Mifepristone and misoprostol versus Dilapan and sulprostone for second trimester termination of pregnancy

Objective. To compare two methods for second trimester termination of pregnancy: mifepristone and misoprostol versus Dilapan® and sulprostone.

Methods. This was a randomized study involving 16 patients with a singleton live fetus with congenital malformations or genetic disorders. Eight patients were treated with 200 mg mifepristone orally followed by 200 μg misoprostol vaginally 3 hourly and eight patients received a sulprostone infusion after cervical dilatation with Dilapan.

Results. Mifepristone and misoprostol had a mean induction interval of 17.8 hours and sulprostone and Dilapan 20.9 hours. The mean induction interval did not differ significantly. Mean hospital stay was shorter in the patients treated with misoprostol: 2.1 vs. 3.3 days (p = 0.02) with a 95% confidence interval of ?2.1 to 0.3.

Conclusion. Mifepristone and misoprostol did not reduce the induction interval significantly compared to the sulprostone and Dilapan treatment for second trimester pregnancy termination. Hospital admission was significantly shorter in patients treated with mifepristone and misoprostol.     

Two dosing regimens for preinduction cervical priming with intravaginal dinoprostone pessary: a randomised clinical trial.

OBJECTIVE: To compare the efficacy within 24 hours of a three-times-a-day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming. DESIGN: Randomised controlled trial. SETTING: Department of Obstetrics and Gynaecology, Singapore General Hospital. PARTICIPANTS: One hundred singleton term primigravidae with cephalic presentation with unfavourable cervical scores (Bishop score < or = 5) requiring induction of labour. METHODS: Eligible women were randomly assigned the standard regimen (3000 microg dinoprostone [Prostin, Upjohn, Crawley, UK] once daily) or an intensive regimen (3000 microg dinoprostone given sequentially three times daily four hours apart) for cervical priming until successful priming (Bishop score of > or = 6) or the onset of active labour occurred. MAIN OUTCOME MEASURES: Number of women whose cervices were ripened successfully or who entered active labour within 24 hours of starting cervical priming, priming to induction interval, and priming to delivery interval. RESULTS: Forty-nine women were assigned to the standard regimen and 51 to the intensive regimen. The median number (range) of dinoprostone pessaries used was two (one to seven) in the standard regimen and three (one to nine) in the intensive regimen. Forty-two women (82.4%) who underwent the intensive regimen achieved successful cervical ripening or active labour within 24 hours, compared with 21 assigned to standard regimen (OR 6.2, 95% CI 2.3-17.4). This difference was statistically significant. The median intervals from priming to induction, and from priming to delivery, were also statistically significantly shorter in women treated with the intensive regimen. Thirty-five women (68.63%) assigned the intensive regimen experienced pain, compared with 21 (42.86%) in the standard regimen (OR 2.92, 95% CI 1.19-7.21), with two and one women in the respective regimens requiring opiate analgesics. Five women with oligohydramnios had transient cardiotocographic abnormalities during priming with the intensive regimen, none of which required immediate intervention, and the babies were born in good condition. There were no cases of uterine hypertonus and the outcomes of labour were similar for women from both regimens. CONCLUSIONS: Preinduction cervical priming with the intensive dosing regimen improves the chances of successful ripening within 24 hours for primigravidae with unfavourable cervical scores at full term singleton pregnancies, and shortens the interval from priming to induction, and priming to delivery. This regimen may be more cost effective by shortening the period of hospital stay. The overall incidence of adverse reactions to the mother and fetus during priming was low. However, close fetal surveillance must be maintained, particularly in pregnancies complicated with oligohydramnios.     

Influence of misoprostol or prostaglandin E(2) for induction of labor on the incidence of pathological CTG tracing: a randomized trial

OBJECTIVE: To compare the efficacy and safety of misoprostol (prostaglandin E(1) (PGE(1))) with dinoprostone (prostaglandin E(2) (PGE(2))) for third trimester cervical ripening and labor induction. STUDY DESIGN: Patients requiring induction of labor were randomly assigned to receive either 50 microg of intravaginal misoprostol every 4 h or 0.5 mg of intracervical dinoprostone gel every 6 h. Eligibility criteria included gestation = 36 weeks. Primary outcome was the time interval from induction to delivery; secondary outcomes were mode of delivery, perinatal outcome, and interpretation of cardiotocogram (CTG) records. RESULTS: Two hundred women were randomly enrolled to receive either misoprostol (n = 100) or dinoprostone (n = 100). Time induction-to-delivery at 12, 24 and 48 h and the need for oxytocin were reduced with misoprostol (P < 0.05). Pathological CTG tracing according to FIGO and Melchior scores were more frequent in the misoprostol-treated group (P < 0.001). CONCLUSION: Misoprostol shortened the induction-to-delivery interval, but is associated with a higher incidence of abnormal CTG than prostaglandin E(2).     

Randomized study on removable PGE2 vaginal insert versus PGE2 cervical gel for cervical priming and labor induction in low-Bishop-score pregnancy

BACKGROUND: Dinoprostone vaginal insert has been compared to Dinoprostone cervical gel in few studies, whose cases presented different Bishop scores and gestational ages at admission, and various treatment strategies in control arms. The present study compares the vaginal insert to the cervical gel in patients with low Bishop score at term. METHODS: Prospective multicenter randomized trial, with parity-based randomization. Admission criteria: single pregnancy with Bishop score of 0-4, gestational age of 37-41 weeks, intact membranes, no previous cesarean section, no bleeding or abnormal cardiotocography at admission. RESULTS: Vaginal prostaglandins were required as a second-line induction procedure in 25% of study patients versus 47.1% of controls (p < 0.03, chi2). Study patients experienced shorter induction-to-delivery time (920 +/- 428 versus 1,266 +/- 740 min, p <0,01), with a mean difference of 5 h and 46 min between the groups. Even though patients that received vaginal insert showed a trend of increased incidence of abnormal cardiotocography during labor (12% versus 6.3%) and hyperkinetic labor (11.8% versus 2.1%), the incidence of cesarean sections (21.4% versus 21.6%), cesareans for fetal distress (12.5% versus 11.8%), and umbilical artery pH <7.10 (4.9% versus 2.5%) was comparable between the two groups. CONCLUSIONS: Dinoprostone vaginal insert is more efficient than cervical gel in promoting cervical priming and labor induction in low-Bishop-score patients at term. The vaginal insert placement seems to be safe for the mother and the newborn, although larger studies are required to investigate uterine hyperstimulation incidence.     

Dose-dependent effect of locally administered sulprostone gel on serum luteal and placental hormones in cervix priming in the 1st trimester

In a prospective, randomised study 30 primigravidae were treated with 25 micrograms, 50 mu, or 100 micrograms sulprostone gel in order to soften the cervix prior to first trimester termination of pregnancy. 10 multigravidae received only the gel vehicle tylose. For objective demonstration of the priming effect, the force required for dilatation of the cervical canal was measured in Newton by a special tonometer before prostaglandin (PG) application and before operation. Serum progesterone, 17-beta-estradiol and hP1 levels were determined radioimmunologically prior to PG application and at two-hours intervals until curettage. A sonographic examination for determing the vitality of the pregnancy was performed before PG administration and immediately before the surgical intervention. There were no significant differences in the primig effect between the 50 micrograms and 100 micrograms sulprostone-treated group; the application of 25 micrograms sulprostone was significantly less effective. After 100 micrograms sulprostone gel abortion occurred in 2 patients, 6 women showed a marked decrease in hPl concentrations, progesterone levels were found to be reduced to 31.6-78.7% and 17-beta-estradiol to 10-40% of the initial values before PG application. We found a close time correlation between the occurrence of contraction-induced lower abdominal pain and the fall in hormone concentrations. No abortions occurred in any of the patients treated with 50 micrograms sulprostone gel; in 9 women without clinical symptoms no significant changes of the hormone concentrations were observed. In contrast to the previously published literature our results indicate that effective cervical ripening can be achieved by this method without disturbance of the feto-placental unit and the trophoblast respectively.     

Intravaginal misoprostol 600 μg and 800 μg for the treatment of early pregnancy failure

Objective: To compare the respective effectiveness and safety of 600 μg and 800 μg of intravaginal misoprostol for complete abortion in cases of early pregnancy failure (occurring in the first 12 weeks). Method: A total of 114 women with a diagnosis of early pregnancy failure made by transvaginal ultrasonography at Rajavithi Hospital between November 25, 2002 and July 31, 2003, were assigned randomly to 2 groups of equal size. In one group the women received 600 μg of misoprostol and in the other 800 μg of misoprostol intravaginally. Results: The rate of complete abortion within 24 h was significantly higher in the group that received 800 μg of misoprostol (68.4%) than in the other group (45.6%) (P < 0.05). There were no significant differences between the 2 groups regarding time interval between misoprostol insertion and complete abortion or side effects. Conclusion: Intravaginal misoprostol 800 μg is significantly more effective than vaginal misoprostol 600 μg for the termination of an early pregnancy failure, with no significant differences in side effects.     

Oral versus vaginal misoprostol administered one hour before surgical termination of pregnancy: a randomised controlled trial

OBJECTIVE: To assess the efficacy of oral and vaginal misoprostol as cervical priming agents administered 1 hour before first trimester surgical termination of pregnancy. DESIGN: A randomised controlled trial. SETTING: Chelsea and Westminster Hospital, London. POPULATION: Pregnant women of 10 weeks or less gestation attending the termination of pregnancy clinic. METHODS: Ninety eligible women were recruited to the study during September 2001 and September 2002. Women were randomised to one of the three groups: misoprostol administered orally (400 microg), misoprostol administered vaginally (800 microg) and standard care (no cervical priming agent) administered prior to surgical termination of pregnancy. Under general anaesthesia, and prior to the operation, a cervical tonometer was used to determine the main outcome measures. MAIN OUTCOME MEASURES: Baseline cervical dilatation and the cumulative force required to dilate the cervix from 3 to 9 mm. RESULTS: There was no significant difference in the mean baseline cervical dilation (P= 0.16) or the cumulative force required to dilate the cervix (P= 0.12) between the three randomised groups. CONCLUSION: No cervical priming effects were detectable with oral or vaginal misoprostol administered 1 hour before first trimester surgical termination of pregnancy.     

Vaginal misoprostol for pre-abortion cervical priming: is there an optimal evacuation time interval?

OBJECTIVE: To determine the optimal evacuation time interval in the use of vaginal misoprostol for cervical priming before first trimester termination of pregnancy. DESIGN: Prospective double-blind randomised study. SETTING: Fertility Control Centre, National University Hospital, Singapore. METHODS: Sixty healthy nulliparous women requesting legal termination of pregnancy between 6 and 11 weeks of gestation were randomly allocated to either the 400 microg or 600 microg misoprostol group. Vacuum aspiration was performed after three hours in the 400 microg group and at the end of two hours in the women given 600 microg misoprostol. Using Hegar's dilator, degree of cervical dilatation before operation was measured. Other parameters assessed included the amount of additional dilatation required (if < Hegar 8), pre-operative and intra-operative blood loss, and associated side effects. RESULTS: For the 600 microg group, only five women (16.7%) achieved a cervical dilatation of > or = 8 mm, compared with 28 women (93.3%) in the 400 microg group. Using the 400 microg misoprostol group as a baseline, the odds ratio was 0.014 (95% CI 0.003-0.080) for 600 microg for successful pre-operative cervical dilatation of > or = 8 mm. The mean cervical dilatation for 400 and 600 microg misoprostol was 8.1 mm and 6.6 mm, respectively (P < 0.001). Despite the shorter evacuation time interval of two hours, the 600 microg dose was associated with an increase in side effects such as vaginal bleeding, abdominal pain and a fever of > 38.0 degrees C. However, other than abdominal pain, no significant differences in the frequency of these side effects were shown. CONCLUSION: Use of 400 microg misoprostol with a minimal evacuation time interval of three hours still appears the optimal dosage and evacuation time for cervical priming before first trimester termination of pregnancy.     

Vaginal Misoprostol vs. Concentrated Oxytocin Plus Low-Dose Prostaglandin E2 for Second Trimester Pregnancy Termination

Objective: To examine the efficacy of vaginal misoprostol for mid-trimester pregnancy termination.

Results: Interim analysis of the first 30 (15-misoprostol, 15-concentrated oxytocin) women demonstrated that the 2 groups were similar with regard to indication for delivery, gestational age, and demographic characteristics. Misoprostol was associated with a lower success rate (67 vs. 87%, P =. 2), a longer induction-delivery interval (22 h vs. 18 h, P =. 09), a higher rate of retained placenta requiring curettage (27 vs. 13%, P =. 65), and a higher live birth rate (50 vs. 0%, P =. 006).

Conclusions: Compared to a regimen of concentrated oxytocin plus low-dose prostaglandin E₂, misoprostol administered as vaginal tablets in a dose of 200 μg q 12 h is not satisfactory for mid-trimester pregnancy termination in an unselected population.

Methods: This randomized trial compared misoprostol, 200 μg per vaginum q 12 h to a protocol of concentrated oxytocin plus low-dose vaginal prostaglandin E₂ suppositories (10 mg q 6 h). Success was defined as an induction-to-delivery interval ≤24 h.     

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.     

The efficiency of the uterocervical angle in the prediction of second-trimester pregnancy terminations in multiparous women

Aim: To show how uterocervical angles are used for the prediction of second-trimester pregnancy terminations in multiparous women.

Material and methods: A total of 148 multiparous singleton women in their second trimesters were enrolled in this prospective study. The intracervical Foley catheter was used for the induction of delivery. The cervical length (CL) and the uterocervical angle (UCA) were measured before the beginning of induction. The study population was subdivided into four groups; successful and failed terminations at the end of 24 and 48?h time frames. A stepwise multiple regression analysis was carried out to examine the contribution of UCA and other parameters to the induction-to-delivery time. A survival analysis was conducted to compare two groups defined by the cut-off value.

Results: The UCA was broader in the successful termination group compared to the failed termination group in 24?h of induction (112.50°?±?29.00° versus 100.68°?±?27.13°, p?=?.02). A negative correlation was found between the UCA and the induction-to-delivery time (r?=??0.27, p?=?.0007). A cut-off value of 97.5° was found for the UCA in predicting induction outcomes. During the 24-h period, 63.1% of women with the UCA ≥97.5° terminated successfully while 36.8% of women with the UCA <97.5° terminated successfully (p?=?.001). The mean induction-to-delivery time was significantly shorter in the UCA ≥97.5° group compared to the UCA <97.5° group (38.2?±?19.5?h versus 47.8?±?27.5?h, p?=?.02). The binary logistic regression analysis showed that the UCA was the only contributor to a successful termination (OR?=?1.01, 95% CI: 1–1.02, p?=?.02).

Conclusion: The UCA is broader in multiparous women who successfully terminated and is linked to a shorter duration of induction. The UCA by itself is the only significant contributor to the outcome of second trimester pregnancy terminations.

Trial registration: ClinicalTrials.gov identifier: NCT03400358.     

Termination of 2nd and 3rd trimester pregnancies with mifepristone and misoprostol

Objective: The purpose of this study was to evaluate our use of the association of mifepristone and misoprostol for terminating second and third trimester pregnancies. Study design: One hundred and six patients undergoing termination of pregnancy between January 1993 and June 1995 in our center were studied. Each patient received 600 mg of mifepristone followed 24 h later by 400 microgrammes of misoprostol every 6 h. Results: The average interval from the first administration of misoprostol to expulsion was 12.5 ± 7.5 h (interval markedly decreased to 9.6 ± 6.3 h in cases of intrauterine fetal death). Conclusion: The efficacy of the association of mifepristone and misoprostol is comparable with that of current regimens with greater ease of utilization and at a much lower cost.     

Mifepristone versus vaginally administered misoprostol for cervical priming before first-trimester termination of pregnancy: a randomized, controlled study

OBJECTIVE: This study was undertaken to compare the effectiveness of mifepristone orally administered at 24 or 48 hours before first-trimester vacuum aspiration abortion with that of vaginally administered misoprostol as a cervical priming agent. STUDY DESIGN: In a randomized comparative trial 90 women who requested surgical termination of pregnancy were randomly assigned to receive 200 mg mifepristone orally 24 or 48 hours before the operation or 800 microg misoprostol vaginally 2 to 4 hours before the operation. The main outcome measures were baseline cervical dilatation, cumulative force required to dilate the cervix to 9 mm, and intraoperative blood loss. RESULTS: The baseline cervical dilatation was significantly greater among women who received mifepristone 48 hours before the operation (P =.02). This group also required the least mechanical force to dilate the cervix (P =.06). There were no significant differences among the 3 groups in the intraoperative blood loss, in the operating time, or in patient acceptability. Side effects such as hot flushes and headaches were significantly higher among women who received mifepristone 24 or 48 hours before the operation than among those who received misoprostol (P =.01 and P =. 002, respectively). CONCLUSION: Mifepristone is an effective cervical priming agent when orally administered 48 hours before vacuum aspiration for termination of first-trimester pregnancy. Because of its cost and availability in comparison with misoprostol, however, selective use may have to be considered.     

Mifepristone and second trimester pregnancy termination for fetal abnormality in Western Australia: Worth the effort

Objective:  To determine the impact on the process of second trimester medical termination for fetal abnormality following the introduction of adjunctive mifepristone in an Australian tertiary hospital.
Methods:  All second trimester medical terminations for fetal abnormality between July 2006 and June 2009 were prospectively identified. Two temporal therapeutic cohorts were created: the first (1 July 2006 to 31 December 2007) using vaginal misoprostol alone and the second (1 January 2008 to 30 June 2009) using mifepristone priming prior to the administration of misoprostol. The primary outcome was to evaluate the impact of mifepristone priming upon the duration of pregnancy termination.
Results:  During the study period, 388 women with prenatally recognised fetal anomalies between 14 and 24 weeks gestation underwent medical termination: 189 with misoprostol alone and 199 with mifepristone priming followed by misoprostol. There was no difference between the groups for maternal age, parity or prior caesarean delivery. The median abortion duration was 15.5 h (interquartile ranges (IQR) 11.2–22.7) in the misoprostol group and 8.6 h (IQR 5.6–13.8) in the mifepristone primed group ( P  < 0.001). In both the groups, nulliparity and advancing gestation were associated with a significant prolongation of the abortion interval. Duration of hospitalisation was significantly longer in the misoprostol alone group (31.5 h (27–48.9) vs 27.2 h (22–31.5), misoprostol vs mifepristone priming, respectively, P  < 0.001).
Conclusions:  The introduction of mifepristone priming prior to second trimester medical termination with misoprostol has resulted in a significant reduction in the duration of the termination procedure and length of inpatient stay. These observed benefits of mifepristone provide objective support for the decision to permit use of this medication in Australia.     

Laminaria and sulprostone in second trimester pregnancy termination for fetal abnormalities.

The efficacy and safety of intracervical placement of laminaria and intravenous prostaglandin E2 (sulprostone) infusion for termination of second-trimester pregnancies with abnormal fetuses was investigated. One hundred and six pregnant women at 13-29 weeks' gestation with fetal anomalies underwent laminaria tent insertion into the cervical canal on admission. The next morning, Sulprostone infusion was started at a rate of 16 microg/h and increased by 16 microg/h every 30 min to induce uterine contractions. Induction-to-abortion time (IAT), success and complete abortion rates, and sulprostone-related side effects were registered. The overall success and complete abortion rates within 24 h were 91.5 and 80.2%, respectively. The mean IAT was 12.1+/-7.6 h. The incidence of nausea and/or vomiting was 17.9%, with 1.7 episodes per case. Diarrhea and fever (9.5%) were not common. Laminaria tent insertion plus sulprostone infusion was an effective and safe regimen for second-trimester termination of pregnancy with live fetuses.     

Gemeprost versus misoprostol for cervical priming before first-trimester abortion: a randomized controlled trial

OBJECTIVE: To compare the efficacy of 400 microg of misoprostol with that of 1 mg of gemeprost as cervical priming agents when administered vaginally 3 to 4 hours before first-trimester vacuum aspiration abortion. METHODS: In a prospective controlled trial 90 nulliparous women who requested termination of pregnancy before 12 weeks' gestation were randomized to receive vaginally either misoprostol or gemeprost for cervical priming. The force to dilate the cervix was measured by the use of a cervical tonometer connected to Hegar dilators from 3 to 10 mm. The main outcome measures were baseline cervical dilation; the peak force to dilate the cervix at 8, 9, and 10 mm; and the cumulative force to dilate the cervix to 10 mm. RESULTS: Baseline cervical dilation did not differ significantly between the women who received misoprostol and those who were treated with gemeprost. Neither the peak force required to dilate the cervix at 8, 9, and 10 mm nor the cumulative force to dilate the cervix to 10 mm showed any significant difference between the two groups. CONCLUSION: Vaginally administered misoprostol (400 microg) is as effective as gemeprost (1 mg) for cervical priming 3 to 4 hours before surgical termination of first-trimester pregnancies.     

Oral misoprostol vs. vaginal gemeprost prior to surgical termination of pregnancy in nulliparae

BACKGROUND: To compare the efficacy and side-effects of intravaginal gemeprost with those of oral misoprostol for cervical ripening prior to first-trimester pregnancy termination in nulliparous women. METHODS: Retrospective analysis of surgical terminations of pregnancy performed before 90 days of gestation. Intravaginal gemeprost 1 mg or oral misoprostol 800 micro g was administered 2 h before the procedure. RESULTS: In total, 746 women were enrolled into the study, 84 received intravaginal gemeprost and 662 oral misoprostol. Median baseline cervical dilatation was significantly greater in women who received misoprostol before the operation than in those who received gemeprost (7 mm vs. 3 mm; p < 0.0001). The incidence of fever, vomiting and diarrhea was not different between the two groups. The incidence of abdominal pain with request for pain medication, emergency admission to operating room due to vaginal bleeding, hospital stay longer than 24 h and surgical repair of cervical injury due to Hegar dilatation was significantly higher among the gemeprost group than the misoprostol group. CONCLUSIONS: In cervical priming prior to first-trimester pregnancy termination in nulliparous women, oral misoprostol is more effective and is associated with fewer side-effects and complications than intravaginal gemeprost.     

Medical management for termination of second and third trimester pregnancies: a comparison of strategies

OBJECTIVE: Misoprostol and sulprostone are prostaglandins that can be used for the termination of second and third trimester pregnancy. The aim of the present study was to compare the effectiveness of both agents for the termination of second and third trimester pregnancy in cases of congenital or genetic abnormalities, and for the induction of labour in cases of intra-uterine foetal death. STUDY DESIGN: We collected data from all women who had been treated with misoprostol in the second or third trimester of pregnancy between January 2001 and July 2002 in cases of congenital or genetic abnormalities, and for the induction of labour in cases of intra-uterine foetal death. In cases where the foetus was alive, misoprostol was usually (77%) combined with mifepristone. Women were matched to women who had been treated with sulprostone for termination of second and third trimester pregnancy before 2001. We matched for hospital, previous vaginal delivery, intra-uterine death and duration of pregnancy. The primary outcome measure was time to delivery. RESULTS: Since the treatment effect was different in patients in whom labour was induced for intra-uterine death and patients in whom labour was induced while the foetus was alive, the analysis was stratified for this parameter. In 94 patients with intra-uterine death, there was no significant difference in time to delivery, blood loss, operative removal of the placenta and need for pain relief between misoprostol and sulprostone. In vital pregnancy (n = 96), time to delivery was significantly shorter in the misoprostol group. The relative risk for haemorrhage exceeding 1000 ml in this group was 0.40 (95% confidence interval, CI, 0.13-1.2). We observed no significant differences with respect to operative removal of the placenta or need for pain relief. CONCLUSION: In cases of intra-uterine death, the effectiveness of misoprostol for termination of pregnancy is comparable to that of sulprostone. In vital pregnancy, combination of mifepristone and misoprostol is more effective than sulprostone alone.     

Elective cervical ripening in women beyond the 290th day of pregnancy: a randomized trial comparing 2 dinoprostone preparations

OBJECTIVE: To determine the better performer among cervical ripening agents for the elective induction of labor. STUDY DESIGN: An open-label, randomized study was done in consecutive patients undergoing elective induction of labor at the 41st week and beyond. Inclusion criteria were: singleton pregnancy, gestational age ascertained through first-trimester ultrasound, Bishop score <4 and nulliparity. Exclusion criteria were: oligohydramnios, maternal/fetal disorder or pregnancy complication, previous uterine surgery, rupture of membranes and presence of uterine activity. Patients received either slow-release dinoprostone vaginal insert (VI) or 0.5-mg dinoprostone intracervical (IC) gel, twice, 6 hours apart. RESULTS: Women receiving VI showed increased risk of entering labor without further stimulation (OR = 6.48, 95% CI 2.06-21.67, p < 0.001) and delivering vaginally within 24 hours (OR = 2.71, 95% CI 1.19-6.21, p = 0.01) in comparison to those receiving IC gel. A stay in the hospital (> 4 days) was more prevalent in women treated with IC gel in comparison to those treated with VI (OR = 2.35, 95% CI 1.04-5.37). CONCLUSION: Preinduction cervical ripening with the dinoprostone slow-release vaginal insert is associated with a hight rate of women undergoing vaginal delivery within 24 hours, with a shorter stay. Considering its good performance, the dinoprostone slow-release vaginal insert is the first choice for elective induction of labor in postdate pregnancy.     

Randomized trial of concurrent oxytocin with a sustained-release dinoprostone vaginal insert for labor induction at term.

OBJECTIVE: The purpose of this study was to determine whether the concurrent administration of oxytocin with sustained-release dinoprostone results in shorter induction times when compared with oxytocin after the removal of the dinoprostone insert. STUDY DESIGN: Women with singleton pregnancies at > or = 36 weeks, vertex presentations, reactive nonstress tests, no prior uterine scar, intact membranes, and Bishop scores of < or = 6 were randomly assigned to receive oxytocin either immediately after placement of a sustained-release dinoprostone insert (immediate) or 30 minutes after its removal (delayed). The primary outcome was the time interval from induction to delivery. RESULTS: Seventy-one patients were enrolled (immediate, 34 patients; delayed, 37 patients). There were no differences between treatment groups in non-reassuring fetal heart tracings, excess uterine activity, and epidural use. The mean time from dinoprostone placement until delivery was 544 minutes, shorter in the immediate group (972 vs 1516 minutes; P =.001). The proportion of deliveries within 24 hours was higher (90% vs 53%; P =.002) in the immediate group. Cesarean delivery rates were similar between the immediate and delayed groups (16% vs 13%; P =.73). No adverse maternal or neonatal outcomes were observed with concurrent therapy. CONCLUSION: Oxytocin that is administered concurrently with sustained-release dinoprostone significantly shortens induction-to-delivery times and results in a higher proportion of vaginal deliveries of < or = 24 hours with no apparent adverse effects.