Update on Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose

Last August, I argued against ACOG’s current position on inducing labor with misoprostol, which is that misoprostol is safe “when used appropriately” (p. 387), by which ACOG means provided it is used in doses no greater than 50 micrograms in women with an unscarred uterus. In March, I started work on the induction chapter for the new edition of Obstetric Myths Versus Research Realities, and I decided to see if I could find evidence that ACOG’s confidence was misplaced. I looked for reports of misoprostol catastrophes occurring in U.S. hospitals in women with unscarred uteruses who received no more than 50 microgram doses of misoprostol. I found 11 cases fitting my criteria. Two were single case reports: a uterine rupture leading to hysterectomy in a woman induced solely with two 25 microgram vaginal doses of misoprostol, and a uterine rupture leading to stillbirth and hysterectomy in a woman induced solely with one 25 microgram vaginal dose. The other nine were reported in a case series of severe adverse events following misoprostol induction vaginally or, in one case, orally. All nine women experienced uterine hyperstimulation, which in seven cases was reported as accompanied by severely abnormal fetal heart rate, meconium, or both. The nine cases of hyperstimulation resulted in a total of two cases of uterine rupture, five cases of permanent fetal neurologic injury, two perinatal deaths, and three maternal deaths. One woman with uterine rupture experienced disseminated intravascular coagulation, a life-threatening consequence of severe hemorrhage, and three women had diagnoses of amniotic fluid embolism (AFE). The AFE cases resulted in a maternal death, a maternal death and a brain injured child, and a maternal and perinatal death among the mother-baby pairs. We probably have a twelfth case in comment #17 to the original blog post, but not enough information is given to be sure. (Maddy Oden also posted a comment, but Tatia Oden French’s case is the third of the three AFE cases reported in the case series, a case, by the way, in which Maddy tells me that the coroner’s report mentions AFE but lists the cause of maternal death as “natural causes: cardiac arrest.”)

We’re not done yet. I also ran across a study comparing 95 pre-eclamptic women undergoing pre-induction cervical ripening with vaginal misoprostol with 108 women having ripening with prostaglandin E2. Among women receiving misoprostol, 18% had cesareans for fetal heart rate abnormalities, A.K.A. fetal distress, versus 8% of those having prostaglandin E2, and 14% having misoprostol experienced placental abruption (the placenta detaches partially or completely before delivery) versus 2% receiving prostaglandin E2. So it isn’t just women with cesarean scars who are at especially high risk with misoprostol inductions but women with severe hypertension as well.

I don’t know about you, but if there were a compelling medical reason why I needed labor induced—and most inductions do not fall in this category—and the situation was, moreover, of such concern that induction could not wait for cervical readiness to labor, I would insist on using some means other than misoprostol.

3 Comments

Update on Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose

October 7, 2010 07:00 AM by Healthy Pregnancy, Healthy Baby « Healing Children Through Healthy Eating
[...] the end, the doctors induced me right on my due date, gave me cytotec (click here for more info on cytotec), augmented it with pitocin, which led to my uterus spasming uncontrollably, which led to an [...]

Update on Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose

October 18, 2012 07:00 AM by What You Should Know About…. Cytotec | Crème De La Birth
[...] Science & Sensibility: Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose [...]

In 2008, my water broke with d

October 9, 2015 07:00 AM by Kacie
In 2008, my water broke with delayed onset of labor, augmented with Cervidil. My CNM in a hospital setting wanted to do misoprostol, and I declined (my Bradley instructor cautioned against and I agreed!). Three hours before he was born, my preeclampsia diagnosis came back from the labs. In 2010, I had my 2nd child and again had preeclampsia, which got severe in the 12 hours postpartum. Spontaneous labor, no augmentation. The birth itself was pleasant. In 2013, I had my third child and I had to push my OB to induce me at 38w, despite preeclampsia showing up this time at 35w5d. This time, I was on labetelol and I still had unacceptable BPs. And I had to push to be induced, despite studies showing outcomes of inducing at 37 are much better. ANYWAY -- my OB reluctantly agreed and she wanted to do misoprostol. Are you flipping kidding me? Let's just explode this child right out of me. So we did pitocin, my baby was born (exploded out of me -- 7cm to out in 14 mins and a nurse barely caught) my BP immediately started to correct (though I remained on labetelol for a few weeks) and I was showing signs of cerebral involvement with brisk reflexes and beats of clonus in my ankles. If we waited much longer, I don't think we would have had as favorable of an outcome. I can't know for sure, but I do worry about what would have happened to me if I had misoprostol. I was able to advocate for myself, but what about moms who aren't? It's unacceptable.

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