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PubMed1987

[Reproductive pharmacology of prostaglandins].

Effects of prostaglandins and their analogues in reproduction were investigated using rats and Japanese monkeys. Prostaglandin of the F series exerted uterine contractile, luteolytic, anti-nidation and abortifacient effects. Prostaglandins of the E series exhibited a potent uterine contractile effect, although their luteolytic, anti-nidation and abortifacient effects were much less potent than those of the PGF series. A comparison of animal and human data on prostaglandins and their analogues indicated a good cor-relationship between the uterine contractile effect in animals (rates and monkeys) and the abortifacient or labor inducing effect in humans.

Abortifacient Agents↗

PubMed1979

Effect of prostaglandin A1 on renal hemodynamics in pregnancy toxemia.

PGA1 was infused at a constant rate for 2 hours in 35 pregnant women in the third trimester. Twenty-five patients had clinical manifestations of pregnancy toxemia and 10 served as control subjects. Two dose levels (0.5 to 1.0 mug/kg/min) were investigated and obstetric aspects as well as renal hemodynamics were evaluated. At the high-dose level, the drug induced labor in half the subjects (toxemia patients and control subjects) and elicited a hypotensive response only in hypertensive cases. A marked increase in GFR and RPF was achieved at both dose levels in all cases. Plasma electrolytes, osmolality, and urea levels were unaltered. Also, the infusions did not induce any appreciable diuresis or natriuresis. Tph mechanisms of the induced changes and possible etiologic involvement of PGA1 in toxemia are discussed.

Blood Pressure↗

PubMed2004

First trimester ultrasound screening is effective in reducing postterm labor induction rates: a randomized controlled trial.

OBJECTIVE: This study was designed to test the null hypothesis that first trimester ultrasound crown-rump length measurement for gestational age determination will result in no difference in the rate of induction of labor for postterm pregnancy, compared with second trimester biometry alone. STUDY DESIGN: Two hundred eighteen women were randomly assigned to receive either first trimester ultrasound screening or second trimester ultrasound screening to establish the expected date of confinement. Sample size was calculated by using a 2-tailed alpha=.05 and power (1-beta)=80%. Data were analyzed with chi(2) and Fisher exact tests. RESULTS: Of 104 women randomly assigned to the first trimester screening group, 41.3% had their gestational age adjusted on the basis of the crown-rump length measurement. Of 92 women randomly assigned to the second trimester screening group, 10.9% were corrected as a result of biometry (P <.001, relative risk=0.26, 95% CI=0.15-0.46). Five women in the first trimester screening group and 12 women in the second trimester screening group had labor induced for postterm pregnancy (P=0.04, relative risk=0.37, 95% CI=0.14-0.96). CONCLUSION: The application of a program of first trimester ultrasound screening to a low-risk obstetric population results in a significant reduction in the rate of labor induction for postterm pregnancy.

Adolescent↗

PubMed1992

Prostaglandin E2 for induction of labor in patients with premature rupture of membranes at term.

OBJECTIVE: A prospective study comparing three management schemes for patients at term with premature rupture of membranes was performed. STUDY DESIGN: One hundred forty patients were randomized to one of three study groups: prostaglandin E2, placebo, or oxytocin. Patients randomized to prostaglandin E2 and placebo received vaginal suppositories containing 3 mg prostaglandin E2 or glycerin only, respectively; suppositories were administered in a double-blind fashion, on one or two occasions, 6 hours apart. Oxytocin was given only if labor was not established after 12 hours or to augment inadequate labor. In patients randomized to oxytocin labor was induced with intravenous oxytocin. The time interval to delivery, delivery outcome, and complications were analyzed. RESULTS: Patients receiving prostaglandin E2 were more likely to be in labor after one suppository and to be delivered without the addition of oxytocin when compared with placebo. The time interval to delivery was shorter with prostaglandin E2 and oxytocin induction versus placebo ("expectant management"). The incidence of maternal infection was lowest in patients with labor induced by prostaglandin E2. Although the overall cesarean section rate was low, there was a trend toward a lower rate with prostaglandin E2 induction. No adverse effects were observed with prostaglandin E2. CONCLUSION: Prostaglandin E2 can be used successfully to induce labor after premature rupture of membranes at term with greater ease of administration when compared with oxytocin.

Cesarean Section↗

PubMed1991

Open randomized comparison of prostaglandin E2 given by intracervical gel or vagitory for preinduction cervical ripening and induction of labor.

Intracervical application of prostaglandin E2 (PGE2) in a viscous gel was compared with conventional wax-based PGE2 vagitories (pessaries) for ripening of the cervix prior to induction of labor. A total of 226 healthy pregnant women at term were randomly allocated to receive intracervical gel with an effective dose of 0.5 mg (n = 116) or vagitories containing 2.5 mg PGE2 (n = 110). All women had a modified cervical score of less than or equal to 4. The numbers of cases contributed by each of the three centers were similar. There was no significant difference in parity, gestational length, maternal characteristics, indications for induction or preinduction cervical scores between the treatment groups. The rate of spontaneous birth was 71% in the gel group, compared with 69% in the vagitory group. Successful treatment was defined as active labor within 24 h or a change in cervical dilatation allowing artificial rupture of the membranes with subsequent progressive labor. The success rate was not significantly different in the gel group (82%) compared with the vagitory group (80%). There were no differences in the frequency of fetal distress, outcome of labor, assisted delivery rates or maternal side effects. The cervical scores were not different at 12 and 24 h after application. Intracervical gel and intravaginal application of PGE2 were similar in their efficacy and safety for ripening of the cervix and inducing labor at term.

Administration, Intravaginal↗

PubMed1992

An intravaginal controlled-release prostaglandin E2 pessary for cervical ripening and initiation of labor at term.

The purpose of this randomized, double-blind study was to evaluate the efficacy and safety of a new controlled-release hydrogel pessary for ripening the cervix and initiating labor. Subjects had an entry Bishop score of 4 or less and gestational age of 37 or more weeks. One hundred fourteen women received a placebo pessary and 101 received the hydrogel pessary, containing 10 mg of prostaglandin (PG) E2. Compared with the placebo group, those given the PGE2 pessary were more likely to have an increase in Bishop score of 3 or more (60 or 59% versus 21 or 18%; P less than .0001), change to a Bishop score of 6 or higher (59 or 58% versus 18 or 16%; P less than .0001), and active labor (68 or 67% versus 15 or 13%; P less than .0001). Including the crossover study, uterine hyperstimulation (28 of 182, 15%) and fetal heart rate abnormalities (18 of 182, 10%) in PGE2-treated subjects were reversed on removal of the pessary with no apparent harm to the mother or fetus. These temporary adverse effects appeared while the pessary was in place and after the onset of active labor. Oxytocin was unnecessary in 89 of 182 (49%) of the PGE2-treated cases and was used more often to augment than to induce labor. We conclude that the described controlled-release PGE2 vaginal pessary induces appreciable cervical ripening and frequently initiates active labor with little or no need for oxytocin. The pessary may cause uterine hyperstimulation or fetal heart rate abnormalities, but these would be expected to reverse on removal of the pessary.

Delayed-Action Preparations↗

PubMed1986

Ripening of the human cervix and induction of labor with intracervical purified porcine relaxin.

In a randomized double-blind placebo-controlled trial involving 71 patients, a viscous gel containing distilled water or 1 or 2 mg pure porcine relaxin was instilled in the cervical canal on the evening before the surgical induction of labor. Eleven of 48 patients receiving relaxin labored overnight, whereas only one of 23 patients went into labor. Only the 2-mg dose significantly improved the mean cervical score compared with the placebo treatment; the effect was greatest in primigravid patients with unripe cervixes. Intracervical application appeared to confer no benefit over vaginal application in effecting cervical ripening or inducing labor. Systemic absorption of the porcine relaxin after its intracervical application was confirmed by the measurement of immunoreactive relaxin in a homologous porcine relaxin radioimmunoassay. Thus, the cervical ripening effect of exogenous relaxin may be mediated either systemically or by direct action at the site of local application. This trial confirms the responsiveness of the human term cervix to exogenous relaxin and supports the suggestion that endogenous relaxin may play a similar role at term in facilitating cervical ripening and parturition.

Administration, Intravaginal↗

PubMed1976

[The induction of labor by prostaglandin F2alpha Clinical, tocographic and electrohysterographic study].

Induction of labor was performed in 65 patients by intravenous infusion of PgF2alpha. 55 patients were near term and induction made electively. 5 cases failed. No correlation was found between the stade of the cervix and the probability of success nor the length of the induction time. PgF2alpha induced labor needs to be closely monitored (electronical pumps and monitoring) because of the risk of hypertonus. With such a technique the side effects are minimal and no undesirable consequences were observed concerning either the mother or the child. During the course of this investigation a study was performed for the first time of the electrical activity of the human myometrium subjected to PgF2alpha stimulation. (26 recordings through the extra-amniotic intrauterine technique). The pattern of this activity is quite similar to spontaneously occuring alectrical activity.

Apgar Score↗

PubMed2000

Uterine rupture during induced trial of labor among women with previous cesarean delivery.

OBJECTIVE: This study was undertaken to compare the rates of uterine rupture during induced trials of labor after previous cesarean delivery with the rates during a spontaneous trial of labor. STUDY DESIGN: All deliveries between 1992 and 1998 among women with previous cesarean delivery were evaluated. Rates of uterine rupture were determined for spontaneous labor and different methods of induction. RESULTS: Of 2119 trials of labor, 575 (27%) were induced. The overall rate of uterine rupture was 0.71% (15/2119). The uterine rupture rate with induced trial of labor (8/575; 1.4%) was significantly higher than with a spontaneous trial of labor (7/1544; 0.45%; P =.0004). Uterine rupture rates associated with different methods of induction were compared with the rate seen with spontaneous labor and were as follows: prostaglandin E(2) gel, 2.9% (5/172; P =.004); intracervical Foley catheter, 0.76% (1/129; P =.47); and labor induction not requiring cervical ripening, 0.74% (2/274; P =.63). The uterine rupture rate associated with inductions other than with prostaglandin E(2) was 0.74% (3/474; P =.38). The relative risk of uterine rupture with prostaglandin E(2) use versus spontaneous trial of labor was 6.41 (95% confidence interval, 2. 06-19.98). CONCLUSION: Induction of labor was associated with an increased risk of uterine rupture among women with a previous cesarean delivery, and this association was highest when prostaglandin E(2) gel was used.

Cesarean Section↗

PubMed2001

Balloon cervical ripening with extra-amniotic infusion of saline or prostaglandin E2: a double-blind, randomized controlled study.

OBJECTIVE: To compare extra-amniotic infusion of diluted prostaglandin (PG) E2 solution with saline infusion in balloon cervical ripening and labor induction. METHODS: Women with pregnancy complications and Bishop scores of 3 or lower (n = 116) were assigned randomly to receive extra-amniotic infusion (1 mL/minute) of normal saline or PGE2 in saline (0.5 microg/mL) through a Foley catheter with a 30-mL inflated balloon. We induced labor using intravenous oxytocin only when labor had not developed by 6 hours after balloon expulsion. Analysis was by intent-to-treat. We assessed ripening efficiency and course of labor in women who had spontaneous balloon expulsion (n = 110) and trial of labor (n = 107), respectively. RESULTS: Ripening with PGE2 was associated with significantly shorter mean (+/- standard error of the mean [SEM]) time for balloon expulsion (4.7 +/- 0.4 versus 6.5 +/- 0.6 hours) and with significantly higher Bishop scores (P <.002), compared with ripening with saline. In the PGE2 group, rates of labor induction (15%) and oxytocin use (37%) were significantly lower than in the saline group (51% and 72%, respectively). The groups did not differ significantly in other labor abnormalities, labor duration, mode of delivery, birth weight, Apgar scores, and puerperal morbidity. CONCLUSION: Cervical ripening by extra-amniotic balloon and PGE2 infusion is faster and more effective than by balloon and saline infusion, resulting in a higher rate of spontaneous labor and a lower rate of oxytocin use.

Adult↗

PubMed1992

Cervical priming and labor induction by multiple doses of intracervical prostaglandin E2 gel.

One hundred seventy-two term pregnant women with medical or obstetric conditions requiring induction of labor were treated with intracervical administration of 0.5 mg prostaglandin E2 in tylose gel. Multiple administrations were necessary in 42 cases (24.4%), two administrations in 31 cases (18.0%) and three administrations in 11 cases (6.4%). Intracervical administration of PGE2 tylose gel (0.5 mg dose) is useful to prime the cervix, induce labor, and significantly modify Bishop score.

Cervix Uteri↗

PubMed2006

Acute viral hepatitis C-induced jaundice in pregnancy.

OBJECTIVE: Acute viral hepatitis C-induced jaundice in pregnancy is very rare and may be fatal. Here, we report a complicated case with acute hepatitis C-induced jaundice in pregnancy with successful management. CASE REPORT: A 27-year-old pregnant woman, gravida 2, para 1, with gestational age of 36 weeks and 5 days, was referred to our hospital due to jaundice and elevated liver enzymes of undetermined cause. She had been suffering from general weakness, diarrhea and vomiting for 1 week, and jaundice with tea-colored urine for 3 days. At our medical center, acute viral hepatitis C-induced jaundice was suspected. Since her general condition deteriorated at 36 weeks and 6 days of gestation, we decided to induce labor. A male baby was born smoothly via the vaginal route, with birth weight 2,857 g, birth length 48.6 cm, and 1- and 5-minute Apgar scores of 7 and 9, respectively. Maternal condition improved dramatically after delivery and her serum liver enzymes and bilirubin levels gradually approached normal ranges. CONCLUSION: Mothers and fetuses with acute viral hepatitis C-induced jaundice during pregnancy are at great risk of mortality and morbidity. Timely termination may be one of the choices of treatment when fetal maturity has been reached and the maternal condition has deteriorated.

Acute Disease↗

PubMed1981

Demonstration of novel compounds in human fetal tissues and a consideration of their possible role in parturition.

A study of a new group of compounds and their possible relevance to human parturition is presented. These compounds behave chemically and chromatographically like steroids and have been tentatively identified as analogues of 11-hydroxypregnenolone. Determined by radioenzymatic assay, highest levels were found in the fetal zone of the fetal adrenal and were about 100 times those of fetal serum. Umbilical cord levels were higher after spontaneous labor than after elective cesarean section or induced labor in premature as well as mature infants. It is hypothesized that a fetal factor distinct from adrenocorticotropic hormone acts on the adrenal cortex, particularly the fetal zone, to stimulate 11 beta-hydroxylation of nonglucocorticoid corticosteroids and that these steroids and their metabolites are excreted via the urine into the amniotic fluid. Thus they would reach the membranes and decidua where they might complete with progesterone for receptor sites, decreasing lysosomal stability with the resultant production of prostaglandins and the onset of labor.

11-Hydroxycorticosteroids↗

PubMed2005

Differences between hospitals in cesarean rates for term primigravidas with cephalic presentation.

OBJECTIVE: The purpose of this study was to quantify patient populations and practice patterns at perinatal centers with the highest and lowest cesarean delivery rates. METHODS: The 2 perinatal centers in our state with the lowest (Hospital A-16.6%) and highest (Hospital B-20.3%) overall cesarean rates for Robson group 1 (term primigravidas, vertex, spontaneous labor) and group 2 (term primigravidas, vertex, induced labor) were identified. A total of 174 medical records at Hospital A and 150 records at Hospital B were reviewed. Statistical analysis was performed using independent-sample t tests, chi(2), and multiple logistic regression. RESULTS: Indications for cesarean delivery were not different between the 2 groups, with the majority being for failure to progress in labor and nonreassuring fetal status. There were no differences between groups in rates of postpartum hemorrhage, chorioamnionitis, or endometritis. There were no differences in neonatal outcomes. Although women delivering in hospital A were not more likely to receive oxytocin augmentation (P = .291), their mean maximal oxytocin dosage was higher (14.5 units compared with 11.6 units, P < .001), and they were more likely to receive both fetal scalp electrodes (60.9% compared with 37.3%, P < .001) and intrauterine pressure catheters (63.8% compared with 26.0%, P < .001). CONCLUSION: Because safe reduction in cesarean delivery rates for primigravidas will proportionately reduce the number of repeat cesarean delivery required, benchmarking practices as described in this study can be considered in obstetric practices interested in long-term reductions of their cesarean delivery rates. LEVEL OF EVIDENCE: III.

Adult↗

PubMed1994

Epidural analgesia in active management of labor.

OBJECTIVES: To examine the determinants of epidural analgesia in the active management of labor. To examine the association of epidural with instrumental delivery and cesarean section. STUDY DESIGN: Observational study in a teaching hospital with a uniform active labor management and availability of epidural analgesia on demand. A thousand consecutive nulliparous women at term, were assessed. RESULTS: Requests for epidural anesthesia were predominantly expressed at the time the patient was notified that spontaneous labor was going to be augmented by the administration of oxytocin, or later, when this latter treatment caused labor to be subjectively more arduous. In induced labor, the same observation applied to a greater degree, still. Operative delivery was significantly more frequent in patients with epidural. However, when the incidence of operative delivery was adjusted for the use of oxytocin, the significance between patients with epidural versus the others abated. CONCLUSION: The use of oxytocin in active management of labor results in a high demand for epidural when this is available on demand. This, however, need not be associated with an increased incidence of operative delivery.

Adult↗

PubMed1995

Fetal surveillance. Should it begin at 40 weeks' gestation in a low-risk population?

We evaluated the possible benefits of antepartum surveillance during the 41st week of pregnancy in a low-risk population. Three hundred low-risk patients (study group) underwent a nonstress test (NST) at the beginning of the 41st week of pregnancy. Outcomes in study group patients who delivered during the 41st week were compared to those in 100 similar control patients who were not tested. One antepartum fetal demise occurred in each group: study group rate, 1/300 (0.3%); control group rate, 1/100 (1%), P > .05. During the 41st week, 158 of 300 (53%) study patients and 59 (59%) control patients delivered. Four of 158 (2.5%) study patients had labor induced for the indication of an abnormal antepartum test during the 41st week. Cesarean delivery for distress during the 41st week was performed on 1/157 (0.6%) study and 1/58 (1.7%) control patients (P > .05). No statistically significant improvement in outcome occurred in the study group even though 4 of 300 study group patients required induction of labor for abnormal antepartum testing during the 41st week of gestation. The current practice of not evaluating low-risk pregnancy with an NST until after the completion of 41 weeks is supported by the results of this study.

Female↗

PubMed1997

A comparison of intravaginal misoprostol and intracervical prostaglandin E2 gel for ripening of unfavorable cervix and labor induction.

OBJECTIVE: To study the effectiveness of single application of intravaginal misoprostol versus intracervical prostaglandin E2 gel for ripening the unfavorable cervix and labor induction. METHOD: One hundred and ten patients with indications for induction of labor with unfavorable cervices were randomized to receive either 100 microgram tablets of misoprostol placed in the posterior vaginal fornix or prostaglandin E2 1.5 mg in gel placed into the endocervix. Those, who were not in active labor after 24 hours, had labor induced with amniotomy and oxytocin. RESULTS: Among 110 patients recruited, 60 received misoprostol and 50 received prostaglandin E2 gel. The average interval from start of induction to vaginal delivery was 19.14 +/- 10.64 hours in misoprostol group and 21.37 +/- 13.09 hours in the prostaglandin E2 group (p = 0.33). Five patients (8%) in the misoprostol group had induction of labor after 24 hours of the treatment compared with 13 patients (26%) in the PGE2 group. The difference was significant (p = 0.03). Oxytocin augmentation was 35% in the misoprostol group and 34% in the prostaglandin E2 group (p = 0.86). There were no significant differences between routes of delivery. Nineteen patients (31%) in misoprostol group and 16 patients (32%) in the PGE2 gel group had cesarean deliveries. There was one case (1.7%) of uterine hyperstimulation in the misoprostol group and none in the PGE2 gel group. There were no significant difference in Apgar scores < 7 at 1 and 5 minutes, or admission to the neonatal intensive care unit between the 2 groups. CONCLUSION: Vaginal misoprostol is an effective agent for cervical ripening and induction of labor. Complications associated with prostaglandin administration were not statistically different between the 2 groups, but hyperstimulation occurred more in misoprostol group.

Administration, Intravaginal↗

PubMed1999

Comparing two dinoprostone agents for preinduction cervical ripening at term. A randomized trial.

OBJECTIVE: To compare the safety, efficacy and cost of two methods of administering commercially available dinoprostone for preinduction cervical ripening at term. STUDY DESIGN: Sixty-nine women admitted for labor induction were randomized to receive one of two commercially available agents for cervical ripening. Half the patients received a gel containing 0.5 mg of dinoprostone placed intracervically every four hours. The other half received a polymer insert containing 10 mg of dinoprostone intravaginally. After 12 hours of cervical ripening, oxytocin was given and amniotomy performed to induce labor. RESULTS: Among 69 women randomized, 35 received the gel and 34 the polymer. No significant differences were noted between the two groups in starting characteristics or indication for induction. Both groups were similar with respect to change in Bishop score, start-to-delivery interval, amount of oxytocin required, mode of delivery and success of induction. A slightly higher rate of hyperstimulation was noted in the polymer group, although this did not lead to fetal or maternal morbidity. The average costs per patient for the two agents were similar. CONCLUSION: The two dinoprostone agents are similar with respect to efficacy. The polymer group had slightly more complications but without adverse fetal or maternal outcomes. A larger, multicenter trial would be required to determine actual differences in the efficacy, safety and cost of these two agents.

Adolescent↗