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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] ARM: [log in to unmask] Mailing list: [log in to unmask] Please visit our website: www.midwifery.org.uk %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%