Several mailings have come in to the [log in to unmask] mailing list
concerning this drug. As none of them seemed to be copied to Midwifery
Research or Professional Midwife mailing lists, and as use of the drug seems
to be more widespread than we had previously thought, I thought the authors
would not object to their mailings being forwarded for wider dissemination
of information.

I have withheld the names and email addresses, but I will forward any
messages to the authors.

Message 1.

I recently worked an agency shift at a hospital in Essex to discover that
they are using Misoprostol for induction of labour. I was unaware that we
had started using it for such purposes in the UK, although I knew that
there
was an RCT a while back looking at the effectiveness for third stage. I
have
read some pretty damning stuff about Misoprostol from the States and was
therefore quite shocked to find it being introduced. I do not think that it
is licensed for use in this country for these purposes. Does anyone know if
that is the case. The midwife who was about to administer it had to break a
tablet in half because it is not marketed for the dosage required for
induction which leads me to doubt that it is licensed.

I would be interested to know how prevalent the use of the drug is here, and
I would appreciate your comments.

Message 2

I thought that Misoprostol was only used in some circumstances to induce
labour
in ladies who had an IUD.....am I wrong? (as I am still a student I might
well
be wrong!)

When I had my son in Holland 4 years ago I had to be induced and was induced
with tablets...first one, then an hour later two then an hour later three
and
then 3 all the other times...at the time I knew nothing about pregnancy
labour
etc, do you think it is possible I was given Misoprostol?

Message 3

In Liverpool we have been Misopristol for cervical ripening /IOL
but as part of research trial ...Will find out more but so far it seems
to be seen as the 'gentle' alternative to Syntocinon
Dose is very gradually increased according to response.
thanks for raising the issue .it'll make me find out !
let you know

Message 4

I said it was percieved as not that it was !
The trial at Liverpool has finished the results will be available next week

Message 5

Hi! Misoprostol is not a "gentle" variation of Syntocinon. Marsden Wagner
gave a presentation at the last Midwifery Today conference pointing out that
this drug produces vicious contractions and in America there has been a
spate
of ruptured uterii and maternal deaths (not to mention infant deaths).
Midwifery Today has tape recordings of this conference and they may well
have
one of Mardy's talk. He is very angry about this drug and may well have
some
useful information. Midwifery Today subscribes to this list (I think) and
they may also have Mardy's email number. Unfortunately, my email crashed a
month ago and wiped my address list. (Fax: 0045-33337760).

Message 6

I am a midwife (fairly newly qualified) working at the
John Radcliffe Hospital in Oxford. After nearly a
year's break from midwifery I'm really enjoying the
opportunity to work as a midwife doing "family
friendly" hours. The John Radcliffe's attitude to
single parents is a breath of fresh air compared to
other Trusts "if you can't hack the hours then we
can't employ you" attitude!

There is a trial running in our hospital called the
COREC trial. It is a prospective randomized study
comparing current induction methods using Prostin with
misoprostol.

There are 3 randomized treatment groups:

a) misoprostol 50 micrograms (quarter of a Cytotec
tablet) in the evening. If not in labour in the
morning then ARM and synto.

b) same as above but if not in labour in the morning
and with a Bishops score of less than 8, another dose
of misoprostol and 6 hours later (if necessary) ARM &
synto.

c) Prostin 2mg gel in the evening, if not in labour in
the morning, ARM & synto.

The study has only been running since October so I
guess it'll be some time before there are any results.

The info. given to us midwives states:

"Present publications suggest that misoprostol is safe
to use, the induction to delivery interval is reduced
by a third but uterine hyperstimulation might be more
frequent. Furthermore, misoprostol is much less
expensive than PGE2 therefore significant savings can
be made".

The research midwife is Heather Bower and she can be
contacted on 01865 220405.

I'm not sure exactly what they're looking at - it'll
be a missed opportunity if they don't record severity
of contractions, use of pain relief and women's
opinions.

I havn't come across the midwife involved as I'm new
in the hospital, but if I meet her I'll ask for more
details & let you have them.

Message 7

The following abstracts on the use of this drug came up while I was
searching for VBAC information - hope they help.

Angela Horn

*************
Obstet Gynecol 1998 May;91(5 Pt 2):828-30 Related Articles, Books

Disruption of prior uterine incision following misoprostol for labor
induction in women with previous cesarean delivery.

Wing DA, Lovett K, Paul RH

Department of Obstetrics-Gynecology, University of Southern California
School of Medicine, Los Angeles, USA. [log in to unmask]

BACKGROUND: Although induction of labor in women with prior cesareans is
controversial, we compared misoprostol to oxytocin in such women in a
randomized trial. The investigation was terminated prematurely because of
safety concerns. CASES: Disruption of the prior uterine incision was found
in two of 17 misoprostol-treated women. The first woman underwent repeat
cesarean delivery at 42 weeks because of fetal tachycardia and repetitive
late decelerations. A 10-cm vertical rent in the anterior myometrium was
discovered. The second woman underwent induction for fetal growth
restriction. Loss of fetal heart tones and abnormal abdominal contour
prompted emergent cesarean for suspected uterine rupture. An 8-cm
longitudinal uterine defect was found. CONCLUSION: When misoprostol is used
in women with previous cesareans, there is a high frequency of disruption of
prior uterine incisions.
**************

Aust N Z J Obstet Gynaecol 1998 Feb;38(1):96-7

Uterine rupture during preinduction cervical ripening with misoprostol in a
patient with a previous Caesarean delivery.

Sciscione AC, Nguyen L, Manley JS, Shlossman PA, Colmorgen GH

Department of Obstetrics and Gynecology, Medical Center of Delaware, Newark,
USA.

We report a case of uterine rupture in a patient with a previous low
transverse Caesarean delivery, in which transvaginal misoprostol was used
for preinduction cervical ripening.
****************

Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1551-9

Comparison of the safety and efficacy of intravaginal misoprostol
(prostaglandin E1) with those of dinoprostone (prostaglandin E2) for
cervical ripening and induction of labor in a community hospital.

Blanchette HA, Nayak S, Erasmus S

MetroWest Medical Center, Department of Obstetrics and Gynecology, British
Columbia, Canada.

OBJECTIVE: This clinical trial evaluated the efficacy of intravaginal
misoprostol (prostaglandin E1) and compared it with that of dinoprostone
(prostaglandin E2) for cervical ripening and induction of labor in a
community hospital. STUDY DESIGN: This study involved a retrospective
analysis of 81 patients undergoing cervical ripening and induction of labor
with prostaglandin E2 from May 1, 1996, to May 1, 1997. A comparison
prospective analysis of 145 patients undergoing the same procedure with
prostaglandin E1 from May 1, 1997 to May 1, 1998, was performed. RESULTS:
The mean time to delivery was significantly shorter with misoprostol (19.8
+/- 10.4 hours) than with prostaglandin E2 (31.3 +/- 13.0 hours, P <.001).
Delivery within 24 hours of induction was significantly more frequent with
misoprostol (71.9% of subjects vs 31.3%, P <.001). There was no difference
in the cesarean delivery rate with misoprostol (25.6% vs 22.2%, P <.67). The
incidence of uterine hyperstimulation was higher with prostaglandin E2 (7.4%
vs 0.7%, P <.007). There were no uterine ruptures with prostaglandin E2.
There were 2 uterine ruptures and 1 dehiscence with prostaglandin E1 in 3
patients with previous cesarean deliveries and 1 rupture in a patient
without a history of uterine scarring. There was no difference in neonatal
outcome, with the exception of a fetal death related to uterine rupture in
the misoprostol group. CONCLUSIONS: Compared with prostaglandin E2,
misoprostol is more effective in cervical ripening and induction of labor,
is as safe for patients who do not have a history of cesarean birth, may
carry a higher incidence of uterine rupture, and should not be used for
patients attempting vaginal birth after previous cesarean delivery.

************
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1535-42

Uterine rupture associated with the use of misoprostol in the gravid patient
with a previous cesarean section.

Plaut MM, Schwartz ML, Lubarsky SL

Department of Obstetrics, Northwest Permanente PC, British Columbia, Canada.

OBJECTIVE: Our purpose is to report our experience with uterine rupture in
patients undergoing a trial of labor after previous cesarean delivery in
which labor was induced with misoprostol. The literature on the use of
misoprostol in the setting of previous cesarean section is reviewed. STUDY
DESIGN: This report was based on case reports, a computerized search of
medical records, and literature review. RESULTS: Uterine rupture occurred in
5 of 89 patients with previous cesarean delivery who had labor induced with
misoprostol. The uterine rupture rate for patients attempting vaginal birth
after cesarean section was significantly higher in those who received
misoprostol, 5.6%, than in those who did not, 0.2% (1/423, P =.0001). Review
of the literature reveals insufficient data to support the use of
misoprostol in the patient with a previous cesarean delivery. CONCLUSION:
Misoprostol may increase the risk of uterine rupture in the patient with a
scarred uterus. Carefully controlled studies of the risks and benefits of
misoprostol are necessary before its widespread use in this setting.



From: Ishbel Kargar SRN SCM (retired)
Admin. Secretary
Association of Radical Midwives
62 Greetby Hill, Ormskirk, L39 2DT

Personal: [log in to unmask]
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