title: Titrated oral misoprostol solution for induction of labour: a multi-centre, randomised trial.
abstract: OBJECTIVE
  To determine the effects of titrated oral misoprostol solution, compared with vaginal dinoprostone.
  
  
  METHODS
  Open, randomised clinical trial.
  
  
  METHODS
  Academic hospitals in South Africa and Liverpool, UK.
  
  
  METHODS
  Women undergoing induction of labour after 34 weeks of pregnancy were allocated by randomised, sealed opaque envelopes, to induction of labour with titrated oral misoprostol solution, or two doses of vaginal dinoprostone (2mg) administered six hours apart. Failure to deliver within 24 hours of randomisation was the primary outcome on which the sample size was based. The data were analysed by intention-to-treat.
  
  
  RESULTS
  Six hundred and ninety-five women were randomly allocated: 346 to oral misoprostol and 349 to vaginal dinoprostone. There were no significant differences in substantive outcomes. Vaginal delivery within 24 hours was not achieved in 38% of women in the oral misoprostol group and 36% in the vaginal dinoprostone group (RR 1.08; 95% CI 0.89-1.31). The caesarean section rates were 16% and 20%, respectively (RR 0.80; 95% CI 0.58-1.11). Hyperstimulation with fetal heart rate changes occurred in 4% of women in the oral misoprostol group and 3% after vaginal dinoprostone (RR 1.32, 95% CI 0.59-2.98). The response to induction of labour in women with unfavourable cervices was somewhat slower with misoprostol when membranes were intact, and with dinoprostone when membranes were ruptured. There were no differences in neonatal outcome between the two groups.
  
  
  CONCLUSIONS
  This new approach to oral misoprostol administration was successful in minimising the risk of uterine hyperstimulation, which has been a feature of misoprostol use for induction of labour, at the expense of a somewhat slower response in women with intact membranes and unfavourable cervices. Misoprostol is not registered for use in pregnant women, and further research is needed to confirm optimal and safe dosages.
authors.affiliation: Department of Obstetrics and Gynaecology, Frere/Cecilia Makiwane Hospitals and Effective Care Research Unit, University of Witwatersrand, South Africa.
authors.forename: G J
authors.initials: GJ
authors.lastname: Hofmeyr
authors.forename: Z
authors.initials: Z
authors.lastname: Alfirevic
authors.forename: B
authors.initials: B
authors.lastname: Matonhodze
authors.forename: P
authors.initials: P
authors.lastname: Brocklehurst
authors.forename: E
authors.initials: E
authors.lastname: Campbell
authors.forename: V C
authors.initials: VC
authors.lastname: Nikodem
mesh_terms: D000282:Administration, Intravaginal; D000284:Administration, Oral; D000328:Adult; D015232:Dinoprostone; D005260:Female; D006801:Humans; D007751:Labor, Induced / Q000379:methods*; D016595:Misoprostol; D010120:Oxytocics; D011247:Pregnancy; D016896:Treatment Outcome
chemical_list: D010120:Oxytocics; D016595:Misoprostol; D015232:Dinoprostone