Intracervical prostaglandins for induction of labour

  • Review
  • Intervention

Authors

  • Michel Boulvain,

    Corresponding author
    1. Maternité Hôpitaux Universitaires de Genève, Département de Gynécologie et d'Obstétrique, Unité de Développement en Obstétrique, Genève 14, Switzerland
    • Michel Boulvain, Département de Gynécologie et d'Obstétrique, Unité de Développement en Obstétrique, Maternité Hôpitaux Universitaires de Genève, Boulevard de la Cluse, 32, Genève 14, CH-1211, Switzerland. michel.boulvain@hcuge.ch.

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  • Anthony J Kelly,

    1. Brighton and Sussex University Hospitals NHS Trust, Department of Obstetrics and Gynaecology, Brighton, UK
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  • Olivier Irion

    1. Maternité Hôpitaux Universitaires de Genève, Département de Gynécologie et d'Obstétrique, Unité de Développement en Obstétrique, Genève 14, Switzerland
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Abstract

Background

Prostaglandins have been used for cervical ripening and induction of labour since the 1970s. The goal of the administration of prostaglandins in the process of induction of labour is to achieve cervical ripening before the onset of contractions. One of the routes of administration that was proposed is intracervical. Using this route, prostaglandins are less easy to administer and the need for exposing the cervix may cause discomfort to the woman.

Objectives

To determine the effects of intracervical prostaglandins for third trimester cervical ripening or induction of labour compared with placebo/no treatment and with vaginal prostaglandins (except misoprostol).

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007) and bibliographies of relevant papers.

Selection criteria

Clinical trials comparing intracervical prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods (vaginal prostaglandins, except misoprostol).

Data collection and analysis

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

Main results

Fifty-six trials (7738 women) are included.

Intracervical PGE2 with placebo/no treatment: 28 trials, 3764 women
Four studies reported the number of women who did not achieve vaginal delivery within 24 hours, showing a decreased risk with PGE2 (relative risk (RR) 0.61; 95% confidence interval (CI) 0.47 to 0.79). There was a small, and statistically non-significant, reduction of the risk of caesarean section when PGE2 was used (RR 0.88; 95% CI 0.77 to 1.00). The finding was statistically significant in a subgroup of women with intact membranes and unfavourable cervix only (RR 0.82; 95% CI 0.68 to 0.98). The risk of hyperstimulation with fetal heart rate (FHR) changes was not significantly increased (RR 1.21; 95% CI 0.72 to 2.05). However, the risk of hyperstimulation without FHR changes was significantly increased (RR 1.59; 95% CI 1.09 to 2.33.

Intracervical PGE2 with intravaginal PGE2: 29 trials, 3881 women
The risk of not achieving vaginal delivery within 24 hours was increased with intracervical PGE2 (RR 1.26; 95% CI 1.12 to 1.41). There was no change in the risk of caesarean section (RR 1.07; 95% CI 0.93 to 1.22). The risks of hyperstimulation with FHR changes (RR 0.76; 95% CI 0.39 to 1.49) and without FHR changes (RR 0.80; 95% CI 0.56 to 1.15) were non-significantly different with the two methods of PGE2 administration. Only one trial with small sample size reported on women's views, with no difference between groups.

Intracervical PGE2 low dose with intracervical PGE2 high dose: two trials, 102 women
The trials are too small to provide any useful information.

Authors' conclusions

Intracervical prostaglandins are effective compared to placebo, but appear inferior when compared to intravaginal prostaglandins.

摘要

背景

子宮頸內前列腺素在引產的角色

前列腺素從1970年代以來就被用來促進子宮頸成熟和引產。 在引產過程中,前列腺素使用的目的是為了在子宮收縮之前使子宮頸成熟。其中一種給藥方式就是將前列腺素直接置入子宮頸內。但此方法較不容易施行,且會造成孕婦的不適。

目標

比較子宮頸內前列腺素投予和不接受治療的對照組及使用陰道前列腺素(不包括PGE1 misprostol),在第三孕程促進子宮頸成熟或引產的效果。

搜尋策略

我們搜詢了 Cochrane Pregnancy and Childbirth Group's Trials Register(2007年8月)和其文章的參考書目。

選擇標準

選擇臨床試驗,其內容為比較第三孕程使用子宮頸內前列腺素投予來促進子宮頸成熟或引產,和沒有介入治療或使用其它上述預定的方式(陰道內前列腺素,不包括 misoprostol),兩者間的差異。

資料收集與分析

兩階段的資料選取用來分析龐大且複雜有關引產的臨床試驗。

主要結論

我們收納了總共包含7738位孕婦的56篇文獻。其中有28篇文獻,共包含了3764位孕婦,內容是在比較使用子宮頸內前列腺素(PGE2)和沒有介入治療的差異。其中四篇文章指出使用PGE2可降低24小時內未陰道生產所發生的危險(relative risk (RR) 0.61; 95% confidence interval (CI) 0.47 to 0.79)。另有一篇較小型且在統計學上沒有顯著意義的研究指出,使用PGE2可降低剖腹產的比率(RR 0.88; 95% CI 0.77 to 1.00)。若從上述這些文獻,挑出其中只有子宮頸不成熟但未有破水的情形的孕婦去做分析,PGE2可降低剖腹產的比率在統計學上具有顯著意義(RR 0.82; 95% CI 0.68 to 0.98)。造成子宮過度刺激伴隨胎兒心跳變化方面,使用PGE2並沒有增加此機率(RR 1.21; 95% CI 0.72 to 2.05)。然而,子宮過度刺激但不伴隨胎兒心跳變化的機率則是有意義的上升了(R .59; 95% CI 1.09 to 2.33)。另有29篇臨床試驗,共包含了3881位孕婦,其內容是在比較使用子宮頸內PGE2和陰道內PGE2的差異。使用子宮頸內PGE2,24小時內未達到陰道生產的比率是較高的(RR 1.26; 95% CI 1.12 to 1.41)。但在剖腹生產率方面,兩者沒有差異(R .07; 95% CI 0.93 to 1.22)。此兩種投予PGE2的方式,在子宮過度刺激,伴隨(RR 0.76; 95% CI 0.39 to 1.49)或是沒有(RR 0.80; 95% CI 0.56 to 1.15)胎兒心跳變化方面是沒有差異的。只有一篇小型的臨床試驗指出,就孕婦的觀點來看,兩者並無差異。另有兩篇試驗,包含了102位孕婦,其內容是在比較高劑量及低劑量子宮頸內PGE2的差異。其結果因為人數太少並不足以提供有效的資訊。

作者結論

子宮頸內前列腺素投予效果優於沒有介入治療的對照組,但卻比陰道內前列腺素投予效果來得差。

翻譯人

本摘要由周產期醫學會(Taiwan Society of Perinatology)林佩萱翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

子宮頸內前列腺素投予對於陣痛的產生是有效的,但是其效果並不優於陰道內前列腺素投予。前列腺素在產程中會有身體自然產生。它的角色在於使子宮頸較軟化及成熟,因而在子宮收縮時會較易使子宮頸打開。當決定引產但子宮頸尚未打開,在使用促進子宮收縮的藥之前(通常是催產素oxytocin),人工合成的前列腺素會先被用來使子宮頸成熟。其中一個投予的方式是在陰道內診時使用cannula將前列腺素置入子宮頸內。我們回顧56篇文獻,共包含了7738位孕婦,其結果顯示使用子宮頸內前列腺素投予對於引產是有效的,但和陰道內前列腺素投予比較並沒有較好。

Plain language summary

Intracervical prostaglandins for induction of labour

Prostaglandins inserted into the cervix are effective in starting labour, but are inferior to vaginal administration.

Prostaglandins are produced naturally by the body during the process of labour. Their role is to prepare the cervix and to help open the cervix in response to contractions. When it is decided to induce labour and the cervix is not yet open, synthetic prostaglandins are used to ripen it before drugs that produce contractions (usually oxytocin) are given. One way to give prostaglandin is to insert it into the cervix, using a cannula during a vaginal examination. The review of fifty-six trials (7738 women) found that although this route of administration is effective, it offers no advantages when compared to other methods of administration, namely the vaginal route.

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