# So can we talk about cytotec...



## AugustLia23 (Mar 18, 2004)

After being terrified from these horror stories of cytotec and uterine rupture, and then blindly warning my clients on the horrors of it, I've finally actually done some research into the current studies done on cytotec and it's effects. Let me first say that I am NOT trying to say that it is for sure a safe drug, but from the studies that have been done(and done well) judicious us of it can be used to safely induce labor when indicated.

True, cytotec is not approved for it's usage in obstetrics, but then again, neither is terbutaline(brethine, to stop pre-term labor), or fentanyl or reglan, all of which are very widely used. Isn't the main reason it's unapproved simply because it's such a cheap med, and there would be no money to be made in doing an official study of it.

Almost all of the rupture, HIE, and Amniotic fluid embolism stories that I have heard are either 1. because mom had previously had a c-section, regardless of type, 2. because they gave mom too much of the drug too often, or 3. the drug was clearly contraindicated in the mom-to-be(i.e. grand multiparity).

From what I've read, a low dose given to the right woman can induce labor very well pretty closely to how she may have gone into labor on her own(not like the mack truck labors that pitocin can bring). Of course it is far from perfect, but maybe it needs some closer inspection before we can just outrightly say that cytotec is always a terrible drug and very, very dangerous for everyone.








:

ETA: I am not in any way suggesting that it be used more often, just thinking about the few times where induction really can be beneficial to mother and baby...


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## bryonyvaughn (May 4, 2007)

I think it's great that Cytotec can help *some* moms without causing fertility and life threatening side effects. My problem with Cytotec is they can't predict who it will help, who it will lead to a cascade of interventions, and who it will cause to lose her uterus or life.

I really can't rationalize the use of Cytotec WHEN women can get a more effective dose of prostaglandins from human semen and can supplement with essential fatty acids to build their own prostaglandins AND neither increase risk of uterine rupture.

~BV


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## katja (Apr 13, 2004)

A brave woman you are, AugustLia!







:


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## wannabe (Jul 4, 2005)

The off-label use argument has never held water with me - aren't some huge percentage of all prescriptions for off-label uses?

Quote:

I really can't rationalize the use of Cytotec WHEN women can get a more effective dose of prostaglandins from human semen
and that would require vaginal application, wouldn't it? As opposed to oral cytotec with ruptured membranes.

Quote:

and can supplement with essential fatty acids to build their own prostaglandins
reference?


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## pamamidwife (May 7, 2003)

the issue with cytotec is its unpredictability - one never knows how a woman will respond to cytotec. it's also the cavalier attitude that the 'cure' to a problem with cytotec is easy - a cesarean.

I think the broader issue we should be looking at is the induction epidemic. not just from hospital based births, but also homebirths. why are we so set on dates and the idea that a woman's body is set out to fail a baby because of a timeline?

Induction is something that is ruining births - and the health of babies and mothers - all because of a manmade idea of dating.


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## pamamidwife (May 7, 2003)

Quote:


Originally Posted by *wannabe* 
and that would require vaginal application, wouldn't it? As opposed to oral cytotec with ruptured membranes.

well, it seems many providers have no issue sticking their fingers up inside women with ruptured membranes and NO contractions.

I think the problem is not looking at the evidence - that women with ruptured membranes do better in a wait and see (meaning, no fingers climbing up inside you every two hours) situation than induction.


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## wannabe (Jul 4, 2005)

But there needs to be an end to that wait and see, when the odds of labour starting drop below the odds that an infection will (even in someone with good care - nil by vagina). At some point, in a woman significantly past her due date, with ruptured membranes and no real uterine activity at all, you're going to start running a risk of infection that outweighs the risk of induction. Sure, it's not at 24 hours, but it's somewhere in those couple of weeks.


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## mwherbs (Oct 24, 2004)

There are some very large multi-center trials that I am waiting to read about before I say yea or no-- so far the way they have arrived at a criteria is to have experimented on the mom/baby pair and produced some serious consiquences -
the multi-center trials that were done in 2006 compare a newer vaginal application of cytotec that would have 50 or 100 mcg to cervidil
--- here was their criteria list--

"Ages Eligible for Study: 18 Years and above,
Genders Eligible for Study: Female

Inclusion Criteria:
* Pregnant women at least 36 weeks gestation requiring cervical ripening and induction of labor

Exclusion Criteria:
* No uterine scar (no previous delivery by cesarean section)
* No multiple gestation
* No condition that disallows use of prostaglandins for induction of labor
* No more than 3 previous vaginal births beyond 24 weeks gestation"

---------------------------
so a pretty narrow group to begin with and after talking with CNMs who have had some experience in hospitals they wondered why there wasn't a 25mcg amount- so I wrote the researchers and the reply I received was because the effect was the same as cervadil or less at 25 and that there were 2 studies one in 02 and one in 03 that pointed to the higher amounts.
other than hemorrhage I think it has no place in out of hospital birth- and I am not won over that it is safe for in hospital birth- it is certainly cheaper than cervadil -- the African study published this year still using tabs instead of a vaginal insert - came up with unpredictable results --so I still just don't know- I wouldn't want my daughter to use it...


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## bryonyvaughn (May 4, 2007)

Quote:


Originally Posted by *wannabe* 
The off-label use argument has never held water with me - aren't some huge percentage of all prescriptions for off-label uses?

I didn't make it.

Quote:


Originally Posted by *wannabe* 

Quote:


Originally Posted by *bryonyvaughn*
I really can't rationalize the use of Cytotec WHEN women can get a more effective dose of prostaglandins from human semen

and that would require vaginal application, wouldn't it? As opposed to oral cytotec with ruptured membranes.









: No.







:

In fact everything I've read has indicated it's more effective orally than topically. That make sense if the prostaglandins are not inducing labor but giving the woman something she can break down to build her own hormones (hence the effectiveness of EFA supplementation.)

Quote:


Originally Posted by *wannabe* 

Quote:


Originally Posted by *bryonyvaughn*
and can supplement with essential fatty acids to build their own prostaglandins

reference?

Nope. I thought it was a soundly and widely established physiological fact. I googled "essential fatty acids" +prostaglandins and got over 1/4 million sites. I nursed the baby to sleep at the keyboard so I can't dig out my physiology books right now. LMK if you want some text book references. I can get them when I get back online tonight.

~BV


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## AugustLia23 (Mar 18, 2004)

Nice to see such civil responses, I was almost afraid to check on this post I created for fear of some serious flaming.

I wonder what it is in the woman or the cytotec that causes some women to respond so well to it, some women not to respond at all, and some women to have these catastrophic events...


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## crsta33 (Oct 13, 2004)

Are there any of the serious side effects when it is used to stop post partum hemmorage? Is that also "off label" use? Is it more effective than IM pitocin?

This discussion just got me wondering.

Christa


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## mwherbs (Oct 24, 2004)

the minor side effects yes fairly common- fever and nausea
I think that there has been one older report of a maternal death when it was used to stop hemorrhage-

here is a link to an older review
http://www.pubmedcentral.nih.gov/art...medid=17273309


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## courtenay_e (Sep 1, 2005)

Quote:


Originally Posted by *crsta33* 
Are there any of the serious side effects when it is used to stop post partum hemmorage? Is that also "off label" use? Is it more effective than IM pitocin?

This discussion just got me wondering.

Christa

It's funny you should ask that question, because I asked the same question of a room full of midwives recently, when they were talking about how cytotek is the wonder drug for pp hemmorage. I have had it used on me to expel a tubal pregnancy (long time ago, long story), and it was a freaking nightmare. I thought I was going to die. My mother and husband were also seriously concerned for my health and well being...and they are usually the last people to become concerned about anything like that. It's NOTHING like real labor, by the way. I've had two live births since, and it is NOTHING like a labor that is naturally induced. Or it wasn't for me, anyway! From what I know NOW, it seems that they used about ten times the recommended dose (tablets used vaginally), so the WAY I labored makes complete sense...the problem is that is seems around here that every practitioner uses their own favorite dose, there is no norm...though I'm not sure about pp hemmorage.

but my question to the group was actually if any of THEM had ever had it used on THEM. Not to be cranky, but to see if THEY had ever experienced the contractions that it induces, and whether they knew if that same kind of CRAZY strong, to the point of frightening, contractions were the kind that you get if it's applied rectally to stop a bleed. I suppose that a common thought on this might be, "Who cares how it feels if you don't bleed to death?" BUT...it was a frightening experience. And I've also hemmoraged post partum, and that is frightening and exhausting in itself, and I don't know that I'd have fared it as well with a cytotek experience on top of that...

I guess that there are just too many questions for me to feel comfortable using it on a client when I am a midwife, or being comfortable attending a birth as a doula if it's used in a hospital. I, too, will be interested to see the studies when they come out.


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## cottonwood (Nov 20, 2001)

Quote:

and can supplement with essential fatty acids to build their own prostaglandins
Also, zinc is important in the process of converting EFAs into prostaglandins. Prostaglandin inhibitors are cortisone, aspirin, acetaminophen, and ibuprofen. Apparently vitamin E is a prostaglandin inhibitor also (it's suggested for relief of menstrual cramping) but I wonder if it affects all prostaglandins or just inflammatory ones? I don't have enough time or interest to do the research right now, but just thought I'd mention it...


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## pamamidwife (May 7, 2003)

Quote:


Originally Posted by *wannabe* 
But there needs to be an end to that wait and see, when the odds of labour starting drop below the odds that an infection will (even in someone with good care - nil by vagina). At some point, in a woman significantly past her due date, with ruptured membranes and no real uterine activity at all, you're going to start running a risk of infection that outweighs the risk of induction. Sure, it's not at 24 hours, but it's somewhere in those couple of weeks.


See, I disagree. With most infections, you will see it within the first 12 hours after rupture or within 12 hours of the first vaginal exam. Definitely if you're dealing with signs of an infected baby, do you really want the unpredictability of cytotec involved? Give me pitocin instead.


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## bluegrassgirl (May 8, 2007)

After reading the book "Born In The USA" and hearing all about these women who have died after being induced with Cytotec, I would never want it in my body. You can have bad side effects from with WITHOUT having a prior C-Section scar. I read online that some first time mom's have had to have hysterectomy's and have died after being induced with Cytotec. Plus, I have read that Cytotec causes more fetal stress than any other labor inducing medicine on the market.

Jessie
(single mommy to Emma, 3 years and Angela, 2 years)


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## bryonyvaughn (May 4, 2007)

Me: _and can supplement with essential fatty acids to build their own prostaglandins_

Quote:


Originally Posted by *wannabe* 
reference?

From my class notes:
EFAs are converted to polyunsaturated fatty acids (PUFA).
Some of the PUFAs are substrates for eicosanoid biosynthesis which leads to the production of prostaglandins, leukotrienes & lipoxins.

Not a journal reference but hopefully should give you enough buzzwords to narrow down and increase the effectiveness of your googling.









BV, who's so old she did medical research before Google


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## pamamidwife (May 7, 2003)

thanks, BV - it's a perfect explanation as to why Evening Primrose oil *could* work to soften the cervix.


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## mwherbs (Oct 24, 2004)

from what I understand misoprostol is a synthetic prostaglandin E1 (PGE1) analogue and that it isn't "food" for your body to turn into something it is similar to what the body produces a signaling molecule- and probably why it is problematic is that the body makes cascades of things not just a single element to bring on birth
-.
our bodies need essential fatty acids for many things it does- we have to eat them because our bodies cannot make linoleic acid --- but we have some parallel path ways for different forms of linoleic acid-- there is omega 3 oils and they do not create as much inflammation.
eicosanoids are signaling molecules derived from omega-3 (ω-3) or omega-6 (ω-6) fats---- for most of us in our current lifestyle and dietary habits we get too much of the omega 6 oils and not enough of omega 3- the ratio should be1-1 to as much as 4 times more omega 3 to the amount of omega 6 we eat.
when converting omega 6 oils into eicosanoids the going through the arachadonic acid cascade the side effect is far more inflammatory products are produced- which translates into pain- omega 3 can put out similar eicosanoids but with much less inflammatory by-products
---------------------------------------------------------------------
eicosanoids are the signaling molecules that include prostaglandins, prostacyclins, leucutrines and thromboxane
--------------------------------------------------------------------
here is an abstract that can somewhat speak to the complexity of the subject
it is dealing with the eicosanoids and the actions they have on the heart-so even if it is not talking about the uterus it shows how complex the different signaling bio-chemicals are labor is more than the uterus contracting it also relaxes inbetween the body needs to produce a group of complementary bio-chemicals and hormones to fill out the process--

Prostaglandins. 1997 Aug;54(2):511-30.

Differential effects of various eicosanoids on the production or prevention of
arrhythmias in cultured neonatal rat cardiac myocytes.

Li Y, Kang JX, Leaf A.

Department of Medicine, Massachusetts General Hospital, Charlestown 02129, USA.

To identify the arrhythmogenic and the antiarrhythmic eicosanoids, cultured,
spontaneously beating, neonatal rat cardiac myocytes were used to examine the effects of various eicosanoids added to the medium superfusing the cells at different concentrations on the contraction of the myocytes. Superfusion of the myocytes with the prostaglandins (PGD2, PGE2, PGF2 alpha) or the thromboxane (TXA2)-mimetic, U 46619, induced reversible tacharrhythmias characterized by an increased beating rate, chaotic activity and contractures. These effects are concentration-dependent. PGF2 alpha and U 46619 were much more potent than PGD2 or PGE2 in the production of tachyarrhythmias. Prostacyclin (PGI2) induced a marked reduction in the contraction rate of the cells with a slight increase in the amplitude of the contractions and showed a protective effect against the arrhythmias induced by PGF2 alpha and TXA2 (U 46619). PGE1 exerted a dose-dependent dual effect on the contraction of the myocytes. At low concentrations (< 2 microM), PGE1 reduced the contraction rate of the cells with an increase in the amplitude of the contractions and effectively terminated the tachyarrhythmias induced by arrhythmogenic agents, such as isoproterenol, ouabain and U 46619. At higher concentrations (> 5 microM), PGE1 caused cell contractures and chaotic activity. In contrast, the lipoxygenase products [leukotriene (LT) B4, LTC4, LTD4 & LTE4] of arachidonic acid (AA) had no significant effect on the myocyte contractions. The eicosanoids derived from eicosapentaenoic acid (EPA), including both the cyclooxygenase products (PGD3, PGE3, PGF3 alpha, TXB3) showed
lesser effects on the contraction of the myocytes. The lipoxygenase products
(LTB5, LTC5, LTD5 & LTE5), as with the AA metabolites showed little effect on the contraction of cardiac myocytes. The arrhythmias induced by the arrhythmogenic prostaglandins and thromboxane A2 could be suppressed by the nonmetabolizable AA analog eicosatetraynoic acid (ETYA) or free AA and EPA, indicating a distinction in the effect on cardiac arrhythmia between the precursor fatty acids (AA & EPA) themselves and their metabolites. In conclusion, the major arrhythmogenic eicosanoids are the cyclooxygenase products of AA, whereas those products of EPA are much less or not effective; PGE1, PGI2, ETYA and EPA have antiarrhythmic effects.

Publication Types:
Research Support, U.S. Gov't, P.H.S.

PMID: 9380795 [PubMed - indexed for MEDLINE]
---------------------------------------------

here is a link on essential fatty acids- and a cascade that shows production ----
http://en.wikipedia.org/wiki/Essenti...d_interactions


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## etoilech (Mar 25, 2004)

Quote:


Originally Posted by *pamamidwife* 
the issue with cytotec is its unpredictability - one never knows how a woman will respond to cytotec. it's also the cavalier attitude that the 'cure' to a problem with cytotec is easy - a cesarean.

I think the broader issue we should be looking at is the induction epidemic. not just from hospital based births, but also homebirths. why are we so set on dates and the idea that a woman's body is set out to fail a baby because of a timeline?

Induction is something that is ruining births - and the health of babies and mothers - all because of a manmade idea of dating.

Absolutely. I think induction is such a *false* bill of goods and when it is most needed or wanted, it is most likely to fail.

The argument over cytotec (misoprostol) is moot for me. Where I live misoprostol is contraindicated during pregnancy. Period. Anyone giving it pregnant women here would risk losing their license.

I also agree with Pam, *if* there is going to be infection you are very likely to see it in the first 12 hours. Best practice and clinical evidence suggests watchful waiting for prolonged rupture of membranes.


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## bryonyvaughn (May 4, 2007)

Quote:


Originally Posted by *etoilech* 
...The argument over cytotec (misoprostol) is moot for me. Where I live misoprostol is contraindicated during pregnancy. Period. Anyone giving it pregnant women here would risk losing their license.

Well don't keep it secret! Where do you live?

BV, who thought such a place only existed in her dreams


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## monocyte (Jun 17, 2004)

Quote:


Originally Posted by *katja* 
A brave woman you are, AugustLia!







:









:


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## AugustLia23 (Mar 18, 2004)

Hey, I will take that as a compliment. I am getting used to being the different voice. I just want there to be a sound judgement on the drug one way or the other. I won't be pointing anyone towards it anytime soon, but it'd be nice to have some reliable results from reliable studies.

It's hard to have studies done on this sort of thing though, I mean, I wouldn't be signing up for the study...

It's definitely not okay to risk moms and baby's lives in the name of science.


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## AugustLia23 (Mar 18, 2004)

Quote:


Originally Posted by *jessie.gray* 
After reading the book "Born In The USA" and hearing all about these women who have died after being induced with Cytotec, I would never want it in my body. You can have bad side effects from with WITHOUT having a prior C-Section scar. I read online that some first time mom's have had to have hysterectomy's and have died after being induced with Cytotec. Plus, I have read that Cytotec causes more fetal stress than any other labor inducing medicine on the market.

Jessie
(single mommy to Emma, 3 years and Angela, 2 years)


Do you know what the dosages were? Mom's likely weren't having these side effects from 25mcg per 4-6 hours...probably closer to 50-100mcg


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## Ellie'sMom (Aug 10, 2002)

Quote:


Originally Posted by *AugustLia23* 
I wonder what it is in the woman or the cytotec that causes some women to respond so well to it, some women not to respond at all, and some women to have these catastrophic events...

I'm not sure it is something about a particular woman, rather than something about that particular pregnancy. I have used cytotec twice to complete an incomplete miscarriage. The first time I hemmorhaged and had to go to the ER in spite of the fact that some of the tabs (intravag.) fell out an hour or so after insertion. The second time (long story about why I decided to try it again) it did nothing at all even with a repeat dose. The primary difference I think was that with the first pregnancy I had been spotting for 2 weeks, whereas with the second we found no heartbeat on u/s, but I had no symptoms of m/c. I have always assumed that my body was just really ready the first time and not so much the second.


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## mwherbs (Oct 24, 2004)

unfortunately many of the ruptures have occured without it even being in a study so harder to find in the lit--- so I by far prefer a study where women are told that they are using an experimental drug...
also I think that there has been a bigger cost to unofficial off label use and that is the withdrawl of VBAC on a national level- I do believe that the increase in rupture that was being reported via insurance was related to cytotec being used on VBACs -- there is a pretty decent risk list in the CNM journal maybe 2 or 3 years ago---
------------------------------------------------------


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## AugustLia23 (Mar 18, 2004)

I definitely don't understand the usage with VBAC moms, especially if they are aware of that increased risk of rupture witht he drug alone.

It also makes you think a lot more about why so many moms "need" to be induced in the first place...


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## pinksprklybarefoot (Jan 18, 2007)

FWIW, they gave me Cytotec to stop a pp hemorrhage. I was very anti Cytotec before going to the hospital and would have refused it as an induction method. I had a CPM as my labor support (I was originally supposed to homebirth) and we had a few conversations about it. She thought it was a very dangerous drug for inducing labor.

However, when I hemorrhaged and the CNM recommended the Cytotec (which I did not know could be used for hemorrhages), I turned to my CPM and asked if it was a good idea. She said that it was. So I let them give it to me. The hemorrhage stopped and I had no side effects. Don't know if that is what usually happens, but for the purpose of stopping severe bleeding, it worked for me.


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## turtlewomyn (Jun 5, 2005)

I also just read Born in the USA, and it really scared me. I know that many of the horror stories occurred before they knew "safer" dosages to use, but it bothers me that doctors experimented with this drug on women without their knowledge or consent. I had a former coworker who lost a nephew due to Uterine Hyperstimulation, she told me that they sued the doctors for not doing a c-section in time, but I doubt that uterine hyperstimulation occurs on its own without inducing drugs.
Anyway, in an event where the mom or baby is in danger (i.e. pre-E), inducing might be preferable to just going in and doing a c-section, I would think. However, I hear way too many stories of women who were induced at 38 or 39 weeks because they were sick of being pregnant, or because the doctor was going on vacation. I seriously doubt that these women were informed that they could be putting their lives or their children lives in danger.


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## birthgreeter (Aug 31, 2006)

Quote:


Originally Posted by *pamamidwife* 
thanks, BV - it's a perfect explanation as to why Evening Primrose oil *could* work to soften the cervix.










Agree!


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## pamamidwife (May 7, 2003)

I think that cytotec for postpartum hemorrhage or even to induce an early miscarriage is a wayyyy different situation than a term pregnancy induction.


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## Jane (May 15, 2002)

It's pretty clear the cytotec causes more uterine contractions when given orally - typically beginning to act in 10 mintues. However, it has a longer acting effect when given vaginally or rectally, but doesn't kick in for 25 minutes. I think it's a great second line for hemorrhage, but pitocin is more physiologic and acts in a few minutes. But it's way better than methergine, IMO.
If it were being given for induction, I like the protocols that call for a tablet to be dissolved into water first, then portioned out. So, a 1/4 tablet dose is 25 ml of water after one tablet is dissolved into 100 ml of water. At least then the dosing is actually what is ordered, instead of cutting a tablet with no score lines.
I've never heard of it being given for ectopic pregnancy - only methotrexate. Misoprostol would cause uterine contractions - I can't think of a mechanism to expel an ectopic, but that isn't my area of expertise.
I do think it should be an option for induction. When a mom needs to be delivered for maternal health reasons, but is long and closed, cytotec can get the baby out vaginally. I don't think it should be used for "general" inductions for postdates or convenience. Lots of things are dangerous, but used in moderation in pregnancy. If they weren't needed, no one would use pitocin, antidepressants, asthma medications, beta blockers, or seizure medications, either. There's a reason that Lady Justice carries a scale. Maybe medicine needs a scale, too.


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## etoilech (Mar 25, 2004)

Quote:


Originally Posted by *bryonyvaughn* 
Well don't keep it secret! Where do you live?

BV, who thought such a place only existed in her dreams









Switzerland but, we're moving to the UK. It's also contraindicated there.


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## DoomaYula (Aug 22, 2006)

When I was pregnant with my twins, I was induced (for TTTS and IUGR in one twin) at 34w with Cervidil. When I moved here and started being a doula, a CNM told me they use Cytotec because it costs 25 cents vs $500 for Cervidil. I don't know if Cervidil is safer (although I think it's approved for use in pregnancy and labor, right?) but it bothers me that our local hospital uses it just based on the cost. Although I'm sure it's not the only drug that is used specifically because it costs less than better drugs, but that's another thread.


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## mwherbs (Oct 24, 2004)

last year a dosage of cervadil cost- $150 which is PGE 2
it is in the form of a vaginal insert so can be removed and the process can be stopped--- not as many ruptures associated with the use -

and yep one dose of Misoprostol is about $1.00 which is PGE 1
one or 2 pills taken orally or intervaginally/intercervical placement hard to find to remove and cannot withdraw it if taken orally--
that is why there is a big multi-center study making a vaginal insert so it can be removed---


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## DoomaYula (Aug 22, 2006)

So it can't be removed or anything if the mom is having a problem? Eeek. I remember having the cervidil removed after I got going in active labor.


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## mwherbs (Oct 24, 2004)

imagine tiny little pill meant to be taken orally that is what is put into the cervix some may put it in the vagina but for the most part they are trying to get it right up into the cerivx and it is a different pge 1 and the critter stuff is pge 2.

and they have clinical trials that will be going on in the UK ending in 08 the name of the drug is Isprolor--

here is a promotional web site on misoprostol-- under availability is where I found the info about the UK

http://www.misoprostol.org/File/guidelines.php


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## zoeyzoo (Jul 6, 2007)

Quote:


Originally Posted by *AugustLia23* 
It also makes you think a lot more about why so many moms "need" to be induced in the first place...

IMO, this is why this drug is so dangerous. You are giving these untested interventions usually out of convience; not need for the saftey of the mom/baby. As we all know one interviention is likely to lead to another intervention.

From a lot of the birth show's I've seen like "A Baby's Story", I'm sure most of the moms think this drug is tested and safe. I've actually seen doctors on that show tell moms there are no side effects to pit and the epidural and that they're completely safe. Next thing you know the baby is in distress and they're setting up an OR room for a C Section. I'm sure most moms don't receive full disclosure on this drug either or the ricks of induction in general either.


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## StacyL (May 4, 2004)

THis has been said already, but I second the rec that you need to read Dr. Marsden Wagner's book, "Born In The USA."

I also went to an anti-cytotec rally here in D.C. last year at the annual ACOG conference and they had a huge quilt embroidered with the names of Moms and babies that died from cytotec. It was very sad and disturbing. The woman who organized the rally did get a meeting with the vice president of the ACOG, although I don't know what the results of it were.


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## Ixcuina (Feb 22, 2003)

Quote:


Originally Posted by *AugustLia23* 
.

Almost all of the rupture, HIE, and Amniotic fluid embolism stories that I have heard are either 1. because mom had previously had a c-section, regardless of type, 2. because they gave mom too much of the drug too often, or 3. the drug was clearly contraindicated in the mom-to-be(i.e. grand multiparity).

Well, the one story I know about personally (I knew the Bradley instructor that the mom took classes from), had none of those issues. I know it is simply "anecdotal evidence", but she was a first time mom, had an amniotic fluid embolism (cannot be "proven" the tear was caused by cytotec, of course







)...

Her husband lost both her and their baby.

http://tatia.org/index.html

PS. The cost factor is part of what really irks me...the fact that cytotec is so darn cheap and Prepidil and Cervidil (the "easier to remove" options) are not so cheap...hmmm....wonder if that plays a factor in cytotec's popularity?


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## courtenay_e (Sep 1, 2005)

Quote:


Originally Posted by *Apricot* 
It's pretty clear the cytotec causes more uterine contractions when given orally - typically beginning to act in 10 mintues. However, it has a longer acting effect when given vaginally or rectally, but doesn't kick in for 25 minutes. I think it's a great second line for hemorrhage, but pitocin is more physiologic and acts in a few minutes. But it's way better than methergine, IMO.
If it were being given for induction, I like the protocols that call for a tablet to be dissolved into water first, then portioned out. So, a 1/4 tablet dose is 25 ml of water after one tablet is dissolved into 100 ml of water. At least then the dosing is actually what is ordered, instead of cutting a tablet with no score lines.
I've never heard of it being given for ectopic pregnancy - only methotrexate. Misoprostol would cause uterine contractions - I can't think of a mechanism to expel an ectopic, but that isn't my area of expertise.
I do think it should be an option for induction. When a mom needs to be delivered for maternal health reasons, but is long and closed, cytotec can get the baby out vaginally. I don't think it should be used for "general" inductions for postdates or convenience. Lots of things are dangerous, but used in moderation in pregnancy. If they weren't needed, no one would use pitocin, antidepressants, asthma medications, beta blockers, or seizure medications, either. There's a reason that Lady Justice carries a scale. Maybe medicine needs a scale, too.

Yup, neither has basically anybody I've talked to about it...one OB had heard of it. It was basically before "they" were doing surgery on the tube and were able to remove the pregnancy without removing the tube (now I know that, at that time, there WERE specialists doing it, but I couldn't even get my regular OB to believe that there was something wrong, let alone find a specialist to see me who hadn't ever seen me before), and they told me that this would expel the pregnancy without damaging the tube.

I've found one written reference to that particular "procedure" since then, in an OLD copy of the dreaded "What to Expect..." but they've since edited it out. Go figure.

Anyway. From personal experience...I certainly wouldn't recommend it. That's not statistical, I know, only anecdotal, but thank you to the pp who mentioned the fact that it was used for her post partum to stop a bleed. I'd be interested to hear of more experiences from the recipients.


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## mwherbs (Oct 24, 2004)

I haven't read any protocols that include using misoprostol for ectopic pregnancy when it is used to terminate in early pregnancy with mifeprex- only given after an ultrasound- that is done for dates as well as location--
here is some info from the FDA web site
http://www.fda.gov/cder/drug/infopag...qa_4_17_02.htm

"An ectopic pregnancy is any pregnancy that develops outside of the womb. It occurs in 2% of all pregnancies. The ectopic pregnancy is usually in the fallopian tube. As it grows, it damages the tube causing it to rupture (burst) and bleed. Unless it is discovered and treated early, almost 40% of ectopic pregnancies rupture suddenly, causing pain and dangerous bleeding in the abdominal cavity. The other 60% usually cause slow bleeding in the abdomen. Ruptured ectopic pregnancies can be fatal. According to data gathered from death certificates in the U.S. by the National Center for Heath Statistics (NCHS) in 1999, 19 women were reported to have died of ectopic pregnancies.

The Mifeprex label states uses of Mifeprex and misoprostol for the termination of pregnancy is contraindicated in patients with confirmed or suspected ectopic pregnancy. Mifeprex is not an effective treatment for an ectopic pregnancy."


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## courtenay_e (Sep 1, 2005)

Yup. As I said, it's a long story...I believe it was a trial, but don't remember for sure, as the entire summer is like a bad movie being played in slow motion...didn't plan the pregnancy, found out early that I was pregnant, came to terms with the pregnancy just in time to figure out that there was someting just not right. Told doc as much, with a response of "Have you ever been pregnant before? NO? Well, then, how do you know HOW it's supposed to feel!? I don't DO routine ultrasounds before 18 weeks. Go home and enjoy your pregnancy." And, out the door he walked.

I had to seek another doctor to do an ultrasound. Nobody wanted to take me because I was not an established patient. I couldn't afford an emergency room visit if it was in fact just normal "cramping." Finally I went to planned parenthood. They gave me an ultrasound...and we went from there. It was awful, I was sitting in a room FULL of women talking about how they'd had multiple abortions, I really wanted this baby, and needed to know whether I was going to be able to carry it to term. I then had to find somebody to help me end my pregnancy, with which I had JUST come to terms. They recommended a doc, again, I think he was part of a study...I remember signing paperwork... I wouldn't ever recommend it to anybody. I would take having only one tube before I did it again. I just didn't know any better, and they told me that it was a "safe" drug to induce labor, and that that's basically what they were doing, except that they had to end the pregnancy first. They gave me a shot of something that made me pretty sick, and then sent me HOME with a packet of pills to insert vaginally. And the nightmare continued...several times in the next day or three (it runs together) my mom and husband seriously considered bringing me to the ER because of the way I reacted to the drugs. FWIW, it DID expel the pregnancy... Whether or not there's literature about it, it was used on me in that way, and I pray to God that nobody is still doing it...apparently somebody thought it was a great idea to test out a theory...hopefully their theory was proven wrong?...dunno. EVERY practitioner I talk to now has the same reaction, "They used WHAT?! WHAT is that doctor's name!? They sent you H-O-M-E!!!!? Oh my God." Again, it was such a nightmare of a summer that I don't remember most of it, but that's what I do remember.

It was really terrible.

This experience is one of the major things that has led me to do birthwork. The fact that the GOD in the white coat thought he knew more about what was going on in my body than I did and treated me sooo poorly...that really touched something in me. Nobody should be treated like that.

In the end, the pain, bleeding, vomiting, shakes, you name it, is what concerns me so majorly about using it on a woman who is hemorraging. Again, I've also hemorraged post partum...now, my bleed was ten days post partum, but still was an exhausting and scary and LONG day, ending in a d&c that seems to have ruined my uterine lining...I'd hate to see a woman go through all that and have a horrific reaction to the drugs. I mean, gee, if it really does immediately stop the bleeding, maybe not bleeding out would be worth it...but if there were another option, I sure would try it on my client first!!

Sorry. That was long...


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## Jane (May 15, 2002)

That sounds awful - bad care all the way around. I'm sorry that you had to lose your baby.

In hearing your story, it sounds like you may have been given a drug to stop the growth of the pregnancy in the tube, and then they induced labor. Typically the treatment is to stop the growth and then wait. There's no need to induce labor, too. That would be torturing someone for no reason.

Used for hemorrhage, women given cytotec often have cramping, nausea, vomitting, increased temperature, and shivering. However, the number of women experiencing nausea, vomitting, and cramping isn't higher than the number of women post partum without any drugs given. Shivering (30%) and increased temperature (8%) are significantly higher than women on a normal course. More side effects than pitocin, but less than methergine.


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## courtenay_e (Sep 1, 2005)

Thanks, Apricot. So basically they put me through the wringer for nothing. Par for the course for the whole situation, I guess. *sigh*

Okay, so, yes, there are side effects when used post partum as well. Makes sense, and good to know. I guess that whatever you use'll have side effects. I had so much pit and methergine when I was bleeding pp that they had to call in a pulmonary therapist with some albuterol...I had a big time asthma flare-up.

Hmmm. Having been on the receiving end, and having had all of those reactions (okay, no fever, had I had a fever, they DEFINATELY would have brought me in), I think it'd make me think twice about administering it if there is something else that might work as well with fewer side effects (pitocin?). Maybe the _dosage_ had a large part to play in my reaction...sorry, musing out loud now.


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## superfastreader (Aug 6, 2007)

Quote:


Originally Posted by *courtenay_e* 
Finally I went to planned parenthood. They gave me an ultrasound...and we went from there. It was awful, I was sitting in a room FULL of women talking about how they'd had multiple abortions, I really wanted this baby, and needed to know whether I was going to be able to carry it to term. I then had to find somebody to help me end my pregnancy, with which I had JUST come to terms. They recommended a doc, again, I think he was part of a study...I remember signing paperwork... I wouldn't ever recommend it to anybody. I would take having only one tube before I did it again. I just didn't know any better, and they told me that it was a "safe" drug to induce labor, and that that's basically what they were doing, except that they had to end the pregnancy first. They gave me a shot of something that made me pretty sick, and then sent me HOME with a packet of pills to insert vaginally. And the nightmare continued...several times in the next day or three (it runs together) my mom and husband seriously considered bringing me to the ER because of the way I reacted to the drugs. FWIW, it DID expel the pregnancy... Whether or not there's literature about it, it was used on me in that way, and I pray to God that nobody is still doing it...apparently somebody thought it was a great idea to test out a theory...hopefully their theory was proven wrong?...dunno. EVERY practitioner I talk to now has the same reaction, "They used WHAT?! WHAT is that doctor's name!? They sent you H-O-M-E!!!!? Oh my God." Again, it was such a nightmare of a summer that I don't remember most of it, but that's what I do remember.

I can really relate to your post. I was given cytotec in January when I had a miscarriage. The midwife was concerned b/c I was supposed to get on a plane in a few days, and she gave me two options: a D&C at an abortion clinic or, as she put it, "something that will help it happen naturally in about a day." I told her I couldn't go to an abortion clinic, because I knew I wouldn't be able to handle a scenario like the one you described, so the midwife just prescribed me the drug. I wasn't given any other options for the D&C I wanted from the beginning, and I was in so much grief that I didn't think to ask any questions.

3 hours after I took the drug I was in the emergency room after cramping that was so severe and unrelenting that I passed out. My husband called 911 when I went unconscious. The paramedics found me unable to stand or walk with a BP of 80/40. I had a D&E in the hospital and felt fine as soon as I woke up.

I am relieved to hear that your birth experiences were nothing like what you experienced with the misoprostol. I'm pregnant again, due in November, and I am having a home birth. My (new) midwife says that I have no reason to equate the two experiences, because my m/c with cytotec was an unnatural experience, unlike birth. I believe her intellectually, but I still have flashbacks to the pain and how frightened I was. The physical experience ended up being much, much worse than the grief over losing the baby.


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## junamoss (Jun 24, 2004)

I am a cytotec placer. I have now said it. I work in labor and delvery as an RN. I hate cytotec because once it's in it's really hard to get out. With cervidil you have a tamponish string to pull it out. And sometimes it causes hyperstim. of the uterus too. But cytotec in the dosage for cervical ripeining is a tiny quarter of a pill. and i have short fingers....
In the dosage for termination of pregnancy, the dosages we use are a lot higher....like 200 to 600 micrograms compared to 25 micrograms for cervical ripeing.
If there was a way to pull it out or it was time released it would be a much better drug.


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## amygoforth (Jun 21, 2005)

Quote:


Originally Posted by *junamoss* 
I am a cytotec placer. I have now said it. I work in labor and delvery as an RN. I hate cytotec because once it's in it's really hard to get out. With cervidil you have a tamponish string to pull it out. And sometimes it causes hyperstim. of the uterus too. But cytotec in the dosage for cervical ripeining is a tiny quarter of a pill. and i have short fingers....
In the dosage for termination of pregnancy, the dosages we use are a lot higher....like 200 to 600 micrograms compared to 25 micrograms for cervical ripeing.
If there was a way to pull it out or it was time released it would be a much better drug.

This has been a fascinating thread, and is especially timely for me as my next doula client is facing induction.

Junamoss, can you talk a little more about your RN experiences w/ cytotec? How do the mothers respond to it? What happens in the case of uterine hyperstimulation which can't be slowed? Automatic C-sec?


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## lorijds (Jun 6, 2002)

The place I used to work used cytotec. We loved it. If I were pregnant and needing to be induced, I'd choose it over pitocin anyday.

Depending upon the cervix and maternal history, we used either 50 mcg or 25 mcg vaginally, followed by another 25 mcg 4-6 hours later if there is little or no uterine activity. If that doesn't do it, we repeat in typically 48 hours if we have time, or if circumstances dictate otherwise, we repeat with typically a single dose of 25 mcg the next day. We kept stats on this, but I don't have them in front of me. Over 90% of our moms had babies within 24 hours of the first does of cytotec.

This was at an out of hospital birth center. By state law, we cannot attend post date births (greater than 42 weeks). We would use the latest date possible (if there was a discrepancy between when the client said her ovulation or conception day, and when an ultrasound said her date was--we didn't do routine US, but if they transferred from a practice that did, or needed one for another reason). We would encourage other forms of induction first--EPO at 36 weeks (it has lots of benefits, not just cervical ripening, and I don't think EPO sends anyone into labor, anyhow), intercourse, accupressure, webster technique to correct any pelvic issues that could be holding up labor, even moxibustion. If none of these worked, we'd try a castor oil recipe, which worked about 70% of the time.

But sometimes none of these things would work, and the mom was looking at either having to birth in the hospital or use cytotec at the birth center. Every mom that was faced with this decision while I was there anyhow chose cytotec. We would give them the informational sheet on it, tell them to go look it up on line, that most of the natural birth community was vehemently against it, and to come back the next day and we could talk about it. Every one of them had very informed consent, lots of discussion. We had a certain criteria that had to be met--no previous uterine surgery, for example.

Another regulation placed on us is that a woman needs to be in active labor with 24 hours of rupture of membranes. Luckily state regs don't state the actual definition of active labor, so we have a little play there. And a tablespoon of castor oil seems to take care of that if we are getting down to the wire. But once a year or so we'll use cytotec for this, too.

We've had excellent outcomes using it. We've never had a case of hyperstimulation or rupture (obviously, or we wouldn't feel okay about using it). We've never had a cytotec induction end in a c-section. We haven't had to use it extremely often; I would guess maybe 2% of our pregnancies? Maybe less; it seems to come in waves, though, where we won't use any for months and months, and then suddenly we use it for two or three moms in one month. The last couple of years I was there, I think we gave it to about 3 moms a year, and we had about 120-140 births a year. We would prefer not to have to use it at all; but we don't have that luxury. Technically we do not give it in the birth center; we give it in the office, where we can run a EFM strip. Our office is a separate entity from the birthing center itself. Then we admit and move them to the birth center when in labor.

My interpretation of the literature, case studies, and reviews of poor outcomes is that the dangers of cytotec are associated with excessive amounts; excessive doses (one study I read, the doc administed it every four hours until active labor); administering cytotec and then adding pitocin on top of it; using it to augment labor; performing AROM during the labor; administering it to women with risk factors for uterine rupture; and not listening to or observing a woman closely enough during labor.

We are very careful when we use it; it is always the woman's choice, we have a pretty lengthy discussion of the pros and cons of it, and we encourage them to check out sites like these to hear other practitioner and natural birth community points of view. They hear all the negatives. They know we'd rather not use it at all, but that we've gotten to a point where we must do something, or they cannot birth at our facility. They always have the option of going to the hospital to be attended our physician; they don't even have to be induced--they can then wait as long as they want. Or if they and we feel induction is needed because of other factors, not just the fact that they are post dates, they will receive pitocin in the hospital.

I would be frustrated if we could not use cytotec. I've seen cytotec births and pitocin births; I would have a cytotec birth over a pitocin induction ANY day. Pitocin is also associated with ALL the same dangers as cytotec.

Just thought I'd throw that out into the ring. I'm impressed with the discussion thus far. It seems as though the discourse will remain civil and thoughtful; I appreciate that.


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## junamoss (Jun 24, 2004)

Quote:


Originally Posted by *amygoforth* 
This has been a fascinating thread, and is especially timely for me as my next doula client is facing induction.

Junamoss, can you talk a little more about your RN experiences w/ cytotec? How do the mothers respond to it? What happens in the case of uterine hyperstimulation which can't be slowed? Automatic C-sec?


It works great when it works. With hyperstim, we would first try to fish it out, iv fluid bolus, turning and brethine to stop contrx. It's never an automatic section where I work. We really just wait and see. Cytotec is not time released, so it has disolved very quickly and acts very quickly in the body.
I am super picky with placement. I really want to be sure that there are no signs of spontaneous labor. I use the bishop score, and if it's greater than 6It is against protocol to place it.

I really feel this is the key to avoiding hyperstim. And if the woman is hypersensitive, it seems that you know right away. I go to the girls with the long fingers to help me dig it out.

I feel like I am extremely critical of fht's and follow the cytotec protocol to the extreme because I come from the more natural side of things, I worked in homebirth and was a doula, wheras a lot of RNs feel like the goal is just to get the baby out. No matter which way. Cytotec requires constant monitoring for 2 hours post placement by our protocol.

I work midnights and have heard that the morning girls get ticked because my pit has to start late.

Of course we have cytotecs that end in section, but usually for fht's, not for cytotec. I have witnessed one placental abruption, it was awful, I came in on days and found it. YIKES. I thought this woman was dying in front of me. She was really tiny and I wonder if the dose was just too big for her. She and the baby were okay. She required a transfusion.

But a lot of times cytotec will put women into labor and they don't require anything additional. If they do we start pit (which i really hate, I am not a pit pusher) We will pit them all day and turn the pit off and restart cytotec the next night if need be. My hospital deals with a lot of family practice docs, so they don't feel that urge to cut so soon.

I had assisted with many wonderful cytotec births.
But it would never be my first option. OR my 10th. It would be very last resort.


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## AugustLia23 (Mar 18, 2004)

I;ve appreciated it too, and have gotten a lot out of the conversation. I think that people must be completely informed about any drug they use, hearing just one side of the story is never enough.

I was reading through a medical professional board where they are saying that searle(the manufacturing company) is the one that doesn't want to do trials for FDA approval, and that the biggest reason that they sent out that warning letter was because of the approval of RU486(which occured just before the letter was published).


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## dynamicdoula (Jun 11, 2004)

I haven't read through the whole thread but I did want to say that I've seen more 'side effects' with Pitocin and Cervidil for inductions than I've seen with Cytotec, but this could possibly be because I've only seen Cytotec used a few times. It's far more common now than it was five years ago when I started (a lot of doulas hadn't even heard of Cytotec and it wasn't in broad use at all), so I expect that I'll see a lot more of it. I know my own OB/GYN doesn't use it for induction and made a face when I asked him like... "eww, no."
















The thing I tell my clients is that Cytotec can give you that sweet 8 hour labor where everything flows perfectly, or you can have problems with heart tones that they don't know what caused it, or you can have your uterus rupture, or you can have an abruption, etc.. you just don't know with Cytotec and it's not well studied, nor been in use long enough, for anyone to really hazard a guess at how differently people are going to respond to it.

Truly though, you can say the same things for Pit or Cervidil- both run the risk of hyperstimulating the uterus, causing ruptures/abruptions, etc.


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## CarsonBookworm (Sep 25, 2006)

My question is this....

My OB really is encouraging me to allow Cytotec to be used to induce me on Thursday. The induction is being done for medical reasons. (see my other post on TAO) I'm wary because of all of the stories that I've heard regarding Placental Abruption and other major side effects.

What can you tell me about your experiences seeing Cytotec being used to induce labor? The OB says that he uses a dose of 25 mg. (or is it mcg? I don't recall exactly.)


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## MsBlack (Apr 10, 2007)

For my last birth, I had a mw friend try to induce my labor at nearly 39 weeks (I agreed that sooner was better than later for various reasons, and my cervix was plenty ripe/partly dilated already). She brought cytotec, which I'd never heard of at the time (this was 1998), but I trusted her implicitly and she never mentioned possible dangers. She gave me the cytotec orally--1 pill, then 2 pills, then 2 pills again at a shorter interval--this took place over the course of 5-6hrs. I felt nothing at first--no contrax, nothing at all. Then I suddenly began to shake. I shook so hard and so uncontrollably that it frightened me badly. I finally instructed my 2 other friends present to wrap me in a blanket and sit on me, basically. They sat tight against me, and on the edges of the blanket so that I was tightly bound. Finally, I fell asleep--passed out is more like it. I told my mw friend when I woke up that I was done with attempt to induce. Went into spontaneous labor a few days later--with a partial abruption that led to csec.

I would never have taken the cytotec if I'd known the whole story--which I do know now.

My opinion is that cytotec has no place anywhere near birthing women. Period. It's not that it's an 'off label use'. It's that the risks are too huge. And I don't care how many wonderful cytotec inductions anyone has seen, or it's great work on pph. I still think this drug is far too dangerous to be used for birth, at any dose.

And yes, we have an induction epidemic going on, for a variety of reasons. Even apart from all this reasonable and mannerly discussion of this drug, I am really kind of stunned by what I am reading in some here with this discussion, what seems like a cavalier attitude toward that primary fact. WHY ARE THERE SO MANY INDUCTIONS? How have so many people gotten so casual about this? And yeah, given cytotec's unpredictability and the great damage it can cause, why is any woman telling herself or anyone else that it is redeemable with proper use?


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## Kiddoson (Nov 19, 2001)

As someone that was given cytotec with my first birth, I definately slammed into labor and after birthing my 2 nd totally natural, cytotec created a lot of problems for me and did not have a good birth expierience because of it (nothing like natural labor).


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## Turquesa (May 30, 2007)

Quote:


Originally Posted by *AugustLia23* 
True, cytotec is not approved for it's usage in obstetrics, but then again, neither is terbutaline(brethine, to stop pre-term labor), or fentanyl or reglan, all of which are very widely used. Isn't the main reason it's unapproved simply because it's such a cheap med, and there would be no money to be made in doing an official study of it.

The Cochrane Library, arguably the most reputable repository for obstetric "information, retains a database (www.cochrane.org) compiled by some of the world's best and brightest scientists. This team reviews meticulously the international scientific literature and draws conclusions accordingly. You may be familiar with the database, but I wanted to draw attention to it for other posters.

From a page on Cochrane's website, we see the following (http://www.cochrane.org/reviews/en/ab000941.html):

"Sometimes it is necessary to bring on labour artificially because of safety concerns for the mother or baby. Misoprostol is a hormone given by insertion through the vagina or rectum, or by mouth to ripen the cervix and bring on labour. The review of trials found that misoprostol given vaginally is more effective than prostaglandin and that oxytocin is used in addition less often. _However, misoprostol also increases hyperstimulation of the uterus. The trials reviewed are too small to determine whether the risk of rupture of the uterus is increased. More research is needed into the safety and best dosages of misoprostol."_

[Emphasis my own].

There is no question about whether or not Misoprostol (a.k.a. Cytotec) works. It does. Its safety, however, remains in question.

I'm not opposed to the use of Cytotec IF its safety is proven by a study that is randomized, controlled, ideally longitudinal and _definitely_ independent (i.e. not sponsored or otherwise influenced by the manufacturer or other parties who stand to benefit). I've yet to see such a study, although there could be one out there!

Given some recent obstetric fiascoes, however, I DO take issue with doctors using Cytotec until such a study is released.

No mention has been made in this thread of Marsden Wagner's book, "Born in the U.S.A," which I'm in the process of reading. Wagner presents a scathing but compelling case against its use. (But then, I need to read other points of view!)

You mentioned clients. Do you work in health care? If so, I'd love to hear your views on the book if you've read it or get around to reading it!


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## jengacnm (Oct 26, 2006)

I had the ineresting experience of seeing cytotec used two ways at the same time. When I was a labor and delivery nurse at Hospital A, they used 50 mg doses every four hours. These women didn't go into labor, they were launched into orbit. They had crazy hyperstim patterns, fetal bradycardias, forceps/vacuums....I remember one woman who was filled with righteous indignation that she didn't have time for "her" epidural.

I was also a CNM student and at Hospital B down the street I was doing clinicals. They used doses of 25 every 6 hours. The women got an NST, the cytotec was placed, then two hours of monitoring. Then they could be intermittently monitored. They had very nice inductions.

AugustLia, I haven't researched the way you have, but I'm willing to bet that catastrophic events are in doses of 50 or higher.

Lorijds, thank you for your balancing view. Yours is an excellent description of the prudent use of pharmacology, right down to the informed consent.

MsBlack, your experience was tragic. You received what sounds like 500 mg of cytotec in five hours. That's 20 times the recommended dose. If someone were to get 200 units of pitocin or 16000 mg of ibuprofen, bad things will happen. Your midwife friend's hubris had very real consequences, ones that played out on your body. My heart goes out to you. I imagine that your friendship suffered terribly or came to an end.

Thank you for an engaging dialogue, folks....


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## peskyflylady (Apr 14, 2008)

This is very interesting to me as I have just had a VERY positive experience with Cytotec induction (reasons of being post-dates with gestational diabetes and weeks of prodromal labor which required me to take sleeping pills and ran me down physically and emotionally).

The dosage was 1/4 tablet (25 mg) every four hours until active labor. I had my first dose at 10 a.m., second one at 2 p.m., had light contractions starting shortly after the second dose, and my water broke on it's own around 6:15 p.m. Labor followed a natural pattern of 4-5 minute apart until transition, when things changed to 2-3 min. apart, then spaced out more at 9 cm right before pushing, which was only 10 minutes. It all felt very manageable to me, no epidural or pain meds.

My doctor says she's never seen a case of uterine hyperstim when she follows that dosage. She is also a huge fan of natural childbirth, and sees more patients have pain-med free labors with it than with pit. Another doctor in the group uses pit a lot more than cytotec, and his rate of C-sections from inductions is higher than the other docs. A L&D nurse who's worked at our hospital for nine years also said she sees bad stuff happen with pit all the time with mom and baby, but never with cytotec when careful dosage is used. Another doctor I talked to said that in the extremely rare event of hyper-stim, meds can be used to stop contractions.

I just remembered seeing this thread, and thought I would revive it as this subject is very interesting to me.


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## boadhagh (Sep 19, 2007)

nak

glad you revived it, too!

but i want to reiterate what several pps have said -- *c**ytotec is unpredictable!*

i had 3 25m doses, 4 hours apart

horrible (and unproductive) labor that made me ashamed i couldn't handle the pain of childbirth (later found out, after epidural and internal monitoring, that my contractions were off the scale; cnm and rn were having a pretty big argument about whether or not the monitor was malfunctioning; fortunately dp overheard them and later told me)

emergent c/s for fetal distress

i made an "informed" decision to try cytotec, and i believe it was the worst decision i've ever made, both physically and psychologically


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## SabbathD (Apr 4, 2006)

I just finished having a debate about this in a different venue. Let me sum up what we came to -

- it's not that it's off label usage. It's that it's ON LABEL CONTRAINDICATED.

- that being said, if used in the proper venue under the right circumstances, it can work very well.

- those circumstances include:

1)no uterine scarring
2)an unripe cervix (this is what it should be used primarily for!)
3)one baby only please








4)when PGE2 have failed
5)CAREFUL monitoring with a controlled low dose.

If all of those things are in place, it can be a fabulous option. And trust me, I was on the NO NO NO! side of the fence with this drug. But, it would appear through studies and experience that this drug while not to be commonly used DOES have it's place.


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## bri276 (Mar 24, 2005)

if all of those things are in place, it can be a fabulous option (if non-medically necessary induction is ever a fabulous option) OR, as has been repeatedly shown right here in this thread, it can go horribly wrong.

Hi. When I was 19, I had a missed miscarriage. According to ultrasound, the fetus had no heartbeat and stopped developing around 9 wks, and I was now 12 wks (and yes, sure of my dates).

I was prescribed cytotec and went home and took ONE pill. I then panicked at the pain I was about to go through, and somewhere in my totally uninformed, uneducated 19 yr old head, I knew this was a bad option. I went to my father's hospital (he's a surgeon) the next day and had a D&C performed, it went well. Two days later, I woke up with a fever and a very strange pain in my lower abdomen. I was rushed back to the hospital just in time to be intercepted at the ER by a huge, terrible car accident with multiple victims.

I sat in that ER with nothing but one dose of tylenol with my fever creeping upwards, dealing with the most unimaginably horrific pain I've ever felt, INCLUDING PITOCIN INDUCTION, in my life. I begged and begged for drugs or to die but my cries fell on deaf ears as I was just a teen and they were so busy. Once they finally gave me some IV pain relief and did an ultrasound it was clear that I wasn't faking it- I had a blood clot the size of a softball "behind" my cervix (this is what I was told and I still don't understand if that meant inside my cervix or uterus). Another D&C had to be performed. My ob-gyn said he'd never seen that happen before (and he's a very experienced, great guy) and that it had to have been the cytotec. I've been tested since for clotting disorders (none) and had a subsequent spontaneous, uncomplicated miscarriage, followed by an uncomplicated pregnancy and vaginal delivery via pit induction. It wasn't me, and it wasn't the doc- it was the med. I wonder how many people seeing these great inductions are following up to see how the recovery was.

I would never take cytotec again. Not to birth in a nice birth center, not to get on a plane, not to induce miscarriage, not ever. I'd easily choose a c-section even if I were 44 weeks pregnant and 7 centimeters dilated if my only choices were 25 mcg cytotec or a section. Not worth it to me- it's proven it's unpredictability enough for me for one lifetime.


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## lorijds (Jun 6, 2002)

I cannot believe that the physician blamed the above story on the cytotec. He's off his rocker. The D&C would be the primary culprit. You can develop a blood clot after any type of uterine procedure, including birth (natural labor or otherwise), a D&C, a section, or a miscarriage. I'm not saying that you are lying or misrepresenting anything; I'm saying the doc here was incorrect. He's a experienced OB/GYN and hasn't ever seen a large blood clot in the uterus (ie behind the cervix) after a D&C? I haven't spent a whole lot of time in the hospital at births and women's procedures and *I've* seen them--though I've only seen them in the ER. If a D&C is done and everything isn't completely removed (and sometimes even when it is), a clot can form. They can get huge--the largest I've ever seen was the size of a grapefruit. Your fever makes me think infection--which correlates with a potential complication of a D&C as well as retained fragments. Maybe your father's friend was trying to cover his a$$, if he or a colleague was the one to perform the D&C? It makes his stats look bad if one of his clients develops and infection or a clot post D&C, even though those things can happen no matter how well he performed the procedure.

We follow up on all our births, of course. 1 day, 2 day, 2 wk, 6 wk, and 12 wk postpartum visits. We have no documentation that cytotec (or castor oil) inductions have any more difficult recoveries. We have mixed data on whether cytotec inductions prevent postpartum hemorrhage or contribute to increased postpartum bleeding--we just don't do enough to have a good sample, and some years the data seems to go one way, some years the other. We haven't yet identified a trend, if there is one.

In any case, what a terrible experience for you. I can totally understand being gun shy of cytotec after that. I stand by my opinion though that cytotec can be completely appropriate under certain circumstances, and that if I had to be induced, if the choice were between cytotec, rupture of membranes, pit, or cervidil, I would choose the cytotec. If I had your history, I would probably avoid the cytotec, too, even if in my head I still had all the knowledge and experience I have now. You have to do what you feel is best for you, you know?


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## bri276 (Mar 24, 2005)

yes he did say he had NEVER see what happen to me happen. and so did all the nurses!!! they acted like they had no idea why I was there and when I would tell them it was a total shock. also every ob/gyn and midwife who I have described this story to were confused and did not understand what caused it. so if you're saying you see huge softball/grapfruit sized blood clots forming routinely after d&cs then you're the first one. my understanding is that the cytotec wasn't blamed for the clot itself but for the bleeding. I had a ton ton TON of bleeding after my d&c, enough to make me concerned enough to call the dr but he said it was normal...then the next day all this happened. I would think fever=infection except no one said it was infected and there was no other evidence that it was, I didn't leave the hospital on abx, and the fever disappeared immediately after that 2nd d&c. who knows?


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## peskyflylady (Apr 14, 2008)

Regardless of whether or not the cytotec caused the clot, you said you got an entire pill all at once--four times the standard dosage. That should never have happened.

My first birth was also cytotec-induced. I would have blamed cytotec for the awfulness of it if this birth hadn't been so easy. Now I know that lack of good positioning, going into labor with an unripe cervix (even at 9 days past my due date--induced for gestational diabetes), AROM at 1 cm to try to get things moving on their own, epidural at 2 cm, posterior baby, pushing for two hours, etc. were the reasons why it was so awful. With this birth, I was only in upright, hands and knees positions, started out 1.5 cm dilated, allowed water to break on its own, listened to my body more, and had a wonderful experience. Nope, I think the epidural was a much more dangerous decision the first time than the cytotec.


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## lorijds (Jun 6, 2002)

I wouldn't say I see it routinely at all; but I can think of 3 times in the last 6 years that I've seen it after a D&C, spontaneous miscarriage, or a birth. One mom had a bleeding disorder, but the other two did not. Mostly if there is a complication, there is bleeding and/or infection. Usually the bleeding does not result in a clot; it's just bleeding, you know?

Don't quote me on this, because where I work we never give cytotec for miscarriage, but I think that in the event of an early miscarriage, the dose of cytotec given is much, much higher than the dose given in labor. Somewhere along the lines of 400-800 mcg; meaning 4-8 pills.

I don't want to sound cavalier about cytotec--it is potent and frequently abused and misused in the medical and birthing community. I feel the same way about epidurals and pitocin, though. I honestly feel that all three of those have a place in a birth setting, but in a very limited and restricted role. None of them should be routine. None of them should be used lightly, or without complete informed consent. I know that isn't how they are used, though.

I don't want to necessarily sound supportive of the use of cytotec, either. I just feel it is the lesser of two evils, when compared to pitocin. I think we need to be able to use some sort of induction agent for the rare birth that needs to be induced. But if it came down to it, I'd support banning its use rather than the continued unrestricted use that it currently enjoys. I wish ACOG would just get around to setting a firm, conservative standard that would at least protect women against the large doses. When I hear about women getting a whole pill, or a dose every 4 hours until labor sets in (sometimes upwards of 4+ doses) or when it is used concurrently with pit, or with an epidural (so the woman can't tell you about the contractions) it just makes me want to scream. If those uses continue to be the standard, I'd just as soon see it banned. If ACOG or the FDA would have the balls to set up some strict guidelines on its usage, it'd be so much safer.


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