II. Indications
- Bishop Score <6
- Membranes intact
- No active contraction pattern
- Less than 10 mild contractions per hour
III. Contraindications
- Contractions >3 in 10 minutes prior to placement
IV. Precautions
- 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)
- Initiate Fetal Heart Rate and tocometry
- Start 15-30 minutes before gel inserted
- Continue monitoring for 30-120 minutes after
- Insertion Technique
- Dosing
- Repeat every 6 hours up to 3 doses in 24 hours
- End points
- Bishop Score of 8 or greater
- Strong uterine contractions
-
Drug Interactions
- Wait 6-12 hours before starting Pitocin
VI. Medication: DinoprostonePessary or Vaginal Insert (PGE2, Cervidil)
- Dinoprostone 10 mg insert releases Dinoprostone at 0.3 mg/hour for 12 hours
- Insert Pessary at Cervix
- Monitor Fetal Heart Tones and tocometry
- Start 15 to 30 minutes before insertion
- Continue monitoring for 15 minutes after removal
- Remain recumbent for 2 hours after insertion
- Pull Pessary out via string if hyper-stimulated
VII. Medication: Misoprostol (PGE1, Cytotec)
- Insert 25-50 mcg tablet intravaginally (100 mcg Misoprostol tablet broken into quarters)
- Dose of 25 mcg is preferred due to less tachysystole, Fetal Heart Rate abnormalities and neonatal complications
- Sublingual Misoprostol may be used instead but higher risk of complications (e.g. tachysystole)
- Avoid use of K-Y or other gel at time of insertion
- Interferes with gel dissolving
- Patient remains supine for 30 minutes
- Monitor Fetal Heart Tones and tocometry for 3 hours
- Repeat every 4-6 hours as needed
- Wait at least 3 hours before Pitocin
- References
VIII. Medication: Newer agents (experimental)
-
Mifepristone (Mifeprex)
- Antiprogesterone
- Relaxin Hormone
IX. Adverse Effects
- Tachysystole
- Criteria: >10 contractions in 20 minutes (or >5 contractions in 10 minutes)
- Dinoprostone Tachysystole Incidence: 33%
- Misoprostol Tachysystole Incidence
- Intravaginal gel or tablet: 31 to 49%
- Oral crushed form or tablet: 16 to 22%
- Hyperstimulation
- Criteria
- Exaggerated uterine response (i.e. Tachysystole)
- Concerning Fetal Heart Rate tracing
- Late Decelerations
- Fetal Tachycardia >160 beats per minute
- Dinoprostone Hyperstimulation Incidence: 17%
- Misoprostol Hyperstimulation Incidence
- Intravaginal gel or tablet: 8%
- Oral crushed form or tablet: 1 to 2%
- Criteria
-
Uterine Rupture in VBAC
- Risk: 2.5% in Trial of Labor after Cesarean
- References
X. Complications: Hyperstimulation Management
- Consider Terbutaline SQ
- Dinoprostone (Cervidil): Remove
-
Misoprostol (Cytotec): Irrigate vagina
- Use Normal Saline via 100 cc Syringe (no needle)
- Repeat several times until pill fragments recovered