Context

Treatment alternatives

If induction of labour is clinically justified, the NICE clinical guideline on induction of labour states that vaginal prostaglandin E2 (dinoprostone) is the preferred method, unless there are specific clinical reasons for not using it (in particular the risk of uterine hyperstimulation). It should be administered as a gel, tablet or controlled-release insert. Costs may vary over time, and trusts and units should take this into consideration when prescribing vaginal prostaglandin E2. The recommended regimens are:

  • vaginal prostaglandin E2 tablets or gel: 1 dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of 2 doses)

  • prostaglandin E2 controlled-release vaginal insert: 1 dose over 24 hours.

NICE advises that oral, intravenous, extra-amniotic and intracervical prostaglandin E2, and intravenous oxytocin alone should not be used for the induction of labour. Misoprostol or mifepristone should be offered as a method of induction of labour only to women who have had an intrauterine fetal death or, for misoprostol, in the context of a clinical trial.

Costs of treatment alternatives

Usual dose a

Estimated cost excluding VAT b

Misoprostol 200 micrograms controlled-release vaginal insert

1 dose over 24 hours

£93c

Dinoprostone 10 mg controlled-release vaginal insert

1 dose over 24 hours

£30.00

Dinoprostone 3 mg vaginal tablet

1 dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of 2 doses)

£13.28 to £26.56

Dinoprostone 1 mg or 2 mg vaginal gel

1 dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of 2 doses)

£13.28 to £26.56

a Doses taken from the summaries of product characteristics and recommendations in the NICE clinical guideline on induction of labour. The doses shown do not represent the full range that can be used and they do not imply therapeutic equivalence.

b Costs taken from MIMS, January 2014.

c Ferring Pharmaceuticals: personal communication, January 2014.

Ferring Pharmaceuticals, the UK marketing authorisation holder, has advised that the misoprostol vaginal insert is likely to be more expensive than dinoprostone, but suggests it might offer economic benefits for obstetric units in terms of a reduction in the use of resources (for example, staffing) and the total cost of inducing labour, compared with current management. This is because the median time to vaginal delivery is reduced by 11.3 hours (13.9 hours in nulliparous women and 6.7 hours in parous women) with misoprostol compared with dinoprostone, and the need for oxytocin and intrapartum and postpartum intravenous or intramuscular antibiotics is lower (Ferring Pharmaceuticals: personal communication, January 2014). However, uterine tachysystole requiring intervention and use of tocolysis were about 3 times higher in the misoprostol group compared with the dinoprostone group and further evidence on cost effectiveness is needed to support this claim. Health economic analyses of the misoprostol vaginal insert are expected to be published later in 2014.