cochrane Pregnancy and Childbirth Group Trial Register, Ovid Embase, Ovid Emcare, Ovid MEDLINE, Scopus and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

Randomised controlled trials (RCTs), with viable singleton gestation, no language restrictions, and all published and unpublished data.

DATA COLLECTION AND ANALYSIS

An individual participant data meta-analysis was carried out.

MAIN RESULTS

Ten of 52 eligible trials provided individual participant data, of which two were excluded after checking data integrity. The remaining eight trials compared low-dose vaginal misoprostol versus dinoprostone, including 4180 women undergoing IOL, which represents 32.8% of all participants in the published RCTs. Of these, 2077 were assigned to low-dose vaginal misoprostol and 2103 were assigned to vaginal dinoprostone. Compared with vaginal dinoprostone, low-dose vaginal misoprostol had a comparable rate of vaginal birth. Composite adverse perinatal outcomes did not differ between the groups. Compared with vaginal dinoprostone, composite adverse maternal outcomes were significantly lower with low-dose vaginal misoprostol (aOR 0.80, 95% CI 0.65-0.98, P = 0.03, I2  = 0%).

CONCLUSIONS

Low-dose vaginal misoprostol and vaginal dinoprostone for IOL are comparable in terms of effectiveness and perinatal safety. However, low-dose vaginal misoprostol is likely to lead to a lower rate of composite adverse maternal outcomes than vaginal dinoprostone.

Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit

OBJECTIVE

To determine risk factors and outcomes for women with severe preeclampsia and renal failure.

STUDY DESIGN

Retrospective study from 1995 to 1998 of all women with renal failure who were admitted to the obstetric intensive care unit at Groote Schuur Hospital, South Africa. A total of 89 women were identified with severe preeclampsia defined as blood pressure > or = 160/110 mm Hg and > or = 2+ proteinuria, renal failure defined as a creatinine level of > or = 1.13 mg/dL, and oliguria defined as < 100 mL urine produced in 4 hours; 72 charts were available for analysis. A comparison was made between the 3 groups, which were defined by the maximum recorded creatinine levels.

RESULTS

Of the 72 women, 31 women (43%) were primiparous and 41 (57%) were multiparous. Median gestation at delivery was 32 weeks (range, 21-40 weeks). The median maximum creatinine was 3.85 mg/dL (range, 1.13-12.50 mg/dL). Twelve women (16%) had a history of chronic renal disease or hypertension, and 36 women (50%) had HELLP syndrome and 23 (32%) abruptio placentae. All women with severe renal impairment had either abruptio placentae or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Perinatal mortality was 38% (27/72). However, in this series only 7 women (10%) required dialysis in the short term and none required long-term dialysis or kidney transplant. There were no maternal deaths.

CONCLUSIONS

In women with severe preeclampsia and renal failure, major obstetric complications were common and perinatal outcome was poor. However, the need for dialysis was infrequent, with only 10% women requiring transient dialysis, and there were no cases of chronic renal failure that required dialysis or kidney transplant.