Cardiotocographic abnormalities associated with dinoprostone and misoprostol cervical ripening.

OBJECTIVE: To characterize the frequency and timing of cardiotocographic abnormalities associated with the use of 3 commercially available prostaglandin analogues, misoprostol, dinoprostone gel, and dinoprostone pessary, as labor preinduction agents. METHODS: One-hundred and eleven women undergoing induction of labor with an unfavorable cervix were randomized to receive either misoprostol 50 microg every 6 hours x 2 doses, dinoprostone gel 0.5 mg every 6 hours x 2 doses, or dinoprostone pessary 10 mg x 1 dose for 12 hours intravaginally. Oxytocin induction was initiated per standardized protocol. Cardiotocographic tracings were blindly reviewed, with abnormalities coded using established definitions. RESULTS: Fifty-five percent of women treated with misoprostol demonstrated an abnormal tracing event within the initial 24 hours of induction, compared with 21.1% with dinoprostone pessary and 31.4% with the dinoprostone gel. The mean (+/- standard deviation) number of abnormal events was significantly greater in women treated with misoprostol (5.0 +/- 5.9) versus the dinoprostone pessary (1.6 +/- 2.5) and gel (2.2 +/- 3.1) (P < .05). In addition, these events occurred earlier after initial misoprostol dosing (5.0 +/- 4.0 hours), compared with the dinoprostone pessary (9.4 +/- 5.6 hours) and gel (7.7 +/- 6.6). Thirty-nine percent of the misoprostol-treated women had abnormal patterns within 6 hours of initial dosing, compared with those treated with the dinoprostone pessary (7.9%) and gel (17.1%). CONCLUSION: Cardiotocographic abnormalities are more frequent after misoprostol administration compared with the dinoprostone analogues. The early onset and frequent nature of the tracing abnormalities associated with misoprostol raises concern for the potential use of misoprostol for outpatient cervical ripening.

Implication of delayed TNF-alpha exposure on dendritic cell maturation and expansion from cryopreserved cord blood CD34+ hematopoietic progenitors.

Most currently used systems for dendritic cell (DC) production from progenitors entail tumor necrosis factor alpha (TNF-alpha) at the onset of cell culture, based on the notion that TNF-alpha might be required in the early stages of DC development. To optimize conditions for DC expansion from cryopreserved cord blood (CB) CD34+ hematopoietic progenitors, we took a dynamic approach to define the timing of TNF-alpha exposure to the culture. We cultured cord blood CD34+ cells in RPMI-1640 with 10% human AB plasma, stem cell factor (days 1-6), granulocyte-macrophage colony-stimulating factor (days 1-18), interleukin-4 (days 6-18) and varying schedules of TNF-alpha (0-144 h after thawing). Expression of the DC-associated markers, including CD83/CD1a, HLA DR/CD86/CD80, CD14/CD40, was monitored every 3 days. Our data demonstrate that delayed TNF-alpha exposure by 48-72 h after thawing gave rise to two- to three-fold increase in the yield of CD83+ DCs that were highly active in stimulating allogeneic T-cell proliferation compared to immediate TNF-alpha exposure. Thus, the immediate exposure of cryopreserved cord blood CD34+ cells to TNF-alpha, potentially compromising DC expansion, should be avoided. This finding should be of significant consideration when using cryopreserved CD34+ progenitor cells as a source of immunologically competent DCs in a clinical setting.

A prospective trial of elective preterm delivery for fetal gastroschisis.

To test the hypothesis that preterm delivery of fetal gastroschisis prevents serious gastrointestinal compromise, facilitates primary surgical closure, and improves surgical outcome, we enrolled 16 women in a management plan. This included high-resolution ultrasound, weekly re-evaluation of the fetal gut (> or = 26 weeks), corticosteroids, and delivery if evidence of bowel compromise was present > 30 weeks. These fetuses were compared with 16 consecutive patients treated prior to establishment of this plan. Comparison of prospective trial patients with controls revealed significant differences in age at delivery (34.2 versus 37.7 weeks), serious bowel compromise (0 versus 70%), use of a surgically constructed silo (0 versus 77%), wound complications (0 versus 23%), duration of total parenteral nutrition (18.7 versus 34.7 days), time to full enteral feeding (19.1 versus 35.1 days), and hospital discharge (22.7 versus 37.7 days). Elective preterm delivery using specific ultrasound criteria resulted in improved surgical outcome without significant morbidity secondary to prematurity.

Antenatal corticosteroids: are incomplete courses beneficial?

OBJECTIVE: To assess the effectiveness of an incomplete course of antenatal corticosteroids on perinatal morbidity and mortality. METHOSD: We studied consecutive neonates born at 23-34 weeks' gestation between January 1, 1998, and July 31, 2002. The study population was divided into a group exposed to one 12-mg dose of betamethasone before delivery and a non-corticosteroid-exposed group, which were compared for various perinatal outcome variables. The Student t test, chi(2), Fisher exact tests, and logistic regression were used for analysis. RESULTS: One hundred twenty-five neonates (55.6%) were exposed to one 12-mg dose of betamethasone before delivery, whereas 104 neonates (45.4%) did not receive antenatal corticosteroids. Mean gestational age at delivery (28.4 +/- 3.1 weeks versus 29.7 +/- 3.5 weeks, P =.002) and birth weight (1189 +/- 409 g versus 1289 +/- 441 g, P =.07) were lower among the steroid-exposed group. Adjusting for gestational age, one dose of betamethasone was associated with significant reduction in the need for vasopressors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.14, 0.85; P =.02), the rate of intraventricular hemorrhage (OR 0.42; 95%CI 0.19, 0.92; P =.03), and neonatal death (OR 0.31; 95% CI 0.11, 0.86; P =.02). There were no differences between groups in the rate of clinical and histological chorioamnionitis, low Apgar scores, postnatal surfactant exposure, respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, patent ductus arteriosus, retinopathy of prematurity, and neonatal sepsis. CONCLUSION: An incomplete course of antenatal corticosteroids is associated with reduction in the need for vasopressors, the rate of intraventricular hemorrhage, and neonatal death in preterm neonates.

Comparative efficacy and cost of the prostaglandin analogs dinoprostone and misoprostol as labor preinduction agents.

OBJECTIVE: The purpose of this study was to compare the relative efficacy and cost of three commercially available prostaglandin analogs, misoprostol (Cytotec), dinoprostone gel (Prepidil), and dinoprostone insert (Cervidil), as labor preinduction agents. STUDY DESIGN: One-hundred eleven women with an unfavorable cervix who underwent labor induction were assigned randomly to receive either misoprostol 50 microg every 6 hours for two doses, dinoprostone gel 0.5 mg every 6 hours for two doses, or dinoprostone insert 10 mg for one dose intravaginally. Twelve hours later, oxytocin induction was initiated per standardized protocol. Efficacy and cost of the labor preinduction/induction with the study treatments were compared. RESULTS: Mean Bishop score change (+/-SD) over the initial 12-hour interval was significantly greater in the misoprostol group (5.2 +/- 3.1) compared with the dinoprostone insert (3.2 +/- 2.3) or the dinoprostone gel groups (2.2 +/- 1.3, P <.0001). The proportion of women who reached complete dilation (68.4%, 50.0%, 51.4%, respectively; P =.14) and who were delivered (60.5%, 47.4%, 40.0%, respectively; P =.10) within 24 hours of the initiation of induction were not significantly different between the misoprostol, dinoprostone insert, and dinoprostone gel groups. Induction-to-delivery intervals, however, were significantly shorter among women who treated with misoprostol (24.0 +/- 10.8 hours) compared with either the dinoprostone gel (31.6 +/- 13.4 hours) or the dinoprostone insert (32.2 +/- 14.7 hours, P <.05). Overall mean cost per patient that was incurred by labor induction was significantly less for the misoprostol group ($1036.13) compared with the dinoprostone insert group ($1565.72) or the dinoprostone gel group ($1572.92, P <.0001). No significant differences were noted with respect to the mode of delivery or to the adverse maternal/neonatal outcome. CONCLUSION: Misoprostol is more cost-effective than the comparable commercial dinoprostone prostaglandin preparations as an adjuvant to labor induction in women with an unfavorable cervix.

Effect of vaginal pH on efficacy of the dinoprostone gel for cervical ripening/labor induction.

OBJECTIVE: The purpose of this study was to evaluate whether vaginal pH has an effect on the efficacy of the dinoprostone gel for cervical ripening/labor induction. STUDY DESIGN: Thirty-two women with an unfavorable cervix who were undergoing labor induction were enrolled in this prospective, double-blinded investigation. Initial vaginal pH and Bishop score assessment were made by an independent examiner. All women received cervical ripening with the dinoprostone gel 5 mg intracervically, with repeated dosing one time 6 hours later. Twelve hours later, oxytocin induction was initiated per standardized protocol, and outcome data were collected. RESULTS: Mean (+/-SD) initial vaginal pH was 4.7 +/- 0.6 (range, 4.0-6.0) for the study cohort. No significant differences were noted between women with a high vaginal pH (>4.5, n = 16 women) and women with a low vaginal pH (< or =4.5, n = 16 women) with respect to maternal age, parity, gestational age, or initial Bishop score. Although Bishop score change over the initial 12 hours of cervical ripening did not significantly differ between the high vaginal pH (2.3 +/- 2.3) and the low vaginal pH group (2.3 +/- 2.5, P = not significant), time to active labor (19 +/- 10 hours vs 33 +/- 17 hours, P =.001), complete dilation (24 +/- 10 hours vs 37 +/- 19 hours, P =.03), and delivery (26 +/- 10 hours vs 38 +/- 18 hours, P =.02) were significantly shorter in women with a high vaginal pH compared with women with a low vaginal pH, respectively. A significant association was noted between vaginal pH and time to active labor (r = -0.52, P =.003), complete dilation (r = -0.50, P =.006), and delivery (r = -0.44, P =.01); however, pH was not significantly associated with Bishop score change during the initial 12 hours of cervical ripening. CONCLUSION: Vaginal pH is an important factor that affects the efficacy of the dinoprostone gel as an adjuvant for labor induction.

High-dose oral misoprostol for mid-trimester pregnancy interruption.

OBJECTIVE: To evaluate the efficacy of high-dose oral misoprostol for mid-trimester pregnancy interruption. METHODS: We reviewed our experience with high-dose oral misoprostol for mid-trimester pregnancy interruption from November 1995 to May 1999. Patients undergoing labor induction for intrauterine fetal demise or medically indicated pregnancy termination at 13-32 weeks of gestation with a non-dilated cervix were evaluated. Patients received 400 microg misoprostol orally every 4 h. Women undelivered within 24 h were considered failures and were treated with high-dose oxytocin as previously described. For comparison, a group of women treated with high-dose oxytocin were evaluated. RESULTS: Forty-seven pregnancies were managed with misoprostol (n = 23) or high-dose oxytocin regimen (n = 24). Both groups were similar with respect to induction indication, gestational age, maternal age/parity, laminaria use, and initial cervical dilation. Induction-to-delivery interval (mean +/- SD) was significantly shorter in the misoprostol cohort (15.2 +/- 6.7 h) compared with those treated with oxytocin (21.7 +/- 11.0 h; p = 0.02). Additionally, a significantly greater percentage of women treated with misoprostol delivered within 24 h (91.0%) compared with the oxytocin group (62.0%; p = 0.04). Adverse outcomes and side effects were not significantly different between the study groups. CONCLUSION: High-dose oral misoprostol is more effective than concentrated oxytocin infusion for mid-trimester pregnancy interruption.