JOURNAL READING

Oral or Vaginal Misoprostol for Labor Induction

and Cesarean Delivery Risk: a Cohort Study
Presented by:
1.Aditya Sadewa
2.Angel Chen
3.Arief Budiman
4.Doni Damora SUPERVISORS:
5.Mardhiyatul Aflah  dr. Sri Wahyu Maryuni, Sp.OG (K)
 dr. Dafnil Akhir Putra, Sp.OG
6.Nurul Humairah Arfiza
7.Nurul Ulya Rahim
8.Sonia Dinda Paramitha
9.Yulfhita Wahyu Rinaldi
Objectives
ABSTRACT
To evaluate whether cervical ripening with oral misoprostol increases cesarean delivery risk and
prolongs time to vaginal delivery compared with vaginal misoprostol in a predominantly overweight
population.
Methods
This single center, retrospective cohort study was performed at a tertiary care academic medical center and compared
labor induction outcomes with vaginal misoprostol to outcomes with oral misoprostol after a complete institutional
shift to oral misoprostol. Labor induction using 25 micrograms vaginal misoprostol in 2013–2014 was compared with
50 micrograms oral misoprostol in 2014–2015. The primary outcome was cesarean delivery. Secondary outcomes
included time to vaginal delivery, uterine tachysystole, maternal hemorrhage, and composite adverse neonatal
outcomes. Demographics and outcomes were analyzed using standard statistical tests. Multivariable regression models
accounting for potential confounders were created for the primary and secondary outcomes with adjusted odds ratios
(aOR) as the measures of effect.
Results
There were 138 women in the oral and 138 women in the vaginal misoprostol groups. In the overall cohort, the
median (interquartile range) body mass index was 31.7 (28.2–36.8) and most women (72%) were of either black or
Hispanic race or ethnicity. The frequency of cesarean delivery was higher in the oral than the vaginal misoprostol
group (32% vs 21%; P5.04). The adjusted odds of cesarean was higher with oral misoprostol (aOR 2.01; 95% CI 1.07–
3.76). Among nulliparous women, the frequency of cesarean delivery was 41% in the oral and 28% in the vaginal
misoprostol groups (aOR 2.79; 95% CI 1.26–6.19). Women had a longer time to vaginal delivery in the oral compared
with vaginal misoprostol group (41 vs 31 hours respectively, P5.01). Tachysystole occurredmore frequently with vaginal
misoprostol (20% vs 11%; P5.04).

Conclusions
Compared with vaginal misoprostol, oral misoprostol may be associated with increased risk of
cesarean delivery and longer time to vaginal delivery.
Introduction
According to the National Center for Health Statistics data from
2017, 25.7% of gravid women underwent labor induction, an incr
1 ease from 23% in 2012.

ARRIVE trial, which showed decreased risk for cesarean among

2 nulliparous women undergoing induction compared with expecta

nt management.

3
Misoprostol, a synthetic prostaglandin E1 analog, is a common me
dication used for cervical ripening during labor induction and is ad
ministered in various doses, frequencies, and routes

In 2014, a Cochrane review on the use of orally administered misop

rostol for labor inductions suggested that vaginal misoprostol was l
4 ess effective than oral misoprostol at achieving vaginal birth, with a
n increased risk of uterine tachysystole and cesarean delivery with
vaginal misoprostol.

5
A subgroup analysis of the safest recommended dose of vaginal m
isoprostol (25 micrograms) compared with a commonly used oral
misoprostol dose (50 micrograms)
MATERIALS & METHODS
Insert the title of your subtitle Here
MATERIALS & METHODS

Sampel
Place 276 (138/group)

Design Boston University

women were used
vaginal or oral
Cohort Retrospektif Medical Centre Misoprostol for
cervical ripening

TIME:
2013 - 2015

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INCLUSION & EXCLUSION CRITERIA
INCLUSION
• a live singleton pregnancy
of at least 34 weeks of
gestation
• a documented cervical
examination with dilatation
of 1 cm or less
• initiation of labor induction
with either vaginal
misomisoprostol or oral
misoprostol
EXCLUSION
• they had a prior cesarean
delivery
• if they erroneously received
multiple forms of
misoprostol during their
induction
• if the labor induction was
interrupted as a result of
systems issues such as floor
acuity
Demographics of population
Exclusion for the derivation ofthe
study cohort
Confounding factors
Result
Result
DISCUSSION
 DISCUSSION 1
Our Study
• Oral misoprostol undergoes rapid
absorption from the gastrointestinal
tract and rapid and extensive de-
esterification during first-pass
metabolism to an active metabolite. In
contrast, after vaginal misoprostol
administration, plasma concentrations
gradually increase, reaching a maximum
level after 70–80 minutes before slowly
being eliminated with plasma levels still
detectable 6 hours after administration.
• Compared with vaginal misoprostol,
oral misoprostol may be associated
with increased risk of cesarean delivery
and longer time to vaginal delivery
Other Studied
• A double blind randomized trial
comparing the use of 25
micrograms of vaginal and 50
micrograms of oral misoprostol
showed similar results to our study.
• Shorter labor induction times,
lower cesarean delivery rates, and
fewer required doses of
misoprostol to achieve vaginal
delivery in the vaginal misoprostol
group.
 DISCUSSION 2
Our studied
• The study used design retrospective
cohort to analysis the compare oral and
vaginal misoprostol for labor induction.
There were many potensial bias.
• To address this issue,
charts of women who presented for
induction were assessed in chronologic
order by time of induction and the first
138 women meeting criteria in each
group were included in the study to
limit selection bias. In addition, two
investigators independently screened
the charts to ensure accuracy and
consistency of inclusion.
Other studied
• a randomized trial including a total of
200 women, using similar misoprostol
doses as our study, showed no
significant difference in time to vaginal
delivery between the two groups, and a
lower cesarean delivery rate with oral
misoprostol.
• This study had more women with
hypertensive disease or preeclampsia in
the vaginal (43%) compared with oral
misoprostol group (20%), which may
have confounded the results because
preeclampsia was the main indication
for cesarean delivery in this trial.
 PICO ANALYSIS

PATIENT,
COMPARISON/
POPULATION, INTERVENTION OUTCOME
CONTROL
PROBLEM,
• Women who • There were no •- • There was an
received interventions in the increased risk of
misoprostol on two study groups. caesarean delivery
labor induction at • Data was extracted and prolonged labor
the Boston by inclusion and in a female
University Medical exclusion criteria, population
Center from 2013 to quality assessment (predominantly
2015. tool, and using OR & overweight) induced
• The problem is 95% CI to analyze using oral
change in results misoprostol versus
administration of vaginal misoprostol.
misoprostol from
vaginal
administration to
oral in 2014
Critical Appraisal
Critical Appraisal Skills Programme (CASP) Cohort Study Cecklist 31.05.13
 12 Questionstomake sense of a Cohort Study
Yes No Can’t
No Questions tell
A. Are the result of the study valid ?
1. Did the study address a clearly focused issue? V
2. Was the cohort recruited in an acceptable way? V
3. Was the exposure accurately measured to minimise bias? V
4. Was the outcome accurately meassured to minimise bias? V
5. (a) Have the authors identified all important confounding factors? V

(b) Have they taken account of the confounding factors in the design and/or analysis? V

6. (a) Was the follow up of subjects complete enough? V

(b) Was the follow up of subjects long enough?
B. What are the results?
7. What are the result of this study? V
8. How precise are the results? V
9. Do you believe the results? V
C. Will the results help locally?
10. Can the results of this study fit with other available evidence? V
11. Do the results of this study fit with other available evidence? V
12. What are the implications of this study for practice? V
 CRITICAL APPRAISAL
Did the study address a clearly focused issue?
- According to the National Center for Health Statistics data from 2017, 25.7% of gravid women
underwent labor induction, an increase from 23% in 2012.
. .
- In 2014, a Cochrane review on the use of orally administered misoprostol for labor inductions
suggested that vaginal misoprostol was less effective than oral misoprostol at achieving vaginal birth
- To assess the effect of this change, outcomes for women receiving vaginal misoprostol for cervical
ripening from 2013 to 2014 during labor induction were compared with women receiving oral
misoprostol from 2014 (after the switch to oral misoprostol) through 2015

Was the cohort recruited in an acceptable way?

- This retrospective cohort study was performed at a single academic tertiary care center, Boston University
Medical Center.
- The population of this study are 672 women receiving vaginal misoprostol and oral misoprostol for cervical
ripening from 2013 to 2015 during labor induction. Based on the inclusion criteria and excluded criteria there are
138 women receiving vaginal misoprostol and 138 women receiving oral misoprostol as the sample analysis.
- The women in this study collected and analyzed a variety of baseline
characteristics. Based on demographics (table 1) the women a predominantly over weight populat ion.
- The outcome of this study are to find the Caesarean delivery risk dan time to vaginal delivery on the women
receiving vaginal and oral misoprostol.
TERIMA KASIH