Dinoprostone

Cervical Ripening in Labor Induction
1. Bishop Score <6
2. Membranes intact
3. No active contraction pattern
  1. Less than 10 mild contractions per hour
Evacuation of Uterine Contents after Fetal Death
1. Up to 28 weeks gestation

Uterine Contractions >3 in 10 minutes prior to placement
Factors increasing the risk for Uterine Rupture
1. Prior Cesarean Section
2. Major uterine surgery with scar dehiscence risk

See Prostaglandin
Dinoprostone is a synthetic Prostaglandin E2 (PGE2) analog
1. Prostaglandin E2 (PGE2) is the most common and the most biologically active Prostaglandin
Dinoprostone induces smooth Muscle Contraction in the Uterus (myometrium) and Stomach
1. Increases cAMP levels, activating adenylate cyclase, and increasing Calcium Ion transport across cell membranes

Monitor Fetal Heart Rate and tocometry in Cervical Ripening
1. Start 15 to 30 minutes before
2. Vaginal Gel monitoring should continue for 30-120 minutes after gel placement
3. Vaginal Insert monitoring should continue while inserted, and for 15 min after removal

Cervical Ripening Agents for Labor Induction
1. Dinoprostone Gel (PGE2 Gel, Prepidil): 0.5 mg per 3 g syringe
2. Dinoprostone Pessary or Vaginal Insert (PGE2, Cervidil): 10 mg
Evacuation of Uterine Contents after Fetal Death or Termination of Pregnancy
1. Dinoprostone Vaginal Suppository (Prostin E2): 20 mg

Initiate Fetal Heart Rate and tocometry
1. Start 15-30 minutes before gel inserted
2. Continue monitoring for 30-120 minutes after placement
Insertion Technique
1. Use one syringe of gel (0.5 mg in 3cc KY)
2. Patient remains supine for 30 minutes after insertion
3. Introduce gel into Cervix
  1. Cervix not effaced: Use 20 mm catheter
  2. Cervix effaced 50% or greater: Use 10 mm catheter
  3. Intracervical is preferred over posterior fornix
    1. Perry (2004) Obstet Gynecol 103:13-7 [PubMed]
Dosing
1. May repeat every 6 hours up to 3 doses in 24 hours
End points
1. Bishop Score of 8 or greater
2. Strong uterine contractions
Drug Interactions
1. Wait 6-12 hours before starting Oxytocin

Dinoprostone 10 mg vaginal insert releases Dinoprostone at 0.3 mg/hour for 12 hours
Insert Pessary into posterior fornix (adjacent to Cervix)
Monitor Fetal Heart Tones and tocometry
1. Start 15 to 30 minutes before insertion
2. Continue monitoring for 15 minutes after removal
Patient remains recumbent for 2 hours after insertion
Pull Pessary out via string if hyper-stimulated

Dosing
Dinoprostone Vaginal Suppository (Prostin E2) in Evacuation of Uterine Contents

Indicated in up to 28 weeks gestation for Fetal in utero death
Insert 20 mg intravaginal suppository
May repeat up to every 3 to 5 hours (maximum use 2 days) as needed until uterine contents expelled

Uterine Tachysystole
1. Criteria: >10 contractions in 20 minutes (or >5 contractions in 10 minutes)
2. Dinoprostone Tachysystole Incidence: 33%
Uterine Hyperstimulation
1. Criteria
  1. Exaggerated uterine response (i.e. Tachysystole)
  2. Concerning Fetal Heart Rate tracing
    1. Late Decelerations
    2. Fetal Tachycardia >160 beats per minute
2. Dinoprostone Hyperstimulation Incidence: 17%
3. Hyperstimulation Management
  1. Remove Dinoprostone
  2. Consider Terbutaline SQ
Uterine Rupture in VBAC
1. Risk: 2.5% in Trial of Labor after Cesarean
References
1. Crane (2001) Obstet Gynecol 97:926-31 [PubMed]
2. Ravasia (2000) Obstet Gynecol 183:1176-9 [PubMed]