Neue Möglichkeiten der medikamentösen Geburtseinleitung mit Prostaglandinen Hanns Helmer Medizinische Universität Wien
Murthy K, Grobman WA, Lee TA, et al. Trends in induceon of labor at early- term gestaeon. Am J Obstet Gynecol 2011;204:435.e1-6.
Catherine Y. Spong Timing of Indicated Late- Preterm and Early- Term Birth Obstet Gynecol 2011;118:323 33
IndikaEonen zur Einleitung Elektive Einleitung PROM PPROM Präeklampsie Gestationsdiabetes Vermutete Makrosomie
Erfolg der Einleitung
Physiology of Cervical Ripening R. Ann Word et al. Dynamics of Cervical Remodeling during Pregnancy and ParturiEon: Mechanisms and Current Concepts SEMINARS IN REPRODUCTIVE MEDICINE 2007;25,1:69-79
Review content assessed as up-to-date: 24 April 2012 Objective: Whether a policy of labour induction can reduce perinatal mortality 22 trials reporting on 9383 women Majority of trials adopted a policy of induction at 41 weeks
Authors conclusions Aktive Einleitungspolitik reduziert die perinatale Sterblichkeit sowie die Sektiorate Number needed to treat (NNT) um einen perinatalen Todesfall zu vermeiden: 410 Reduktion der Fälle von Mekoniumaspiration und anderer kindlicher Morbiditäten
Maternal age and the risk of sellbirth throughout pregnancy in the US Am J Obstet Gynecol, 2006,195(3)
Timing of ElecEve InducEon Elective delivery before 39 ProspecEve observaeonal study 2007, 27 hospitals 4645 eleceve deliveries at 37 weeks or greater completed weeks gestation is inappropriate. Clark SL, Miller DD, Belfort MA, et al. Neonatal and maternal outcomes associated with eleceve term delivery. Am J Obstet Gynecol 2009;200:156.e1-156.e4.
Mild Preeclampsia Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks gestation Delivery 1.2 weeks earlier than control group Significantly lower rate of cesarean delivery
Vermutete Makrosomie Wird eine Einleitung bei vermuteter Makrosomie empfohlen? Makrosomie ist schwierig zu diagnostizieren Geringe Wahrscheinlichkeit einer permanenten neurologischen Verletzung (Erb sche Lähmung) durch Schulterdystokie Eine Geburtseinleitung wegen vermuteter, fetaler Makrosomie reduzierte weder die Nummer an Schulterdystokien noch die der Kaiserschnitte Olivier Irion, Michel Boulvain Induction of labour for suspected fetal macrosomia Cochrane Database Syst Rev. 2000. Assessed as up-to-date: 13 JAN 2011
KONTRAINDIKATIONEN ZUR GEBURTSEINLEITUNG Vorangegangene, klassischer Kaiserschnitt Vorangegangene Ruptur des Uterus Vorangegangene, transmurale Eröffnung des Cavum uteri Plazenta praevia oder Vasa praevia Drohender Nabelschnurvorfall Querlage Pathologisches CTG Aktive Infektion mit Herpes genitalis
Prostaglandine Wichtigste Moleküle: PGE2 and PGF2a Arachidonsäure als Ausgangsstoff ist beim Menschen in großer Menge vorhanden
Prostaglandin Präparate Präparat Cergem Cytotec MinprosEn- Vaginalgel MinprosEn 3 mg Nalador 500 Prepidil Propess Cyprostol (Österreich) Substanz 1 mg Gemeprost- Vaginalsupp. 200: 200 µg Misoprostol- Tablefe [in Deutschland aus dem Handel] 1 mg/2 mg Dinoproston- Vaginalgel 3 mg Dinoproston- Vaginaltablefe 500 µg Sulproston- Amp. 0,5 mg Dinoproston- Intrazervikalgel 10 mg Dinoproston- Vaginalinsert 200 µg Misoprostol
Prostaglandine - Wirksamkeit Vaginal PGE2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (RR 0.19, 95% CI 0.14 to 0.25) Risk of the cervix remaining unfavourable or unchanged was reduced (PGE2 vs. placebo) Risk of oxytocin augmentation was reduced (PGE2 vs. placebo) Kelly AJ, Malik S, Smith L et al. Vaginal prostaglandin (PGE2 and PGF2a) for induceon of labour at term. Cochrane Database Syst Rev. 2009
Prostaglandins - AdministraEon PGE2 tablet, gel and pessary appear to be as efficacious as each other Use of sustained release PGE2 vs. vaginal PGE2 gel or tablets are associated with reduceon in instrumental vaginal delivery rates (RR 0.51, 95% CI 0.35 to 0.76, NNT 10) Kelly AJ, Malik S, Smith L et al. Vaginal prostaglandin (PGE2 and PGF2a) for induceon of labour at term. Cochrane Database Syst Rev. 2009
Prostaglandins - Misoprostol Khan RU, El- Refaey H, Sharma S et al. Oral, rectal, and vaginal pharmacokineecs of misoprostol. Obstet Gynecol 2004;103:866 70
Prostaglandins Misoprostol (PGE1) Compared with vaginal/intracervical PGE2 and oxytocin, vaginal misoprostol was associated with Less epidural analgesia use Fewer failures to achieve vaginal delivery within 24 hours More uterine hyperstimulation. Hofmeyr GJ, Gülmezoglu AM, Pileggi C Vaginal misoprostol for cervical ripening and induceon of labour. Cochrane Database Syst Rev. 2010
Prostaglandins Dinoprostone vs. Misoprostol Logistische Probleme: Rechtsunsicherheit Schwieriges Teilen der Tabletten Dosierungsfehler Dinoproston ist Standard in Ländern ohne Lizenz für Misoprostol zur Einleitung A. Weeks, Z.Alfirevic, A. Faundes et al. Misoprostol for induceon of labor with a life fetus. Int J Gyn Obstet 2007;99,194-7
Trotz umfangreicher Studien zur Anwendung von Misoprostol in der Gynakologie und Geburtshilfe besteht ein Off-Label-Use, so dass der Einsatz von Misoprostol in der Geburtshilfe in der individuellen Therapiefreiheit jeden Arztes liegt. Daher hat sich jeder Arzt über die Bedeutung des Off- Label-Use zu informieren. Die Patientin muss entsprechend aufgeklart werden
Misoprostol is the single most commonly used drug for labor induceon in Switzerland It is not licensed and although there are effeceve, licensed alternaeve drugs available A minority of praceeoners inform the paeents about the off- label use.
Misoprostol Controlled- Release Vaginal Insert B. Powers et al. PharmacokineEc Profiles of Controlled- Release Hydrogel Polymer Vaginal Inserts Containing Misoprostol. Journal of Clinical Pharmacology, 2008;48:26-34
Misoprostol Controlled- Release Vaginal Insert To compare the efficacy and safety of a 200- mcg misoprostol vaginal insert with a 10- mg dinoprostone vaginal insert for reducing the Eme to vaginal delivery Obstet Gynecol 2013;122:201 9
Misoprostol Controlled- Release Vaginal Insert 200-mcg misoprostol vaginal insert significantly reduced the time to vaginal delivery Reduced need for oxytocin Rate of cesarean delivery was similar Tachysystole (if occurred with fetal heart rate category II or III patterns) was more common B. Powers et al. PharmacokineEc Profiles of Controlled- Release Hydrogel Polymer Vaginal Inserts Containing Misoprostol. Journal of Clinical Pharmacology, 2008;48:26-34
Mechanical Methods Balloon catheters Foley Kath. CRB- Ballon (Cook Med.) Hygroscopic dilators within the endocervical canal
Mechanical Methods Release of PGF2-alpha (decidua and membranes) Prostaglandin E2 from the cervix Directly dilates the cervix
Mechanical Methods vs. Prostaglandins Proportion of women who did not achieve vaginal delivery within 24 hours was not significantly different For multiparous women the risk of not achieving delivery within 24 hours was higher Mechanical methods reduced the risk of hyperstimulation with fetal heart rate changes Risk of caesarean section was comparable. Neonatal and maternal morbidity did not differ Jozwiak M, Bloemenkamp KW, Kelly AJ et al. Mechanical methods for induceon of labour. Cochrane Database Syst Rev. 2012;3:CD001233.
Other Methods Limited Data Relaxin Mifepristone NO donors Hyaluronidase Castor oil Sexual intercourse Breast stimulation Herbal preparations
Zusammenfassung - Geburtseinleitung Applikation von PG-Präparaten ist eine effektive Methode zur Einleitung sowie zur Zervixreifung Slow release PG-Anwendungen (Propess) senken die Rate an vaginal-operativen Entbindungen Erstmals wird Misoprostol als zugelassenes Präparat zur Einleitung registriert (Misodel) Ballon-Katheter zur Einleitung senken das Risiko der Überstimulation mit pathologischen CTG- Mustern