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Is Cytotec still used for induction? - Page 2

post #21 of 54
I'll be the voice of dissent here. I'm a home and hospital birth CNM. I've attended about 400 births in my career, with 200-250 of them being in the hospital. I would use cytotec in the hospital if my collaborating doctor would let me.

It's used, as is obvious from these postings. It's used because it's effective. The horrible things we hear are when excessive amounts are used, excessive doses are administered (in one study it was administed every four hours until active labor), administering cytotec and then adding pitocin on top of it, using it to augment labor, performing AROM during the labor, administering it to women with risk factors for uterine rupture, and not listening to or observing a woman closely enough during labor. (Thanks to loridjs! Want to give credit where it's due...)

Generally speaking, 25 mg of cytotec is unlikely to result in the effects everyone here is citing.

I recently did a literature review on the use of cytotec for outpatient preinduction cervical ripening. I found 7 articles, 2 of which were editorial/commentaries. I only have the abstracts, not the articles, but here are some of the findings:

1) A definite weakness is that all of the studies have a relatively small study group, anywhere from 49-270, usually divvied up into two groups.

2) Of the five studies, the ONLY one that makes mention of low apgar scores, fetal intolerance to labor, and/or neonatal complications was the one that used 50 mg. (total study size 270)

3) From the 25 mg studies:

"No patient had hyperstimulation or required cesarean delivery for nonreassuring fetal assessment during the ripening period." (total study size 84)

"There were no adverse outcomes in either group." (Either group being placebo or 25 mg cytotec) (total study size 68)

"No adverse effects were encountered." (total study size 60)

4) One study brought women in the evening before an induction, gave 25 of cytotec OR prepidil gel, monitored for three hours, and sent them home if everything looked good. "Misoprostol induced labor during the ripening period in 19 of 41 of patients, compared with 6 of 42 after dinoprostone" (Prepidil gel) (For the mathematically challenged, that's 46% vs 14%)

5) One study used a single dose of 25 or 50 of cytotec every 3 days for a maximum of 3 doses. The 25 mg group delivered, on average, in 3.9 days; the 50 mg group delivered in an average of 2.4 days.

6) One randomized, double blind, placebo controlled trial (the gold standard in the world of research) used a single dose of 25 mg without subsequent induction. The medication to delivery interval was 4.2 days in the misoprostol group and 6.1 days in the placebo group. For first time mothers, the interval was 4.2 days in the misoprostol group and 7.2 days in the placebo group.

7) Another randomized placebo controlled trial used 25 mg of misoprostol, followed by another 25 mg 24 hours later if undelivered, followed by admission 24 hours later for pitocin induction if still undelivered. NINETY percent of the miso group delivered within 48 hours, compared with SEVENTEEN percent of the placebo group. Average dosing to delivery time was 37 hours for the miso group and 61 hours for the control group.

Given the choice, I would rather get the cytotec and go home than go through a pitocin induction, which requires an IV and continuous monitoring.

So-confustication-how many doses and in what intervals did you get the cytotec? I would be EXTREMELY surprised if your reaction was from one dose of 25 mg, and very NOT surprised if it were anything else.

Rikki-cytotec doesn't come in 25 mg pills. It comes in 100 mg. If you got half a pill, it was 50 mg. Administering 12.5 mg is impossible, because that would require cutting a pill into 8 pieces, and it's such a small pill it's not possible. Is it possible to have a 45 minute labor on 50 mg of cytotec? Yep. On 25? Possible, but not as likely. It's also possible for a woman to have uterine hyperstimulation and fetal distress on 2 units of pitocin.

Another interesting factoid: cytotec is used in a few birthing centers.

Bottom line-cytotec is not the devil. Irresponsible use of it is. If I were able to use it, I would present my patient with all of the above information and give her a day or two to do her own research. Depending on the urgency of the induction, the MAXIMUM dosing I would do is 25 mg every 6 hours. If we have time, I'd rather follow the every 24 hour dosing study.

My STRONGEST preference, of course, is not at all, but induction is sometimes needed.

Preparing for overripe fruit flying my way.....

Jennifer
post #22 of 54
(not a BP)

I think this is the one time I'm thinking, "thank goodness I've a vbac." It is horrifying to me that stuff is still being misused in this fashion.
post #23 of 54
Jengacnm,

I appreciate your perspective on this. Unfortunately many women have cytotec used on them in less than careful way. For instance, the mom on here whose doctor's notes say that she was given half a 25mg dose when you and I both know that it only comes in 100mg doses. Her doctor made a clear mistake then by either documenting it incorrectly or giving her the wrong dose.

I met a first time mom once who was planning a natural birth with a respected CNM practice which is known for being hands off. They induced her with cytotec because she reached 41 weeks and they had lost a baby once at 42 weeks. No pitocin, only two doses (I'm not sure the amount) of cytotec. Two hours after her induction began her son was born by emergency cesearean and she had to have a blood transfusion. I don't know all the details of her story but she was a bit shocked by her traumatic birth.

There is not a standard on how to use this drug. It is used in varying does and protocols.

Quote:
Given the choice, I would rather get the cytotec and go home than go through a pitocin induction, which requires an IV and continuous monitoring...Another interesting factoid: cytotec is used in a few birthing centers.
These statements just chill me to the bone. Why should cytotec not require continuous monitoring? Especially since it can't be turned off like pitocin once its started. I for one would not go to any birth center where it was used for cervical ripening.

Please understand I'm not sending any fruit your way, but enjoy discussing this with you. You said that your collaborating doctor will not let you use cytotec. Why is this? Its obvious that you've done a lot of research on this topic but do you have any personal experience administering this drug? Please share, I appreciate your perspective.
post #24 of 54
OP, what country are you in? (I ask because you use "mum")? Cytotec is not used on the NHS AFAIK--all inductions are done with prostin (Cervidil). There were phase III trials for misoprostol for induction of labor, using a 25mcg vaginal tablet, but it hasn't been approved yet.

In some countries, there are 25mcg vaginal tablets available, and a few countries have specifically licensed misoprostol for OB/GYN use. http://www.misoprostol.org has a map.
post #25 of 54
Quote:
Originally Posted by jengacnm View Post
I'll be the voice of dissent here. I'm a home and hospital birth CNM. I've attended about 400 births in my career, with 200-250 of them being in the hospital. I would use cytotec in the hospital if my collaborating doctor would let me.
One question. Would you tell your patients that there are warnings about it, and that use for induction is off-label...or would you just give it to them?
post #26 of 54
Well then the nurse or doctor wrote the dosage incorrectly. I've got my record right here and it says "1030 1/2 25mg misoprostol". Was it ever made in 25mg dosages? This was 7 years ago.

Also, I have quick births naturally. My prior pregnancy to the one that was induced via Cytotec was 1hr23min, I was not induced and was pushing in the elevator at the hospital.

The one after that was induced with cervadil. It was in place for 12 hours with no change, they took it out and I was at 0cm. 23 minutes later she was born.

So while I can't say that the Cytotec caused hyperstim of my uterus, it was a *ton* more violent than the other two surrounding it.
post #27 of 54
Quote:
Originally Posted by Storm Bride View Post
One question. Would you tell your patients that there are warnings about it, and that use for induction is off-label...or would you just give it to them?
Actually, it's not off-label, it is contraindicated, right on the label, by Searle. They have also send "Dear Doctor" letters to discourage the use of cytotec in pregnant women.
post #28 of 54
Quote:
Originally Posted by Equuskia View Post
Actually, it's not off-label, it is contraindicated, right on the label, by Searle. They have also send "Dear Doctor" letters to discourage the use of cytotec in pregnant women.
Yes, I know. I was just wondering if the poster who wants to use it would inform her patients that it's not actually an approved use of the drug.
post #29 of 54
I didn't read through all the responses, but in my recent experience my midwife gave me Cytotec because i had a retained placenta. she tried Pitocin before that. I would never use either of these drugs BEFORE the baby comes out, but administering them for issues occuring AFTER the birth is a completely different story--- I don't see anything wrong with using these drugs if there's no baby involved. They certainly didn't hurt me.
Unfortunatley, neither drug worked on me. I had to transfer to the stupid hospital after my perfect and amazing homebirth because my stupid placenta refused to come out
post #30 of 54
I haven't read all of the responses, but I induced using Cytotec 2 years ago with my daughter. I knew the risks ahead of time and did NOT want to use it. My doula even recommended against it. But, I got to a point where I didn't have a choice. I had to be induced, no other option and it was used.

I was terrified and extremely unhappy that it came to that as my only option. I still chose to go unmedicated and had a good birth (for the most part). My baby was born a few weeks early but incredibly healthy and I am grateful things worked out the way they did.
post #31 of 54
Thread Starter 
Alexis T, I'm from England, but live in Baltimore now. There are lots of things that are done differently over there!
post #32 of 54
Yep, I had my daughter there.
post #33 of 54
I was being threatened w/ induction before I thankfully went into labor naturally w/ my 7 week old DD. This drug was the first one my OB mentioned when the discussion happened (I'm in SC, USA).
post #34 of 54
I met a first time mom once who was planning a natural birth with a respected CNM practice which is known for being hands off. They induced her with cytotec because she reached 41 weeks and they had lost a baby once at 42 weeks. No pitocin, only two doses (I'm not sure the amount) of cytotec. Two hours after her induction began her son was born by emergency cesearean and she had to have a blood transfusion. I don't know all the details of her story but she was a bit shocked by her traumatic birth.

"Two hours after her induction began" meaning two hours after the second dose and 6 hours after the first?

I'm willing to bet dollars to donuts that it was a 50 mg dose given four hours apart.

Why should cytotec not require continuous monitoring? Especially since it can't be turned off like pitocin once its started.

After oral administration, miso peaks in plasma in 12 minutes and has a 20-40 minute half life. If any hyperstimulation or fetal compromise will happen, it will happen in the first hour. Pitocin is a continuous infusion. In the above studies, women first got an NST, then got miso, then were monitored for anywhere from 1 to 4 hours before being sent home.

I for one would not go to any birth center where it was used for cervical ripening.

You wouldn't go to one, or you wouldn't choose to use cytotec if given the option? Because making that kind of sweeping judgement based on the clinical decision making of other professionals, and on the women who accept it who make an informed decision, seems a bit harsh. They don't us it willy nilly, they use it as a last resort, when all other methods have been tried, with very informed consent, on carefully selected women. They're not giving it to women on the sly or slipping it into their water. If it were offered to you, you wouldn't have to take it.

Please understand I'm not sending any fruit your way, but enjoy discussing this with you. You said that your collaborating doctor will not let you use cytotec. Why is this? Its obvious that you've done a lot of research on this topic but do you have any personal experience administering this drug? Please share, I appreciate your perspective.

I equally appreciate that this discussion is happening, and that it is happening in quite a civil manner. I haven't talked much with my doctor about it, but I'm guessing she had some sort of bad outcome from it.

My experience with it was an interesting side by side. When I was in graduate school (late 90's), I still worked as a labor and delivery nurse. At the hospital where I worked, they gave 50 mg every 4 hours. These women didn't get induced, they were launched into orbit. Crazy precipitious labors, terminal bradycardias, forceps deliveries because of low fetal heart rates, c sections, and a few abruptions. It made babies come flying out at warp speed, and moms and babies were equally stunned.

Meanwhile, down the street, at the hospital where I did clinicals, they used 25 mg every 6 hours. They experienced few, if any, of the side effects happening at the other hospital down the street. It induced women very nicely, and few of them required pitocin.

Now, storm bride:

"One question. Would you tell your patients that there are warnings about it, and that use for induction is off-label...or would you just give it to them?"

I actually find this question quite offensive. My patients don't get so much as a blood test without understanding why they're getting it. I would discuss it with them, as I would any procedure. I would share my experience with them (described above), share my literature review with them, share how irresponsible use of it led to tragic outcomes and a bad reputation. I would also share the maker's contraindication.

(By the way, the reason for them doing that is directly because of the tragic outcomes. Putting the contraindication on their drug absolves them of responsibility in a lawsuit.)

Finally, I would offer for them to come to boards like this to read about how awful it is.

If, after all that, they come back to me the next day and want to use it, we would.


Again-cytotec is not the devil, overuse/overdose of it is.

Jennifer
post #35 of 54
*removed by request*
post #36 of 54
Quote:
Originally Posted by jengacnm View Post
"Two hours after her induction began" meaning two hours after the second dose and 6 hours after the first?

I'm willing to bet dollars to donuts that it was a 50 mg dose given four hours apart.
No. It went exactly like I said. She had two doses (again I'm not sure of the amount of the dose) one hour apart and 2 hours after her first dose was given her son was born by emergency cesarean. This was less than a year ago.

Quote:
(By the way, the reason for them doing that is directly because of the tragic outcomes. Putting the contraindication on their drug absolves them of responsibility in a lawsuit.)
All drugs have some tragic outcomes when misused. Pitocin itself has had some tragic outcomes and it is approved for this use.

If this drug was as effective and safe as you (and these studies claim) then couldn't they stand to make a lot of money on this drug by researching it and proving it safe. I understand that Cytotec is dirt cheap because no research has been done on it by the manufacturer other than for ulcer research. And if they did studies regarding labor induction the cost of the drug would increase and they would be able to charge more for it.

One of the problems I see is that because both the FDA and Searle won't approve this drug for use there is no clear standard of use. There are no guidelines. Even though clinical trials have been done, differing practices use different doses throughout different timelines. You yourself have said this.
Quote:
My experience with it was an interesting side by side. When I was in graduate school (late 90's), I still worked as a labor and delivery nurse. At the hospital where I worked, they gave 50 mg every 4 hours. These women didn't get induced, they were launched into orbit. Crazy precipitious labors, terminal bradycardias, forceps deliveries because of low fetal heart rates, c sections, and a few abruptions. It made babies come flying out at warp speed, and moms and babies were equally stunned.

Meanwhile, down the street, at the hospital where I did clinicals, they used 25 mg every 6 hours. They experienced few, if any, of the side effects happening at the other hospital down the street. It induced women very nicely, and few of them required pitocin.
Perhaps most of the experience of the women shared here would be of the former group.

Quote:
After oral administration, miso peaks in plasma in 12 minutes and has a 20-40 minute half life. If any hyperstimulation or fetal compromise will happen, it will happen in the first hour. Pitocin is a continuous infusion. In the above studies, women first got an NST, then got miso, then were monitored for anywhere from 1 to 4 hours before being sent home.
Pitocin's Half life is 1-6 minutes once its turned off. Pitocin has to be an continuous infusion because it is metabolized so quickly. Source: http://www.drugs.com/pro/pitocin.html I am relieved to see that the women were monitored before going home. I read from your original post on the topic that women were just administered the drug and sent home to labor on their own for a while. That is why I expressed concern about it being used in birth centers for induction purposes. Thank you for clarifying this.
post #37 of 54
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post #38 of 54
Not a BP.

I was given cytotec to deliver our 2nd trimester stillborn son in 2005. I was given it by my midwives in hospital. I didn't ask any questions at all about it.

I was given cervadil for 38 week induction of my dd in 2006. I've actually been wondering in the last week what the difference is between the two and will now go do more research. Am hoping not to do an induction of any kind this time around, though!
post #39 of 54
Oh Jengacnm, I can't just leave you all by yourself up here!

I think people are missing the point that there is a way to use Cytotec for induction judiciously, just like there is a way to use Pitocin judiciously. If we look to the past we can see that many of the same horrors that have happened with the use of Cytotec also happened when Pitocin was first introduced. Yes, it's terrible that women were used a guinea pigs for both of these drugs and many are still being used as such by uninformed practitioners - which is why we have all these terrible stories.

At this point in time, there is research available (as our friend Jengacnm summarized so nicely) that allows for the safest usage of Cytotec as an induction drug. The same goes for Pitocin - it too can now be used safely. Which doesn't mean that either don't carry risks. And yes, everyone should be provided with information on the use of either before consenting.

Many drugs are used off label. Many, many, many drugs that are commonly used in obstetrics also carry the same warning against usage in pregnancy - Fentanyl, for example.
post #40 of 54
Quote:
Originally Posted by Equuskia View Post
Actually, it's not off-label, it is contraindicated, right on the label, by Searle. They have also send "Dear Doctor" letters to discourage the use of cytotec in pregnant women.
The only reason it's contraindicated is because it can result in birth inducing contractions.

Another that can appreciate the judicious and well informed usage of this much misunderstood drug. I wish that there were a better larger knowledge base of it.
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