Prostaglandin Gel

Aka: Prostaglandin Gel, Dinoprostone, PGE2 Gel, Cervidil, Prepidil

1. See Also
   1. Cervical Ripening
   2. Labor Induction
   3. Misoprostol (Cytotec)
2. Indications
   1. Bishop Score <6
   2. Membranes intact
   3. No active contraction pattern
      1. Less than 10 mild contractions per hour
3. Medication: Dinoprostone Gel (PGE2 Gel, Prepidil)
   1. Initiate Fetal Heart Rate and tocometry
      1. Start 15-30 minutes before gel inserted
      2. Continue monitoring for 30-120 minutes after
   2. Insertion Technique
      1. Use one syringe of gel (0.5 mg in 3cc KY)
      2. Introduce gel into Cervix
         1. Cervix not effaced: Use 20 mm catheter
         2. Cervix effaced 50% or greater: Use 10 mm catheter
         3. Intracervical is preferred over posterior fornix
            1. Perry (2004) Obstet Gynecol 103:13-7
      3. Patient remains supine for 30 minutes
   3. Dosing
      1. Repeat every 6 hours up to 3 doses in 24 hours
   4. End points
      1. Bishop Score of 8 or greater
      2. Strong uterine contractions
   5. Drug interactions
      1. Wait 6-12 hours before starting Pitocin
4. Medication: Dinoprostone Pessary (PGE2, Cervidil)
   1. Releases Dinoprostone at 0.3 mg/hour for 12 hours
   2. Insert Pessary at Cervix
   3. Monitor Fetal Heart Tones and tocometry
      1. Start 15 to 30 minutes before insertion
      2. Continue monitoring for 15 minutes after removal
   4. Remain recumbent for 2 hours after insertion
   5. Pull Pessary out via string if hyper-stimulated
5. Medication: Misoprostol (PGE1, Cytotec)
   1. Insert one fourth of 50 mcg tablet intravaginally
      1. Avoid use of K-Y or other gel at time of insertion
         1. Interferes with gel dissolving
      2. Patient remains supine for 30 minutes
      3. Monitor Fetal Heart Tones and toco for 3 hours
      4. Repeat every 4-6 hours as needed
      5. Wait at least 3 hours before Pitocin
   2. Cytotec 50 mcg orally may be preferred
      1. Effective ripening with lower hyperstimulation risk
      2. See Adverse Effects below
   3. References
      1. Vengalil (1998) Obstet Gynecol 91:774-9
6. Medication: Newer agents (experimental)
   1. Mifepristone (Mifeprex)
      1. Antiprogesterone
   2. Relaxin Hormone
7. Adverse Effects
   1. Tachysystole
      1. Criteria: >10 contractions in 20 minutes
      2. Dinoprostone Tachysystole Incidence: 33%
      3. Misoprostol Tachysystole Incidence
         1. Intravaginal gel or tablet: 31 to 49%
         2. Oral crushed form or tablet: 16 to 22%
   2. Hyperstimulation
      1. Criteria
         1. Exaggerated uterine response (i.e. Tachysystole)
         2. Concerning Fetal Heart Rate tracing
            1. Late Decelerations
            2. Fetal Tachycardia >160 beats per minute
      2. Dinoprostone Hyperstimulation Incidence: 17%
      3. Misoprostol Hyperstimulation Incidence
         1. Intravaginal gel or tablet: 8%
         2. Oral crushed form or tablet: 1 to 2%
   3. Uterine Rupture in VBAC
      1. Risk: 2.5% in Trial of Labor after Cesarean
   4. References
      1. Crane (2001) Obstet Gynecol 97:926-31
      2. Ravasia (2000) Obstet Gynecol 183:1176-9
8. Complications: Hyperstimulation Management
   1. Consider Terbutaline SQ
   2. Dinoprostone (Cervidil): Remove
   3. Misoprostol (Cytotec): Irrigate vagina
      1. Use Normal Saline via 100 cc Syringe (no needle)
      2. Repeat several times until pill fragments recovered
9. References
   1. Adair (2000) Clin Obstet Gynecol 43:447-54
   2. Crane (2001) Obstet Gynecol 97:926-31
   3. Sanchez-Ramos (1997) Obstet Gynecol 89:633-4
   4. Tenore (2003) Am Fam Physician 67(10):2123-8