1. Jessica Cook, M.D. and Sally P. Weaver, Ph.D., M.D.
Vaginal misoprostol for cervical ripening in term pregnancy: a review of the literature
Jessica Cook, M.D. and Sally P. Weaver, Ph.D., M.D.
McLennan County Medical Education and Research Foundation Family Practice Residency Program, Waco, Texas
How safe and efficacious is vaginal misoprostol for cervical ripening in a term pregnancy?
CONCLUSIONS
BACKGROUND
Low dose (25 mcg) intravaginal misoprostol appears to be safe and effective for cervical ripening in term pregnancy without a history of prior cesarean section.
Misoprostol (Cytotec™) is a synthetic prostaglandin E1 analog
Used ‘off-label’ for cervical ripening and labor induction
METHODS
Cost-effective versus other methods:
COST ACOG Our hospital
Misoprostol $ $1.11
(Cytotec, per 100 mcg)___________________
Dinoprostone $ $180
(Cervidil, 10 mg)
Review of systematic reviews and new randomized-controlled trials on the use of intravaginal misoprostol for cervical ripening in term pregnancy.
RECOMMENDATIONS FROM OTHERS
The American College of Obstetricians and Gynecologists (ACOG) recommends that lower dose misoprostol (25 mcg q 3-6 h) is effective for cervical ripening, but should not be used in women with previous cesarean section.6
A practice recommendation from the American Academy of Family Physicians’ supports the safety and efficacy of vaginal misoprostol for cervical ripening and labor induction.7
RESULTS
Compared to other cervical ripening methods, misoprostol has an increased rate of vaginal delivery within 24 hours without significant differences in cesarean section rates or fetal outcomes.1 (Systematic review of RCT)
There may be a higher cesarean section rate with misoprostol 50 mcg compared to 25 mcg dosing.3 (Single prospective RCT)
Lower doses (25 mcg) of misoprostol are associated with more need for oxytocin augmentation, but result in less uterine hyperstimulation compared to 50 mcg doses.1 (Systematic review of RCT)
There is a potential increased risk of uterine rupture, therefore misoprostol is relatively contraindicated in women with prior cesarean section.5 (Large population-based retrospective cohort study)
PURPOSE
To determine the safety and efficacy of intravaginal misoprostol as a cervical ripening agent in term pregnancy
REFERENCES:
1. Hofmeyr, GJ. Gulmezoglu, AM. Vaginal misoprostol for cervical ripening and induction of labour. [Systematic Review] Cochrane Pregnancy and Childbirth Group Cochrane Database of Systematic Reviews. 4, (Level of evidence: 1a)
2. Centre for Reviews and Dissemination. Labor induction with 25 microg versus 50 microg intravaginal misoprostol. [Miscellaneous] Database of Abstracts of Reviews of Effectiveness. Issue 4, (Level of evidence: 1a)
3. Has R.  Batukan C.  Ermis H.  Cevher E.  Araman A.  Kilic G.  Ibrahimoglu L. Comparison of 25 and 50 microg vaginally administered misoprostol for preinduction of cervical ripening and labor induction. Gynecol Obstet Invest.  53(1):16-21, (Level of evidence: 1b)
4. McKenna DS.  Ester JB.  Proffitt M.  Waddell KR. Misoprostol outpatient cervical ripening without subsequent induction of labor: a randomized trial. Obstet Gynecol. 104(3):579-84, 2004 Sep. (Level of evidence: 1b)
5. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345:3-8. (Level of evidence: 2b)
6. Induction of labor. ACOG Practice Bulletin No. 10, November 1999.
7. Labor Induction & Cervical Ripening, American Academy of Family Physicians (AAFP), approval date July 2002, Accessed December 20, 2004, at