PROSTIN E2 VAGINAL

Usage is restricted to qualified health care professionals and to hospitals and clinics with specialised obstetric units with facilities for continuous monitoring. The recommended dose should not be exceeded, and the dosing interval should not be shortened as this increases the risk of uterine hyperstimulation, uterine rupture, uterine haemorrhage, foetal and neonatal death.

Posology Adults In primigravida patients with unfavourable induction features (Bishop score of 4 or less), an initial dose of 2 mg should be administered vaginally. In other patients an initial dose of 1 mg should be administered vaginally.

In both groups of patients, a second dose of 1 mg or 2 mg may be administered after 6 hours as follows: 1 mg should be used where uterine activity is insufficient for satisfactory progress of labour. 2 mg may be used where response to the initial dose has been minimal.

4). Elderly Not applicable. Paediatric population Not applicable. Method of administration Vaginally. The gel should be inserted high into the posterior fornix avoiding administration into the cervical canal. The patient should be instructed to remain recumbent for at least 30 minutes.

The table below lists the adverse reactions identified through clinical trial experience and post-marketing surveillance by system organ class and frequency. Adverse reactions identified from post-marketing experience are included in italics.

The frequency grouping is defined using the following convention:

Very common (≥1/10); Common (≥ 1/100 to <1/10); Uncommon (≥1/1 000 to <1/100); Rare (≥ 1/10 000 to <1/1 000); Very Rare (< 1/10 000); and Not known (cannot be estimated from the available data). Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

Table 1. Adverse Reactions System Organ Class Very Common ≥1/10 Common ≥1/100 to <1/10 Uncommon ≥1/1 000 to <1/100 Rare ≥1/10 000 to <1/1 000 Very Rare <1/10 000 Frequency Not Known (Cannot Be Estimated From Available Data) Blood and lymphatic system disorders Disseminated intravascular coagulation* System Organ Class Very Common ≥1/10 Common ≥1/100 to <1/10 Uncommon ≥1/1 000 to <1/100 Rare ≥1/10 000 to <1/1 000 Very Rare <1/10 000 Frequency Not Known (Cannot Be Estimated From Available Data) Immune system disorders Hypersensitivity, Anaphylactic reaction, Anaphylactic shock, Anaphylactoid reaction Cardiac disorders Cardiac arrest Vascular disorders Hypertension∗∗ Respiratory, thoracic and mediastinal disorders Asthma∗∗, Bronchospasm∗∗ Gastrointestinal disorders Vomiting Nausea Diarrhoea Skin and subcutaneous tissue disorders Rash Musculoskeletal and connective tissue disorders Back pain Pregnancy, Puerperium and Perinatal conditions Uterine hypertonus, Foetal distress syndrome, Uterine contractions abnormal Uterine rupture, Premature separation of placenta, Anaphylactoid syndrome of pregnancy∗∗, Rapid cervical dilatation, Neonatal distress, Death neonatal††, Stillbirth†, Foetal death Reproductive system and breast disorders Vulvovaginal burning sensation Irritation, Pain General disorders and administration site conditions Pyrexia Investigations Foetal heart rate abnormal† Apgar score low * Reported during post marketing surveillance ∗∗ Maternal adverse events that have been reported only with use of the vaginal tablets.

† Foetal adverse events that have been reported with use of the cervical gel, intravaginal gel and vaginal tablets. †† Foetal adverse event has only been reported with vaginal tablets. Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important.

It allows continued monitoring of the benefit/risk balance of the medicinal product. uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

This product is only available to hospitals and clinics with specialised obstetric units and should only be used where 24-hour resident medical cover is provided. Use the total contents of the syringe for one patient only. Discard after use.

Use caution in handling the product to prevent contact with skin. Wash hands thoroughly with soap and water after administration. As with any oxytocic agent, the risk of uterine rupture should be considered. Concomitant medication, maternal and foetal status should be taken into consideration in order to minimise the risk of uterine hyperstimulation, uterine rupture, uterine haemorrhage, foetal and neonatal death.

Careful and regular monitoring of uterine activity and foetal heart rate should be conducted during use of dinoprostone. Patients who develop uterine hypertonus or hypercontractility, or in whom unusual foetal heart rate patterns develop, should be managed in a manner that addresses the welfare of the foetus and mother.

Prostin E2 Vaginal Gel and Prostin E2 Vaginal Tablets are not bioequivalent. Caution should be exercised in the administration of Prostin E2 Vaginal Gel for the induction of labour in patients with: • asthma or a history of asthma • epilepsy or a history of epilepsy • glaucoma or raised intra-ocular pressure • compromised cardiovascular, hepatic, or renal function • hypertension • ruptured chorioamniotic membranes.

Dinoprostone should be used with caution in patients with multiple pregnancy. In labour induction, cephalopelvic relationships should be carefully evaluated before use of Prostin E2 Vaginal Gel. g. hypertonus, sustained uterine contractions, or foetal distress.

In cases where there is a known history of hypertonic uterine contractility or tetanic uterine contractions, it is recommended that uterine activity and the state of the foetus (where applicable) should be continuously monitored throughout labour.

The possibility of uterine rupture should be borne in mind where high-tone uterine contractions are sustained. Animal studies lasting several weeks at high doses have shown that prostaglandins of the E and F series can induce proliferation of bone.

Such effects have also been noted in newborn infants who received prostaglandin E1 during prolonged treatment. There is no evidence that short-term administration of prostaglandin E2 can cause similar bone effects. Women aged 35 years or older, those with complications during pregnancy and those with a gestational age over 40 weeks have been shown to have an increased risk of post-partum disseminated intravascular coagulation.

8). Therefore, in these women, use of dinoprostone should be undertaken with caution. Measures should be applied to detect as soon as possible an evolving fibrinolysis in the immediate post-partum phase.

1. Prostin E2 Vaginal Gel should not be used where the patient is sensitive to prostaglandins or other constituents of the gel. Prostin E2 Vaginal Gel is not recommended in the following circumstances: • For patients in whom oxytocic drugs are generally contra-indicated or where prolonged contractions of the uterus are considered inappropriate such as: - Cases with a history of Caesarean section or major uterine surgery.

- Cases where there is cephalopelvic disproportion. - Cases in which foetal malpresentation is present. - Cases where there is clinical suspicion or definite evidence of pre-existing foetal distress. - Cases in which there is a history of difficult labour and/or traumatic delivery.

• In patients with a past history of, or existing, pelvic inflammatory disease, unless adequate prior treatment has been instituted. • In patients where there is clinical suspicion or definite evidence of placenta praevia or unexplained vaginal bleeding during this pregnancy.

• Patients with active cardiac, pulmonary, renal or hepatic disease.