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Low-Dose Oral Misoprostol for Induction of Labor: A Systematic Review

Kundodyiwa, Timothy W. MB ChB, MRCOG; Alfirevic, Zarko MD, FRCOG; Weeks, Andrew D. MD, MRCOG

doi: 10.1097/AOG.0b013e3181945859

OBJECTIVE: To estimate the efficacy and safety of low-dose oral misoprostol compared with dinoprostone (PGE2), vaginal misoprostol, and oxytocin for labor induction in women with a viable fetus.

DATA SOURCES: We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published before January 2008 using the keywords misoprostol, labor, induction, randomized controlled trials, dinoprostone, oxytocin, pregnancy, and maternal and fetal side effects.

METHODS OF STUDY SELECTION: We included randomized controlled trials comparing 20–25 micrograms oral misoprostol with vaginal misoprostol, dinoprostone or oxytocin given to women at 32–42 weeks of gestation for labor induction. From 401 citations identified, results from nine studies were finally analyzed using the Review Manager software. Relative risk (RR) and 95% confidence intervals (CIs) were calculated using fixed and random-effects models.

TABULATION, INTEGRATION, AND RESULTS: Nine articles with 2,937 women met the inclusion criteria. The five trials comparing oral misoprostol and dinoprostone showed significantly fewer women requiring cesarean delivery in the misoprostol group (20% compared with 26%; RR 0.82, 95% CI 0.71–0.96). There were no statistically significant differences in risks of uterine hyperstimulation or need for oxytocin augmentation. Two trials compared oral with vaginal low-dose misoprostol. Women using oral misoprostol were significantly less likely to experience uterine hyperstimulation with fetal heart rate changes (2% compared with 13%; RR 0.19, 95% CI 0.08–0.46), but there were no significant differences in other outcomes.

CONCLUSION: Low-dose oral misoprostol solution (20 micrograms) administered every 2 hours seems at least as effective as both vaginal dinoprostone and vaginal misoprostol, with lower rates of cesarean delivery and uterine hyperstimulation, respectively.

Low-dose oral misoprostol is at least as effective as both dinoprostone and vaginal misoprostol for induction of labor.

From the 1Liverpool Women's NHS Foundation Trust, Liverpool, United Kingdom; and 2Division of Perinatal and Reproductive Medicine, University of Liverpool, Liverpool Women's Hospital, Liverpool, United Kingdom.

Corresponding author: Dr. A. Weeks, School of Reproductive and Developmental Medicine, Liverpool Women's Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK; e-mail:

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2009 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.