Tartous symposium of the Syrian Association of Obstetricians and Gynecologists 2019

1. Cervical Ripening In IOL in
scarred uterus
dr. Mohamed Alajami
Higher Studies in Obs.Gyne- MD
Lecturer in HAMA Univ

2. INTRODUCTION
Ꚛ With increasing cesarean sections worldwide,
women with a scarred uterus who will need
induction of labor in a subsequent pregnancy
will also rise.
Ꚛ Nearly 25% candidates for (TOLAC) requires
induction of labor.
Ꚛ VBAC success 60 - 85%
BJOG 2004
BJOG 2014
Cochrane 2013
Dr. Mohamed Alajami

3. DEFINITION
Ꚛ Cervical ripening is a physiological process
occurring throughout the latter weeks of
pregnancy and is completed with the
onset of labor.
Clin Obstet Gynecol. 2006
Dr. Mohamed Alajami

4. Ꚛ‘Unfavorable’ cervix
= Bishop score < 6
Obstet Gynecol 1964
DEFINITION
Dr. Mohamed Alajami

5. METHODS OF
CERVICAL RIPENING
PHARMACOLOGIC
MECHANICAL
Dr. Mohamed Alajami

6. METHODS OF CERVICAL RIPENING
֎PHARMACOLOGIC
©Oxytocin
©Prostaglandins
 E1 (misoprostol)
 E2 (dinoprostone, Prepidil gel and Cervidil time-
released vaginal insert)
© Estrogen
© Relaxin
© Hyaluronic acid
© Progesterone receptor antagonists
Dr. Mohamed Alajami

7. ֎MECHANICAL
©Membrane stripping
©Amniotomy
©Mechanical dilators
Laminaria tents
• Dilapan
• Lamicel
Transcervical balloon catheters
 With extraamniotic saline infusion
 With concomitant oxytocin administration
METHODS OF CERVICAL RIPENING
Dr. Mohamed Alajami

8. Oxytocin
Acts on oxytocin receptors in the
uterus with no direct effects on the
cervix
J Obstet Gynaecol Can 2013
Dr. Mohamed Alajami

9. Oxytocin use in unfavorable cervical
through serial induction sessions of
10 to 12 hours a day, followed by
rest, with duration of 3-4
consecutive days.
Obstet Gynecol 1993
Oxytocin
Dr. Mohamed Alajami

10. Oxytocin efficacy for cervical
ripening is lower than other more
specific methods.
Oxytocin should be used judiciously as its
uncontrolled use can be associated with a risk
of hyperstimulation and FHR abnormalities
São Paulo Med J 2003
Am J Obstet Gynecol 2008
Oxytocin
Dr. Mohamed Alajami

11. Oxytocin induction may increase the
rate of surgical interventions in
labor, especially when the cervix is
unfavorable
Cochrane 2009
Oxytocin
Dr. Mohamed Alajami

12. Two main types of PGs used for IOL:
PGE1
(oral or vaginal misoprostol)
PGE2
(tablets and gels, and a controlled-release
preparation called dinoprostone).
Prostaglandins
Dr. Mohamed Alajami

13. ֎Misoprostol is the preferred
prostaglandin for cervical ripening
֎25 μg every 3 - 6 hours vaginally
֎ Oral misoprostol for cervical ripening 25 - 50
μg associated with less uterine tachysystole
Prostaglandins
ACOG 2017
Dr. Mohamed Alajami

14. Recommends against the use
of prostaglandins (Misoprostol) for
cervical ripening or labor induction in
women with a prior uterine incision
Prostaglandins
ACOG 2017
Dr. Mohamed Alajami

15. The lowest caesarean section risk was
associated with the use of a low-dose oral
solution (<50 μg) of misoprostol.
Vaginal delivery within 24 hours of
induction was most likely to be achieved
when vaginal misoprostol tablet (≥50 μg)
BMJ 2015;5:h217
Prostaglandins
Dr. Mohamed Alajami

16. METHODS OFOTHER PHARMACOLOGIC
CERVICAL RIPENING
Insufficient evidence on efficacy of:
© Mifepristone
© Estrogen
© Relaxin
© Dehydroepiandrosterone Sulfate
© Dexamethasone Sulfate
© Hyaluronidase
© Nitric Oxide Donors
(J Perinat Med. 2003)
(Int J Gynaecol Obstet. 2005
Cochrane 2001-2003-2009-2011
Dr. Mohamed Alajami

17.  Membrane stripping
 Amniotomy
 Balloon catheters
 Hygroscopic dilators
 Balloon with extra-amniotic infusion
Mechanical methods of cervical ripening
Dr. Mohamed Alajami

18.  Membrane sweeping by a finger passed through an open
cervical os and separate the chorioamniotic membrane
from the decidua of the lower uterine segment.
 Increase local prostaglandin concentration.
 When the cervical os remains closed, the cervix may be
massaged around the vaginal fornices for a similar effect .
Membrane sweeping
Am J Obstet Gynecol 1993
Cochrane 2005
Dr. Mohamed Alajami

19. Associated with
1. Higher rates of spontaneous vaginal delivery
2. Shorter induction-to-delivery interval
3. Reduced likelihood of post-term pregnancy
4. A decreased need for IOL
Membrane sweeping
Cochrane 2005
Dr. Mohamed Alajami

20. Undesirable effects of membrane sweeping:
1. Discomfort from the procedure
2. vaginal bleeding
3. irregular uterine contractions in the 24 hours after the
procedure
Membrane sweeping
Semin Perinatol.2015
Dr. Mohamed Alajami

21. ֎ Membrane sweeping does not increase the
risk of maternal and neonatal infection
֎ Even in carriers of Group B Streptococcus
Membrane sweeping
PLoS One 2015
Cochrane 2005
Dr. Mohamed Alajami

22.  Prior to IOL, offer a membrane sweeping as an adjunct
to induction
 Weekly membrane sweeping in attempting (TOLAC),
had no effect on duration of pregnancy, spontaneous
labor, or CD rate
Membrane sweeping
Obstet Gynecol. 2009;114:745–751
BUT
(NICE) 2008
Dr. Mohamed Alajami

23. Amniotomy
Dr. Mohamed Alajami

24. Amniotomy
֎ When oxytocin is used to induce labor, an
amniotomy is always performed first
֎ The immediate versus delayed use of an
oxytocin infusion after amniotomy for the
purpose of IOL was comparable
Arch Gynecol Obstet 2009
Obstet Gynecol 2013
Cochrane 2001
Dr. Mohamed Alajami

25.  does not recommend the use of an
amniotomy, with or without oxytocin, as a
primary method of labor induction, unless there
are specific contraindications to the use of PGs
 Data on the effectiveness and safety of
amniotomy and intravenous oxytocin alone are
lacking
Amniotomy
Cochrane 2011
(NICE) 2008
Dr. Mohamed Alajami

26. Transcervical Balloon catheters
Dr. Mohamed Alajami

27. Transcervical Balloon catheters
Dr. Mohamed Alajami

28. 1. Mechanical stretching of the cervix
2. Stimulate release of endogenous PGs
3. Biochemical mediators higher in women
who have received a Foley catheter
J Obstet Gynaecol 2013
Mechanism of action:
Transcervical Balloon catheters
Dr. Mohamed Alajami

29. 1. Switzerland rarely (Eur J Obstet Gynecol Reprod Biol 2011)
2. Germany 2% (Eur J Obstet Gynecol Reprod Biol 2015)
3. Netherlands 10% (Obstet Gynecol Int 2013)
4. France nearly 50% (Gynecol Obstet Fertil 2014)
The use of balloon catheters for cervical ripening
and labor induction : (of all labor inductions )
Netherlands the use of the Foley catheter for labor
induction after prior cesarean section has
increased from 49% in 2006 to 72.2% in 2010
Obstet Gynecol Int 2013
Transcervical Balloon catheters
Dr. Mohamed Alajami

30. ֎ The use of a transcervical Foley catheter
for cervical ripening have:
similar success rates for induction of labor
with intravaginal prostaglandins.
fewer abnormalities of contraction &
maternal side-effects than prostaglandins
a history of cesarean sectionWithout
BJOG 2011Am J Obstet Gynecol 2010 Cochrane 2012
Transcervical Balloon catheters
Dr. Mohamed Alajami

31. ֎Balloon catheters have become an
attractive alternative to prostaglandins for
patients with an unfavorable cervix.
BJOG 2011Am J Obstet Gynecol 2010
a history of cesarean sectionWithout
Cochrane 2012
Transcervical Balloon catheters
Dr. Mohamed Alajami

32. ֎The risk of uterine rupture is not different
between induction of labor using balloon
catheters and spontaneous onset of labor
Arch Gynecol Obstet 2014 Acta Obstet Gynecol Scand 2014
J Gynecol Obstet Biol Reprod (Paris) 2015
With a history of cesarean section
Transcervical Balloon catheters
Dr. Mohamed Alajami

33. J Matern Fetal Neonatal Med 2012
֎ No difference in delivery intervals or modes of birth
֎ The better cost-effectiveness of the Foley catheter
Geburtshilfe Frauenheilkd 2015
Obstet Gynecol 2011
BJOG 2009
Foley catheter vs. double balloon catheter
Foley catheter
should be over
double balloon
catheter
Balloon catheters
Dr. Mohamed Alajami

34.  The likelihood of a favorable cervix & The rate of
delivery within 24 hours is greater with larger filling
volumes
 Use 80 ml Foley catheters than with 30 ml Foley
catheters
Obstet Gynaecol Can 2014
Balloon filling
Balloon catheters
Dr. Mohamed Alajami

35. Filling the balloon to 80 mL versus 30 mL:
1.increased rate of delivery within 24 hours
2.increase in vaginal delivery rate
3.decreased need for oxytocin
4.higher rate of postripening dilation > 3 cm
Balloon catheters
Dr. Mohamed Alajami

36. ֎After expulsion, a favorable Bishop score is
most often achieved and induction may
begin.
֎If the Foley is not expulsed within 12
hours, remove it
֎as leaving it in 24 hours is associated with
longer inductions
Am J Obstet Gynecol. 2011
Balloon catheters
Dr. Mohamed Alajami

37. No differences
Am J Obstet Gynecol 2013
Balloon traction:
Balloon catheters
Dr. Mohamed Alajami

38.  No evidence that balloon catheters increase
infection risk
 But these results should be interpreted with
caution
 Foley catheters Only increased risk of
chorioamnionitis (defined as body temperature ≥ 38°C and
commencement of broad spectrum antibiotics) but not endomyometritis
Am J Obstet Gynecol 2008;199:177–87
Risk of infection
Cochrane 2012
Balloon catheters
Dr. Mohamed Alajami

39. ֎In conclusion it can be assumed that the
placement of a balloon catheter is not associated
with increased infection risk, particularly when
compared to repeated vaginal application of
prostaglandins
Risk of infection
Cochrane 2012
Balloon catheters
Dr. Mohamed Alajami

40.  No increase in the risk of chorioamnionitis when
using intracervical balloons in women with PROM
 Foley is safe and efficacious for cervical ripening
of women with PROM and unfavorable cervical
examination
J Matern Fetal Neonatal Med 2016
Premature rupture of membranes:
Am J Obstet Gynecol 2013
Gynecol Obstet Invest.1998 J Am Osteopath Assoc. 2014
J Matern Fetal Neonatal Med. 2015
Balloon catheters
Dr. Mohamed Alajami

41.  83% delivered vaginally when a Foley catheter was
used following failed induction with 50 μg vaginal
misoprostol – applied 6-hourly to the unripe cervix (no
evidence of labor onset after 24 hours).
Austr NZJ Obstet Gynecol 2004
Without previous CS
Failed induction with prostaglandin/misoprostol
Obstet Gynecol Surv 2011
Balloon catheters
Dr. Mohamed Alajami

42. Foley catheters and misoprostol for
cervical ripening & IOL are
comparable effectiveness and
safety profiles
Prostaglandins versus Foley catheters
Lancet 2016
Without previous CS
Cochrane 2014
Balloon catheters
Dr. Mohamed Alajami

43. Prostaglandins versus Foley catheters
Without previous CS
The PROBAAT-II trial
 Misoprostol was more effective for delivery within 24
hours;
 Foley catheter was found to be more effective when this
interval was increased to 36 hours.
 Achieving a safe vaginal birth is more important than
timescales alone
Lancet 2016;387:1619–28
BMC Pregnancy and Childbirth 2013, 13:67
Balloon catheters
Dr. Mohamed Alajami

44.  Addition of a Foley catheter to locally applied PGE1 and
PGE2
 increases the likelihood of vaginal delivery within 24
hours
 No difference in CD between the groups
Compared with prostaglandin alone:
Cochrane 2012 Int J Gynaecol Obstet. 2015
Without previous CS
Balloon catheters
Dr. Mohamed Alajami

45.  Foley catheter use without oxytocin was associated with
a lower rate of CD
 No difference in tachysystole
 Insufficient evidence to support concurrent use of Foley
catheter with oxytocin
Foley catheters + oxytocin for cervical ripening
Cochrane 2012
Balloon catheters
Dr. Mohamed Alajami

46. ֎There is insufficient evidence to support
early amniotomy after Foley induction
J Matern Fetal Neonatal Med. 2012
BJOG. 2002
Balloon catheters
Foley catheters + amniotomy
Dr. Mohamed Alajami

47. Extra-amniotic saline infusion
Dr. Mohamed Alajami

48. ֎There is insufficient evidence to use EASI instead
of Foley balloon for cervical ripening.
Obstet Gynecol. 2007Obstet Gynecol 2006
 Insufficient evidence to use of EASI alone for IOL
 No benefit to using EASI in combination with
Foley catheters.
 Not increase chorioamnionitis and/or
endometritis
Obstet Gynecol. 2007
Cochrane 2012
Cochrane 2012
Extra-amniotic saline infusion
Dr. Mohamed Alajami

49. Balloon catheters vs. Misoprostol
Pros Cons
single application greater need for oxytocin
augmentation
no uterine hyperstimulation
→less risk to the fetus
potentially increased infection risk
compared to oral prostaglandin
less monitoring required lower vaginal delivery rate in 24 h
More suitable for induction in
women at risk of placental
insufficiency
home induction!!
Dr. Mohamed Alajami

50. Osmotic dilators
֎Osmotic (or hygroscopic)
dilators used in the cervical
ripening prior to surgical
termination of pregnancy at
advanced gestations.
Dr. Mohamed Alajami

51. Osmotic dilators
 Utilization time of laminaria may vary from 12 to 24 hours
 No increased risk of hyperstimulation or associated FHR
abnormalities with Osmotic dilators use.
[https://clinicaltrials.gov/ct2/show/NCT02318173]
Dr. Mohamed Alajami

52. Osmotic dilators
 Osmotic dilators may be used as an outpatient agent for
IOL including in women who have had previous
caesarean sections
 Currently, no evidence support using luminaria to
decrease either the interval from induction to delivery
or the rate of CD
[https://clinicaltrials.gov/ct2/show/NCT02318173
BUT
Dr. Mohamed Alajami

53. OTHER METHODS IN CERVICAL RIPENING
Obstet Gynecol. 2006 BJOG. 2013
There is NO BENIFETS of:
© Breast Stimulation (release of oxytocin)
© Castor Oil (Castor oil should not be used for induction
of labor)
© Enemas and Baths
© Homeopathy
© Sexual Intercourse
Cochrane 2003-2005-2013
Dr. Mohamed Alajami

54. The heart of the matter is
֎ Prostaglandins should not be used in 3ed
trimester. &
֎ The Foley catheter be used
In different phrases in different guidelines in different
grading as:
Cervical ripening in a previous cesarean
delivery
Dr. Mohamed Alajami

55. ֎The use of Misoprostol should be
avoided in the third trimester in
women with prior cesarean delivery or
major uterine surgery .
ACOG 2009
Grade
A
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

56. ֎ Misoprostol should not be used for
cervical ripening or labor induction in
patients at term who have had a
cesarean delivery or major uterine
surgery.
ACOG 2017
Grade
A
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

57. ֎The Foley catheter is a reasonable and
effective alternative for cervical
ripening and inducing labor.
ACOG 2017Grade
A
ACOG 2009
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

58. Intracervical Foley catheters are acceptable
agents that are safe both in VBAC and in the
outpatient setting.
Neither PGE2 (cervical and vaginal) nor
misoprostol should be used in VBAC.
SOGC 2013
I-B
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

59.  Misoprostol is not recommended for use in
women who have had a previous caesarean
section
 other low-dose vaginal PGs (PGE2) and balloon
catheters are suitable
 The balloon catheter is as an option for labor
induction after previous caesarean section
WHO recommendations 2011
(no recommendation grade stated)
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

60. Vaginal PGE2 is not recommended in
women with a history of previous
caesarean section
Misoprostol should be offered as a method
of IOL only in intrauterine fetal death
Mechanical methods (balloon catheters,
Laminaria tents) should not be routinely
used for IOL
NICE 2008
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

61. PGs should be used with caution
Balloon catheters should not be used
routinely for labor induction with
unfavorable cervix.
The RCOG 2015 (VBAC)
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

62. Induction of labor using mechanical
methods (amniotomy or Foley catheter)
is associated with a lower risk of scar
rupture compared with induction using
prostaglandins.
The RCOG 2015 (VBAC)
D
Cervical ripening in a previous
cesarean delivery
Dr. Mohamed Alajami

63. Special condition
(IUFD) > 28 weeks with a prior cesarean scar;
֎cervical ripening with a transcervical Foley
catheter associated with uterine rupture
rates comparable with spontaneous labor.
Am J Perinatol 2010
Obstet Gynecol 2017ACOG 2017
Dr. Mohamed Alajami

64. 2nd-trimester (IUFD) in women with single
previous low transverse hysterotomy incision;
֎ misoprostol is acceptable alternative to
mechanical methods (a misoprostol dose
≤200 mcg vaginally every four hours )
Obstet Gynecol 2005 J Gynsecol Obstet 2007Euer J Obstet Gynecol Repord Biol 2003
Special condition
ACOG 2017
Dr. Mohamed Alajami

65. 2nd-trimester (IUFD) in women with > 2 single
previous CD:
֎ Misoprostol increases the risk of uterine
rupture to (2.5%)
֎ Halve the dose
Gomez Ponce de Leon et al. IJGO,2007
Am J Obstet Gynecol 2016
Special condition
Dr. Mohamed Alajami
so

66. IUFD & a previous caesarean section:
֎The dose of vaginal prostaglandin
should be reduced particularly in
the third trimester.
Special condition
NICE 2008
Dr. Mohamed Alajami

67. ֎Foley is as effective as other
methods, including misoprostol,
and possibly safer than
pharmaceutical methods, and
should be considered as first line in
all inductions, including those with
PROM
Conclusion
Dr. Mohamed Alajami

68. ֎It is Era of The Renaissance of
Transcervical Balloon Catheters
for Cervical Ripening and Labor
Induction !!!!
Ladies And Gentlemen
Dr. Mohamed Alajami

69. Have a nice eveningDr. Mohamed Alajami