Cervical Score Research Articles

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term.

Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol). The Cochrane Pregnancy and Childbirth Group trials register (May 2003) and bibliographies of relevant papers. Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods. A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. In total, 101 studies were considered: 43 excluded and 57 (10,039 women) included. One study is awaiting assessment. Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18% versus 99%, relative risk (RR) 0.19, 95% confidence interval (CI) 0.14 to 0.25, 2 trials, 384 women), there was no evidence of a difference between caesarean section rates although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.6% versus 0.51%, RR 4.14, 95% CI 1.93 to 8.90, 13 trials, 1203 women). Comparison of vaginal prostaglandin F2a with placebo showed similar caesarean section rates but the cervical score was more likely to be improved (15% versus 60%, RR 0.25, 95% CI 0.13 to 0.49, 5 trials, 467 women), and the risk of oxytocin augmentation reduced (53.9% versus 89.1%, RR 0.60, 95% CI 0.43 to 0.84, 11 trials, 1265 women) with the use of vaginal PGF2a. There were insufficient data to make meaningful conclusions for the comparison of vaginal PGE2 and PGF2a.PGE2 tablet, gel and pessary appear to be as efficacious as each other. Lower dose regimens, as defined in the review, appear as efficacious as higher dose regimens. The primary aim of this review was to examine the efficacy of vaginal prostaglandin E2 and F2a. This is reflected by an increase in successful vaginal delivery rates in 24 hours, no increase in operative delivery rates and significant improvements in cervical favourability within 24 to 48 hours. Further research is needed to quantify the cost-analysis of induction of labour with vaginal prostaglandins, with special attention to different methods of administration.

Cervical Ripening with Prostaglandin E1: How an Ambulatory Method Decreases the Hospital Stay in Abortus with Intrauterine Fetal Demise

Objective: This study was designed to determine whether use of prostaglandin E₁(PGE₁) is justified to improve the known clinical outcome of prostaglandin E₂ (PGE₂) gel, because PGE₂ gel preparations are more costly than PGE₁ tablets in most countries, and data to support the use of the gel in clinical practice is not conclusive. The aim was to compare the safety and efficacy of PGE₁ gel when applied in both an in-hospital or ambulatory setting to oxytocin infusion in those women with unfavorable cervical conditions prior to surgical abortion for either medical or obstetrical indications with intrauterine fetal demise. Surgical dilatation of the unripe cervix may result in cervical injury of uterine perforation which could prolong the hospital stay. Methods: We used PGE₁ gel prepared from tablets and administered in the ambulatory form (group 1), the same PGE₁ gel administered in the labor room (group 2) and intravenously administered oxytocin in the labor room (group 3) for the induction of abortus in women complicated with intrauterine fetus death and missed abortion. Patients requesting abortion were eligible for inclusion, with >8 and <13 weeks of gestation. Eighty-nine women with unfavorable cervices (Bishop score ≤4) were included in this study. Comparisons between the three groups for such variables were done by ANOVA. Results: The statistical test did reveal significant differences in the cervical changes, doses of PGE₁ used and maternal labor stay between the three groups. The difference in effect on cervical ripening was seen following PGE₁ application in both of these groups, but no difference was seen with the oxytocin use. Cervical score changed in 100% of both groups with the PGE₁ gel and 89.6% of the group with oxytocin use, within 6 days in the latter group. The mean number of days of maternal labor stay were 1.5, 4.6 and 6.2 respectively. There was no difference regarding the effect on clinical characteristics of the women on the final Bishop score. The number, initial and final Bishop score, vaginal bleeding and other complications were not different. Conclusions: Duration of hospital stay may be decreased by applying PGE₁ gel in an ambulatory setting when compared to in-hospital PGE₁ gel applications or intravenous oxytocin infusion for cervical ripening. Further research is necessary to determine the safety of PGE₁ gel application for preabortion cervical ripening prior to surgical abortion.

透析患者の頚髄症に対する頚部脊柱管拡大術の手術成績の検討

Six patients with hemodialysis-associated cervical myelopathy underwent cervical expansive laminoplasty. Duration of hemodialysis ranged from 0.5 to 26 years (average: 11.8 years). No patients had destructive spondyloarthropathy (DSA). Pre- and postoperative neurologic status was assessed using the cervical myelopathy scoring system of the Japanese Orthopedic Association. Neurologic recovery was obtained in all six patients. We compared this group with forty patients, whose cervical myelopathy was not associated with hemodialysis. There was no significant difference between the two groups.

Metformin therapy improves ovulatory rates, cervical scores, and pregnancy rates in clomiphene citrate-resistant women with polycystic ovary syndrome

Objective: To evaluate the effect of metformin therapy on hyperandrogenism, insulin resistance, cervical scores, ovulation, and pregnancy rates in clomiphene citrate-resistant women with polycystic ovary syndrome (PCOS). Design: Prospective, randomized, double-blind, placebo-controlled study. Setting: Infertility clinic of a tertiary referral center. Patient(s): Fifty-six women with clomiphene citrate-resistant PCOS. Intervention(s): Two cycles of oral metformin therapy (850 mg, twice daily) in group I and placebo therapy (twice daily) in group II. Clomiphene citrate (100 mg/day) on cycle days 3–7 of the second cycle in both groups. Main Outcome Measure(s): Insulin, T, DHEAS, FSH, LH, body mass index (BMI), waist-to-hip ratio, endometrial thickness, cervical score, ovulation, and pregnancy rates in clomiphene-induced cycles after metformin therapy. Result(s): Metformin therapy resulted in a significant decrease in total T, LH level, LH/FSH ratio, insulin resistance, and mean BMI. No difference in waist-to-hip ratio, DHEAS level, and fasting insulin level was observed. Clomiphene citrate induction resulted in higher ovulation rates and thicker endometrium in the metformin group than in the placebo group. There was higher cumulative pregnancy rate in the metformin group; however, there was no significant difference in the pregnancy rate between the two groups. Conclusion(s): Metformin therapy not only decreases hyperandrogenism and insulin resistance but also improves ovulation rates, cervical scores, and pregnancy rates in clomiphene citrate-resistant women with PCOS.

Do practice guidelines guide practice? A prospective audit of induction of labor - three years experience

To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures. Guidelines for induction of labor were implemented in January 1996 following an audit report identifying inconsistency in clinical practice. A prospective audit was carried out following the implementation of a new strategy directed towards pre-induction cervical ripening in nulliparae with unfavorable cervices and the use of low dosages of vaginal prostaglandin E2 for induction of labor. Level of compliance and outcome measures were compared before and after implementation of guidelines. In the period of January 1995 to November 1997, 1,230 women were induced with a singleton viable pregnancy in a cephalic presentation with a gestational age > or = 37 weeks with no history of rupture of membranes or cesarean section. Completed forms were available for 1,147 women (370, 421 and 356 in 1995, 1996 and 1997, respectively). Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit. Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.

Inhibition of ovulation by a novel progestogen (drospirenone) alone or in combination with ethinylestradiol

Objective To investigate ovulation inhibition with drospirenone, a novel progestogen that has a profile similar to natural progesterone, when given alone or in combination with ethinylestradiol.Method Hormonal parameters (LH, FSH, 17ß-estradiol and progesterone) and peripheral parameters (cervical score, spinnbarkeit and crystallization), as well as follicle size assessed by ultrasonography, were measured in two groups of healthy women. Forty-eight women aged 19–35 years were randomly assigned to receive 0.5 mg, 1.0 mg, 2.0 mg or 3.0 mg of drospirenone over a single treatment cycle, and 52 women aged 20–35 years were randomized to receive either 2 mg drospirenone/30 μg ethinylestradiol or 3 mg drospirenone/30 μg ethinylestradiol over three treatment cycles. Baseline measurements were taken during a control pretreatment cycle.Results Adequate ovarian suppression with drospirenone alone was evident at dose levels of 2 and 3 mg, and at 3 mg all subjects had anovulatory cycles. Although both combined preparations (2 mg and 3 mg drospirenone/30 μg ethinylestradiol) inhibited the hypothalamic–pituitary–ovarian axis, follicular maturation leading to escape ovulation was observed in three subjects in the 2 mg drospirenone/30 μg ethinylestradiol group. Only one of these ovulations was considered to be definitely the result of treatment failure. All cycles in the 3 mg drospirenone/30 μg ethinylestradiol group were anovulatory. No statistically significant difference was found between treatment groups.Conclusion The combination of 3 mg drospirenone/30 μg ethinylestradiol (Yasmin ®, Schering AG) reliably inhibits ovulation, with a low frequency of follicular maturation, and provides a reasonable safety margin.

Cervical Dimensions and Risk of Preterm Birth

In Brief Objective To examine the relation between cervical dilatation and length and the risk of spontaneous preterm birth, including its subtypes preterm labor and preterm premature rupture of membranes (PROM). Methods Cervical dimensions assessed by clinical examination were recorded prospectively at 24–29 weeks' gestation in 871 subjects with singleton pregnancies who were followed to delivery. Relative risks (RRs) of preterm birth, preterm labor, and preterm PROM were calculated for clinically distinguishable categories of cervical dilatation and length and for cervical score (length minus dilatation). Regression analysis was used to adjust for confounding. Time to delivery from baseline examination was summarized using survival analysis. Results There were 73 spontaneous preterm births (8.3%), 46 preterm labors and 27 cases of preterm PROM. All cervical measurements were associated with increased risks of preterm birth, with increasing abnormality more strongly predictive of risk. The adjusted RR for preterm birth with dilatation of at least 0.5 cm was 2.9 (95% confidence interval [CI] 1.2, 7.3); for length of 1.5 cm or less, the RR was 2.1 (95% CI 1.0, 4.5), and for cervical score less than 2.0, the RR was 2.8 (95% CI 1.4, 5.6). The association with cervical measurements was stronger for preterm PROM than for preterm labor, although precision was limited. These measurements had high specificity (93–99%) and low sensitivity (8–20%) for predicting preterm birth. Conclusion In asymptomatic women at 24–29 weeks' gestation, greater cervical dilatation and shorter length were associated with increased risk of spontaneous preterm delivery, particularly preterm PROM. Greater cervical dilatation and shorter length are associated with increased risk of spontaneous preterm delivery, particularly after preterm premature rupture of membranes.

Cervical dimensions and risk of preterm birth: a prospective cohort study

Objective: To examine the relation between cervical dilatation and length and the risk of spontaneous preterm birth, including its subtypes preterm labor and preterm premature rupture of membranes (PROM). Methods: Cervical dimensions assessed by clinical examination were recorded prospectively at 24–29 weeks’ gestation in 871 subjects with singleton pregnancies who were followed to delivery. Relative risks (RRs) of preterm birth, preterm labor, and preterm PROM were calculated for clinically distinguishable categories of cervical dilatation and length and for cervical score (length minus dilatation). Regression analysis was used to adjust for confounding. Time to delivery from baseline examination was summarized using survival analysis. Results: There were 73 spontaneous preterm births (8.3%), 46 preterm labors and 27 cases of preterm PROM. All cervical measurements were associated with increased risks of preterm birth, with increasing abnormality more strongly predictive of risk. The adjusted RR for preterm birth with dilatation of at least 0.5 cm was 2.9 (95% confidence interval [CI] 1.2, 7.3); for length of 1.5 cm or less, the RR was 2.1 (95% CI 1.0, 4.5), and for cervical score less than 2.0, the RR was 2.8 (95% CI 1.4, 5.6). The association with cervical measurements was stronger for preterm PROM than for preterm labor, although precision was limited. These measurements had high specificity (93–99%) and low sensitivity (8–20%) for predicting preterm birth. Conclusion: In asymptomatic women at 24–29 weeks’ gestation, greater cervical dilatation and shorter length were associated with increased risk of spontaneous preterm delivery, particularly preterm PROM.

COMPARISON OF INTRACERVICAL PROSTAGLANDIN E2 AND INTRAVENOUS OXYTOCIN IN INDUCTION OF LABOUR

154 patients requiring induction with unfavourable cervix at varying period of gestation were studied. Patients were distributed into two groups. 76 patients were induced with 0.5 mgm single dose intracervical application of Prostaglandin E2 gel and remaining 78 patients with Oxytocin and efficacy of the two methods of induction was compared. Labour was established within 24 hours in 71.4% of primigravidas and 91.7% of multigravidas in the prostaglandin treated group compared to 65.6% of primigravidas and 89.1% of multigravidas in the oxytocin group. The study found substantial improvement in cervical score 12 hours after application of intracervical prostaglandin E2 gel and decrease in Caesarean section rate with no major adverse effect to mother or neonate.

Cervical fetal fibronectin correlates to prostaglandin E 2–induced cervical ripening and can be identified in cervical tissue

OBJECTIVE: Our purpose was to investigate whether prostaglandin E 2–induced cervical ripening can be related to changes in fetal fibronectin levels and whether fetal fibronectin can be detected by immunohistochemistry in amniotic and cervical tissue. STUDY DESIGN: Fetal fibronectin levels in cervical mucus were quantitated in 28 nulliparous term pregnant women with unfavorable cervical states before and after intracervical application of prostaglandin E 2 gel. The concentration of fetal fibronectin was determined with use of an enzyme immunoassay. Cervical biopsy specimens and amniotic tissue for immunohistochemical analysis were obtained from three term pregnant women and after parturition in three women. Cervical biopsy specimens from two nonpregnant women served as controls. Immunohistochemical analysis was performed with antibodies directed toward fetal fibronectin. RESULTS: The fetal fibronectin level in cervical mucus was low in all women before prostaglandin E 2 application. In women with a successful prostaglandin E 2–induced ripening (i.e., an increase of cervical score with ?3 points), a tenfold increase in the fetal fibronectin level was registered. In women with an insufficient cervical ripening after prostaglandin E 2 treatment no significant increase in the fetal fibronectin level was registered. The immunohistochemical analyses have identified fetal fibronectin in the epithelial cells of the cervix uteri. CONCLUSION: Successful prostaglandin E 2–induced cervical ripening seems to be related to a significant increase in cervical fetal fibronectin levels. Fetal fibronectin can be detected immunohistochemically in the pregnant human cervix. (Am J Obstet Gynecol 1998;178:540-5.)

Extraamniotic saline infusion is promising in preparing the cervix for induction of labor

The application of local prostaglandins before induction of labor in women with an unripe cervix is standard procedure in Sweden. Side effects include uterine hypertonus and occasionally fetal heart rate abnormalities. Failed ripening is reported in up to 25% of cases. A previous report of ripening of the cervix by use of extraamniotic physiologic saline infusion through a Foley catheter applied in the cervix claimed results superior to topical prostaglandins. To conduct a prospective randomized trial of extraamniotic saline infusion and intracervical application of dinoprost 0.5 mg on cervical ripening and outcome of labor. Eighty-five term singleton pregnant women with unripe cervices where induction of labor was indicated were randomized to prostaglandin or saline infusion after obtaining informed consent. Outcome variables were improvement of cervical score, induction delivery time and mode of delivery. The 42 women in the saline infusion group obtained significantly (p < or = 0.001) higher cervical scores and shorter induction delivery intervals (p < or = 0.005) than the 43 women in the prostaglandin group. Cases of unripe cervix after 24 hours were significantly (p < or = 0.01) fewer in the saline group. There were more Cesarean sections in the saline group, but this difference was not significant. Saline infusion did not induce uterine activity and oxytocin was given in every case after the expulsion of the catheter. In this study extraamniotic saline infusion was a more efficacious method for ripening of the cervix than intracervical prostaglandin. The absence of early painful contractions is an advantage, but effective stimulation of labor is required to effect delivery after maturation of the cervix.

Cervical Ripening With Prostaglandin Gel andHygroscopic Dilators

Objective: To study the effectiveness and morbidity of adding hygroscopic cervical dilators to prostaglandin gel for cervical ripening and labor induction.Study design: Patients of at least 34 weeks’ gestation with a medical indication for induction of labor and with a modified Bishop score of 5 or less were randomized to receive either prostaglandin gel or prostaglandin gel with hygroscopic cervical dilators. Primary outcomes were time to delivery, change in cervical score, and infection. Secondary outcomes included cesarean delivery rate and deliveries before 24 hours of induction. Continuous variables were analyzed by Wilcoxon sum rank test and categorical data by chi‐square or Fisher exact test, with P &lt; 0.05 being significant.Results: Seventeen patients were randomized to intracervical prostaglandin alone and 23 patients received intracervical prostaglandin plus hygroscopic dilators. No demographic differences were noted between the groups. After six hours of ripening, the combined group achieved a greater change in Bishop score (3.6 vs. 2.1, P = 0.007) and tended to have a shorter induction time (21.7 vs. 26.4 hours, P = 0.085). The combined therapy group had a higher infection rate than the prostaglandin‐only group (59% vs. 12%, P = 0.003).Conclusion: Combining cervical dilators with prostaglandin gel provides more effective cervical ripening and a more rapid induction to delivery interval than prostaglandin alone but with a significant and prohibitive rate of infection.

The value of the cervical score in predicting successful outcome of labor induction

To compare cervical dilation and the Bishop score as correlates of successful labor induction and vaginal delivery and to determine whether the prognosis of post-ripening cervical characteristics varies with the method of ripening used. Four hundred forty-three women with Bishop scores less than 9 who required induction of labor were assigned randomly to cervical ripening with prostaglandin E2 gel or hygroscopic dilation. The Bishop score and its component characteristics were evaluated as univariate correlates of successful induction of labor and vaginal delivery and then were assessed using logistic regression to adjust for other maternal and fetal factors. The differences in the association between method of ripening and successful labor induction were evaluated relative to pre-ripening and post-ripening cervical examination characteristics. Cervical dilation was a better correlate of successful labor induction and vaginal delivery than was the Bishop score, even after exclusion of patients with initial Bishop scores greater than 6 and dilation greater than 3.0. Both ripening methods yielded similar success in labor induction and vaginal delivery, but when categorized by post-ripening cervical examinations, patients undergoing hygroscopic ripening had lower rates of successful labor induction and vaginal delivery. Cervical dilation is a better predictor of successful labor induction and vaginal delivery than either the Bishop score or any other Bishop score component characteristic. The likelihood of successful labor induction and vaginal delivery based on post-ripening cervical characteristics varies by the ripening method used.

Comparison of Endometrial Biopsy, Cervical Mucus Score and Incidence of Unruptured Follicle Syndrome Between Infertile Women on Clomiphene Citrate and in Natural Cycles

Comparison of Endometrial Biopsy, Cervical Mucus Score and Incidence of Unruptured Follicle Syndrome Between Infertile Women on Clomiphene Citrate and in Natural Cycles

Rapid fetal fibronectin swab-test in preterm labor patients treated by betamimetics

Objective: A preliminary study to examine the value of a rapid fetal fibronectin swab-test used as a bedside test in the prognosis of preterm labor. Study design: Women presenting with preterm labor and intact membranes and less than 3 cm dilated were enrolled in a single referal center. Cervicovaginal swabs were assessed for the presence or absence of fetal fibronectin by means of a rapid monoclonal antibody assay the positivity of which was revealed by a colorimetric reaction. Results were compared with uterine contractions frequency, Bishop cervical score, duration of tocolysis and interval to delivery. The predictive value of fetal fibronectin test for delivery within 7, 14 or 21 days from sampling and before 32 and 37 weeks' of gestation was assessed in the two groups. Results: Among 124 eligible patients, 19 presented with a positive fibronectin test and 105 with a negative one. Gestational age at sampling. Bishop cervical score and duration of tocolysis were identical in the two groups. The number of contractions was significantly lower and gestational age at delivery was significantly higher in the fibronectin negative group. Fetal fibronectin in cervicovaginal secretions has a high sensitivity (89%) for delivery within 7 days. Absence of fetal fibronectin in cervicovaginal secretions of patients presenting with uterine contractions could rule out preterm labor within 7 and 14 days with a predictive value of 99 and 95.2%, respectively. In negative fetal fibronectin patients, preterm delivery before 32 and 37 weeks' is unlikely to occur with a predictive value of 97 and 85%, respectively. Conclusion: Cervicovaginal fetal fibronectin detected by a rapid bedside swab-test in women with symptoms of preterm labor compares favourably with quantitative assays and could prove useful in the management of preterm labor. This should be confirmed in a longer prospective study.

Correlation of antepartum uterine activity and cervical change in twin gestation.

To determine the correlation between quantitative measurements of antepartum uterine activity and cervical change twin gestations. Forty women from our Twin Clinic constituted the study group. Participants had a cervical examination each week between 20 and 37 weeks gestation and a cervical score (CS) was calculated as follows: CS = cervical length (cms)-cervical dilation (cms) at the internal os. The women also performed blinded home uterine activity monitoring (HUAM) for a mean of 7.0 + 3.0 hrs/wk (+SD). Uterine activity was expressed as mean number of contractions/hour/week gestation based on the average of three independent reviewers. CS was determined by a single clinician unaware of the HUAM recordings. A significant change in the CS was defined as a reduction of at least 0.5 from the preceding week. Correlation coefficients were used to determine the association between uterine activity and change in the cervical score. Twin pregnancy was characterized by a rise from 0.2 + .03 contractions/hr at 20 weeks to 3.2 + 2.4 contractions/hr at 37 weeks gestation. CS fell from a mean of 2.6 + 0.2 at 20 weeks to -2.1 + 0.9 at 37 weeks gestation. There was a significant negative correlation (-0.317, p < .0001) between increasing uterine activity and decreasing CS. There were significantly more (p < .002) contractions during the 7 days preceding a significant reduction in CS (3.3 + 3.5 contractions/hr) than when the CS was unchanged (1.6 +/- 1.5 contractions/hr). In twin gestations, an increasing frequency of uterine contractions is strongly correlated with quantifiable cervical change between 20-37 weeks gestation. Persistent daytime contraction frequencies of > 3/hr represent a risk factor for cervical dilation and/or effacement.

Prostaglandin-induced labor--is the prostaglandin E2 vaginal gel a "new" alternative?

In Germany, intracervical application of 0.5 mg PGE2 gel and the 3 mg PGE2 vaginal tablet are registered for induction of labour. Both methods are highly effective; however, the are associated with several problems in practice. Major problems of the intracervical route are the strict application of the gel into the cervical canal, not spreading it to the vaginal and/or extra-amniotic space, the "technical" difficulties of application in cases of an unfavourable cervix in a posterior position and the risk of artificial rupture of the membranes. The problems with the PGE2 vaginal tablet are the incalculable release and absorption, the unpredictable clinical response and the unclear definition of CTG monitoring intervals. The application of the 2 mg PGE2 vaginal gel has proved an efficient and practicable method for induction of labour in both the unfavourable and the favourable cervix. The advantages over the intracervical procedure are in particular the practicability and safety of administration, even in "anatomically" difficult situations (e.g., narrow cervical canal); the advantages over the PGE2 vaginal tablet are greater bioavailability with a quicker release and absorption, the more predictable clinical response and the closer correlation with the subsequent changes in cervical scores. Since well-defined comparative studies are lacking, no definite conclusions can so far be drawn regarding the method of choice for induction of labour. Recently, a prospective, randomised multi-centre study has gone under way to clarify this question.

Ripening of the Unfavorable Cervix With Extraamniotic Catheter Balloon

The use of an extraamniotic catheter balloon, inflated above the internal cervical os, has been advocated as a nonpharmacological, mechanical method of cervical ripening before induction of labor. Additional measures may include applying traction on the catheter, or the infusion of normal saline (1 ml/min) via the catheter's port into the extraamniotic space. The results of catheter balloon cervical ripening are reviewed from 13 published reports and a departmental series of 190 pregnancies with unfavorable cervix, encompassing nearly 1000 patients. A mean change in cervical score of at least 3 points, was noted in most studies after balloon expulsion or removal. The present series and other studies suggest that oxytocin use for induction and/or augmentation of labor is increased after balloon ripening, compared with its use in spontaneous labor or after cervical ripening by prostaglandins. In 11 studies, catheter balloon ripening was compared with cervical ripening by other mechanical, or pharmacological (i.e., oxytocin or prostaglandins) methods. Of these, eight were prospective and randomized-controlled and three were case-controlled studies. It is suggested that ripening efficacy by catheter balloon is similar, or better, than other methods; but there is no significant difference in the mode of delivery or perinatal outcome. This review also suggests that cervical ripening with extraamniotic catheter balloon has the advantages of simplicity, low cost, reversibility, and lack of systemic or serious side effects.

Cervical priming with oral misoprostol in pre-labor rupture of membranes at term

To investigate the effectiveness of oral misoprostol as a cervical priming agent for patients presenting with pre-labor rupture of membranes at term. Eighty patients presenting with pre-labor rupture of membranes at term were randomized to receive either 200 micrograms of misoprostol or 50 mg of vitamin B6 orally 1 hour after admission. Labor was induced with intravenous oxytocin infusion 12 hours after oral medication if the patient did not go into labor. We compared the induction rate, duration of labor, mode of delivery, and leaking-to-delivery interval in the two groups. The cervical score was significantly improved and the induction rate was also reduced in the misoprostol group when compared with the control group. The interval from recruitment to onset of labor, duration of labor, and the interval from recruitment to delivery were significantly shorter in the misoprostol group. The mode of delivery and the perinatal outcome were similar for the two groups. Oral misoprostol is an effective agent for cervical priming and labor induction in patients with pre-labor rupture of membranes at term.

Unmeasurable relaxin concentrations in repeated pregnancies after embryo transfer

Unmeasurable serum relaxin concentrations were found in repeated serum samples taken during two subsequent pregnancies in a woman pregnant after in vitro fertilization in artificial cycles. Despite the absence of relaxin both pregnancies were carried out normally until term except for symptoms of pelvic girdle relaxation. Labour induction was attempted at term as placental insufficiency was suspected. However, the cervical score remained unfavourable and Cesarian section was performed. In the second pregnancy elective Cesarian section was performed due to mild preeclampsia. This case indicates that relaxin may not be important for either suppression of myometrial activity or pelvic girdle relaxation during human pregnancy.