[Comparison of vaginal prostaglandins with oral misoprostol as a second line of cervical ripening after using a cervical balloon catheter]

OBJECTIVE

To compare vaginal prostaglandins with oral misoprostol as a second line of cervical ripening after using a cervical balloon catheter.

MATERIAL AND METHODS

This is a retrospective monocentric study (Lille, France), according to a "before"/"after" design. The inclusion criteria were a singleton pregnancy, with a fetus in cephalic presentation, a term >37 WA, with a cervix having a Bishop score lower than 6 after a first line of maturation by cervical balloon catheter. Two groups were formed: "before" corresponding to the continuation of maturation by vaginal prostaglandins, from March 2019 to November 2019, and "after": corresponding to the continuation of maturation by oral misoprostol, from June 2020 to December 2020. The primary outcome was vaginal delivery rate.

RESULTS

One hundred women were included in each group. The rate of vaginal delivery was similar between the 2 groups (76% vs 81%, p=0.39), as were the times between the start of induction and the birth and between the start of induction and the transition to birth room. There was no difference in the indication for caesarean section, with in particular an identical rate of caesarean sections for induction failure (p=0.52). Subgroup analysis in obese women showed a significantly higher rate of vaginal delivery in the "after" group (OR=4.17;95% CI [1.02;17.07]).

CONCLUSION

The vaginal delivery rate is similar when using vaginal prostaglandins or oral misoprostol as second line cervical ripening after use of a cervical balloon catheter.

Comparison of the Efficacy and Safety of Sublingual Versus Oral Misoprostol for the Induction of Labor: A Randomized Open-Label Study

Introduction Misoprostol (prostaglandin E1 analog) is being used for the induction of labor by vaginal, oral, and sublingual routes. Oral misoprostol is the preferred route for induction of labor, but the use of sublingual misoprostol appears promising due to a faster onset of action. This study was done to compare the efficacy and safety of oral and sublingual misoprostol for induction of labor in term pregnancy. Materials and methods One hundred and sixty patients were randomly allocated to one of the two groups to receive 50 micrograms of oral and sublingual misoprostol four hourly for a maximum of six doses. Primigravida at 37-42 weeks of gestation with singleton pregnancy, cephalic presentation, Bishop score (<5), and reassuring fetal heart rate were included in the study. Misoprostol dose was withheld if the active phase of labor was reached or if the cervix was favorable for amniotomy (Bishop score greater than or equal to eight). The change in the Bishop score with misoprostol was studied along with adverse effects and neonatal outcomes. Results The mean number of 50 mcg misoprostol doses required was significantly less in the sublingual group (2.94±0.97 versus 2.13±0.92; p<0.0001). The rate of change of the mean Bishop score was faster in the sublingual group. After four hours of the first dose, the mean Bishop score changed to 3.52±2.14 versus 4.68±2.34 (p=0.001), and, similarly, after eight hours, it was 10.48±2.59 versus 11.39±2.06, and this difference was statistically significant (p=0.015). The mean induction delivery interval was significantly lower in the sublingual group. The need for labor augmentation, mode of delivery, and adverse effects were similar in both groups. The incidence of meconium-stained liquor and NICU admission was also similar in both groups. Conclusion Sublingmisoprostolstol has a short induction delivery interval and comparable side effects when compared to omisoprostolstol. Sublingmisoprostolstol is recommended for induction of labor at term.

Effect of maternal age and body mass index on induction of labor with oral misoprostol for premature rupture of membrane at term: A retrospective cross-sectional study

The aim of this study was to evaluate the effect of maternal age and body mass index (BMI) on induction of labor with oral misoprostol for premature rupture of membrane (PROM) at term. We have conducted retrospective cross-sectional study, including only term (37 weeks or more of gestation) PROM in healthy nulliparous women with a negative vaginal-rectal swab for group B streptococcus, a single cephalic fetus with normal birthweight, and uneventful pregnancy that were induced after 24 h from PROM. Ninety-one patients were included. According to the multivariate logistic regression, age and BMI odds ratio (OR) for induction success were 0.795 and 0.857, respectively. The study population was divided into two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). Older women reported a higher induction failure rate (p < 0.001); longer time to cervical dilation of 6 cm (p = 0.03) and delivery (p < 0.001). Obese women reported a higher induction failure rate (p = 0.01); number of misoprostol doses (p = 0.03), longer time of induction (p = 0.03) to cervical dilatation of 6 cm (p < 0.001), and delivery (p < 0.001); and higher cesarean section (p = 0.012) and episiotomy rate (p = 0.007). In conclusion, maternal age and BMI are two of the main factors that influence oral misoprostol efficacy and affect the failure of induction rate in term PROM.

Oral misoprostol tablets (25 µg) for induction of labor: a targeted literature review and cost analysis

BACKGROUND

Various methods exist for the induction of labor (IOL), and there is limited consensus as to optimal methods. Off-label misoprostol is recommended by the World Health Organization (WHO) for IOL but preparing it into doses suitable for IOL lacks precision, with potential adverse outcomes if dosing is inaccurate. This study explores potential outcomes and costs associated with increased uptake of a low-dose (25 µg) oral misoprostol formulation (Angusta; Norgine BV, Amsterdam) approved for IOL, in France, Belgium, and the Netherlands.

METHODS

A literature review was undertaken to derive probabilities of delivery outcomes (vaginal, instrumental, and cesarean sections) for IOL methods, from published meta-analyses. Outcomes for oral misoprostol tablets (25 µg) were unavailable in the meta-analyses, so were estimated using data from two published retrospective cohort studies. A model was developed to predict the frequency of IOL outcomes and associated costs at the national level, across multiple scenarios. Scenarios were tested using a moderate, medium, and high increase in oral misoprostol tablet (25 µg) uptake. Market shares, costs, and induction rates were defined for each country using multiple data sources.

RESULTS

Increased uptake of oral misoprostol tablets (25 µg) was estimated to be associated with a slightly increased rate of routine vaginal deliveries, and concurrent decreases in instrumental vaginal deliveries and cesarean sections. Since routine vaginal deliveries are less costly than other delivery outcomes, increased uptake of oral misoprostol tablets (25 µg) within the IOL market has the potential to be cost-saving. These trends were predicted using 25 µg oral misoprostol tablet outcomes informed by both retrospective studies.

CONCLUSION

Preliminary outcomes suggest that oral misoprostol tablets at 25 µg per dose may improve outcomes in IOL and be cost-saving. Further study is required to validate these findings and assess the comparative efficacy of IOL methods, including oral misoprostol tablets (25 µg).

Safety and efficacy of an oral misoprostol standard-dose regimen vs a low-dose regimen for induction of labour in Papua New Guinean women: An open-label randomised controlled trial

BACKGROUND

Oral misoprostol is widely used for induction of labour (IOL) in developing countries because of its many advantages. However, limited data exist concerning its safety and efficacy when lower doses are used.

AIM

To determine the safety and efficacy of a low-dose oral misoprostol regimen (commencing at 12 μg) compared to a standard-dose regimen (commencing at 25 μg) in Papua New Guinea (PNG) women undergoing IOL.

MATERIALS AND METHODS

This was an open-label non-inferiority randomised controlled trial conducted at a provincial hospital in PNG. Women with singleton pregnancies ≥36 weeks with cephalic presentation and a Bishops score of <6, requiring IOL were enrolled. Both regimens were incremented second-hourly to a maximum required dose within 24 h or until commencement of labour. The primary outcome was the proportion of women who delivered within 24 h of drug administration without any severe adverse events.

RESULTS

Of the 262 women induced (130 standard-dose vs 132 low-dose), rates of successful induction were high for both regimens (120/130 (92%) vs 118/132 (89%); P = 0.52). Fourteen women (11%) in the standard-dose regimen and 20 (15%) in the low-dose regimen had severe adverse events. There was no significant difference in the safety profile of the two regimens (106/130 (82%) vs 98/132 (74%); P = 0.18). The induction-to-delivery time was significantly shorter in the standard-dose arm (15.2 ± 8.7 h vs 18.0 ± 9.1 h; P = 0.01).

CONCLUSION

The standard-dose regimen for IOL has greater efficacy in reducing induction-to-delivery time compared to the low-dose regimen. There was no significant difference in the number of adverse events between the two regimens.

An audit of oral administration of Angusta® (misoprostol) 25 µg for induction of labor in 976 consecutive women with a singleton pregnancy in a university hospital in Denmark

INTRODUCTION

Induction of labor (IOL) is used to improve the outcome of pregnancy for mother and child. Since 2013, oral misoprostol has been used for IOL at Aarhus University Hospital, Denmark. The purpose of the present paper is to describe our experience of the use of a new, 25-µg misoprostol tablet commercially manufactured for the purpose of IOL regarding efficacy and outcome for mother and neonate in both an inpatient and an outpatient regimen.

MATERIAL AND METHODS

We performed an audit from 1 April 2016, including data on all IOL in women with singleton pregnancies until 1000 consecutive women were registered. Data from 976 consecutive women with gestational age ≥37⁺⁰  weeks induced in accordance with the "Aarhus protocol" were included in the present analyses. All inductions were by oral misoprostol. Outpatient induction is standard procedure in low-risk pregnancies, that is, pregnancies with a healthy mother and no signs of placental insufficiency. In the outpatient IOL, the first dose of misoprostol is administered after a normal cardiotocography registration at the hospital. Subsequent doses are taken at home according to a predefined regimen. Following delivery, data on baseline variables and outcome variables for the mother and neonate were retrieved from the medical records.

RESULTS

In 71.9% of cases, the women were induced in an outpatient regimen. Delivery within 24 hours was achieved in 38.8% of women (nulliparous 32.3%, multiparous 50.9%) and within 48 hours in 70.1% (nulliparous 66.2%, multiparous 77.2%). Hyperstimulation during induction occurred in 0.6%. The mode of delivery was spontaneous vaginal in 75.5% of cases. The cesarean section rate was 14.9% (nulliparous 20.7%, multiparous 4.1%). Apgar <7 at 5 minutes and pH <7.0 in the umbilical artery was seen in 0.9% and 0.7%, respectively.

CONCLUSIONS

Induction of labor by a commercially produced low-dose (25 µg) misoprostol tablet for oral induction according to the "Aarhus protocol" is feasible in an outpatient as well as an inpatient regimen. Delivery was achieved within 48 hours for 70.1% of women. Few adverse events were seen; however, the audit was underpowered for safety.

Do we need a 200 μg misoprostol vaginal insert? A retrospective cohort study comparing the misoprostol vaginal insert to oral misoprostol

AIM

The misoprostol vaginal insert (MVI) was reported to be more effective than dinoprostone but discussed critically because of high rates of fetal heart rate changes due to uterine tachysystole. The aim of this study was to investigate the outcome of induced labor using the MVI compared to off-label orally-administered misoprostol (OM).

METHODS

Retrospective study including a total of 401 patients with singleton pregnancies in whom labor was induced at ≥36 0/7 gestational weeks with MVI (203) or OM (198). Primary outcomes were the time from induction to delivery, vaginal delivery in 24 h and the mode of delivery and the neonatal outcome.

RESULTS

Median time until any delivery was 833 min (645-1278) for MVI and 1076.5 min (698-1686.3) for OM group; 83.7% of the patients in the MVI group gave birth within 24 h versus 63.6% in the OM group. The MVI group needed significantly less pre-delivery oxytocin (29%). Tachysystole (6.4%) and pathological CTG (30.5%) occurred at a significantly higher frequency in the MVI group. The cesarean section rate was significantly higher in the MVI group amounting to 21.7% versus 14.6% in the OM group (P < 0.05). Neonatal outcome did not differ between the groups.

CONCLUSION

The MVI might be an option if you are in need for an approved and faster method to induce labor. Although we observed a significantly higher rate of fetal heart rate changes and cesarean sections in the MVI group this did not affect the neonatal outcome.

Induction of labor with high- or low-dosage oral misoprostol-A Danish descriptive retrospective cohort study 2015-16

INTRODUCTION

In Denmark, the rate of induced labor from 37 gestational weeks has increased by 108% from 12.4% in 2000 to 25.1% in 2012, and today more than 1 in 4 deliveries are induced. Standard procedure at North Zealand Hospital changed in 2016 from a dosage of 50 µg oral misoprostol 2-3 times daily, to 25 µg up to 8 times daily. Also, since 2016 healthy women with uncomplicated pregnancies (primiparous and multiparous) have been offered induction as an outpatient procedure. This study aimed to compare the current low-dosage procedure (25 µg) with the former high-dosage procedure (50 µg) in terms of induction to delivery time, maternal and fetal outcomes, and risk of uterine hyperstimulation.

MATERIAL AND METHODS

Data from June 2015 to October 2016 were included. Comparable baseline, demographic, and obstetric data for women induced according to high-dosage or low-dosage protocols were retrieved from local medical files. Descriptive statistics, Pearson's chi-squared tests, Kaplan-Meier survival estimates, and logistic regression analyses were performed.

RESULTS

The study included 816 induced deliveries. The high- and low-dosage groups differed in rates of plurality and place of induction. Induction to delivery times lasting longer than 72 hours were significantly decreased in the low-dosage group (adjusted odds ratio [aOR] 0.48, 95% confidence interval [95% CI] 0.27 to 0.86). Women in the low-dosage group also less often needed additional induction (P = 0.02), and the rate of uterine hyperstimulation was low irrespective of protocol (1% vs 3%, P = 0.16). There were no cases of uterine rupture in either group. The probability of vaginal delivery in the low-dosage group increased (adjusted hazard ratio 1.27, 95% CI 1.08 to 1.49), as did the risk of delivery with vacuum extraction (aOR 2.27, 95% CI 1.24 to 4.15), whereas delivery by cesarean section slightly decreased (aOR 0.89, 95% CI 0.59 to 1.33). The risk of meconium-stained liquor was nonsignificantly decreased (aOR 0.82, 95% CI 0.55 to 1.23).

CONCLUSIONS

The low-dosage induction protocol was associated with favorable obstetric outcomes in terms of increased probability of vaginal delivery, but with higher risk of vacuum extraction. Protracted inductions and additional nonmedical interventions were reduced. There were no cases of uterine rupture. Statistically nonsignificant, the risk of uterine hyperstimulation was increased whereas the risk of meconium-stained liquor and of cesarean section was slightly decreased.

Oral misoprostol for induction of labor at term: a randomized controlled trial of hourly titrated and 2 hourly static oral misoprostol solution

Background: Misoprostol has been shown to be effective in induction of labor (IOL) with different dosages and routes of administration.Objectives: This study compared the efficacy and safety of hourly titrated and 2-hourly static low dose oral misoprostol for IOL in Ekiti State University Teaching Hospital, Ado-Ekiti.Methods: One hundred fifty women with singleton pregnancy at term admitted for IOL were randomized into the two groups. Oxytocin augmentation was done as necessary. The primary outcome is rate of vaginal delivery within 24 hours. Data were analyzed using SPSS.Results: Vaginal delivery was achieved within 24 hours in 40 (67.8%) women who received hourly titrated-doses oral misoprostol and 42 (70.0%) women who received 2-hourly static-dose of oral misoprostol, p > .05. The rate of vaginal delivery, oxytocin augmentation, induction delivery time and cesarean section rate were similar in both groups, p > .05. Occurrence of uterine hyperactivity did not differ significantly among the women (p > .05) and no cases of uterine rupture were recorded. There were no adverse neonatal outcomes.Conclusions: The hourly titrated oral misoprostol is as effective and safe as the 2-hourly static oral misoprostol for IOL. Both can be utilized in IOL without the fear of adverse outcomes.

Vaginal assessment and expedited amniotomy in oral misoprostol labor induction in nulliparas: a randomized trial

BACKGROUND

Labor is induced in 20-30% of maternities, with an increasing trend of use. Labor induction with oral misoprostol is associated with reduced risk of cesarean deliveries and has a safety and effectiveness profile comparable to those of mechanical methods such as Foley catheter use. Labor induction in nulliparous women continues to be challenging, with the process often quite protracted. The eventual cesarean delivery rate is high, particularly when the cervix is unfavorable and ripening is required. Vaginal examination can cause discomfort and emotional distress particularly to nulliparous women, and plausibly can affect patient satisfaction with the induction and birth process.

OBJECTIVE

The aim of this study was to evaluate regular (4-hourly prior to each oral misoprostol dose with amniotomy when feasible) compared with restricted (only if indicated) vaginal assessments during labor induction with oral misoprostol in term nulliparous women MATERIALS AND METHODS: We performed a randomized trial between November 2016 and September 2017 in a university hospital in Malaysia. Our oral misoprostol labor induction regimen comprised 50 μg of misoprostol administered 4 hourly for up to 3 doses in the first 24 hours. Participants assigned to regular assessment had vaginal examinations before each 4-hourly misoprostol dose with a view to amniotomy as soon as it was feasible. Participants in the restricted arm had vaginal examinations only if indicated. Primary outcomes were patient satisfaction with the birth process (using an 11-point visual numerical rating scale), induction to vaginal delivery interval, and vaginal delivery rate at 24 hours.

RESULTS

Data from 204 participants (101 regular, 103 restricted) were analyzed. The patient satisfaction score with the birth process was as follows (median [interquartile range]): 7 [6-9] vs 8 [6-10], P = .15. The interval of induction to vaginal delivery (mean ± standard deviation) was 24.3 ± 12.8 vs 31.1 ± 15.0 hours (P = .013). The vaginal delivery rate at 24 hours was 27.7% vs 20.4%; (relative risk [RR], 1.4; 95% confidence interval [CI], 0.8-2.3; P = .14) for the regular vs restricted arms, respectively. The cesarean delivery rate was 50% vs 43% (RR, 1.1; 95% CI, 0.9-1.5; P = .36). When assessed after delivery, participants' fidelity to their assigned vaginal examination schedule in a future labor induction was 45% vs 88% (RR, 0.5; 95% CI, 0.4-0.7; P < .001), and they would recommend their assigned schedule to a friend (47% vs 87%; RR, 0.6; 95% CI, 0.5-0.7; P < .001) in the regular compared with the restricted arms, respectively.

CONCLUSION

Despite a shorter induction to vaginal delivery interval with regular vaginal examination and a similar vaginal delivery rate at 24 hours and birth process satisfaction score, women expressed a higher preference for the restricted examination schedule and were more likely to recommend such a schedule to a friend.

Is vaginal misoprostol more effective than oral misoprostol for cervical ripening in obese women?

Objective: To determine if vaginal misoprostol is more effective than oral misoprostol for cervical ripening in obese women.Study design: A retrospective cohort study of obese women undergoing induction of labor from Jan 2013 to Dec 2016 with singleton, viable pregnancies beyond 37 completed weeks of gestational age. Women with an initial Bishop score of 7 or less, with a cervical dilatation of less than 2 cm, who received either vaginal or oral misoprostol as a cervical ripening agent, were included. Primary outcome was interval from the start of induction to the attainment of 3 cm cervical dilatation. Secondary outcomes included the interval from the start of induction to delivery and the rate of cesarean delivery (CD).Result: Of women who met the inclusion criteria, 966 (75.5%) women received oral misoprostol and 314 (24.5%) received vaginal misoprostol. The mean time-interval from the start of induction to attainment of 3-cm dilatation was shorter in the vaginal group (10.5 ± 10.4 h) compared to the oral group (17.2 ± 11.5 h), (p < .0001). Significantly shorter times to delivery were also noted in the vaginal group (17.4 h for vaginal vs. 24.8 h for oral, p < .0001). In the subgroup analysis of nulliparous women, shorter time intervals from the start of induction to attainment of 3-cm dilatation, as well as to delivery, were noted in the vaginal misoprostol group (p < .0001 for both). Multiple linear regression model confirmed route of misoprostol administration as an independent variable in predicting the outcomes (time from start of induction to 3 cm as well as to delivery). Significant findings amongst neonatal outcomes included lower umbilical artery pH and higher rates of neonatal jaundice in the oral misoprostol group.Conclusion: In a population of obese women undergoing induction of labor, vaginal administration of misoprostol was associated shorter time intervals from the start of induction to the attainment of 3 cm of dilatation, as well as to delivery, without increasing the rate of cesarean deliveries or the incidence of adverse maternal and neonatal outcomes.

Comparing induction of labour with oral misoprostol or Foley catheter at term: cost-effectiveness analysis of a randomised controlled multi-centre non-inferiority trial

OBJECTIVE

To assess the costs of labour induction with oral misoprostol versus Foley catheter.

DESIGN

Economic evaluation alongside a randomised controlled trial.

SETTING

Obstetric departments of six tertiary and 23 secondary care hospitals in the Netherlands.

POPULATION

Women with a viable term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix (Bishop score <6) without a previous caesarean section, were randomised for labour induction with oral misoprostol (n = 924) or Foley catheter (n = 921).

METHODS

We performed economic analysis from a hospital perspective. We estimated direct medical costs associated with healthcare utilisation from randomisation until discharge. The robustness of our findings was evaluated in sensitivity analyses.

MAIN OUTCOME MEASURES

Mean costs and differences were calculated per women induced with oral misoprostol or Foley catheter.

RESULTS

Mean costs per woman in the oral misoprostol group and Foley catheter group were €4470 versus €4158, respectively [mean difference €312, 95% confidence interval (CI) -€508 to €1063]. Multiple sensitivity analyses did not change these conclusions. However, if cervical ripening for low-risk pregnancies in the Foley catheter group was carried out in an outpatient setting, with admittance to labour ward only at start of active labour, the difference would be €4470 versus €3489, respectively (mean difference €981, 95% CI €225-1817).

CONCLUSIONS

Oral misoprostol and Foley catheter generate comparable costs. Cervical ripening outside labour ward with a Foley catheter could potentially save almost €1000 per woman.

TWEETABLE ABSTRACT

Oral misoprostol or Foley catheter for induction of labour generates comparable costs.

Comparative evaluation of 50 microgram oral misoprostol and 25 microgram intravaginal misoprostol for induction of labour at term: a randomized trial

OBJECTIVES

To assess and compare the efficacy and safety of 50 µg oral misoprostol and 25 µg intravaginal misoprostol for induction of labour at term.

METHODS

This non-blinded, randomized clinical trial included 228 pregnant women at term with obstetric or medical indications for induction of labour. Women either took 50 µg misoprostol orally (two 25 µg tablets) or had one 25 µg tablet of misoprostol inserted in the posterior vaginal fornix. In each group, misoprostol administration was repeated every four hours in the same dose until regular uterine contractions were established or to a maximum of five doses. Time to delivery and outcome data for each group were compared.

RESULTS

Of the 228 women, eight (3.5%) were excluded from the analysis as they withdrew their consent after randomization. Mean induction-to-delivery interval was similar in both groups (21.22 hours in the oral group vs. 20.15 hours in the vaginal group; P = 0.58). There was no significant difference between the groups with respect to the number of women who delivered within 24 hours or who required oxytocin augmentation of labour, the mode of delivery, and neonatal outcomes (P > 0.05). Uterine hyperstimulation occurred in two women who received misoprostol vaginally, but not in any of the women in the oral misoprostol group.

CONCLUSION

Oral misoprostol in a dose of 50 µg every four hours, to a maximum of five doses, has the potential to induce labour as safely and effectively as 25 µg misoprostol administered vaginally every four hours.