II. Indications

  1. Cervical Ripening in Labor Induction
    1. Bishop Score <6
    2. Membranes intact
    3. No active contraction pattern
      1. Less than 10 mild contractions per hour
  2. Evacuation of Uterine Contents after Fetal Death
    1. Up to 28 weeks gestation

III. Contraindications

  1. Uterine Contractions >3 in 10 minutes prior to placement
  2. Factors increasing the risk for Uterine Rupture
    1. Prior Cesarean Section
    2. Major uterine surgery with scar dehiscence risk

IV. Mechanism

  1. See Prostaglandin
  2. Dinoprostone is a synthetic Prostaglandin E2 (PGE2) analog
    1. Prostaglandin E2 (PGE2) is the most common and the most biologically active Prostaglandin
  3. Dinoprostone induces smooth Muscle Contraction in the Uterus (myometrium) and Stomach
    1. Increases cAMP levels, activating adenylate cyclase, and increasing Calcium Ion transport across cell membranes

V. Precautions

  1. Monitor Fetal Heart Rate and tocometry in Cervical Ripening
    1. Start 15 to 30 minutes before
    2. Vaginal Gel monitoring should continue for 30-120 minutes after gel placement
    3. Vaginal Insert monitoring should continue while inserted, and for 15 min after removal

VI. Medications

  1. Cervical Ripening Agents for Labor Induction
    1. Dinoprostone Gel (PGE2 Gel, Prepidil): 0.5 mg per 3 g syringe
    2. Dinoprostone Pessary or Vaginal Insert (PGE2, Cervidil): 10 mg
  2. Evacuation of Uterine Contents after Fetal Death or Termination of Pregnancy
    1. Dinoprostone Vaginal Suppository (Prostin E2): 20 mg

VII. Dosing: Dinoprostone Gel (PGE2 Gel, Prepidil) for Cervical Ripening

  1. Initiate Fetal Heart Rate and tocometry
    1. Start 15-30 minutes before gel inserted
    2. Continue monitoring for 30-120 minutes after placement
  2. Insertion Technique
    1. Use one syringe of gel (0.5 mg in 3cc KY)
    2. Patient remains supine for 30 minutes after insertion
    3. 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. Dosing
    1. May 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 Oxytocin

VIII. Dosing: Dinoprostone Pessary or Vaginal Insert (PGE2, Cervidil) for Cervical Ripening

  1. Dinoprostone 10 mg vaginal insert releases Dinoprostone at 0.3 mg/hour for 12 hours
  2. Insert Pessary into posterior fornix (adjacent to 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. Patient remains recumbent for 2 hours after insertion
  5. Pull Pessary out via string if hyper-stimulated

IX. Dosing: Dinoprostone Vaginal Suppository (Prostin E2) in Evacuation of Uterine Contents

  1. Indicated in up to 28 weeks gestation for Fetal in utero death
  2. Insert 20 mg intravaginal suppository
  3. May repeat up to every 3 to 5 hours (maximum use 2 days) as needed until uterine contents expelled

X. Adverse Effects

  1. Uterine Tachysystole
    1. Criteria: >10 contractions in 20 minutes (or >5 contractions in 10 minutes)
    2. Dinoprostone Tachysystole Incidence: 33%
  2. Uterine 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. Hyperstimulation Management
      1. Remove Dinoprostone
      2. Consider Terbutaline SQ
  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]

XI. Safety

  1. Unknown safety in Lactation
  2. Pregnancy use only in peripartum (or intended evacuation of Uterus)

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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
Russian PROSTAGLANDIN E2, PGE2 AL'FA, DINOPROSTON, PROSTAGLANDIN E2 AL'FA, PGE2, PGE2 АЛЬФА, ДИНОПРОСТОН, ПРОСТАГЛАНДИН E2, ПРОСТАГЛАНДИН E2 АЛЬФА
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
Croatian DINOPROSTON
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: 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