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Yenuberi H, Mathews J, George A, Benjamin S, Rathore S, Tirkey R, Tharyan P. The efficacy and safety of 25 μg or 50 μg oral misoprostol versus 25 μg vaginal misoprostol given at 4- or 6-hourly intervals for induction of labour in women at or beyond term with live singleton pregnancies: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 164:482-498. [PMID: 37401143 DOI: 10.1002/ijgo.14970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Misoprostol is widely used for cervical ripening and labour induction as it is heat-stable and inexpensive. Oral misoprostol 25 μg given 2-hourly is recommended over vaginal misoprostol 25 μg given 6-hourly, but the need for 2-hourly fetal monitoring makes oral misoprostol impractical for routine use in high-volume obstetric units in resource-constrained settings. OBJECTIVES To compare the efficacy and safety of oral misoprostol initiated at 25 or 50 μg versus 25 μg vaginal misoprostol given at 4- to 6-hourly intervals for labor induction in women at or beyond term (≥ 37 weeks) with a single viable fetus and an unscarred uterus. SEARCH STRATEGY We identified eligible randomized, parallel-group, labor-induction trials from recent systematic reviews. We additionally searched PubMed, Cochrane CENTRAL, Epistemonikos, and clinical trials registries from February 1, 2020 to December 31, 2022 without language restrictions. Database-specific keywords for cervical priming, labor induction, and misoprostol were used. SELECTION CRITERIA We excluded labor-induction trials exclusively in women with ruptured membranes, in the third trimester, and those that initiated misoprostol at doses not specified in the review's objectives. The primary outcomes were vaginal birth within 24 h, cesarean section, perinatal mortality, neonatal morbidity, and maternal morbidity. The secondary outcomes were uterine hyperstimulation with fetal heart rate changes, and oxytocin augmentation. DATA COLLECTION AND ANALYSIS Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived pooled weighted risk ratios with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the dose and frequency of misoprostol regimens. We used the I2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach to assess certainty (confidence) in the effect estimates. MAIN RESULTS Thirteen trials, from Canada, India, Iran, and the US, randomizing 2941 women at ≥37 weeks of gestation with an unfavorable cervix (Bishop score <6), met the eligibility criteria. Five misoprostol regimens were compared: 25 μg oral versus 25 μg vaginal, 4-hourly (three trials); 50 μg oral versus 25 μg vaginal, 4-hourly (five trials); 50 μg followed by 100 μg oral versus 25 μg vaginal, 4-hourly (two trials); 50 μg oral, 4-hourly versus 25 μg vaginal, 6-hourly (one trial); and 50 μg oral versus 25 μg vaginal, 6-hourly (two trials). The overall certainty in the evidence ranged from moderate to very low, due to high risk of bias in 11/13 trials (affecting all outcomes), unexplained heterogeneity (1/7 outcomes), indirectness (1/7 outcomes), and imprecision (4/7 outcomes). Vaginal misoprostol probably increased vaginal deliveries within 24 h compared with oral misoprostol (risk ratio [RR] 0.82, 95% CI 0.70-0.96; 11 trials, 2721 mothers; moderate-certainty evidence); this was more likely with 4-hourly than with 6-hourly vaginal regimens. The risk of cesarean sections did not appreciably differ (RR 1.00, 95% CI 0.80-1.26; 13 trials, 2941 mothers; very low-certainty evidence), although oral misoprostol 25 μg 4-hourly probably increased this risk compared with 25 μg vaginal misoprostol 4-hourly (RR 1.69, 95% CI 1.21-2.36; three trials, 515 mothers). The risk of perinatal mortality (RR 0.67, 95% CI 0.11-3.90; one trial, 196 participants; very low-certainty evidence), neonatal morbidity (RR 0.84, 95% CI 0.67-1.06; 13 trials, 2941 mothers; low-certainty evidence), and maternal morbidity (RR 0.83, 95% CI 0.48-1.44; 6 trials; 1945 mothers; moderate-certainty evidence) did not differ appreciably. The risk of uterine hyperstimulation with fetal heart rate changes may be lower with oral misoprostol (RR 0.70, 95% CI 0.52-0.95; 10 trials, 2565 mothers; low-certainty evidence). Oxytocin augmentation was probably more frequent with oral compared with vaginal misoprostol (RR 1.29, 95% CI 1.10-1.51; 13 trials, 2941 mothers; moderate-certainty evidence). CONCLUSIONS Low-dose, 4- to 6-hourly vaginal misoprostol regimens probably result in more vaginal births within 24 h and less frequent oxytocin use compared with low-dose, 4- to 6-hourly, oral misoprostol regimens. Vaginal misoprostol may increase the risk of uterine hyperstimulation with fetal heart changes compared with oral misoprostol, without increasing the risk of perinatal mortality, neonatal morbidity, or maternal morbidity. Indirect evidence indicates that 25 μg vaginal misoprostol 4-hourly may be more effective and as safe as the recommended 6-hourly vaginal regimen. This evidence could inform clinical decisions in high-volume obstetric units in resource-constrained settings.
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Affiliation(s)
- Hilda Yenuberi
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Jiji Mathews
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Anne George
- Department of Community Health, Christian Medical College, Vellore, India
| | - Santosh Benjamin
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Swati Rathore
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Richa Tirkey
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Prathap Tharyan
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
- Clinical Epidemiology Unit, Christian Medical College, Vellore, India
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Efficacy and safety of oral and sublingual versus vaginal misoprostol for induction of labour: a systematic review and meta-analysis. Arch Gynecol Obstet 2022:10.1007/s00404-022-06867-9. [DOI: 10.1007/s00404-022-06867-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
Abstract
Objective
Misoprostol is a synthetic PGE1 analogue that is used for induction of labour. Current guidelines support the use of doses that do not exceed 25 mcg in order to limit maternal and neonatal adverse outcomes. The present meta-analysis investigates the efficacy and safety of oral compared to vaginally inserted misoprostol in terms of induction of labor and adverse peripartum outcomes.
Methods
We searched Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar, and Clinicaltrials.gov databases from inception till April 2022. Randomized controlled trials that assessed the efficacy of oral misoprostol (per os or sublingual) compared to vaginally inserted misoprostol. Effect sizes were calculated in R. Sensitivity analysis was performed to evaluate the possibility of small study effects, p-hacking. Meta-regression and subgroup analysis according to the dose of misoprostol was also investigated. The methodological quality of the included studies was assessed by two independent reviewers using the risk of bias 2 tool. Quality of evidence for primary outcomes was evaluated under the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, ranging from very low to high.
Results
Overall, 57 studies were included that involved 10,975 parturient. Their risk of bias ranged between low-moderate. There were no differences among the routes of intake in terms of successful vaginal delivery within 24 h (RR 0.90, 95% CI 0.80) and cesarean section rates (RR 0.92, 95% CI 0.82, 1.04). Sublingual misoprostol was superior compared to vaginal misoprostol in reducing the interval from induction to delivery (MD – 1.11 h, 95% CI – 2.06, – 0.17). On the other hand, per os misoprostol was inferior compared to vaginal misoprostol in terms of this outcome (MD 3.45 h, 95% CI 1.85, 5.06). Maternal and neonatal morbidity was not affected by the route or dose of misoprostol.
Conclusion
The findings of our study suggest that oral misoprostol intake is equally safe to vaginal misoprostol in terms of inducing labor at term. Sublingual intake seems to outperform the per os and vaginal routes without increasing the accompanying morbidity. Increasing the dose of misoprostol does not seem to increase its efficacy.
Clinical trial registration
Open Science Framework (https://doi.org/10.17605/OSF.IO/V9JHF).
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Kuba K, Estrada-Trejo F, Lambert C, Vani K, Eisenberg R, Nathan L, Bernstein P, Hughes F. Novel Evidence-Based Labor Induction Algorithm Associated with Increased Vaginal Delivery within 24 Hours. Am J Perinatol 2022; 39:1622-1632. [PMID: 35709742 DOI: 10.1055/a-1877-8996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to assess whether concordance with our proposed labor induction algorithm is associated with an increased rate of vaginal delivery within 24 hours. STUDY DESIGN We conducted a retrospective review of 287 induction of labors (IOLs) at a single urban, tertiary, academic medical center which took place before we created an evidence-based IOL algorithm. We then compared the IOL course to the algorithm to assess for concordance and outcomes. Patients age 18 years or over with a singleton, cephalic pregnancy of 366/7 to 420/7 weeks' gestation were included. Patients were excluded with a Bishop's score >6, contraindication to misoprostol or cervical Foley catheter, major fetal anomalies, or intrauterine fetal death. Patients with 100% concordance were compared with <100% concordant patients, and patients with ≥80% concordance were compared with <80% concordant patients. Adjusted hazard ratios (AHRs) were calculated for rate of vaginal delivery within 24 hours, our primary outcome. Competing risk's analysis was conducted for concordant versus nonconcordant groups, using vaginal delivery as the outcome of interest, with cesarean delivery (CD) as a competing event. RESULTS Patients with 100% concordance were more likely to have a vaginal delivery within 24 hours, n = 66 of 77 or 85.7% versus n = 120 of 210 or 57.1% (p < 0.0001), with an AHR of 2.72 (1.98, 3.75, p < 0.0001) after adjusting for delivery indication and scheduled status. Patients with 100% concordance also had shorter time from first intervention to delivery (11.9 vs. 19.4 hours). Patients with ≥80% concordance had a lower rate of CD (11/96, 11.5%) compared with those with <80% concordance (43/191 = 22.5%; p = 0.0238). There were no differences in neonatal outcomes assessed. CONCLUSION Our IOL algorithm may offer an opportunity to standardize care, improve the rate of vaginal delivery within 24 hours, shorten time to delivery, and reduce the CD rate for patients undergoing IOL. KEY POINTS · Studies on IOL have focused on individual steps. A labor induction algorithm allows for standardization.. · Algorithm concordance is associated with decreased time to delivery.. · Algorithm concordance is associated with decreased CD rate..
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Affiliation(s)
- Kfier Kuba
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Fatima Estrada-Trejo
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Calvin Lambert
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Kavita Vani
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Ruth Eisenberg
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Lisa Nathan
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Peter Bernstein
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Francine Hughes
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Kerr RS, Kumar N, Williams MJ, Cuthbert A, Aflaifel N, Haas DM, Weeks AD. Low-dose oral misoprostol for induction of labour. Cochrane Database Syst Rev 2021; 6:CD014484. [PMID: 34155622 PMCID: PMC8218159 DOI: 10.1002/14651858.cd014484] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Misoprostol given orally is a commonly used labour induction method. Our Cochrane Review is restricted to studies with low-dose misoprostol (initially ≤ 50 µg), as higher doses pose unacceptably high risks of uterine hyperstimulation. OBJECTIVES To assess the efficacy and safety of low-dose oral misoprostol for labour induction in women with a viable fetus in the third trimester of pregnancy. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (14 February 2021) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing low-dose oral misoprostol (initial dose ≤ 50 µg) versus placebo, vaginal dinoprostone, vaginal misoprostol, oxytocin, or mechanical methods; or comparing oral misoprostol protocols (one- to two-hourly versus four- to six-hourly; 20 µg to 25 µg versus 50 µg; or 20 µg hourly titrated versus 25 µg two-hourly static). DATA COLLECTION AND ANALYSIS Using Covidence, two review authors independently screened reports, extracted trial data, and performed quality assessments. Our primary outcomes were vaginal birth within 24 hours, caesarean section, and hyperstimulation with foetal heart changes. MAIN RESULTS We included 61 trials involving 20,026 women. GRADE assessments ranged from moderate- to very low-certainty evidence, with downgrading decisions based on imprecision, inconsistency, and study limitations. Oral misoprostol versus placebo/no treatment (four trials; 594 women) Oral misoprostol may make little to no difference in the rate of caesarean section (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.11; 4 trials; 594 women; moderate-certainty evidence), while its effect on uterine hyperstimulation with foetal heart rate changes is uncertain (RR 5.15, 95% CI 0.25 to 105.31; 3 trials; 495 women; very low-certainty evidence). Vaginal births within 24 hours was not reported. In all trials, oxytocin could be commenced after 12 to 24 hours and all women had pre-labour ruptured membranes. Oral misoprostol versus vaginal dinoprostone (13 trials; 9676 women) Oral misoprostol probably results in fewer caesarean sections (RR 0.84, 95% CI 0.78 to 0.90; 13 trials, 9676 women; moderate-certainty evidence). Subgroup analysis indicated that 10 µg to 25 µg (RR 0.80, 95% CI 0.74 to 0.87; 9 trials; 8652 women) may differ from 50 µg (RR 1.10, 95% CI 0.91 to 1.34; 4 trials; 1024 women) for caesarean section. Oral misoprostol may decrease vaginal births within 24 hours (RR 0.93, 95% CI 0.87 to 1.00; 10 trials; 8983 women; low-certainty evidence) and hyperstimulation with foetal heart rate changes (RR 0.49, 95% CI 0.40 to 0.59; 11 trials; 9084 women; low-certainty evidence). Oral misoprostol versus vaginal misoprostol (33 trials; 6110 women) Oral use may result in fewer vaginal births within 24 hours (average RR 0.81, 95% CI 0.68 to 0.95; 16 trials, 3451 women; low-certainty evidence), and less hyperstimulation with foetal heart rate changes (RR 0.69, 95% CI 0.53 to 0.92, 25 trials, 4857 women, low-certainty evidence), with subgroup analysis suggesting that 10 µg to 25 µg orally (RR 0.28, 95% CI 0.14 to 0.57; 6 trials, 957 women) may be superior to 50 µg orally (RR 0.82, 95% CI 0.61 to 1.11; 19 trials; 3900 women). Oral misoprostol probably does not increase caesarean sections overall (average RR 1.00, 95% CI 0.86 to 1.16; 32 trials; 5914 women; low-certainty evidence) but likely results in fewer caesareans for foetal distress (RR 0.74, 95% CI 0.55 to 0.99; 24 trials, 4775 women). Oral misoprostol versus intravenous oxytocin (6 trials; 737 women, 200 with ruptured membranes) Misoprostol may make little or no difference to vaginal births within 24 hours (RR 1.12, 95% CI 0.95 to 1.33; 3 trials; 466 women; low-certainty evidence), but probably results in fewer caesarean sections (RR 0.67, 95% CI 0.50 to 0.90; 6 trials; 737 women; moderate-certainty evidence). The effect on hyperstimulation with foetal heart rate changes is uncertain (RR 0.66, 95% CI 0.19 to 2.26; 3 trials, 331 women; very low-certainty evidence). Oral misoprostol versus mechanical methods (6 trials; 2993 women) Six trials compared oral misoprostol to transcervical Foley catheter. Misoprostol may increase vaginal birth within 24 hours (RR 1.32, 95% CI 0.98 to 1.79; 4 trials; 1044 women; low-certainty evidence), and probably reduces the risk of caesarean section (RR 0.84, 95% CI 0.75 to 0.95; 6 trials; 2993 women; moderate-certainty evidence). There may be little or no difference in hyperstimulation with foetal heart rate changes (RR 1.31, 95% CI 0.78 to 2.21; 4 trials; 2828 women; low-certainty evidence). Oral misoprostol one- to two-hourly versus four- to six-hourly (1 trial; 64 women) The evidence on hourly titration was very uncertain due to the low numbers reported. Oral misoprostol 20 µg hourly titrated versus 25 µg two-hourly static (2 trials; 296 women) The difference in regimen may have little or no effect on the rate of vaginal births in 24 hours (RR 0.97, 95% CI 0.80 to 1.16; low-certainty evidence). The evidence is of very low certainty for all other reported outcomes. AUTHORS' CONCLUSIONS Low-dose oral misoprostol is probably associated with fewer caesarean sections (and therefore more vaginal births) than vaginal dinoprostone, and lower rates of hyperstimulation with foetal heart rate changes. However, time to birth may be increased, as seen by a reduced number of vaginal births within 24 hours. Compared to transcervical Foley catheter, low-dose oral misoprostol is associated with fewer caesarean sections, but equivalent rates of hyperstimulation. Low-dose misoprostol given orally rather than vaginally is probably associated with similar rates of vaginal birth, although rates may be lower within the first 24 hours. However, there is likely less hyperstimulation with foetal heart changes, and fewer caesarean sections performed due to foetal distress. The best available evidence suggests that low-dose oral misoprostol probably has many benefits over other methods for labour induction. This review supports the use of low-dose oral misoprostol for induction of labour, and demonstrates the lower risks of hyperstimulation than when misoprostol is given vaginally. More trials are needed to establish the optimum oral misoprostol regimen, but these findings suggest that a starting dose of 25 µg may offer a good balance of efficacy and safety.
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Affiliation(s)
- Robbie S Kerr
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Nimisha Kumar
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Myfanwy J Williams
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Anna Cuthbert
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Nasreen Aflaifel
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew D Weeks
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
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Wallstrom T, Bjorklund J, Frykman J, Jarnbert-Pettersson H, Akerud H, Darj E, Gemzell-Danielsson K, Wiberg-Itzel E. Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study. PLoS One 2018; 13:e0200024. [PMID: 29965989 PMCID: PMC6028115 DOI: 10.1371/journal.pone.0200024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/17/2018] [Indexed: 11/18/2022] Open
Abstract
Objective Uterine rupture is a well-known but unusual complication in vaginal deliveries with a Cesarean section in the history. The risk of uterine rupture is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous Cesarean section, regardless if labor starts spontaneously or is induced. The aim of the study is to compare the proportion of uterine ruptures between the three methods (balloon catheter, Minprostin® and Cytotec®) for induction of labor in women with an unfavorable cervix and one previous Cesarean section. Material and methods Retrospective cohort study of all women with one previous Cesarean section and induction of labor with an unfavorable cervix at the four largest clinics in Stockholm during 2012–2015. Inclusion criteria: Women with a previous Cesarean section and induction of labor with a viable fetus, cephalic presentation, singleton, at ≥34 w, (n = 910). Results 3.0% (27/910) of the women with induction of labor had a uterine rupture, 91% of them had no previous vaginal delivery. The proportion of uterine ruptures was 2.0% (6/295) with orally administrated Cytotec®, 2.1% (7/335) with balloon catheter and 5.0% (14/ 281) when Minprostin® was used. Conclusions No difference in the proportion of uterine ruptures was shown when orally administrated Cytotec® and balloon catheter were compared (p = 0.64). Orally administrated Cytotec® and balloon catheter give a high success rate of vaginal deliveries (almost 70%) despite an unfavorable cervix.
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Affiliation(s)
- Tove Wallstrom
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
- * E-mail:
| | - Jenny Bjorklund
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
| | - Joanna Frykman
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
| | - Hans Jarnbert-Pettersson
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
| | - Helena Akerud
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Elisabeth Darj
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Oslo, Norway
| | - Kristina Gemzell-Danielsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Wiberg-Itzel
- Department of Clinical Science and Education Karolinska Institute, Women’s Clinic, Sodersjukhuset, Sweden
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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: 54] [Impact Index Per Article: 9.0] [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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Prasad N, Yadav V. Comparison of 50 μg Oral and Vaginal Misoprostol Tablets in Induction of Labor at Term. ACTA ACUST UNITED AC 2018. [DOI: 10.5005/jp-journals-10045-0071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hassan AS, Soliman GM, Ali MF, El-Mahdy MM, El-Gindy GEDA. Mucoadhesive tablets for the vaginal delivery of progesterone: in vitro evaluation and pharmacokinetics/pharmacodynamics in female rabbits. Drug Dev Ind Pharm 2017; 44:224-232. [DOI: 10.1080/03639045.2017.1386203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Abeer S. Hassan
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Ghareb M. Soliman
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut, Egypt
- Department of Pharmaceutics, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Marwa F. Ali
- Department of Pathology, Faculty of Veterinary Medicine, Assiut University, Assiut, Egypt
| | - Mona M. El-Mahdy
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut, Egypt
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Morris M, Bolnga JW, Verave O, Aipit J, Rero A, Laman M. Safety and effectiveness of oral misoprostol for induction of labour in a resource-limited setting: a dose escalation study. BMC Pregnancy Childbirth 2017; 17:298. [PMID: 28886702 PMCID: PMC5591556 DOI: 10.1186/s12884-017-1483-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 09/04/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity in resource-limited settings because it is cheap, stable at ambient temperatures, and logistically easier to administer compared to dinoprostone and oxytocin. We aim to investigate the safety and effectiveness of a regimen of oral misoprostol in Papua New Guinean women undergoing IOL. METHODS As part of a prospective dose escalation study conducted at Modilon Hospital in Papua New Guinea, women with a singleton pregnancy in cephalic presentation and an unfavourable cervix who gave written informed consent were administered oral misoprostol, commencing at 25mcg once every 2 h for 4 doses and increased to 50mcg once every 2 h for 8 doses within 24 h. The primary outcomes studied were i) the proportion of women delivering within 24 h of oral misoprostol administration, and ii) rates of maternal and perinatal severe adverse events. RESULTS Of 6167 labour ward screened admissions, 209 women (3%) fulfilled the study inclusion criteria and underwent IOL. Overall, 74% (155/209 [95% confidence interval 67.6-79.9]) delivered within 24 h. Most women (90%; 188/209; 95% CI [84.9-93.5]) delivered vaginally with 86% (180/209) having a good outcome for both the mother and baby. Of the 10% (21/209) who failed IOL and underwent caesarean section, a significant proportion of their babies were admitted to special-care nursery compared to babies delivered vaginally (20/21 [95%] versus 8/188 [4%]; Fisher Exact test P < 0.001), but their perinatal mortality rate was not significantly higher (1/21 [5%] versus 2/188 [1%]; P = 0.30). The only maternal death was not study related and occurred in a patient with post-partum haemorrhage, 15 h post-delivery. CONCLUSION The oral misoprostol regimen for IOL described in the present study is safe, effective and logistically feasible to administer in a resource-limited setting.
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Affiliation(s)
- Marilyn Morris
- Department of Obstetrics and Gynaecology, Modilon General Hospital, Madang, Papua New Guinea
| | - John W. Bolnga
- Department of Obstetrics and Gynaecology, Modilon General Hospital, Madang, Papua New Guinea
| | - Ovoi Verave
- Department of Obstetrics and Gynaecology, Modilon General Hospital, Madang, Papua New Guinea
| | - Jimmy Aipit
- Department of Paediatrics, Modilon General Hospital, Madang, Papua New Guinea
| | - Allanie Rero
- Department of Paediatrics, Modilon General Hospital, Madang, Papua New Guinea
| | - Moses Laman
- Department of Paediatrics, Modilon General Hospital, Madang, Papua New Guinea
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
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Weeks AD, Navaratnam K, Alfirevic Z. Simplifying oral misoprostol protocols for the induction of labour. BJOG 2017; 124:1642-1645. [PMID: 28342186 PMCID: PMC5638087 DOI: 10.1111/1471-0528.14657] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 11/29/2022]
Affiliation(s)
- A D Weeks
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - K Navaratnam
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Z Alfirevic
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Drakopoulos P, Duyck C, Gayet-Ageron A, Fernandez S, Irion O, Martinez de Tejada B. What is the optimal duration of oral misoprostol treatment for cervical ripening? J Matern Fetal Neonatal Med 2016; 30:1494-1499. [PMID: 27493019 DOI: 10.1080/14767058.2016.1220520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the number of misoprostol tablets needed to obtain a Bishop score (BS) ≥ 6 or a significant cervical change (≥2 points in BS) during cervical ripening. METHODS Retrospective study of women with term singleton pregnancies and a BS < 6 taking oral misoprostol (20 μg first 2 doses followed by 40 μg every 2 h) for cervical ripening. RESULTS We included 400 women, 72% nulliparous, mean age of 31.3 ± 5.9 years and 70% with a baseline BS ≤ 2. During cervical ripening, 61 (15.3%) achieved a BS ≥ 6 and 205 (51.3%) a significant change in BS. The incremental risk to achieve a BS ≥ 6 after 4 tablets was low (+3.25%) with an incremental probability of +12.75% for painful uterine contractions and +0.5% for abnormal fetal tracing (AFT). The incremental probability to achieve a significant change in BS after 7 tablets was low (+2.0%). 24.3% women delivered by cesarean section which likelihood significantly increased with maternal age <35 years, BMI ≥ 30, nulliparity, AFT, and baseline BS ≤ 2. CONCLUSIONS The marginal benefit of giving more than 7 misoprostol tablets (14 h) during cervical ripening is very low.
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Affiliation(s)
- Panagiotis Drakopoulos
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Geneva University Hospitals , Geneva , Switzerland.,b Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel , Brussels , Belgium , and
| | - Céline Duyck
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Geneva University Hospitals , Geneva , Switzerland
| | - Angèle Gayet-Ageron
- c Department of Community Health and Medicine , Clinical Research Center and Division of Clinical Epidemiology, Geneva University Hospitals, University of Geneva , Geneva , Switzerland
| | - Sonia Fernandez
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Geneva University Hospitals , Geneva , Switzerland
| | - Olivier Irion
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Geneva University Hospitals , Geneva , Switzerland
| | - Begoña Martinez de Tejada
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Geneva University Hospitals , Geneva , Switzerland
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Rath W, Tsikouras P. Misoprostol for Labour Induction after Previous Caesarean Section - Forever a "No Go"? Geburtshilfe Frauenheilkd 2015; 75:1140-1147. [PMID: 26719597 DOI: 10.1055/s-0035-1558171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Misoprostol in oral or vaginal form is an established method of labour induction worldwide. Its use after previous caesarean section is associated with a high rate of uterine rupture; according to international guidelines it is therefore contraindicated in this setting. However the evidence base for this recommendation comprises case reports, one randomised trial that was discontinued prematurely, and numerous low quality retrospective data analyses published between 1997 and 2004. New insights into e.g. resorption kinetics, dosage and application intervals, dose dependant uterine hyperstimulation rates, as well as increasing clinical experience with misoprostol have lead to a critical reappraisal of these "historical" studies. Accordingly the evidence supporting a ban on vaginal and particularly oral misoprostol for labour induction in the context of a scarred uterus is currently insufficient for a convincing guideline recommendation. In view of the clear advantages of misoprostol over prostaglandin E2 (cheaper, more effective) a retrospective review of registry data should be conducted to determine the incidence of uterine rupture following misoprostol and the circumstances in which it occurs. A prospective, randomised trial could then be conducted on the basis of these findings (e.g. oral misoprostol vs. vaginal prostaglandin E2); known risk factors for uterine rupture including the type of uterine scar would need to be taken into account when selecting patients for vaginal delivery. Until new data from well-designed studies are available, misoprostol will continue to be contraindicated in clinical guidelines for use in labour induction after previous caesarean section.
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Affiliation(s)
- W Rath
- Faculty of Medicine, Gynaecology and Obstetrics, University Hospital RWTH Aachen, Aachen
| | - P Tsikouras
- Democritus University of Thrace, Department of Obstetrics and Gynecology, Alexandroupolis, Greece
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Abstract
BACKGROUND Misoprostol is an orally active prostaglandin. In most countries misoprostol is not licensed for labour induction, but its use is common because it is cheap and heat stable. OBJECTIVES To assess the use of oral misoprostol for labour induction in women with a viable fetus. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 January 2014). SELECTION CRITERIA Randomised trials comparing oral misoprostol versus placebo or other methods, given to women with a viable fetus for labour induction. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial data, using centrally-designed data sheets. MAIN RESULTS Overall there were 76 trials (14,412) women) which were of mixed quality.In nine trials comparing oral misoprostol with placebo (1109 women), women using oral misoprostol were more likely to give birth vaginally within 24 hours (risk ratio (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49; one trial; 96 women), need less oxytocin (RR 0.42, 95% CI 0.37 to 0.49; seven trials; 933 women) and have a lower caesarean section rate (RR 0.72, 95% CI 0.54 to 0.95; eight trials; 1029 women).In 12 trials comparing oral misoprostol with vaginal dinoprostone (3859 women), women given oral misoprostol were less likely to need a caesarean section (RR 0.88, 95% CI 0.78 to 0.99; 11 trials; 3592 women). There was some evidence that they had slower inductions, but there were no other statistically significant differences.Nine trials (1282 women) compared oral misoprostol with intravenous oxytocin. The caesarean section rate was significantly lower in women who received oral misoprostol (RR 0.77, 95% CI 0.60 to 0.98; nine trials; 1282 women), but they had increased rates of meconium-stained liquor (RR 1.65, 95% CI 1.04 to 2.60; seven trials; 1172 women).Thirty-seven trials (6417 women) compared oral and vaginal misoprostol and found no statistically significant difference in the primary outcomes of serious neonatal morbidity/death or serious maternal morbidity or death. The results for vaginal birth not achieved in 24 hours, uterine hyperstimulation with fetal heart rate (FHR) changes, and caesarean section were highly heterogenous - for uterine hyperstimulation with FHR changes this was related to dosage with lower rates in those with lower doses of oral misoprostol. However, there were fewer babies born with a low Apgar score in the oral group (RR 0.60, 95% CI 0.44 to 0.82; 19 trials; 4009 babies) and a decrease in postpartum haemorrhage (RR 0.57, 95% CI 0.34 to 0.95; 10 trials; 1478 women). However, the oral misoprostol group had an increase in meconium-stained liquor (RR 1.22, 95% CI 1.03 to 1.44; 24 trials; 3634 women). AUTHORS' CONCLUSIONS Oral misoprostol as an induction agent is effective at achieving vaginal birth. It is more effective than placebo, as effective as vaginal misoprostol and results in fewer caesarean sections than vaginal dinoprostone or oxytocin.Where misoprostol remains unlicensed for the induction of labour, many practitioners will prefer to use a licensed product like dinoprostone. If using oral misoprostol, the evidence suggests that the dose should be 20 to 25 mcg in solution. Given that safety is the primary concern, the evidence supports the use of oral regimens over vaginal regimens. This is especially important in situations where the risk of ascending infection is high and the lack of staff means that women cannot be intensely monitored.
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Affiliation(s)
- Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Nasreen Aflaifel
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Andrew Weeks
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Gaudineau A, Vayssière C. Maturation cervicale par misoprostol sur fœtus viable. ACTA ACUST UNITED AC 2014; 43:169-78. [DOI: 10.1016/j.jgyn.2013.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Jindal P, Avasthi K, Kaur M. A Comparison of Vaginal vs. Oral Misoprostol for Induction of Labor-Double Blind Randomized Trial. J Obstet Gynaecol India 2011; 61:538-42. [PMID: 23024525 DOI: 10.1007/s13224-011-0081-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 07/27/2011] [Indexed: 10/16/2022] Open
Abstract
OBJECTIVE To compare efficacy and safety of 50 μgm misoprostol vaginal with oral for labor induction. METHODS 110 women at term gestation, Bishop score ≤4, with various indications for labor induction were randomized and double blinded. After decoding 51 women had received misoprostol orally and 52 vaginally, four hourly (maximum six doses) or till woman went into active labor. RESULTS Statistical analysis was done with SPSS 11.0. In vaginal misoprostol group induction delivery interval was significantly less (9.79 vs. 16.47 h) and successful induction was significantly higher (90.38 vs. 74.51%) than oral group, with in 24 h of induction. As for as dose required is concerned in vaginal group 40.38% women needed two doses for delivery, in contrast 35.29% in oral group maximum six doses were required. CONCLUSION Vaginal route of misoprostol is more effective labor inducing agent than oral.
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Affiliation(s)
- Promila Jindal
- Department of Obstetrics and Gynecology, Dayanand Medical College and Hospital, 20-B, Rishi Nagar, Ludhiana, 141001 Punjab India
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Ande AB, Ezeanochie CM, Olagbuji NB. Induction of labor in prolonged pregnancy with unfavorable cervix: comparison of sequential intracervical Foley catheter-intravaginal misoprostol and intravaginal misoprostol alone. Arch Gynecol Obstet 2011; 285:967-71. [PMID: 22012248 DOI: 10.1007/s00404-011-2094-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 09/21/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare the outcome of induced labor at term using sequential intracervical Foley catheter with intravaginal misoprostol versus intravaginal misoprostol alone. METHODS A prospective matched case control study among parturient with prolonged pregnancy and unfavorable cervix at a tertiary hospital in Nigeria. RESULTS The study population was 100 with a mean age of 29.46 ± 3.88 years. Parturient with prior cervical priming using intracervical Foley catheter had significantly lower oxytocin augmentation of uterine contractions in labor (44 vs. 64%, P = 0.045), shorter mean insertion to active phase labor duration (233 ± 98 vs. 354 ± 154 min, P = 0.0001), shorter insertion to delivery interval (514 ± 175 vs. 627 ± 268, P = 0.014), more vaginal delivery <12 h (92.5 vs. 60%, P = 0.001) and less delivery by caesarean section (20 vs. 40%, P = 0.029). CONCLUSIONS The sequential combination of intracervical Foley catheter and intravaginal misoprostol for cervical ripening and induction of labor appears to be a safe and more effective method compared to intravaginal misoprostol in parturient at term with unfavorable cervices.
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Affiliation(s)
- A Babatunde Ande
- Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.
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Hombach J, Palmberger TF, Bernkop‐Schnürch A. Development and In Vitro Evaluation of a Mucoadhesive Vaginal Delivery System for Nystatin. J Pharm Sci 2009; 98:555-64. [DOI: 10.1002/jps.21457] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kundodyiwa TW, Alfirevic Z, Weeks AD. Low-dose oral misoprostol for induction of labor: a systematic review. Obstet Gynecol 2009; 113:374-83. [PMID: 19155909 DOI: 10.1097/aog.0b013e3181945859] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the efficacy and safety of low-dose oral misoprostol compared with dinoprostone (PGE2), vaginal misoprostol, and oxytocin for labor induction in women with a viable fetus. DATA SOURCES We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published before January 2008 using the keywords misoprostol, labor, induction, randomized controlled trials, dinoprostone, oxytocin, pregnancy, and maternal and fetal side effects. METHODS OF STUDY SELECTION We included randomized controlled trials comparing 20-25 micrograms oral misoprostol with vaginal misoprostol, dinoprostone or oxytocin given to women at 32-42 weeks of gestation for labor induction. From 401 citations identified, results from nine studies were finally analyzed using the Review Manager software. Relative risk (RR) and 95% confidence intervals (CIs) were calculated using fixed and random-effects models. TABULATION, INTEGRATION, AND RESULTS Nine articles with 2,937 women met the inclusion criteria. The five trials comparing oral misoprostol and dinoprostone showed significantly fewer women requiring cesarean delivery in the misoprostol group (20% compared with 26%; RR 0.82, 95% CI 0.71-0.96). There were no statistically significant differences in risks of uterine hyperstimulation or need for oxytocin augmentation. Two trials compared oral with vaginal low-dose misoprostol. Women using oral misoprostol were significantly less likely to experience uterine hyperstimulation with fetal heart rate changes (2% compared with 13%; RR 0.19, 95% CI 0.08-0.46), but there were no significant differences in other outcomes. CONCLUSION Low-dose oral misoprostol solution (20 micrograms) administered every 2 hours seems at least as effective as both vaginal dinoprostone and vaginal misoprostol, with lower rates of cesarean delivery and uterine hyperstimulation, respectively.
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Abstract
Using oral agents for induction of labor would reduce the need for repeated vaginal examinations; this is more acceptable to women and could reduce infection rates. A systematic review was conducted of 41 randomized trials comparing oral misoprostol to other induction agents. Oral misoprostol is effective at achieving vaginal delivery, and may have benefits over both vaginal and intracervical dinoprostone. Although it does not achieve vaginal delivery as quickly as vaginal misoprostol, the rates of hyperstimulation are lower when using comparable doses. As the primary consideration should be safety rather than speed, an oral regimen using a maximum of 50 mcg 4 hourly is recommended.
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Affiliation(s)
- Andrew Weeks
- School of Reproductive and Developmental Medicine, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK.
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20
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De A, Bagga R, Gopalan S. The routine use of oxytocin after oral misoprostol for labour induction in women with an unfavourable cervix is not of benefit. Aust N Z J Obstet Gynaecol 2006; 46:323-9. [PMID: 16866794 DOI: 10.1111/j.1479-828x.2006.00600.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Induction of labour with misoprostol is often augmented with oxytocin with the possible consequence of uterine hypercontractility. It is important to determine whether the use of oxytocin in this circumstance has benefit as well as risk. AIM To compare two regimens for labour induction in women with an unfavourable cervix: oral misoprostol vs. oral misoprostol routinely followed by oxytocin. METHODS A prospective randomised trial in which 200 women with an unfavourable cervix received either oral misoprostol 25 microg every 3 h (group 1, n = 100) or two such doses routinely followed by oxytocin (group 2, n = 100). Outcomes included change in Bishop score, induction delivery interval, oxytocin requirement, contraction abnormalities, mode of delivery and neonatal outcome. RESULT The improvement in Bishop score with two misoprostol doses in all 200 women was highly significant (2.9 +/- 1.5 to 6.6 +/- 1.9, P < 0.0001). The induction delivery interval, Caesarean delivery rate, vaginal delivery rate within 24 h, contraction abnormalities and neonatal outcome were similar in both groups. Contraction abnormalities were remarkably low with either regimen (1%). Routine addition of oxytocin 3 h after the second misoprostol dose (group 2) resulted in the maximum oxytocin dose (64 mU/min) being given to more women (66% in group 2; 36% in group 1). CONCLUSION There was no benefit of routine addition of oxytocin after two doses of misoprostol. Reduced oxytocin requirement was observed when it was added only if needed. Both regimens achieved 85-87% vaginal deliveries with low incidence of hypercontractility.
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Affiliation(s)
- Arunangsu De
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
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Abstract
BACKGROUND Misoprostol is a synthetic prostaglandin that can be given orally or vaginally. In most countries misoprostol has not been licensed for use in pregnancy, but its unlicensed use is common because misoprostol is cheap, stable at room temperature and effective in causing uterine contractions. Oral use of misoprostol may be convenient, but high doses could cause uterine hyperstimulation and uterine rupture which may be life-threatening for both mother and fetus. OBJECTIVES To assess the effectiveness and safety of oral misoprostol used for labour induction in women with a viable fetus in the third trimester of pregnancy. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group Trials Register (January 2005). SELECTION CRITERIA Randomised trials comparing oral misoprostol versus other methods, placebo or no treatment, given to women with a viable fetus for labour induction. DATA COLLECTION AND ANALYSIS Three authors independently assessed trial quality and extracted data, using centrally-designed data sheets. MAIN RESULTS Forty-one trials (8606 participants) were included. In four trials comparing oral misoprostol with placebo (474 participants), women using oral misoprostol were less likely to have long labours (relative risk (RR) 0.16, 95% confidence interval (CI) 0.05 to 0.49), needed less oxytocin (RR 0.32, 95% CI 0.24 to 0.43) and had a lower caesarean section rate (RR 0.62, 95% CI 0.40 to 0.96). In nine trials comparing oral misoprostol with vaginal dinoprostone (2627 participants), women given oral misoprostol were less likely to need a caesarean section, but this reduction reached statistical significance only in the subgroup with intact membranes (RR 0.78, 95% CI 0.66 to 0.94). Uterine hyperstimulation was more common after oral misoprostol (RR 1.63, 95% CI 1.09 to 2.44) although this was not associated with any adverse fetal events. Seven trials (1017 participants) compared oral misoprostol with intravenous oxytocin. The only difference between the groups was an increase in meconium-stained liquor in women with ruptured membranes following administration of oral misoprostol (RR 1.72, 95% 1.08 to 2.74). Sixteen trials (3645 participants) compared oral and vaginal misoprostol and found no difference in the primary outcomes. There was less uterine hyperstimulation without fetal heart rate changes in those given oral misoprostol (RR 0.37, 95% 0.23 to 0.59). Oral misoprsotol was associated with increased need for oxytocin augmentation (RR 1.28, 95% 1.11 to 1.48) and more meconium-stained liquor (RR 1.27, 1.01 to 1.60). AUTHORS' CONCLUSIONS Oral misoprostol appears to be more effective than placebo and at least as effective as vaginal dinoprostone. However, there remain questions about its safety because of a relatively high rate of uterine hyperstimulation and the lack of appropriate dose ranging studies. In countries where misoprostol remains unlicenced for the induction of labour, many practitioners will prefer the legal protection of using a licenced product like dinoprostone. There is no evidence that misoprostol given orally is inferior to the vaginal route and has lower rates of hyperstimulation. If misoprostol is used orally, the dose should not exceed 50 mcg.
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Affiliation(s)
- Z Alfirevic
- University of Liverpool, Division of Perinatal and Reproductive Medicine, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK, L8 7SS.
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Colón I, Clawson K, Hunter K, Druzin ML, Taslimi MM. Prospective randomized clinical trial of inpatient cervical ripening with stepwise oral misoprostol vs vaginal misoprostol. Am J Obstet Gynecol 2005; 192:747-52. [PMID: 15746667 DOI: 10.1016/j.ajog.2004.12.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the efficacy and safety of stepwise oral misoprostol vs vaginal misoprostol for cervical ripening before induction of labor. STUDY DESIGN Two hundred and four women between 32 to 42 weeks of gestation with an unfavorable cervix (Bishop score < or = 6) and an indication for labor induction were randomized to receive oral or vaginal misoprostol every 4 hours up to 4 doses. The oral misoprostol group received 50 microg initially followed by 100 microg in each subsequent dose. The vaginal group received 25 microg in each dose. The primary outcome was the interval from first misoprostol dose to delivery. Patient satisfaction and side effects were assessed by surveys completed after delivery. RESULTS Ninety-three (45.6%) women received oral misoprostol; 111 (54.4%) received vaginal misoprostol. There was no difference in the average interval from the first dose of misoprostol to delivery in the oral (21.1 + 7.9 hrs) and vaginal (21.5 + 11.0 hrs, P = NS) misoprostol groups. The incidence of hyperstimulation in the oral group was 2.2% vs 5.4% in the vaginal group, P = NS. Eighteen patients in the oral group (19.4%) and 36 (32.4%) in the vaginal group underwent cesarean section (P < .05). This difference was attributed to better tolerance of more doses of misoprostol by the women in the oral group. There was no difference in side effects (nausea, vomiting, diarrhea, shivering) between groups. Fourteen percent of women in the vaginal group versus 7.5% in the oral group were dissatisfied with the use of misoprostol (P = NS). CONCLUSION Stepwise oral misoprostol (50 microg followed by 100 microg) appears to be as effective as vaginal misoprostol (25 microg) for cervical ripening with a low incidence of hyperstimulation, no increase in side effects, a high rate of patient satisfaction, and is associated with a lower cesarean section rate.
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Affiliation(s)
- Iris Colón
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA 94305-5317, USA
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Dällenbach P, Boulvain M, Viardot C, Irion O. Oral misoprostol or vaginal dinoprostone for labor induction: a randomized controlled trial. Am J Obstet Gynecol 2003; 188:162-7. [PMID: 12548212 DOI: 10.1067/mob.2003.108] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of the study was to compare the effectiveness, safety, and side effects of low-dose oral misoprostol with vaginal dinoprostone for cervical ripening and labor induction. STUDY DESIGN Women with Bishop score 6 or less admitted for labor induction at term were eligible for this randomized controlled trial. Exclusion criteria were multiple pregnancy, breech, fetal distress, or previous uterine scar. The allocation to the oral misoprostol group (20 microg given every 2 hours increased to 40 microg depending on uterine contractions) or to the vaginal dinoprostone group (2 mg twice, 6 hours apart) was contained in a sealed, opaque, and consecutively numbered envelope. RESULTS Two hundred women (100 in each group) were included. The proportion of vaginal delivery within 24 hours was 56% in the misoprostol group and 62% in the dinoprostone group (relative risk 0.90, 95% CI 0.72-1.14). The risk of cesarean section was 18% and 19%, respectively. The median interval to delivery, calculated from survival analysis, was longer in the misoprostol group (1305 minutes) compared with the dinoprostone group (1080 minutes). The log-rank test was not significant (P =.35). Uterine hyperstimulation occurred in 9% of women in the misoprostol group compared with 14% in the dinoprostone group (P =.27). The only significant difference in neonatal outcomes was a more frequent presence of thick meconium in the misoprostol group (P =.03). CONCLUSION We found no difference in terms of effectiveness and safety between low-dose oral misoprostol and vaginal dinoprostone used for induction of labor. This regimen avoids the excessive uterine contractility noted in previous studies, where higher doses of misoprostol were administered at longer intervals.
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Affiliation(s)
- Patrick Dällenbach
- Department of Obstetrics and Gynecology, Geneva University Hospitals, Geneva, Switzerland.
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