The Influence of Diabetes on Labor Induction with Dinoprostone Vaginal Inserts.

OBJECTIVE: The aim of this study was to compare duration of labor induction between diabetic and nondiabetic women receiving dinoprostone vaginal insert (10 mg). STUDY DESIGN: This is a secondary analysis of two large randomized controlled trials using dinoprostone vaginal inserts for labor induction. We compare time to active labor, overall delivery, and vaginal delivery between diabetic and nondiabetic women undergoing induction of labor with a 10-mg dinoprostone vaginal insert. RESULTS: Diabetic women receiving dinoprostone vaginal insert had a longer time to onset of active labor, overall delivery, and vaginal delivery than their nondiabetic counterparts. There was no difference in abnormal labor affecting fetal heart rate pattern in diabetic women compared with nondiabetic women. The rates of neonatal hyperbilirubinemia were higher in diabetic women. CONCLUSION: Diabetes may represent an independent factor associated with prolonged induction among women undergoing induction of labor with dinoprostone. Dinoprostone is well tolerated in both diabetic and nondiabetic women. KEY POINTS: · Diabetic women receiving DVI have slower labor curves than nondiabetic women.. · Nulliparous diabetic women took longer to achieve active labor, overall delivery, and vaginal delivery than nondiabetic women.. · Parous diabetic women took longer to achieve vaginal delivery than nondiabetic women..

Free oscillation rheometry detects changes in clot properties in pregnancy and thrombocytopenia.

Improved methods are needed to identify patients at risk for thrombotic or bleeding events. Free oscillation rheometry (FOR) is a technique that offers information on coagulation, based on contributions of all blood components, by measurement of clotting time and changes in clot elasticity. This is the first study that evaluates FOR parameters in subjects likely to represent hypercoagulability (pregnant women) and hypocoagulability (thrombocytopenic patients). Clotting time and blood clot elasticity were measured by FOR in blood samples obtained from women in different pregnancy trimesters (n = 58), in thrombocytopenic patients before and after a platelet transfusion (n = 20) and in healthy blood donors (n = 60). The clotting time was shorter and the clot elasticity higher in pregnant women compared to the non-pregnant female blood donors. The elasticity was higher in late pregnancy compared to early pregnancy. Compared to the blood donors, the thrombocytopenic patients had lower elasticity, which was increased by a platelet transfusion, but there was no difference in clotting time. The results suggest that FOR can provide new information on the haemostatic status of patients at risk of thrombotic or bleeding events as well as information on the haemostatic effect of a platelet transfusion.

Associations of hypertensive disorders of pregnancy and outcomes of labor induction with prostaglandin vaginal inserts.

OBJECTIVE: To evaluate the association between hypertensive (HTNsive) disorders of pregnancy and outcomes of labor induction, in two cohorts of women induced with either misoprostol vaginal insert (MVI) or dinoprostone vaginal insert (DVI). STUDY DESIGN: This investigation was a post-hoc analysis of data from three Phase II and III, multi-center, double blind, randomized controlled trials of women induced with identical efficacy endpoints. A competing risk framework investigated the association between HTNsive disorders of pregnancy and the time-to-event endpoints of onset of active labor and vaginal delivery. We analyzed the overall incidence of the competing risk, cesarean delivery, by logistic regression to identify potential differences between the proportion of patients with cesarean and vaginal deliveries for each cohort. RESULTS: 401 women with HTNsive disorders during pregnancy underwent induction of labor in these studies (175 with DVI and 226 with MVI). Significant differences were noted in the cumulative incidence of vaginal delivery 24 hours following insertion between the non-HTNsive and HTNsive groups for both treatments, (57.1% vs. 47.4% (p=0.023) among MVI patients and 39.9% vs. 27.2% (p=0.017) among DVI patients). However, upon adjusting for potential confounders, the estimated relative rates of vaginal delivery among HTNsive vs. non-HTNsive patients was 0.947 (95% CI (0.637, 1.371), p=0.631) and 0.904 (95% CI (0.735, 1.113) p=0.341) within the MVI and DVI sub-groups respectively. CONCLUSION: After adjustment for confounders, such as BMI, baseline modified Bishop score and gestational age, time-to-event outcomes for induction of labor using MVI or DVI in HTNsive women are not significantly different from non-HTNsive women.

Optimising daytime deliveries when inducing labour using prostaglandin vaginal inserts.

OBJECTIVE: To determine induction start time(s) that would maximise daytime deliveries when using prostaglandin vaginal inserts. METHODS: Women enrolled into the Phase III trial, EXPEDITE (clinical trial registration: NCT01127581), had labour induced with either a misoprostol or dinoprostone vaginal insert (MVI or DVI). A secondary analysis was conducted to determine the optimal start times for induction by identifying the 12-h period with the highest proportion of deliveries by parity and treatment. RESULTS: Optimal start times for achieving daytime deliveries when using MVI appear to be 19:00 in nulliparae and 23:00 in multiparae. Applying these start times, the median time of onset of active labour would be approximately 08:30 for both parities and the median time of delivery would be the following day at approximately 16:30 for nulliparae and 12:00 (midday) for multiparae. Optimal start times when using DVI appear to be 07:00 for nulliparae and 23:00 for multiparae. Using these start times, the median time of onset of active labour would be the following day at approximately 04:00 and 11:50, and the median time of delivery would be approximately 13:40 and 16:10, respectively. CONCLUSIONS: When optimising daytime deliveries, different times to initiate induction of labour may be appropriate depending on parity and the type of retrievable prostaglandin vaginal insert used.

Galanin in the hippocampal formation of female rats--effects of 17beta-estradiol.

17Beta-estradiol induced an increase in tissue concentrations of galanin in the hippocampal formation of ovariectomized rats. This increase was dose- and time dependent, and occurred already 60 min after steroid administration and was not blocked by Tamoxifen). There was also an increase in galanin in the pro-estrous phase in regularly cycling rats. The estrogen-induced rapid increase may at least in part be due to decreased release of galanin as demonstrated by in vivo microdialysis studies. Thus, sex steroid hormones may influence signalling molecules in brain areas of importance for cognitive functions.

Misoprostol vaginal insert and time to vaginal delivery: a randomized controlled trial.

OBJECTIVE: To compare the efficacy and safety of a 200-microgram misoprostol vaginal insert with a 10-mg dinoprostone vaginal insert for reducing the time to vaginal delivery. METHODS: In a phase III, double-blind, multicenter study, women being induced with a modified Bishop score of 4 or less were randomly assigned to receive either a 200-microgram misoprostol vaginal insert or a 10-mg dinoprostone vaginal insert. Coprimary end points were time to vaginal delivery and rate of cesarean delivery. Secondary end points included time to any delivery mode, time to onset of active labor, and oxytocin use. RESULTS: A total of 1,358 women were randomized to receive the 200-microgram misoprostol vaginal insert (n=678) or dinoprostone vaginal insert (n=680). Women receiving the misoprostol vaginal insert had a significantly shorter median time to vaginal delivery compared with patients receiving the dinoprostone vaginal insert (21.5 hours compared with 32.8 hours, P<.001). Cesarean delivery occurred in 26.0% and 27.1% of women receiving the misoprostol vaginal insert and dinoprostone vaginal insert, respectively. A significant reduction in time to any delivery (18.3 hours compared with 27.3 hours), time to onset of active labor (12.1 hours compared with 18.6 hours), and proportion of women requiring predelivery oxytocin (48.1% compared with 74.1%) was observed with the misoprostol vaginal insert compared with dinoprostone vaginal insert (P<.001 for each). Uterine tachysystole requiring intervention occurred in 13.3% and 4.0% of participants receiving the misoprostol vaginal insert and dinoprostone vaginal insert, respectively (P<.001). CONCLUSION: Use of a 200-microgram misoprostol vaginal inset significantly reduced times to vaginal delivery and active labor with reduced need for oxytocin compared with the dinoprostone vaginal insert. Cesarean delivery rates were similar with both treatments. Tachysystole was more common in women receiving the 200-microgram misoprostol vaginal insert. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01127581. LEVEL OF EVIDENCE: I.

Eclampsia at a tertiary hospital 1973-99.

BACKGROUND: To investigate changes in incidence, patient characteristics, comorbidity and in the care provided in cases of eclampsia at a tertiary hospital during the period 1973-99. METHODS: Thirty-nine cases were identified through the Swedish National Birth Registry. Incidences and rates regarding patient characteristics and outcomes (duration of intensive care unit surveillance, assisted ventilation, multiple seizures, predefined major complications, perinatal mortality, small for gestational age, and neonatal intensive care surveillance) were compared between the time periods 1973-79, 1980-89 and 1990-99 with trend analysis. RESULTS: The incidences in the three time periods were 3.0/10,000 births [95% confidence interval (CI) 0.1-5.9], 6.2/10,000 births (95% CI 2.7-9.7) and 10.9/10,000 births (95% CI 6.4-15.4), respectively, which constitutes a significant difference according to trend analysis (p = 0.006). There were no differences in patient characteristics or comorbidity. Onset occurred in hospital in 85% of the cases. CONCLUSIONS: The increase in the incidence of eclampsia reported here is contrary to international trends up until the early 1990s. The incidence in 1990-99 is also higher than the reported national incidence in Sweden 1976-80, which was 2.9/10,000 births. Despite successful identification of women at risk for eclampsia and hospital surveillance, several cases were not prevented. Better prognostic tests that identify impending eclampsia are needed to bring the incidence down further.