الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
I
nduction of labor (IOL) is the process of initiating contractions of pregnant persons who are currently not in labour, to help them achieve vaginal delivery within 24 to 48 hours. Cervical ripening is one of the methods used for labour induction; it is “the use of pharmacological or other means to soften, efface, or dilate the cervix to increase the likelihood of a vaginal delivery”.
The two major techniques for cervical ripening are mechanical interventions (e.g. insertion of balloon catheters), and the application of pharmacological agents (e.g. prostaglandins) Prostaglandins are one of the preferred methods for cervical ripening, including the agents dinoprostone and misoprostol. It was proposed that estradiol act synergistically with misoprostol in labor induction.
This study aimed to evaluate the effectiveness of vaginal misoprostol versus vaginal misoprostol and estradiol cream for ripening of the unfavorable cervix in patients requiring induction of labor.
This study was a randomized controlled trial conducted during the period from April 2021 to October 2021 at Ain Shams University Maternity Hospital to compare the safety and effectiveness of vaginal misoprostol with combined vaginal misoprostol and estradiol for IOL in unfavorable cervix. Eligible patients (according to our inclusion criteria which were female patients with gestational age from 36 - 41 weeks, with singleton living fetus less than 4 k.gs with cephalic presentation, had no labor pain, or liquor abnormalities with Bishop score < 5), were randomly allocated to one of two treatment arms in a single-blind manner by the computer-generated system.
The study was conducted on 120 women with unfavorable cervix. Patients were randomized into two equal groups as follows; group I (control group) included 60 patients who were given only vaginal misoprostol 25 μg, and group II included 60 patients in which women were given vaginal misoprostol 25 μg with vaginal estradiol 150 m.
In the current study, in the misoprostol group and estradiol group, the means of the maternal age (26.2 ±5.1 vs 27.7 ±6.9 years), and the means of gestational age (38.9 ± 1.5, vs 38.8 ±1.6 weeks) were comparable in both groups with no statistically significant difference between the two groups as regards maternal and gestational age (P= 0.179, 0.91, respectively). Multipara females were more than primipara females in both groups, however, parity in addition to abortion times were comparable in both groups with no statistically significant difference between the two groups at (P= 0.508, and 0.576, respectively).
Regarding the medical and surgical history in both groups, the most frequent diseases were hypertension and diabetes, and the most previous surgical operations were tonsillectomy and appendectomy. No statistically significant difference between the two groups as regards medical and surgical history was reported (p=0.509).
The most common causes of labor induction were decreased fetal kicks, severe preeclampsia, and premature rupture of the membrane. There was no statistically significant difference between the two groups at (p=0.151).
As regards maternal outcomes, no uterine rupture was recorded, but uterine hyperstimulation was reported in 3 patients (one patient in the estradiol group and 2 patients in the misoprostol group).
As regards fetal complications in the current study, no fetal hypoxia was reported, but neonatal infections occurred in one patient in the misoprostol group. Meconium staining was higher in the misoprostol group than the estradiol group (21.7% vs 10%) with no significant difference between both groups as regards meconium staining (p=0.134). Six patients in the estradiol group and 10 patients in the misoprostol group were admitted to NICU with no statistically significant difference at (p=0.421). Although the 1st minute APGAR in the misoprostol group was significantly lower than the estradiol group (p=0.009*), the 5th minute APGAR was also lower in the misoprostol group than the estradiol group but with no statistically significant difference (p=136).
In terms of oxytocin intake and time of taking oxytocin, no statistically significant difference between the two groups was found (p= 0.994, 0.315 respectively). Also, as regards the active phase, the time needed to enter the active phase, and the induction delivery time in the active phase, all were comparable in both groups with no statistically significant difference at (p= 0.355, 0.701, 0.519, respectively).
In this study, although not statistically significant, the percentage of spontaneous labor in the misoprostol group (51.7%) was lower than the estradiol group (60%), and the CS in the misoprostol group was higher than the estradiol group (48.9% vs 40%, respectively). The causes of CS were failed induction and fetal distress with no statistically significant difference between both groups as regards causes of CS (p= 0.825, p= 0.63).
In this study, the mean ± SD of misoprostol doses in the estradiol group was higher than that in the misoprostol group (2.5 ± 0.83 vs 2.19 ± 0.64, respectively) with no statistically significant difference at (p=0.201).
CONCLUSION
A
lthough it was proposed that estradiol act synergistically with misoprostol in labor induction. This study was a randomized controlled trial to evaluate the effectiveness of vaginal misoprostol versus vaginal misoprostol and estradiol cream for ripening of the unfavorable cervix in patients requiring induction of labor. We found that although the spontaneous labor was more frequent in patients who received combined vaginal misoprostol and vaginal estradiol, however, this combination does not achieve a significant difference in labor induction compared to vaginal misoprostol alone with exception of the 1st minute APGAR score.
RECOMMENDATIONS
W
e recommended complementary studies, to evaluate a combination of more than one method whether pharmacological or mechanical in labor induction to establish the best model to be used safely in the clinical practice, and validate the contradictory findings as regard the use of estradiol in labor induction.