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Clinical Question
How safe and effective is vaginal misoprostol (Cytotec) for cervical ripening in a term pregnancy?
Evidence-Based Answer
Low-dose (25 meg) intravaginal misoprostol appears to be safe and effective for cervical ripening in term pregnancy for patients without a history of cesarean section. Compared with other cervical ripening methods, misoprostol has an increased rate of vaginal delivery within 24 hours without significant differences in cesarean section rates or fetal outcomes. (Strength of recommendation: B, systematic review of randomized controlled trials)
A 50-mcg dose of intravaginal misoprostol causes increased rates of uterine hyperstimulation and may be associated with an increased cesarean section rate. (Strength of recommendation: B, single prospective randomized controlled trial)
Because of a potential increased risk of uterine rupture, use of misoprostol for labor induction in women with a previous cesarean section is relatively contraindicated. (Strength of recommendation: B, large population-based retrospective cohort study)
Evidence Summary
Cervical ripening is a process that is intended to soften, dilate, and efface the cervix. An unripe cervix is generally not yet soft, is dilated less than 2 cm, and is less than 50 percent effaced. Procedures that ripen the cervix commonly are used in routine pregnancies (with an unripe cervix) that extend past 41 weeks or when complications dictate a delivery before the mother spontaneously goes into labor. Misoprostol is a synthetic prostaglandin E^sub 1^ analogue commonly used for cervical ripening and labor induction; however, it is not approved by the U.S. Food and Drug Administration for this purpose. A recent Cochrane systematic review1 of 70 studies, 13 of which were blinded, examined the use of vaginal misoprostol for cervical ripening and labor induction. Subgroup analysis of vaginal misoprostol versus other vaginal prostaglandins and versus intracervical prostaglandins found more patients delivering vaginally within 24 hours when misoprostol was used (>17 trials, number needed to treat [NNT] = 10).1 Cesarean section rates for patients receiving vaginal misoprostol and other vaginal/intracervical prostaglandins varied between studies, but no significant overall difference was found...