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Patabendige M, Chan F, Vayssiere C, Ehlinger V, Van Gemund N, le Cessie S, Prager M, Marions L, Rozenberg P, Chevret S, Young DC, Le Roux PA, Gregson S, Waterstone M, Rolnik DL, Mol BW, Li W. Vaginal misoprostol versus vaginal dinoprostone for cervical ripening and induction of labour: An individual participant data meta-analysis of randomised controlled trials. BJOG 2024. [PMID: 38425020 DOI: 10.1111/1471-0528.17794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
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Randomised controlled trials (RCTs), with viable singleton gestation, no language restrictions, and all published and unpublished data.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.
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Affiliation(s)
- Malitha Patabendige
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
- Ministry of Health, Colombo, Sri Lanka
- Monash Health - Casey Hospital, Berwick, Victoria, Australia
| | - Fei Chan
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Christophe Vayssiere
- Centre for Epidemiology and Research in Population Health (CERPOP), UMR1295, Toulouse University, Inserm, Paul Sabatier University, Toulouse, France
- Department of Obstetrics and Gynaecology, Paule de Viguier Hospital, Toulouse University Hospital, Toulouse, France
| | - Virginie Ehlinger
- Centre for Epidemiology and Research in Population Health (CERPOP), UMR1295, Toulouse University, Inserm, Paul Sabatier University, Toulouse, France
| | - Nicolette Van Gemund
- Department of Obstetrics and Gynaecology, Franciscus Gasthuis, Rotterdam, the Netherlands
| | - Saskia le Cessie
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Martina Prager
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lena Marions
- Division of Obstetrics and Gynaecology, Department of Women's and Children's Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Patrick Rozenberg
- Department of Gynaecology and Obstetrics, Poissy Hospital, University Paris V, Paris, France
| | - Sylvie Chevret
- Department of Biostatistics, Hopital Saint-Louis, University Paris VII, INSERM, Paris, France
| | - David C Young
- Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Paul A Le Roux
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Sarah Gregson
- Maternity Unit, Queen Mary's Sidcup NHS Trust, Kent, UK
| | | | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Wentao Li
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
- National Perinatal Epidemiology and Statistics Unit (NPESU), Centre for Big Data Research in Health, and School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia
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Chiossi G, D’Amico R, Tramontano AL, Sampogna V, Laghi V, Facchinetti F. Prevalence of uterine rupture among women with one prior low transverse cesarean and women with unscarred uterus undergoing labor induction with PGE2: A systematic review and meta-analysis. PLoS One 2021; 16:e0253957. [PMID: 34228760 PMCID: PMC8259955 DOI: 10.1371/journal.pone.0253957] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As uterine rupture may affect as many as 11/1000 women with 1 prior cesarean birth and 5/10.000 women with unscarred uterus undergoing labor induction, we intended to estimate the prevalence of such rare outcome when PGE2 is used for cervical ripening and labor induction. METHODS We searched MEDLINE, ClinicalTrials.gov and the Cochrane library up to September 1st 2020. Retrospective and prospective cohort studies, as well as randomized controlled trials (RCTs) on singleton viable pregnancies receiving PGE2 for cervical ripening and labor induction were reviewed. Prevalence of uterine rupture was meta-analyzed with Freeman-Tukey double arcsine transformation among women with 1 prior low transverse cesarean section and women with unscarred uterus. RESULTS We reviewed 956 full text articles to include 69 studies. The pooled prevalence rate of uterine rupture is estimated to range between 2 and 9 out of 1000 women with 1 prior low transverse cesarean (5/1000; 95%CI 2-9/1000, 122/9000). The prevalence of uterine rupture among women with unscarred uterus is extremely low, reaching at most 0.7/100.000 (<1/100.000.000; 95%CI <1/100.000.000-0.7/100.000, 8/17.684). CONCLUSIONS Uterine rupture is a rare event during cervical ripening and labor induction with PGE2.
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Affiliation(s)
- Giuseppe Chiossi
- Division of Obstetrics, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto D’Amico
- Statistics Unit, Department of Diagnostic and Clinical Medicine and Public Health, University of Modena and Reggio Emilia, Modena, Italy
| | - Anna L. Tramontano
- Division of Obstetrics, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Veronica Sampogna
- Division of Obstetrics, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Viola Laghi
- Division of Obstetrics, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Division of Obstetrics, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
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Anikwe CC, Okorochukwu BC, Uchendu E, Ikeoha CC. The Effect of Ultrasound-Measured Preinduction Cervical Length on Delivery Outcome in a Low-Resource Setting. ScientificWorldJournal 2020; 2020:8273154. [PMID: 32410909 DOI: 10.1155/2020/8273154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 04/04/2020] [Indexed: 11/25/2022] Open
Abstract
Background Induction of labour is not without risk, and it calls for a method that will be sensitive enough to predict successful labour induction. Aim This study aims to evaluate the role of transvaginal ultrasonographic cervical length measurement at term in the prediction of successful induction of labour (IOL). Materials and Methods This prospective study was carried out in the Department of Obstetrics and Gynaecology of Federal Teaching Hospital Abakaliki between 1st of July and 30th of November 2015. Preinduction Bishop score and cervical length were assessed before induction of labour. Intracervical, cervical, extraamniotic Foley catheter was used to improve the Bishop score. The data were analyzed using the IBM SPSS Statistics 20. Results The mean maternal age of the study group was 30.68 ± 6.38 years with a range of 19–43 years. The mean gestational age and parity were 39.57 ± 1.49 and 1.85 ± 0.63, respectively. All the women studied had successful induction of labour with mean induction delivery time of 8.1 ± 3.0 hours and mean duration of labour of 7.4 ± 2.9 hours. Preinduction cervical length is a good predictor of a short duration of labour (P = 0.001). Parturient with a preinduction cervical length of less than 3 cm was likely to have labour lasting less than 6 hours (RR = 4.20 (95% CI 1.85–9.529). Conclusion Transvaginal sonographic measurement of cervical length provides a useful prediction of the likelihood of duration of labour following the induction of labour. It is recommended that IOL should be considered and success anticipated in a parturient with a cervical length less than 3 cm.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ouerdiane N, Tlili N, Othmani K, Daaloul W, Masmoudi A, Hamouda SB, Bouguerra B. [Induction of labour at term with misoprostol: the experience of a Tunisian maternity ward]. Pan Afr Med J 2016; 24:28. [PMID: 27583092 PMCID: PMC4992371 DOI: 10.11604/pamj.2016.24.28.8141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/28/2016] [Indexed: 11/11/2022] Open
Abstract
To evaluate the efficacy and safety of vaginal misoprostol for term labour induction. A prospective study conducted at the Department of Obstetrics and Gynecology B of hospital Charles Nicolle, Tunis, over a period of 4 months. The group of subjects, selected to represent the population of interest, were pregnant patients at term undergoing cervical ripening. Patients received 50 mcg vaginal misoprostol every 12 hours. The parameters studied were: contractile abnormalities, abnormalities of fetal heart rate (FHR), mode of delivery, delayed delivery and neonatal status. 44 patients underwent cervical ripening with misoprostol. The average term was 40 WA. Nulliparous rate was 23/44 (52%). Vaginal birth rate was 31/44 (70.4%). 84% of patients received a single dose of misoprostol. FHR abnormalities were observed in 14/44 (32%). The rates of meconium-stained amniotic fluid was 12/44 (27%). Apgar score of less than 7 at 5 minutes was found in 7/44 (16%). A case of uterine rupture occurred in a primipara after a single dose of misoprostol. Our results are disappointing due to the occurrence of 1 uterine rupture and of 1 significant neonatal morbidity. Other multicentre prospective studies will be useful to better ensure the effectiveness but primarily the safety of low-dose misoprostol for induction of labour at term.
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Affiliation(s)
- Nadia Ouerdiane
- Service de Gynécologie Obstétrique B, Hôpital Charles Nicolle Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
| | - Nihel Tlili
- Service de Gynécologie Obstétrique B, Hôpital Charles Nicolle Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
| | - Kaouther Othmani
- Service de Gynécologie Obstétrique B, Hôpital Charles Nicolle Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
| | - Walid Daaloul
- Service de Gynécologie Obstétrique B, Hôpital Charles Nicolle Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
| | - Abdelwaheb Masmoudi
- Service de Gynécologie Obstétrique B, Hôpital Charles Nicolle Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
| | - Sonia Ben Hamouda
- Service de Gynécologie Obstétrique B, Hôpital Charles Nicolle Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
| | - Badreddine Bouguerra
- Service de Gynécologie Obstétrique B, Hôpital Charles Nicolle Tunis, Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
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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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Rozenberg P, Chevret S, Chastang C, Ville Y. Comparison of digital and ultrasonographic examination of the cervix in predicting time interval from induction to delivery in women with a low Bishop score. BJOG 2005; 112:192-6. [PMID: 15663583 DOI: 10.1111/j.1471-0528.2004.00549.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare pre-induction ultrasonographic cervical length and Bishop score in predicting time to delivery after labour induction with prostaglandins. DESIGN Prognostic cohort study. SETTING Tertiary referral maternity unit in a teaching hospital. POPULATION Two hundred and sixty-six women with singleton pregnancies at between 34(+0) and 41(+3) weeks of gestation requiring induction of labour with prostaglandins for medical indications. METHODS A secondary analysis of a trial comparing two prostaglandins. Assessment of the Bishop score and measurement of the cervical length by transvaginal sonography were performed by two operators, blinded to each other's results. We estimated the predictive effects on the outcomes of ultrasonographic cervical length and Bishop score. MAIN OUTCOME MEASURE Time intervals from induction to delivery and to vaginal delivery. RESULTS Cervical length and Bishop score were associated with the time interval from induction to delivery, based on univariable analyses. When considered jointly in a multivariable model, only the Bishop score was significantly related to the outcome: The higher the Bishop score, the higher the hazard to delivery [hazard ratio (HR): 1.2, 95% confidence interval (CI): 1.1-1.3], illustrating that once the Bishop score is taken into account, further knowledge of cervical ultrasound length (HR: 0.99, 95% CI: 0.98-1.0) did not add any predictive information. Also, Bishop score was predictive of time interval between induction and vaginal delivery (HR: 1.2, 95% CI: 1.1-1.4) while cervical length had no additional predictive value (HR: 0.99, 95% CI: 0.98-1.0) when both cervical length and Bishop score were introduced in the model. CONCLUSIONS The Bishop score appears to be a better predictor of the time interval from induction to delivery and to vaginal delivery than cervical length after induction of labour for medical reasons.
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Affiliation(s)
- Patrick Rozenberg
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Versailles-St Quentin University, France
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Papanikolaou EG, Plachouras N, Drougia A, Andronikou S, Vlachou C, Stefos T, Paraskevaidis E, Zikopoulos K. Comparison of misoprostol and dinoprostone for elective induction of labour in nulliparous women at full term: a randomized prospective study. Reprod Biol Endocrinol 2004; 2:70. [PMID: 15450119 PMCID: PMC524504 DOI: 10.1186/1477-7827-2-70] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Accepted: 09/27/2004] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The objective of this randomized prospective study was to compare the efficacy of 50 mcg vaginal misoprostol and 3 mg dinoprostone, administered every nine hours for a maximum of three doses, for elective induction of labor in a specific cohort of nulliparous women with an unfavorable cervix and more than 40 weeks of gestation. MATERIAL AND METHODS One hundred and sixty-three pregnant women with more than 285 days of gestation were recruited and analyzed. The main outcome measures were time from induction to delivery and incidence of vaginal delivery within 12 and 24 hours. Admission rate to the neonatal intensive care unit within 24 hours post delivery was a secondary outcome. RESULTS The induction-delivery interval was significantly lower in the misoprostol group than in the dinoprostone group (11.9 h vs. 15.5 h, p < 0.001). With misoprostol, more women delivered within 12 hours (57.5% vs. 32.5%, p < 0.01) and 24 hours (98.7% vs. 91.4%, p < 0.05), spontaneous rupture of the membranes occurred more frequently (38.8% vs. 20.5%, p < 0.05), there was less need for oxytocin augmentation (65.8% vs. 81.5%, p < 0.05) and fewer additional doses were required (7.5% vs. 22%, p < 0.05). Although not statistically significant, a lower Caesarean section (CS) rate was observed with misoprostol (7.5% vs. 13.3%, p > 0.05) but with the disadvantage of higher abnormal fetal heart rate (FHR) tracings (22.5% vs. 12%, p > 0.05). From the misoprostol group more neonates were admitted to the intensive neonatal unit, than from the dinoprostone group (13.5% vs. 4.8%, p > 0.05). One woman had an unexplained stillbirth following the administration of one dose of dinoprostone. CONCLUSIONS Vaginal misoprostol, compared with dinoprostone in the regimens used, is more effective in elective inductions of labor beyond 40 weeks of gestation. Nevertheless, this is at the expense of more abnormal FHR tracings and more admissions to the neonatal unit, indicating that the faster approach is not necessarily the better approach to childbirth.
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Affiliation(s)
- Evangelos G Papanikolaou
- Department of Obstetrics and Gynecology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
| | - Nikos Plachouras
- Department of Obstetrics and Gynecology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
| | - Aikaterini Drougia
- Department of Neonatology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
| | - Styliani Andronikou
- Department of Neonatology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
| | - Christina Vlachou
- Department of Obstetrics and Gynecology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
| | - Theodoros Stefos
- Department of Obstetrics and Gynecology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
| | - Evangelos Paraskevaidis
- Department of Obstetrics and Gynecology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
| | - Konstantinos Zikopoulos
- Department of Obstetrics and Gynecology, University Hospital of Ioannina, Medical School of Ioannina, Ioannina, Greece
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van Gemund N, Scherjon S, LeCessie S, van Leeuwen JHS, van Roosmalen J, Kanhai HHH. A randomised trial comparing low dose vaginal misoprostol and dinoprostone for labour induction. BJOG 2004; 111:42-9. [PMID: 14687051 DOI: 10.1046/j.1471-0528.2003.00010.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare vaginal misoprostol with dinoprostone for induction of labour. DESIGN Randomised multicentre trial. SETTING Labour wards of one university hospital and two teaching hospitals. POPULATION Six hundred and eighty-one women with indication for labour induction at >or=36 weeks of gestation, singleton pregnancy and no previous ceasarean section. METHODS Misoprostol (25 mcg, hospital-prepared capsule) in the posterior vaginal fornix, every four hours, maximum three times daily or dinoprostone gel (1 mg) every four hours. Oxytocin was administered if necessary. MAIN OUTCOME MEASURES Primary: 'adverse neonatal outcome' (5-minute Apgar score <7 and/or umbilical cord pH <7.15). Secondary: labour duration, mode of delivery and patient satisfaction. RESULTS Three hundred and forty-one women received misoprostol and 340 dinoprostone. The median induction-delivery interval was longer in the misoprostol group compared with the dinoprostone group (25 versus 19 hours, P= 0.008). The caesarean section rate was lower in the misoprostol group: 16.1%versus 21%, but this difference was not statistically significant RR = 0.8 (95% CI 0.6-1.04). 'Adverse neonatal outcome' was found to be similar in both groups: 21% in the misoprostol and 23% in the dinoprostone groups. Significantly fewer neonates were admitted to NICU in the misoprostol group compared with dinoprostone 19%versus 26% (RR = 0.7, 95% CI 0.5-0.98). CONCLUSIONS Misoprostol in this dosing regimen is a safe method of labour induction. NICU admission rates were lower in the misoprostol group. No difference could be detected in patient satisfaction between groups.
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Affiliation(s)
- N van Gemund
- Department of Obstetrics, Leiden University Medical Centre, The Netherlands
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Agarwal N, Gupta A, Kriplani A, Bhatla N. Six hourly vaginal misoprostol versus intracervical dinoprostone for cervical ripening and labor induction. J Obstet Gynaecol Res 2003; 29:147-51. [PMID: 12841697 DOI: 10.1046/j.1341-8076.2003.00091.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM Prospective clinical trials were conducted to assess the safety and efficacy of 6-hourly vaginal misoprostol versus intracervical dinoprostone for induction of labor. METHODS A total of 120 pregnant women requiring induction of labor were recruited. Cases were randomized to receive either 50 microg vaginal misoprostol 6 hourly (group 1, n = 60) or 0.5 mg intracervical dinoprostone 6 hourly (group II, n = 60). Outcome measures, such as change in Bishop's score, need of oxytocin, induction delivery interval; complications like tachysystoly, hyperstimulation, abnormal fetal heart rate, and meconium passage were compared between two groups. Statistical analysis was performed by Wilcoxan's Rank sum and Student's t-test. RESULTS Bishop score rise, after 6 h of initiation of therapy was significantly higher in the misoprostol group than dinoprostone, 2.98 +/- 2.57 versus 2.05 +/- 1.83 (P = 0.04). The need of oxytocin augmentation was reduced in misoprostol versus dinoprostone group, 16.6% versus 78.3% (P = <0.001). Induction delivery interval was shorter in misoprostol; 12.8 +/- 6.4 h versus 18.53 +/- 8.5 h in dinoprostone group (P = <0.01). One case (1.6%) in misoprostol group, but none in dinoprostone had tachystole (P = 1.00). Abnormal heart rate pattern was found more in misoprostol than dinoprostone 16.6% versus 4.9% (P = 0.14) and so was the incidence of cesarean section, 26.6 versus 15%, respectively (P = 0.47). Meconium passage was the same in both groups, 10% in each group. CONCLUSION Vaginal misoprostol 50 microg 6-hourly is safe and effective for induction of labor with lesser need of oxytocin augmentation and shorter induction delivery interval.
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Affiliation(s)
- Nutan Agarwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.
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Abstract
BACKGROUND Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue marketed for use in the prevention and treatment of peptic ulcer disease. It is inexpensive, easily stored at room temperature and has few systemic side effects. It is rapidly absorbed orally and vaginally. Although not registered for such use, misoprostol has been widely used for obstetric and gynaecological 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 trials register (October 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002) and bibliographies of relevant papers. SELECTION CRITERIA The criteria for inclusion included the following: (1) 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; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. DATA COLLECTION AND ANALYSIS A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. To avoid duplication of data in the primary reviews, the labour induction methods have been listed in a specific order, from one to 25. Each primary review includes comparisons between one of the methods (from two to 25) with only those methods above it on the list. MAIN RESULTS Sixty-two trials have been included. Compared to placebo, misoprostol was associated with increased cervical ripening (relative risk of unfavourable or unchanged cervix after 12 to 24 hours with misoprostol 0.09, 95% confidence interval (CI) 0.03 to 0.24). It was also associated with reduced failure to achieve vaginal delivery within 24 hours (relative risk (RR) 0.36, 95% CI 0.19 to 0.68). Uterine hyperstimulation, without fetal heart rate changes, was increased (RR 11.7 95% CI 2.78 to 49). Compared with vaginal prostaglandin E2, intracervical prostaglandin E2 and oxytocin, vaginal misoprostol labour induction 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. Compared with intracervical prostaglandin E2, unchanged or unfavourable cervix after 12 to 24 hours was less common with misoprostol. Lower doses of misoprostol compared to higher doses were associated with more need for oxytocin augmentation, less uterine hyperstimulation, with and without fetal heart rate changes, and a non-significant trend to fewer admissions to neonatal intensive care unit. Use of a gel preparation of misoprostol versus tablet was associated with less hyperstimulation and more use of oxytocin and epidural analgesia. Information on women's views is conspicuously lacking. REVIEWER'S CONCLUSIONS Vaginal misoprostol appears to be more effective than conventional methods of cervical ripening and labour induction. The apparent increase in uterine hyperstimulation is of concern. Doses not exceeding 25 mcg four-hourly of concern. Doses not exceeding 25 mcg four-hourly appeared to have similar effectiveness and risk of uterine hyperstimulation to conventional labour inducing methods. The studies reviewed were not large enough to exclude the possibility of rare but serious adverse events, particularly uterine rupture, which has been reported anecdotally following misoprostol use in women with and without previous caesarean section. The authors request information on cases of uterine rupture known to readers. Further research is needed to establish the ideal route of administration and dosage, and safety. 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 J Hofmeyr
- (Director, Effective Care Research Unit, University of the Witwatersrand), Frere/Cecilia Makiwane Hospitals, Private Bag 9047, East London 5200, Eastern Cape, South Africa.
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