L Sanchez-Ramos’s research while affiliated with University of Florida Health Science Center and other places

(BJOG. 2015;122(4):468–476) Approximately half of all women who undergo labor induction will have an unfavorable cervix that requires ripening. Prostaglandins, which are often used for pharmacological cervical ripening, have the advantage of not only ripening the cervix, but also stimulating myometrial contractility.

Background The optimal dose of misoprostol for the induction of labour remains uncertain.Objectives To compare the efficacy and safety of 25 versus 50 micrograms of intravaginal misoprostol tablets for the induction of labour and cervical ripening.Search strategyWe performed electronic and manual searches to identify relevant randomised trials.Selection criteriaThe efficacy outcomes assessed were rates of vaginal delivery within 24 hours, delivery within one dose, and oxytocin augmentation, and interval to delivery. The safety outcomes assessed were incidences of tachysystole, hyperstimulation, caesarean delivery, cesarean delivery for non-reassuring fetal heart rate (FHR), operative vaginal delivery, abnormal 5-minute Apgar score, abnormal cord gas values, admission to a neonatal intensive care unit (NICU), and meconium passage.Data collection and analysisThirteen studies (1945 women) were included. Relative risk (RR) and 95% confidence intervals (CI) were calculated using fixed-effects and random-effects models.Main resultsWe found that 25 micrograms was less efficacious, with lower rates of delivery after one dose (RR 0.59; 95% CI 0.39-0.88) and vaginal delivery within 24 hours (RR 0.88; 95% CI 0.79-0.96), and with increased rates of oxytocin augmentation (RR 1.54, 95% CI 1.36-1.75). We noted an improved safety profile with 25 micrograms, however, with decreased rates of tachysystole (RR 0.46; 95% CI 0.35-0.61), hyperstimulation (RR 0.5; 95% CI 0.31-0.78), caesarean deliveries for non-reassuring FHR (RR 0.67; 95% CI 0.52-0.87), NICU admissions (RR 0.63; 95% CI 0.4-0.98), and meconium passage (RR 0.65; 95% CI 0.45-0.96).Conclusions Although 50 micrograms of intravaginal misoprostol may be more efficacious, safety concerns make the 25-microgram dose preferable.

To investigate the relationship between cervical length (CL) at 37 to 40 weeks and delivery within 7 days and delivery by 41 weeks. We performed transvaginal ultrasound to measure CL in women with singleton gestations at 37 to 40 weeks. We then used a receiver operating characteristic curve (ROC) to assess the relationship between CL and delivery within 7 days and delivery by 41 weeks. For the 120 women included in the analysis, the mean CL (+/-s.d.) was 25.3+/-9.8 mm. The logistic regression model to predict each of the outcomes includes gestational age at ultrasound (GA-US) and CL. Neither birthweight, nor parity seems to affect the probability of delivery within 7 days. The ROC curve was used to assess the probability of spontaneous labor within 7 days at each CL measurement. The likelihood ratio of delivery within 7 days when CL is < or = 10 mm is 12. CL measurement at 37-40 weeks is an independent predictor of delivery within 7 days and delivery by 41 weeks regardless of GA-US. This information can be utilized when counseling patients regarding the management of term pregnancies.

Within the obstetric community, several studies suggest that cervical ripening and labor induction after 40 weeks' gestation leads to improved maternal and neonatal outcomes. The most effective drug regimen to safely promote labor has not been determined. Forty-nine subjects followed in an outpatient obstetrical clinic with pregnancies of at least 40 weeks' gestation, and an unfavorable Bishop score were assigned randomly to receive oral misoprostol 50 or 25 microg every 3 days for a maximum of three doses. Twenty-three subjects received misoprostol 25 microg and 26 received 50 microg. The mean interval (+/-standard deviation) from start of cervical ripening to delivery was 2.4 days +/-0.3 vs. 3.9 days +/-0.7 for the 50 and 25 microg groups (P<0.05). No adverse events were noted. However, due to small sample size, less frequent adverse events may be missed. Type II errors cannot be excluded. In the prevention of postdate pregnancy, outpatients use of oral misoprostol 50 microg appears to result in earlier delivery, as compared to 25 microg.

To determine whether human chorionic gonadotropin (hCG) detected in cervicovaginal secretions of patients with symptoms suggestive of preterm labor is a predictor of preterm birth. Women presenting to labor and delivery with symptoms of preterm labor were invited to participate. After collecting secretions with a cotton-tipped applicator from the posterior fornix and endocervical canal, we placed the swab in a test tube containing 1 ml of normal saline. From this solution, we performed qualitative and quantitative hCG measurements. Qualitative and quantitative hCG results from women who delivered at term were compared with those delivering prior to 37 weeks' gestation. Samples were obtained and analyzed from 86 women at a mean (+/- standard deviation) gestational age of 30.7+/-2.9 weeks. Of the 86 subjects enrolled, 28 (32.6%) delivered preterm. A positive rapid qualitative assay from cervicovaginal secretions between 24 and 34 weeks' gestation was associated with a significant increase in the incidence of preterm delivery (relative risk 2.62, 95% confidence interval (CI) 1.38, 4.98). The likelihood ratios for a positive and negative test were 2.19 (95% CI 1.35, 3.56) and 0.51 (95% CI 0.30, 0.85) respectively. Using a cut-off of 19 mIU/ml, similar diagnostic accuracy for predicting preterm birth was obtained with the quantitative test 1.93 (95% CI 1.14, 3.26) and 0.62 (95% CI 0.40, 0.98). Qualitative and quantitative hCG measurements from cervicovaginal secretions may be useful predictors of preterm birth in symptomatic patients. The qualitative hCG test can be used at the bedside with results obtained in minutes.