II. Indications

  1. Bishop Score <6
  2. Membranes intact
  3. No active contraction pattern
    1. Less than 10 mild contractions per hour

III. Contraindications

  1. Contractions >3 in 10 minutes prior to placement

IV. Precautions

  1. Monitor Fetal Heart Rate and tocometry starting 15 to 30 minutes before, and for 30-120 minutes after placement

V. Medication: Dinoprostone Gel (PGE2 Gel, Prepidil)

  1. Initiate Fetal Heart Rate and tocometry
    1. Start 15-30 minutes before gel inserted
    2. Continue monitoring for 30-120 minutes after
  2. Insertion Technique
    1. Use one syringe of gel (0.5 mg in 3cc KY)
    2. Introduce gel into Cervix
      1. Cervix not effaced: Use 20 mm catheter
      2. Cervix effaced 50% or greater: Use 10 mm catheter
      3. Intracervical is preferred over posterior fornix
        1. Perry (2004) Obstet Gynecol 103:13-7 [PubMed]
    3. Patient remains supine for 30 minutes
  3. Dosing
    1. Repeat every 6 hours up to 3 doses in 24 hours
  4. End points
    1. Bishop Score of 8 or greater
    2. Strong uterine contractions
  5. Drug Interactions
    1. Wait 6-12 hours before starting Pitocin

VI. Medication: Dinoprostone Pessary or Vaginal Insert (PGE2, Cervidil)

  1. Dinoprostone 10 mg insert releases Dinoprostone at 0.3 mg/hour for 12 hours
  2. Insert Pessary at Cervix
  3. Monitor Fetal Heart Tones and tocometry
    1. Start 15 to 30 minutes before insertion
    2. Continue monitoring for 15 minutes after removal
  4. Remain recumbent for 2 hours after insertion
  5. Pull Pessary out via string if hyper-stimulated

VII. Medication: Misoprostol (PGE1, Cytotec)

  1. Insert 25-50 mcg tablet intravaginally (100 mcg Misoprostol tablet broken into quarters)
    1. Dose of 25 mcg is preferred due to less tachysystole, Fetal Heart Rate abnormalities and neonatal complications
    2. Sublingual Misoprostol may be used instead but higher risk of complications (e.g. tachysystole)
  2. Avoid use of K-Y or other gel at time of insertion
    1. Interferes with gel dissolving
  3. Patient remains supine for 30 minutes
  4. Monitor Fetal Heart Tones and tocometry for 3 hours
  5. Repeat every 4-6 hours as needed
  6. Wait at least 3 hours before Pitocin
  7. References
    1. Vengalil (1998) Obstet Gynecol 91:774-9 [PubMed]

VIII. Medication: Newer agents (experimental)

  1. Mifepristone (Mifeprex)
    1. Antiprogesterone
  2. Relaxin Hormone

IX. Adverse Effects

  1. Tachysystole
    1. Criteria: >10 contractions in 20 minutes (or >5 contractions in 10 minutes)
    2. Dinoprostone Tachysystole Incidence: 33%
    3. Misoprostol Tachysystole Incidence
      1. Intravaginal gel or tablet: 31 to 49%
      2. Oral crushed form or tablet: 16 to 22%
  2. Hyperstimulation
    1. Criteria
      1. Exaggerated uterine response (i.e. Tachysystole)
      2. Concerning Fetal Heart Rate tracing
        1. Late Decelerations
        2. Fetal Tachycardia >160 beats per minute
    2. Dinoprostone Hyperstimulation Incidence: 17%
    3. Misoprostol Hyperstimulation Incidence
      1. Intravaginal gel or tablet: 8%
      2. Oral crushed form or tablet: 1 to 2%
  3. Uterine Rupture in VBAC
    1. Risk: 2.5% in Trial of Labor after Cesarean
  4. References
    1. Crane (2001) Obstet Gynecol 97:926-31 [PubMed]
    2. Ravasia (2000) Obstet Gynecol 183:1176-9 [PubMed]

X. Complications: Hyperstimulation Management

  1. Consider Terbutaline SQ
  2. Dinoprostone (Cervidil): Remove
  3. Misoprostol (Cytotec): Irrigate vagina
    1. Use Normal Saline via 100 cc Syringe (no needle)
    2. Repeat several times until pill fragments recovered

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Related Studies

Ontology: Dinoprostone (C0012472)

Definition (NCI) A synthetic prostaglandin E2 (PGE2) analogue with smooth muscle contraction inducing property. It has been suggested that PGE2 regulates the intracellular levels of cyclic 3, 5-adenosine monophosphate (cAMP) by activating adenylate cyclase and thereby increases cellular membrane calcium ion transport. By acting directly on the myometrium, dinoprostone induces uterine and gastrointestinal smooth muscle contractions.
Definition (MSH) The most common and most biologically active of the mammalian prostaglandins. It exhibits most biological activities characteristic of prostaglandins and has been used extensively as an oxytocic agent. The compound also displays a protective effect on the intestinal mucosa.
Concepts Pharmacologic Substance (T121) , Hormone (T125) , Eicosanoid (T111)
MSH D015232
SnomedCT 387245009, 44798001, 22237003, 259584001
LNC LP15824-3, MTHU003620
English E2alpha, Prostaglandin, PGE2, PGE2 alpha, PGE2alpha, Prostaglandin E2, Prostaglandin E2 alpha, Prostaglandin E2alpha, E2 alpha, Prostaglandin, E2, Prostaglandin, alpha, PGE2, alpha, Prostaglandin E2, Prosta-5,13-dien-1-oic acid, 11,15-dihydroxy-9-oxo-, (5Z,11alpha,13E,15S)-, PGE2 - Prostaglandin E2 prod, PGE2 - Prostaglandin E2, PGE2 preparation, Prostaglandin E2 preparation, PGE<sub>2</sub> preparation, Prostaglandin E<sub>2</sub> preparation, dinoprostone, PGE 02, PGE 02 ALPHA, PROSTAGLANDIN E 02, PROSTAGLANDIN E 02 ALPHA, dinoprostone (medication), prostaglandins dinoprostone, Dinoprostone [Chemical/Ingredient], prostaglandin e2, e2 prostaglandin, pge2, pge2 alpha, Prostaglandin PGE>2<, Prostaglandin PGE<sub>2</sub> (substance), Prostaglandin PGE2 (substance), Prostaglandin E2 (substance), Prostaglandin PGE<sub>2</sub>, Prostaglandin PGE2, Prostaglandin PGE>2< (substance), Dinoprostone, DINOPROSTONE, Dinoprostone preparation, PGE2 - Prostaglandin E2 product, Prostaglandin E2 product, Dinoprostone product, Prostaglandin E>2< preparation, PGE>2< preparation, Dinoprostone (substance), Dinoprostone preparation (product), Dinoprostone preparation (substance)
Swedish Dinoproston
Spanish preparado de dinoprostona, preparado con prostaglandina E>2<, prostaglandina E2, preparado con prostaglandina E2, preparado con prostaglandina E<sub>2</sub>, preparado con PGE<sub>2</sub>, preparado con PGE2, dinoprostona (producto), preparado con PGE>2<, preparado con dinoprostona (producto), preparado con dinoprostona, prostaglandina PGE>2<, PGE2, prostaglandina PGE<sub>2</sub>, prostaglandina PGE2, prostaglandina PGE2 (sustancia), prostaglandina PGE<sub>2</sub> (sustancia), prostaglandina PGE>2< (sustancia), prostaglandina E2 (sustancia), dinoprostona (sustancia), dinoprostona, preparado de dinoprostona (sustancia), Dinoprostona, PGE2 alfa, Prostaglandina E2 alfa, Prostaglandina E2
Czech dinoproston
Finnish Dinoprostoni
Italian PGE2, Prostaglandina E2 alfa, Prostaglandina E2alfa, PGE2 alfa, PGE2alfa, Prostaglandina E2, Dinoprostone
German PROSTAGLANDIN E 02 ALPHA, PROSTAGLANDIN E 02, PGE 02 ALPHA, PGE 02, Dinoprostonum, Dinoproston, PGE2Alpha, PGE2, Prostaglandin E2Alpha, Prostaglandin E2
French PG-E2-alpha, Prostaglandine E2alpha, PGE-2-alpha, PGE-2, PGE2alpha, PG-E2, Prostaglandine E-2-alpha, Prostaglandine E2-alpha, PGE2, Dinoprostone, Prostaglandine E2
Polish Dinoproston, Prostaglandyna E2, PGE2
Japanese ジノプロストン, PGE2アルファ, プロスタグランジンE2, プロスタグランジンE2アルファ, プロスタグランジンE2α, プロスタグランディンE2
Portuguese PGE2, Dinoprostona, PGE2 alfa, Prostaglandina E2 alfa, Prostaglandina E2

Ontology: Cervical ripening with drug (C0404335)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 236965001
English Cervical ripening with drug, Cervical ripening with drug (procedure)
Spanish maduración cervical farmacológica (procedimiento), maduración cervical farmacológica

Ontology: Prepidil (C0592000)

Concepts Pharmacologic Substance (T121) , Eicosanoid (T111)
English Prepidil

Ontology: Cervidil (C0719232)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109) , Hormone (T125)
English Cervidil, cervidil