Abstract
Prostaglandins are a widely used method of labor induction. Individual studies have compared different prostaglandins, dosages, and routes of treatment, but there have not been single studies that have compared them all simultaneously. The current study uses network meta-analysis to compare multiple prostaglandins as well as dosages and route of treatment to estimate which treatment is best for a range of obstetric outcomes. A search of the Cochrane Pregnancy and Childbirth Group's Database of Trials was used to find eligible trials. To be eligible, trials had to be randomized clinical trials comparing a prostaglandin or prostaglandin analog versus a placebo or different prostaglandin, or comparing 2 different forms or doses of 1 prostaglandin, specifically examining the impact on labor induction or cervical ripening in the third trimester. Only trials exclusively studying women with a viable fetus were included. The 12 types of prostaglandin or prostaglandin analog included were intracervical prostaglandin E2; vaginal misoprostol tablet or sustained-release pessary; oral misoprostol tablet; vaginal prostaglandin E2 as tablets, gel, pessary, or sustained-release pessary; prostaglandin F2a gel; and oral misoprostol solution. Outcomes included serious maternal morbidity or death, serious neonatal morbidity or perinatal death, vaginal delivery not achieved within 24 hours, uterine hyperstimulation with fetal heart rate changes, and cesarean delivery.
Two hundred eighty studies were included in the review: 94 were available for the outcome of vaginal delivery not achieved within 24 hours, 269 for cesarean delivery, and 129 for uterine hyperstimulation with fetal heart changes. Not enough trials reported neonatal or maternal mortality or serious morbidity outcomes, despite the inclusion of any definitions of those outcomes. Only data for perinatal and maternal death were included in the analysis, with 51 of the 280 trials reporting perinatal death with an incidence of 0.2% and 18 reporting 4 maternal deaths.
For vaginal delivery within 24 hours, vaginal misoprostol tablet 50 μg or greater was found to be the best with a probability of 53% of being the best option. This treatment had a 97% probability of top 3 ranking, and titrated oral misoprostol solution had a 73% probability of being ranked in the top 3. For cesarean delivery, titrated oral misoprostol solution was found to have the lowest rate with a 70% probability of ranking as the best. Oral misoprostol tablet had a probability of 66% of being ranked in the top 3. Robust network analysis estimates or rankings were not reported for the outcome of uterine hyperstimulation with fetal heart changes because of inconsistency. The only 2 comparisons to reach significance found vaginal misoprostol 50 μg or greater was associated with a 4-fold increase in the likelihood of uterine hyperstimulation than intracervical prostaglandin E2 (odds ratio, 3.57; 95% credible interval, 1.66–8.06) and that compared with slow-release vaginal prostaglandin E2 vaginal misoprostol 50 μg or greater was associated with a nearly 3-fold increase in the odds of hyperstimulation.
The network meta-analysis found misoprostol to likely be superior to dinoprostone for labor induction. Informally combining vaginal delivery within 24 hours and cesarean delivery, the best ranked treatment would likely be oral misoprostol solution of less than 50 μg followed by high-dose misoprostol vaginal tablets and low-dose vaginal misoprostol tablets. Vaginal misoprostol tablets (≥50 μg) are best for vaginal delivery within 24 hours, and titrated low-dose oral solution appears to be best for cesarean delivery safety.
Two hundred eighty studies were included in the review: 94 were available for the outcome of vaginal delivery not achieved within 24 hours, 269 for cesarean delivery, and 129 for uterine hyperstimulation with fetal heart changes. Not enough trials reported neonatal or maternal mortality or serious morbidity outcomes, despite the inclusion of any definitions of those outcomes. Only data for perinatal and maternal death were included in the analysis, with 51 of the 280 trials reporting perinatal death with an incidence of 0.2% and 18 reporting 4 maternal deaths.
For vaginal delivery within 24 hours, vaginal misoprostol tablet 50 μg or greater was found to be the best with a probability of 53% of being the best option. This treatment had a 97% probability of top 3 ranking, and titrated oral misoprostol solution had a 73% probability of being ranked in the top 3. For cesarean delivery, titrated oral misoprostol solution was found to have the lowest rate with a 70% probability of ranking as the best. Oral misoprostol tablet had a probability of 66% of being ranked in the top 3. Robust network analysis estimates or rankings were not reported for the outcome of uterine hyperstimulation with fetal heart changes because of inconsistency. The only 2 comparisons to reach significance found vaginal misoprostol 50 μg or greater was associated with a 4-fold increase in the likelihood of uterine hyperstimulation than intracervical prostaglandin E2 (odds ratio, 3.57; 95% credible interval, 1.66–8.06) and that compared with slow-release vaginal prostaglandin E2 vaginal misoprostol 50 μg or greater was associated with a nearly 3-fold increase in the odds of hyperstimulation.
The network meta-analysis found misoprostol to likely be superior to dinoprostone for labor induction. Informally combining vaginal delivery within 24 hours and cesarean delivery, the best ranked treatment would likely be oral misoprostol solution of less than 50 μg followed by high-dose misoprostol vaginal tablets and low-dose vaginal misoprostol tablets. Vaginal misoprostol tablets (≥50 μg) are best for vaginal delivery within 24 hours, and titrated low-dose oral solution appears to be best for cesarean delivery safety.
Original language | English |
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Pages (from-to) | 371-373 |
Number of pages | 3 |
Journal | Obstetrical and Gynecological Survey |
Volume | 70 |
Issue number | 6 |
DOIs | |
Publication status | Published - 17 Jun 2015 |