Induction of labor with vaginal prostaglandin E2 pessaries

Prostaglandin E2 vaginal pessaries (3 mg) were compared with conventional amniotomy and oxytocin infusion as a method of induction of labor in 160 patients in the study group compared with 160 in the control group. Each group consisted of 100 primigravidae and 60 multigravidae. When the features of labor, delivery and fetal status were analyzed for the study and the control groups, the patients who received PGE2 pessaries had a better outcome. The difference was more significant for those patients with a low Bishop score. Compared with controls, the PGE2-treated patients had fewer cesarean sections either for failed induction or fetal distress (P less than 0.01); the incidence of infants with low Apgar score was significantly less (P less than 0.05) and there were fewer postpartum haemorrhages (P less than 0.01).     

The effect of vaginal prostaglandin E2 pessaries on induction of labor

In a prospective randomized study, patients with a valid obstetric indication for induction of labor received either 3 mg prostaglandin E₂ vaginal pessaries immediately prior to oxytocin (prostaglandin group, n = 99), or oxytocin alone (oxytocin group, n = 103). At the conclusion of the second day of induction, a significant reduction was noted in the incidence of failed induction in the prostaglandin group (4%) as compared to the oxytocin group (13%) (p < 0.05). Twenty percent of patients in the prostaglandin group experienced successful induction with prostaglandin pessaries only. When oxytocin was required in the prostaglandin group, the maximal concentration of oxytocin infused and the duration at this concentration were significantly less than in the oxytocin group. No perinatal complications were attributed to the use of prostaglandin. Three minor maternal complications that were attributed to vaginal prostaglandin E₂ did not require treatment. Our conclusion is that patients who require an induction of labor, when artificial rupture of the membranes is not feasible, benefit from the use of prostaglandin pessaries before the administration of oxytocin.     

A randomized trial of vaginal prostaglandin E2 for induction of labor. Insert vs. tablet

OBJECTIVE: To compare the efficacy and safety of a prostaglandin E2 (PGE2) vaginal insert with PGE2 administered as a vaginal tablet. STUDY DESIGN: A randomized, observational study was performed. Women requiring induction of labor were randomly assigned to receive either a 10-mg PGE2 vaginal insert (group 1, n = 100) or 3-mg PGE2 tablets twice at six-hour intervals (group 2, n = 100). The primary efficacy outcome variable was vaginal delivery within 24 hours of insertion. The criteria for safety were the occurrence of uterine hyperstimulation, abnormal fetal heart rate patterns, use of beta 2-sympathomimetic drugs and fetal outcome. RESULTS: No differences in terms of vaginal delivery or cesarean section within 24 hours of induction were found. The cesarean section rate was 21% in group 1 and 22% in group 2. The interval from insertion of the induction agent to the onset of regular uterine contractions and the insertion-to-delivery interval were not different between the two cohorts. No difference in the frequency of uterine hyperstimulation, use of beta 2-sympathomimetic drugs, abnormal fetal heart rate patterns, fetal outcome, or oxytocin and analgesic requirements were found. In seven of eight patients in group 1 who experienced uterine hyperstimulation, removal of the insert was sufficient to stop it, whereas in group 2, of nine cases, eight needed medical interventions to end hyperstimulation (P = .003). CONCLUSION: The continuous release of PGE2 from the vaginal insert permits controlled induction of labor, and easy removal of the drug in cases of uterine hyperstimulation is possible.     

A randomized trial of vaginal prostaglandin E2 gel and dinoprostone vaginal insert for induction of labor at term

Objective: The aim of this study was to determine whether dinoprostone vaginal insert (Cervidil) can ripen the cervix and induce labor more effectively and safely than a hospital-prepared intravaginal gel.Methods: Three hundred thirty-six patients undergoing cervical ripening for induction of labor at term were randomly assigned to receive either Cervidil insert or a hospital-formulated prostaglandin E₂ gel. Bishop scores were evaluated before and after administration of the ripening agent, and charts were subsequently reviewed for labor characteristics, mode of delivery, and complications of labor and delivery.Results: Cervical ripening as measured by a change in Bishop score was significantly better in those patients receiving Cervidil than those receiving the gel (3.54 vs 2.29, P < .0001). Although duration of labor was similar between the two groups, those receiving Cervidil were less likely to require oxytocin stimulation (RR 0.51, 95% CI 0.29–0.91). Though the Cervidil group had a lower cesarean section rate than the gel group, the difference did not achieve statistical significance (25.4% vs 33.8%, P = .089). Complication rates did not differ significantly between the two groups.Conclusions: Cervidil insert is superior to intravaginal gel in ripening the cervix and inducing labor, with no increase in morbidity. It has not been shown to have a significant effect on duration of labor or mode of delivery.     

Induction of labor by vaginal prostaglandin E2. A randomized study comparing pessaries with vaginal tablets.

A prospective randomized study of 267 pregnant women was undertaken to compare the efficacy of a pharmacy-prepared 3-mg prostaglandin E2 (PGE2) vaginal suppository with a 3-mg PGE2 vaginal tablet for induction of labor and cervical ripening. No statistically significant difference in success frequency was found between the two groups, either on the first day (72% and 74%, respectively; p greater than 0.05) or on the second day (89% in both groups). There was an equal proportion of women requiring oxytocin augmentation in the two groups, but the slower releasing properties of the vaginal tablet were reflected in a longer mean induction--delivery interval of about 4 h for this group. In both the pessary and the vaginal tablet groups, women who had not gone into labor on the first day showed a statistically significant increment in the Bishop score on the morning of the second day. The frequency of cesarean section was the same in both groups, but instrumental deliveries were more frequent in the vaginal tablet group. It is concluded that PGE2 vaginal tablets--a chemically stable alternative to pharmacy prepared pessaries--appear to be effective as regards cervical ripening as well as for labor induction.     

A randomised comparison of oral misoprostol and vaginal prostaglandin E2 tablets in labour induction at term

OBJECTIVE: To compare the efficacy of 100 microg of oral misoprostol with 3 mg prostaglandin E2 vaginal tablets in term labour induction. DESIGN: A non-blinded, randomised, controlled trial. SETTING: A tertiary level, teaching Scottish Hospital. POPULATION: Two hundred women at term with indications for labour induction and modified Bishop's cervical score of less than 8. METHODS: The women were randomly allocated to receive either 100 microg of misoprostol orally (which could be repeated 4 hourly to a maximum of five doses if indicated), or a 3 mg tablet of prostaglandin E2 vaginally (which could be repeated in 6 hours, according to routine departmental protocol). MAIN OUTCOME MEASURE: The number delivering vaginally within 24 hours of the induction. RESULTS: Seventy-five women delivered vaginally in the misoprostol group and 73 in the PGE2 group. Of these, 50.7% in the misoprostol group and 54.8% in the PGE2 group delivered within 24 hours of the induction (RR 0.92, 95% CI 0.7 to 1.3). More women in the misoprostol group were given oxytocin, but this was not statistically significant (60%vs 47%, RR 1.3, 95% CI 0.98 to 1.7). Two women in the misoprostol group had uterine hyperstimulation. The neonatal outcomes were not significantly different in the two groups. There was a pound 1100 saving on direct drug costs in the misoprostol group. CONCLUSIONS: Oral misoprostol (100 microg) has similar efficacy to vaginal PGE2 tablets, and may be an option to consider for term labour induction.     

A comparison of three dosages of prostaglandin E2 pessaries for ripening the unfavourable cervix prior to induction of labor

A study was planned to evaluate the effect of Prostaglandin E2 pessaries in three different dosages in ripening the unfavourable cervix prior to the induction of labor. A single dose of PGE2 as pessary in the three different dosages was administered into the posterior vaginal fornix to ripen an unfavourable cervix with a Bishop score less than or equal to 4 in 101 primigravid and 79 multigravid patients. The pessary containing 2 mgm was as effective as 3 mgm and 5 mgm PGE2 pessary in ripening the cervix, and the outcome of labor and fetal status were similar with the different dosages of PGE2. However, two multigravid patients who received 5 mg of PGEs pessary and one multigravid patient who received 3 mg of PGE2 pessary developed hypertonic uterine activity. None of the patients who received 2 mg PGE2 pessary developed any adverse effect on uterine activity.     

Sensitivity test in labor induction with prostaglandin E2 vaginal tablets

The study was designed to evaluate whether an oxytocin sensitivity test in addition to pelvic scoring would increase the predictive value concerning successful induction in cases of elective induction by means of prostaglandin (PG) E2 vaginal tablets. Furthermore we investigated if this test could lead to a further reduction in the already low rate of protracted labour and operative deliveries. In order to establish the optimal dosage we compared the endocervical application of 1.5 ml PG E2 with 3 mg intravaginal. 160 pregnant women without any risks were included at due date; 73% decided spontaneously to have labour induced by means of PG E2 tablets. In these induction groups the delivery intervals were significantly shorter and the rate of operative deliveries was reduced. The fetal outcome, however, was the same as in those women who decided to await spontaneous onset of labour. The endocervical application did not prove any better. The oxytocin sensitivity test yielded additional information about the chances of inducing labour successfully. The results confirmed again the efficacy and acceptance of this method of labour induction.     

A comparison of Lamicel and prostaglandin E2 vaginal gel for cervical ripening before induction of labor

The efficiency and safety of Lamicel, a new synthetic cervical ripening agent, were compared with those of intravaginal prostaglandin E2 gel in a group of 80 primigravid women about to undergo induction of labor. Lamicel caused less uterine activity and fetal distress than prostaglandin gel, although the induction-delivery intervals were similar in both groups. More normal deliveries occurred in the Lamicel group than in the prostaglandin group. It is suggested that Lamicel is a useful, efficient preinduction ripening agent that is safer than intravaginal prostaglandin gel.     

A scoring system for induction of labor using prostaglandin E2 vaginal tablets

A randomized controlled trial was carried out in order to establish the efficacy of a scoring system for calculating the dose of vaginal prostaglandin E2 tablets for the induction of labor. One hundred ten women were included in the study. The patients received a dose of prostaglandin E2 calculated according to a scoring system based on the Bishop's score, or the standard dose of 3 mg repeated 6 h later if labor did not start. The percentage of inductions achieved was the same with both regimens (92.7%). The mean total dose used in the scoring system-group (2.7 mg) was significantly lower than that used in the 3-mg group (3.5 mg, P less than 0.025). Thirty-seven of 55 women receiving the scoring dose delivered with amounts of 2.5 mg prostaglandin E2 or less. Three cases of uterine hyperstimulation were observed in the 3-mg group whereas no cases were observed in the scoring group. The scoring system is proposed as a method for calculating the dose of vaginal prostaglandin E2 for induction of labor and minimizing the risk of overdosage.     

Induction of labor by prostaglandin E2: intracervical gel or vaginal pessaries?

To investigate the best route of prostaglandin medication for induction of labor, 125 pregnant women with unfavorable cervices (Bishop scores less than or equal to 6) were randomized to induction of labor with either PGE2 (0.5 mg) in a viscous intracervical gel once daily or PGE2 pessaries (2.5 mg) 1-2 a day. As estimated by life table analysis, the pessaries were significantly more effective inducing vaginal delivery compared to intracervical gel (24 h: P less than 0.025, 48 h: P less than 0.01, logrank test) and vaginal delivery was obtained within 24 h/48 h in 50%/72% of the women in the pessary group and in 29%/55% of the women in the intracervical group. Cervical ripening was found within 3 h (P less than 0.001) and in the subsequent 3 to 24 h period (P less than 0.005) after both treatments, no difference being found between the groups. The pessaries were much more effective inducing regular contractions compared to the intracervical gel (P less than 0.005, logrank test), so the latter seems preferable if cervical ripening rather than induction is intended. No difference was found analyzing the active labor period. No difference was found in methods of delivery, neonatal parameters (Apgar scores, umbilical artery blood pH and standard base excess), and the patients' attitude towards both methods of induction were equally favorable.     

Elective induction of term labor with amniotomy and oral prostaglandin E2

Labor at term was electively induced in 50 clinically normal cases by a combined procedure (low amniotomy plus oral PGE₂ given as a draught). This type of induction is efficacious in both the primi- and the multiparous patient. Maternal side effects are negligible. The procedure appears to be safer for the fetus of a multipara than for the fetus of a primipara, as indicated by a significant though slight tendency toward acidosis and hypoxia, which becomes apparent in the course of the second stage of labor. A tentative explanation for this divergence in fetal behavior is advanced. For various reasons, uninterrupted electronic surveillance of the unborn is considered mandatory in cases in which PGE₂ is administered orally for labor induction.     

Oral prostaglandin E2 for induction of labor at term. II. Comparison of two low-dosage regimens.

Prostaglandin E2 was administered orally for induction of labor in 100 normal term gravidas with two dosage regimens. The data derived were compared with comparable data from gravidas matched with study patients according to prelabor cervical preparation and other relevant obstetric and actuarial features. Analysis of patterns of cervical dilatation and station vs. time was carried out. A dose of 0.5 mg. hourly was found to be effective in inducing labor of good quality with minimal side effects, providing a better balance between efficacy and adverse reactions than the higher dosage level.     

Mid-second-trimester labor induction: concentrated oxytocin compared with prostaglandin E2 vaginal suppositories

A concentrated oxytocin infusion and prostaglandin E2 (PGE2) vaginal suppositories were compared in a retrospective analysis for indicated abortion in the mid-second trimester (17-24 weeks' gestation). Eighty-one women underwent second-trimester pregnancy termination, 59 by PGE2 suppositories and 22 by concentrated oxytocin infusion. Success was achieved by PGE2 in 93% (55 of 59) and oxytocin in 91% (20 of 22). The mean duration of labor was 13.1 hours with PGE2 and 8.2 hours with oxytocin. The mean dose of PGE2 was 65.2 mg; of oxytocin, 200 units. Women who received PGE2 experienced nausea (46%), vomiting (37%), fever (64%), and diarrhea (20%) despite appropriate premedication. Few side effects occurred in the women who were treated with oxytocin. We conclude that concentrated oxytocin infusion seems to be a reasonable alternative to PGE2 vaginal suppositories for induction of labor in the mid-second trimester.     

Mode of delivery in pregnancies with premature rupture of membranes at or before term following induction of labor with vaginal prostaglandin E2

Our aim was to evaluate the mode of delivery in pregnancies complicated with premature rupture of the membranes (PROM) at or before term following induction of labor with vaginal application of prostaglandin E2 (PGE2), and to identify possible predictors leading to cesarean section (CS). The study sample consisted of 220 women with term-PROM who did not enter spontaneous labor after 24 hours of expectant management and 42 with preterm (P)-PROM, who underwent labor induction with vaginal PGE2. Findings were compared with 115 women admitted for elective induction of labor, and 510 women with normal spontaneous-onset labor. There were no between-group differences in gravidity, parity, nulliparity rate, or number of PGE2 tablets used. Women with P-PROM were admitted at 34.6 +/- 2.4 weeks gestation, and delivered at 36.1 +/- 1.6 weeks (mean interval, 5.0 +/- 7.9 days; range, 0.5 to 40 days). The rate of CS was different only between the term-PROM (18.6%) and spontaneous onset of labor (9%) groups (odds ratio, 2.08; 95% confidence interval, 1.4 to 3.4). The rate of low 5-minute Apgar score (< 7) was similar in all groups, but the incidence of nonreassuring fetal heart rate pattern leading to CS was significantly lower in the PROM groups. A logistic regression model and forward likelihood analysis in the PROM groups yielded parity, higher number of PGE2 tablets used, and higher birth weight as independent and significant variables associated with increased risk of CS. Using our management protocol, 36.4% and 20.4% of women with term-PROM and P-PROM, respectively, required labor induction with PGE2, which was successful in more than 80% of cases, with no apparent serious maternal or fetal complications.     

Uterine rupture at term pregnancy with the use of intracervical prostaglandin E2 gel for induction of labor

Prostaglandin E2 is a powerful oxytocic agent that reliably initiates labor, even in the presence of an unripe cervix. The low incidence of fetomaternal complication contributes to its universal use. We report a rare case of uterine rupture after intracervical application of prostaglandin E2 gel. Thus far no prostaglandin compound or method of administration seems to be exempt from such a complication.     

欣普贝生用于足月胎膜早破低宫颈评分引产的效果观察

目的:探讨欣普贝生(地诺前列酮栓)在足月胎膜早破初产孕妇中应用的安全性及有效性。方法:100例足月胎膜早破单胎孕妇,破膜2h后未临产,宫颈条件未成熟(宫颈Bishop评分≤4分),孕妇知情同意后欣普贝生组入组50例,催产素组50例。比较两组的分娩方式及母儿结局情况。结果:与催产素组比较,欣普贝生组8h、12h促宫颈成熟总有效率明显增加(92.0%vs 64.5%,P0.01;95.9%vs 79.2%,P0.05)。欣普贝生组阴道分娩率明显升高(86.0%vs 60.0%,P0.01),且欣普贝生组用药12h、24h内阴道分娩率亦显著提高(42.0%vs 8.0%,P0.001;64.0%vs 34.0%,P0.01)。欣普贝生组用药至临产、用药至阴道分娩时间明显短于催产素组[(7.4±1.0)h vs(14.2±2.0)h,P0.01;(15.4±1.4)h vs(21.4±1.6)h,P0.01]。欣普贝生组引产失败率、绒毛膜羊膜炎发生率显著降低(2.0%vs 16.0%,P0.05;0 vs 12.0%,P0.05);两组急产、胎儿宫内窘迫、相对性头盆不称发生率无明显统计学差异;两组均无产后出血、新生儿窒息。结论:足月胎膜早破且宫颈条件未成熟的初产孕妇,应用欣普贝生促宫颈成熟安全、有效,且效果优于直接催产素引产,但用药期间应加强母儿监护。