Comparison of the effect of oral and vaginal misoprostol on labor induction: updating a systematic review and meta-analysis of interventional studies

Rahimi, Maryam; Haghighi, Ladan; Baradaran, Hamid Reza; Azami, Mobin; Larijani, Samaneh Saghafian; Kazemzadeh, Paniz; Moradi, Yousef

doi:10.1186/s40001-023-01007-8

Cited by 7 publications

(8 citation statements)

References 26 publications

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“…This contrasts with studies that have found a higher frequency of caesarean sections in women who received oral misoprostol compared to vaginal misoprostol. 5,6 Fortunately, none of the women in any of the groups had developed uterine hyperstimulation. However, there was an increase in the number of women who developed PPH in the sequential group (OM-VM) but we could not compute a statistical difference.…”

Section: Discussionmentioning

confidence: 95%

“…In contrast, another systematic review has shown that the risk of meconiumstained amniotic fluid (MSAF) and caesarean sections were higher in women who took oral misoprostol in comparison to those who received the drug vaginally. 4,5 Moreover, a study conducted by Handal-Orefice et al has concluded that women who received 50 mcg oral misoprostol every 4-6 hours up to a maximum of 6 doses had a higher risk of caesarean delivery compared to those who received 25 mcg vaginal misoprostol in the same dosing interval. 6 Therefore, standardization of misoprostol dose schedules and routes of administration is necessary to reduce primary caesarean section rates during labor induction.…”

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confidence: 99%

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Sequential use of oral and vaginal misoprostol versus oral or vaginal misoprostol alone for induction of labor and the caesarean delivery risk: a retrospective study

George,

Francis,

Zachariah

et al. 2024

Int J Reprod Contracept Obstet Gynecol

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Background: Induction of labor is now a common practice and every institute faces the task of developing a safe and cost-effective protocol. We aimed to study the effects of sequential use of oral and vaginal misoprostol when compared to oral or vaginal misoprostol alone. Our primary objective was to determine the caesarean delivery rates and secondarily the maternal and neonatal complications between the different induction regimes. Methods: A single-center retrospective observational study was conducted, with patient records divided into three groups based on their methods of induction: those who were administered vaginal misoprostol only, those who had oral misoprostol only, and those who had oral misoprostol followed by vaginal misoprostol. We extracted all the necessary data from the records and analyzed it using SPSS. Results: 768 records with comparable demographic characteristics were reviewed. The majority of women were induced at 39 completed weeks. There was no significant difference in the proportion of caesarean deliveries when comparing the three groups but the number of caesarean sections was lower among women who had been administered vaginal misoprostol alone. Among the patients included in the study, the women who developed postpartum hemorrhage received a higher mean dose of misoprostol (130±70 mcg) compared to those who did not (104±57 mcg). Conclusions: Sequentially administering misoprostol may not decrease the caesarean section rate compared to using only one route of administration. However, it is important to monitor the amount of misoprostol given to each patient to prevent the incidence of PPH.

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Section: Discussionmentioning

confidence: 95%

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confidence: 99%

Sequential use of oral and vaginal misoprostol versus oral or vaginal misoprostol alone for induction of labor and the caesarean delivery risk: a retrospective study

George,

Francis,

Zachariah

et al. 2024

Int J Reprod Contracept Obstet Gynecol

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“…A more recently published systematic review comparing oral versus vaginal misoprostol for labor induction 44 identified 33 trials from systematic database‐searching between January 1990 and January 2022. These included the 13 trials we included in the present review.…”

Section: Discussionmentioning

confidence: 99%

The efficacy and safety of 25 μg or 50 μg oral misoprostol versus 25 μg vaginal misoprostol given at 4‐ or 6‐hourly intervals for induction of labour in women at or beyond term with live singleton pregnancies: A systematic review and meta‐analysis

Yenuberi

Mathews

Cherian

et al. 2023

Intl J Gynecology & Obste

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BackgroundMisoprostol is widely used for cervical ripening and labour induction as it is heat‐stable and inexpensive. Oral misoprostol 25 μg given 2‐hourly is recommended over vaginal misoprostol 25 μg given 6‐hourly, but the need for 2‐hourly fetal monitoring makes oral misoprostol impractical for routine use in high‐volume obstetric units in resource‐constrained settings.ObjectivesTo compare the efficacy and safety of oral misoprostol initiated at 25 or 50 μg versus 25 μg vaginal misoprostol given at 4‐ to 6‐hourly intervals for labor induction in women at or beyond term (≥ 37 weeks) with a single viable fetus and an unscarred uterus.Search StrategyWe identified eligible randomized, parallel‐group, labor‐induction trials from recent systematic reviews. We additionally searched PubMed, Cochrane CENTRAL, Epistemonikos, and clinical trials registries from February 1, 2020 to December 31, 2022 without language restrictions. Database‐specific keywords for cervical priming, labor induction, and misoprostol were used.Selection CriteriaWe excluded labor‐induction trials exclusively in women with ruptured membranes, in the third trimester, and those that initiated misoprostol at doses not specified in the review's objectives. The primary outcomes were vaginal birth within 24 h, cesarean section, perinatal mortality, neonatal morbidity, and maternal morbidity. The secondary outcomes were uterine hyperstimulation with fetal heart rate changes, and oxytocin augmentation.Data Collection and AnalysisTwo or more authors selected studies independently, assessed risk of bias, and extracted data. We derived pooled weighted risk ratios with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the dose and frequency of misoprostol regimens. We used the I2 statistic to quantify heterogeneity and the random‐effects model for meta‐analysis when appropriate. We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach to assess certainty (confidence) in the effect estimates.Main ResultsThirteen trials, from Canada, India, Iran, and the US, randomizing 2941 women at ≥37 weeks of gestation with an unfavorable cervix (Bishop score <6), met the eligibility criteria. Five misoprostol regimens were compared: 25 μg oral versus 25 μg vaginal, 4‐hourly (three trials); 50 μg oral versus 25 μg vaginal, 4‐hourly (five trials); 50 μg followed by 100 μg oral versus 25 μg vaginal, 4‐hourly (two trials); 50 μg oral, 4‐hourly versus 25 μg vaginal, 6‐hourly (one trial); and 50 μg oral versus 25 μg vaginal, 6‐hourly (two trials).The overall certainty in the evidence ranged from moderate to very low, due to high risk of bias in 11/13 trials (affecting all outcomes), unexplained heterogeneity (1/7 outcomes), indirectness (1/7 outcomes), and imprecision (4/7 outcomes).Vaginal misoprostol probably increased vaginal deliveries within 24 h compared with oral misoprostol (risk ratio [RR] 0.82, 95% CI 0.70–0.96; 11 trials, 2721 mothers; moderate‐certainty evidence); this was more likely with 4‐hourly than with 6‐hourly vaginal regimens. The risk of cesarean sections did not appreciably differ (RR 1.00, 95% CI 0.80–1.26; 13 trials, 2941 mothers; very low‐certainty evidence), although oral misoprostol 25 μg 4‐hourly probably increased this risk compared with 25 μg vaginal misoprostol 4‐hourly (RR 1.69, 95% CI 1.21–2.36; three trials, 515 mothers). The risk of perinatal mortality (RR 0.67, 95% CI 0.11–3.90; one trial, 196 participants; very low‐certainty evidence), neonatal morbidity (RR 0.84, 95% CI 0.67–1.06; 13 trials, 2941 mothers; low‐certainty evidence), and maternal morbidity (RR 0.83, 95% CI 0.48–1.44; 6 trials; 1945 mothers; moderate‐certainty evidence) did not differ appreciably. The risk of uterine hyperstimulation with fetal heart rate changes may be lower with oral misoprostol (RR 0.70, 95% CI 0.52–0.95; 10 trials, 2565 mothers; low‐certainty evidence). Oxytocin augmentation was probably more frequent with oral compared with vaginal misoprostol (RR 1.29, 95% CI 1.10–1.51; 13 trials, 2941 mothers; moderate‐certainty evidence).ConclusionsLow‐dose, 4‐ to 6‐hourly vaginal misoprostol regimens probably result in more vaginal births within 24 h and less frequent oxytocin use compared with low‐dose, 4‐ to 6‐hourly, oral misoprostol regimens. Vaginal misoprostol may increase the risk of uterine hyperstimulation with fetal heart changes compared with oral misoprostol, without increasing the risk of perinatal mortality, neonatal morbidity, or maternal morbidity. Indirect evidence indicates that 25 μg vaginal misoprostol 4‐hourly may be more effective and as safe as the recommended 6‐hourly vaginal regimen. This evidence could inform clinical decisions in high‐volume obstetric units in resource‐constrained settings.

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“…The presented data suggest that vaginal misoprostol has a low complication rate. However, on the other hand, studies show that the use of vaginal misoprostol may be associated with an increased percentage of uterine hyperstimulation [ 51 , 52 , 53 ]. Additionally, the differences in the results may probably be due to the different designs of the studies and the different ways of dosing vaginal misoprostol.…”

Section: Discussionmentioning

confidence: 99%

The Efficacy of Misoprostol Vaginal Inserts for Induction of Labor in Women with Very Unfavorable Cervices

Socha

Flis

Wartęga

et al. 2023

JCM

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Background: The purpose of the present study was to evaluate the effectiveness of a misoprostol vaginal insert as an induction-of-labor (IOL) agent in women with an unfavorable cervix (Bishop score < 2) in achieving vaginal delivery (VD) within 48 h, depending on the gestational week, with particular emphasis on the cesarean section (CS) percentage, intrapartum analgesia application and possible side effects, such as tachysystole ratio. Methods: In this retrospective observational study involving 6000 screened pregnant patients, 190 women (3%) fulfilled the study inclusion criteria and underwent vaginal misoprostol IOL. The pregnant women were collected into three groups: patients who delivered at up to 37 weeks of gestation (<37 Group)—42 patients; patients who delivered between 37 and 41 weeks of gestation (37–41 Group)—76 patients; and patients who delivered after 41 weeks of gestation (41+ Group)—72 patients. The outcomes included time to delivery and mode of delivery, rate of tachysystole, need for intrapartum analgesia, and need for oxytocin augmentation. Results: Most of the patients delivered vaginally (54.8% in <37 Group vs. 57.9% in 37–41 Group vs. 61.1% in 41+ Group). A total of 89.5% (170/190) of patients delivered within 48 h (<37 Group—78.6% vs. 37–41 Group—89.5% vs. 41+ Group—95.8%). Statistical significance was demonstrated for the increased rate of vaginal deliveries and shortened time to delivery in the 41+ weeks group (p = 0.0026 and p = 0.0038). The indications for cesarean section were as follows: abnormal CTG pattern vs. lack of labor progression: 42.1% vs. 57.9% in <37 Group, 59.4% vs. 40.6% in 37–41 Group and 71.4% vs. 28.6% in 41+ Group. Statistical significance was demonstrated for the increased rate of abnormal CTG patterns as cesarean section indications in the 41+ Group (p = 0.0019). The need for oxytocin augmentation in each group was: 35.7% in <37 Group vs. 19.7% in 37–41 Group vs. 11.1% in 41+ Group. Statistical significance was shown for decreased need for oxytocin augmentation in +41 Group (p = 0.0016). The need for intrapartum anesthesia, depending on the group, was: 78.6% in <37 Group vs. 82.9% in 37–41 Group vs. 83.3% in 41+ Group. Statistical significance was demonstrated for increased need for intrapartum anesthesia application during labor in +41 Group (p = 0.0018). The prevalence of hyperstimulation was similar in all three groups (4.8% vs. 7.9% vs. 5.6% p > 0.05). Conclusions: The misoprostol vaginal regimen for IOL used in our study is effective in achieving vaginal delivery within 48 h. In post-term women, the use of this regimen is characterized by an increased rate of vaginal deliveries, a shorter time to delivery and a lower need for oxytocin.

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Comparison of the effect of oral and vaginal misoprostol on labor induction: updating a systematic review and meta-analysis of interventional studies

Cited by 7 publications

References 26 publications

Sequential use of oral and vaginal misoprostol versus oral or vaginal misoprostol alone for induction of labor and the caesarean delivery risk: a retrospective study

Sequential use of oral and vaginal misoprostol versus oral or vaginal misoprostol alone for induction of labor and the caesarean delivery risk: a retrospective study

The efficacy and safety of 25 μg or 50 μg oral misoprostol versus 25 μg vaginal misoprostol given at 4‐ or 6‐hourly intervals for induction of labour in women at or beyond term with live singleton pregnancies: A systematic review and meta‐analysis

The Efficacy of Misoprostol Vaginal Inserts for Induction of Labor in Women with Very Unfavorable Cervices

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