Insucesso de indução por misoprostol em gestantes: revisão integrativa / Fracaso de la inducción por misoprostol en mujeres embarazadas: revisión integradora / Unsuccessful misoprostol induction in pregnant women: an integrative review

Resumo Objetivo Analisar as evidências disponíveis na literatura acerca do insucesso da indução do trabalho de parto com misoprostol em gestações a termo. Métodos Revisão integrativa, realizada entre janeiro e novembro de 2022, cuja pergunta de pesquisa e descritores foram delineados por meio da estratégia PECO. As buscas foram realizadas nas bases de dados MEDLINE; Web of Science; CINAHL; EMBASE e Scopus por duas pesquisadoras de forma independente, assim como a avaliação. Para a fase de seleção e identificação dos estudos foi utilizado o Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A avaliação do risco de viés dos artigos incluídos foi realizada através do questionário Newcastle Ottawa Scale. Resultados Foram identificados 3.674 artigos, 84 foram lidos na íntegra, dos quais 11 compuseram a revisão (n=9.010 gestantes), com publicação entre os anos de 2005 a 2021, sendo a maioria nos Estados Unidos. Quanto ao nível de evidência, todos os artigos foram classificados como 2b, avaliada coforme o delineamento de cada investigação. O estudo apontou evidências quanto aos seguintes fatores: IMC elevado (maior igual a 30kg/m2), nuliparidade, bishop imaturo, comprimento cervical (maior igual a 30mm), estatura, etnia (não caucasianas do sul da Europa) e peso fetal (maior igual a 4kg). Conclusão Alcançou-se o objetivo do estudo tendo sido demonstrado seis fatores maternos e um fetal que podem levar ao insucesso da indução. Vale ressaltar a necessidade de evidências que incorporem a individualidade de cada característica e destaca-se a contribuição desse estudo para embasar a escolha da melhor conduta para cada gestação de forma individualizada.

Resumen Objetivo Analizar las evidencias disponibles en la literatura acerca del fracaso de la inducción del trabajo de parto con misoprostol en gestaciones a término. Métodos Revisión integradora, realizada entre enero y noviembre de 2022, cuya pregunta de investigación y descriptores fueron definidos mediante la estrategia PECO. Las búsquedas fueron realizadas en las bases de datos MEDLINE, Web of Science, CINAHL, EMBASE y Scopus por dos investigadoras de forma independiente, al igual que la evaluación. Para la fase de selección e identificación de los estudios se utilizó el Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). La evaluación del riesgo de sesgo de los artículos incluidos se realizó a través del cuestionario Newcastle Ottawa Scale. Resultados Se identificaron 3.674 artículos, 84 se leyeron en su totalidad, de los cuales 11 conformaron la revisión (n=9.010 mujeres embarazadas), publicados entre los años 2005 y 2021, la mayoría en Estados Unidos. Respecto al nivel de evidencia, todos los artículos fueron clasificados como 2b, evaluada de acuerdo con el diseño de cada investigación. El estudio indicó evidencias respecto a los siguientes factores: IMC elevado (mayor igual a 30 kg/m2), nuliparidad, bishop bajo, longitud cervical (mayor o igual a 30 mm), estatura, etnia (no caucasoide del sur de Europa) y peso fetal (mayor igual a 4 kg). Conclusión Se alcanzó el objetivo del estudio y se demostraron seis factores maternos y uno fetal que pueden llevar al fracaso de la inducción. Cabe resaltar la necesidad de evidencias que incorporen la individualidad de cada característica y se destaca la contribución de este estudio para fundamentar la elección de la mejor conducta en cada gestación de forma individualizada.

Abstract Objective To analyze the evidence available in literature regarding unsuccessful labor induction with misoprostol in full-term pregnancies. Methods This is an integrative review, carried out between January and November 2022, whose research question and descriptors were outlined using the PECO strategy. The searches were carried out in the MEDLINE, Web of Science, CINAHL, EMBASE and Scopus databases by two researchers independently as well as assessment. For the study selection and identification phase, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. The risk of bias assessment of included articles was carried out using the Newcastle-Ottawa Scale. Results A total of 3,674 articles were identified, and 84 were read in full, of which 11 comprised the review (n=9,010 pregnant women), published between 2005 and 2021, with the majority in the United States. Regarding the level of evidence, all articles were classified as 2b, assessed according to the design of each study. The study showed evidence regarding the following factors: High BMI (greater than 30 kg/m2), nulliparity, immature bishop, cervical length (greater than 30 mm), height, ethnicity (non-Caucasians from southern Europe) and fetal weight (greater equal to 4 kg). Conclusion The objective study was achieved, having demonstrated six maternal factors and one fetal factor that can lead to unsuccessful induction. It is worth highlighting the need for evidence that incorporates the individuality of each characteristic and the contribution of this study to support the choice of the best conduct for each pregnancy on an individual basis stands out.

Misoprostol and mid trimester termination of pregnancy in patients with two previous scars and more at Elwiya Maternity Teaching Hospital / Misoprostol e interrupção da gravidez no meio do trimestre em pacientes com duas cicatrizes anteriores e mais no Elwiya Maternity Teaching Hospital

Abstract Objectives: to determine efficiency and safety of three misoprostol regimens for 2nd trimester pregnancy termination in individuals with two or more cesarean section scars. Methods: a cross-sectional study included 100 pregnant ladies at 13th-26th weeks gestation with previous two cesarean sections (CSs) who were scheduled for pregnancy termination using misoprostol. Patients were conveniently assigned to 100µg/3h, 200µg/3h or 400 µg/3h regimens. Primary outcome was time to abortion, secondary outcomes were side effect and complications. Results: a significant association was found between number previous CSs and longer time to abortion (p=0.01). A highly significant association was identified between earlier gestational age and longer time to abortion (p<0.001). Lower side effects and complications were associated with 200 µg misoprostol every 3 hours of (p<0.001). Incomplete abortion was the most frequent recorded complication for the successive doses of misoprostol. Conclusions: misoprostol is an effective drug at low doses for pregnancy termination in women with prior two or more caesarean sections. However, its safety needs monitoring of the patient in the hospital to decrease morbidity and mortality behind its use.

Resumo Objetivos: determinar a eficiência e segurança de três regimes de misoprostol para interrupção da gravidez no segundo trimestre em indivíduos com duas ou mais cicatrizes de cesariana. Métodos: um estudo transversal incluiu 100 gestantes entre 13ª e 26ª semanas de gestação com duas cesarianas (CEs) anteriores que foram agendadas para interrupção da gravidez com uso de misoprostol. Os pacientes foram convenientemente designados para regimes de 100 µg/3 horas, 200 µg/3 horas ou 400 µg/3 horas. O desfecho primário foi o tempo para o aborto, os desfechos secundários foram efeitos colaterais e complicações. Resultados: foi encontrada associação significativa entre o número de cesáreas anteriores e o maior tempo até o aborto (p=0,01). Foi identificada associação altamente significativa entre idade gestacional mais precoce e maior tempo para abortar (p<0,001). Menores efeitos colaterais e complicações foram associados com 200 µg de misoprostol a cada 3 horas (p<0,001). O aborto incompleto foi a complicação mais frequente registrada para as doses sucessivas de misoprostol. Conclusões: o misoprostol é um medicamento eficaz em doses baixas para interrupção da gravidez em mulheres com duas ou mais cesarianas anteriores. Porém, sua segurança necessita de monitoramento do paciente no hospital para diminuir a morbimortalidade por trás de seu uso.

Efficacy, Safety, and Acceptability of Misoprostol in the Treatment of Incomplete Miscarriage: A Systematic Review and Meta-analysis / Eficácia, segurança e aceitabilidade do misoprostol no tratamento do aborto incompleto: Uma revisão sistemática e metanálise

Abstract Objective To assess the efficacy, safety, and acceptability of misoprostol in the treatment of incomplete miscarriage. Data sources The PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Clinical Trials databases (clinicaltrials.gov) were searched for the relevant articles, and search strategies were developed using a combination of thematic Medical Subject Headings terms and text words. The last search was conducted on July 4, 2022. No language restrictions were applied. Selection of studies Randomized clinical trials with patients of gestational age up to 6/7 weeks with a diagnosis of incomplete abortion and who were managed with at least 1 of the 3 types of treatment studied were included. A total of 8,087 studies were screened. Data collection Data were synthesized using the statistical package Review Manager V.5.1 (The Cochrane Collaboration, Oxford, United Kingdom). For dichotomous outcomes, the odds ratio (OR) and 95% confidence interval (CI) were derived for each study. Heterogeneity between the trial results was evaluated using the standard test, I2 statistic. Data synthesis When comparing misoprostol with medical vacuum aspiration (MVA), the rate of complete abortion was higher in the MVA group (OR = 0.16; 95%CI = 0.07-0.36). Hemorrhage or heavy bleeding was more common in the misoprostol group (OR = 3.00; 95%CI = 1.96-4.59), but pain after treatment was more common in patients treated with MVA (OR = 0.65; 95%CI = 0.52-0.80). No statistically significant differences were observed in the general acceptability of the treatments. Conclusion Misoprostol has been determined as a safe option with good acceptance by patients.

Resumo Objetivo Avaliar a eficácia, segurança e aceitabilidade do misoprostol no tratamento do aborto incompleto. Fontes de dados Os bancos de dados PubMed, Scopus, Embase, Web of Science, Cochrane Library e bancos de dados de Ensaios Clínicos (clinicaltrials.gov) foram pesquisados para os artigos relevantes, e estratégias de busca foram desenvolvidas usando uma combinação de termos temáticos de Medical Subject Headings e palavras de texto. A última pesquisa foi realizada em 4 de julho de 2022. Nenhuma restrição de idioma foi aplicada. Seleção dos estudos Foram incluídos ensaios clínicos randomizados com pacientes com idade gestacional até 6/7 semanas com diagnóstico de aborto incompleto e que foram manejadas com pelo menos um dos três tipos de tratamento estudados. Um total de 8.087 estudos foram selecionados. Coleta de dados Os dados foram sintetizados usando o pacote estatístico Review Manager V.5.1 (The Cochrane Collaboration, Oxford, United Kingdom). Para resultados dicotômicos, o odds ratio (OR, na sigla em inglês) e o intervalo de confiança (IC) de 95% foram derivados para cada estudo. A heterogeneidade entre os resultados do ensaio foi avaliada usando o teste padrão, estatística I2. Síntese dos dados Ao comparar misoprostol com aspiração a vácuo médico (MVA, na sigla em inglês), a taxa de aborto completo foi maior no grupo MVA (OR = 0,16; IC95% = 0,07-0,36). Hemorragia ou sangramento intenso foi mais comum no grupo do misoprostol (OR = 3,00; 95%CI = 1,96-4,59), mas a dor após o tratamento foi mais comum em pacientes tratados com MVA (OR = 0,65; 95%CI = 0,52-0,80). Não foram observadas diferenças estatisticamente significativas na aceitabilidade geral dos tratamentos. Conclusão O misoprostol tem se mostrado uma opção segura e com boa aceitação pelos pacientes.

Conocimientos sobre el aborto inducido y opiniones sobre el uso del misoprostol en Aguascalientes / Knowledge about induced abortion and opinions about the use of misoprostol in Aguascalientes

Resumen Antecedentes: El misoprostol es un medicamento de fácil acceso con el que se puede tener un aborto seguro. Objetivo: Explorar los conocimientos sobre la situación legal del aborto en el Estado de Aguascalientes, en donde el aborto está penalizado, así como los conocimientos y opiniones sobre el misoprostol. Método: Se aplicó un cuestionario en línea a 208 adultos. Resultados: La mayoría de las participantes no conocía la situación legal del aborto ni del Estado de Aguascalientes ni del país. Cerca de la mitad conocía el misoprostol, y sus principales fuentes de información fueron Internet y redes sociales. Aproximadamente la mitad de estos participantes no supo qué complicaciones puede ocasionar que requieran atención médica. Conclusión: El conocimiento sobre la situación legal del aborto y sobre el uso del misoprostol como método abortivo es limitado. Existe consciencia de la importancia de la supervisión médica cuando se usa, aunque esta se dificulta debido a la ilegalidad del aborto en Aguascalientes.

Abstract Background: Misoprostol is an easily accessible medication with which to have a safe abortion. Objective: To explore knowledge about the legal situation of abortion in the state of Aguascalientes, where abortion is criminalized, as well as knowledge and opinions about misoprostol. Method: An online questionnaire was administered to 208 adults. Results: Most of the participants did not know the legal situation of abortion neither in the state of Aguascalientes nor in the country. Almost half of them knew about misoprostol, and their main sources of information were the Internet and social networks. About half of these participants did not know which are the complications that misoprostol may cause that require medical attention. Conclusion: Knowledge about the legal situation of abortion and about the use of misoprostol as an abortion method is limited. There is awareness of the importance of medical supervision when misoprostol is used, but obtaining this supervision is difficult due to the illegality of abortion in Aguascalientes.

Dystocia Due to Secondary Uterine Inertia and its Obstetrical Management- A Case Report

Background: A full-term pregnant Ongole cow was presented to the Large Animal Obstetrical Ward with a history of reduced feed intake, dull and ruptured foetal membranes 24 hours before presentation without progress in parturition. The temperature was within the normal physiological range. Per-vaginal examination revealed second-degree cervical dilation, lack of uterine and abdominal contractions and the vaginal discharges were reddish brown and putrid. Methods: The case was diagnosed as secondary uterine inertia and treated with an intracervical application of misoprostol and intravenous calcium therapy. Results: Three hours after the application of misoprostol and calcium therapy, full dilatation of the cervix was achieved to facilitate the delivery of the dead male emphysematous foetus by traction. Uneventful recovery of the dam was noticed. Conclusion: Usage of misoprostol along with CMC massage and calcium therapy resulted in speedy recovery of dystocia suffering with incomplete cervical dilation.

Foley catheter plus misoprostol versus misoprostol alone for labor induction

SUMMARY OBJECTIVE: This study aimed to analyze the effects of Foley catheter combined with misoprostol in the labor induction process. METHODS: This is a nonblinded, block randomized, controlled trial that compared the association between transcervical Foley catheter/vaginal misoprostol 25 μg combination and vaginal misoprostol 25 μg alone in normal-risk and healthy pregnant women undergoing labor induction in the south of Brazil. RESULTS: A total of 230 patients with indications for labor induction were evaluated and classified into the "combined" group (Foley catheter plus misoprostol), consisting of 107 patients, and the "misoprostol" group (misoprostol only), consisting of 123 patients. The "combined" group was observed to have a shorter labor induction time (p=0.008). In addition, there was a lower need for misoprostol use for overall cervical ripening (p<0.001) and a lower relative risk of needing a second, third, or fourth misoprostol tablet in the "combined" group (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.71-0.91; RR 0.41; 95%CI 0.31-0.56; and RR 0.29, 95%CI 0.17-0.52, respectively) (p<0.001). No statistically significant difference was found in induction failure rate, cesarean section rate, or perinatal outcomes. CONCLUSION: A combination of methods leads to shorter labor induction, lower need for misoprostol doses, and lower risk of cesarean section, with no increase in the rate of perinatal complications. REBEC number is RBR-7xcjz3z.

Determination of misoprostol in workplace air by high performance liquid chromatography / 中华劳动卫生职业病杂志

Objective: To establish a high performance liquid chromatography method for the determination of misoprostol in workplace air. Methods: From February to August 2021, the misoprostol in the workplace air was collected by glass fiber filter membrane, and theeluent was separated by C18 liquid chromatography column, determined by UV detector, and quantified by external standard method. Results: The quantitative lower limit of misoprostol determination method was 0.05 μg/ml, and the lowest quantitative concentration was 1.4 μg/m(3) (calculated by collecting 75 L air sample). The concentration of misoprostol has a good linear relationship between 0.05 to 10.00 μg/ml. The relative coefficient was 0.9998. The regression equation of the standard working curve was y=495759x-45257. The range of average recovery rates were from 95.5% to 102.8%. The intra-assay precision of the method was 1.2%-4.6%, and the inter-assay precision was 2.0%-5.9%. The samples could be stored stably for 7 days at 4 ℃. Conclusion: The high performance liquid chromatography method for the determination of misoprostol has high sensitivity, good specificity and simple procedure of sample pretreatment. It is suitable for the detection of misoprostol in the workplace air.

Anomalías congénitas disruptivas asociadas con misoprostol. Reporte de un caso / Disruptive congenital anomalies associated with misoprostol. Case report

Resumen ANTECEDENTES: La exposición prenatal al misoprostol puede asociarse con un espectro de defectos congénitos que varían desde anomalías del sistema nervioso central, secuencia de Moebius, defectos en la pared abdominal, defectos transversales en las extremidades hasta alteraciones fetales. Esos defectos se observan más comúnmente con esquemas de solo misoprostol para inducción del aborto. Por esos antecedentes es importante que la historia clínica de toda paciente obstétrica sea exhaustiva para permitir identificar el antecedente de la exposición prenatal luego de un aborto fallido. CASO CLINICO: Paciente de 21 años, con 32 semanas de embarazo, con diagnóstico de feto con ventriculomegalia. En la evaluación ecográfica destacó la ventriculomegalia triventricular severa, simétrica y la angulación de ambas extremidades inferiores en varo. La resonancia magnética reportó: ventriculomegalia no comunicante severa, bilateral, simétrica, por probable estenosis del acueducto de Silvio. Cariotipo 46,XY y perfil TORCH negativo. El embarazo finalizó mediante cesárea, por indicación fetal a las 35 semanas. La evaluación al nacimiento reportó: parálisis facial bilateral, macrocefalia y pie equino varo bilateral. Al volver a interrogar a la paciente refirió haber sido tratada con misoprostol en el primer trimestre del embarazo, con fines abortivos. Al descartar las alteraciones cromosómicas e infecciosas se estableció el diagnóstico de secuencia Moebius. CONCLUSIONES: La exposición prenatal al misoprostol está relacionada con la aparición de defectos vasculares en algunos fetos expuestos. Aún no se ha determinado el espectro preciso ni la estimación potencial de teratogenicidad. La historia clínica es el pilar para la asociación en estos casos.

Abstract BACKGROUND: Prenatal misoprostol exposure can be associated with a spectrum of birth defects, ranging from central nervous system abnormalities, Moebius sequence, abdominal wall defects, as well as transverse limb defects, fetal abnormalities are more commonly seen with the use of the misoprostol-only regimen for induction of abortion, such that a thorough medical history is essential to detect a history of prenatal exposure after a failed abortion. CLINICAL CASE: A 21-year-old patient, with a 32-week pregnancy, who attended the institute with a diagnosis of a fetus with ventriculomegaly, the ultrasound evaluation highlighted severe symmetric triventricular ventriculomegaly and angulation of both lower extremities in varus, magnetic resonance imaging reported severe non-communicating ventriculomegaly Symmetric bilateral, due to probable stenosis of the aqueduct of Silvio, the karyotype reported 46, XY, as well as a negative TORCH profile, however, a cesarean section was performed for fetal indication at 35 weeks, the evaluation at birth showed bilateral facial paralysis, macrocephaly and foot Bilateral equinus varus, upon re-examination the patient referred the use of misoprostol in the first trimester of pregnancy for abortive purposes, so as there were no chromosomal or infectious alterations, a Moebius sequence was suggested. CONCLUSIONS : Prenatal exposure to misoprostol is related to the appearance of vascular disruption defects in some exposed fetuses, the precise spectrum and potential estimation of teratogenicity have not yet been determined, the clinical history is the mainstay for the association in these cases.

Misoprostol Administration Before Hysteroscopy Procedures - A Retrospective Analysis / O uso do misoprostol prévio aos procedimentos histeroscópicos - Um estudo retrospectivo

Abstract Objective To evaluate the use of misoprostol prior to hysteroscopy procedures regarding technical ease, the presence of side effects, and the occurrence of complications. Methods This is a retrospective, observational, analytical, case-control study, with the review of medical records of 266 patients followed-up at the Gynecological Videoendoscopy Sector of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the Universidade de São Paulo (HCFMRP - USP, in the Portuguese acronym) from 2014 to 2019, comparing 133 patients who used the drug before the procedure with 133 patients who did not. Results The occurrence of postmenopausal uterine bleeding was the main indication for hysteroscopy and revealed a statistical difference between groups (p < 0.001), being present in 93.23% of the patients in the study group and in 69.7% of the patients in the control group. Only 2 patients (1.5%) in the study group reported adverse effects. Although no statistical differences were observed regarding the occurrence of complications during the procedure (p = 0.0662), a higher total number of complications was noted in the group that used misoprostol (n = 7; 5.26%) compared with the group that did not use the drug (n = 1; 0.75%), a fact that is clinically relevant. When evaluating the ease of the technique (measured by the complete performance of all steps of the hysteroscopy procedure), it was verified that although there was no difference between groups (p = 0.0586), the control group had more than twice as many incompletely performed procedures (n = 17) when compared with the group that used misoprostol previously (n = 8), which is also clinically relevant. Conclusion The use of misoprostol prior to hysteroscopy in our service indicated that the drug can facilitate the performance of the procedure, but not without side effects and presenting higher complication rates.

Resumo Objetivo Avaliação do misoprostol prévio à histeroscopia quanto à facilidade técnica, efeitos colaterais e a ocorrência de complicações durante o procedimento. Métodos Estudo analítico observacional retrospectivo tipo caso controle com revisão de prontuários de 266 pacientes do Setor de Videoendoscopia Ginecológica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo (HCFMRP - USP), de 2014 a 2019, sendo comparadas 133 pacientes que utilizaram o medicamento prévio ao procedimento com 133 pacientes que não o utilizaram. Resultados Sangramento uterino após a menopausa foi a principal indicação de histeroscopia, apresentando diferença estatística (p < 0,001), estando presente em 93,23% das pacientes do grupo de estudo e em 69,17% das pacientes do grupo controle. Apenas 2 pacientes (1,5%) do grupo de estudo relataram efeitos adversos. Não foram observadas diferenças quanto à presença de complicações durante o procedimento (p = 0,0662), mas observamos um número total de complicações maior no grupo de estudo (n = 7; 5,26%) do que no grupo controle (n = 1; 0,75%), o que é clinicamente relevante. Não houve diferença entre os grupos quanto à facilidade técnica (p = 0,0586), mas o grupo controle apresentou mais do que o dobro de procedimentos não completamente realizados (n = 17) quando comparado com o grupo de estudo (n = 8), o que é clinicamente relevante. Conclusão O uso de misoprostol prévio à histeroscopia no nosso serviço demonstrou que ele pode facilitar a realização do procedimento, mas não é isento de efeitos colaterais e apresenta maiores taxas de complicações.

Study of Effectiveness of Medical Method for Induction of Labor and its Outcome

Background: Modern obstetrics has a tremendous issue in inducing full-term labor in women with a viable fetus. When the hazards of prolonging pregnancy outweigh the advantages of birth, induction is undertaken. This study’s objective was to evaluate the efficacy of misoprostol 50µg administered sublingually, orally and vaginally in the process of inducing labor.Material & Methods:Between June 2021 and July 2022, 120 pregnant women admitted in Department of Gynecology and Obstetrics, ShaheedZiaur Rahman Medical College and Hospital, Bogura in Bangladesh were recruited randomly for a randomized control trial as per inclusion criteria. Misoprostol was administered either orally or sublingually to each patient. A maximum of three doses might be administered if necessary. A previous cesarean birth was an exclusion criterion. The number of women who had a vaginal birth during 24 hours of induction was our major metric for success. SPSS 26 was used to analyze the data.Results:The induction to delivery intervals were considerably shorter in the sublingual group (18 hours versus 25.5 hours; mean difference was 6.2 hours; 95 percent confidence interval, 1.5 to 14.6). In the sublingual group, there was just 2% occurrence of uterine hyperstimulation. The two groups did not vary significantly in terms of delivery method, fetal distress, or newborn outcomes. A total of 80% percent and 82.60 percent of patients were satisfied with the oral and sublingual groups, respectively, and only 10% percent believed the sublingual tablets didn’t entirely dissolve.Conclusion:Sublingual misoprostol seems to be a successful method of delivery, although further clinical studies are needed to demonstrate the safety and effectiveness of the sublingual mode.

Comparison of misoprostol in conjunction with oxytocin and oxytocin alone for the prevention of postpartum hemorrhage during active management of the third stage of labor

Background: When it occurs after a cesarean section or a normal vaginal delivery, postpartum hemorrhage (PPH) is a potentially fatal obstetric emergency. Aims and objectives: The aim of the study was to compare the efficacy and safety of oxytocin against oxytocin plus misoprostol in avoiding PPH during active management of the third stage of labor (AMTSL). Materials and Methods: Using simple randomization, 150 women from the labor ward of the Department of Obstetrics and Gynaecology at the Indore Medical College were recruited and randomly allocated to either test Group A or test Group B. Standard pharmacological treatment, including intramuscular injection of 10 IU of oxytocin and other components of AMTSL criteria, was administered to patients in Group A. In addition to the other components of the AMTSL criteria, Group B patients got the usual pharmacological treatment of 10 IU of oxytocin through the injectable route and 600 g of misoprostol through the oral route. Various characteristics of both groups were compared, including parity, gravida, delivery style, PPH etiology, blood transfusion, and surgical intervention. Results: Mode of delivery was vaginally seen in 85% and 92% and cesarean in 15% and 8%. Etiology was uterine atony in 54% and 64%, retained tissue in 26% and 12%, laceration in 11% and 18%, and coagulopathy in 9% and 6%. Blood transfusion was needed in 27% and 57% and surgical intervention in 82% and 68% in Groups A and B, respectively. A statistically significant difference was observed (P ? 0.05). Conclusion: The results of this study support the use of misoprostol in hospital settings as an adjunct to oxytocin since it reduces the incidence of PPH, eliminates the need for intrusive interventions, and ultimately reduces maternal mortality.

O uso do misoprostol na interrupção da gestação: revisão de estudos realizados no Brasil / The use of misoprostol in the termination of pregnancy: a review of studies carried

Resumo O uso do misoprostol com finalidade abortiva é um fenômeno observado no Brasil desde o final da década de 1980. O medicamento começou a ser utilizado nessa época para autoindução do aborto, quando passou a ser comercializado para o tratamento de úlcera péptica. Seu acesso foi restringido a partir de 1998, porém o fármaco continua sendo comercializado na ilegalidade. O objetivo desse artigo é sintetizar o conhecimento produzido em pesquisas no Brasil sobre o aborto induzido e o uso do misoprostol. Foi realizada uma revisão integrativa de estudos originais feitos no Brasil e publicados em revistas indexadas nas bases SciELO, PubMed e Lilacs. Foram encontrados 68 títulos e incluídos 28 artigos na revisão. A maioria das mulheres que induz a interrupção da gestação é jovem e o faz antes das 15 semanas de gestação. A taxa de utilização do misoprostol variou entre 89% e 36%. Esse medicamento é eficaz para a interrupção da gestação no primeiro trimestre e apresenta baixa taxa de complicações. Contudo, quanto mais vulnerável socialmente a mulher, maiores os riscos para a saúde no processo do abortamento. Conclui-se que a compra do misoprostol como abortivo é facilitada, apesar de proibida, e suas complicações estão associadas ao contexto de vulnerabilidade da gestante.

Abstract The use of misoprostol for abortifacient purposes is a phenomenon observed in Brazil since the late 1980s. The drug started to be used at that time for self-induced abortion, when it began to be commercialized for the treatment of peptic ulcer. Its access was restricted from 1998 onwards, but the drug continues to be commercialized illegally. The objective of this article is to summarize the knowledge produced by research in Brazil about induced abortion and the use of misoprostol. An integrative review of original studies carried out in Brazil and published in journals indexed in SciELO, PubMed and Lilacs databases was performed. The search found 68 titles, and 28 articles were included in the review. Most women who induced pregnancy interruption were young and did it before 15 gestational weeks. The rate of misoprostol use ranged from 89% to 36%. This drug is effective for terminating pregnancy in the first trimester and has a low rate of complications. However, the more socially vulnerable the woman is, the greater are the health risks in the abortion process. The conclusion is that the purchase of misoprostol as an abortifacient is facilitated, despite it being prohibited, and its complications are associated with the context of vulnerability of the pregnant woman.

A Comparison of Misoprostol and Dinoprostone Gel for Induction and Cervical Ripening

Introduction: Labour induction at term is a universal conventional obstetric interference with an objective to stimulate uterine contractions artificially to attain a spontaneous vaginal delivery. The current study was aimed to compare the efficacy and safety profile of low dose vaginal Misoprostol with Dinoprostone gel for induction of labour in term pregnancies with unfavorable cervix and intact membranes. Methodology: This Randomized Controlled Trial was conducted among pregnant women with term pregnancy with obstetrical or medical indication for induction of labour after institutional ethical committee approval. A detailed history, complete physical examination and investigations were done for all patients. Result: Misoprostol and Dinoprostone gel are equally effective inducing agents. Both are equally effective in Primigravida and Multigravida. Failure of induction rate for Misoprostol and Dinoprostone was statistically not significant. The need of Oxytocin augmentation, maternal complication rate, NICU admission rate, caesarean section rate and occurrence of meconium-stained liquor are statistically not significant in both the study groups. Our study was unable to demonstrate superiority of any single drug compared to other. Only the difference is cost, induction with Conclusion: considering the easy to preserve and administer, we recommend use of Misoprostol as a safe, effective, cheaper, and more convenient drug for induction of labour.

Analysis of Variables that Influence the Success Rates of Induction of Labor with Misoprostol: A Retrospective Observational Study / Análise de variáveis que influenciam na taxa de sucesso da indução do parto com misoprostol: Um estudo observacional retrospectivo

Abstract Objective Determine the predictive criteria for success in inducing labor for live fetuses using misoprostol in pregnant women. Secondarily, the objective is to determine the rates of vaginal or cesarean delivery, duration of induction, interval of administration of misoprostol, the main causes of induction of labor and indication for operative delivery. Methods Medical records of 873 pregnant women admitted for cervical maturation from January 2017 to December 2018 were reviewed in a descriptive observational study of retrospective analysis, considering the following response variables: age, parity, Bishop Index, doses of misoprostol, labor induction time. Logistic regression models were used to predict success with misoprostol in non-operative deliveries. Results Of the 873 patients evaluated, 72% evolved with vaginal delivery, 23% of the cases were cesarean, 5% forceps or vacuum-extractor. For non-operative delivery the predictive variables at admission were age, parity, gestational age and dilation. During hospitalization, fewer vaginal touches,amniotomy or amniorrhexis with clear fluid lead to a shorter induction time and a greater chance of non-operative delivery. False positives and false negatives of the model were always below 50% and correct answers above 65%. Conclusion At admission, age less than 24 years, previous normal births, lower the gestational age and greater the dilation, were predictive of greater probability of nonoperative delivery. During hospitalization, the less vaginal touches and occurrence of amniotomy/amniorrhexis with clear liquid indicate shorter induction time. Future studies with a prospective design and analysis of other factors are necessary to assess the replicability, generalization of these findings.

Resumo Objetivo Determinar os critérios preditivos para o sucesso na indução do trabalho de parto para fetos vivos utilizando misoprostol em gestantes. Em segundo lugar, o objetivo é determinar as taxas de parto vaginal ou cesáreo, duração da indução, intervalo de administração de misoprostol, as principais causas de indução do trabalho de parto e indicação para parto operatório. Métodos Foram revisados os prontuários de 873 gestantes internadas para amadurecimento cervical entre janeiro de 2017 e dezembro de 2018 em um estudo descritivo observacional de análise retrospectiva, considerando as variáveis-resposta: idade, paridade, Índice de Bishop, doses de misoprostol, tempo de indução do trabalho de parto. Modelos de regressão logística foram utilizados para prever o sucesso com misoprostol em partos não operatórios. Resultados Dos 873 pacientes avaliados, 72% evoluíram com parto vaginal, 23% dos casos foram cesáreos, 5% fórceps ou vácuo-extrator. Para o parto não operatório as variáveis preditivas na internação foram idade, paridade, idade gestacional e dilatação. Durante a internação, um menor número de toques vaginais, amniotomia ou amniorrexe com líquido claro, levam a menor tempo de indução e maior chance de parto não operatório. Falsos positivos e falsos negativos do modelo sempre foram inferiores a 50% e respostas corretas acima de 65%. Conclusão Na internação, idade menor que 24 anos, ocorrência de partos normais anteriores, menor idade gestacional e maior dilatação, foram preditivos de maior probabilidade de parto não-operatório. Durante a internação, o menor número de toques vaginais, amniotomia/amniorrexe com líquido claro indicam menor tempo de indução. Estudos futuros com design prospectivo e análise de outros fatores são necessários para avaliar a replicabilidade, generalização desses achados.

Eficacia y seguridad del misoprostol vaginal comparado con dinoprostona en maduración cervical e inducción del parto / Effectiveness and safety of vaginal misoprostol vs dinoprostone for cervical ripening and labour induction

Resumen OBJETIVO: Comparar la eficacia del misoprostol intravaginal con el dispositivo vaginal de liberación prolongada de dinoprostona en la inducción del parto. Además, analizar el perfil de seguridad en relación con los desenlaces maternos y perinatales. MATERIALES Y MÉTODOS: Estudio retrospectivo y comparativo efectuado en pacientes atendidas entre 2018 y 2020 en el Área Sanitaria de Ferrol, La Coruña, España, con partos que se iniciaron con inducción con prostaglandinas. Las pacientes se dividieron en dos cohortes, en función de la prostaglandina sintética administrada (misoprostol por vía vaginal o dinoprostona en dispositivo intravaginal). Para la comparación entre ambos grupos se aplicó la prueba U de Mann-Whitney. Para las variables cualitativas se describió su cantidad total y el porcentaje, que se compararon con prueba de χ2 de Pearson. RESULTADOS: Se analizaron 508 pacientes con inducción del parto. En las indicaciones de ésta no se encontraron diferencias entre uno y otro grupo, aunque destacó la indicación del misoprostol en pacientes con embarazo cronológicamente prolongado (63%) y de dinoprostona en rotura prematura de membranas (49%). En relación con los desenlaces perinatales, se registró un Apgar menor de 7 a los 5 minutos en 2 pacientes tratadas con dinoprostona y 1 con misoprostol; así como un pH arterial umbilical menor de 7.10 en 8 pacientes tratadas con dinoprostona y 7 con misoprostol. CONCLUSIONES: Los datos aquí reportados hacen suponer que ambas prostaglandinas consiguen una tasa de inicio del parto similar, aunque la dinoprostona parece reducir el tiempo hasta el inicio del parto en mujeres con indicación de inducción.

Abstract OBJECTIVE: To compare the efficacy of intravaginal misoprostol with the dinoprostone extended-release vaginal device in labor induction. In addition, to analyze the safety profile in relation to maternal and perinatal outcomes. MATERIALS AND METHODS: Retrospective and comparative study performed in patients attended between 2018 and 2020 in the Health Area of Ferrol, La Coruña, Spain, with deliveries that were initiated with prostaglandin induction. The patients were divided into two cohorts, depending on the synthetic prostaglandin administered (misoprostol vaginally or dinoprostone in intravaginal device). The Mann-Whitney U test was used to compare the two groups. For qualitative variables, the total number and percentage were described and compared with Pearson's 2 test. RESULTS: A total of 508 patients undergoing labor induction were analyzed. No differences were found in the indications for induction of labor between one group and the other, although the indication for misoprostol in patients with chronologically prolonged pregnancy (63%) and for dinoprostone in premature rupture of membranes (49%) stood out. In relation to perinatal outcomes, an Apgar of less than 7 at 5 minutes was recorded in 2 patients treated with dinoprostone and 1 with misoprostol; as well as an umbilical arterial pH of less than 7.10 in 8 patients treated with dinoprostone and 7 with misoprostol. CONCLUSIONS: The data reported here suggest that both prostaglandins achieve a similar rate of onset of labor, although dinoprostone appears to reduce the time to onset of labor in women indicated for induction.

Comparing the Clinical Efficacy of Mifepristone and Misoprostol Treatment Protocol for Induction of Parturition in Bitches

Successful management of parturition induction is a challenging task in canine. This study made to assess the efficacy of antiprogestagen mifepristone and prostaglandin misoprostol in induction of parturition in bitches. Total of 11 pregnant bitches with gestational age of more than 62 days confirmed by ultrasound scanning and not showing any sings of initiation of parturition were selected. Induction of parturition was initiated by mifepristone (3 mg/ kg b wt PO) twice a day or a combination of mifepristone (3 mg/kg b wt PO) and misoprostol (200 ?g for < 20 kg, 400 ?g for > 20 kg b wt, i/vg) 12 h after second dose of mifepristone. The combination of both drugs mifepristone and misoprostol was more effective for parturition induction.

Interrupción voluntaria del embarazo en Latinoamérica, superando barreras / Voluntary interruption of the pregnancy in Latin America, overcoming barriers

Resumen Introducción: El embarazo no planeado o no intencional y el aborto son situaciones que afectan la vida de mujeres a nivel mundial, sin distinción de etnia, edad, riqueza, o ubicación geográfica, sin embargo, tiene una mayor posibilidad de presentarse y generar consecuencias negativas en mujeres con ciertas determinantes sociales. Objetivo: Mostrar el estado actual de la interrupción voluntaria del embarazo en países de Latinoamérica y del Caribe con énfasis en el reciente avance de la legislación argentina sucedido durante diciembre del 2020. Metodología: Se realizó una búsqueda no estructurada de información sobre la legislación del aborto en países de Latinoamérica y del Caribe y se hizo una revisión de tema sobre aspectos actuales y relevantes de la interrupción voluntaria del embarazo. Conclusiones: Es necesario que prestadores de servicios de salud y sociedad latinoamericana repasen las lecciones aprendidas de diferentes países sobre las consecuencias negativas para la salud de las mujeres y sus familias debido a las restricciones para acceder al aborto seguro. El mejoramiento de la calidad y las capacidades de los sistemas de salud en los países de bajos y medianos recursos, con mayor inversión e investigación en temas de salud sexual y reproductiva, resultará en la eliminación de barreras e inequidades en la prestación de atención médica a las mujeres, respetando sus derechos y autonomía.

Abstract Introduction: Unplanned or unintended pregnancy and abortion are situations that affect the lives of women worldwide without distinction of ethnicity, age, economic level, or geographical location. However, they have a greater probability of occurring and negative consequences in women with certain social determinants. Objective: Our main objective is to show the current state of the Voluntary Interruption of Pregnancy in Latin American and Caribbean countries with special emphasis on the recent advance of the legislation of Argentina that occurred last December. Methodology: An unstructured search for information about Abortion Legislation in Latin American and Caribbean countries was carried out and a subject revision on current and relevant aspects of Voluntary Interruption of Pregnancy was made. Conclusions: It is necessary that as Health Service providers and as a Latin American Society, we review the lessons learned from different countries about the negative consequences on the health of women and their families due to the restrictions for accessing legal abortions. Improving the quality and capacity of the health system in low- and middle- income countries, in addition to greater investment and research in sexual and reproductive health issues, will derive a removal of barriers and inequity related to the provision of medical attention for women while respecting their rights and autonomy.

Manejo conservador de retención de productos de la concepción con anticonceptivos orales combinados / Conservative Management of Retained Products of Conception with Combined Oral Contraceptives. Case Report

Objetivo: presentar el caso de una paciente con retención de productos de la concepción (RPC) después de aborto médico, tratada con anticonceptivos orales combinados (ACOC), y efectuar revisión de la literatura. Caso Clínico: paciente de 37 años, con sangrado genital escaso y leve dolor pélvico, quien tuvo aborto provocado con misoprostol cuatro días antes, acude sin signos de infección, con endometrio mixto de 18,5 mm. Durante seis semanas de seguimiento persiste sangrado y endometrio mixto engrosado, con disminución lenta de la gonadotrofina corionica humana (GCH); se sospecha RPC, se suministra ciclo de ACOC y al terminarlos expulsa completamente el tejido retenido. Metodología: búsqueda bibliográfica en bases de datos Google Scholar, Science Direct, RIMA, PubMed. Revisión de literatura: la RPC se presenta después de parto o aborto (más frecuente). Criterios diagnósticos: sangrado persistente, hallazgos ecográficos y medición de GCH. Diagnóstico diferencial: enfermedad trofoblastica gestacional y malformaciones arteriovenosas uterinas. Es factible el manejo conservador, con bajas tasas de infección o procedimientos quirúrgicos. Ante la evolución prolongada, presencia de signos de infección o hemorragia importante, se impone la evacuación quirúrgica, tradicionalmente con dilatación y legrado, y más recientemente resección histeroscópica. La bibliografía reciente sugiere el uso de ACOC como manejo médico. En nuestro caso, la paciente tomó un ciclo de ACOC y al terminarlos presentó expulsión de los restos retenidos. Conclusiones: el manejo conservador de la RPC con ACOC surge como una opción en casos seleccionados; son necesarios estudios controlados para definir su utilidad..Au

Objective: to report the case of a patient with retained products of conception (RPC) after a medical abortion, successfully treated with combined oral contraceptives (COCs), and to review the literature. Clinical case: a 37-year-old patient, with little genital bleeding and slight pelvic pain, who had had a misoprostol-induced abortion four days before consulting, she attended without signs of infection, with a thikened 18.5 mm mixed endometrium. After six weeks follow-up genital bleeding and thickened mixed endometrium persist, with a slow decrease in human chorionic gonadotropin (HCG), RPC is suspected, and a COC cycle is administered, when finished, she completely expelled the retained tissue. Methodology: Google Scholar, Science Direct, RIMA and PubMed databases were searched. Literature review: RPC occurs after delivery or abortion (more frequent), diagnostic criteria: persistent bleeding, ultrasound findings and HCG measurement; the differential diagnosis includes gestational trophoblastic disease and uterine arteriovenous malformations. Conservative management is feasible, with low rates of infection or surgical procedures, however, in case of prolonged evolution, evident signs of infection or significant bleeding, surgical evacuation is required, traditionally with dilation and curettage, and more recently hysteroscopic resection. Novel bibliography suggests the use of ACOC as medical management. In our case, the patient took a cycle of COC and at the end she expelled the retained remains. Conclusions: conservative management of RPC with COC arises as an option in selected cases, controlled trails are needed to define its usefulness..Au

Protocolo assistencial do uso do misoprostol / Care protocol for the use of misoprostol

Estabelecer a utilização e ampliação da administração do medicamento Misoprostol de 25mcg e 200mcg nas maternidades e hospitais com serviços de obstetrícia no Maranhão. Este Protocolo se aplica à farmácia central, centro cirúrgico, sala de parto e todo âmbito de internação da instituição.

Meta-analysis of Clinical Efficacy and Safety of Misoprostol versus Oxytocin in Preventing Postpartum Hemorrhage / 中国药房

OBJECTIVE：To systematically evaluate the c linical efficacy and safety of misoprostol versus oxytocin in preventing postpartum hemorrhage ，and to provide evidence-based reference for clinical drug use. METHODS ：Retrieved from CNKI，VIP，Wanfang database ，CBM，PubMed，Embase and the Cochrane Library ，randomized controlled trials （RCTs） published at home and abroad about clinical efficacy and safety of misoprostol and oxytocin in preventing postpartum hemorrhage were collected during the inception to Feb. 15th，2021. According to the inclusion and exclusion criteria ，the included studies were screened and evaluated. RevMan 5.3 software was used for Meta-analysis. RESULTS ：A total of 14 RCTs involving 25 732 lying-in women were included. The results of Meta-analysis showed that compared with oxytocin group ，there was no difference in the mean blood loss （MD＝14.96，95％CI（－2.62，32.54），P＝0.10），the time of the third stage of labor （MD＝－0.03，95％CI （－0.19，0.13），P＝0.69），the incidence of blood transfusion （RR＝0.91，95％CI（0.74，1.12），P＝0.37）or the incidence of nausea（RR＝1.06，95％CI（0.85，1.31），P＝0.60）in misoprostol group ；but the incidence of shivering（RR＝2.99，95％CI （2.22，4.04），P＜0.000 01），the incidence of fever （RR＝4.31，95％CI（2.79，6.67），P＜0.000 01），the incidence of vomiting （RR＝2.16，95％CI（1.63，2.88），P＜0.000 01）and the incidence of diarrhea （RR＝2.67，95％CI（1.79，3.98），P＜0.000 01）in misoprostol group were higher. CONCLUSIONS ：The effect of misoprostol in the prevention of postpartum hemorrhage is similar to oxytocin ，but the incidence of ADR is higher. It is necessary to pay close attention to the adverse reactions during use. Due to the limitation of included studies ，multi-center，large-scale and high-quality RCTs are needed for further validation.