Induction of Labor: The Misoprostol Controversy

Alisa B. Goldberg, MD, MPH, Deborah A. Wing, MD

Disclosures

J Midwifery Womens Health. 2003;48(4) 

In This Article

Trial of Labor After Cesarean Delivery

Misoprostol has been associated with uterine rupture among women attempting vaginal birth after cesarean delivery.[34,35,36] The first randomized controlled trial of 25 mcg of vaginal misoprostol for induction of labor among women with one prior cesarean delivery was terminated after two women in the misoprostol group had disruption of their uterine scar.[35] No further prospective trials of misoprostol for induction of labor among women with a prior cesarean have been conducted.

In a retrospective study of 512 women attempting vaginal birth after cesarean delivery, 5.6% of women treated with misoprostol had symptomatic uterine rupture compared to 0.2% of the women undergoing a trial of labor without misoprostol (P < .001).[36] Other studies have similarly demonstrated an increased risk of uterine rupture in women with a previous cesarean undergoing an induction of labor with prostaglandin E2.[37,38,39] The reported uterine rupture rates with prostaglandin E2 range from 2.5% to 3.9% compared to uterine rupture rates ranging from 0.45% to 0.7% when labor begins spontaneously.[37,38,39] In one large population-based study, a time-trend analysis demonstrated similar uterine rupture rates with prostaglandin-induced labor before and after the introduction of misoprostol for labor induction.[39]

It remains unclear whether misoprostol alone increases the frequency of uterine rupture among women attempting vaginal birth after cesarean delivery, or if induction of labor with any agent in a woman with a scarred uterus and an unfavorable cervix confers increased risk. Nonetheless, misoprostol should not be given for induction of labor in women with a uterine scar.

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