Highlights
-
•
This randomized clinical trial determined that using dexamethasone vaginally in nulliparous pregnant women does not improve cervical Bishop scores.
-
•
Administration of dexamethasone vaginally does not reduce the latent phase of labor duration.
Key words: corticotropin-releasing hormone, cervix uteri, dexamethasone, obstetrics, pregnancy
Abstract
Background
Cervix ripening and labor induction are common interventions in obstetrics. For optimal maternal health, labor may be induced under certain situations to improve fetal survival outcomes. Labor induction of an unripe cervix can lead to complications; therefore, several approaches can facilitate the ripening process.
Methods
This randomized clinical trial was a triple-blind study that involved 84 pregnant nulliparous women enrolled between October 2019 and June 2021 in the labor ward of Kamali Hospital, Karaj, Iran. The pregnant women in the study underwent labor induction and were randomized into 2 groups: 1 group received vaginal dexamethasone and the other group was given a placebo.
Results
There was no significant difference between the groups regarding maternal age, demographic characteristics, and initial Bishop score. The median second Bishop score (6 hours after intervention) was 3.5 in dexamethasone recipients and 3 in placebo recipients (P = 0.48). The median labor latent phase duration was 4 hours in dexamethasone recipients and 5 hours in placebo recipients (P = 0.57).
Conclusions
This randomized clinical trial demonstrated that administering dexamethasone tablets vaginally did not significantly improve cervical Bishop scores. (Curr Ther Res Clin Exp. 2023; 84:XXX–XXX). ClinicalTrials.gov identifier: NCT05070468.
Introduction
Inducing labor can be required as a therapeutic option. This requires stimulating uterine contractions before the spontaneous onset of labor. The most common indications for labor induction may include gestational or chronic hypertension, severe fetal growth restriction, preeclampsia, eclampsia, gestational diabetes, and postterm pregnancy. Ending a pregnancy can be needed when there is premature rupture of membranes without labor; oligohydramnios; or concerns related to fetal status, such as nonreassuring heart sounds.1,2 Two primary techniques are used for cervical ripening when the cervix is unfavorable to facilitate the ripening process. The techniques can be mechanical interventions and/or the application of pharmacologic agents. Techniques like the administration of prostaglandins (eg, misoprostol), extra amniotic saline infusion, traction on the cervix with a Foley balloon catheter, and/or hygroscopic cervical dilators are as showed in Figure 1.3,4 In nulliparous pregnant women, the cervix has a smooth, round external os. The average time from induction to delivery is between 15 and 20 hours. The cervical ripening phase can take up to 12 hours before the start of labor. Labor may be prolonged in about 10% of pregnant women, which can cause maternal and/or fetal risks. These risks include antepartum and postpartum hemorrhage and maternal and/or neonatal infection, leading to maternal, fetal, or neonatal death.5 Therefore, labor induction is essential in managing prolonged labor.6,7
Figure 1.
Types of Induction of labor.
Corticotropin-releasing hormone (CRH) is a principal regulator of the hypothalamic-pituitary-adrenal axis. CRH is released from the placenta and fetal membranes during pregnancy. Plasma CRH levels observed during labor peak during vaginal delivery (serum levels ranging from 2 to 3000 pmol/L during labor).6,8,9 The CRH functions as the surveillance and response for the placental. This allows the fetus to detect threats to survival, and if viable, the fetus can adjust its developmental course. In 2007, O'Sullivan et al10 reported that congenital adrenal hyperplasia in the fetus is associated with 21-hydroxylase deficiency. In addition, a late gestational rise may lead to impaired cortisol production by the fetal adrenal gland.10
Studies by Mohaghegh et al2 and Latif et al8 demonstrated that glucocorticoids like dexamethasone play a pivotal role in cervical ripening and aid labor induction. Prior studies have used dexamethasone as the chosen glucocorticoid to investigate its role in labor induction. The effect of dexamethasone on the interval length at the beginning of labor induction has been explored because its effects at the beginning of the active phase of labor.3,8,11, 12, 13, 14 However, there is a paucity of studies because of the high heterogeneity among pregnant women. There is a need for double-blind clinical trials to solidify the use of dexamethasone for improving cervical Bishop scores in pregnant women. As outlined, the role of corticosteroids in labor induction remains unclear. The effect of using corticosteroids vaginally for labor induction requires further investigations. Therefore, we undertook a triple-blinded randomized controlled trial (RCT) where dexamethasone was the chosen glucocorticoid used for labor induction. This study aimed to examine the effect of using dexamethasone administered vaginally and whether or not it can enhance the Bishop score and reduce the duration of the latent phase of labor in nulliparous pregnant women.
Methods
Study design
This was a triple-blinded RCT conducted in Kamali Hospital, Karaj, Iran. Kamali Hospital is among the teaching hospital subsets at Alborz University of Medical Sciences. Ethical approval was ceded to the ethical committee of Alborz University. The ethics committee approved the study protocol. The RCT was conducted between October 2019 and June 2021. It was registered as an RCT with the following ID number: IR. ABZUMS. REC1399.067. Additionally, it was registered on ClinicalTrials.gov (NCT05070468).
A sufficient sample size is required to compare the mean of the 2 groups.15 Using a 95% CI and power of 90%, it was estimated that at least 84 participants were required. The participants were randomly divided into 2 groups of 42 as either cases or controls. The statistician assigned the participants to 2 groups using a balanced block randomization method using allocation into quadruple blocks. There were 6 modes for each case, 2 participants were in the control group, and 2 were in the intervention group. Thus, the participants were selected using the table of random numbers and assigned the numbers 1 to 6 within the groups of 4.
Study selection
The clinical trial investigators and research staff were involved in all aspects of the study design and administration of the RCT. This included screening pregnant patients to assess if they met the study inclusion criteria. These criteria required being a nulliparous Iranian woman and pregnant, having full-term gestation (≥38 weeks), a singleton pregnancy, between ages 18 and 35 years, and having normal body mass index of 18.5 to 24.9. Labor induction was started in the participants when the membranes ruptured without the initiation of labor. The fetus was required to be in cephalic presentation, as shown on an ultrasound; there was a Bishop score ≤2 and an estimated fetal weight 2500 to 4000 g. Participants were expected to have had normal nonstress test results. If the patient's obstetrics physician indicated termination of pregnancy, they could be eligible and randomized into case and control groups by a statistician.
Exclusion criteria required the pregnant woman not to take any hormones or herbal medicines (traditional medicines), herbal/natural products, or conventional/prescribed medications during her pregnancy. Those who had the following preexisting diseases, including diabetes mellitus, hypertension, a history of obstetric complications such as preeclampsia or eclampsia, or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, were excluded. If the pregnant individual had previously presented with fetal immobility/decelerations or a history of maternal bleeding, she could not be enrolled in the clinical trial.
To enroll eligible patients, the investigator explained the study to potential participants and asked them to consider being in the study after considering all the presented information. Written consent was obtained from all recruited patients. Once enrolled, the patients, investigators, and research staff were blinded to which groups the patients were allocated. Dexamethasone and placebo tablets were labeled Tablets A and B and delivered by the hospital pharmacist. The research staff was blinded to which tablets were the study drug. The study design required that the tablets be administered vaginally by the obstetrician. Fourteen dexamethasone tablets (0.5 mg) were administered in group A, and 14 placebo tablets were given in the same manner to the participants in group B.
Data collection
Data were collected using several tools, including interviews, observations, and a vaginal examination. The research staff designed a 2-page questionnaire that was used, and this included demographic information; that is, current age, education, job, gravidity, parity, past medical history, and body mass index. The first and second Bishop scores, the latent phase duration, and delivery and intervention type were also recorded for each patient. The collected information was initially collected on paper forms.
Clinical intervention phase
During the intervention phase, the modified Bishop score was assessed; this comprised a physical examination that evaluated the cervical length, consistency, dilation and position, and fetal head station. Per the study protocol, an obstetrician placed 14 tablets (either Tablets A or B) within the vagina during labor. The fetal heart rate was closely monitored, and any changes in the Bishop score within 6 hours were recorded. During this time, an obstetrics physician undertook the labor induction for the study patients.
There were 3 types of interventions used. The first was when the pregnant woman did not require to be induced. These individuals had effective and robust contractions during labor. Therefore, further induction of uterine contractions was not performed, and labor took its natural course. Second, labor was induced when the pregnant woman did not have strong enough or effective uterine contractions. In these situations, oxytocin was administered to aid in the induction if the patient had a Bishop score ≥5. Third, during labor induction in those participants assigned to the cases group, misoprostol was administered to patients with a Bishop score <5. Once proper cervix ripening had been achieved, this indicated the termination of misoprostol's effects. Labor induction continued with oxytocin until uterine contractions were satisfactory and strong. At each stage, from initial enrollment into the study, the onset of labor symptoms, and until the end of the latent phase of labor (4 cm dilation), the research staff followed and evaluated the individual women every 30 minutes. To further increase the reliability of the examination results, the patient's cervical dilation was established by 2 separate examiners to verify the result of the vaginal examinations.
Statistical Analysis
The statistical analysis collected data from reviewing the patient questionnaires. This was converted for analysis using the SPSS statistical software version 25.0 (IBM-SPSS Inc, Armonk, New York). A χ2 test was used to assess any statistical hypotheses. Qualitative variables were reported as percentages and frequency. Through the evaluation of data, the findings were evaluated by using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Additional parametric and nonparametric analyses were performed. The subsequent assessment used the Mann-Whitney or t test (depending on the case). A P value ≤ 0.05 was considered statistically significant in this study.
Results
Study characteristics
The study recruited individual pregnant women at full-term gestation (≥38 weeks). A total of 87 women were initially enrolled in this study, 3 of whom declined to take part further after enrolment. The remaining 84 pregnant women were included in the randomized clinical trial. The women were randomly grouped into 42 cases and 42 controls using a block method with a statistician's oversight. All patients completed the study except 1 pregnant woman from group A receiving dexamethasone. This patient did not complete the study because of maternal and fetal complications. Therefore, she was excluded from the intervention group and further analyses. Figure 2 represented the enrollment of this study. Table 1 illustrated the detailed comparison between the two groups.
Figure 2.
The enrollment of this study.
Table 1.
Demographic and obstetric characteristics of participants between the 2 groups.
| Parameter | Total |
Dexamethasone group |
Placebo group |
P value* | ||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | 0.491 | ||
| Education | Illiterate | 10 | 11.9 | 4 | 9.5 | 6 | 14.3 | |
| Primary school | 7 | 8.3 | 2 | 4.8 | 5 | 11.9 | ||
| Junior school | 21 | 25.0% | 14 | 33.3 | 7 | 16.7 | ||
| High school | 35 | 41.7 | 16 | 38.1 | 19 | 45.2 | ||
| Associate's degree | 4 | 4.8 | 2 | 4.8 | 2 | 4.8 | ||
| Bachelor's degree or higher | 7 | 8.3 | 4 | 9.5 | 3 | 7.1 | ||
| Job | Unemployed | 77 | 91.7 | 37 | 88.1 | 40 | 95.2 | 0.236 |
| employed | 7 | 8.3 | 5 | 11.9 | 2 | 4.8 | ||
| Gestational age†, y | 40 (39-40) | 40 (39-40) | 40 (39-40) | 0.937 | ||||
| Gravidity and parity | G1ab1 | 82 | 97.6 | 42 | 100.0 | 40 | 97.6 | 0.359 |
| G1ab2 | 1 | 1.2 | 0 | 0.0 | 1 | 1.2 | ||
| G1ab3 | 1 | 1.2 | 0 | 0.0 | 1 | 1.2 | ||
G ab = gravidity and abortion.
All P values calculated by χ2 test except gestational age.
Gestational age was calculated by Mann-Whitney test and is presented as median (interquartile range).
The therapeutic approach in the 2 groups
A total of 84 patients with a median age of 24 years (IQR, 22-29 years) were included. In group A, the median age was 25 years (IQR, 22-31 years); in group B, this amount was 23 years (IQR, 21-28.25 years). A P value of 0.151 was reported, and no statistically significant difference was observed between the 2 groups. The majority of women in this study (41.7%) passed high school, and in terms of occupation, the majority (91.7%) were unemployed.
The mean gestational age was 40 weeks (IQR, 39-40 years); group A and group B had the same result: 40 weeks (IQR, 39-40 weeks). No statistically significant difference was seen between the 2 groups (P = 0.691). In group A, the 42 patients were nulliparous without a history of abortions. In group B, 40 patients were nulliparous with no history of abortions, 1 patient had a history of having had an abortion, and another patient had a history of previously having 2 abortions.
The collected data showed the 25th and 75th percentiles for the first Bishop score in groups A and B were the same. In group A, the second Bishop score was 3.3, and in group B it was 3.1.
The median of the latent phase between group A and group B was 4 and 5 hours, respectively, although in group B the time value of this variable was more; however, there were no statistical differences between both groups. Table 2 presents both groups’ detailed first and second Bishop scores and latent phases.
Table 2.
Comparison of Bishop score and latent phase between the 2 groups.
| Parameters | Total | Dexamethasone group | Placebo group | P value* | |
|---|---|---|---|---|---|
| First Bishop score | Median | 1.0 | 1.0 | 1.0 | 0.618 |
| 25th percentile | 1.0 | 1.0 | 1.0 | ||
| 75th percentile | 2.0 | 2.0 | 2.0 | ||
| Second Bishop score | Median | 3.0 | 3.5 | 3.0 | 0.483 |
| 25th percentile | 2.0 | 2.0 | 2.0 | ||
| 75th percentile | 4.0 | 4.0 | 4.0 | ||
| Latent phase | Median | 5.0 | 4.0 | 5.0 | 0.571 |
| 25th percentile | .0 | .0 | .0 | ||
| 75th percentiles | 8.0 | 9.0 | 8.0 | ||
P value calculated by Mann-Whitney test.
The rate of vaginal birth was 38.1% in group A and 47.6% in group B. It was almost 10% higher in group B, but there was no statistically significant difference between them. When labor induction did not lead to vaginal childbirth, and the cervix remained unripe, a Cesarean section was performed for the safety of the fetus and the mother. A Cesarean section was performed in 61.9% of group A patients and 52.4% of group B patients. Therapeutic intervention (not induced induction with only oxytocin, induction with oxytocin and misoprostol) was almost similar in both groups, and there were no statistical differences between the 2 groups. Table 3 represents a detailed comparison of the type of delivery and the type of intervention between the 2 groups. None of these women received antenatal corticosteroids before induction for fetal lung maturity.
Table 3.
Comparison of types of delivery and types of interventions between the 2 groups.
| Parameter |
Dexamethasone group | Placebo group | P value* | ||
|---|---|---|---|---|---|
| Type of delivery | Vaginal birth | Number | 16 | 20 | 0.378 |
| Percent | 38.1 | 47.6 | |||
| Cesarean section | Number | 26 | 22 | ||
| Percent | 61.9 | 52.4 | |||
| Total | Number | 42 | 42 | ||
| Percent | 100.0 | 100.0 | |||
| Typ of intervention | Not induced | Number | 10 | 11 | 0.943 |
| Percent | 24.3 | 26.2 | |||
| Induction (oxytocin only) | Number | 23 | 22 | ||
| Percent | 56 | 52.4 | |||
| Induction (oxytocin and misoprostol) | Number | 8 | 9 | ||
| Percent | 19.5 | 21.4 | |||
| Total | Number | 41 | 42 | ||
| Percent | 100.0 | 100.0 | |||
P value calculated by χ2 test.
Discussion
Previous studies mainly used 8 mg parenteral dexamethasone.12 In contrast, the total dose of the inserted tablets in our study was 7 mg. This difference was decided by considering the intravenous/intramuscular dose, the bioavailability of the drug, and possible adverse effects of doses higher than 8 mg. Previous studies have stated that the half-life of dexamethasone did not differ when used orally or intravenously.16 A recent study reported that a Franz cell diffusion test could measure the permeability of the vaginal mucosa and assess the potential bioavailability of the drug when administered vaginally. Their investigation showed that dexamethasone could permeate the vaginal mucosa, and so can be administered as a noninjectable treatment.17 Also, Bakhtiari et al18 suggested that dexamethasone tablets (0.5 mg each) can be absorbed from the mouth mucosa. Because dexamethasone is readily absorbed via the mucosa with a bioavailability of about 80%,19 we used dexamethasone tablets vaginally for the higher bioavailability.
Recent investigations have clarified that intramuscular dexamethasone can reduce the interval between the induction of labor and the active phase.13,20, 21, 22, 23 Elsayed et al15 studied 80 pregnant women in a randomized clinical trial. They observed that administration of intramuscular dexamethasone before induction had no statistically significant differences in the active phase of labor between the 2 groups. However, they reported that dexamethasone administration before induction seemed to shorten the induction-active phase interval.15 These findings showed that dexamethasone administration might reduce labor's latent phase. It was not in concordance with our study. Also, Sammour et al14 studied 60 pregnant women. A single dose of intramuscular dexamethasone (2 mL) was administered in the case group. They reported that intramuscular dexamethasone shortened the duration of labor induction by decreasing the interval between the start and the beginning of the active phase.14
Salman et al24 studied 60 pregnant women in a randomized, double-blind clinical trial. The control group received vaginal misoprostol, but intravenous dexamethasone was administered to the experimental group. They found that dexamethasone shortened the duration of labor induction by reducing the time interval between the initiation of labor induction and the onset of an active phase (P < 0.001).24 However, in this study, the vaginal use of dexamethasone showed no effect in reducing the latent phase or the induction-active phase interval. These differences in outcomes could be because of the different dexamethasone administration routes (intramuscular/intravenous vs vaginal).
In a meta-analysis, Mohaghegh et al2 showed that using dexamethasone by intramuscular, intravenous, or extra-amniotic routes can reduce the duration between labor induction and active phase of labor and also improve Bishop scores. In their meta-analysis, vaginal administration of dexamethasone was not studied. They also reported that dexamethasone injection did not affect maternal outcomes or Cesarean rate. In our study, vaginal administration of dexamethasone was not shown to increase the rate of natural vaginal delivery compared with the control group.
Bishop scores after cervical ripening significantly predicted induction success.25 Kashanian et al. studied 84 pregnant women. They administered 20 mg dexamethasone extra-ovulary plus extra-amniotic saline solution infusion in the case group and extra-amniotic saline solution infusion alone in the control group. They found that the primary Bishop score in the case and control groups were similar.3
The effect of vaginal administration of dexamethasone on labor induction or its bioavailability in this form has never been studied; therefore, further investigations are needed in future studies.
Conclusions
In this study, we have described how using dexamethasone tablets vaginally improves Bishop scores in nulliparous pregnant women. The current study showed that administrating vaginal dexamethasone did not affect improving Bishop scores and did not reduce the duration of the latent phase of labor.
Conflicts of interest
The authors have indicated that they have no conflicts of interest regarding the content of this article.
Acknowledgments
This study was funded by Alborz University of Medical Sciences. None of the researchers paid to assist with the study. Alborz University supplied the dexamethasone and the placebo tablets and paid their cost.
The authors thank the Kamali Clinical Research and Development unit of the Kamali Hospital for their assistance in planning and performing this study. We want to acknowledge photo contributor Pepermpron, Stock Photo 2015137865 “Labor swept drug baby Foley Strip sweep sac uterus hook Amnio fetus risk Cook ripe IV line bulb speed up plug mucus previa water vagina ripen first gland loop birth give method induce cervix sweeping” (Figure 1). https://www.shutterstock.com/image-vector/labor-swept-drug-baby-foley-strip-2015137865.
Study concept and design were contributed by M. Farahani, M.Nirouei, S. Moghadam, M. Hashemnejad, B. Mashak, T. Alinia, and S. Torabi. Acquisition of data was contributed by S. Torabi and S. Moghadam. Drafting of the manuscript was contributed by M. Nirouei and T.Alinia. Critical revision of the manuscript for important intellectual content was contributed by M. Farahani, M. Hashemnejad, B. Mashak, and M. Nirouei. Administrative, technical, and material support were contributed by M. Farahani, M. Nirouei, S. Moghadam, M. Hashemnejad, B. Mashak, T. Alinia, and S. Torabi. Study supervision was contributed by M. Farahani, M. Hashemnejad, and B. Mashak.
References
- 1.Tenore JL. Methods for cervical ripening and induction of labor. American family physician. 2003;67(10):2123–2128. [PubMed] [Google Scholar]
- 2.Mohaghegh Z, Faal Siahkal S, Bahmaei H, Sharifipour F, Leyli EK, Zahedian M. The effect of dexamethasone on labor induction: a systematic review. BMC Pregnancy and Childbirth. 2021;21(1):563. doi: 10.1186/s12884-021-04010-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kashanian M, Fekrat M, Naghghash S, Ansari NS. Evaluation of the effect of extra-amniotic normal saline infusion alone or in combination with dexamethasone for the induction of labor. Journal of Obstetrics and Gynaecology Research. 2008;34(1):47–50. doi: 10.1111/j.1447-0756.2007.00703.x. [DOI] [PubMed] [Google Scholar]
- 4.Alfirevic Z, Keeney E, Dowswell T, Welton NJ, Medley N, Dias S, et al. Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess. 2016;20(65) doi: 10.3310/hta20650. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Harrison MS, Ali S, Pasha O, Saleem S, Althabe F, Berrueta M, et al. A prospective population-based study of maternal, fetal, and neonatal outcomes in the setting of prolonged labor, obstructed labor and failure to progress in low- and middle-income countries. Reproductive Health. 2015;12(2):S9. doi: 10.1186/1742-4755-12-S2-S9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Wadhwa PD, Porto M, Garite TJ, Chicz-DeMet A, Sandman CA. Maternal corticotropin-releasing hormone levels in the early third trimester predict length of gestation in human pregnancy. American journal of obstetrics and gynecology. 1998;179(4):1079–1085. doi: 10.1016/s0002-9378(98)70219-4. [DOI] [PubMed] [Google Scholar]
- 7.Cunningham F, Leveno K, Bloom S, Spong CY, Dashe J. Mcgraw-hill; New York, NY, USA: 2014. Williams obstetrics, 24e: [Google Scholar]
- 8.Abdel Latif EM, Taha WS, Ahmed AARA. Effect of Intra-Muscular Administration of Dexamethasone on the Duration of Induction of Labor in Primigravida Full-Term Pregnancy. The Egyptian Journal of Hospital Medicine. 2018;73(6):6973–6982. [Google Scholar]
- 9.King BR, Smith R, Nicholson RC. The regulation of human corticotrophin-releasing hormone gene expression in the placenta. Peptides. 2001;22(5):795–801. doi: 10.1016/s0196-9781(01)00393-x. [DOI] [PubMed] [Google Scholar]
- 10.O'Sullivan J, Iyer S, Taylor N, Cheetham T. Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is associated with a prolonged gestational age. Archives of disease in childhood. 2007;92(8):690–692. doi: 10.1136/adc.2006.112029. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Nour El-Din Hashad AM, Yehia AH, Mohammed AA. Effect of Intravenous Dexamethasone on the Duration of Labor Induction: A Randomized Controlled Trial. QJM: An International Journal of Medicine. 2021;114(Supplement_1) [Google Scholar]
- 12.Fatemeh L, Negin A, Ameneh B, Farideh M. Ezzatossadat Haj Seyed j. Effect of Intravenous Dexamethasone on Preparing the Cervix and Labor Induction. Acta Medica Iranica. 2015;53(9) [PubMed] [Google Scholar]
- 13.Elmaraghy MA-A, El Refaie T, Labib KM, Mohamed MG. Effect of intramuscular administration of dexamethasone on the duration of labor induction. Evidence Based Women's Health Journal. 2018;8(4):311–317. [Google Scholar]
- 14.Sammour HM, Ashoush SA, Elhawwary GE, Rekaby SH. Effect of Intramuscular Administration of Dexamethasone on Shortening of the Duration of Induction of Labor. QJM: An International Journal of Medicine. 2021;114(Supplement_1) [Google Scholar]
- 15.Elsayed HM, Bahaa AM, Alanwar AA, Mohamed KM. Role of Dexamethasone in Induction of Labor: (A Randomized Clinical Trial) QJM: An International Journal of Medicine. 2020;113(Supplement_1) [Google Scholar]
- 16.Egerman RS, Pierce IV WF, Andersen RN, Umstot ES, Carr TL, Sibai BM. A comparison of the bioavailability of oral and intramuscular dexamethasone in women in late pregnancy. Obstetrics & Gynecology. 1997;89(2):276–280. doi: 10.1016/S0029-7844(96)00446-2. [DOI] [PubMed] [Google Scholar]
- 17.Ward SA, Kirkwood RN, Song Y, Garg S, Plush KJ. Effect of Dexamethasone and Route of Administration on Sow Farrowing Behaviours, Piglet Delivery and Litter Performance. Animals. 2022;12(7):847. doi: 10.3390/ani12070847. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Bakhtiari S, Azari-Marhabi S, Mojahedi SM, Namdari M, Rankohi ZE, Jafari S. Comparing clinical effects of photodynamic therapy as a novel method with topical corticosteroid for treatment of Oral Lichen Planus. Photodiagnosis and photodynamic therapy. 2017;20:159–164. doi: 10.1016/j.pdpdt.2017.06.002. [DOI] [PubMed] [Google Scholar]
- 19.Zadik Y, Elad S, Shapira A, Shapira MY. Treatment of oral mucosal manifestations of chronic graft-versus-host disease: dexamethasone vs. budesonide. Expert Opinion on Pharmacotherapy. 2017;18(3):235–242. doi: 10.1080/14656566.2017.1282464. [DOI] [PubMed] [Google Scholar]
- 20.Kashanian M, Dadkhah F, Mokhtari F. Effect of intramuscular administration of dexamethasone on the duration of labor. International Journal of Gynecology & Obstetrics. 2008;102(3):259–262. doi: 10.1016/j.ijgo.2008.04.009. [DOI] [PubMed] [Google Scholar]
- 21.Nour El-Din Hashad AM, Yehia AH, Mohammed AA. Effect of Intravenous Dexamethasone on the Duration of Labor Induction: A Randomized Controlled Trial. QJM: An International Journal of Medicine. 2021;114(Supplement_1) hcab115. 007. [Google Scholar]
- 22.Moutaz El-Sherbini MDOHMD, Zaki MDSS. The Effect of Intramuscular Administration of Dexamethasone Alone or in Combination with Hyoscine Butylbromide in Shortening the duration of Induced Labor in Primigravidas. The Medical Journal of Cairo University. 2018;86(September):2335–2340. [Google Scholar]
- 23.El-Refaie T, Yehia M, Younan R. Effect of Dexamethasone on The Duration of Labor among Women Undergoing Labor Induction: A Randomized Controlled Trial. JESGO. 2011;37:0258–3216. [Google Scholar]
- 24.Salman MM, Salama FA, Yacoub M. Intravenous Dexamethasone Versus Vaginal Misoprostol in Enhancing Cervical Ripening and Labor Induction. QJM: An International Journal of Medicine. 2021;114(Supplement_1) hcab115. 021. [Google Scholar]
- 25.Lueth GD, Kebede A, Medhanyie AA. Prevalence, outcomes and associated factors of labor induction among women delivered at public hospitals of MEKELLE town-(a hospital based cross sectional study) BMC Pregnancy and Childbirth. 2020;20(1):203. doi: 10.1186/s12884-020-02862-7. [DOI] [PMC free article] [PubMed] [Google Scholar]