Correction: Oral misoprostol, low dose vaginal misoprostol, and vaginal dinoprostone for labor induction: Randomized controlled trial.

[This corrects the article DOI: 10.1371/journal.pone.0227245.].

Oral misoprostol, low dose vaginal misoprostol, and vaginal dinoprostone for labor induction: Randomized controlled trial.

OBJECTIVE: To compare effectiveness and safety of oral misoprostol (50 µg every four hours as needed), low dose vaginal misoprostol (25 to 50 µg every six hours as needed), and our established dinoprostone vaginal gel (one to two mg every six hours as needed) induction. MATERIALS AND METHODS: Consenting women with a live term single cephalic fetus for indicated labor induction were randomized (3N = 511). Prior uterine surgery or non-reassuring fetal surveillance were exclusions. Concealed computer generated randomization was stratified and blocked. Newborns were assessed by a team unaware of group assignment. The primary outcome was time from induction at randomization to vaginal birth for initial parametric analysis. Sample size was based on mean difference of 240 minutes with α2 = 0.05 and power 95%. Non-parametric analysis was also pre-specified ranking cesareans as longest vaginal births. RESULTS: Enrollment was from April 1999 to December 2000. Demographics were similar across groups. Analysis was by intent to treat, with no loss to follow up. Mean time (±SD) to vaginal birth was 1356 (±1033) minutes for oral misoprostol, 1530 (±3249) minutes for vaginal misoprostol, and 1208 (±613) minutes for vaginal dinoprostone (P = 0.46, ANOVA). Median times to vaginal birth were 1571, 1339, and 1451 minutes respectively (P = 0.46, Kruskal-Wallis). Vaginal births occurred within 24 hours in 44.9, 53.5 and 47.7% respectively (P = 0.27, χ2). There were no significant differences in Kaplan Meier survival analyses, cesareans, adverse effects, or maternal satisfaction. The newborn who met birth asphyxia criteria received vaginal misoprostol, as did. all three other newborns with cord artery pH<7.0 (P = 0.04, Fisher Exact). CONCLUSION: There was no significant difference in effectiveness of the three groups. Profound newborn acidemia, though infrequent, occurred only with low dose vaginal misoprostol.

Transvaginal ultrasonography in the prediction of preterm birth after treatment for cervical intraepithelial neoplasia.

OBJECTIVE: To estimate whether cervical length measured by transvaginal ultrasonography in women having had loop electrosurgical excision procedure (LEEP), cold knife conization, or cryotherapy predicts spontaneous preterm birth. METHODS: Women with a history of LEEP, cold knife conization, or cryotherapy and who were subsequently pregnant with singleton gestations were prospectively compared with both a low-risk control group and women with previous spontaneous preterm birth. A transvaginal ultrasonogram measuring cervical length was performed at 24 to 30 weeks of gestation. Primary outcomes included cervical length and spontaneous preterm birth less than 37 weeks. Secondary outcomes were spontaneous preterm birth less than 34 weeks, low birth weight, and maternal and neonatal outcomes. RESULTS: Women with previous LEEP (N = 75), cold knife conization (N = 21), and cryotherapy (N = 36) had shorter cervical lengths (3.54, 3.69, and 3.75 cm respectively) than the low-risk control group (N = 81, 4.21 cm) (P < .001, P = .03, P = .02 respectively) and similar lengths to women with a previous spontaneous preterm birth (N = 63, 3.78 cm). Loop electrosurgical excision procedure and cold knife conization, but not cryotherapy, were associated with spontaneous preterm birth less than 37 weeks (odds ratio 3.45, 95% confidence interval 1.28-10.00, P = .02; and odds ratio 2.63, 95% confidence interval 1.28-5.56, P = .009, respectively). Using a cutoff of 3.0 cm, transvaginal ultrasonography had a positive predictive value of 53.8% and negative predictive value of 95.2% for spontaneous preterm birth less than 37 weeks in women with LEEP. CONCLUSION: Women with a history of LEEP, cold knife conization, and cryotherapy all independently have shorter cervical lengths than low-risk controls and similar lengths to women with previous spontaneous preterm birth. Loop electrosurgical excision procedure and cold knife conization are associated with spontaneous preterm birth less than 37 weeks, and transvaginal ultrasonography predicts preterm birth in women who have had LEEP. LEVEL OF EVIDENCE: II-2.

Oral misoprostol for premature rupture of membranes at term.

OBJECTIVE: The study was undertaken to compare the efficacy, safety, and maternal satisfaction of oral misoprostol and intravenous oxytocin for labor induction in women with premature rupture of membranes at term. STUDY DESIGN: One hundred five women were stratified by parity and randomly assigned to oral misoprostol 75 microg every 4 hours as needed to establish labor or to intravenous oxytocin. RESULTS: The induction to vaginal delivery time with oral misoprostol was 737 (+/-426) minutes compared with 573 (+/-318) minutes with oxytocin (P=.04). The incidence of hyperstimulation was lower in the misoprostol group (6.0% vs 27.1%, P=.005). Women were more likely to be very satisfied with their care in the misoprostol group (86.0% vs 63.4%, P=.02). CONCLUSION: In women at term with premature rupture of membranes, oral misoprostol resulted in a longer induction to vaginal delivery interval but increased maternal satisfaction and less hyperstimulation compared with intravenous oxytocin. Further research is needed to assess uncommon neonatal and maternal outcomes.

Spontaneous versus induced labor after a previous cesarean delivery.

OBJECTIVE: To compare maternal and neonatal outcomes in spontaneous versus induced labor after one previous cesarean delivery. METHODS: Women with one previous cesarean delivery who had spontaneous labor between January 1992 and January 2000 were compared with those whose labor was induced. RESULTS: Three thousand seven hundred forty-six patients had a trial of labor (2943 spontaneous, 803 induced). Those induced had more frequent early postpartum hemorrhage (7.3% versus 5.0%; odds ratio [OR] 1.66; 95% confidence interval [CI] 1.18, 2.32), cesarean delivery (37.5% versus 24.2%; OR 1.84; 95% CI 1.51, 2.25), and neonatal intensive care unit (NICU) admission (13.3% versus 9.4%; OR 1.69; 95% CI 1.25, 2.29). There was a trend toward higher uterine rupture rates in those with induced versus spontaneous labor (0.7% versus 0.3%, P =.128) and for patients undergoing dinoprostone (prostaglandin E(2)) induction versus other methods (1.1% versus 0.6%, P =.62), although neither difference achieved statistical significance. CONCLUSION: Induced labor is associated with an increased rate of early postpartum hemorrhage, cesarean delivery, and neonatal ICU admission. The higher rate of uterine rupture in those who had labor induced was not statistically significant.

Trial of labour compared to elective Caesarean in twin gestations with a previous Caesarean delivery.

OBJECTIVE: To compare maternal and neonatal outcomes in twin gestations with a vertex presenting first twin undergoing either an elective repeat Caesarean section or a trial of labour subsequent to having had a Caesarean delivery in a prior pregnancy. METHODS: Maternal and newborn data from 1980 to 1999 in twin gestations, having 1 or more previous lower-segment Caesarean section(s) and a vertex presentation of the first twin, were analyzed from the Nova Scotia Atlee Perinatal Database. Categorical data were compared using chi-square or Fisher exact tests and continuous data by the Student t test. Logistic regression was used to control for covariates. RESULTS: Of the 121 women eligible for the data analysis, 38 chose to have a trial of labour, and 28 delivered vaginally with no uterine ruptures, scar dehiscences, maternal deaths, or increase in neonatal morbidity or mortality reported. Two Caesareans in the trial-of-labour group were for the delivery of the second twin. Women choosing elective Caesarean section had a higher incidence of infectious morbidity (p = 0.04). CONCLUSION: In twin pregnancies with twin A presenting as a vertex, a cautious trial of labour may be an effective and safe alternative to elective repeat Caesarean section. Further research on a trial of labour after previous Caesarean section in twin gestations is warranted, as the studies published to date do not have sufficiently large numbers to detect adverse maternal and neonatal outcomes.