Outpatient Cervical Ripening: A Systematic Review and Meta-analysis

Marian McDonagh, Andrea C Skelly, Ellen Tilden, Erika D Brodt, Tracy Dana, Erica Hart, Shelby N Kantner, Rongwei Fu, Amy C Hermesch, Marian McDonagh, Andrea C Skelly, Ellen Tilden, Erika D Brodt, Tracy Dana, Erica Hart, Shelby N Kantner, Rongwei Fu, Amy C Hermesch

Abstract

Objective: To assess the comparative effectiveness and potential harms of cervical ripening in the outpatient compared with the inpatient setting, or different methods of ripening in the outpatient setting alone.

Data sources: Searches for articles in English included MEDLINE, EMBASE, CINAHL, Cochrane Library, ClinicalTrials.gov, and reference lists (up to August 2020).

Methods of study selection: Using predefined criteria and DistillerSR software, 10,853 citations were dual-reviewed for randomized controlled trials (RCTs) and cohort studies of outpatient cervical ripening using prostaglandins and mechanical methods in pregnant women at or beyond 37 weeks of gestation.

Tabulation, integration, and results: Using prespecified criteria, study data abstraction and risk of bias assessment were conducted by two reviewers, random-effects meta-analyses were conducted and strength of evidence was assessed. We included 30 RCTs and 10 cohort studies (N=9,618) most generalizable to women aged 25-30 years with low-risk pregnancies. All findings were low or insufficient strength of evidence and not statistically significant. Incidence of cesarean delivery was not different for any comparison of inpatient and outpatient settings, or comparisons of different methods in the outpatient setting (most evidence available for single-balloon catheters and dinoprostone). Harms were inconsistently reported or inadequately defined. Differences were not found for neonatal infection (eg, sepsis) with outpatient compared with inpatient dinoprostone, birth trauma (eg, cephalohematoma) with outpatient compared with inpatient single-balloon catheter, shoulder dystocia with outpatient dinoprostone compared with placebo, maternal infection (eg, chorioamnionitis) with outpatient compared with inpatient single-balloon catheters or outpatient prostaglandins compared with placebo, and postpartum hemorrhage with outpatient catheter compared with inpatient dinoprostone. Evidence on misoprostol, hygroscopic dilators, and other outcomes (eg, perinatal mortality and time to vaginal birth) was insufficient.

Conclusion: In women with low-risk pregnancies, outpatient cervical ripening with dinoprostone or single-balloon catheters did not increase cesarean deliveries. Although there were no clear differences in harms when comparing outpatient with inpatient cervical ripening, the certainty of evidence is low or insufficient to draw definitive conclusions.

Systematic review registration: PROSPERO, CRD42020167406.

Conflict of interest statement

Financial Disclosure Amy Hermesch disclosed that money was paid to her from GenBioPro as a consultant. The other authors did not report any potential conflicts of interest.

Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.

Figures

Fig. 1.. Meta-analysis of cesarean delivery with…
Fig. 1.. Meta-analysis of cesarean delivery with prostaglandins for cervical ripening: outpatient (OP) vs inpatient (IP). *Risk ratio estimate calculated from author's adjusted odds ratio comparing inpatient with outpatient. RCT, randomized controlled trial.
McDonagh. Outpatient Cervical Ripening. Obstet Gynecol 2021.
Fig. 2.. Meta-analysis of cesarean delivery with…
Fig. 2.. Meta-analysis of cesarean delivery with catheters for cervical ripening: outpatient (OP) vs inpatient (IP). *Risk ratio estimate calculated from author's adjusted odds ratio comparing inpatient with outpatient. RCT, randomized controlled trial.
McDonagh. Outpatient Cervical Ripening. Obstet Gynecol 2021.
Fig. 3.. Meta-analysis of cesarean delivery with…
Fig. 3.. Meta-analysis of cesarean delivery with prostaglandins vs placebo for cervical ripening in the outpatient setting.
McDonagh. Outpatient Cervical Ripening. Obstet Gynecol 2021.

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