Two dosing regimens for preinduction cervical priming with intravaginal dinoprostone pessary: a randomised clinical trial

Abstract

Objective To compare the efficacy within 24 hours of a three-times-a-day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming.Design Randomised controlled trial.Setting Department of Obstetrics and Gynaecology, Singapore General Hospital.Participants One hundred singleton term primigravidae with cephalic presentation with unfavourable cervical scores (Bishop score 1 5 ) requiring induction of labour.Methods Eligible women were randomly assigned the standard regimen (3000 pg dinoprostone [Prostin, Upjohn, Crawley, UK] once daily) or an intensive regimen (3000 pg dinoprostone given sequentially three times daily four hours apart) for cervical priming until successful priming (Bishop score of 2 6) or the onset of active labour occurred.Main outcome measures Number of women whose cervices were ripened successfully or who entered active labour within 24 hours of starting cervical priming, priming to induction interval, and priming to delivery interval.Results Forty-nine women were assigned to the standard regimen and 5 1 to the intensive regimen. The median number (range) of dinoprostone pessaries used was two (one to seven) in the standard regimen and three (one to nine) in the intensive regimen. Forty-two women (82.4%) who underwent the intensive regimen achieved successful cervical ripening or active labour within 24 hours, compared with 21 assigned to standard regimen (OR 6-2, 95% CI 2-3-17.4). This difference was statistically significant. The median intervals from priming to induction, and from priming to delivery, were also statistically significantly shorter in women treated with the intensive regimen. Thirty-five women (68.63%) assigned the intensive regimen experienced pain, compared with 21 (42.86%) in the standard regimen (OR 2-92, 95% CI 1.19-7.21), with two and one women in the respective regimens requiring opiate analgesics. Five women with oligohydramnios had transient cardiotocographic abnormalities during priming with the intensive regimen, none of which required immediate intervention, and the babies were born in good condition. There were no cases of uterine hypertonus and the outcomes of labour were similar for women from both regimens.Conclusions Preinduction cervical priming with the intensive dosing regimen improves the chances of successful ripening within 24 hours for primigravidae with unfavourable cervical scores at full term singleton pregnancies, and shortens the interval from priming to induction, and priming to delivery. This regimen may be more cost effective by shortening the period of hospital stay. The overall incidence of adverse reactions to the mother and fetus during priming was low. However, close fetal surveillance must be maintained, particularly in pregnancies complicated with oligohydramnios.

The cost‐effectiveness of outpatient (at home) cervical ripening with isosorbide mononitrate prior to induction of labour

“…Although we were not able to demonstrate overall cost savings attributable to IMN, we did find that women receiving IMN spent less time in the prenatal assessment ward, and this accounted for the largest cost difference between the trial groups. Similar to our findings, another study of women receiving intensive dose vaginal dinoprostone in pre-induction cervical priming has shown shortening of the period of pre-labour hospital stay for women 22 although no cost-effectiveness analysis was performed. Higher doses of IMN administered on an outpatient (at home) basis might have an even greater effect on reducing prenatal assessment ward stay, although this has yet to be investigated.…”

Obstetric outcomes after cervical ripening by multiple doses of vaginal prostaglandin E2

“…Rowlands et al also reported recently that 66% of women had their cervix successful ripen by one dose of dinoprostone (5). On the contrary, Tan and Tay found that only 42% of women achieved a favorable cervical score after a single dose of vaginal prostaglandin E 2 (4). This is probably because of the difference in the initial cervical score before ripening.…”

“…When the cervix is unripe, induction is more likely to be successful if vaginal prostaglandin E 2 is used for cervical priming rather than induction by amniotomy and intravenous oxytocin infusion alone (3). However, only 40–66% of primiparous women with unfavorable cervical status had their cervices ripened successfully by a single dose of vaginal prostaglandin E 2 (4,5). Although repeated doses of prostaglandin are commonly administered in these circumstances, the value of using multiple doses of prostaglandin for cervical ripening remains controversial, as does the maximal number of doses (4,6).…”

“…However, only 40–66% of primiparous women with unfavorable cervical status had their cervices ripened successfully by a single dose of vaginal prostaglandin E 2 (4,5). Although repeated doses of prostaglandin are commonly administered in these circumstances, the value of using multiple doses of prostaglandin for cervical ripening remains controversial, as does the maximal number of doses (4,6). In this study, we evaluated the risk and indication of emergency cesarean section in women who had undergone labor induction after different doses of vaginal prostaglandin E 2 for cervical priming.…”

The association between repeated doses of vaginal PGE2 (Dinoprostone, Prostin®) and both maternal and neonatal outcomes among women in the north of Jordan

“…However, vaginal prostaglandin E2 (Dinoprostone, Prostin®) [4,5] has been used extensively as the preferred way for induction by most specialized institutions and is considered to be the safest option for the mother and neonate as well as the most effective one to induce vaginal delivery within 24 hours for women with an unfavorable cervix [6][7][8][9][10][11]. However, there is no full agreement on the ideal dosage of PGE2 that should be used to achieve the optimal outcome [12][13][14]. Moreover, there is much de-bate concerning the frequency of PGE2 use, whether there are different regimens for multiparous women [15], and at what point induction of labor has failed and that a cesarean section should be the exclusive and definitive mode of delivery.…”