Pregnancy outcome in early-onset severe pre-eclampsia in Trinidad

ObjectiveTo compare 2 different methods—multiple doses of misoprostol and a combination of misoprostol and oxytocin—for termination of pregnancy in the second trimester.MethodsBetween 2006 and 2008, 120 women undergoing termination of second-trimester pregnancy in 2 hospitals in Kermanshah, Iran, were enrolled in a randomized trial comparing 2 treatments. In each treatment group, an initial vaginal dose of 600 μg of misoprostol was placed in the posterior fornix. After 6 hours, an intravenous infusion of concentrated oxytocin was given to women in group A, and 400 μg of vaginal misoprostol was given every 6 hours to women group B, up to a maximum of 4 doses. The outcomes were compared via χ² and independent t tests.ResultsWithin 30 hours, 96.7% of women in group A and 96.7% of women in group B delivered successfully. The average duration between induction and delivery time was 12.3 ± 6.0 hours in group A and 12.1 ± 6.0 hours in group B (P > 0.05).ConclusionThe use of misoprostol with oxytocin, and multiple doses of misoprostol gave similar results for termination of pregnancy in the second trimester.     

Comparison of the efficacy and safety of titrated oral misoprostol and a conventional oral regimen for cervical ripening and labor induction

ObjectiveTo compare the efficacy and safety of titrated oral misoprostol and a conventional oral regimen for cervical ripening and labor induction.MethodsA randomized double-blind trial of women with term singleton pregnancies with indications for labor induction. Participants were allocated to receive 20 mL of misoprostol solution (1 μg/mL) orally every 1 hour for 4 doses then titrated to 40 μg every 1 hour (titrated group) or 50 μg of misoprostol orally every 4 hours up to 12 hours (conventional group). Primary outcomes were success rate of cervical ripening within 12 hours, interval from first dose until more favorable cervix or active labor occurred, and total dose of misoprostol.ResultsSixty-four participants were included. Mean total dose of misoprostol and incidence of tachysystole were significantly higher in the titrated compared with the conventional group (236.2 ± 110.1 μg vs 103.1 ± 35.7 μg; P = 0.001 and 25.0% vs 6.3%; P = 0.03), whereas success rate, interval from drug administration to more favorable cervix and delivery, proportion of patients delivered vaginally within 12 hours and 24 hours, need for oxytocin augmentation, cesarean delivery rate, maternal adverse effects and complications, and neonatal outcome were not significantly different (P > 0.05).ConclusionConventional oral misoprostol is as effective as titrated misoprostol for cervical ripening and labor induction, but has a lower incidence of tachysystole and a lower total dose of misoprostol is required. ClinicalTrial.gov: NCT00886860.     

Addition of isosorbide mononitrate to misoprostol for cervical ripening in post-term pregnancy: A randomized controlled trial

ObjectiveThe purpose of this paper is to compare the effect of vaginal isosorbide mononitrate added to misoprostol versus misoprostol alone in cervical ripening and labor induction in post-term pregnancy.MethodsIn this double-blind controlled trial study, 150 pregnant women in post-term pregnancy who were candidates for labor induction were selected. The participants were assigned randomly to receive either vaginal isosorbide mononitrate (IMN) (40 mg) or placebo. Misoprostol (25 mg) was added to both groups as needed. Time to full cervical ripening, time to delivery, and the amount of misoprostol used in each group were assessed.ResultsThe time interval from the administration of IMN to full cervical ripening was shown to be significantly lower in the IMN+ misoprostol groups versus the comparison group (p = .032). The adjusted analysis of this time interval after controlling for age, BMI, gravidity, and Bishop score on administration remained significantly less (p = .045),the mean difference being ?4.85 h, CI 95% ?9.58 to ?.12. Isosorbide treatment resulted in significantly less misoprostol used versus misoprostol alone (2.37 ± 1.02 versus 3.08 ± 1.29), adjusted p-value = .001, CI 95% ?1.09 to ?.32. We found no significant increase in maternal–fetal outcomes or side effects of the IMN+ misoprostol group compared with the misoprostol group.ConclusionThis study found that intravaginal IMN added to misoprostol is more effective in reducing time to full cervical ripening versus misoprostol alone in post-term pregnancy. It also reduces the need for more misoprostol.     

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.     

Simultaneous use of mifepristone and misoprostol for early pregnancy termination

ObjectiveSimultaneous mifepristone 200 mg and vaginal misoprostol 800 μg produces a complete abortion rate of approximately 90% at up to 63 days of gestation. The aim of this study was to determine the effectiveness of concurrent administration of mifepristone 200 mg and vaginal misoprostol 600 μg with respect to early medical abortion.Materials and MethodsA total of 254 women with undesired pregnancies of less than 49 days of gestation were enrolled. All women received oral mifepristone 200 mg and vaginal misoprostol 600 μg concurrently. Follow-up assessment by transvaginal ultrasonography was performed 3 days and 2 weeks after treatment.ResultsEfficacy outcome was analyzed for 242 women (95.3%) after excluding 12 individuals lost to follow-up. The complete abortion rate was 92.6%. The mean induction to abortion interval was about 5.8 hours. The mean bleeding duration was about 12.6 days. The women indicated that the side effects were tolerable and 90% of them said that their experience was satisfactory.ConclusionConcurrent administration of oral mifepristone 200 mg and vaginal misoprostol 600 μg is an efficacious regimen for medical abortion of pregnancies up to 49 days of gestation.     

Sublingual misoprostol versus intramuscular oxytocin for prevention of postpartum hemorrhage in low-risk women

ObjectiveTo compare sublingual misoprostol with intramuscular oxytocin for prevention of postpartum hemorrhage (PPH) in low-risk vaginal birth.MethodsIn a prospective, randomized, double-blind trial, 530 women without risk of PPH were randomly allocated to receive either 400 μg of misoprostol sublingually or 10 units of oxytocin intramuscularly within 1 minute of delivery. The outcome measures were incidence of PPH, postpartum blood loss, drop in hemoglobin level in 24 hours, need for additional uterotonic drug, incidence of adverse effects, and need for blood transfusion. Student t, χ², Mann–Whitney U, and Fisher exact tests were used for comparison.ResultsIncidence of postpartum hemorrhage (≥ 500 mL) and postpartum blood loss in the misoprostol group were similar to those in the oxytocin group (6% versus 5.7%, P = 0.85; 153 mL versus 146 mL, P = 0.36). Shivering and pyrexia were encountered more often in the misoprostol than in the oxytocin group (shivering: 19% versus 0.8%, P < 0.001, relative risk [RR] 0.86, 95% confidence interval [CI] 0.82–0.90; pyrexia: 2.3% versus 0%, P = 0.03, RR 0.97, 95% CI 0.95–0.99).ConclusionThe efficacy of 400 μg of misoprostol administered sublingually was equivalent to that of 10 units of oxytocin given intramuscularly for prevention of PPH in low-risk vaginal delivery.     

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.     

Élastographie du col utérin : prédiction du délai d’accouchement lors d’un déclenchement par prostaglandines

ObjectiveInduction of labor for medical indications has become a routine practice. To date, the Bishop score remains as the standard method to predict the duration of induced labor. Elastography is an objective method of assessing the relative consistency of tissues. Therefore, we sought to assess strain elastography of cervix to predict delay from induction to delivery in pregnant women with a low Bishop score.Patients and methodsUltrasound elastography was immediately performed before induction of labor for medical indications among patients with a singleton pregnancy at > 36 weeks of gestation and a Bishop score < 6. Patients received 50 μg of misoprostol intravaginally, repeated 6 hours later if regular painful uterine contractions had not started. A second ultrasound elastography was also performed 6 hours after starting the induction before the second dose of misoprostol if regular painful uterine contractions had not started. At each examination, a color map from blue (hardest tissue) to red (softest tissue) was produced. The cervical elastography was considered as positive if at least one part of its anterior wall was red. We assessed the predictive value of elastography on vaginal delivery within 24 hours. Patients delivering by cesarean section were excluded from this study.ResultsElastography was initially performed in 48 patients. Twelve patients delivering by cesarean section after induction of labor were excluded, leading to 36 patients evaluated in this study. Among these 36 patients with elastography performed before induction of labor, 20 had a second elastography before the second dose of misoprostol. Sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of elastography performed before induction of labor on vaginal delivery within 24 hours were 40%, 27.3%, 55.6%, and 16.7%, respectively. Sensibility, specificity, PPV and NPV of elastography performed before the second dose of misoprostol were 64.3%, 16.7%, 64.3% and 16.7%, respectively. Among the 8 patients with red color occurring on the second cervical color map, sensibility, specificity, PPV and NPV were 83.3%, 0%, 62.5%, and 0%.Discussion and conclusionQualitative cervical elastography is a poor predictor for delay from induction to delivery in pregnant women with a low Bishop score.     

Sustainable scale-up of active management of the third stage of labor for prevention of postpartum hemorrhage in Ecuador

ObjectiveTo analyze the Ecuadorian experience regarding the adoption, scale-up, and institutionalization of active management of the third stage of labor (AMTSL) for prevention of postpartum hemorrhage via continuous quality improvement (CQI) processes.MethodsAverage AMTSL implementation rates for women with vaginal deliveries were compared using unweighted provincial aggregate data from facilities participating in 3 phases of AMTSL programming. Months taken to implement AMTSL at 80% or more and 90% or more compliance were compared across phases.ResultsRate of oxytocin administration during the first 3 months was 5.0% in phase 1, 9.8% in phase 2, and 72.2% in phase 3 (P ≤ 0.001 vs phases 1 and 2). The average number of months provinces took to increase oxytocin administration to 80% or more and 90% or in more women with vaginal deliveries was, respectively, 21.6 ± 18.7 and 30.6 ± 16.4 in phase 1, 23.5 ± 15.1 and 30.1 ± 14.9 in phase 2, and 4.7 ± 4.9 (P ≤ 0.01 vs phase 1; P ≤ 0.001 vs phase 2) and 4.0 ± 3.4 (P ≤ 0.001 vs phases 1 and 2) in phase 3. By December 2009, AMTSL implementation was sustained at 90% or more in all provinces.ConclusionCQI processes identified resistance and operational barriers, and developed mechanisms to overcome them.     

Comparison of mifepristone combination with misoprostol and misoprostol alone in the management of intrauterine death: condensation - misoprostol and mifepristone combination is more effective than misoprostol alone in the management of intrauterine death

ObjectivesTo compare the efficacy and safety of misoprostol and mifepristone combination with misoprostol alone in management of intrauterine death.Materials and MethodsIt is a prospective study carried out in 40 pregnant women admitted with intrauterine death after 28 weeks of gestation at a tertiary care referral centre divided into two groups of 20 each. Every alternate patient was assigned Group I and Group II. Group I (combination group) – the women received 200 mg of mifepristone; and after 36 hours, misoprostol was administered orally (100 μg if pregnancy was <37 weeks and 50 μg if pregnancy was >37 weeks) for every 3 hour till they went into active labor for a maximum of four doses. Group II (misoprostol group) – Women received oral misoprostol (100 μg if pregnancy was <37 weeks and 50 μg if pregnancy was >37 weeks) for every three hours till she went into active labor for maximum of four doses.Primary outcome measures were achievement of successful induction and induction delivery interval (IDI). Women who did not deliver after four doses of misoprostol were considered as failure. In all the women, bishop score before the start of mifepristone and misoprostol, induction delivery interval, and adverse effect of the drug were noted. Data were analyzed by using Student t test and Chi-square test.ResultsIn the Group I, 60% of women, delivered with mifepristone alone. The rest of the patients [8 (40%)] had significant improvement of the bishop score after 36 hour. Parity, gestation, and bishop score did not affect the success of induction in the Group I. IDI was significantly less in the Group I (6.72 ± 3.34) as compared with that of the Group II (11.81 ± 6.33). Parity, gestation, and bishop score did not affect the IDI in the two groups. Number of doses of misoprostol required were significantly less in patients who were pretreated with mifepristone.ConclusionCombination of mifepristone and misoprostol is more effective than the misoprostol alone for induction of labor in women with intrauterine death.     

Cervical ripening using vaginal misoprostol before hysteroscopy: a double-blind randomized trial

Study ObjectiveThe aim of this study was to evaluate the use of vaginal misoprostol to decrease both the force required to dilate the cervix and the pain experienced during a hysteroscopy.DesignRandomized clinical trial (RCT) (Canadian Task Force classification I).SettingUniversity hospital gynecology clinic.PatientsA total of 101 patients needing a diagnostic hysteroscopy. Fifty patients were randomized to the misoprostol group and 51 to the placebo group. Patient characteristics were similar in the 2 groups.InterventionsSelf-administration of 400 μg of vaginal misoprostol or vaginal placebo 12 to 24 hours before a hysteroscopy.Measurements and Main ResultsThe force needed to dilate the cervix was assessed by a tonometer, and pain was measured by a visual analog scale. The force to dilate the cervix to 6 mm was significantly less in the misoprostol group (5.0 vs 7.5 N, p = .02). Pain-related measurements after dilatation of the cervix to 6 mm were significantly reduced in the misoprostol group (42.1 vs 57.2, p = .004). The main side effect reported with the use of the drug was pelvic cramping.ConclusionThe use of 400 μg of vaginal misoprostol 12 to 24 hours before hysteroscopy reduces the pain and the force needed to dilate the cervix, with only mild side effects.     

Comparison of misoprostol-only and combined mifepristone-misoprostol regimens for home-based early medical abortion in Tunisia and Vietnam

ObjectiveTo assess the potential advantages of combined mifepristone–misoprostol versus misoprostol-only for early medical abortion.MethodsA double-blind randomized placebo controlled study was conducted that enrolled 441 pregnant women (< 63 days since last menstrual period) at 2 hospitals in Tunisia and Vietnam. The mifepristone–misoprostol group (n = 220) received 200 mg of mifepristone on day 1 and 800 μg buccal misoprostol followed by placebo 3 hours later on day 2. The misoprostol-only group (n = 221) received placebo on day 1 and 1600 μg of misoprostol (2 doses of 800 μg, given 3 hours apart) on day 2. All medications were self-administered at home with follow-up 1 week later. The primary outcome was complete uterine evacuation without surgical intervention.ResultsSuccessful uterine evacuation occurred for 78.0% (n = 170) of women with misoprostol only versus 92.9% (n = 195) of women with mifepristone–misoprostol (relative risk 0.84, 95% CI, 0.78–0.91; P < 0.001). Ongoing pregnancy occurred for 13.8% (n = 30) of women given misoprostol-only and 1.4% (n = 3) of women given mifepristone–misoprostol (relative risk 9.63, 95% CI 2.98–31.09; P < 0.001).ConclusionMifepristone plus misoprostol is significantly more effective than misoprostol-only for early medical abortion.Clinical trials.gov registration number: NCT00680394.     

Mifepristona (600 mg) + misoprostol (400 μg) en el aborto del primer trimestre

ObjectiveTo evaluate the safety and efficacy of mifepristone 600 mg + oral or vaginal misoprostol 400 μg for early abortionSubjectsThey were included in the study 450 women that freely requested a voluntary pregnancy interruption (IVE) up to 9 weeks gestation, from the private sector in the Clinica Mediterrània Mèdica of Valencia and CastellónResultsRate of complete abortion was 96.7% (95% CI 95–98%); there were not significant statistical differences for the abortion rates among the groups for gestacional age (p = 0.24). The total vaginal bleeding lasted 11.7 ± 5.4 days. The mean time of expulsion was of 4.1 h ± 2.1 hours. The mean time of returning menses was 37 ± 5 daysConclusionsThe association of 600 mg of mifepristone + 400 μg vaginal misoprostol doses is a valid method for abortion up to 9 weeks gestations     

Excessive uterine activity accompanying induced labor

OBJECTIVE: To estimate the incidence and timing of excessive uterine activity accompanying induction of labor with misoprostol using different routes (oral or vaginal) and forms (intact tablet or crushed) and to compare these with dinoprostone gel, oxytocin, and spontaneous labor. METHODS: This retrospective cohort study included 519 women at term who had labor induced and 86 women at term in spontaneous labor. Induction agents included misoprostol, dinoprostone, or oxytocin. Fetal heart rate and uterine activity tracings were analyzed independently by three maternal-fetal medicine physicians. The diagnosis of tachysystole or hyperstimulation required the agreement of two or more reviewers. RESULTS: The incidence of tachysystole was highest with misoprostol administered by vaginal tablet (misoprostol vaginal tablet 50 microg every 4 hours, 48.6%; vaginal tablet crushed 50 microg and suspended in hydroxyethyl gel every 4 hours, 30.7%, P =.009; oral tablet 50 microg every 4 hours, 22.2%, P =.001; oral tablet crushed 50 microg every 4 hours, 15.5%, P <.001; dinoprostone gel, 33.0%, P =.022; intravenous oxytocin, 30.2%, P =.027; and spontaneous onset of labor, 23.3%, P <.001). Hyperstimulation occurred more often with dinoprostone gel (16.5%) than with other forms of induction or spontaneous labor. Hyperstimulation occurred significantly more often with vaginal misoprostol crushed tablet (7.9%) and vaginal misoprostol intact tablet (7.6%) than with crushed oral misoprostol (1.0%) (P =.016 and.018, respectively). There was a shorter time to tachysystole with increasing doses of vaginal misoprostol tablet (P =.01). CONCLUSION: The incidence of tachysystole and hyperstimulation, and time to tachysystole, varied depending on the route and form of misoprostol given.     

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.     

Misoprostol for midtrimester termination of pregnancy in women with 1 or more prior cesarean deliveries

ObjectiveTo evaluate the safety and efficacy of vaginal misoprostol for midtrimester termination of pregnancy (TOP) in women with 1 or more prior cesarean deliveries (CDs).MethodsA retrospective study was conducted with 279 women undergoing TOP with vaginal misoprostol between 14 and 26 weeks of gestation. Of these, 193 had no uterine scars (group 1), 60 had 1 prior CD (group 2), and 26 had 2 or more prior CDs (group 3). The primary outcome was the success rate of TOP. Secondary outcomes were time from induction to abortion, total dose of misoprostol used, and occurrence of uterine rupture.ResultsThe success rates were 96.4% in group 1, 81.7% in group 2, and 76.9% in group 3 (P = 0.001). Time from induction to abortion, total dose misoprostol, and duration of hospital stay differed significantly among the groups (P = 0.001 for all variables). There were 3 cases (11.5%) of uterine rupture in group 3, for an overall rate of 1.1%.ConclusionMisoprostol inserted vaginally was effective for midtrimester TOP but the safety of using misoprostol in women with 2 or more prior CDs cannot be confirmed from the present study. Misoprostol should be used carefully, particularly in women with 2 or more prior CDs.     

Cervicovaginal matrix metalloproteinase-9 and cervical ripening in human term parturition

ObjectiveTo investigate the changes of matrix metalloproteinase-9 (MMP-9) in cervicovaginal fluid during pregnancy and its association with parturition.Study designA prospective study was conducted on nulliparous women between 16 and 42 weeks with normal singleton pregnancies in the following categories: (1) preterm control (n = 39); (2) term labor induction without labor or rupture of membranes (n = 68); (3) term spontaneous labor with intact membranes (n = 42); (4) term premature rupture of membranes (n = 24). The MMP-9 concentration in the cervicovaginal fluid was measured by immunoassay.Results(1) Cervicovaginal MMP-9 did not change significantly with advancing gestation until 37 weeks, and significantly increased after 37 weeks. (2) Cervicovaginal MMP-9 levels were similar in women with no labor, spontaneous labor, and premature rupture of membranes at term. (3) For the induced labor group, a high Bishop score (≥4) was significantly correlated with cervicovaginal MMP-9. However, an elevated cervicovaginal MMP-9 did not predict achieving active phase of labor or vaginal delivery after labor induction.ConclusionCervicovaginal MMP-9 correlated with cervical ripening before labor at term. However, cervicovaginal MMP-9 did not change with spontaneous labor or rupture of membranes at term and did not predict success of labor induction.     

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.     

A Randomized Trial of Oral Misoprostol in Premenopausal Women Before Hysteroscopy

ObjectiveTo determine if the use of oral misoprostol in premenopausal women undergoing diagnostic hysteroscopy produces a clinically important difference in pre-procedural cervical dilatation.MethodsAt a tertiary care hospital, premenopausal women undergoing diagnostic hysteroscopy were randomized to receive either 400 μg of misoprostol or a vitamin B6 placebo orally 12 hours before the procedure. Patients were stratified on the basis of parity. The primary outcome was the pre-procedural dilatation of the cervix. Secondary outcomes included the need to further dilate the cervix, the time required to further dilate the cervix, and side effects.ResultsSixty-four women (11 nulliparous and 53 parous) undergoing diagnostic hysteroscopy consented to participate in the study. Thirty-three women received misoprostol and 31 received placebo. Baseline demographics showed no difference in age and parity between the two groups. There were no significant differences in pre-procedural dilatation (5.0 mm vs. 4.7 mm, P = 0.52), need to further dilate the cervix (56.7% vs. 63.0%, P = 0.63), and time required to further dilate the cervix (12.7 seconds vs. 25.7 seconds, P = 0.27). Significantly more women in the misoprostol group experienced menstrual-like cramping (24.2% vs. 3.3%, P = 0.03) and vaginal spotting (21.2% vs. 3.3%, P = 0.05).ConclusionIn premenopausal women, there is no improvement in pre-procedural cervical dilatation with administration of oral misoprostol 12 hours before diagnostic hysteroscopy. Further research is required in both nulliparous and parous premenopausal women to determine whether oral misoprostol improves cervical dilatation and, if so, the ideal dose, route and timing.     

Effect of vaginal pH on efficacy of the controlled-release dinoprostone vaginal insert for cervical ripening/labor induction

Objective: To evaluate whether vaginal pH alters the efficacy of the controlled-release dinoprostone vaginal insert (Cervidil^®) for cervical ripening/labor induction. Methods: Thirty-four women with an unfavorable cervix undergoing labor induction were enrolled in this prospective, double-blind investigation. Vaginal pH and Bishop score assessments were made by an independent examiner. All women received preinduction with the dinoprostone vaginal insert 10 mg intravaginally for 12 h. Twelve hours later, oxytocin induction initiated according to the standardized protocol and outcome data were collected. Results: Mean (± SD) initial vaginal pH was 4.9 ± 0.5 for the study cohort. No significant differences were noted between women with a high vaginal pH (> 4.5, n = 18) and those with a low vaginal pH (≤ 4.5, n = 16) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over the preinduction interval (3.2 vs. 3.3), time to active labor (28.6 vs. 24.6 h) and time to delivery (33.7 vs. 31.4 h) were not significantly different between the low and the high pH groups, respectively. Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during the preinduction interval, time to active labor, time to complete dilatation, or time to delivery. Conclusion: Vaginal pH does not appear to influence the efficacy of the controlled-released dinoprostone vaginal insert for cervical ripening/labor induction.