Women's experiences and views of outpatient and inpatient induction of labor with oral misoprostol: A secondary qualitative study.

INTRODUCTION: As labor induction rates continue to increase, so has the interest in performing induction in an outpatient setting for pregnancies defined as low-risk. Twenty women participated in the pilot study of a Randomized Controlled Trial (RCT) comparing inpatient and outpatient labor induction with oral misoprostol. This study aimed to explore women's experiences of outpatient induction of labor and their views on this as an alternative method to inpatient labor induction. METHODS: Semi-structured interviews were conducted, from November 2021 to January 2022 with eight women randomized to outpatient induction and four women randomized to inpatient induction. Verbatim transcribed interviews were analyzed using Graneheim and Lundman's content analysis. RESULTS: Three main categories emerged: the required framework around outpatient labor induction, what felt better at home and what felt safer at the hospital. To feel secure at home, women needed sufficient information, close follow-up while at home, and an easy-to-administer induction method. Outpatient labor induction gave women the opportunity of constant support from the partner and increased freedom of movement and self-expression. Some expressed relief over being randomized to inpatient labor induction, because of easy access to health providers, fetal monitoring, and not risking giving birth before arrival to the hospital. Women stressed the importance of being given a choice. CONCLUSIONS: Outpatient labor induction contributed to a positive birth experience and should be considered as an alternative for women with low-risk pregnancies. Shared decision-making, including the opportunity for women to change their mind, is essential as induction and early labor affects women's whole childbirth experience.

Changes in labor outcomes after implementing structured use of oxytocin augmentation with a 4-hour action line.

INTRODUCTION: Oxytocin augmentation is essential in labor management, but how to optimize its use is still debated. Joint international guidelines regarding prolonged labor and the use of oxytocin augmentation are still not available. Due to its potential harmful side effects, a decreased use of oxytocin is encouraged. We aimed to implement a structured protocol on the use of oxytocin augmentation and to observe changes in labor outcomes. MATERIALS AND METHODS: The protocol was implemented at the Obstetric Department of Sørlandet Hospital, Kristiansand, Norway on 1 January 2012; therefore, data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009-2010) and the study period cohort (2012-2013). The structured protocol instructs, and restricts, the birth attendants to diagnose prolonged labor, by protocol definition only, before commencing oxytocin infusion for augmentation. Nulliparous women with singleton, term deliveries (≥37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis. The main outcome was use of oxytocin augmentation. RESULTS: The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (p < .01). The protocol was followed satisfactorily in 78% of the study cohort. The use of oxytocin augmentation was reduced in the study cohort versus the control cohort; 41.3 versus 48.9% (p < .01); mean oxytocin infusion duration was shorter (100 versus 123 min; p < .01); and mean total oxytocin dose decreased (1009 versus 1293 mU; p < .01). The cesarean section rate was 5.9% in the study cohort versus 8.0% in the control cohort (p = .04). The estimated mean duration of the active phase of labor increased by 47 min (p < .01) after the implementation. The frequency of estimated postpartum hemorrhage >1000 ml was higher, 4.9 versus 2.0% (p < .01), but the use of blood transfusions remained stable, 2.5 versus 2.7% (p = .78), the study cohort versus control cohort, respectively. CONCLUSIONS: Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Multiple roles for the endocannabinoid system during the earliest stages of life: pre- and postnatal development.

The endocannabinoid system, including its receptors (CB(1) and CB(2)), endogenous ligands ('endocannabinoids'), synthesising and degrading enzymes, as well as transporter molecules, has been detected from the earliest stages of embryonic development and throughout pre- and postnatal development. In addition, the endocannabinoids, notably 2-arachidonyl glycerol, are also present in maternal milk. During three distinct developmental stages (i.e. embryonic implantation, prenatal brain development and postnatal suckling), the endocannabinoid system appears to play an essential role for development and survival. Thus, during early pregnancy, successful embryonic passage through the oviduct and implantation into the uterus both require critical enzymatic control of optimal anandamide levels at the appropriate times and sites. During foetal life, the cannabinoid CB(1) receptor plays a major role in brain development, regulating neural progenitor differentiation into neurones and glia and guiding axonal migration and synaptogenesis. Postnatally, CB(1) receptor blockade interferes with the initiation of milk suckling in mouse pups, by inducing oral motor weakness, which exposes a critical role for CB(1) receptors in the initiation of milk suckling by neonates, possibly by interfering with innervation of the tongue muscles. Manipulating the endocannabinoid system by pre- and/or postnatal administration of cannabinoids or maternal marijuana consumption, has significant, yet subtle effects on the offspring. Thus, alterations in the dopamine, GABA and endocannabinoid systems have been reported while enhanced drug seeking behaviour and impaired executive (prefrontal cortical) function have also been observed. The relatively mild nature of the disruptive effects of prenatal cannabinoids may be understood in the framework of the intricate timing requirements and frequently biphasic effects of the (endo)cannabinoids. In conclusion, the endocannabinoid system plays several key roles in pre- and postnatal development. Future studies should further clarify the mechanisms involved and provide a better understanding of the adverse effects of prenatal exposure, in order to design strategies for the treatment of conditions such as infertility, mental retardation and failure-to-thrive.

Endocannabinoids, feeding and suckling--from our perspective.

In this overview we have summarized some aspects of our published work related to the effects of the endocannabinoid system on appetite and suckling. As noted also by several other groups we have found that anandamide, a major endocannabinoid, enhances appetite in mice. On partial or full food deprivation over 24 h the levels of 2-arachidonoyl glycerol (2-AG), a second major cannabinoid, are initially elevated in mouse brain; however, partial food deprivation over a longer period causes reduction of 2-AG levels. Blocking the endocannabinoid system with a CB1 antagonist on the 1st day after birth leads to inhibition of suckling; later administration also affects suckling, but does not fully block it.

Differential response to acute and repeated stress in cannabinoid CB1 receptor knockout newborn and adult mice.

Previous studies have suggested that the endocannabinoid CB1 receptor (ECBR) system is involved in stress. However, the nature of this association is complex. Here, we investigated the role of CB1 receptors in the response to stress by comparing the effects of various stress modalities in CB1-/- receptor deficient and wild-type mice, at adulthood and during early development. Response to acute stress was assayed by plasma corticosterone (CS) and adrenocorticotrophic hormone (ACTH), USVs and motor inhibition. The response to repeated stress was assessed by USVs and motor inhibition. Since repeated bell stress seemed to cause a cumulative fear in CB1 receptor knockout mice, these behavioral responses were also compared to those observed after a single severe stress (forced swimming). In wild-type, but not in CB1 receptor knockout mice, bell stress-induced elevations of ACTH and CS were significant. The first exposure to bell stress had no significant effect on USVs or mobility. Upon repeated exposures, significant suppression of USVs, together with behavioral inhibition, were observed in CB1 knockout but not in wild-type mice. Swim stress inhibited USVs in the knockout animals, and the profound motor inhibition displayed by all animals was greater and more prolonged in the CB1-/- mice. Since the knockout mice lack the CB1 receptor throughout pre- and postnatal life, the stress response in pups was also assayed (by separation-induced USVs). Wild-type pups displayed the characteristic developmental peak in USV emissions; it was completely lacking in knockout pups. We conclude that acutely, the absence of CB1 receptors reduces the neuroendocrine response and does not affect the behavioral response to moderate stress. However, upon repeated stress or acute severe stress, CB1 receptor deficiency causes persistent behavioral inhibition. Finally, the CB1 receptor plays a role in modulating the stress response from an early age. These observations suggest that CB1 receptors participate in the mediation of the stress response and that the absence of these receptors results in a greater vulnerability to stress. We suggest that the stress-induced endocrine and behavioral suppression in CB1 receptor deficient mice may serve as a model for some forms of post-traumatic stress disorder (PTSD). Further, the role of CB1 receptors in coping with stress is a lifelong function. Finally, although equivalent research has not been performed in human infants, the postnatal suppression of the stress response in CB1 receptor knockout pups may have implications when cannabinoid-based therapy is considered for children.

The Jerusalem Balsam: from the Franciscan Monastery in the old city of Jerusalem to Martindale 33.

The Jerusalem Balsam, a remedy based on an ethanolic extract of a herbal mixture, was formulated in 1719 in the pharmacy of the Saint Savior monastery in the old city of Jerusalem. Having gained fame, the Jerusalem Balsam was replicated and prepared in Europe. One can still find variations of the formula in current pharmacopoeias (B.P., 1998. The Stationary Office, London, p. 1510; Sweetman, S.C., Blake, P.S., McGlashan, J.M., Parsons, A.V., 2002. Martindale: The Extra Pharmacopeia, 33rd ed. Pharmaceutical Press, London, p. 1101). We report here, five different formulas, all referred to as "The Jerusalem Balsam". Three of those formulas were translated and two of these translations are presented in the text. A third one is available as Supplementary data online. As the formulas originate from different historical periods, the Jerusalem Balsam may be a good case study of the development of pharmaceutical formulations over a 250 years period. One of the formulas, found in a manuscript form in the archive of the monastery, contains four plants: olibanum (Boswellia spp.), myrrh (Commiphora spp.), aloe (Aloe sp.) and mastic (Pistacia lentiscus L.). We conducted pharmacological assays on this four-plant formula. It showed anti-inflammatory, as well as anti-oxidative, and anti-septic properties.

Up-regulation of the endocannabinoid system in the uterus of leptin knockout (ob/ob) mice and implications for fertility.

The levels of the endocannabinoids anandamide and 2-arachidonoylglycerol (2-AG) are under the negative control of leptin in the rodent hypothalamus. As leptin and endocannabinoids play opposite roles in the control of reproduction, we have investigated whether the impaired fertility typical of leptin-defective ob/ob mice is due, in part, to enhanced uterine endocannabinoid levels. We found that levels of both anandamide and 2-AG in the uterus of ob/ob mice are significantly elevated with respect to wild-type littermates, due to reduced hydrolase activity in the case of anandamide, and to reduced monoacylglycerol lipase and enhanced diacylglycerol lipase activity in the case of 2-AG. Furthermore, the process mediating endocannabinoid cellular uptake was also impaired in ob/ob mice, whereas the levels of cannabinoid and anandamide receptors were not modified. Although ineffective in wild-type mice, treatment of ob/ob mice with leptin re-established endocannabinoid levels and enzyme activities back to the values observed in wild-type littermates. Finally, treatment of ob/ob females with the CB1 receptor antagonist SR141716A did not improve their fertility, and inhibition of endocannabinoid inactivation with the endocannabinoid uptake inhibitor OMDM-1 in wild-type females did not result in impaired fertility.

Endocannabinoids in the central nervous system--an overview.

Many aspects of the physiology and pharmacology of anandamide (arachidonoyl ethanol amide), the first endogenous cannabinoid ligand ("endocannabinoid") isolated from pig brain, have been studied since its discovery in 1992. Ethanol amides from other fatty acids have also been identified as endocannabinoids with similar in vivo and in vitro pharmacological properties. 2-Arachidonoyl glycerol and noladin ether (2-arachidonyl glyceryl ether), isolated in 1995 and 2001, respectively, so far, display pharmacological properties in the central nervous system, similar to those of anandamide. The endocannabinoids are widely distributed in brain, they are synthesized and released upon neuronal stimulation, undergo reuptake and are hydrolyzed intracellularly by fatty acid amide hydrolase (FAAH). For therapeutic purposes, inhibitors of FAAH may provide more specific cannabinoid activities than direct agonists, and several such molecules have already been developed. Pharmacological effects of the endocannabinoids are very similar, yet not identical, to those of the plant-derived and synthetic cannabinoid receptor ligands. In addition to pharmacokinetic explanations, direct or indirect interactions with other receptors have been considered to explain some of these differences, including activities at serotonin and GABA receptors. Binding affinities for other receptors such as the vanilloid receptor, have to be taken into account in order to fully understand endocannabinoid physiology. Moreover, possible interactions with receptors for the lysophosphatidic acids deserve attention in future studies. Endocannabinoids have been implicated in a variety of physiological functions. The areas of central activities include pain reduction, motor regulation, learning/memory, and reward. Finally, the role of the endocannabinoid system in appetite stimulation in the adult organism, and perhaps more importantly, its critical involvement in milk ingestion and survival of the newborn, may not only further our understanding of the physiology of food intake and growth, but may also find therapeutic applications in wasting disease and infant's "failure to thrive".

Critical role of the endogenous cannabinoid system in mouse pup suckling and growth.

Delta9-tetrahydrocannabinol, the active principle in marijuana, is a cannabinoid receptor agonist. Both the crude drug and delta9-tetrahydrocannabinol have been used as appetite promoters. The endogenous cannabinoid, arachidonoyl ethanolamide (anandamide), likewise a cannabinoid receptor agonist, has been shown to have the same effect. In contrast, the cannabinoid CB1 receptor antagonist N-(piperidin-1-yl)-5(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1-H-pyrazole-3-carboxamide (SR141716A) reduces food intake. Here, we report that administration of SR141716A to newly born mouse pups (either a single administration on postnatal day 1, or daily for a week as of postnatal day 2) had a devastating effect on milk ingestion and growth. The first 24 h after birth appeared the most critical for the growth stunting effect of SR141716A. Death followed within 4-8 days. Co-administration of delta9-tetrahydrocannabinol almost fully reversed the effect of the antagonist in the week-long regimen. Co-administration of 2-arachidonoyl glycerol, an endocannabinoid, with 2-palmitoyl glycerol and 2-linoleoyl glycerol, which enhance 2-arachidonoyl glycerol potency, resulted in a significant delay in mortality rates caused by the antagonist. We conclude that the endocannabinoid system plays a vital role in milk suckling, and hence in growth and development during the early stages of mouse life.

2-arachidonyl glyceryl ether, an endogenous agonist of the cannabinoid CB1 receptor.

Two types of endogenous cannabinoid-receptor agonists have been identified thus far. They are the ethanolamides of polyunsaturated fatty acids--arachidonoyl ethanolamide (anandamide) is the best known compound in the amide series--and 2-arachidonoyl glycerol, the only known endocannabinoid in the ester series. We report now an example of a third, ether-type endocannabinoid, 2-arachidonyl glyceryl ether (noladin ether), isolated from porcine brain. The structure of noladin ether was determined by mass spectrometry and nuclear magnetic resonance spectroscopy and was confirmed by comparison with a synthetic sample. It binds to the CB(1) cannabinoid receptor (K(i) = 21.2 +/- 0.5 nM) and causes sedation, hypothermia, intestinal immobility, and mild antinociception in mice. It binds weakly to the CB(2) receptor (K(i) > 3 microM).

HU-308: a specific agonist for CB(2), a peripheral cannabinoid receptor.

Two cannabinoid receptors have been identified: CB(1), present in the central nervous system (CNS) and to a lesser extent in other tissues, and CB(2), present outside the CNS, in peripheral organs. There is evidence for the presence of CB(2)-like receptors in peripheral nerve terminals. We report now that we have synthesized a CB(2)-specific agonist, code-named HU-308. This cannabinoid does not bind to CB(1) (K(i) > 10 microM), but does so efficiently to CB(2) (K(i) = 22.7 +/- 3.9 nM); it inhibits forskolin-stimulated cyclic AMP production in CB(2)-transfected cells, but does so much less in CB(1)-transfected cells. HU-308 shows no activity in mice in a tetrad of behavioral tests, which together have been shown to be specific for tetrahydrocannabinol (THC)-type activity in the CNS mediated by CB(1). However, HU-308 reduces blood pressure, blocks defecation, and elicits anti-inflammatory and peripheral analgesic activity. The hypotension, the inhibition of defecation, the anti-inflammatory and peripheral analgesic effects produced by HU-308 are blocked (or partially blocked) by the CB(2) antagonist SR-144528, but not by the CB(1) antagonist SR-141716A. These results demonstrate the feasibility of discovering novel nonpsychotropic cannabinoids that may lead to new therapies for hypertension, inflammation, and pain.

Carbachol, an acetylcholine receptor agonist, enhances production in rat aorta of 2-arachidonoyl glycerol, a hypotensive endocannabinoid.

The production of 2-arachidonoyl glycerol, an endogenous cannabinoid, is enhanced in normal, but not in endothelium-denuded rat aorta on stimulation with carbachol, an acetylcholine receptor agonist. 2-Arachidonoyl glycerol potently reduces blood pressure in rats and may represent an endothelium-derived hypotensive factor.

Endocannabinoids.

The background knowledge leading to the isolation and identification of anandamide and 2-arachidonoyl glycerol, the principal endocannabinoids is described. The structure-activity relationships of these lipid derivatives are summarized. Selected biochemical and pharmacological topics in this field are discussed, the main ones being levels of endocannabinoids in unstimulated tissue and cells, biosynthesis, release and inactivation of endocannabinoids, the effects of 'entourage' compounds on the activities of anandamide and 2-arachidonoyl glycerol, their signaling mechanisms and effects in animals.

An entourage effect: inactive endogenous fatty acid glycerol esters enhance 2-arachidonoyl-glycerol cannabinoid activity.

2-Arachidonoyl-glycerol (2-Ara-GI) has been isolated from various tissues and identified as an endogenous ligand for both cannabinoid receptors, CB1 and CB2. Here we report that in spleen, as in brain and gut, 2-Ara-GI is accompanied by several 2-acyl-glycerol esters, two major ones being 2-linoleoyl-glycerol (2-Lino-Gl) and 2-palmitoyl-glycerol (2-Palm-Gl). These two esters do not bind to the cannabinoid receptors, nor do they inhibit adenylyl cyclase via either CB1 or CB2; however, they significantly potentiate the apparent binding of 2-Ara-Gl and its apparent capacity to inhibit adenylyl cyclase. Together these esters also significantly potentiate 2-Ara-Gl inhibition of motor behavior, immobility on a ring, analgesia on a hot plate and hypothermia caused by 2-Ara-Gl in mice. 2-Lino-Gl, but not 2-Palm-GI, significantly inhibits the inactivation of 2-Ara-Gl by neuronal and basophilic cells. These data indicate that the biological activity of 2-Ara-Gl can be increased by related, endogenous 2-acyl-glycerols, which alone show no significant activity in any of the tests employed. This effect ('entourage effect') may represent a novel route for molecular regulation of endogenous cannabinoid activity.

Biphasic effects of anandamide.

Effects of the endogenous cannabimimetic anandamide were assessed over a wide dose range in a series of physiological and behavioral assays. These included the tetrad of tests in mice commonly used to assess cannabinoid-induced effects (motor activity, ring catalepsy, hypothermia, and analgesia tests), as well as a model for agonistic behavior on dyadic interactions of singly housed males with nonaggressive group-housed partners. Anandamide-induced effects on leukocyte phagocytosis were measured in a chemiluminescence assay. Results indicated that the higher doses tested (10-100 mg/kg) produced the well-known inhibitory effects in all of the above parameters as well as inhibition of phagocytosis. The lowest dose of anandamide tested (0.01 mg/kg) stimulated behavioral activities in the open field, on the ring and aggressive behavior in timid singly housed mice. This dose of 0.01 mg/kg, also stimulated phagocytosis. We suggest several possible mechanisms to explain these findings such as a differential involvement of a Gs and a Gi protein activated at low and high doses, respectively, allosteric modulation of the cannabinoid, and activation of presynaptic cannabinoid receptors by low doses of anandamide.