So can we talk about cytotec...

[AugustLia23]

After being terrified from these horror stories of cytotec and uterine rupture, and then blindly warning my clients on the horrors of it, I've finally actually done some research into the current studies done on cytotec and it's effects. Let me first say that I am NOT trying to say that it is for sure a safe drug, but from the studies that have been done(and done well) judicious us of it can be used to safely induce labor when indicated.

True, cytotec is not approved for it's usage in obstetrics, but then again, neither is terbutaline(brethine, to stop pre-term labor), or fentanyl or reglan, all of which are very widely used. Isn't the main reason it's unapproved simply because it's such a cheap med, and there would be no money to be made in doing an official study of it.

Almost all of the rupture, HIE, and Amniotic fluid embolism stories that I have heard are either 1. because mom had previously had a c-section, regardless of type, 2. because they gave mom too much of the drug too often, or 3. the drug was clearly contraindicated in the mom-to-be(i.e. grand multiparity).

From what I've read, a low dose given to the right woman can induce labor very well pretty closely to how she may have gone into labor on her own(not like the mack truck labors that pitocin can bring). Of course it is far from perfect, but maybe it needs some closer inspection before we can just outrightly say that cytotec is always a terrible drug and very, very dangerous for everyone.


:


ETA: I am not in any way suggesting that it be used more often, just thinking about the few times where induction really can be beneficial to mother and baby...

[bryonyvaughn]

I think it's great that Cytotec can help *some* moms without causing fertility and life threatening side effects. My problem with Cytotec is they can't predict who it will help, who it will lead to a cascade of interventions, and who it will cause to lose her uterus or life.

I really can't rationalize the use of Cytotec WHEN women can get a more effective dose of prostaglandins from human semen and can supplement with essential fatty acids to build their own prostaglandins AND neither increase risk of uterine rupture.

~BV

[katja]

A brave woman you are, AugustLia! :

[wannabe]

The off-label use argument has never held water with me - aren't some huge percentage of all prescriptions for off-label uses?

I really can't rationalize the use of Cytotec WHEN women can get a more effective dose of prostaglandins from human semen

and that would require vaginal application, wouldn't it? As opposed to oral cytotec with ruptured membranes.

and can supplement with essential fatty acids to build their own prostaglandins

reference?

[pamamidwife]

the issue with cytotec is its unpredictability - one never knows how a woman will respond to cytotec. it's also the cavalier attitude that the 'cure' to a problem with cytotec is easy - a cesarean.

I think the broader issue we should be looking at is the induction epidemic. not just from hospital based births, but also homebirths. why are we so set on dates and the idea that a woman's body is set out to fail a baby because of a timeline?

Induction is something that is ruining births - and the health of babies and mothers - all because of a manmade idea of dating.

[pamamidwife]

Originally Posted by wannabe

and that would require vaginal application, wouldn't it? As opposed to oral cytotec with ruptured membranes.

well, it seems many providers have no issue sticking their fingers up inside women with ruptured membranes and NO contractions.

I think the problem is not looking at the evidence - that women with ruptured membranes do better in a wait and see (meaning, no fingers climbing up inside you every two hours) situation than induction.

[wannabe]

But there needs to be an end to that wait and see, when the odds of labour starting drop below the odds that an infection will (even in someone with good care - nil by vagina). At some point, in a woman significantly past her due date, with ruptured membranes and no real uterine activity at all, you're going to start running a risk of infection that outweighs the risk of induction. Sure, it's not at 24 hours, but it's somewhere in those couple of weeks.

[mwherbs]

There are some very large multi-center trials that I am waiting to read about before I say yea or no-- so far the way they have arrived at a criteria is to have experimented on the mom/baby pair and produced some serious consiquences -
the multi-center trials that were done in 2006 compare a newer vaginal application of cytotec that would have 50 or 100 mcg to cervidil
--- here was their criteria list--

"Ages Eligible for Study: 18 Years and above,
Genders Eligible for Study: Female

Inclusion Criteria:
* Pregnant women at least 36 weeks gestation requiring cervical ripening and induction of labor

Exclusion Criteria:
* No uterine scar (no previous delivery by cesarean section)
* No multiple gestation
* No condition that disallows use of prostaglandins for induction of labor
* No more than 3 previous vaginal births beyond 24 weeks gestation"

---------------------------
so a pretty narrow group to begin with and after talking with CNMs who have had some experience in hospitals they wondered why there wasn't a 25mcg amount- so I wrote the researchers and the reply I received was because the effect was the same as cervadil or less at 25 and that there were 2 studies one in 02 and one in 03 that pointed to the higher amounts.
other than hemorrhage I think it has no place in out of hospital birth- and I am not won over that it is safe for in hospital birth- it is certainly cheaper than cervadil -- the African study published this year still using tabs instead of a vaginal insert - came up with unpredictable results --so I still just don't know- I wouldn't want my daughter to use it...

[bryonyvaughn]

Originally Posted by wannabe

The off-label use argument has never held water with me - aren't some huge percentage of all prescriptions for off-label uses?

I didn't make it.

Originally Posted by wannabe

Originally Posted by bryonyvaughn

I really can't rationalize the use of Cytotec WHEN women can get a more effective dose of prostaglandins from human semen

and that would require vaginal application, wouldn't it? As opposed to oral cytotec with ruptured membranes.

: No. :

In fact everything I've read has indicated it's more effective orally than topically. That make sense if the prostaglandins are not inducing labor but giving the woman something she can break down to build her own hormones (hence the effectiveness of EFA supplementation.)

Originally Posted by wannabe

Originally Posted by bryonyvaughn

and can supplement with essential fatty acids to build their own prostaglandins

reference?

Nope. I thought it was a soundly and widely established physiological fact. I googled "essential fatty acids" +prostaglandins and got over 1/4 million sites. I nursed the baby to sleep at the keyboard so I can't dig out my physiology books right now. LMK if you want some text book references. I can get them when I get back online tonight.

~BV

[AugustLia23]

Nice to see such civil responses, I was almost afraid to check on this post I created for fear of some serious flaming.

I wonder what it is in the woman or the cytotec that causes some women to respond so well to it, some women not to respond at all, and some women to have these catastrophic events...

[crsta33]

Are there any of the serious side effects when it is used to stop post partum hemmorage? Is that also "off label" use? Is it more effective than IM pitocin?

This discussion just got me wondering.

Christa

[mwherbs]

the minor side effects yes fairly common- fever and nausea
I think that there has been one older report of a maternal death when it was used to stop hemorrhage-

here is a link to an older review
http://www.pubmedcentral.nih.gov/art...medid=17273309

[courtenay_e]

Originally Posted by crsta33

Are there any of the serious side effects when it is used to stop post partum hemmorage? Is that also "off label" use? Is it more effective than IM pitocin?

This discussion just got me wondering.

Christa

It's funny you should ask that question, because I asked the same question of a room full of midwives recently, when they were talking about how cytotek is the wonder drug for pp hemmorage. I have had it used on me to expel a tubal pregnancy (long time ago, long story), and it was a freaking nightmare. I thought I was going to die. My mother and husband were also seriously concerned for my health and well being...and they are usually the last people to become concerned about anything like that. It's NOTHING like real labor, by the way. I've had two live births since, and it is NOTHING like a labor that is naturally induced. Or it wasn't for me, anyway! From what I know NOW, it seems that they used about ten times the recommended dose (tablets used vaginally), so the WAY I labored makes complete sense...the problem is that is seems around here that every practitioner uses their own favorite dose, there is no norm...though I'm not sure about pp hemmorage.

but my question to the group was actually if any of THEM had ever had it used on THEM. Not to be cranky, but to see if THEY had ever experienced the contractions that it induces, and whether they knew if that same kind of CRAZY strong, to the point of frightening, contractions were the kind that you get if it's applied rectally to stop a bleed. I suppose that a common thought on this might be, "Who cares how it feels if you don't bleed to death?" BUT...it was a frightening experience. And I've also hemmoraged post partum, and that is frightening and exhausting in itself, and I don't know that I'd have fared it as well with a cytotek experience on top of that...

I guess that there are just too many questions for me to feel comfortable using it on a client when I am a midwife, or being comfortable attending a birth as a doula if it's used in a hospital. I, too, will be interested to see the studies when they come out.

[cottonwood]

and can supplement with essential fatty acids to build their own prostaglandins

Also, zinc is important in the process of converting EFAs into prostaglandins. Prostaglandin inhibitors are cortisone, aspirin, acetaminophen, and ibuprofen. Apparently vitamin E is a prostaglandin inhibitor also (it's suggested for relief of menstrual cramping) but I wonder if it affects all prostaglandins or just inflammatory ones? I don't have enough time or interest to do the research right now, but just thought I'd mention it...

[pamamidwife]

Originally Posted by wannabe

But there needs to be an end to that wait and see, when the odds of labour starting drop below the odds that an infection will (even in someone with good care - nil by vagina). At some point, in a woman significantly past her due date, with ruptured membranes and no real uterine activity at all, you're going to start running a risk of infection that outweighs the risk of induction. Sure, it's not at 24 hours, but it's somewhere in those couple of weeks.

See, I disagree. With most infections, you will see it within the first 12 hours after rupture or within 12 hours of the first vaginal exam. Definitely if you're dealing with signs of an infected baby, do you really want the unpredictability of cytotec involved? Give me pitocin instead.

[bluegrassgirl]

After reading the book "Born In The USA" and hearing all about these women who have died after being induced with Cytotec, I would never want it in my body. You can have bad side effects from with WITHOUT having a prior C-Section scar. I read online that some first time mom's have had to have hysterectomy's and have died after being induced with Cytotec. Plus, I have read that Cytotec causes more fetal stress than any other labor inducing medicine on the market.

Jessie
(single mommy to Emma, 3 years and Angela, 2 years)

[bryonyvaughn]

Me: and can supplement with essential fatty acids to build their own prostaglandins

Originally Posted by wannabe

reference?

From my class notes:
EFAs are converted to polyunsaturated fatty acids (PUFA).
Some of the PUFAs are substrates for eicosanoid biosynthesis which leads to the production of prostaglandins, leukotrienes & lipoxins.

Not a journal reference but hopefully should give you enough buzzwords to narrow down and increase the effectiveness of your googling.

BV, who's so old she did medical research before Google

[pamamidwife]

thanks, BV - it's a perfect explanation as to why Evening Primrose oil *could* work to soften the cervix.

[mwherbs]

from what I understand misoprostol is a synthetic prostaglandin E1 (PGE1) analogue and that it isn't "food" for your body to turn into something it is similar to what the body produces a signaling molecule- and probably why it is problematic is that the body makes cascades of things not just a single element to bring on birth
-.
our bodies need essential fatty acids for many things it does- we have to eat them because our bodies cannot make linoleic acid --- but we have some parallel path ways for different forms of linoleic acid-- there is omega 3 oils and they do not create as much inflammation.
eicosanoids are signaling molecules derived from omega-3 (ω-3) or omega-6 (ω-6) fats---- for most of us in our current lifestyle and dietary habits we get too much of the omega 6 oils and not enough of omega 3- the ratio should be1-1 to as much as 4 times more omega 3 to the amount of omega 6 we eat.
when converting omega 6 oils into eicosanoids the going through the arachadonic acid cascade the side effect is far more inflammatory products are produced- which translates into pain- omega 3 can put out similar eicosanoids but with much less inflammatory by-products
---------------------------------------------------------------------
eicosanoids are the signaling molecules that include prostaglandins, prostacyclins, leucutrines and thromboxane
--------------------------------------------------------------------
here is an abstract that can somewhat speak to the complexity of the subject
it is dealing with the eicosanoids and the actions they have on the heart-so even if it is not talking about the uterus it shows how complex the different signaling bio-chemicals are labor is more than the uterus contracting it also relaxes inbetween the body needs to produce a group of complementary bio-chemicals and hormones to fill out the process--

Prostaglandins. 1997 Aug;54(2):511-30.

Differential effects of various eicosanoids on the production or prevention of
arrhythmias in cultured neonatal rat cardiac myocytes.

Li Y, Kang JX, Leaf A.

Department of Medicine, Massachusetts General Hospital, Charlestown 02129, USA.

To identify the arrhythmogenic and the antiarrhythmic eicosanoids, cultured,
spontaneously beating, neonatal rat cardiac myocytes were used to examine the effects of various eicosanoids added to the medium superfusing the cells at different concentrations on the contraction of the myocytes. Superfusion of the myocytes with the prostaglandins (PGD2, PGE2, PGF2 alpha) or the thromboxane (TXA2)-mimetic, U 46619, induced reversible tacharrhythmias characterized by an increased beating rate, chaotic activity and contractures. These effects are concentration-dependent. PGF2 alpha and U 46619 were much more potent than PGD2 or PGE2 in the production of tachyarrhythmias. Prostacyclin (PGI2) induced a marked reduction in the contraction rate of the cells with a slight increase in the amplitude of the contractions and showed a protective effect against the arrhythmias induced by PGF2 alpha and TXA2 (U 46619). PGE1 exerted a dose-dependent dual effect on the contraction of the myocytes. At low concentrations (< 2 microM), PGE1 reduced the contraction rate of the cells with an increase in the amplitude of the contractions and effectively terminated the tachyarrhythmias induced by arrhythmogenic agents, such as isoproterenol, ouabain and U 46619. At higher concentrations (> 5 microM), PGE1 caused cell contractures and chaotic activity. In contrast, the lipoxygenase products [leukotriene (LT) B4, LTC4, LTD4 & LTE4] of arachidonic acid (AA) had no significant effect on the myocyte contractions. The eicosanoids derived from eicosapentaenoic acid (EPA), including both the cyclooxygenase products (PGD3, PGE3, PGF3 alpha, TXB3) showed
lesser effects on the contraction of the myocytes. The lipoxygenase products
(LTB5, LTC5, LTD5 & LTE5), as with the AA metabolites showed little effect on the contraction of cardiac myocytes. The arrhythmias induced by the arrhythmogenic prostaglandins and thromboxane A2 could be suppressed by the nonmetabolizable AA analog eicosatetraynoic acid (ETYA) or free AA and EPA, indicating a distinction in the effect on cardiac arrhythmia between the precursor fatty acids (AA & EPA) themselves and their metabolites. In conclusion, the major arrhythmogenic eicosanoids are the cyclooxygenase products of AA, whereas those products of EPA are much less or not effective; PGE1, PGI2, ETYA and EPA have antiarrhythmic effects.

Publication Types:
Research Support, U.S. Gov't, P.H.S.

PMID: 9380795 [PubMed - indexed for MEDLINE]
---------------------------------------------

here is a link on essential fatty acids- and a cascade that shows production ----
http://en.wikipedia.org/wiki/Essenti...d_interactions

[etoilech]

Originally Posted by pamamidwife

the issue with cytotec is its unpredictability - one never knows how a woman will respond to cytotec. it's also the cavalier attitude that the 'cure' to a problem with cytotec is easy - a cesarean.

I think the broader issue we should be looking at is the induction epidemic. not just from hospital based births, but also homebirths. why are we so set on dates and the idea that a woman's body is set out to fail a baby because of a timeline?

Induction is something that is ruining births - and the health of babies and mothers - all because of a manmade idea of dating.

Absolutely. I think induction is such a *false* bill of goods and when it is most needed or wanted, it is most likely to fail.

The argument over cytotec (misoprostol) is moot for me. Where I live misoprostol is contraindicated during pregnancy. Period. Anyone giving it pregnant women here would risk losing their license.

I also agree with Pam, *if* there is going to be infection you are very likely to see it in the first 12 hours. Best practice and clinical evidence suggests watchful waiting for prolonged rupture of membranes.