Cervical ripening and plasma prostaglandin levels. Comparison of endocervical and extra-amniotic PGE2

Two modes of cervical application of a gel containing PGE2 have been compared in a total of 30 patients with indication for induction of labor and unripe cervix. Fifteen patients had gel injected endocervically; in 10 patients the gel contained 400 micrograms PGE2, in 5 controls the gel was inactive. Fifteen subjects had a 15 ml Foley catheter passed through the cervix and placed extra-amniotically; in 10 of them 3 ml gel with 400 or 800 micrograms PGE2 was injected, while 5 controls received inactive gel. Plasma levels of 13,14-dihydro-15-keto-PGE2 alpha (PGFM) were measured in blood samples drawn before and 1/2, 1, 2, 4, 6, and 8 hours after gel application. Neither the Foley catheter nor the application of inactive gel caused significant changes in the cervical scores or the PGFM levels. PGE2 in the endocervix increased cervical scores without altering plasma PGFM levels. Extra-amniotic PGE2 caused a more rapid increase of the cervical scores and a progressive rise in PGFM levels. The plasma (PGFM) levels were found to be related to the degree and to the rate of cervical dilatation. The correlation with cervical dilatation was highly significant. Labor began spontaneously or after artificial rupture of the membranes in 80% of the extra-amniotic, and 50% of the endocervical PGE2-group, but in none of the controls. These data indicate that increased uterine PGF2 alpha production is not necessary for the early stages of cervical ripening, whereas dilatation beyond 4 cm does not proceed without such increase.     

Cervical ripening with intravaginal prostaglandin E2 gel.

We describe a technique of administering prostaglandin E2 (PGE2) in a viscous cellulose gel into the vagina to ripen the unfavourable cervix in patients requiring induction of labour. A total of 168 primigravidae were studied, of whom 102 received 2 mg PGE2 in 2% gel and 66 received 5 mg PGE2 in 4% gel. In the latter group, the state of the cervix was significantly improved in 58 patients (87.9%), while 32 (48.5%) had started labour before planned induction. There were no maternal or fetal side effects or complications.     

Fetal effects of cervical ripening with extra-amniotic prostaglandin E2 in gel

A gel containing 0.5 mg prostaglandin E2 (PGE2) was extra-amniotically instilled to 90 clinically normal gravidae at term, for ripening of the cervix before elective induction of labor by amniotomy and intravenous PGE2. An acceptable increase in the Bishop score was noted to have occurred in 87/90 women, when assessed eight hours after administration of the gel; 14 of these women were then in established labor, which progressed uneventfully. Four of the 90 subjects required cesarean section for cephalopelvic disproportion. No adverse maternal or fetal effects of the procedure were detected under careful clinical, electronic and biochemical monitoring. However, epidural anesthesia adversely influenced the acid-base equilibrium of the fetus.     

Clinical experiences with a new gel for intracervical application of prostaglandin E2 before therapeutic abortion or induction of term labor

A new gel for intracervical application of prostaglandin E₂ (PGE₂) has been elaborated and evaluated. The main component of the gel is a cross-linked starch polymer to which prostaglandins can be added and preserved for long-term storage (> 12 months).In a double blind study, 20 patients requiring legal abortion in late first trimester were given gel containing 0.25 mg PGE₂ or gel without PGE₂. The gel was applied within the cervical canal. In all patients receiving PGE₂-gel, a rapid ripening of the cervix occurred which facilitated the subsequent dilatation and evacuation. In patients receiving gel without PGE₂ cervix did not ripen. In a subsequent open study, 30 patients were treated with PGE₂-gel before therapeutic abortion. The same degree of cervical ripening was registered as for the patients receiving PGE₂-gel in the double blind study.In 50 patients at term, intracervical application of 3 ml gel containing 0.50 mg PGE₂ induced labor in 27 cases, i.e. 54 per cent of the patients. In the remaining undelivered women, a prominent cervical ripening occurred within 24 hours. No side effects of the treatment were observed.We conclude the new PGE₂-gel to be a promising future alternative in the treatment of patients with an unfavorable cervix, prior to surgical evacuation of the uterus in late first trimester abortion, as well as before induction of labor at term.     

Effects of RU486 on the interstitial collagenase in the process of cervical ripening in the pregnant rat.

Changes in interstitial collagenase activity in the rat uterine cervix during ripening were clarified in a time-dependent manner. Premature delivery was induced by an antiprogesterone agent, RU486, for rats in late pregnancy. The presence of interstitial collagenase in the extract from the rat cervical tissue was demonstrated, by sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis using the natural and unaffected collagen as a substrate. The collagenase activity was determined as the release of digested peptides from the radio-labeled collagen. Our experiments with RU486 were performed in rats on the 18th day of pregnancy. A single administration of RU486 (15 mg/kg) resulted in the premature delivery of all treated rats within 30 h after the injection (average time was 23.9 h). The marked increase in cervical wet weight was observed up to the time to premature delivery along with a significant acceleration from 18 h after the administration of RU486. In this state, the cervical collagenase activity was enhanced, the highest levels being recorded at 21 h after the administration. The interstitial collagenase in the uterine cervix appears to play a significant role in the regulation mechanisms of cervical ripening in late pregnant rats.     

Effects of intracervical PGE2-gel on myometrial activity and cervical state in first trimester pregnancy

In 7 primigravidae admitted for first trimester abortions by dilatation and evacuation, 0.5 mg PGE₂ in viscous gel (5 patients) or placebo gel (2 patients) was applied intracervically 6 hours prior to the operation. Throughout the treatment period intrauterine pressure was recorded. Application of placebo gel induced no cervical ripening or myometrical activation. In all patients receiving active gel, a marked improvement of the cervical state was induced by the treatment. In three cases, this priming occurred in parallel to minimal changes in myometrial activity, without regular uterine contractions. In two patients, marked uterine activation was registered due to partly extraamniotic application. It is suggested, that the PGE₂-gel has a direct effect on the cervical tissues. Further, the risk of partially applying the gel in the extraamniotuc space, thus stimulating the myometrium, depends on the gel volume relative to the dimensions of the cervical canal and the application technique.     

Increased prostaglandin concentrations in the cervical mucus of pregnant women with bacterial vaginosis.

Microorganisms associated with bacterial vaginosis are commonly recovered from the amniotic fluid and chorion-amnion of patients who deliver prematurely. Bacteria closely related to those causing bacterial vaginosis may play a role in the initiation of uterine contractions, ripening of the cervix and weakening of the fetal membranes by stimulating prostaglandin synthesis. In the present investigation, cervical mucus was collected by brush from early pregnant women with and without bacterial vaginosis. The concentrations of PGE2, PGF2 alpha and 6-keto-PGF1 alpha were determined in the mucus samples by methyl oximation and then radioimmunoassay, utilizing antibodies raised against oximated prostaglandins. It was found that the concentration of PGE2 and PGF2 alpha was significantly higher in the mucus of women with bacterial vaginosis compared with healthy women. The concentration of 6-keto-PGF1 alpha was similar in both study groups. All patients had been instructed to abstain from sexual intercourse for 24 hours before sampling. However, it may be that women with high concentrations in their mucus may have had intercourse anyway. However, it is fairly well possible that the significant differences in the PGE2 and PGF2 alpha values are causally related to the higher rate of preterm labor in women with the commonplace infection of bacterial vaginosis.     

Facilitation of suction termination using extra-amniotic prostaglandins in gel

Extra-amniotic prostaglandin E2 (PGE2) suspended in a slow release gel (Tylose) was instilled in 35 patients prior to a planned surgical termination in an attempt to dilate the cervix, minimize cervical trauma, and reduce the possible risk of cervical trauma, and reduce the possible risk of cervical incompetence and its sequelae. Dilatation occurred in all patients to a minimum of 8 mm and 74% aborted before surgical evacuation performed 6 to 24 hours after injection. No serious side effects occurred. Extra-amniotic PGE2 in gel should be considered as a primary procedure when the cervix is obviously immature on examination. If the cervix is found to be tight and unyielding at surgical dilatation, the latter procedure should be dicontinued and PGE2 in gel injected.     

Prospective study of different methods and routes of administration of prostaglandin E2 to improve the unripe cervix.

Methods of vaginal and extra-amniotic prostaglandin administration to achieve ripening of the cervix as a preliminary to induction of labour are described. Three groups of twenty patients with unfavourable induction features were studied, each receiving prostaglandin E2 the evening prior to planned induction. One group received PGE2 500 micrograms suspended in a viscous medium extra-amniotically. One group received PGE2 3 mg suspended in a viscous medium into the vaginal vault. A third group received a 3 mg PGE2 vaginal pessary to the posterior fornix. Improvement in cervical status at time of induction occurred in all groups but no single group had a significant advantage when regarding mean improvement, the induction-delivery interval or the number of patients in whom labour began before formal induction. However, with regard to relative cost, ease of preparation and storage, as well as patient and medical staff convenience, Prostaglandin E2 in pessary form is a superior form of administration.     

Plasma concentration of 13,14-dihydro-15-keto-PGE2 (PGEM) after various ways of cervix ripening with PGE2

PGEM concentration was determined radioimmunologically in a non-pregnant woman, in whom PGE2 was infused intravenously at increasing rates and in women, in whom labor was induced by various methods for local application of PGE2. There was excellent correlation between the amount of PGE2 infused intravenously and the levels of PGEM determined in the peripheral plasma. The following methods of local application of PGE2 were included in the study: 0.4 mg PGE2 gel placed retroamnially by means of a balloon catheter, 0.4 and 0.5 mg PGE2 applied endocervically and 3 mg PGE2 placed intravaginally in form of a single vaginal tablet; also included was a control-group, where only vaginal examination was performed. Bloods were drawn before, 30 minutes, 1, 2 and 3 hours after PGE2 administration. Mean levels of PGEM in the maternal peripheral plasma did not change neither within nor between the various groups. It is concluded from the present study, that local application of doses currently used to soften the cervix and/or induce labor at term do not lead to the same PGEM-concentration in the maternal blood as after intravenous infusion of PGE2 in doses normally used to induce labor.     

Cervical ripening and plasma prostaglandin levels. Comparison of endocervical and extra-amniotic PGE2

Two modes of cervical application of a gel containing PGE₂ have been compared in a total of 30 patients with indication for induction of labor and unripe cervix. Fifteen patients had gel injected endocervically; in 10 patients the gel contained 400μg PGE₂, in 5 controls the gel was inactive. Fifteen subjects had a 15 ml Foley catheter passed through the cervix and placed extra-amniotically; in 10 of them 3 ml gel with 400 or 800μg PGE₂ was injected, while 5 controls received inactive gel. Plasma levels of 13,14-dihydro-15-keto-PGF_2α (PGFM) were measured in blood samples drawn before and , 1, 2, 4, 6, and 8 hours after gel application. Neither the Foley catheter nor the application of inactive gel caused significant changes in the cervical scores or the PGFM levels. PGE₂ in the endocervix increased cervical scores without altering plasma PGFM levels. Extra-amniotic PGE₂ caused a more rapid increase of the cervical scores and a progressive rise in PGFM levels. The plasma (PGFM) levels were found to be related to the degree and to the rate of cervical dilatation. The correlation with cervical dilatation was highly significant. Labor began spontaneously or after artificial rupture of the membranes in 80% of the extra-amniotic, and 50% of the endocervical PGE₂-group, but in none of the controls. These data indicate that the increased uterine PGF_2α production is not necessary for the early stages of cervical ripening, whereas dilatation beyond 4 cm does not proceed without such increase.     

Sensory nerves and neuropeptides in uterine cervical ripening

At the time of parturition (fetal delivery) the uterine cervix must "ripen," becoming soft, pliable, and dilated to accommodate the fetus' delivery. The fundamental processes underlying cervical ripening remain poorly understood. Knowledge that abundant autonomic and sensory nerves supply the uterine cervix, that transection of afferent nerves supplying the cervix blocks parturition, and that some of the changes in the cervix resemble those seen in inflammatory reactions suggests nerves may have a role in the cervical ripening changes. The present study utilized immunohistochemistry, plasma extravasation, and solution hybridization-nuclease protection assay to elucidate the complement of primary afferent nerves and some receptors in the rat cervix during pregnancy, and to determine if they may have roles in the ripening process at term. This study revealed an abundance of nerves associated with the cervical vasculature and myometrial smooth muscle containing immunoreactivity for substance P, calcitonin gene-related peptide, secretoneurin, and nitric oxide synthase throughout pregnancy. Many of these are small unmyelinated capsaicin-sensitive C-fibers. Substance P- (NK1-) and calcitonin gene-related peptide receptors were apparent on uterine cervix vasculature from pregnant, parturient, and postpartum rats. NK1 receptor mRNA was maximal at 20 days of pregnancy. Plasma extravasation of i.v. administered Evans Blue or Monastral Blue was most pronounced at parturition (shortly after NK1 mRNA is maximal); this was similar to plasma extravasation evoked by i.v. administration of substance P or capsaicin-treatment. This study revealed new data about the nervous system of the rat uterine cervix and that these nerves and their transmitters could very well be part of a neurogenic inflammatory process involved in cervical ripening.     

Effect of PGE2 on uterine contractility and tone in mares

A technique for transvaginal, ultrasound-guided intrauterine injection was developed. After preliminary study using different approaches, the procedure was successful in 24 of 25 (96%) mares, based on detecting fluid in the uterine lumen during and after the injection. The technique was used to study the effect of PGE2, reportedly produced by the embryonic vesicle, on uterine contractility on Day 12 (Day 0 = ovulation). Uterine contractility was scored (1 = minimal, 4 = maximal) every 10 min for 1 h and every 30 min for the next hour by a continuous 1-min ultrasound examination of a longitudinal section of the uterine body without knowledge of group. In Experiment 1, the main effect of group (1-mL vehicle, n = 6; 0.25 microgram PGE2, n = 7) tended to be significant (P < 0.09), and the effect of time was significant (P < 0.008). The mean score was higher for the PGE2 group (2.0 +/- 0.1) than for the vehicle group (1.7 +/- 0.1). An increase in contractility occurred between 0 and 5 min in the vehicle group (P < 0.0004) and between 0 and 10 min in the PGE2 group (P < 0.04). In Experiment 2, there was a tendency (P < 0.08) for effect of group (control without injection, n = 6; 1-mL vehicle, n = 6; 0.025 microgram PGE2, n = 6). The PGE2 group (2.0 +/- 0.1) was different from the vehicle group (1.6 +/- 0.1) and the control group (1.6 +/- 0.1). An increase in contractility occurred between 0 and 20 min in the PGE2 group, and the changes were not significant in the other groups. However, scores were higher in the PGE2 group before treatment, and there were no significant effects when data were converted to percentage changes. The results for an effect of intrauterine treatment of PGE2 on uterine contractility are considered uncertain because of the transient increase in contractility from vehicle injections in Experiment 1 and the higher score in the PGE2 group before treatment, with no significant differences in percentages in Experiment 2. Indirectly, however, an effect of PGE2 was suggested by a shorter (P < 0.05) period of detectability of intrauterine fluid in the PGE2 groups (21 +/- 31 min) than in the vehicle groups (50 +/- 42 min). The shorter period was attributable to greater dispersion of the fluid as a result of increased contractility. In Experiment 3, PGE2 (10 mg, n = 5) and vehicle (4 mL, n = 5) were given intravenously. In addition to uterine contractility, uterine tone was scored (1 = minimal, 4 = maximal) by transrectal digital compression. The main effect of group was significant (P < 0.03) for uterine contractility score, which increased between 0 and 20 min after PGE2 injection. The time effect and interaction were highly significant (P < 0.0001) for uterine tone score, and tone increased in the PGE2 group between 0 and 20 min after injection. The results indicated that PGE2 should be considered as a potential stimulator of both uterine contractions and uterine tone during the time of embryo mobility in mares.     

Preinduction cervical priming with PGE2 vaginal film in primigravidae--a randomised, double blind, placebo controlled study

Previous reports with an 850 micrograms prostaglandin E2 film for cervical ripening before induction of labour in term pregnancy have been favourable. These studies however had no controls. The present study compares this PGE2 vaginal film with a nonmedicated similar vaginal film (placebo) for preinduction cervical ripening in primigravid women at term. A total of 69 women with modified Bishop's cervical scores 1-5 were assigned randomly to either the PGE2 group (33 women) or placebo group (36 women). Cervical score assessments were made at 12 and 24 hours after which labour was induced by amniotomy and oxytocin infusion. Although the cervical scores between placebo and PGE2 groups at 12 and 24 hours were not significantly different, the scores were marginally better with the prostaglandin film. Pregnancy outcome was satisfactory in both groups with no perinatal or maternal mortality and morbidity. The caesarean rate was 30.6% in the placebo group and 24.2% in the PGE2 group. This study emphasizes the need for a control group when studying the success of agents used for ripening the pregnant cervix at term.     

The role of collagenases and proteases in prostaglandin-induced cervical ripening

Tissue samples were taken from the posterior lip of the cervix of 10 non-pregnant women, 10 women having a termination of pregnancy at 9-12 weeks' gestation and 16 women having a termination who had had an intracervical application of either 50 micrograms sulprostone gel or 2 ml 5% tylose 8-12 hours previously. The efficacy of cervical priming was demonstrated objectively by tonometric measurements. Collagenase activity was determined by a new highly specific technique using native, triple helical collagen. Protease activity was measured by a modified Anson-test. For identification of collagen fragments SDS-polyacrylamide electrophoresis was done on the acetic acid soluble fractions. The sulprostone gel induced effective cervical ripening in all of the patients. Collagenase and protease activity were found in all extracts from the different groups, however, PG-pretreatment of the cervix led to no significant increase in enzymatic activities. In addition, the absence of typical collagen cleavage products in the SDS-electrophoresis suggested that no significant collagen breakdown had occurred. In contrast to previously published literature we conclude that enzymatic collagen degradation does not play a predominant role in PG-induced cervical ripening.     

Chronic stimulation of uterine prostaglandin synthesis during cervical ripening before the onset of labor

Concentrations of 13, 14-dihydro-15-keto-PGF2α (PGFM) were measured in plasma of six carefully selected primigravid women with an unripe cervix at term before and at various intervals after extra-amniotic insertion of a Foley catheter with or without methylhydroxyethylcellulose (Tylose^R) gel. The procedure caused an acute elevation of PGFM levels within 5 min (P < 0.025), which was maintained for at least 6 hours in the absence of uterine activation at 179 ± 32% of the initial values (P < 0.01). Extra-amniotic administration of Tylose gel caused an increase in PGFM levels which was both higher and more prolonged ( > 12 hours) than insertion of a Foley catheter alone.The observations indicate that cervical ripening without concomitant uterine activation is associated with an increase in PGFM levels. They also demonstrate that prolonged activation of (intra)uterine prostaglandin synthesis may occur several hours before the onset of labor-like uterine activity. A chance finding further suggests that spontaneous rupture of the membranes too may be preceeded by an increase in (intra)uterine prostaglandin synthesis. In their totality these observations lend strong support to the proposition that an increase in (intra)uterine prostaglandin production is a prerequisite to rather than a consequence of the initiation of labor.     

Endocrine regulation of cervical ripening in humans--potential roles for gonadal steroids and insulin-like growth factor-I

Cervical softening is crucial for a normal parturition and corresponds to remodeling of the dominating cervical extra cellular matrix (ECM). The onset of labor as well as cervical ripening is under hormonal control. To get further information about the endocrine regulation of term cervical ripening the following study was undertaken: cervical biopsies were obtained vaginally at elective caesareans, after normal vaginal delivery and after PGE2 or antiprogestin RU486. Biopsies from non-pregnant women served as controls. The concentrations of estrogen receptor (ER) and progesterone receptor (PR) protein were quantitated by EIA and the mRNA levels by solution hybridization. The ERalpha and beta were localized by immunohistochemistry, identified by RT-PCR and quantitated by solution hybridization. The co-localizations of CD45 (leukocyte antigen) and CD68 (macrophage antigen) were studied by immunohistochemistry. The cervical concentrations of ER and PR proteins decreased at term to 15 and 25%, respectively, compared to the non-pregnant levels. A further decrease was measured in the maximal ripened cervix at parturition. The mRNA levels were unchanged but IGF-I mRNA reached a maximum at term. ERalpha mRNA was significantly decreased until delivery, whereas ERbeta mRNA, like IGF-I; was maximum at term. By immunostaining ERbeta could be co-localized with CD45 leukocyte antigen and CD68 macrophage specific antigen. Oral administration of RU486 induced a significant increase in ER protein concentration, whereas PGE2 and spontaneous ripening did not. These findings indicate that cervical ripening is related to significant local hormonal changes.     

Effect of dehydroepiandrosterone sulfate on uterine cervical ripening in late pregnancy

In order to elucidate the effects of dehydroepiandrosterone sulfate (DHAS) on softening and dilatation of the uterine cervix, changes of oestriol, 17 beta-oestradiol and progesterone levels in serum and cervix, Bishop score and collagenase activity in the cervical tissue were assessed in pregnant women before and after treatment with DHAS. 17 beta-oestradiol level in the serum and cervical tissue markedly increased after the administration of DHAS, while oestriol level remained unchanged. Serum progesterone level did not change in the majority of cases, while it decreased within several hours in patients in whom delivery was accomplished within 24 hours after the administration of DHAS. Among the factors connected with the Bishop score, effacement and consistency of the cervix were remarkably improved by DHAS administration. Total collagenase activity in the cervical tissue of patients treated with DHAS was elevated by an average of 152%. These results suggest that DHAS is potent in ripening the uterine cervix through an activation of collagenase activity induced by the enhanced conversion to 17 beta-oestradiol. Thus, DHAS administration in the late stage of pregnancy is valuable in prepartal treatment for induction of labour.     

Bioconversion of arachidonic acid to prostaglandins and related compounds in human myometrium and uterine cervix

Arachidonic Acid metabolites in human myometrium and uterine cervix were studied using silicic acid column chromatography, thin layer chromatography, reversed phase partition chromatography and gas-liquid chromatography. Myometrium produced 6-ketoPGF1 alpha, PGF2 alpha, PGE2, thromboxane B2. Uterine cervix produced 6-ketoPGF1 alpha, PGF2 alpha, PGE2, thromboxane B2, and one hydroxyacid. There was no difference between the rate of conversion of prostaglandins in myometrium and cervix. But only cervix could convert arachidonic acid to hydroxyacid.     

The role of collagenases and proteases in prostaglandin-induced cervical ripening

Tissue samples were taken from the posterior lip of the cervix of 10 non-pregnant women, 10 women having a termination of pregnancy at 9 – 12 weeks' gestation and 16 women having a termination who had had an intracervical application of either 50 μg sulprostone gel or 2 ml 5% tylose 8 – 12 hours previously. The efficacy of cervical priming was demonstrated objectively by tonometric measurements. Collagenase activity was determined by a new highly specific technique using native, triple helical collagen. Protease activity was measured by a modified Anson-test. For identification of collagen fragments SDS-polyacrylamide electrophoresis was done on the acetic acid soluble fractions. — The sulprostone gel induced effective cervical ripening in all of the patients.Collagenase and protease activity were found in all extracts from the different groups, however, PG-pretreatment of the cervix led to no significant increase in enzymatic activities. In addition, the absence of typical collagen cleavage products in the SDS-electrophoresis suggested that no significant collagen breakdown had occurred. In contrast to previously published literature we conclude that enzymatic collagen degradation does not play a predominant role in PG-induced cervical ripening.