PGE2 Gel Induction Protocol
For cervical ripening with PGE2 gel (dinoprostone), administer a single intravaginal dose of 0.5 mg intracervically or 2-5 mg intravaginally, with continuous fetal and uterine monitoring from 30 minutes to 2 hours post-administration, and remove or reassess at 12 hours. 1
Dosing and Administration
Standard Dosing Options
- Intracervical gel: 0.5 mg PGE2 in 2.5 mL gel as a single dose 2
- Intravaginal gel: 2-5 mg PGE2 in viscous gel (2% or 4% concentration) 3, 4
- Vaginal insert (CERVIDIL): 10 mg dinoprostone insert releasing approximately 0.3 mg/hour for up to 12 hours 5
The intracervical 0.5 mg dose achieves an 82% success rate (defined as active labor within 24 hours or cervical change allowing amniotomy), with 46% of patients entering spontaneous labor within 12 hours 2. The higher intravaginal doses (5 mg in 4% gel) improve cervical status in 87.9% of patients, with 48.5% entering spontaneous labor before planned induction 3.
Administration Technique
- Insert gel transversely into the posterior vaginal fornix 5
- Use minimal water-miscible lubricant if needed (excess lubricant prevents dinoprostone release) 5
- Patient must remain recumbent for 2 hours after insertion 5
- May ambulate after 2 hours, but ensure insert remains in place 5
Critical Monitoring Requirements
Continuous fetal heart rate and uterine activity monitoring is mandatory from 30 minutes to 2 hours after PGE2 gel administration 1. For vaginal inserts, monitoring must continue from insertion until at least 15 minutes after removal 1.
Removal Criteria
Remove PGE2 insert immediately if: 5
- Active labor begins
- 12 hours have elapsed since insertion
- Uterine tachysystole or hyperstimulation occurs
- Fetal distress develops
- Amniotomy is planned
Timing Before Oxytocin
Wait at least 30 minutes after removing PGE2 before administering oxytocin 5. The FDA label explicitly contraindicates concurrent use of intravenous oxytocic agents with dinoprostone 5.
If cervical ripening is complete but labor has not begun after 12 hours, providers should allow at least 12 hours after completion of cervical ripening before considering cesarean delivery for "failed" induction in the latent phase 1.
Absolute Contraindications
PGE2 gel is absolutely contraindicated in: 5
- Prior cesarean section or uterine surgery (including myomectomy)
- Known hypersensitivity to prostaglandins
- Evidence or suspicion of fetal distress where delivery is not imminent
- Unexplained vaginal bleeding in current pregnancy
- Marked cephalopelvic disproportion
- Six or more previous term pregnancies
- Any contraindication to labor induction
The uterine rupture risk with prostaglandin use in scarred uteri is 2% for PGE2, compared to 13% for misoprostol 6.
Safety Considerations
Common Adverse Events
The most frequent complications (≥2%) include: 5
- Uterine tachysystole without fetal distress
- Uterine tachysystole with fetal distress
- Fetal distress without uterine tachysystole
Special Populations
- History of glaucoma: Consider non-prostaglandin cervical ripening methods 5
- Postpartum monitoring: Assess for evolving fibrinolysis and disseminated intravascular coagulation 5
Storage and Handling
CERVIDIL vaginal inserts must be kept frozen until use and should not be warmed prior to insertion 5. In contrast, misoprostol is stable at room temperature, while dinoprostone requires refrigeration to maintain potency 1.
Cost Considerations
Dinoprostone gel kits cost $65-75, while the CERVIDIL vaginal insert costs approximately $165 1. This represents significantly higher cost compared to misoprostol ($0.36-1.20 per 100 mcg tablet), though misoprostol carries higher risks in certain populations 1.