What are the implications of using Misoprostol (Cytotec) in a grand multipara (a woman who has given birth five or more times)?

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From the Guidelines

Cytotec (misoprostol) should be used with caution in a grand multiparous woman for labor induction, starting with a lower dosage of 25 micrograms vaginally every 3-6 hours, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1. The use of misoprostol in grand multiparas requires careful consideration due to the increased risk of uterine rupture and hyperstimulation.

  • Key considerations for the use of misoprostol in grand multiparas include:
    • Lower dosages (25 µg every three to six hours) are effective for cervical ripening and induction of labor 1
    • Close monitoring for uterine hyperstimulation is essential as grand multiparas have a higher risk of uterine rupture due to weakened uterine walls from multiple previous pregnancies
    • Continuous fetal monitoring should be implemented throughout the induction process
    • Prior to administration, a thorough assessment of maternal and fetal status is necessary, including evaluation of fetal position, estimated fetal weight, and cervical status
    • Cytotec should be avoided if there are signs of fetal distress, abnormal fetal presentation, or previous uterine surgery The increased sensitivity of the uterus in grand multiparous women to prostaglandins like misoprostol is due to higher expression of prostaglandin receptors in the myometrium after multiple pregnancies, making the uterus more responsive to lower doses of the medication. The primary goal is to minimize the risk of complications while achieving a successful labor induction, and therefore, the use of misoprostol in grand multiparas should be individualized and closely monitored 1.

From the FDA Drug Label

The risk of uterine rupture associated with misoprostol use in pregnancy increases with advancing gestational ages and prior uterine surgery, including Cesarean delivery. Grand multiparity also appears to be a risk factor for uterine rupture Misoprostol should not be used in cases where uterotonic drugs are generally contraindicated or where hyperstimulation of the uterus is considered inappropriate, such as ... grand multiparity...

Cytotec use in a grand multipara is associated with an increased risk of uterine rupture.

  • The use of Cytotec is contraindicated in cases of grand multiparity due to the risk of uterine hyperstimulation and rupture 2, 3, 3.
  • Uterine rupture can lead to severe complications, including maternal and fetal death.
  • Therefore, Cytotec should be avoided in grand multiparous women.

From the Research

Cytotec in Grand Multiparity

  • Cytotec, also known as misoprostol, is a medication used for labor induction in grand multiparous women, who have had five or more previous deliveries 4.
  • A study published in 1999 found that vaginal misoprostol was a safe and cost-effective alternative for labor induction in grand multiparous women, with a low rate of cesarean section (6.0%) and no cases of uterine rupture 4.
  • However, another study published in 1997 reported a case of uterine rupture during labor induction with intravaginal misoprostol in a multiparous woman, highlighting the potential risk of excessive uterine activity and uterine rupture with misoprostol use 5.

Uterine Rupture Risk

  • A retrospective multicenter study published in 2020 found that grand multiparity did not increase the risk of uterine rupture in women with a scarred uterus who underwent labor induction or augmentation, with a similar uterine rupture rate (0.3%) compared to multiparous women 6.
  • Another study published in 2004 found that induction of labor with oxytocin or misoprostol was associated with a higher rate of uterine rupture compared to spontaneous labor, but the rupture rate with misoprostol induction was not increased compared to oxytocin induction after one prior cesarean 7.

Safety and Efficacy

  • Misoprostol is considered a useful therapeutic agent in resource-limited practice environments, although its effectiveness as an adjunct to other uterotonic agents has been questioned in recent studies 8.
  • The 1999 study found that labor induction by vaginal misoprostol was successful in grand multiparous women, with significantly shorter application-to-expulsion intervals in women with prelabor rupture of membranes and higher Bishop's scores 4.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Labor induction by vaginal misoprostol in grand multiparous women.

Acta obstetricia et gynecologica Scandinavica, 1999

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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