Slow release vaginal insert of misoprostol versus orally administrated solution of misoprostol for induction of labor in primiparous term pregnant women: a randomized clinical trial.

Objective To compare the World Health Organization (WHO) recommended orally administrated dosage of misoprostol (25 mu g) with a vaginal slow-release (7 mu g/hour) insert of misoprostol regarding time from induction to delivery and safety of the method. Design Open label, Randomised controlled trial (RCT). Setting Delivery ward at a secondary referral hospital in Stockholm, Sweden, from 1 October 2016 to 21 February 2018. Population One hundred and ninety-six primiparous women with singletons in cephalic presentation at >= 37 weeks of gestation and with a Bishop score of <= 4. Methods Women were randomised to an oral solution of misoprostol (Cytotec (R) n = 99) or vaginal slow-release misoprostol (Misodel (R) [MVI] n = 97). Main outcome measures Primary outcome: time from induction to vaginal delivery. Secondary outcomes: mode of delivery; proportion of vaginal deliveries within 24 hours (VD24); neonates with an Apgar score of pH < 7.10; postpartum haemorrhage (PPH) of >1000 ml; hyperstimulation; and women's delivery experience (VAS). Results There was no difference in the time to vaginal delivery (median 21.1 hours in the MVI group and 23.2 hours in the oral group; Kaplan-Mayer log rank P = 0.31). There was no difference regarding the proportion of VD24 (50.5 versus 55.7%, P = 0.16). Hyperstimulation with non-reassuring cardiotocography (CTG) was more common in the MVI group (14.4 versus 3.0%, P < 0.01). Terbutaline (Bricanyl (R)) was used more often for hyperstimulation in the MVI group (22.7 versus 4.0%, P < 0.01). There was no difference in the numbers of children admitted to the neonatal intensive care unit (NICU). Conclusions Vaginal delivery after induction of labour (IOL) with slow-release misoprostol did not result in a shorter time from induction to vaginal delivery, compared with oral misoprostol solution, but was associated with a higher risk for hyperstimulation and fetal distress. There were no differences in mode of delivery or neonatal outcome. Tweetable abstract IOL with MVI was similar to oral solution of misoprostol but hyperstimulation and fetal distress were more common.