como inductor del trabajo de parto
1: BJOG 2002
A randomised placebo-controlled trial of vaginal misoprostol for cervical
priming before hysteroscopy in postmenopausal women.
Fung TM, Lam MH, Wong SF, Ho LC.
Obstetrics and Gynaecology Unit, Princess Margaret Hospital, Lai Chi Kok,
OBJECTIVE: To investigate the effectiveness of misoprostol given vaginally
for cervical priming before hysteroscopy in postmenopausal women. DESIGN:
Double-blind randomised controlled study. SETTING: Regional hospital, Hong
Kong. PARTICIPANTS: One hundred women with postmenopausal bleeding
scheduled for hysteroscopy from October 1998 to September 2001 were
randomly assigned to receive either misoprostol or placebo vaginally
before the operation. MAIN OUTCOME MEASURES: The number of women requiring
cervical dilatation, outcome of hysteroscopy and side effects of the
medication were assessed. RESULTS: Forty-eight women receiving misoprostol
and 48 women receiving placebo were compared. The mean degree of
endocervical diameter estimated by Hegar's dilator was similar between the
treatment group and the control group. A similar number of women in the
treatment group and the control group required cervical dilatation. The
operative times for both groups were similar. The incidence of side
effects was comparable in both groups. The most common side effects for
misoprostol were febrile episodes and diarrhoea. There was no cervical
tear nor uterine perforation encountered in both groups. The mean duration
of hospital stay in both groups were similar. Subanalysis of results were
similar in women receiving vaginal medication at least five hours before
the operation. CONCLUSION: Vaginal misoprostol was not shown to reduce the
need for cervical dilatation in postmenopausal women. It cannot convert
diagnostic hysteroscopy from a hospital procedure into an office one in
postmenopausal women with tight cervical os.
2: Am J Obstet Gynecol 2002 Jun;186(6):1237-1243
Factors affecting the likelihood of successful induction after
intravaginal misoprostol application for cervical ripening and labor
Wing DA, Tran S, Paul RH.
Division of Maternal-Fetal Medicine, Department of Obstetrics-Gynecology,
University of Southern California, Keck School of Medicine.
OBJECTIVE: Our purpose was to determine whether maternal age, height and
weight, parity, duration of pregnancy, cervical dilatation or Bishop
score, and birth weight could be used to predict the likelihood of
successful induction in women given intravaginal misoprostol.Study Design:
A computerized database was compiled of 1373 pregnancies in which
intravaginal misoprostol was given for cervical ripening and labor
induction. Most of these women were placed on investigational protocols in
which the dose of misoprostol administered was 25 to 50 &mgr;g and the
dosing intervals ranged from 3 to 6 hours. No more than 24 hours of
administration was permitted. Induction was undertaken in women with
unfavorable cervical examinations (Bishop scores of 4 or less) and without
spontaneous labor or ruptured membranes. Univariate and stepwise multiple
regression analyses were performed to identify those factors associated
with successful induction, defined as vaginal delivery within 24 hours of
induction. RESULTS: Six hundred fifty-seven (48%) had successful
induction. Parity (odds ratio [OR] 2.5, 95% CI 2.0-2.9, P <.0001),
initial cervical dilatation (OR 1.9, 95% CI 1.6-2.3, P <.0001), Bishop
score (OR 1.6, 95% CI 1.3, 1.8, P <.0001), and gestational age at entry
(OR 1.3, 95% CI 1.1-1.5, P =.002) were significant at the.05 level for
predicting successful induction. A multivariate stepwise logistic
regression was then performed to evaluate each of these as independent
predictors. Parity (OR 2.4, 95% CI 2.0-3.0, P <.0001), initial cervical
dilatation (OR 1.7, 95% CI 1.4-2.1, P <.0001), and estimated
gestational age (OR 1.3, 95% CI 1.1-1.6, P =.003) are significant
independent predictors for successful induction, but initial Bishop score
is not significant (P =.19) after adjustment for other significant
predicting factors. CONCLUSIONS: The clinical characteristics of parity,
initial cervical dilatation, and gestational age at entry are predictors
of the likelihood of success of cervical ripening and labor induction with
intravaginal misoprostol administration.
3: Am J Obstet Gynecol 2002 Jun;186(6):1124-1129
Cervical ripening and induction of labor with misoprostol, dinoprostone
gel, and a foley catheter: A randomized trial of 3 techniques.
Barrilleaux PS, Bofill JA, Terrone DA, Magann EF, May WL, Morrison JC.
Departments of Obstetrics and Gynecology and Preventive Medicine,
University of Mississippi Medical Center.
OBJECTIVE: The purpose of this study was to compare the efficacy of 3
different techniques of cervical ripening and induction.Study Design:
Patients who required cervical ripening and induction were randomized to
one of 3 groups: (1) supracervical Foley catheter and intravaginal
dinoprostone gel, (2) supracervical Foley catheter and 100 &mgr;g oral
doses of misoprostol, or (3) serial 100-&mgr;g oral doses of
misoprostol. Intravenous oxytocin was administered when a protraction
disorder of labor was identified. RESULTS: There were 339 women
randomized. There was no significant difference in the time from first
intervention to delivery in the 3 groups (P =.546). In each group, a
similar percentage of women required oxytocin (P =.103). The rates of
cesarean delivery were equivalent among the groups (P =.722). Rates of
tachysystole were high but statistically equivalent among the 3 groups.
There were no significant differences in Apgar scores or umbilical artery
pH. CONCLUSION: Oral 100 &mgr;g serial doses of misoprostol, with or
without the use of a supracervical Foley catheter, were equivalent to the
use of a supracervical Foley catheter and serial 4-mg doses of
dinoprostone gel for cervical ripening and the induction of labor.
4: Obstet Gynecol 2002 Jun;99(6):1080-4
The effect of tablet moistening on labor induction with intravaginal
misoprostol: a randomized trial.
Sanchez-Ramos L, Danner CJ, Delke I, Kaunitz AM.
Department of Obstetrics and Gynecology, Division of Maternal Fetal
Medicine, University of Florida Health Science Center, Jacksonville,
Florida 32209, USA. email@example.com
OBJECTIVE: To estimate whether a dosage of 50 microg of misoprostol
tablets moistened with 3% acetic acid and administered intravaginally is
more efficacious for labor induction than a similar dosage regimen using
dry tablets. METHODS: A total of 177 women who presented with an
indication for cervical ripening and labor induction were randomly
assigned to one of two treatment groups: 1) intravaginal misoprostol in
dry tablet form, or 2) intravaginal misoprostol moistened with 1 mL of 3%
acetic acid solution. The primary outcome assessed was the interval from
start of induction to vaginal delivery. To detect at least a 3.5-hour
difference in the primary outcome with 80% power, 87 subjects were
required in each group. RESULTS: Among 162 patients evaluated, 80 were
allocated to the misoprostol dry group and 82 to the misoprostol moistened
group. No significant difference was noted for the mean +/- standard
deviation interval to vaginal delivery: 1130 +/- 636 minutes for the group
who received dry tablets and 1004 +/- 636 minutes for those who received
moistened misoprostol tablets (P =.25). Additionally, no statistically
significant differences were noted between the groups with respect to need
for oxytocin, proportion of patients delivered after a single dose,
intrapartum complications (including tachysystole and uterine
hyperstimulation), mode of delivery, or perinatal outcomes. CONCLUSION:
Tablet moistening with 3% acetic acid solution does not seem to improve
the efficacy of intravaginally administered misoprostol for labor
5: Obstet Gynecol 2002 Jun;99(6):1044-8
Oral versus vaginal misoprostol for labor induction.
Hall R, Duarte-Gardea M, Harlass F.
Department of Obstetrics and Gynecology, Texas Tech University Health
Sciences Center at El Paso, El Paso, Texas 79905, USA.
OBJECTIVE: To compare the safety and effectiveness of vaginal with oral
misoprostol for induction of labor. METHODS: A total of 107 women with
clinical indication for induction were randomly assigned to receive oral
or vaginal misoprostol. Doses of 100 microg of oral or 25 microg of
vaginal misoprostol were given every 3-4 hours. If cervical ripening or
active labor did not occur, repeated doses of oral (100-200 microg) or
vaginal (25-50 microg) were given until labor was established. RESULTS:
Fifty-nine women received oral misoprostol, and 48 received vaginal
administration. Delivery time was similar for the vaginal and oral arms
(1074 +/- 488 minutes versus 930 +/- 454 minutes, P =.11). Parity was
significantly different (P =.04) for the vaginal and oral groups. The
cesarean delivery rate was similar for the vaginal and oral arms (17%
versus 15%, P =.72). The number of medication administrations was
consistent between groups. Birth weight was not different for patients in
the control and treatment groups (vaginal 3281 +/- 507 g versus oral 3359
+/- 541 g, P =.44). Chorioamnionitis and tachysystole were comparable for
the oral and vaginal groups. There was no statistical difference in
neonatal outcomes. Similar proportions of infants were admitted to the
well baby nursery and intermediate care nursery. CONCLUSION: These
findings indicate that, in a closely supervised hospital setting with
adequate monitoring, oral misoprostol has the potential to induce labor as
safely and effectively as its vaginal analogue.
6: Am J Obstet Gynecol 2002 May;186(5):876-9
The use of oral misoprostol as a cervical ripening agent in operative
hysteroscopy: a double-blind, placebo-controlled trial.
Thomas JA, Leyland N, Durand N, Windrim RC.
Department of Obstetrics and Gynecology, University of Toronto, Mt Sinai
Hospital, Ontario, Canada.
OBJECTIVE: The purpose of this study was to assess the effectiveness of
oral misoprostol as a cervical ripening agent when used in operative
hysteroscopy. STUDY DESIGN: This was a double-blind, placebo-controlled
trial. Any patient undergoing an operative hysteroscopy (with a 9-mm to
10-mm hysteroscope) was considered eligible for the trial. Patients were
randomly allocated, by means of computer-generated numbers, to receive
either placebo or 400 microg of misoprostol 12 and 24 hours before
surgery. The primary outcome measure in this study was the ease of
cervical dilatation as measured by the largest-number Hegar dilator that
could be inserted into the cervix without resistance. A subjective assessment
of the ease of dilatation was also recorded on a Likert scale. Other
demographic data including age, menopausal status, parity, and use of
gonadotropin-releasing hormone (GnRH) analogues were also recorded.
Adverse effects experienced and any other adverse outcomes were also
recorded for each group. Logistic regression analysis was used to compare
the two groups. RESULTS: Two hundred four patients were recruited into the
study. There were no differences between the two groups in demographic
variables. The misoprostol group demonstrated an increased ease of
cervical dilatation (odds ratio [OR] 2.6; CI 1.28-5.29; P =.008). This was
also demonstrated in the subgroup of patients who were menopausal or who
had been pretreated with a gonadotropin-releasing hormone analog (OR 2.49;
CI 1.11-5.58; P =.026), as well as in those who were premenopausal (OR
2.15; CI 1.04 4.45; P =.04). There were no differences between the two
groups in the time required for dilatation (P =.08) or ease of dilatation
(P =.12). Adverse effects were greater in the treatment group: diarrhea
(28% vs 4%; P <.001), cramps (27% vs 1%; P <.0001), and bleeding
(26% vs 1.3%; P <.001). CONCLUSIONS: Misoprostol demonstrates a benefit
over placebo in the ease of cervical dilatation in premenopausal and
postmenopausal women and in those pretreated with a gonadotropin-releasing
hormone analog. Adverse effects were more common in the treatment group
but did not preclude the patients from taking the medication.
7: Am J Obstet Gynecol 2002 Mar;186(3):470-4
The optimization of intravaginal misoprostol dosing schedules in
second-trimester pregnancy termination.
Dickinson JE, Evans SF.
Department of Obstetrics and Gynaecology, University of Western Australia,
OBJECTIVE: The purpose of this study was to compare the clinical efficacy
and side effects of 3 doses of intravaginal misoprostol for
second-trimester pregnancy termination. STUDY DESIGN: This was a
prospective randomized, double-blind controlled clinical trial of 150
women who underwent pregnancy termination between 14 and 30 weeks of
gestation. Three intravaginal misoprostol regimens were compared: 200
microg misoprostol at 6-hour intervals (group 1), 400 microg misoprostol
at 6-hour intervals (group 2), and a loading dose of 600 microg
misoprostol followed by 200 microg at 6-hour intervals (group 3). RESULTS:
There was a significant difference in the median time to achieve delivery
among the 3 groups: group 1 (18.2 hours [IQ, 13.3-32.5 hours]) vs group
2 (15.1 hours [IQ, 10.9-23.7 hours]) vs group 3 (13.2 hours [IQ, 11.2-21.7
hours]; P =.035). Fifty-nine percent of the women in group 1, 76% of the
women in group 2, and 80% of the women in group 3 delivered within 24
hours (P =.013). There were 7.8% of the women in group 1, 0% of the women
in group 2, and 2% of the women in group 3 who were undelivered at 48
hours (P =.02). There was an increase in the incidence of fever in the
first 12 hours (P =.038) and in the incidence of vomiting within 3 hours
of the initial dose (P =.048) in group 3 compared with the other groups.
CONCLUSION: Intravaginal misoprostol 400 microg at 6-hour intervals
appears to be the preferred regimen for second-trimester pregnancy
termination, with a shorter commencement to delivery interval than the 200
microg regimen and fewer maternal side-effects than the 600 microg loading
8: Clin Obstet Gynecol 2002 Mar;45(1):114-24
Cervical ripening agents and uterine stimulants.
Stitely ML, Satin AJ.
Uniformed Services University, National Naval Medical Center, Bethesda,
Maryland 20814, USA. firstname.lastname@example.org
9: Am J Obstet Gynecol 2002 Feb;186(2):229-33
Buccal versus intravaginal misoprostol administration for cervical
Carlan SJ, Blust D, O'Brien WF.
Department of Obstetrics and Gynecology, Arnold Palmer Hospital for
Children and Women, Orlando, FL, USA. email@example.com
OBJECTIVE: The purpose of this study was to compare the efficacy of
misoprostol that is administered in the buccal pouch with the intravaginal
route of administration. STUDY DESIGN: One hundred fifty-seven pregnant
women with a singleton live gestation, Bishop score of <7, estimated
fetal weight of <4500 g, and gestational age of >24 weeks were
randomized to receive misoprostol that would be placed either in the
buccal pouch or vagina every 6 hours. In the buccal group, after the first
2 doses of 200 microg, the dose was increased to 300 microg for the
duration of the study (up to a total of 1600 microg). In the vaginal
group, after the first 2 doses of 50 microg, the dose was increased to 100
microg for the duration of the study (up to a total of 500 microg). The
primary outcome variable was the interval from the first dose to vaginal
delivery. Power calculations indicated the need to enroll 71 patients in
each arm of the study, which would allow for the detection of a 4-hour
reduction in vaginal birth interval for buccal misoprostol. RESULTS: The
hours from drug administration to vaginal delivery were similar between
the buccal and vaginal groups (23.5 +/- 20.8 hours versus 21.3 +/- 13.4
hours), respectively. Thirty-five women (63%) versus 34 women (67%)
delivered vaginally within 24 hours (P = not significant). The incidence
of tachysystole was higher in the buccal group, 28 occurrences (38%)
versus 15 occurrences (19%; P =.01). CONCLUSION: Buccal misoprostol is
effective for cervical ripening but results in a higher incidence of
tachysystole than does intravaginal administration.
10: Obstet Gynecol 2002 Feb;99(2):316-32
Misoprostol for women's health: a review.
Blanchard K, Clark S, Winikoff B, Gaines G, Kabani G, Shannon C.
Population Council, Johannesburg, South Africa. firstname.lastname@example.org
OBJECTIVE: To review published literature on misoprostol for women's
health indications to provide a synthesis of available information and
highlight areas in need of additional research. DATA SOURCES: Studies were
identified through searches of medical literature databases including
MEDLINE, Cochrane Database, and Popline, in addition to a review of
references from identified articles. STUDY SELECTION: We included all
studies reported in English and published before March 31, 2001, which
evaluated the efficacy of misoprostol alone for labor and delivery,
evacuation of the uterus after pregnancy failure and induced abortion.
Studies were not excluded based on quality or sample size. TABULATION,
INTEGRATION, AND RESULTS: Misoprostol shows promise for all of the women's
health indications addressed. Currently available data, though, are often
hard to interpret because of variations in regimen, dose, and outcome
measures. The low cost, ease of administration and storage, and widespread
availability of misoprostol make it particularly appealing for developing
countries. Because many of the women's health problems for which
misoprostol could be prescribed currently cause significant mortality and
morbidity, increased access to and information on use of misoprostol could
help improve women's health especially where these problems are most
severe. CONCLUSION: Further research is needed to identify optimal
regimens for misoprostol for obstetric and gynecologic health indications.
Registering misoprostol with national drug regulatory authorities for any
of several women's health indications could help increase access to and
safe use of this drug. Provider training would be a logical subsequent
11: Am J Obstet Gynecol 2002 Jan;186(1):72-6
Sublingual misoprostol for the induction of labor at term.
Shetty A, Danielian P, Templeton A.
Department of Obstetrics and Gynecology, Aberdeen Maternity Hospital,
OBJECTIVE: To evaluate the efficacy, safety, and patient acceptability of
sublingual misoprostol compared with an equivalent dose administered
orally for labor induction at term. STUDY DESIGN: One hundred women with
medical or obstetric indications for induction of labor after 37 weeks of
gestation and unfavorable cervices were randomized to receive 50 microg of
misoprostol either orally or sublingually. The dose was repeated every 4
hours to a maximum of 5 doses if indicated. Previous cesarean delivery was
a criteria for exclusion. Our primary outcome measure was the number of
patients who went on to have a vaginal delivery within 24 hours of the
induction. The need for oxytocin, mode of delivery, number of cesarean
deliveries for fetal distress, uterine hyperstimulation rates, and
neonatal outcomes were secondary outcome measures. Patient acceptability
was assessed by questionnaires completed after delivery. RESULTS:
Significantly more patients were delivered of infants within 24 hours
(73.8% versus 45.7%; relative risk, 1.6; 95% confidence interval, 1.1 to
2.4) and the induction to delivery intervals were significantly shorter
(20 hours versus 28.3 hours; mean difference, 8.3 hours; 95% confidence
interval, 1.2 to 15.4) in the sublingual group compared with the oral
group. There was 1 case of uterine hyperstimulation in the sublingual
group. There were no significant differences in the mode of delivery,
interventions for fetal distress, or neonatal outcomes in the 2 groups.
The satisfaction rates were 82.5% and 85.7% in the oral and sublingual
groups respectively, and 9.5% of patients thought that the sublingual
tablets did not dissolve completely. CONCLUSION: There has been no
previous report in the literature of misoprostol given sublingually for
labor induction. Sublingual misoprostol seems to have better efficacy than
oral misoprostol, seems to be acceptable to patients, and is an option to
be considered to induce labor at term.
12: Curr Opin Obstet Gynecol 2001 Dec;13(6):577-81
Induction of labour with misoprostol.
East London Hospital Complex, East London 5200, South Africa.
Misoprostol, an orally active prostaglandin E1 analogue, has been used
the vaginal and oral routes for labour induction at or near term. Several
trials have confirmed that it is highly effective. Overall caesarean
rates appear to be reduced, despite a relative increase in caesarean
for fetal heart rate abnormalities. Concern remains regarding increased
uterine hyperstimulation and meconium-stained amniotic fluid, although
perinatal outcomes have been reassuring. Recent reports reviewed here have
raised the possibility that postpartum haemorrhage may be increased after
induction of labour with misoprostol, and isolated reports of uterine
with or without previous caesarean section, continue to appear. Using
dosages appears to reduce adverse outcomes. Very large trials are needed
evaluate rare adverse outcomes.
13: South Med J 2000 Sep;93(9):881-4 [Texto
completo en formato PDF]
Use of misoprostol for cervical ripening.
Katz VL, Farmer RM, Dean CA, Carpenter ME. Sacred Heart Medical Center,
Eugene, Ore, USA.
BACKGROUND: Misoprostol, the prostaglandin E1 analog, is increasingly used
for cervical ripening and induction of labor. We evaluated our experience
with misoprostol in an open-label setting. METHODS: Patients were selected
for cervical ripening based on clinical profile. At 3 cm cervical
dilation, misoprostol was discontinued and other means of labor
augmentation were used. Over 13 months, 470 inductions of labor occurred,
and 455 charts were available; 254 patients (56%) received misoprostol for
cervical ripening, and 144 (32%) received dinoprostone (prostaglandin E2).
RESULTS: With misoprostol, mean time from beginning of contractions until
delivery was 7 hours, 30 minutes; vaginal birth occurred in 85% of cases,
and spontaneous labor occurred in 38%. Hyperstimulation occurred in 4
cases (1.6%) and precipitate labor in 7 (3%). All infants were discharged
in excellent condition; one had a 5-minute Apgar score <7, and 33 (13%)
had meconium, none with aspiration. Twenty-three patients who had had a
previous cesarean section received misoprostol and delivered vaginally.
CONCLUSION: Misoprostol was found to be a safe and effective agent for
cervical ripening as part of labor induction.
14: South Med J 1998 Mar;91(3):248-52 [Texto
completo en formato PDF]
Bishop score: a poor diagnostic test to predict failed induction versus
Hendrix NW, Chauhan SP, Morrison JC, Magann EF, Martin JN Jr, Devoe LD.
Department of Obstetrics and Gynecology, Medical College of Georgia,
Augusta 30912-3350, USA.
BACKGROUND: We evaluated the accuracy of the Bishop score in predicting
the likelihood of successful labor induction (entry into active phase) in
nulliparous and multiparous women. METHODS: During an index year, all
patients having induction of labor and a preinduction Bishop score were
included in a standard protocol for cervical ripening and use of oxytocin.
Receiver-operating characteristic (ROC) curves were constructed for Bishop
scores (0 to 11) to predict abdominal delivery for failed induction (final
cervical dilation <4 cm) versus vaginal delivery. RESULTS: Parturients
who had vaginal delivery (n = 253) and those in whom attempted induction
failed (n = 38) did not differ significantly with respect to maternal
demographics, length of gestation, Bishop score and its distribution, and
infant birth weight. The area under the ROC curve did not differ
significantly from the area under the nondiagnostic line. CONCLUSION: The
Bishop score appears to be a poor predictor of the outcome of labor