Retrospective Comparison of PGE2 Vaginal Insert and Foley Catheter for Outpatient Cervical Ripening

ObjectiveTo compare the efficacy of two methods of outpatient cervical ripening (CR): an intracervical Foley catheter and a prostaglandin E₂ (PGE)₂ slow-release vaginal insert.MethodsAll records of women receiving outpatient CR at a tertiary care hospital from January 2017 to June 2018 were retrospectively reviewed. We compared time from insertion of first CR agent until delivery between groups using a Cox proportional hazards (CPH) model. Exclusion criteria included age <18 years, multiple gestation, or contraindication to either CR method. Secondary outcomes included time from removal of agent and time from admission until delivery, additional CR used, uterine tachysystole, labour and delivery complications, type of delivery, and adverse neonatal outcomes.ResultsA total of 153 patients were included (82 Foley; 71 PGE₂). Baseline characteristics were comparable except for lower dilation in the PGE₂ group (16% vs. 38% <1cm dilated; P < 0.05). In the CPH model, time from insertion to delivery was not different between PGE₂ and Foley catheter groups (median 27 vs. 33 h), controlling for parity, gestational age, initial dilation, and use of oxytocin (HR 1.13, 95% confidence interval 0.77–1.68). Patients in the PGE₂ group were more likely to experience uterine tachysystole (9% vs. 0%; P < 0.01) and require another method of CR (34% vs. 1%; P < 0.001). There were no differences in neonatal or maternal adverse outcomes between groups.ConclusionOur results suggest that outpatient Foley catheter and PGE₂ CR are comparable in time from insertion to delivery; however, PGE₂ inserts are associated with higher rates of tachysystole and the need for second CR method. A prospective study is warranted to further investigate these findings.     

Cervical ripening: A randomized comparison between intravaginal misoprostol and an intracervical balloon catheter combined with intravaginal dinoprostone

OBJECTIVES: Our purpose was to compare the efficacy of intravaginal misoprostol and intracervical Foley catheter/intravaginal dinoprostone for cervical ripening. STUDY DESIGN: Patients admitted for induction of labor were randomized to receive intravaginal misoprostol 25 μg every 4 hours or intracervical Foley catheter/intravaginal dinoprostone 4 mg every 4 hours. Patients not entering active labor and having ruptured membranes or arrest of dilatation received intravenous oxytocin. RESULTS: Sixty-five patients received Foley catheter/dinoprostone gel and 62 patients received misoprostol. The mean time until cervical ripening was less in the catheter/gel group (7.5 ± 3.4 vs 12.0 ± 5.9 hours, p < 0.01). The mean time until vaginal delivery was less in the catheter/gel group (17.4 ± 6.9 vs 21.2 ± 7.5 hours, p = 0.004). Among vaginal deliveries, more patients in the catheter/gel group delivered within 24 hours (90% vs 69%, p = 0.013). CONCLUSIONS: Intracervical Foley catheter/intravaginal dinoprostone was associated with more rapid cervical ripening, shorter induction to vaginal delivery interval, and greater number of vaginal deliveries within 24 hours. (Am J Obstet Gynecol 1998;178:1333-40.)     

Ripening of the uterine cervix in a post-Cesarean parturient: prostaglandin E2 versus Foley catheter

Objective: To compare the success and complication rates of prostaglandin E₂ tablets (PGE₂) and a Foley catheter for the ripening of the uterine cervix in post-Cesarean section parturients. Study design: The study population in this retrospective cohort study consisted of parturients in their second pregnancy who had undergone Cesarean section in their previous delivery and who underwent ripening of the uterine cervix by using PGE₂ (n = 55) or Foley catheter (n = 161) in the current pregnancy. The control group consisted of 1432 post-Cesarean section parturients without induction of labor. We compared the rates of placental abruption, non-reassuring fetal heart rate patterns, intrapartum fetal deaths (IPFD), uterine rupture, Apgar scores, labor dystocia, severe birth canal lacerations, vacuum deliveries and repeated Cesarean section rates in the three groups by using ANOVA, χ² analysis and Fisher's exact test when appropriate. Results: A significant increase in the rates of labor dystocia during the first stage (30.4% vs. 11.6%, p < 0.01) and repeated Cesarean deliveries (49.1% vs. 35.2%, p < 0.01) were observed in women in whom the Foley catheter was used as compared to controls, respectively. No such changes were demonstrated in the PGE₂ group as compared to the controls. No significant differences were found between the PGE₂ group and Foley catheter group as compared to the controls in rates of placental abruption, IPFD, uterine rupture, fetal distress, birth canal lacerations, vacuum deliveries and Apgar scores. Conclusions: PGE₂ was found to be superior to the Foley catheter for ripening of the uterine cervix in a post-Cesarean parturient, as demonstrated by a lower repeated Cesarean delivery rate.     

Comparative Study of Intra-cervical Foley’s Catheter and PGE2 Gel for Pre-induction Ripening (Cervical)

Aim

The success of induction of labor depends on the cervical status at the time of induction.

Objective

For effective cervical ripening both Foley’s catheter and PGE₂ gel are used. The aim of this study was to compare the efficacy of intra cervical Foley’s catheter and intra cervical PGE₂ gel in cervical ripening for the successful induction of labor.

Study Design

A randomized, prospective study was conducted in the Dept of OBGY, GMCH, Aurangabad from July 2005–January 2008. 400 patients at term with a Bishop’s score ≤3 with various indications for induction were randomly allocated to receive (200 pts) intra-cervical Foley’s catheter or PGE₂ gel (200 pts). After 6 h post induction, Bishop’s score was noted labor was augmented if required. Statistical analysis was done using Chi square test and t test.

Result

The groups were comparable with respect to maternal age, gestation age, indication of induction and initial Bishop’s score. Both the groups showed significant change in the Bishop’s score, 5.56 ± 1.89 and 5.49 ± 1.82 for Foley’s catheter and PGE₂ gel, respectively, P < 0.001; However there was no significant difference between the two groups. There was no significant difference in the side effects. Twenty eight cesarean sections (14%) were performed in Group A and 37 (18.5%) were performed in Group B (not significant). The induction to delivery interval was 15.32 ± 5.24 h in Group A and 14.2 ± 5.14 h in Group B (P = 0.291). Apgar scores, birth weights and NICU admissions showed no difference between the two groups.

Conclusion

This study shows that both Foley’s Catheter and PGE₂ gel are equally effective in pre induction cervical ripening.     

A randomized comparison of extra-amniotic saline infusion and intracervical dinoprostone gel for cervical ripening

Objective: To compare extra-amniotic saline infusion to intracervical dinoprostone gel for preinduction cervical ripening.Methods: Women with Bishop scores less than 5 were assigned randomly to either extra-amniotic saline infusion (n = 26) or intracervical dinoprostone gel (n = 26) for preinduction cervical ripening. A sample size of 50 would have 80% power to detect a 10-hour difference in the mean time from start of cervical ripening to delivery for the two methods of intervention, with a type I error of .05.Results: The study populations were similar in age, gestational age, and initial Bishop score. They differed in parity, with 22 nulliparas in the extra-amniotic saline infusion group versus 13 in the dinoprostone gel group (relative risk [RR] 1.69, 95% confidence interval [CI] 1.11, 2.57). The number of women achieving a favorable Bishop score at 6 hours was greater with extra-amniotic saline infusion (n = 20) than dinoprostone gel (n = 9) (RR 2.14, 95% CI 1.22, 3.75). Mean time from start of ripening to delivery was 25.9 hours with extra-amniotic saline infusion and 30.2 hours with dinoprostone gel (P = .25). Birth weight, Apgar scores, umbilical artery pH, and infectious morbidity were similar between groups.Conclusion: More women achieved a favorable Bishop score at 6 and 12 hours after the start of cervical ripening with extra-amniotic saline infusion compared with dinoprostone gel. Saline infusion is as safe as dinoprostone gel for preinduction cervical ripening.     

Benefits of Self-administered Vaginal Dinoprostone 12 Hours before Levonorgestrel-releasing Intrauterine Device Insertion in Nulliparous Adolescents and Young Women: A Randomized Controlled Trial

Study ObjectiveTo assess safety and efficacy of self-administered vaginal dinoprostone 12 hours before a 52-mg levonorgestrel intrauterine device (LNG-IUD) insertion in adolescents and young nulliparous women.DesignRandomized controlled trial.SettingTertiary referral hospital.ParticipantsNulliparous adolescents and young women aged 18-22 years.InterventionsParticipants were randomly assigned into 2 groups; the dinoprostone group (n = 65) received dinoprostone 3 mg vaginally, and the placebo group (n = 65) received placebo tablets vaginally.Main Outcome MeasuresPrimary outcome was pain scores during LNG-IUD insertion measured using a visual analogue scale. Secondary outcomes were pain scores during speculum insertion, tenaculum placement, uterine sounding, and 20 minutes postprocedure, ease of insertion, Women's satisfaction score, need for additional analgesics, and side effects.ResultsThe dinoprostone group had significantly lower pain scores during LNG-IUD insertion (2.83 ± 1.08 vs 3.95 ± 1.63), tenaculum placement (2.97 ± 1.41 vs 4.55 ± 1.53) and sounding of uterus (3.55 ± 1.71 vs 5.12 ± 1.37) compared with the placebo group (P < .001). No significant differences were found between both groups regarding anticipated pain scores (P = .85), pain during speculum insertion and 20 minutes postinsertion and insertion duration (P = .53). Women's satisfaction, provider reported ease of insertion, and need for additional analgesia were significantly better among dinoprostone users (P < .001, < .001, and .02, respectively). Side effects and procedure complications were similar for the 2 groups.ConclusionSelf-administered dinoprostone 3 mg vaginally 12 hours before a 52-mg LNG-IUD insertion in nulliparous adolescent and young women effectively reduced pain during insertion and increased women's satisfaction and ease of insertion reported by clinicians.     

Controlled-release dinoprostone insert versus Foley catheter for labor induction: a meta-analysis

Objective: To compare the effectiveness and safety of controlled-release dinoprostone insert with Foley catheter balloon for cervical ripening and labor induction.

Methods: PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and China Knowledge Resource Integrated Database were searched. Only randomized controlled trials comparing controlled-release dinoprostone insert with Foley catheter balloon were included. Risk ratio (RR) or mean difference (MD) with 95% con?dence interval (CI) was calculated.

Results: Six studies were included with 731 women received dinoprostone insert and 722 Foley catheter. Time from induction to delivery was significantly shortened in dinoprostone insert group compared to Foley catheter group (MD 5.73 h, 95% CI 1.26–10.20). There were no significant differences in vaginal delivery within 24 h (RR 0.75, 95% CI 0.43–1.30) or cesarean section (RR 0.94, 95% CI 0.80–1.12) between two ripening methods. Dinoprostone insert was related with increased rate of excessive uterine contraction (RR 0.07, 95% CI 0.03–0.19), but less oxytocin use (RR 1.86, 95% CI 1.25–2.77) when compared with Foley catheter.

Conclusions: Induction of labor with controlled-release dinoprostone insert seems to be more effective than Foley catheter. However, the former method causes excessive uterine contraction more frequently.     

A comparison of misoprostol and prostaglandin E2 gel for preinduction cervical ripening and labor induction

Objective: Our purpose was to compare the safety ad efficacy of intravaginal misoprostal versus intracervical prostaglandin E₂ (dinoprostone) gel for preinduction cervical ripening and induction of labor.Study design: One hundred thirty-five patients with indications for induction of labor and unfavorable cercices were randomly assigned to receive either intravaginal misoprostol or intracervical dinoprostate. Fifty microgram tablets of misoprostol were placed in the posterior vaginal fornix every 3 hours for a maximum of six doses. Prostaglandin E₂ in gel form, 0.5 mg, was placed into the endocervix every 6 hours for a maximum of three doses. Medication was not given after either spontaneous rupture of membranes or beginning of active labor.Results: Among 135 patients enrolled, 68 received misprostol and 67 dinoprostone. The average interval from start of induction to vaginal delivery was shorter in the misoprostol group (903.3 ± 482.1 minutes) than in the dinoprostone group (1410.9 ± 869.1 minutes) (p < 0.001). Oxytocin augmentation of labor occurred more often in the dinoprostone group (65.7%) than in the misoprostal group (33.8%) p < 0.001). There were no significant differences between routes of delivery. Ten of the misoprostol-treated patients (14.7%) and 13 of the dinoprostone-treated patients (19.4%) had cesarean deliveries. There was a higher prevalence of tachysystole (six or more uterine contractions in a 10-minute window for two consecutive 10-minute periods) in the misoprostol group (36.7%) than in the dinoprostone group (11.9%) (p < 0.001). However, there were no significant differences in frequency of uterine hyperstimulation or hypertonus. There was a higher prevalence of meconium passage in the misoprostol group (27.9%) than in the dinoprostone group (10.5%) (p < 0.05). Thee was no significant difference in frequency of abnormal fetal heart rate tracings, 1- or 5-minute Apgar scores <7, neonatal resuscitations, or admissions to the neonatal intensive care unit between the two groups.Conclusions: Vaginally administered misoprostol is an effective agent for cervical ripening and induction of labor; however when given at this dosage, it is associated with a higher prevalence of tachysystole and meconium passage than is dinoprostone. Further studies to compare the safety of misoprostol to that of dinoprostone and to delineate an optimal dosing regimen for misoprostol are needed.     

Comparative Efficacy of Vaginal Misoprostol vs Vaginal Dinoprostone Administered 3 Hours Prior to Copper T380A Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial

Study ObjectiveTo compare the effectiveness of misoprostol and dinoprostone tablets administered vaginally 3 hours before copper intrauterine device (IUD) insertion vs placebo in reducing pain and increasing ease of insertion among nulliparous women.DesignRandomized controlled trial.SettingTertiary referral hospital.ParticipantsA total of 129 nulliparous women requesting a Copper T380A IUD insertion.InterventionsWomen were randomized to receive 200 μg misoprostol or 3 mg dinoprostone or placebo 3 hours before IUD insertion.Main Outcome Measure(s)Primary outcome was patient-reported pain during IUD insertion using a 10-cm visual analog scale (VAS). Secondary outcomes include provider ease of insertion, women satisfaction level, and side effects.ResultsParticipants' baseline characteristics were comparable between the study groups. Mean pain score during IUD insertion was lower with misoprostol than placebo (3.1 ± 2.3 vs 4.4 ± 2.2; P = .02) and dinoprostone compared to placebo (2.4 ± 1.8 vs 4.4 ± 2.2; P < .001). Clinicians reported easier IUD insertion with misoprostol than placebo (2.4 ± 1.7 vs 4.0 ± 2.4; P = .001) and dinoprostone compared to placebo (2.0 ± 1.5 vs 4.0 ± 2.4; P < .001). Women's satisfaction levels were higher with both misoprostol and dinoprostone than placebo (P < .001). Side effects did not differ among the 3 study groups.ConclusionsPremedication with vaginal misoprostol or dinoprostone effectively lowered pain during copper IUD insertion. However, the reduction in pain scores was clinically significant only in women who received dinoprostone. In both the misoprostol and dinoprostone groups, clinicians found the procedure easier, and women were more satisfied with IUD insertion. Side effects and complications were similar in all groups.     

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized,Double-blind Trial

Study ObjectiveTo determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women.DesignRandomized, double-blind trial.SettingTertiary referral hospital.PatientsA total of 180 nulliparous women undergoing diagnostic OH.InterventionsWe randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group.Measurements and Main ResultsThe primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups.ConclusionVaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.     

Labor induction with prostaglandin E1 misoprostol compared with dinoprostone vaginal insert: A randomized trial

Objective: To compare the safety, efficacy, and costs of intravaginal misoprostol versus dinoprostone vaginal inserts for cervical ripening and labor induction.Methods: Two hundred twenty-three labor induction patients were assigned randomly to one of two treatment groups: 1) intravaginal misoprostol or 2) dinoprostone vaginal inserts. Fifty micrograms of misoprostol were placed in the posterior vaginal fornix every 3 hours for a maximum period of 24 hours. Ten milligrams of dinoprostone was administered in a single application as a vaginal insert for 12 hours.Results: Among 223 patients evaluated, 108 were allocated to the misoprostol group and 115 to the dinoprostone group. The median interval from induction to vaginal delivery was significantly shorter in the misoprostol group: 698 (range 395–1053) versus 1041 (range 792–1531) minutes (P < .001). Vaginal delivery within 12 hours of ripening occurred in 40.7% of patients who received misoprostol compared with 19.1% for those receiving dinoprostone (P < .001); no significant difference between the groups was noted for vaginal delivery within 24 hours. Uterine tachysystole occurred more frequently in patients in the misoprostol group (21.3%) than in the dinoprostone group (7.0%) (P = .004). Nevertheless, no statistically significant differences were noted between the groups with respect to intrapartum complications, including uterine hyperstimulation, mode of delivery, and neonatal or maternal adverse outcomes. The average cost per patient for misoprostol treatment was $85 compared with $606 for treatment with the vaginal insert.Conclusion: Intravaginal misoprostol and the dinoprosone vaginal insert appear to be safe agents for cervical ripening and labor induction. However, misoprostol is less expensive and more effective than the dinoprostone vaginal insert.     

Efficacy and safety of six hourly vaginal misoprostol versus intracervical dinoprostone: a randomized controlled trial

Objective To compare the efficacy and safety of intravaginal misoprostol versus dinoprostone cervical gel for cervical ripening and labour induction. Methods We carried out an experimental clinical trial in which we enrolled 130 cervical consecutive patients with cervical ripening, randomly assigned to one of the following two treatment groups: (1) intravaginal misoprostol and (2) intracervical dinoprostone gel. A total of 50 μm of misoprostol was placed in the posterior vaginal fornix every 6 h for a maximum period of 24 h and 0.5 mg of dinoprostone was administrated in the uterine cervix every 6 h, for a maximum period of 24 h. The primary outcome measure was the number (rate) of women who went to vaginally deliver within 24 h of the protocol initiation. Results Among 130 patients evaluated, 65 were allocated to the misoprostol group and 65 to the dinoprostone group. The proportion of vaginal delivery within 24 h was significantly higher in the misoprostol group (75%) than in the dinoprostone group (53.8%) (RR = 1.40, 95% CI [1.07–1.45], P = 0.02). There was no significant difference between the mean time interval of delivery in the misoprostol group and the dinoprostone group (14.9 vs.15.8 h) (P = 0.51). The Bishop score was significantly higher in the misoprostol group, 6 h after the onset of the study (1.38; relative risk, 95% CI [1.02–1.85], P = 0.03). The Caesarean delivery rate for fetal distress was higher in the dinoprostone group (21 vs. 10.8%, P = 0.15). The tachysystole (Misoprostol 6.1% vs. dinoprostone 4.6%, relative risk 1.15, 95% CI [0.6–2.24]) and hyperstimulation syndrome rates (Misoprostol 7.6% vs. dinoprostone 4.6%, relative risk 1.26, 95% CI [0.72–2.24]) were slightly increased in the misoprostol group than in the dinoprostone group without reaching the level of statistical signification. Conclusion Misoprostol as used in this protocol is more effective than cervical dinoprostone gel application in the cervical ripening and labour induction. There is a tendency for an increase in the rate of tachysystole and hyperstimulation syndrome.     

Evaluation of isosorbide mononitrate for cervical ripening prior to induction of labor for postdated pregnancy in an outpatient setting

ObjectiveTo determine the safety and effectiveness of self-administered treatment with isosorbide mononitrate (IMN) for cervical ripening in Indian women with postdated pregnancies.MethodsA randomized, placebo-controlled study was conducted with 200 women with postdated pregnancies and unfavorable cervices who self-administered vaginally either 2 40-mg tablets of IMN or 2 40-mg tablets of pyridoxine as placebo prior to admission for induction of labor. The main outcome variables were change in Bishop score, time from admission to delivery, and presence or absence of fetal and maternal morbidity.ResultsThe Bishop score was significantly improved 24 hours after initiation of the outpatient IMN treatment (P < 0.001) and the needs for further cervical ripening and oxytocin infusion were less in the study than in the control group (P < 0.001 and P = 0.008). The time from admission to delivery was also less (P < 0.001). Moreover, the IMN treatment had no major adverse maternal or fetal effects. The vast majority of women in both groups were either satisfied or very satisfied with the outpatient treatment.ConclusionThe self-administration, at home, of isosorbide mononitrate leads to a safe and effective cervical ripening prior to labor induction in women with postdated pregnancies.CTRI Registration No.: CTRI/2011/091/000121     

A comparison of intermittent vaginal administration of misoprostol with continuous dinoprostone for cervical ripening and labor induction

Objective: Our purpose was to compare the effect of vaginal administration of misoprostol (Cytotec) with that of dinoprostone (Cervidil) on cervical ripening and labor induction. Study design: Two hundred patients with indications for induction of labor and unfavorable cervical examinations were randomly assigned to receive vaginally administered misoprostol (prostaglandin E₁) or the dinoprostone (prostaglandin E₂) vaginal insert. Twenty-five microgram tablets of misoprostol were placed in the posterior vaginal fornix every 4 hours for a maximum of six doses. Additional misoprostol was not given after either spontaneous rupture of membranes, adequate cervical ripening (Bishop score of ≥8 or cervical dilatation of ≥3 cm), or beginning of active labor. The vaginal insert, Cervidil, containing 10 mg of dinoprostone in a timed-release preparation was placed in the posterior vaginal fornix for a maximum period of 24 hours. The vaginal insert was removed for spontaneous rupture of membranes, entry into active labor, adequate cervical ripening, or abnormality of uterine contractile pattern or fetal cardiac activity. Results: Of the 200 patients enrolled, 99 were randomized to misoprostol and 101 to dinoprostone. The average interval from start of induction to vaginal delivery was 1 hour shorter in the misoprostol group (1296.7 ± 722.1 minutes) than in the dinoprostone group (1360.0 ± 792.0 minutes), but this difference was not statistically significant (p = 0.97). Oxytocin augmentation of labor was used in 50 (50.5%) misoprostol-treated patients and 43 (43.5%) dinoprostone-treated patients (relative risk 1.14, 95% confidence interval 0.86 to 1.51, p = 0.35). There were no significant differences between routes of delivery with misoprostol or dinoprostone. Overall, 38 patients (19.3%) had cesarean deliveries. There was a significantly lower prevalence of tachysystole (six or more uterine contractions in a 10-minute window for two consecutive 10-minute periods) in the misoprostol group (7.1%) than in the dinoprostone group (18.4%) (relative risk 0.52, 95% confidence interval 0.31 to 0.89, p = 0.02). There were no significant differences in frequency of uterine hyperstimulation or hypertonus. Abnormal fetal heart rate tracings were found in 23 (23.2%) of misoprostol-treated patients and 35 (35.7%) of dinoprostone-treated patients (relative risk 0.73, 95% confidence interval 0.52 to 1.01, p = 0.0546). No significant differences were found in meconium passage, 1- or 5-minute Apgar scores <7, neonatal resuscitations, or admissions to the neonatal intensive care unit between the two groups. CONCLUSIONS: Vaginally administered misoprostol is as effective as dinoprostone for cervical ripening and the induction of labor. Mean time intervals to delivery, need for oxytocin augmentation, and routes of delivery were similar between the two groups. Incidence of uterine tachysystole with misoprostol every 4 hours was significantly less than with dinoprostone.     

Maturation cervicale à terme par utilisation répétée du dispositif intravaginal de dinoprostone

ObjectivesTo evaluate efficacy and safety of cervical ripening with repeated administration of dinoprostone slow release vaginal pessary (Propess^®) in current practice.Patients and methodsAn observational study of 111 women who underwent cervical ripening with two Propess^® during the study period from 1st July 2007 to 31st October 2011. Modes of delivery, success of cervical ripening, failure of labor induction, maternal and neonatal morbidity were reported.ResultsThe nulliparous rate was 75,7%. The main indications for induction of labor were post-term pregnancy in 34,3% (38/111) and premature rupture of membranes in 25,2% (28/111). The rate of vaginal delivery was 53,1% (59/111). Cesarean sections were performed for failure of labor induction in 27/52 (51,9%) and an abnormal fetal heart rate in 17/52 (32.7%). Indication for induction of labor, nulliparous patients (44 [84.6%] versus 40 [67.8%]; P = 0.04), initial Bishop score (2.2 ± 1.2 versus 2.9 ± 1.2; P = 0.04) before the cervical ripening and Bishop score before administration of second Propess^® (3.3 ± 1.4 versus 4.0 ± 1.2; P = 0.05) were significant risk factors of cesarean delivery.Discussion and conclusionIn more than half of the cases, the cervical ripening by two Propess^® is efficient and allows a vaginal delivery. This practice does not appear to increase the maternal or neonatal morbidity.     

Using dinoprostone vaginal insert for induction of labor: A single institute experience

ObjectiveTo evaluate the factors associated with the successful induction of labor (IOL) in women treated with dinoprostone slow-released vaginal insert.Material and methodsA retrospective study was conducted between June 2017 and December 2017, enrolling 65 patients who underwent dinoprostone slow-released vaginal insert-induced labor. The correlation between the characteristics of the pregnant women and its success, as well as perinatal complications and adverse outcomes were analyzed.ResultsFifty-three of 65 (81.5%) achieved a successful vaginal delivery. Only multi-parous pregnant women were an independent predictor factor for successful induction after dinoprostone slow-released vaginal insert, since all of them succeeded after this strategy treatment (100%, n = 18), compared to 74.5% (35/47) of successful rate in the nulliparous pregnant women with a statistically significant difference (p = 0.018). There were no adverse events occurred in both mothers and their offspring.ConclusionDinoprostone slow-released vaginal insert is a good choice for multiparous pregnant women who need IOL, regardless of which reasons are indicated. For nulliparous women, more studies might be needed to evaluate the effectiveness of PGE2 for IOL.     

Second dose of PGE2 vaginal insert versus Foley transcervical balloon for induction of labor after failure of cervical ripening with PGE2 vaginal insert

Purpose: To determine the success rate of induction of labor (IOL) using Foley transcervical balloon (FTB) versus prostaglandin E₂ (PGE₂) vaginal insert, following failure of cervical ripening with PGE₂ vaginal insert.

Materials and methods: A retrospective cohort study of all pregnant women admitted for IOL with either FTB or PGE₂ vaginal insert. Either second dose of PGE₂ vaginal insert or FTB was used as a second line treatment after failure (not giving birth in 24?h from insertion) of first PGE₂ vaginal insert.

Results: During the study period, 1162 women were admitted for IOL. Failure was reported in 322/852 (37.8%) in the FTB versus 162/310 (52.2%) in the PGE₂ group (p?2 as first line who did not deliver after 24?h, 14 had spontaneous rupture of membranes, 15 underwent stripping and 42 were in still in active labor. The remainder were allocated to either second trial of PGE₂ treatment (n?=?58) or FTB (n?=?33) with failure rate higher in the PGE₂ group, not statistically significant (p?=?0.23).

Conclusion: IOL with FTB was not superior to PGE₂ vaginal insert for IOL following failure of cervical ripening with PGE₂ vaginal insert.     

Comparative cost analysis of prostaglandin analogues dinoprostone and misoprostol as labor preinduction agents

Objective: To compare the relative cost efficacy of three commercially available prostaglandin analogues, misoprostol (Cytotec®, PGE₁), dinoprostone gel (Prepidil®, PGE₂), and dinoprostone pessary (Cervidil®, PGE₂), as labor preinduction agents.Methods: The investigation was conducted as a prospective randomized, blinded phase III clinical trial. One hundred twelve gravid females undergoing induction of labor with an unfavorable cervix (Bishop score ≤5) were enrolled and randomized to receive either Cytotec® 50 μg q6 hours × 2 doses, Prepidil® 0.5 mg q6 hours × 2 doses, or Cervidil® 10 mg × 1 intravaginally. Twelve hours after initial treatment, cervical Bishop score was reassigned by the same blinded initial examiner and oxytocin induction initiated per standardized protocol. Therapeutic efficacy and cost of the labor preinduction/induction with the study treatments were compared. Statistical comparisons between groups were made using ANOVA with Bonferroni post test, Wilcoxon rank sum test, and χ² test.Results: The three study groups did not differ significantly with respect to parity, gestational age, indication for induction, or initial cervical Bishop score. A significantly greater proportion of patients had a favorable cervix (Bishop score ≥6) after the initial preinduction interval in the Cytotec® (79.0%) and Cervidil® groups (60.5%) as compared to Prepidil® (40.0%) (P < .05). The average relative cost per patient for prostaglandin preinduction was significantly less with Cytotec® ($0.42) as compared to both Cervidil® ($168.00) and Prepidil® ($184.17) (P < .0001). A greater percentage of patients treated with Cytotec® (42.1%) achieved active labor and delivered without the use of oxytocin when compared to Cervidil® (15.8%) or Prepidil® treatment groups (2.9%) (P < .05). Additionally, time to delivery (±SD) was significantly shorter in the Cytotec® group (24.0 ± 10.8 h) as compared to the Cervidil® (32.2 ± 14.7 h) or Prepidil® groups (33.9 ± 16.2 h) (P < .05). This reduction in time resulted in a significantly lower overall mean cost per patient incurred by labor induction in the Cytotec® group ($723.66) as compared to the Cervidil® ($1058.90) or Prepidil® treatment ($1124.84) (P < .01). No significant differences were noted with respect to rate of cesarean delivery.Conclusion: Misoprostol is more cost-effective than the comparable commercial dinoprostone prostaglandin preparations as an adjuvant to labor induction in patients with an unfavorable cervix.     

Outcomes of Elective Labour Induction and Elective Caesarean Section in Low-risk Pregnancies Between 37 and 41 Weeks’ Gestation

ObjectiveTo compare maternal and neonatal outcomes after elective induction of labour and elective Caesarean section with outcomes after spontaneous labour in women with low-risk, full-term pregnancies.MethodsWe extracted birth data from 1996 to 2005 from an obstetrical database. Singleton pregnancies with vertex presentation, anatomically normal, appropriately grown fetuses, and no medical or surgical complications were included. Outcomes after elective induction of labour and elective Caesarean section were compared with the outcomes after spontaneous labour, using chi-square and Student t tests and logistic regression.ResultsA total of 9686 women met the study criteria (3475 nulliparous, 6211 multiparous). The incidence of unplanned Caesarean section was higher in nulliparous women undergoing elective induction than in those with spontaneous labour (P < 0.001). Postpartum complications were more common in nulliparous and multiparous women undergoing elective induction (P < 0.001 and P < 0.01, respectively) and multiparous women undergoing elective Caesarean section, (P < 0.001). Rates of triage in NICU were higher in nulliparous women undergoing elective Caesarean section (P < 0.01), and requirements for neonatal free-flow oxygen administration were higher in nulliparous and multiparous women undergoing elective Caesarean section (P < 0.01 for each). Unplanned Caesarean section was 2.7 times more likely in nulliparous women undergoing elective induction of labour (95% CI 1.74 to 4.28, P < 0.001) and was more common among nulliparous and multiparous women undergoing induction of labour and requiring cervical ripening (P < 0. 001 and P < 0.05, respectively).ConclusionElective induction leads to more unplanned Caesarean sections in nulliparous women and to increased postpartum complications for both nulliparous and multiparous women. Elective Caesarean section has increased maternal and neonatal risks.     

Failure of cervical ripening with prostaglandin-E2 can it be predicted?

Objective.?To identify factors predicting failure of cervical ripening with prostaglandin E₂ (PGE₂).

Study design.?A retrospective, cohort study of all women admitted for preinduction cervical ripening and failed to respond to PGE₂ in comparison with randomly selected control group of women who underwent successful preinduction cervical ripening with PGE₂ in a 3:1 ratio.

Results.?Overall 488 women were included, of them, 122 in the study group and 366 in the control group. A comparison between the two groups has revealed that maternal age above 30 years (OR?=?2.7, 95%-CI 1.3–5.6), nulliparity (OR?=?4.1, 95%-CI 1.7–10.0), prepregnancy BMI above 25?kg/m² (OR?=?3.5, 95%-CI 1.7–7.1), cervical dilatation of 1?cm (OR?=?9.1, 95%-CI 3.5–13.4), cervical effacement of 50% or less admission (OR?=?5.0, 95%-CI 2.2–8.8), and gestational age of 37 weeks or less (OR?=?2.9, 95%-CI 1.3–6.6), are independent and significant predictors of cervical ripening failure with PGE₂, and account for almost 50% of the variation in ripening outcome (R²?=?0.47). No association was found between the risk of cervical ripening failure and the indication for ripening, rupture of membranes, weight gain during pregnancy, weight before labor, diabetes or preeclampsia during pregnancy, and the newborn weight.

Conclusions.?Characterization of women who have a high probability for cervical ripening failure with PGE₂ will help to improve consultation and may help choosing the optimal method for labor induction in these cases.