Cervical Ripening In Patients Research Articles

Association between intracervical Foley balloon and clinical chorioamnionitis among patients with group B streptococcus colonization undergoing induction with standardized labor management

Intracervical Foley balloons are commonly used for cervical ripening, but there has been a historical concern regarding an increased risk of clinical chorioamnionitis with Foley balloon use in patients with group B streptococcus. This study aimed to determine whether intracervical Foley balloon use in patients with group B streptococcus is associated with an increased risk of clinical chorioamnionitis. This was a secondary analysis of a randomized controlled trial Mechanical and Pharmacologic Methods of Labor Induction: A Randomized Controlled Trial that compared cervical ripening agents within a standardized labor protocol. Foley balloon (alone, with oxytocin, or with misoprostol) was compared with misoprostol only to evaluate the primary outcome of clinical chorioamnionitis, defined based on the American College of Obstetricians and Gynecologists guidelines. Patients with a term, singleton pregnancy with intact membranes and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) and a known group B streptococcus status were included. The secondary outcomes included a composite postpartum maternal infectious outcome consisting of any occurrence of endometritis, wound infection, postpartum urinary tract infection, or maternal sepsis; additional secondary outcomes included neonatal outcomes. Binomial regression with robust error variance was used to evaluate whether group B streptococcus status modified the relationship between Foley balloon use and clinical chorioamnionitis and to adjust for confounders. A total of 491 patients were enrolled in the original trial. Of these patients, 467 had a known group B streptococcus status and underwent cervical ripening: 182 (39.0%) had group B streptococcus, and 285 (61.0%) did not have group B streptococcus. Moreover, 73.0% of patients received a Foley balloon, and 27.0% of patients did not receive a Foley balloon. There was no difference in the demographic or clinical characteristics between groups. The overall rate of clinical chorioamnionitis was 12.2%, with no difference between those with and without a Foley balloon (12.6% vs 11.1%, respectively; P=.66). Group B streptococcus status did not modify the association between Foley balloon use and clinical chorioamnionitis (relative risk, 0.93; 95% confidence interval, 0.50-1.72). This remained unchanged after adjusting for gestational age (adjusted relative risk, 0.87; 95% confidence interval, 0.45-1.67). Furthermore, other maternal and neonatal outcomes were similar between groups. In this secondary analysis of a large randomized trial using a standardized labor protocol, there was no increased risk of infectious morbidity with Foley balloon use in patients overall and in patients with group B streptococcus. Our findings support that a Foley balloon can be safely used for cervical ripening in patients with group B streptococcus colonization.

Dinoprostone Versus Double Balloon Catheter for Cervical Ripening in Patients with Isolated Oligohydramnios

Dinoprostone Versus Double Balloon Catheter for Cervical Ripening in Patients with Isolated Oligohydramnios

Dinoprostone Vaginal Insert: A Review in Cervical Ripening.

Dinoprostone vaginal insert (Cervidil®; Propess®), a retrievable vaginal pessary containing 10mg of dinoprostone [prostaglandinE2 (PGE2)] in a controlled-release drug delivery device, is approved in many countries worldwide for the initiation (or continuation) of cervical ripening in patients at term prior to labour induction. The device is designed to provide a constant and sustained release of dinoprostone to the cervix to promote the complex processes involved in cervical ripening. The vaginal insert is attached to a retrieval system that facilitates easy removal of the device at the onset of labour or in the event of complications. The effectiveness of dinoprostone vaginal insert has been demonstrated in a vast range of randomized clinical trials in women at term. The agent is well tolerated, with a generally favourable safety profile, both maternal and foetal/neonatal. As with all prostaglandin agents used in cervical ripening, dinoprostone vaginal insert is associated with a risk of uterine hyperstimulation. However, this is generally rapidly reversible upon removal of the insert. The demonstrated effectiveness and safety of the device, combined with the benefits of controlled drug release from a simple, single application, and efficient dose control, suggest that dinoprostone vaginal insert is a valuable option for promoting cervical ripening in patients with an unfavourable cervix at term.

Intracervical foleys catheter: Can it serve as an alternative to standard pharmacological method of cervical ripening?

Background: Ripening of cervix is a prerequisite for successful labour induction. Use of prostaglandins for this purpose incurs a high risk of uterine hyperstimulation and a relatively higher cost of treatment. intracervical Foleys catheter insertion is a mechanical method stated in literature. The present study was to compare the efficacy and safety and cost of intracervical Foleys catheter balloon insertion with intracervical dinoprostone application for preinduction cervical ripening in patients requiring labour induction at term.Methods: This was a randomized, parallel group, active controlled study conducted in the obstetrics department of a tertiary care centre over a duration of one year. Group A received Dinoprostone cervical gel 0.5mg instilled in the cervical canal. Maximum of three doses (1.5mg dinoprostone) could be administered 6 hours apart. Patients randomized to group B were subjected to Foleys catheter insertion. Foleys catheter number 16 was used and balloon was inflated with 60ml of water. Primary efficacy parameter was change in Bishops score as compared to baseline and safety was monitored by comparing the total number of adverse events in the two groups.Results: Total of 89 patients were enrolled into the study during one year period out of which 45 received dinoprostone gel and 44 received Foleys catheter insertion respectively. Change in Bishops score, mode of delivery and total number of maternal and foetal adverse events did not differ significantly between the two groups.Conclusions: Efficacy and safety of Foleys catheter as a cervical ripening agent prior to induction of labour is comparable to dinoprostone gel. Since use of Foleys catheter is advantageous in terms of lack of specific storage conditions and cost of treatment, it could be considered a cost effective alternative for preinduction cervical ripening.

Maturation cervicale : y a-t-il un avantage à utiliser un double ballonnet pour le déclenchement du travail ?

ObjectivesTo compare efficiency of a double-balloon to vaginal prostaglandins for cervical ripening in patients with unfavourable cervix. Patients and methodsFifty patients induced with a double-balloon were compared to 50 patients receiving vaginal prostaglandins. Matching criteria were age, parity, history of uterine scar, gestationnal age and Bishop score. The primary outcome was failure induction. Secondary outcomes included improvement in Bishop score, ripening-to-delivey interval, caesarean section rate, maternal and neonatal morbidity. ResultsRisk of failed induction (16% in the double-balloon group vs. 14% in the prostaglandins group) and caesarean section rate (28% vs. 36%) were similar in the two groups. The proportion of favourable cervix and the time to obtain a better Bishop score were similar with the two methods. Maximal pain score during cervical ripening was significantly lower in the double-balloon group (P<0.001). Ripening-to-delivery interval (30.4h±15.6h vs. 28.9h±20.5h) was not different between the two groups. There was no difference about maternal and neonatal outcomes. Discussion and conclusionThe double-balloon was as efficient as vaginal prostaglandins. The ripening-to-delivery interval was not different between the two groups. The main advantage of this device could be a better tolerance favourishing patient satisfaction.

AO-36. Misoprostol versus dinoprostone for cervical ripening in patients with premature rupture of membranes at term

AO-36. Misoprostol versus dinoprostone for cervical ripening in patients with premature rupture of membranes at term

342: A randomized controlled trial of cervical ripening in patients with PROM using an intracervical balloon catheter and oxytocin versus dinoprostone

342: A randomized controlled trial of cervical ripening in patients with PROM using an intracervical balloon catheter and oxytocin versus dinoprostone

Cervico-vaginal foetal fibronectin: A predictor of cervical response at pre-induction cervical ripening

Not all pregnant women with an "unripe" cervix can be successfully ripened by the cervical ripening agents; therefore tests with predictive information are justified. To examine the effect of the presence of foetal fibronectin (FFN) in the cervico-vaginal secretions on pre-induction cervical ripening with either intravaginal Misoprostol or transcervical Foley catheter. Twenty (20) patients managed at a tertiary health institution in South-western Nigeria between March and May 2003 were randomised for cervical ripening by either intravaginal Misoprostol or Transcervical Foley catheters. Cervico-vaginal secretions were assessed for presence of FFN with Foetal Fibronectin Enzyme Immunoassay Kit (Adeza Corp.) prior to commencement of cervical ripening. FFN status, Pre-ripening and Pre-induction modified Bishop scores and duration of cervical ripening. Ten of the fifteen patients with positive membrane immunoassay for FFN achieved ripened cervix (modified Bishop score > or = 6) within 6 - 12 hours of exposure to the agents of cervical ripening. In the FFN negative group, only 2 of the five patients achieved ripe cervix within the >12 - 18 hours period, the rest being in the >18 - 24 hours period. Foetal fibronectin test may offer useful predictive information prior to institution of processes of cervical ripening in patients with unfavourable cervices.

Prostaglandin E2 Gel Versus Misoprostol for Cervical Ripening in Patients With Premature Rupture of Membranes After 34 Weeks

In Brief OBJECTIVE To compare intravaginal misoprostol to prostaglandin (PG) E2 for cervical ripening in women with premature rupture of the membranes (PROM) after 34 weeks of gestation. METHODS Women with PROM after 34 weeks of gestation and an unripe cervix were randomized to receive PGE2 (2.5 mg) or misoprostol (50 μg). Both agents were placed intravaginally immediately after randomization, and the dose was repeated 6 hours later if necessary. After another 6 hours from the second insertion, oxytocin treatment was started if labor had not begun. Forty patients in each group were required to show a 30% improvement in delivery within 12 hours in the misoprostol group. RESULTS One hundred nine patients were randomized; 54 were assigned to misoprostol and 55 to PGE2. Important demographic and clinical characteristics were similar between the groups. The mean time from first insertion to delivery was 16.4 hours in the misoprostol group and 22.0 hours in the PGE2 group. A second dose was required less frequently in the misoprostol group (22% vs 62% in the PGE2 group), and the percentage of patients delivered within 12 hours was higher in the misoprostol group (41% vs 16%). Tachysystole occurred in 20% and 6% of women in the misoprostol and PGE2 groups, respectively. Hyper-stimulation occurred in 9% and 0%, and cesarean delivery in 19% and 26% of women in the misoprostol and PGE2 groups, respectively. Neonatal outcome was similar between groups. CONCLUSION Intravaginal misoprostol is more effective than local PGE2 application to treat PROM after 34 weeks of gestation, but tachysystole occurs more commonly with misoprostol. Intravaginal misoprostol is more effective than prostaglandin E2 for cervical ripening in women with premature ruptured membranes after 34 weeks of gestation.

Prostaglandin E2 gel versus misoprostol for cervical ripening in patients with premature rupture of membranes after 34 weeks

OBJECTIVE:To compare intravaginal misoprostol to prostaglandin (PG) E2 for cervical ripening in women with premature rupture of the membranes (PROM) after 34 weeks of gestation.METHODS:Women with PROM after 34 weeks of gestation and an unripe cervix were randomized to receive PGE2 (2.5 mg) or misoprostol (50 μg). Both agents were placed intravaginally immediately after randomization, and the dose was repeated 6 hours later if necessary. After another 6 hours from the second insertion, oxytocin treatment was started if labor had not begun. Forty patients in each group were required to show a 30% improvement in delivery within 12 hours in the misoprostol group.RESULTS:One hundred nine patients were randomized; 54 were assigned to misoprostol and 55 to PGE2. Important demographic and clinical characteristics were similar between the groups. The mean time from first insertion to delivery was 16.4 hours in the misoprostol group and 22.0 hours in the PGE2 group. A second dose was required less frequently in the misoprostol group (22% vs 62% in the PGE2 group), and the percentage of patients delivered within 12 hours was higher in the misoprostol group (41% vs 16%). Tachysystole occurred in 20% and 6% of women in the misoprostol and PGE2 groups, respectively. Hyperstimulation occurred in 9% and 0%, and cesarean delivery in 19% and 26% of women in the misoprostol and PGE2 groups, respectively. Neonatal outcome was similar between groups.CONCLUSION:Intravaginal misoprostol is more effective than local PGE2 application to treat PROM after 34 weeks of gestation, but tachysystole occurs more commonly with misoprostol.

Misoprostol for cervical ripening in patients with previous cesarean delivery

Purpose: To compare the safety and efficacy of misoprostol cervical ripening in patients who have had at least one previous cesarean delivery.Materials and methods: This was a retrospective review of patients who received either intravaginal or oral misoprostol for cervical ripening between August 1, 1995 and March 1, 1999. Patients received either 50 μg of misoprostol tablet intravaginally or 200 μg orally every 6–8 hours for two doses. Then the dose was increased to 100 μg vaginally for a total of six doses or 300 μg orally for a total of five doses until Bishop score was 7 or higher or the patient had spontaneous labor or a need for intervention.Results: Nine hundred sixty-five subjects were studied, with 131 having had at least one previous low transverse cesarean delivery. The initial median Bishop score was 3 for both groups, and there was no difference with regard to indications for delivery. There was no difference between the groups in the instance of tachysystole, hypersystole, hyperstimulation, need for terbutaline, variable deceleration rate, late deceleration rate, or success. The incidence of abruption between the Tolac and no-previous-cesarean group was 3 (2.3%) versus 3 (0.4%) (P <0.05). The median number of misoprostol used between the groups was similar, as was the incidence of oxytocin used. The number of cesarean births in the Tolac group was 55 (42%) versus 214 (25.7) (P <0.05). The umbilical artery cord pH, as well as the incidence of Apgar scores, was 7 or higher at 1 minute, and 5 minutes was similar. There was no difference in labor chronology between the groups. There were no uterine ruptures in either study group.Conclusions: When used in patients with at least one previous low transverse cesarean delivery, misoprostol has equivalent success with no difference in neonatal outcomes, but a higher incidence of abruption.

Preinduction Cervical Ripening with Intravaginal Prostaglandin E1 Methyl Analogue Misoprostol: A Randomized Controlled Trial

To evaluate the efficacy of intravaginal prostaglandin E1 methyl analogue misoprostol in cervical ripening in patients with unfavorable cervix (Bishop score < 4) requiring labor induction. A randomized controlled clinical trial of 62 women in the third trimester with various indications for induction of labor were randomly allocated to receive either 100 micrograms misoprostol inserted vaginally (32) or placebo similarly applied (30). Transvaginal sonography was performed to measure the cervical length before and 12 hrs after insertion. The mean change in cervical length and Bishop score was significantly greater in the misoprostol group (24 mm and score 8) compared with in the placebo group (2.2 mm and score 1) (p = 0.001). All but one patients receiving misoprostol went into labor while only one in the placebo group did so. The interval from insertion to vaginal delivery was significantly shorter in the misoprostol group (12.0 vs 25.5 hrs, p < 0.001). Delivery occurred within 24 hrs in 75% and 30% of patients in the misoprostol and placebo groups respectively. Uterine tachsystole occurred more frequently in the misoprostol group (38%) than in the placebo group (0%) (p < 0.001). All could be rapidly reversed by tocolytics without apparent untoward intrapartum effects. No significant differences were noted in the 2 groups in terms of perinatal outcomes and mode of delivery. Intravaginal misoprostol is an effective, cheap and safe method for cervical ripening. The higher frequency of uterine tachysystole in the misoprostol group did not increase the risk of adverse intrapartum and neonatal outcomes.

Prostaglandin E 2 gel for cervical ripening in patients with an indication for delivery

To determine if labor can be induced safely and efficiently in patients with a medical or obstetric indication for delivery before 41 completed weeks of gestation by pre-induction cervical ripening with prostaglandin (PG) E2 gel. One hundred eighteen women with confirmed indication for induction of labor before 41 completed weeks were randomized in a double-blind fashion to either intracervical PGE2 gel or placebo before induction by a standard oxytocin protocol. Data regarding the change in Bishop score, interval to complete dilation, maximal oxytocin dose required to establish labor, and route of delivery were collected. Apgar scores and umbilical artery pH were also recorded. The maximum oxytocin dose required to establish progressive labor was significantly lower in the PGE2 group (10.06 +/- 8.50 versus 13.35 +/- 9.27 mU/minute, P = .014). The cesarean rate was also significantly lower in the PGE2 group (13.1 versus 31.6%, P = .016). Pre-induction intracervical deposition of 1 mg PGE2 gel decreased the amount of oxytocin required to induce progressive labor and decreased the cesarean rate in patients who had medical or obstetric indications for delivery before 41 completed weeks. This was accomplished without negative effect on Apgar score or umbilical artery pH.

Cervical ripening before medical induction of labor: a comparison of prostaglandin E 2, estradiol, and oxytocin

Objective: Our purpose was to evaluate the effectiveness of oxytocin, prostaglandin, E 2 intracervical gel, and estradiol cream for ripening the very unfavorable cervix in patients requiring induction of labor at term. Study design: This prospective, randomized study was conducted in a population of women with a very unfavorable cervix (Bishop score <4) requiring induction of labor. The patients received prostaglandin E 2 gel (0.5 mg) intravervically (three doses 6 hours apart), 4 mg estradiol cream in the anterior fornix of the vagina (three doses 6 hours apart), or oxytocin at induction per protocol with an infusion pump. Results: Ninety-nine women were recruited into this trial and evenly distributed among the three groups. The demongraphics of maternal age, race, parity, gestational age, initial Bishop score, and indication for induction were similar among the groups. The incidence of cesarean deliveries was similar in the three groups with approximately 59% of pregnancies delivered abdominally. For patients undergoing abdominal delivery the maximum cervical dilatation among the oxytocin, estradiol, and prostaglandin E 2 groups was similar (3.90 = 3.02 cm, 3.63 ± 2.79 cm, and 4.65 ± 2.78 cm, respectively; p > 0.05). For all patients birth weight and Apgar scores at 1 and 5 minutes were comparable across all regimens ( p > 0.05). In the subset of patients delivered vaginally patients receiving oxytocin for cervical ripening had the greatest improvement on Bishop score over baseline ( p = 0.023) with an improvement of 7.08 ± 2.42. Conclusion: No differences were detected among prostaglandin E 2 gel, estrogen, and oxytocin in relation to cervical ripening in patients with an unfavorable cervix at term who require an induction of labor. Patients with a very unfavorable cervix at term who require delivery may benefit from serial ripening and inductions.