Cytotec for inductions? XP Feb '13

kelly321 · February 2013

It was recommended I come over here and ask you ladies about Cytotec, so here I am!

A few weeks ago I was asking my MW about how an induction would be done with a VBAC - whether there were any differences to a "regular" induction. She said they wouldn't use picotin with a VBAC induction, but instead would give me a "contraction cocktail" (not sure if there are actually any medications in there or just more natural products like RRL that are supposed to induce uterine contractions) and also Cytotec. That surprised me since I know of Cytotec being used off-label for medicated miscarriages (which I know are essentially the same thing as inducing labor) but I thought the company had explicitly stated that it was no longer to be used for labor inductions for some reason.

Does anyone know anything about Cytotec inductions that they can share? Especially any studies related to using it for VBACs?

wifeofadam · February 2013

I was the one that recommended kelly post this here. I remember some of you ladies having some strong opinions about it, as well as research to back it up, from both sides.

Iris, can you help her out?

nosoup4u · February 2013

Iris knows a lot more than me, but Cytotec and other cervical ripening agents are specifically NOT recommended for VBACs.

Why won't she do Pictocin? How about a Foley bulb?

https://vbacfacts.com/2012/05/27/myth-vbacs-should-never-be-induced/

The latest 2010 VBAC Practice Bulletin No. 115 produced by the American Congress of Obstetricians & Gynecologists (ACOG) asserts:

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean]? However, the potential increased risk of uterine rupture associated with any induction, and the potential decreased possibility of achieving VBAC, should be discussed? Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.

kelly321 · February 2013

nosoup4u:
Iris knows a lot more than me, but Cytotec and other cervical ripening agents are specifically NOT recommended for VBACs.
Why won't she do Pictocin? How about a Foley bulb?
https://vbacfacts.com/2012/05/27/myth-vbacs-should-never-be-induced/
The latest 2010 VBAC Practice Bulletin No. 115 produced by the American Congress of Obstetricians & Gynecologists (ACOG) asserts:

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean]? However, the potential increased risk of uterine rupture associated with any induction, and the potential decreased possibility of achieving VBAC, should be discussed? Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.

First off, ::waves to Iris from the May '11 board:: Iris, if you've got info on Cytotec for VBAC inductions, I'd love to hear about it.

Now to your questions - I live in Germany, and here, your OB/MW does not deliver you. Whichever MW happens to be on duty when you go in to L&D does, and if there are problems then they get the on duty OB to come. So my MW has essentially no say in how I am induced, she was just describing normal hospital procedures for VBAC inductions for me (although she does work PT in L&D, so there's a slight chance she would be my MW for at least part of my delivery). I'm lucky in that VBACs are the norm after 1 c/s, at least, and I don't have to fight for it.

As for not using picotin, she said it's not used for VBACs because the contractions are much harder so the risk of rupture increases. It wasn't until after the appt that I thought about what I had read about Cytotec causing horrible contractions (I read up on the possibilities for medicated m/c while I was waiting to see if my body would start a natural m/c on its own, which thankfully it did). No clue about a foley bulb - maybe they would try it.

At the time, I wasn't looking at an imminent induction, so we didn't discuss all the possibilities. Now my BP has been periodically too high, and with my history the possibility of an induction was at least mentioned. That's why I thought I would inform myself about Cytotec with VBAC inductions before I end up facing one and don't know whether to refuse the Cytotec or not!

love4b · February 2013

This excerpt was taken from https://www.ncbi.nlm.nih.gov/pubmed/10368501

That's the US National Library of Medicine, National Institutes of Health online searchable database/archives (PubMed.gov). The language is a little technical, but really informative.

"...The rare, but serious, issue of uterine rupture is most important. In a case control study of 512 women attempting vaginal birth after cesarean (VBAC), 5.6% of women receiving misoprostol had symptomatic uterine rupture compared to 0.2% of women having a trial of labor without misoprostol. No uterine ruptures occurred in women with a previous cesarean birth who had spontaneous labor (Plaut, Schwartz, & Lubarsky, 1999). Other studies reporting uterine rupture when a uterine scar is present include Gherman and Heath, 2001;Gherman, McBrayer, and Browning, 2000; and Wing, Lovett, and Paul, 1998. Therefore, it is recommended that misoprostol should not be used to induce labor in women with uterine scars..."

At the bottom of the page in the References section, you'll find a link to each individual study. The Wing, Lovett, and Paul study, which was conducted at USC School of Medice in LA, is especially interesting because they had to stop the study due to too many women attempting VBAC with Cytotec ending up with uterine ruptures.

The risk with Cytotec, even in an unscarred uterus, is uterine rupture, which is the same major risk associated with VBAC. I'm sure there have been cases where it was used to induce a VBAC and everything was hunky dory, but if it was me, I wouldn't use it.

My OB doesn't induce women attempting VBACs at all. She gives until 41 weeks 4 days for you to go into natural labor and after that, it's a repeat c-section.

kelly321 · February 2013

Thanks, minxy! The 5.6% rupture with Cytotec is scary. I think if I end up needing an induction I'll be doing my best to avoid it.

Does anyone know the rate of rupture when picotin is used?

love4b · February 2013

kelly321:
Thanks, minxy! The 5.6% rupture with Cytotec is scary. I think if I end up needing an induction I'll be doing my best to avoid it.
Does anyone know the rate of rupture when picotin is used?

From: "Uterine rupture during trial of labor: controversy of induction's methods"

"... Evaluation of the evidence on specific methods of induction reveals that the lowest rate of uterine rupture occurs with oxytocin at 1.1% (95% confidence interval [CI], 0.9%-1.5%) then dinoprostone at 2% (95% CI, 1.1%-3.5%), and the highest rate is with misoprostol, 6% (95% CI, 0.74%-51.4%)..."

https://www.ncbi.nlm.nih.gov/pubmed/23151757

iris427 · February 2013

Hi :

I see this has been covered but yeah, I'm really surprised to hear your MW is recommending misoprostol for a VBAC since it is contraindicated. Lowdose Pit and foley bulbs are considered safe for VBAC, as well as amniotomy. I'm generally OK with Cytotec for inductions but I wouldn't do it as a VBAC mom, especially with safer options available. I would also want to know more about this "cocktail."

iris427 · February 2013

As you can see from the studies posted above, a careful Pit induction, while it still increases the risk of rupture, increases it much less than misoprostol. Just curious, how much did you labor before your c/s? How dilated was your cervix?

abell77 · February 2013

I have also heard of cervadil for cervical ripening, but admittedly don't know much about it or whether or not it might be a better option than cytotec.

Are you planning on having an epidural? Risk of uterine rupture aside, I have had two births, one with cytotec (my water broke and I had no contractions for nearly 72 hours, I didn't want pitocin) and one without. The contractions were dramatically different. If you are planning on going epi free, I would definitely explore other options besides cytotec if you can. It can be done epi free, but the contractions are rough, one on top of another and little chance for rest in between. That was just my experience. Good Luck to you.

iris427 · February 2013

abell77:
I have also heard of cervadil for cervical ripening, but admittedly don't know much about it or whether or not it might be a better option than cytotec.
Are you planning on having an epidural? Risk of uterine rupture aside, I have had two births, one with cytotec (my water broke and I had no contractions for nearly 72 hours, I didn't want pitocin) and one without. The contractions were dramatically different. If you are planning on going epi free, I would definitely explore other options besides cytotec if you can. It can be done epi free, but the contractions are rough, one on top of another and little chance for rest in between. That was just my experience. Good Luck to you.

Cervidil is also considered contraindicated for VBAC, although I think there are some mixed results in studies looking at safety and UR rate.

margaritachikita · February 2013

I have no formal evidence, but our Bradley Method instructor said absolutely no cytotec whatsoever. She advised us to decline if cytotec was ever offered for induction.

kelly321 · February 2013

iris427:
As you can see from the studies posted above, a careful Pit induction, while it still increases the risk of rupture, increases it much less than misoprostol. Just curious, how much did you labor before your c/s? How dilated was your cervix?

I didn't labor at all - it was an unplanned c/s due to HELLP. My cervix was closed tight and 4.4cm long, so they said an induction could take days and we didn't have that much time. Does that make a difference for a possible induction?

BriDaily · February 2013

Oooo... I just went to an ICAN on uterine rupture and we talked about induction protocols!

Sooo I can't remember the exact info, but if you go to the ICAN website I am sure you can find some great info! Basically the key to inducing with drugs in a VBAC situation is to take things reeeally slowly. If possible you should be prepping your body using natural means before resorting to medicated induction - things like Evening Primrose Oil, drinking herbal infusions, etc.

kelly321 · February 2013

iris427:
Hi : I see this has been covered but yeah, I'm really surprised to hear your MW is recommending misoprostol for a VBAC since it is contraindicated. Lowdose Pit and foley bulbs are considered safe for VBAC, as well as amniotomy. I'm generally OK with Cytotec for inductions but I wouldn't do it as a VBAC mom, especially with safer options available. I would also want to know more about this "cocktail."

I just looked it up: apricot juice, champagne, almond sauce (like apple sauce but from almonds, apparently?), and castor oil (!) is the typical make-up.

pinkiemo · February 2013

Just to add my two cents, cytotec is one of the things I feel very strongly about. Cytotec is not approved by the FDA for use in induction, or on any woman in labor. It carries very high risks for uterine rupture, especially in women who have had previous uterine surgery (ie c-section). OBs prescribe it because it works fast, not because it it safe. Using it in labor is considered an "off-label" use. In no way would I ever consent to it. I would really really question your MW about this. All the studies show it is unsafe.

I don't mean to be soap-boxy but like I said cytotec is one of those things I acutally feel very strongly about and the more people I can get to question the use of it, the closer it will become to being unacceptable to use on women in labor.

iris427 · February 2013

kelly321:
iris427:
As you can see from the studies posted above, a careful Pit induction, while it still increases the risk of rupture, increases it much less than misoprostol. Just curious, how much did you labor before your c/s? How dilated was your cervix?
I didn't labor at all - it was an unplanned c/s due to HELLP. My cervix was closed tight and 4.4cm long, so they said an induction could take days and we didn't have that much time. Does that make a difference for a possible induction?

A general rule of thumb with VBAC is that your body will behave like a second timer up until the point where you had your c/s, and then it will behave like a first timer. So if you had your c/s before labor, you can expect your VBAC to be more like a first time mom's labor. It's just something to keep in mind.

iris427 · February 2013

kelly321:
iris427:
Hi : I see this has been covered but yeah, I'm really surprised to hear your MW is recommending misoprostol for a VBAC since it is contraindicated. Lowdose Pit and foley bulbs are considered safe for VBAC, as well as amniotomy. I'm generally OK with Cytotec for inductions but I wouldn't do it as a VBAC mom, especially with safer options available. I would also want to know more about this "cocktail."
I just looked it up: apricot juice, champagne, almond sauce (like apple sauce but from almonds, apparently?), and castor oil (!) is the typical make-up.

Wow that is an interesting combo! I have never heard of using some of those things, something new for me to read up on haha.

iris427 · February 2013

pinkiemo:
Just to add my two cents, cytotec is one of the things I feel very strongly about. Cytotec is not approved by the FDA for use in induction, or on any woman in labor. It carries very high risks for uterine rupture, especially in women who have had previous uterine surgery (ie c-section). OBs prescribe it because it works fast, not because it it safe. Using it in labor is considered an "off-label" use. In no way would I ever consent to it. I would really really question your MW about this. All the studies show it is unsafe.
I don't mean to be soap-boxy but like I said cytotec is one of those things I acutally feel very strongly about and the more people I can get to question the use of it, the closer it will become to being unacceptable to use on women in labor.

Why is it unacceptable? The issue of contraindication with VBAC aside, misoprostol has been shown in numerous studies to be a safe and effective form of induction. Its risks are comparable to other induction agents (i.e. Cervidil and Pitocin) and it is just as effective, if not more, at achieving the goal of a vaginal delivery. When you compare the risks of Cytotec with the risks of an unplanned cesarean (which is the alternative choice if other induction methods don't work and delivery is necessary), it seems like a reasonable choice.

Off-label use does not mean that the drug is untested. Nor is off-label use some evil doctor conspiracy. Many new therapies are discovered through off-label use. Cytotec is not even the only off-label drug used in obstetrics and gynecology. Zofran is used off-label to treat nausea and vomiting in pregnancy. Terbutaline is used off-label to stop pre-term labor. Reglan and domperidone, which are commonly recommended off-label for increasing milk production by many in the natural birth/parenting communities. It's also kind of funny to hear the NB community demonize Cytotec for not being FDA-approved for labor induction when things like castor oil and tons of herbal remedies are recommended--those aren't exactly FDA-approved for use in pregnancy either. So I'm not really sure why Cytotec has been singled out by so many natural birth proponents.

pinkiemo · February 2013

iris427:
pinkiemo:
Just to add my two cents, cytotec is one of the things I feel very strongly about. Cytotec is not approved by the FDA for use in induction, or on any woman in labor. It carries very high risks for uterine rupture, especially in women who have had previous uterine surgery (ie c-section). OBs prescribe it because it works fast, not because it it safe. Using it in labor is considered an "off-label" use. In no way would I ever consent to it. I would really really question your MW about this. All the studies show it is unsafe.
I don't mean to be soap-boxy but like I said cytotec is one of those things I acutally feel very strongly about and the more people I can get to question the use of it, the closer it will become to being unacceptable to use on women in labor.
Why is it unacceptable? The issue of contraindication with VBAC aside, misoprostol has been shown in numerous studies to be a safe and effective form of induction. Its risks are comparable to other induction agents (i.e. Cervidil and Pitocin) and it is just as effective, if not more, at achieving the goal of a vaginal delivery. When you compare the risks of Cytotec with the risks of an unplanned cesarean (which is the alternative choice if other induction methods don't work and delivery is necessary), it seems like a reasonable choice.
Off-label use does not mean that the drug is untested. Nor is off-label use some evil doctor conspiracy. Many new therapies are discovered through off-label use. Cytotec is not even the only off-label drug used in obstetrics and gynecology. Zofran is used off-label to treat nausea and vomiting in pregnancy. Terbutaline is used off-label to stop pre-term labor. Reglan and domperidone, which are commonly recommended off-label for increasing milk production by many in the natural birth/parenting communities. It's also kind of funny to hear the NB community demonize Cytotec for not being FDA-approved for labor induction when things like castor oil and tons of herbal remedies are recommended--those aren't exactly FDA-approved for use in pregnancy either. So I'm not really sure why Cytotec has been singled out by so many natural birth proponents.

It's not that it's not approved, it's that they actively advise against it. Even Searle (the manufacturer of cytotec) wrote letters to the FDA and ACOG saying it was not meant to be used in labor and they did not support the study of or use during labor. There have been numerous warnings against this particular off-label use, though I know many other medications are used in this manner. Just because some docs and hospitals choose to ignore the warnings in favor of convenience doesn't mean the patients should.

iris427 · February 2013

pinkiemo:
iris427:
pinkiemo:
Just to add my two cents, cytotec is one of the things I feel very strongly about. Cytotec is not approved by the FDA for use in induction, or on any woman in labor. It carries very high risks for uterine rupture, especially in women who have had previous uterine surgery (ie c-section). OBs prescribe it because it works fast, not because it it safe. Using it in labor is considered an "off-label" use. In no way would I ever consent to it. I would really really question your MW about this. All the studies show it is unsafe.
I don't mean to be soap-boxy but like I said cytotec is one of those things I acutally feel very strongly about and the more people I can get to question the use of it, the closer it will become to being unacceptable to use on women in labor.
Why is it unacceptable? The issue of contraindication with VBAC aside, misoprostol has been shown in numerous studies to be a safe and effective form of induction. Its risks are comparable to other induction agents (i.e. Cervidil and Pitocin) and it is just as effective, if not more, at achieving the goal of a vaginal delivery. When you compare the risks of Cytotec with the risks of an unplanned cesarean (which is the alternative choice if other induction methods don't work and delivery is necessary), it seems like a reasonable choice.
Off-label use does not mean that the drug is untested. Nor is off-label use some evil doctor conspiracy. Many new therapies are discovered through off-label use. Cytotec is not even the only off-label drug used in obstetrics and gynecology. Zofran is used off-label to treat nausea and vomiting in pregnancy. Terbutaline is used off-label to stop pre-term labor. Reglan and domperidone, which are commonly recommended off-label for increasing milk production by many in the natural birth/parenting communities. It's also kind of funny to hear the NB community demonize Cytotec for not being FDA-approved for labor induction when things like castor oil and tons of herbal remedies are recommended--those aren't exactly FDA-approved for use in pregnancy either. So I'm not really sure why Cytotec has been singled out by so many natural birth proponents.
It's not that it's not approved, it's that they actively advise against it. Even Searle (the manufacturer of cytotec) wrote letters to the FDA and ACOG saying it was not meant to be used in labor and they did not support the study of or use during labor. There have been numerous warnings against this particular off-label use, though I know many other medications are used in this manner. Just because some docs and hospitals choose to ignore the warnings in favor of convenience doesn't mean the patients should.

You bring up an interesting point. If a doctor or a hospital or a pharmaceutical company warns against something, does that mean it is unsafe? Not necessarily. We often criticize physicians for practicing CYA medicine, even when something is safe--for example, VBAC. Should we say "well a huge percentage of doctors in the US won't do VBAC" and therefore conclude VBAC is unacceptable, or should we look at the actual scientific evidence? I am sure most people on this board would agree we should look at the evidence.

It is the same with misoprostol. Yes, Searle issued a warning about it years ago, but it is entirely possible that was a CYA move to protect themselves from potential lawsuits. As we all know, lawsuits are common in obstetrics. That does not mean that Cytotec is unsafe for use in labor induction. We need to look at the actual evidence. And the evidence shows that misoprostol, when used appropriately, is safe for labor induction. So why does the NB community ignore that evidence when we are so often saying we support evidence-based practice?

Cytotec is owned by Pfizer and they do not warn against the use of Cytotec in obstetrics. In fact, their drug information acknowledges that it is widely used and gives information about contraindications for obstetric use, implying they accept its use in labor induction/treatment of PPH. So the letter from Searle is kind of a moot point and I dont know why people still bring it up. It makes us NB advocates look like we are stuck in a 1990s echo chamber. Furthermore, another company is currently in the process of getting FDA approval for a new method of misoprostol administration, specifically for labor induction. It will be interesting to see what happens if it is approved--will NBers still say it is dangerous?

I will also add that all the other dugs I mentioned also have had warnings issued about off-label use, so my question remains about why Cytotec has been singled out. The bottom line is that multiple studies have shown misoprostol is effective and has a similar level of risk to Pitocin and Cervidil. We can't claim to be working for evidence-based maternity care if we are ignoring evidence ourselves. It makes us look like a bunch of hippies who are more concerned about the ideology of natural birth than what results in the best outcomes. And that won't get us far in changing the birth culture of this country.

BLPL101 · February 2013

I had Cytotec, but this was my first birth so no VBAC. I would definitely not use it if I was having a VBAC. I was nervous about using it, but trusted my midwives. It ended up doing nothing and I had to had Pit...

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Cytotec for inductions? XP Feb '13

Re: Cytotec for inductions? XP Feb '13

"... Evaluation of the evidence on specific methods of induction reveals that the lowest rate of uterine rupture occurs with oxytocin at 1.1% (95% confidence interval [CI], 0.9%-1.5%) then dinoprostone at 2% (95% CI, 1.1%-3.5%), and the highest rate is with misoprostol, 6% (95% CI, 0.74%-51.4%)..."

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