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Cytotec and Birth Injuries

Woman in LaborWhen a woman is ready to have her child, labor is naturally triggered by the body releasing large amounts of the hormone Oxytocin. Oxytocin is a critical component of beginning the process of labor. It starts contractions, dilates the cervix, and prepares the woman's body for delivery. For some women, the process of labor does not start as scheduled and needs to be medically induced.

Induction is not uncommon. Today, mothers are induced in more than 22% of births. Since 2002, the rate of labor induction has doubled from 9% of births to 18% and is used most often for post-date pregnancies. Inducing labor can have several benefits, such as reducing high blood pressure during delivery and preventing infections that could harm the baby.

Cytotec is a, oral medication this is commonly used to induce labor in women and works by softening the cervix to allow easier dilation (known as "ripening") and producing contractions. In most cases, Cytotec is a safe and reliable medication that can make labor easier for women when administered correctly. Unfortunately, when the medication is not used properly or the mother is not properly monitored, there are potentially severe risks for the baby. Studies have revealed that improper usage of Cytotec can result in different types of birth injuries from adverse reactions to the drug.
What Is Cytotec?

Cytotec is an off-brand version of the medication Misoprostol, which is a synthetic version of the hormone prostaglandin. Cytotec was not originally developed to help induce labor and was instead used to treat stomach ulcers. It lines the wall of the stomach and prevents stomach acid from coming into contact with it. Starting in the 1970s, doctors began to realize that softened the cervix and helped induce labor in women, which ultimately created a new use for the drug.

Today, Cytotec is considered one of the best options to induce labor because of how convenient and cost-effective it is compared to other brands. A prescription of Cytotec only costs $0.60, while other medications like Pitocin and Prepidil can cost up to $150. However, it should be noted that the FDA has NOT approved Cytotec for the use of labor induction or cervical ripening. The FDA has made it known publicly that because of the possible side effects associated with the drug, they do not allow it to be marketed as a solution to post-date pregnancy or labor complications.
What Are the Problems With Cytotec?

Because of the FDA warning, there is a gray area on whether or not Cytotec is completely safe to use for pregnant women. In 2000, the manufacturer of Misoprostol warned against using the drug because of the risk of birth injuries and defects. In 2015, the FDA reaffirmed its opinion that Cytotec has possible severe adverse effects on both the mother and child. Doctors who commonly administer the off-label drug continue to defend its usage and claim the benefits largely outweigh the risks.

The main problems cited for the medication are hyperstimulation, uterine rupture, and placental abruption. Hyperstimulation is where the uterus produces severe, excessive contractions usually two minutes or less apart. In normal labor, a contraction puts pressure on the baby and placenta, helping it move further down the birth canal. The pressure being put on the baby temporarily limits blood flow and oxygen going into the placenta, but that pressure is relieved after the contraction passes and the baby has time to recover before the next one begins.

During hyperstimulation, contractions squeeze much tighter, which can cause complete restriction of blood flow and oxygen. After the pressure is relieved, the baby does not have enough time to recover before another contraction starts and as a result, becomes distressed. Hyperstimulation can lead to uterine rupture, which are tears in the uterus. When the uterus tears, it can cause the baby to slip into the woman's abdomen, effectively suffocating the baby.

Cytotec can also cause placental abruption, which is when the placenta breaks off and separates from the wall of the uterus. Placental abruption can compress the baby's umbilical cord, the primary source of all of its oxygen, blood, and nutrients.

Hyperstimulation, uterine rupture, and placental abruption all present a similar problem of the baby lacking oxygen for an extended period, which is known as hypoxia. A consistent flow of oxygen during the delivery process is critical for the baby because even a few minutes without air can cause permanent injury or defect. If a woman experiences any of these complications, an emergency C-section is usually needed to save the baby's life. Even if the C-section is successful, the baby can still suffer from birth injuries stemming from the hypoxia. These conditions include:

Hypoxic-ischemic encephalopathy (HIE)/birth asphyxia
Cerebral palsy (CP)
Intellectual and developmental disabilities
Seizure disorders
Periventricular leukomalacia (PVL)

It is believed that the risk of these conditions increases when Cytotec is improperly administered. When misoprostol is inserted into the vagina, the pill dissolves and is absorbed immediately. This means that if adverse symptoms develop, there is virtually no way to discontinue the medication. If a doctor does not measure out the right dosage, they could possibly supply too much Cytotec and cause adverse reactions. Choosing the right dosage is hard in itself since there is no real standard for the medication besides what's recommended by the FDA for stomach ulcers.
Guidelines for Cytotec

Doctors are recommended to start Cytotec for pregnant women at a low dosage and slowly move up until labor is induced. Even though Cytotec originally comes in 100mg tablets, it's suggested that pregnant women should start at 25mg by breaking the pill into quarters. If pregnancy is not induced, doctors can use up to 100mg, but this increases the risk of complications. After the Cytotec is given, the woman and baby should be carefully monitored throughout delivery to recognize any fetal distress or intense contractions. If labor is still not induced by 100mg, a C-section should be performed instead of continuing to administer Cytotec.
Will Cytotec Cause an Abortion?

Many women have a fear of Cytotec because they know it is used in combination with mifepristone as an abortion pill. But the purpose of Cytotec in a late-stage pregnancy is not to induce an abortion but to facilitate childbirth. In both cases, it comes with risks.
Sources and Additional Reading

Gaskin, I. M. (2013). Cytotec and the FDA. Midwifery Today With International Midwife, (107), 8-14.

Stephenson, M. L., & Wing, D. A. (2015). Misoprostol for induction of labor. Seminars In Perinatology, 39(6), 459-462.

Wing, D. A. (2002). A benefit-risk assessment of misoprostol for cervical ripening and labour induction. Drug Safety, 25(9), 665-676.

Kolderup, L., McLean, L., Grullon, K., Safford, K., & Kilpatrick, S. J. (1999). Misoprostol is more efficacious for labor induction than prostaglandin E2, but is it associated with more risk? American Journal Of Obstetrics And Gynecology, 180(6 Pt 1), 1543-1550.

King, V., Pilliod, R., & Little, A. (2010). Rapid review: Elective induction of labor. Portland: Center for Evidence-based Policy.

Mozurkewich, E., Chilimigras, J., Koepke, E., Keeton, K., & King, V.J. (2009). Indications for induction of labour: A best-evidence review. BJOG, 116(5): 626-636.

Blanchard K, Clark S, Winikoff B, Gaines G, Kalani G, Shannon C. Misoprostol for women's health: A review. Obstetrics and Gynecology. 2002;99:316-332.

Majoko F, Magwali T, Zwizwai M. Uterine rupture associated with the use of misoprostol for labor. International Journal of Gynecology and Obstetrics. 2002;76(1):77-78.