Opposing Views on Cytotec (Miso, misoprostol)

Recently, two of the blogs I read have posted opposite conclusions regarding the safety of Cytotec as a cervical ripening and/or induction agent. First, A Midwife’s Tale voices the pro-Cytotec opinion (obviously, within reason — not on women with a uterine scar, and at low doses); secondly, Science & Sensibility voices the anti-Cytotec opinion. I put them both up so you can see what has been said for and against it, and you can leave comments on either site if you have any questions about it.

On a side note, it is interesting that even though they cite the same studies (both mention the Cochrane Database, for example), the conclusions are anything but the same. Which is a lesson in how one’s views colors or biases how you look at the data. This has ramifications far beyond birth or studies, but life — look at politics, as an example of how opposing sides can take the same facts to each bolster their own argument and tear the other down. Interesting how that works, sometimes.

Some people have noted that home-birth and natural-birth advocates will point out the possibility of a uterine rupture with Cytotec, playing up the danger of its use, while downplaying the possibility of uterine rupture with VBACs. Perhaps it is hypocritical — however, repeat C-sections have risks of their own both to the mom, the baby, and any future babies; and often the “risk” of not using Cytotec is merely avoiding a non-medical induction. Sometimes inductions are necessary, but of course, often they’re not. Cytotec is introducing an artificial risk into a natural situation; whereas VBAC is a natural process that only an artificial surgery can circumvent. That is a difference. To me, anyway. Vaginal birth is not an intervention; Cytotec is.

I like what the Science & Sensibility article emphasizes:

ACOG STATEMENT: “No studies indicate that intrapartum exposure . . . has any long-term adverse health consequences to the fetus in the absence of fetal distress [emphasis mine]. . . .” (p. 387).

FACT: Well, that’s the catch, isn’t it? The long-term adverse health consequences to the fetus occur in the presence of fetal distress subsequent to uterine rupture…

So, as long as the Cytotec doesn’t cause fetal distress, it doesn’t seem to hurt the baby in the long-term. But how often does it cause fetal distress? I mean, “as long as your baby doesn’t drown in the bathtub, leaving him alone in the tub doesn’t cause any harm.” But how many times will the baby drown without competent adult supervision? I might also say, “In the absence of fire, an electrical short doesn’t seem to cause long-term adverse consequences”; “As long as it doesn’t hit you, lightning doesn’t seem to hurt you”; “As long as you’re not in a car wreck, seat belts don’t help to keep you safe.”

Both blog posts I linked to include multiple study references and/or links, so you can do your own research and reading. For my part, I still don’t like Cytotec — especially as it’s being used and overused. If interventions only happen with the risk of doing nothing outweighed the risk of doing something, then that would be one thing. But they’re not. You don’t have to read very far — birth blogs or birth story websites or just among your friends, family and coworkers — to find stories of women who got unnecessary interventions. And when they’re used when they’re medically unnecessary, then it only serves to introduce medical risk without the corresponding benefit. If, for example, a woman is electively induced then any induction method introduces risks, whereas the “risk” of doing nothing is… nothing. If a woman does need to be induced — for example, if the baby isn’t moving much and seems to be compromised, or she has pre-eclampsia or something — then there is a risk if they do nothing which is greater than the risk involved in doing something.

Finally, let me emphasize that the midwife at A Midwife’s Tale is not a “medwife” — she recently said she has a 6% or less C-section rate, which I don’t think would be possible if she were inducing unnecessarily or otherwise intervening too much. Also, my second midwife (a CPM) liked Cytotec, and thought it helped save some of her mamas from otherwise-certain C-sections. So, Cytotec is a controversial topic, but not everyone who is pro-Cytotec is anti-home/natural birth, nor a medwife.

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“Birth Love”

Here is a link to a website I’ve recently found about: Birth Love, the Revolutionary Passage of Motherhood. I haven’t explored it too much, but it looks like it’s got a lot of great articles and birth stories in it. If you’re looking for a nice, middle-of-the-road, balanced perspective… this isn’t it. It is profoundly and unashamedly pro-natural birth (regardless of how you define it): vaginal, VBAC, homebirth, midwife-attended, drug-free, medication-free, unassisted birth. So, if you’re looking for stories about elective C-sections, or support for an elective induction, you won’t find it here. However, if you’re looking for stories to balance out all those awful medicated-birth stories you’ve already read, this is a good site for it. There are numerous pages with all sorts of information on things like dangers of induction (including one devoted just to Cytotec), and birth stories told from the father’s perspective. Stuff you probably won’t be able to find easily elsewhere. It is, admittedly, a small but fervent segment of society. As Rush Limbaugh says about his conservative commentary, juxtaposed against the mainstream/liberal media: “I don’t need ‘equal time’ — I am equal time!” Whether you agree with his politics or his belief that most of the news organizations are too liberal, I think you can understand the sentiment. The same thing applies here. There is no balancing of opinion on this website (although they do agree with “women’s choice in childbearing”, so I suppose would agree to the right of a woman to choose an unnecessary C-section), because there is enough of that out there — tons of websites where both sides are presented as equal choices, or where the pro-medication or pro-hospital-birth side is given. This is, more or less, “equal time” given to the other side.

Uterine rupture with an unscarred uterus

A previous post (and comment), led me to investigate this topic further. I’d heard of previous C-section scars giving way; and I’d heard of uterine rupture in the case of labor induction or augmentation; but I’d never heard of an unscarred uterus rupturing.

This study talks about it. Unfortunately, it is just an abstract, so I’ve got a few questions which I’m sure could be answered if I had access to the full study. Oh, well. It identified 13 ruptures in an unscarred uterus, and says 3 were caused by car wrecks, and were excluded from the study; oxytocin was used in 4 cases; prostaglandin in 3;  vacuum or forceps in 3; 2 were in women who were grand multiparas; and 2 had fetal malpresentation. It gave a rate of 1 uterine rupture in an unscarred uterus per 16,849 births. Questions I have include whether all of these ruptures were complete, or if some were dehiscence; and whether any of the women with an “unscarred uterus” had any prior uterine surgery (including a D&C, which carries with it a slight possibility of a punctured uterus). I’m assuming that all of the ruptures were complete, considering that in the study discussed in the previous post, all three uterine ruptures in unscarred uteri were complete. Of those three, two occurred in women with prior D&C, but one said she had had no prior uterine surgery.

The numbers above add up to more than 10, though, so I can’t tell from the abstract whether or not obstetric intervention was used in all of them, or if some women had both oxytocin induction or augmentation and forceps removal of the baby. It’s seems reasonable that the babies that were in a poor position were also more likely to have induction of labor or vacuum/forceps use, since such women tend to have longer and slower labors (probably the contractions help to guide the baby into a better position if given enough time; but many hospital and/or doctor protocols don’t allow that much time).

Moving along, there is this tantalizing abstract which talks about a woman whose uterus ruptured after misoprostol was used to induce labor at 29 weeks (for an intra-uterine fetal demise). It says it includes “a review of all cases of uterine rupture with misoprostol induction,” which I’d like to be able to see. There were numerous other case studies and reports of women who suffered a ruptured uterus with second-trimester abortions, typically associated with misoprostol use, sometimes with a previous C-section.

Here’s a second-trimester rupture due to placenta percreta (the placenta grew not just into the uterine lining which is normal, but through the uterine wall).

Here’s one due to fundal pressure (when the mom was pushing, somebody pressed on the top of her uterus, to “help” her push her baby out). The World Health Organization relegates this to “Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue.”

This case was extremely interesting, in that the researchers said, “To the best of our knowledge, this is the first documented rupture of a gravid [pregnant] uterus occurring before onset of labour without previous risk factors.” The woman denied having a D&C or any previous abortions, didn’t have any uterine malformations or anything which were known risk factors. She went to the hospital at 32 weeks gestation because of sharp abdominal pain. Quite interesting, especially since it gives a short summary of various risk factors that other reports and studies have not mentioned. Mother and baby were fine.

This study from Ireland noted a rupture rate in unscarred uteri at 0.02% (8 cases out of more than 48,000 women who had had a previous pregnancy, not counting 0 cases out of nearly 28,000 first-time moms). But there is this case study in which a first-time mom had an unexplained uterine rupture.

This woman from California had her uterus rupture during second-stage labor (pushing), which was blamed on the rate of oxytocin (Pitocin, “Pit”) for labor induction. The researchers noted that despite having contractions every 2-3 minutes, the rate kept being increased during first- and second-stage labor. Although an emergency C-section was performed, the baby had signs of asphyxia.

So, rupture of an unscarred uterus can happen but is blessedly rare, especially when drugs used to induce or augment labor are avoided.

Misoprostol taken without doctors? NO!

This post is inspired by a search term somebody used to find my blog. I hope they found what they were looking for; but just in case, let me be crystal clear in this post:

Misoprostol can be a very dangerous drug to a pregnant woman and her baby.

Used early in pregnancy, it can induce a miscarriage or abortion; the further along in pregnancy a woman takes it, the greater the risk of negative sequelae, like uterine rupture, retained placenta, and postpartum hemorrhage. All of these things, if left untreated, can kill a woman. Even if they are treated, the woman can be left with long-term consequences. For instance, a uterine rupture may necessitate a hysterectomy; a retained placenta can cause heavy blood loss and/or infection; postpartum hemorrhage is by definition a heavy blood loss. Have you ever given a pint of blood as a blood donor? One time I did, I was dragging around all day, from the loss of one little pint of blood. Imagine losing a quart! (Or possibly more.)

The use of Cytotec (misoprostol, “miso”, the “little white pill”) may be beneficial in some select circumstances — in fact, may be preferable to a D&C for miscarriage, for instance. But in my opinion, it should never be used without medical attendance — the potential side effects, though rare, can be deadly. I know some home-birthing midwives will use Cytotec and don’t see a problem with it. I think that’s dangerous. If the uterus becomes hyper-stimulated at home, and the baby can’t handle the oxygen deprivation, or if the uterus splits in two due to the hard contractions, what can be done at home? Can they make it to the hospital in time? Will the hospital be prepared to react the second the woman enters, or will it be another 30 minutes until the O.R. can be prepped?

I rather suspect, however, that the person who was searching for that information was actually wondering about it for use in an abortion. If this applies to you, I will say this to you: Don’t do it! It doesn’t work all the time anyway, can damage the baby if it doesn’t work, and damage you even if it does successfully kill the baby. Go to RealChoice for some stories about women who have died following abortions even under medical care — women whose symptoms of infection, retained products of conception, postpartum (or rather, post-abortion) hemorrhage went undetected or ignored by doctors. If you are wanting to induce an abortion so that your family or friends don’t find out that you are pregnant, and you end up with one of these dangerous and potentially deadly events, they won’t know you’re even sick, or what to do. If you do have a problem, and they take you to the hospital unconscious from lack of blood, they may not know what the problem is, or be able to take the proper steps in time to save your uterus, or even your life.

I think that taking misoprostol is playing with fire anyway, but to do so without any medical supervision is just plain dumb!

I hope I wasn’t unclear.

Cytotec Adverse Event Site

Zorah Oden, mother of Tatia Oden French, has launched a new website for Cytotec awareness, with an email address for anyone to send stories of adverse events from the use of this drug. Tatia and her baby lost their lives when she was induced with Cytotec (without being told anything about the drug), and she suffered an amniotic fluid embolism. Cytotec (miso, misoprostol) is not FDA-approved for this use — nor indeed for any use in pregnancy or inducing labor. Among warnings on the package insert is that it may cause uterine rupture, the need for a hysterectomy, or even the death of the mother or baby.

While some people look favorably upon Cytotec for inductions, I am not one of them — it doesn’t seem to have been tested enough, despite what its supporters say. The risks seem just too great. But to each her own — as long as the woman has been given full information, and been made to understand the risks of this drug, as well as any possible options – if she chooses to take it then, that’s one thing; but many women are not told anything about the drug, including known adverse events.

There are some possible obstetric-related uses for this drug which definitely hold more benefit than risk. Once the baby has been born, the risk of uterine rupture or danger to the baby is nonexistent, so even if it doesn’t work well (and it doesn’t always work — few medications work every time, and I’ve heard numerous stories of miso having little or no effect on, say, postpartum hemorrhage), the risks are minimal. When used for evacuation of the uterus in the case of a miscarriage (i.e., in early pregnancy), the risk of uterine rupture is much lower than in later pregnancy, the baby has already died so there is no risk to him or her, and the risks of alternate options may be worse than the risk of uterine rupture (for instance, the increased risk of infection with retained products of conception, or the risk of infertility from a D&C).

Cytotec is one of those odd drugs which can cause or relieve the same problem. For instance, it may cause retained placenta when given to induce labor; but when given after the baby has been born, may induce the birth of the placenta, instead of having to resort to harsher measures. When given prior to birth, it may lead to postpartum hemorrhage; but it can also cure PPH if given after the birth of the baby. To be perfectly honest, the fact that it can do this bothers me quite a bit — I wonder if the pharmacists, doctors, and other people involved in this medication even understand how it works, and how it can have this “split personality” as it were. There are several other drugs used in gynecology that do this, so it may just be an oddity of the female body and female hormones… but I still don’t like it.

You can click on the tag “cytotec” over in the right-hand side bar to see other posts that talk about this drug. And if you know of an adverse event due to Cytotec (miso, misoprostol), please email it to Zorah French at the email address provided on the website.

One woman suffered a uterine rupture, although she had absolutely no risk factors for it — hadn’t had a uterine surgery, not even any fibroids. When she investigated, on her own, what could have made her uterus rupture without any warning or risk, she came across something that finally mentioned that Cytotec had that possible risk.

Amniotic fluid embolism can happen without drugs; but it is a known risk of Cytotec. It is typically deadly to both mother and baby, although some have survived it.

Uterine hyperstimulation can cause a uterine rupture, which can kill the baby and many times necessitates a hysterectomy to save the life of the mother. This can happen even with an unscarred uterus, but is more common in women who have had uterine surgeries, including C-sections.

Doctors are not required to report adverse events, so the rate and number of “official” adverse events is woefully inadequate (not just this pill, but for other medications as well, including vaccines). It is up to us to report them to each other and to educate each other. They may not be official — just “anecdotal” — but that doesn’t mean they didn’t happen. A common refrain of the stories currently on the Cytotec Adverse Event Site is that of women thinking that what happened to them or their babies was “just one of those things”. It wasn’t for weeks or months afterwards, when they got to the point in their grief and recovery that they had a need to know the details surrounding the loss of baby, uterus, or both, that they investigated and found that they had been given Cytotec. Or, perhaps they knew they had been given it, but didn’t know the adverse events, until they themselves became a statistic.

And if you don’t believe me…

…then check out this article by a former L&D nurse. (Be sure to click “next” which is on the left-hand side of the screen to read the next page of the article.)

She talks about (among other things) why you can’t eat or drink in labor; the downsides of epidurals; why doctors are so quick to call for a C-section; that doctors aren’t trained to attend vaginal breech births; that (in fact) doctors aren’t trained to do a lot of things any more, because they are trained to rely on machines and medicine; giving medicine via IV without the woman’s knowledge or consent; the use of Cytotec; and hospital-acquired infections.

A near-death experience, courtesy of Cytotec

When independent childbirth educator Nicole D. was pregnant with her first child, she consented to an induction when she went nearly two weeks past her due date. Although she said she was “naive and unprepared,” she did know that she most certainly did not want Cytotec (a.k.a. “misoprostol”, “miso” or “the little white pill”) used on her. Her doctor was in agreement with her, saying he never used it. Unfortunately, the doctor who was at the hospital when she went in to be induced did use it — against her express wishes, and without informing her that he had done so.

Read the rest of her story here.

For more information about Cytotec, please visit the Tatia Oden French Memorial website. Tatia Oden French was induced with Cytotec when she went past her due date, and both she and her baby died. Her mother vowed, “That drug is going to go away.” You can read more about her efforts here.