Low-dose vaginal misoprostol best approach for outpatient cervical ripening

For outpatient cervical ripening and labour induction, low-dose vaginal misoprostol has the most favourable risk-benefit profile, reducing the interval to delivery, according to the results of a systematic review and network meta-analysis.

For the study, researchers searched multiple online databases for randomized controlled trials wherein the effectiveness and safety of cervical ripening methods currently used in the outpatient setting were assessed.

A frequentist random effects method was used, and a direct, pairwise meta-analysis facilitated comparison of the effectiveness of various outpatient cervical ripening methods, including placebo. The surface under the cumulative ranking curve (SUCRA) was used to determine the method with the greatest effect, with a higher SUCRA indicating a more effective method.

Outcomes assessed included time from intervention to delivery, caesarean delivery rates, changes in the Bishop score, need for additional ripening methods, incidence of Apgar scores <7 at 5 minutes, and uterine hyperstimulation.

A total of 42 randomized controlled trials, involving 6,093 participants, were included in the meta-analysis. Pooled data showed that in terms of effectiveness, the 25-μg vaginal misoprostol ranked highest for reducing the time from intervention to delivery (SUCRA 1.0) without increasing the odds of caesarean delivery, the need for additional ripening methods, the incidence of a low Apgar score, or uterine hyperstimulation.

On the other hand, the least effective methods for reducing the time to delivery interval were acupressure (SUCRA 0.3) and primrose oil (SUCRA 0.2).

Among the most effective methods, 50-mg oral mifepristone was associated with the lowest odds of caesarean delivery (SUCRA 0.9).