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Prostaglandins for induction of labour and treatment of uterine atony

The use of prostaglandins (PG) is mandatory for induction of labour and treatment of uterine atony in modern obstetrics. Obstetricians should knowthe efficacy and the frequency of side effects associated with the different forms of PG application.

In Germany, intracervical application of 0.5 mg PGE2 gel (Bishop Score ≤ 5), vaginal administration of 1 mg or 2 mg PGE2 gel (Bishop Score ≥ 4), 3 mg PGE2 vaginal tablet (Bishop Score ≥ 6) and 10 mg PGE2 vaginal insert (Bishop Score up to 8) are licensed for induction of labour.

According to the recent RCOG guideline vaginal PGE2 is the method of choice for labour induction; it is superior to intracervical PGE2 and intravenous oxytocin.There are no significant differences in efficacy and safety between the all regimes of vaginal PGE2.

At present there exist no evidence-based recommendations of fetal monitoring (CTG). Monitoring regimens depend on the pharmacokinetics and the onset of labour, which vary widely among the different PGE2 preparations used.

The advantages of misoprostol above licensed PGE2 preparations are the ease of administration (vaginally or orally), the stability of misoprostol at room temperature and the lower costs, the disadvantages are its off-label and off-license use. There are insufficient data regarding its optimal route of administration and its optimal dosage for induction of labour. The vaginal application of 25 µg misoprostol every 4 hours has proven to be a safe and effective method for labour induction in patients with a ripe and an unripe cervix.

There are no significant differences in efficacy and the frequency of uterine hyperstimulation between low-dose oral or vaginal misoprostol and vaginal PGE2. According to licence directions the application of 2 is not permitted in patients with a previous caesarean section because of the increased risk of uterine rupture.According to current national and international guidelines PGE2 can only be administered,if delivery is indicated and the women have been carefully informed of the increased risks with induction of labour; misoprostol is contraindicated after a previous caesarean birth.

In cases of uterine atony the use of PG is mandatory, if others uterotonics (e.g. oxytocin) fail.The intravenous infusion of sulprostone is a licensed effective and safe method for treatment of uterine atony. Despite of limited data rectally applied misoprostol (dose: 600 µg to 1 000 µg) may be a good alternative,but is not licensed. The overall efficacy of PG in the treatment of uterine atony ranges from 92% to 95%, and the frequency of systemic side effects from 10% to 15%.

CME Prakt Fortbild Gynakol Geburtsmed Gynakol Endokrinol 2010; 6(3): 206-220

Induction of labour, uterine atony, prostaglandins, efficacy, side effects

Werner H. Rath
Gynäkologie und Geburtshilfe, Medizinische Fakultät des
Universitätsklinikums Aachen

Reviewer: Alexander Krafft, Zürich, CH
und Volker Briese, Rostock

Rath H. Prostaglandine... Gynakol Geburtsmed Gynakol Endokrinol 2010; 6(3):206-220 publiziert 30.11.10 ©akademos Wissenschaftsverlag 2010 ISSN 1614-8533