• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
Grand Rounds

Mechanical and Misoprostol Ripening vs Misoprostol Alone

image_pdfFavoriteLoadingFavorite

BACKGROUND AND PURPOSE:

  • Nasioudis et al. (AJOG MFM, 2019) assessed the efficacy and safety of combined methods of cervical ripening vs misoprostol only

METHODS:

  • Systematic review and meta-analysis
  • Data sources
    • Medline, EMBASE, and Web-of-Science electronic databases (through to December, 2018)
  • Study inclusion criteria
    • RCTs
    • Singleton, viable fetus
    • IOL that required cervical ripening (Bishop ≤7)
      • (1) Single balloon Foley catheter combined with misoprostol (any dose or route) or (2) misoprostol only
  • Data synthesis and analysis
    • Data pooled using random effects and fixed effects model
    • Bias criteria based on Cochrane Handbook for Systematic Reviews of Interventions
  • Primary outcomes
    • Time to delivery
    • Rate of cesarean delivery

RESULTS:

  • 11 trials | 922 subjects in the combination group | 947 patients in the misoprostol-only group
    • Majority of misoprostol was administered via vaginal route
  • There was no difference in the rate of cesarean delivery between the 2 groups
    • Relative risk (RR): 0.95 (95% CI, 0.80 to 1.13)
  • Combination of mechanical dilation and misoprostol resulted in
    • Shorter time to delivery
      • Mean difference: –3.65 hours (95% CI, 5.23 to –2.07)
    • Shorter time to vaginal delivery
      • Mean difference: –4.53 hours (95% CI, –5.79 to –3.27)
    • Lower risk of NICU admission
      • RR: 0.71 (95% CI, 0.53 to 0.96)
    • Meconium-stained fluid
      • RR: 0.62 (95% CI, 0.43 to 0.90)
    • Tachysystole with fetal heart trace changes
      • RR: 0.53 (95% CI, 0.30 to 0.94)
    • Terbutaline use
      • RR: 0.63 (95% CI, 0.47 to 0.85)
  • Exclusion of preterm patients led to a greater benefit using combination with respect to NICU admission
    • RR: 0.61 (95% CI, 0.40 to 0.93)
  • Risk of endometritis and chorioamnionitis was similar between groups
    • Endometritis: RR 1.07 (95% CI, 0.43 to 2.61)
    • Chorioamnionitis: RR 1.58 (95% CI, 0.88 to 2.84)

CONCLUSION:

  • Misoprostol use with mechanical dilation is safe and effective and compared to misoprostol alone is associated with
    • Shorter delivery time | No difference in cesarean rates | Decreased NICU admission rates
  • AJOG MFM Editor’s Note

This is a practice-changing manuscript, if you have not changed your practice yet in terms of using a double-agent for cervical ripening to start induction of labor.

Using either balloon alone, or misoprostol alone, unless one of the agents is either not insertable or contraindicated, seems now like substandard care given these data.

If misoprostol is contraindicated, a balloon and oxytocin ‘double-agent’ combination can be used instead.

Learn More – Primary Sources:

Maternal and neonatal outcomes with mechanical cervical dilation plus misoprostol compared to misoprostol alone for cervical ripening; a systematic review of literature and metaanalysis

Now You Can Get ObG Clinical Research Summaries Direct to Your Phone, with ObGFirst

Learn More  »

image_pdfFavoriteLoadingFavorite
< Previous
All Grand Rounds Posts
Next >

Related ObG Topics:

What is the Best Labor Induction Method for Multiparous Women?
Double-Balloon Catheter or Prostaglandin E2 for Cervical Ripening
Cochrane Review 2017: Outpatient Cervical Ripening and Labor Induction

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

Are you an
ObG Insider?

Get specially curated clinical summaries delivered to your inbox every week for free

  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Get Guideline Alerts Direct to Your Phone
Try ObGFirst Free!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site