1. prostaglandins in labour dr rabi

PROSTAGLANDINS IN LABOUR

DR. RABI NARAYAN SATAPATHY

ASST.PROFESSOR

DEPT. OF OBST.& GYNAECOLOGY

SCB MEDICAL COLLEGE, CUTTACK

MOB-09861281510

[email protected]

The role of all technological advances is to reduce human suffering.

In relation to obstetrics it can be achieved by:

• Reducing Maternal morbidity and mortality.

• Reducing perinatal mortality and morbidity

• Relievingpain of a parturient mother and thereby reducing her suffering

Historical developments in the development of Prostaglandins

1930 – KURZORK & LEIB DISCOVERED BIOLOGICAL ASPECTS OF PG’S

1935 – VON EULER COINED THE TERM PROSTAGLANDIN BELIEVING IT TO ORIGINATE FROM THE PROSTATE

1959 – ELAISON PROVED THAT PG ORIGINATED IN THE SEMINAL VESICLE

1964 – BERGSTRON ELUCIDATED THE STRUCTURE

1966 – DR. SULTAN KARIM REPORTED PRESENCE OF PG IN THE AMNIOTIC FLUID

- USED SEMEN TO AUGMENT LABOUR

1970 – DR. KARIM I.V. PGF2α FOR 1ST AND 2ND TRIMESTER ABORTIONS

Prostaglandins in Reproduction

Parturition

Birth

Ovulation

Fertilization & implantation

Pregnancy

Fetal placental hemodynamics

PPH

Lactation

Toxaemia

Ductus Aretriosus patency

Spontaneous abortion

Preterm labour

Sperm transport

PDA closure

Umbilical cord closure dysmenorrhoea

Leutolysis

menstruation

Prostaglandin Release

Rupture of membranes

Stretching of cervix

Vaginal

examination

Oxytocin

Estrogen

OXYTOCIN INDUCED

High amplitude

Higher frequency

Higher intensity

Quicker onset

Stops when infusion discontinued

PROSTAGLANDIN INDUCED

Low amplitude

Low frequency

Lower intensity

Continues even after discontinuing treatment

UTERINE CONTRACTIONS

PROSTAGLANDINSMembrane Phospholipids

Arachidonic acid (AA)

NSAID

PGE2

PGH2

Cyclooxygenese

PGI2 PGD2 PGE2 PGF2α Thromboxanes

A2 & B2 (TXA2,TXB2)

GlucocorticoidsPhospholipase A2

PG synthesis

0

2

4

6

8

10

Non pregnant mid pregnancy term pregnancynot in labour

term preg inlabour

area under the curve (sq cm)

Uterine sensitivity to oxytocin

10

50

90

not inlabour

earlystage 1

latestage 1

II stage III stage

oxytocinpg/ml

0

12

24

2 cm 4 cm 6 cm 8 cm 10 cm

PGF2PGE2

Amniotic fluid PG during labour

Indicatons for the use of Cerviprime gel

• Post term

• Hypertension / Toxaemia

• Chronic hypertension

• Oligohydramnios

• Intrauterine growth restriction

• Diabetes

• Reduced fetal movements

• Suspected placental insufficiency

MUSCLE

MUCOSA

PROTEOGLYCAN

FIBROBLASTS

Instillation of PGE2 Gel

Cervical priming

COLLAGEN DEGRADATION

COLLAGEN IS RESISTANT TO MOST PROTEINASES

I COLLAGENASE

II LEUCOCYTE ELASTASE

Fibroblast activation

Vasacular permiability

Tissue hydration

Destabilization of Proteoglycans

Collagen dsegradation

PGE2Cervical ripening

PGE2

FIBROBLAST VASCULATURE

Relaxin, CollagenaseLeucocyte infiltration

Tissue hydration

Collagen

Collagen breakdown

Cervical ripening

Proteoglycans

Expression, production

Increased vascular permiability

Progressive cervical dilatation

Cervical changes during labourNulliparous cervix near term

During labour - effacement

Fully dilated

Cerviprime to improve Bishop scoreAuthors year No. of

PtsBishop scoreBefore After

Bernstein 1987 42 3.2 7.7

ICMR study

1988 221 <3.0 >6.0

Bhide 1992 68 2.8 8.5

Patki & Daftary

1992 80 2.7 6.0

Cerviprime for labour outcomeAuthors Year No. of Pts Vaginal

delivery (%)

Legarht 1988 57 84.2

ICMR Study

1988 221 80.5

Bhide 1991 40 97.0

Patki & Daftary

1992 80 92.5

Prostaglandin induction of Labour (1993-94)

S No.

Author Place % Vag Del.

% C sec.

Avg Dur of lab(hrs)

Primi Multi

1 Patki Mumbai 92.5 7.5 7.3 7.3

2 Bhide Mumbai 90 10 16.4

3 Dubey Kanpur 92.2 7.1 14.6 8.2

4 Mehta Jaipur 100 - 8.0 6.0

5 R. Jina Gorakhpur 95 5 8.13 7.06

6 Sasikala Pondicherry 91.4 8.6 7.4 7.4

7 Daftary G. S. Mumbai 80 20 10.6 8.4

8 Handa P.R. Jamshedpur 85.7 14.3 12 10

Prostaglandin induction of Labour (1995-96)

S No.

Author Place % Vag Del.

% C sec.

Avg Dur of lab(hrs)

Primi Multi

1 S. Gupta Jaipur 79.7 21.3 12.6

2 S. Bhattacharya Calcutta 62.4 37.6 8.2 8.2

3 Sandhu Amritsar 85 15 10.35 6.08

4 S. Kore Mumbai 88 12 11.4 7.6

5 Mukherjee Allhabad 84 16 16.3 10.3

6 Vaneetkuma Jammu 81 19 12.0 -

7 A. Sone Simla 93 7 10 7.4

Contraindicatons for the use of Cerviprime gel

1. Patients hypersensitive to PG’S

2. Patients in whom Oxytocics are contraindicated• Previous LSCS

• Major CPD• Pre-existing fetal distress• Grande multipara

• Previous difficult or traumatic labour

1. Patients with ruptured membranes

2. Non-vertex presentation

Oxytocin PGE2

FUNDUS + +

ISTHMUS + -

+ STIMULATION - INHIBITION

Comparison of PG vs. Pitocin for Induction of labour

Distribution of casesOxytocin PGE2

Total cases 200 200

Indications

Post datism 25 60

P.R.O.M. 75 80

P.I.H. 40 30

Meconium stained liquor

50 15

I.U.G.R 10 15

Effect on Bishop score after single

Intracervical Gel or oxytocin drip after 4 hours

Oxytocin PGE2

Initial Bishop score 2.71± 0.96 2.65± 1.04

Follow up Bishop score 3.86± 1.45 5.02± 1.58

Mean change in Bishop score

1.15 2.37

Mean duration of stages of labour

Oxytocin PGE2

1ST STAGE 10.4 (2-14 HRS)

7.3 (1.5-12 HRS)

2ND STAGE 25.5 MIN 26.7 MIN

3RD STAGE 5 MIN 7 MIN

Comparison of PG vs. Pitocin Mode of delivery

Oxytocin PGE2Normal vaginal delivery

70 (35%) 125 (62.5%)

Instrumental vaginal delivery

90 (45%) 60 (30%)

L.S.C.S. 40 (20%) 15 (7.5%)

Prostaglandins – Induction of labour

SUMMARY:

• A survey of 15 Indian studies 1993 – 1996

• Parts of the country covered – 12 cities

• Average incidence of vaginal delivery 86.6%

• Average incidence of C. sections – 13.4%

• Average induction – Del. Interval – Primi 10.8 hrs

• Average induction – Del. Interval – multi 7.6 hrs

Pitocin induction of labourSummary:• Survey of six Indian studies• Average incidence of vaginal deliveries – 72.8%• Average incidence of C. section – 27.2%• Average induction – delivery time: 16.2 hrs in

primi• Average induction – delivery time: 9.6 hrs in

Multi• Incidence of low APGAR scores 1.5 – 2 times

higher

Comparison of PG vs. Pitocin for InductionS no

Authors drug % success

LSCS % incidence

Ind-Del interval hrs

Perinatal outcome low apgar

1 Gupta et al, Jaipur, 1995

PGO

73.355.5

13.344.4

16.427.9

4.4%13.3%

2 Muhkerjee, Allhabad,1996

PGO

72.750

16.340

16.322.5

--

3 Sandhu et al,Amritsar,1995

PGO

1015

9.510.4

--

4 Patki et al, Mumbai,1993

PGO

7520

7.810.9

5%7.5%

5 Dubey, kanpur, 1994

PGO

7.112.5

14.616.2

NIL4.7%

6 k. Gupta,Agra, 1994

PGO

12%20%

5.66.3

8.3%8.3%

Time lag due to oral administration leads to longer

induction – delivery interval as compared to I.V. Oxytocin

(Lange 1986)

Oral PGE2 – less GI symptoms & more effective than PGF2α and

has become the standard for induction and acceleration of

labour

PG’S are effective even in unripe

cervices due to the direct

softening effect on the cervix as

compared to Oxytocin

Prostaglandins in the induction of labour have been shown to be

devoid of deleterious effects on the physical and psychomotor development of the Neonate

Prostaglandin formulations in Obstetric practice

PROSTAGLANDINS

CERVICAL RIPENING

Cerviprime gel

FETAL DEATH

Prostodin injection

Cerviprime Gel +

Oxytocic

LABOUR

INDUCTION

Primiprost tablet

LABOUR

AUGMENTATION

Primiprost Tablets

THIRD STAGE COMPLICATIONS

Prostodin injections