Misoprostol for Labour Induction after Previous Caesarean Section – Forever a “No Go”?

Abstract

Misoprostol in oral or vaginal form is an established method of labour induction worldwide. Its use after previous caesarean section is associated with a high rate of uterine rupture; according to international guidelines it is therefore contraindicated in this setting. However the evidence base for this recommendation comprises case reports, one randomised trial that was discontinued prematurely, and numerous low quality retrospective data analyses published between 1997 and 2004. New insights into e.g. resorption kinetics, dosage and application intervals, dose dependant uterine hyperstimulation rates, as well as increasing clinical experience with misoprostol have lead to a critical reappraisal of these “historical” studies. Accordingly the evidence supporting a ban on vaginal and particularly oral misoprostol for labour induction in the context of a scarred uterus is currently insufficient for a convincing guideline recommendation. In view of the clear advantages of misoprostol over prostaglandin E₂ (cheaper, more effective) a retrospective review of registry data should be conducted to determine the incidence of uterine rupture following misoprostol and the circumstances in which it occurs. A prospective, randomised trial could then be conducted on the basis of these findings (e.g. oral misoprostol vs. vaginal prostaglandin E₂); known risk factors for uterine rupture including the type of uterine scar would need to be taken into account when selecting patients for vaginal delivery. Until new data from well-designed studies are available, misoprostol will continue to be contraindicated in clinical guidelines for use in labour induction after previous caesarean section.

Zusammenfassung

Die orale oder vaginale Gabe von Misoprostol ist weltweit eine etablierte Methode zur Geburtseinleitung. Allerdings sollte Misoprostol aufgrund des hohen Risikos für eine Uterusruptur nach internationalen Leitlinienempfehlungen nicht bei Schwangeren mit vorangegangener Sectio caesarea angewendet werden. Grundlage dieser Leitlinienempfehlungen sind Fallberichte, eine randomisierte, vorzeitig beendete Studie sowie retrospektive Datenanalysen mit niedriger Qualität, die zwischen 1997–2004 publiziert wurden. Vor dem Hintergrund neuer Erkenntnisse (Resorptionskinetik, Dosierungen und Applikationsintervalle, dosisabhängige Rate uteriner Überstimulierungen) und wachsender klinischer Erfahrungen im Umgang mit Misoprostol wurden daher diese „historischen“ Studien einer kritischen Analyse unterzogen. Danach ist die Evidenz, vaginales und vor allem orales Misoprostol zur Geburtseinleitung nach vorangegangener Sectio zu verbieten, unzureichend, um daraus überzeugende, aktuelle Leitlinienempfehlungen ableiten zu können. Im Hinblick auf die evidenten Vorteile von Misoprostol (effektiver, kostengünstiger) im Vergleich zu zugelassenen, konventionellen Prostaglandin-E₂-Präparaten ist zu empfehlen, in einem retrospektiven Datenregister die Häufigkeit und Umstände von Uterusrupturen nach Misoprostol zu evaluieren. Auf der Grundlage dieses Registers könnte dann eine prospektive, randomisierte Studie (z. B. orales Misoprostol versus vaginales Prostaglandin E₂) initiiert werden, welche die Selektion für eine vaginale Geburt infrage kommender Schwangerer und die bekannten Risikofaktoren für eine Uterusruptur einschließlich der uterinen Schnittführung bei der vorangegangenen Sectio zu berücksichtigen hat. Bevor allerdings keine neuen Ergebnisse aus gut konzipierten Studien vorliegen, bleibt Misoprostol zur Geburtseinleitung nach vorangegangener Sectio entsprechend aktuellen Leitlinien kontraindiziert.

Key words

labour induction - previous caesarean section - misoprostol - uterine rupture - critical reappraisal

Schlüsselwörter

Geburtseinleitung - vorangegangene Sectio caesarea - Misoprostol - Uterusruptur - kritische Neubewertung

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