Effect of ritodrine on labor after premature rupture of the membranes.

The effect on labor of administering ritodrine after a premature rupture of the membranes (PROM) was studied in a double-blind trial in 30 patients. The patients were selected according to the following criteria: 28 to 36 weeks' gestation, only 1 fetus, cervix dilated 4 cm or less, and absence of pyrexia or other signs of uterine infection. Fourteen patients received ritodrine and 16 received a placebo. The 2 groups were statistically comparable. None of the patients receiving ritodrine delivered within 24 hours. The difference between the 2 groups was statistically significant with respect to the number of patients delivered within 24 hours (P less than 0.05). However, after 24 hours, there was no difference between the groups as regards the length of pregnancy. The infections registered in the mothers of infants were few and easily controlled. The incidence of idiopathic respiratory distress syndrome (IRDS) was low in the study and allows no conclusions concerning the benefit of prolonging the pregnancy for more than 24 hours after PROM.

Sequential outpatient application of intravaginal prostaglandin E2 gel in the management of postdates pregnancies.

A randomized blinded investigation was undertaken to determine the efficacy and safety of sequentially applied intravaginal prostaglandin E2 (PGE2) gel for accelerating cervical ripening in an outpatient setting in low-risk prolonged pregnancies. Fifty women with uncomplicated pregnancies at or beyond 41 weeks' gestation and Bishop scores below 9 received twice-weekly outpatient administration of gel containing 2.0 mg of PGE2 or placebo. Thirty nulliparas and 20 multiparas were enrolled. The PGE2 gel failed to improve cervical ripening over placebo, as judged by Bishop scores. There was no difference between the groups in gestational age on admission to the labor and delivery suite, number of gel applications, requirement for oxytocin, incidence of cesarean delivery, or neonatal outcome. Only two patients (4%) experienced regular uterine contractions after gel insertion; these subsided spontaneously in both. None of the subjects experienced labor, tetanic contractions, evidence of fetal distress, or any other side effects related to gel insertion. We conclude that PGE2 gel in this dosage may be used safely in an outpatient setting, but more frequent application or earlier initiation may be required to produce a clinical effect.

A randomized, double-blind, placebo-controlled trial of the safety of vaginal recombinant human relaxin for cervical ripening.

OBJECTIVE: To assess the safety of vaginal recombinant human relaxin in pregnant women treated before the induction of labor and to collect preliminary data on the efficacy of recombinant human relaxin in promoting cervical ripening. METHODS: In a multi-center, randomized, double-blind placebo-controlled trial, 40 women were studied before induction of labor because of post-dates. The women were randomized to receive either 1.5 mg recombinant human relaxin in 3% methylcellulose gel or gel only, placed into the posterior vaginal fornix after a cervical assessment on the evening before scheduled induction. If a subject did not go into spontaneous labor overnight, another cervical assessment was performed 15 hours following treatment, immediately before the standard induction regimen of the hospital. RESULTS: No important maternal or fetal-neonatal complications could be attributed to the drug. The differences between the recombinant human relaxin group and the placebo group for all the outcome measures of efficacy did not achieve statistical significance. Placebo patients were more likely to report moderate or strong uterine contractions in the first 4 hours following treatment than were the recombinant human relaxin-treated patients. CONCLUSIONS: The use of recombinant human relaxin at a dose of 1.5 mg was not associated with any significant maternal or fetal-neonatal complications. The relatively small number of subjects in this study was chosen deliberately because this was the first use of the drug in pregnant subjects. Assessment of efficacy will require studies that include more patients and a range of relaxin doses.

Postcoital antifertility effect of piperine.

The antifertility activity of piperine was investigated in pregnant mice when given by various routes of administration and at different periods of gestation. Piperine effectively inhibited implantation, produced abortion and delayed labor when it was given from day 2 through 5, day 8 through 12 and day 15 until labor, respectively. At the same dose level which interrupts pregnancy, piperine did not affect the estrous cycle. Neither uterotropic, antiestrogenic nor antiprogestational property was observed. Additionally, piperine also inhibited uterine contraction both in vivo and in vitro. These results suggested that the antifertility activity of piperine did not operate through any hormonal actions or uterotonic activity.

Prepidil compared to Propess for cervical ripening.

OBJECTIVES: To compare the efficacy and safety of intracervical PGE(2) gel (Prepidil) with intravaginal PGE(2) insert (Propess) in cervical ripening and induction of labour. STUDY DESIGN: This was a retrospective analysis of patients with single pregnancies, intact membranes and a viable fetus who required cervical ripening. In the first half of 1998, all patients received Prepidil and in the first half of 1999 all patients received Propess. In both periods 50 consecutive files were retrieved and compared. RESULTS: The Prepidil and Propess group were similar in patient characteristics, indication for induction of labour and delivery outcome. Cervical ripening within 24 h was achieved in the Propess group in 80% as compared to 56% in the Prepidil group. The application-membrane rupture-interval was shorter in the Propess group compared to the Prepidil group (23.7 +/- 21.3 h versus 56.4 +/- 77.7 h, P = 0.009) as well as the application-delivery interval (29.8 +/- 22.0 h versus 62.0 +/- 78.8 h, P = 0.039). In the Propess group 62% delivered within 24 h compared to 28% in the Prepidil group. A smaller number of applications was observed in the Propess group (1.2 versus 1.8, P < 0.005). Both methods proved to be safe in cervical priming and no relevant differences in mode of delivery and outcome of labour were detected. None of the patients required an emergency caesarean section during the treatment with prostaglandines. CONCLUSIONS: Both prostaglandin E(2) agents are safe and effective in achieving cervical ripening; however the vaginal insert demonstrated a shorter application-delivery interval. The hospital stay was consequently shorter, contributing to cost effectiveness.

Induction of labor by oral prostaglandin E2 in protracted pregnancy.

Induction of labor was performed in 20 pregnant females with postmaturity (greater than 294 days) using either oral PGE2 tablets (0.5 mg) or i.v. oxytocin drip (each group n = 10). The induction-establishment interval was significantly shorter in the oxytocin group (P less than 0.005). Moreover, the uterine activity (in Alexandria units) at 3 h post-induction and at the end of the first stage of labor, was significantly higher with i.v. oxytocin (P less than 0.005). However, the induction-delivery interval did not differ in both groups. All cases delivered spontaneously with a satisfactory Apgar score.

Effect of ACTH infusion on induction of uterine contraction in prolonged human pregnancy in association with endocrine function.

The role of hormonal interactions in the mechanism initiating labor in women was studied. The serum levels in women was studied. The serum levels of cortisol, progesterone, estradiol estriol, human chorionic somatomammotropin, and prolactin were measured simultaneously before, during and after infusion of ACTH at a rate of 50 microgram/h in 100 ml of physiological saline or infusion of physiological saline without ACTH (as control) at a rate of 100 ml/h into 14 pregnant women of 10 days or more beyond term. In five (group A) of the 10 women infused with ACTH. uterine contractions were induced within 5-15 min after beginning of ACTH infusion. Although the serum progesterone levels in group A were slightly, but not significantly, lower than those in the other five women (group B) in whom uterine contractions were not induced, the ratio of progesterone to estriol was 13/1 in group A and 18/1 in group B, respectively (P less than 0.05). The endocrine levels in group A may be favorable for the initiation of uterine contraction. The serum cortisol levels in group A were higher, but not significantly higher, than those in group B after ACTH infusion. And the serum estriol levels 6 h after ACTH infusion were significantly lower than control levels before ACTH infusion (P less than 0.01 in group A, P less than 0.05 in group B). To the contrast, in all the four control women infused with physiological saline only (group C), neither uterine contractions nor changes in the serum levels of ACTH and cortisol were found. This work may show that ACTH infusion induced uterine contractions by increased corticosteroids via placenta in lower ratio of progesterone to estrogen but it does not provide any precise information on the mechanism of initiation of human labor.

Intracervical prostaglandin in postdate pregnancy. A randomized trial.

A study was designed to see if incorporating intracervical administration of prostaglandin could affect the outcome of postdate pregnancies. All patients with verified dates, at least 41 6/7 weeks pregnant and enrolled in an antepartum testing schedule were randomized in a double-blind fashion to receive either 0.5 mg of prostaglandin E2 (PGE2) suspended in methylcellulose or a placebo of the gel alone. The gel was inserted directly into the cervical canal after the patient had a reactive/negative contraction stress test. The patient was then observed on an external fetal monitor for an hour before going home. A total of 23 patients received PGE2, and 20 received the placebo. Results were analyzed for the following: change in the Bishop score, lag time from dosage to delivery, spontaneous versus induced labor, cesarean section rate, length of labor and neonatal outcome. There were no significant differences between the groups except in the incidence of patients going into labor within 72 hours. The results indicate that, in general, 0.5 mg of intracervical PGE administered at greater than or equal to 41 6/7 weeks without subsequent oxytocin induction of labor did not appear to significantly alter the obstetric outcome.

Term and postterm low-risk pregnancies: management schemes for the reduction of high rates of cesarean section.

BACKGROUND: We compare trends and current levels of cesarean section delivery by indication in some industrialized countries to help us understand factors underlying national differences in obstetric delivery practice and identify pathways to lower cesarean rates. STUDY DESIGN: In this report we describe the schemes employed at our Department for the management of low-risk at term and postterm pregnancies and list the most important motivations for increased cesarean section rate and remedies suggested to reduce high cesarean section rate. Moreover a randomized trial to assess the role of labor induction with PGE2 gel vs i.v. Oxytocin+Amniotomy in the management of prolonged pregnancy is being evaluated presently at our center. METHODS: To date, 75 postterm pregnancies have been followed. Patients are enrolled at > or = 287 days (41 weeks). Intracervical PGE2 gel (0.5 mg) is used for cervical ripening. Induction of labor is randomly performed using intravaginal PGE2 gel (2 mg) or i.v. Oxytocin+Amniotomy. RESULTS: Overall rates of 75% for spontaneous delivery, and 25% for cesarean section have been observed in our study group of prolonged pregnancies. CONCLUSIONS: The accurate labelling of low- and high-risk pregnancy and the appropriate management of term and postterm pregnancy are two important steps for the reduction of a high rate of cesarean section.

A randomised double-blind study of vaginal misoprostol vs dinoprostone for cervical ripening and labour induction in prolonged pregnancy.

BACKGROUND: Dinoprostone, is presently used in our standard protocol for cervical ripening and labour induction. In search for a cheaper alternative, misoprostol has been found to be a good substitute. In view of the potential saving it might offer, we set out to test its efficacy against the standard dinoprostone. METHODS: A randomised double-blind study involving 50 pregnant women with prolonged pregnancy, treated at a government hospital in Malaysia, was carried out. Two hundred micrograms of intravaginal misoprostol were compared with 3 mg of dinoprostone in each treatment arm. RESULTS: In the misoprostol group, labour was successfully established in 92% of cases compared to 64% in the dinoprostone group (p = 0.04). The induction-delivery interval was shorter with more women delivering within 12 hours (72% vs 28%, p = 0.047). Maternal and neonatal complications, mode of delivery, the need for oxytocin and pethidine were quite similar statistically. Polysystole was more frequent (28% vs 12%, p = 0.28) in the misoprostol group but it was not associated with fetal distress. CONCLUSION: The study showed that misoprostol was a more effective drug in labour induction.

Misoprostol versus oxytocin for labor induction in term and post-term pregnancy: randomized controlled trial.

CONTEXT: Misoprostol, a synthetic E1 methyl analog prostaglandin, is at present receiving attention as a cervical modifier and labor induction agent. However, there is still a need for better determination of its safety and effectiveness. OBJECTIVE: To compare intravaginal misoprostol versus intravenous oxytocin for cervical ripening and labor induction in pregnant women with unripe cervices. DESIGN: Randomized controlled trial. SETTING: The study was performed at the Leonor Mendes de Barros Maternity Hospital between November 1998 and December 2000. PARTICIPANTS: 210 pregnant women with intact membranes and indication for labor induction were selected. PROCEDURES: The women randomly received 25 g of vaginal misoprostol every 4 hours, not exceeding 8 doses (105 women), or oxytocin in a continuous infusion (105 women). MAIN MEASUREMENTS: The main parameters measured were: latent period, time from induction to vaginal delivery, delivery route, occurrence of vaginal delivery with time, occurrence of uterine tonus alterations, hypoxia and neonatal morbidity. To verify the statistical significance of the differences between the groups, the chi-squared, Student t and log-rank tests were used. RESULTS: There were no significant differences between the groups concerning conditions for labor induction, age, parity, race, marital status, family income, initial Bishop Index and number of prenatal visits. The cesarean section rate, latent period and period from induction to vaginal delivery were significantly lower for the misoprostol group. With regard to uterine tonus alterations, tachysystole was significantly more common in the misoprostol group. However, there was no difference in hypoxia and neonatal morbidity between the groups. CONCLUSION: 25 g of misoprostol used vaginally every 4 hours is safer and more efficient for cervical ripening and labor induction than oxytocin.

Outcome of induced labour in pregnancies at 41 weeks gestation and over in Saudi Arabia.

A retrospective, descriptive cohort study was conducted at King Faisal Military Hospital, Saudi Arabia, to compare pregnancy outcomes in patients induced with prostaglandin E2 from 41 weeks gestation. A total of 450 women whose antenatal care and delivery were conducted at the hospital during 1995-99 were studied. The main outcome measures used were caesarean section rate and perinatal morbidity and mortality. In otherwise normal pregnancies, the caesarean section rate was not significantly increased when induction of labour was carried out at 41 weeks gestation compared with > or =42 weeks. Although more perinatal complications occurred when induction was carried out at 42 weeks, the results were not statistically significant. A large prospective clinical trial is indicated.

Oral contraceptives postdatism as a complication.

PIP: The relationship between previous use of oral contraceptives (OCs) and postdatism was investigated in 1496 women attending an antenatal clinic in a 7-month period in 1981. Postdatism was defined as spontaneous labor and delivery 14 or more days beyond the expected date of delivery as calculated by Naegele's rule (i.e., 9 months plus 1 week from the last menstrual period). 186 of the women reported OC use in the period before conception of the present pregnancy and 37 of their deliveries were postdate, for a rate of 19.9%. There were 65 postdate cases among the 1310 nonusers, for a rate of 5%. Among OC users, 43% of the postdatism was 28 days beyond term and 21.6% was 35 days beyond term. The corresponding percentages for nonusers were 27.7% and 10.7%. This indicates that not only is there 5 times more postdatism among women who use OCs before conception than among nonusers, but the postdatism is more severe in the former group. Although no association was found between the duration of OC use and postdatism, there was a clear correlation with the length of the OC cessation-conception interval. Women who conceived 1 month after discontinuing OC use demonstrated a 28.5% rate of postdatism. The rates for 1-2, 2-3, and 3-4 months from cessation to conception wer 27%, 25%, and 16%, respectively. Overall, the postdatism rate was 25.7% among women who conceived in the 1st 4 months since cessation of OC use, compared with a rate of 12.3% among women in whom the cessation-conception interval was over 4 months. Routine induction at 14 days beyond term is not recommended for women with a history of recent OC use. This would result in higher rates of induction for this group than for nonusers, more cesarean sections, and increased neonatal mortality due to prematurity. It is concluded that calculation of the expected date of delivery by use of Naegele's rule is not appropriate in many women with a history of recent OC use. It is suggested that clinicians rely on ripeness of the cervix, the date of the 1st fetal movements, fundal heights, and ultrasonography to assess the need for induction.^ieng

Prostaglandin E2 in preinduction cervical ripening in postdate pregnancy.

UNLABELLED: Unripe cervix is a widely recognised factor contributing to the failure to induce labour. Its presence is associated with high frequency of operative delivery, adverse fetal outcome and high maternal morbidity. MATERIAL: We studied the efficacy of PGE2 application for preinduction cervical ripening in women with postdate pregnancy. Two PGE2-containing preparations were used--Prepidil-gel and Prostin E2 (Upjohn). They were administered to 42 women with postdate pregnancy, unripe cervices and indications for labour induction. The study sample was divided into two groups: group I (20 women) received Prepidil-gel, group II (22 women)--Prostin E2. RESULTS: 85.7% of the women responded favourably to the ripening effect of PGE2. There was no difference in the efficacy, safety and outcome of pregnancy between the two groups. CONCLUSION: Prostaglandin PGE2 is effective for preinduction cervical ripening in women with postdated pregnancy. The authors give their preference to Prostin E2 because it is easier to apply.

[The use of Misoprostol preparation (Cytotec) in induction of labor at prolonged pregnancy]. / Indukcja porodu u kobiet w ciazy przenoszonej z zastosowaniem preparatu Mizoprostol.

OBJECTIVES: Safety and effectiveness testing of Misoprostol use at prolonged pregnancies. DESIGN: Prospective, clinical study. MATERIAL AND METHODS: 50 pregnant women with prolonged pregnancy, monocyesis, cephalic longitudinal foetus lie, existing foetal membranes and lack of spontaneous delivery action. Women were given 50 micrograms Misoprostol (Cytotec) to posterior vaginal fornix in case to provoke delivery. Effectiveness of inducing, delivery lasting, way of its finishing and infant condition at birth were controlled. Results were matched with control group of 35 patients with physiological pregnancy, who delivered in spontaneous partus. RESULTS: Effective provocation was observed at 38 pregnant. Natural way delivery was observed at 40 patients. In 10 cases caesarean section was done. Lasting time of birth, way of finishing, infant condition at birth and number of complication do not differ statistically between examined and control group. CONCLUSION: Misoprostol can be effective and save of delivery induction in prolonged pregnancy.

[The use of prostaglandins in prolonged pregnancy and their effect on the newborn infant]. / Prilozhenie na prostaglandini pri prenosena bremennost i efekt vurkhu novorodenoto.

OBJECTIVE: The purpose of this study was to evaluate the neonatal outcome in newborns from mothers with post-term pregnancy and vaginal prostaglandin (Prostin E2) for cervical ripening and labor induction. STUDY DESIGN: This prospective study included 82 newborns, w.g. 41-42, divided into three groups according to the management of post-term pregnancy: group I--preinduction with Prostin E2 before induction of labor with oxytocin; group II--induction with oxytocin only; group III--with expectant management. In each newborn group weight, size, head circumference, Apgar score and neonatal morbidity characteristics were noted. RESULTS: The cesarean delivery rate was 14.2% in group I, 12.9% in the group II and 3.3% in the III-d group. There were no significant differences between groups in the frequency of meconial amniotic fluid, neonatal meconium aspiration. The incidences of severe asphyxia, neonatal injury and pathologic neonatal icter were higher in the group I. CONCLUSIONS: Prostin E2, used for the cervical ripening and labor induction with oxytocin increased the rate of surgical interventions at delivery and neonatal morbidity.