Does BMI Affect Vag Miso Cervical Ripening? (IMPROVE Subanalysis)

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2:07That is astounding and it's getting worse and there's a variety of reasons for that and we're not going to get into those reasons but we are going to focus on this overweight slash obesity issue because it affects health care, it affects your overall wellness, even mental health. Now I have to be careful here because I love me some fat food also so I have to be very very cognizant of what I'm eating to maintain appropriate weight. I try to be within my appropriate, be a my thankfully I am but you know I have to be aware of that. I have to work and burn things off and it's difficult. I get that but being obese affects things that we do even in labor and delivery. Now we know of course that obesity is hard, patients living with obesity, sorry that's me politically and technically correct, patients living with obesity makes monitoring hard, patients living with obesity have longer labors, they have higher perinatal morbidity.

3:09We understand this but as it relates to labor and delivery, here's the question that a new subanalysis of an old study was trying to answer. Since we're getting bigger in the U.S. specifically we've got a lot of listeners in Canada so I know the population is different but even there BMI is having creeping up as well and we've got listeners in the UK saying miss you all right but in the U.S. how does obesity affect our labor induction specifically cervical ripening okay. Now this is something that was recently released in AJOG and it hasn't officially come out yet. It came out ahead of print on March the 4th, 2026 all right so on March the 4th, 2026 we have this new subanalysis of a previous study released in the same journal AJOG back in 2019 that was called the improved study. That improved study was really deep and it even made its way, the findings made its

4:11way into ACOG's 2025 guideline on cervical ripening and induction okay. We're going to touch on all of that in the break but here's a question and here's where we get into here. Does BMI affect vaginal misoprostal side attack cervical ripening now notice I'm focusing on the vaginal even though this new publication which isn't even officially out yet again it came out ahead of print on March the 4th, 2026 compared to different routes. It compared vaginal which most people did okay I'm good with that whether they do 25 or 50 micrograms okay fine and buccal number not oral buccal means you kind of put it in your pouch like a little zin pack or tobacco which we shouldn't do either of those but nonetheless the point is peded bucaly so it gets kind of a quick plasma absorption quite a quick peak in into the into the bloodstream okay. Now here's a catch I got to say this right here in the intro even though this new subanalysis

5:14which just came out and is a subanalysis of a previous trial called the improved trial back in 2019 even though it uses buccal form ACOG does not endorse the buccal formulation for cervical ripening okay it says hey we want to do oral perfect and we want to do vaginal knock yourself out but buccal and we're going to get into this after the intro it does not include buccal dosing because of safety concerns we don't have good data and they quote the exact steady that we're about to talk about in their 2025 summer of 2025 guidance on cervical ripening okay we're going to review all of this very quickly and then we're just very quickly going to dive into the results of this subanalysis of the improved trial the improved trial was out of Indianapolis very well done we'll remind ourselves of what that was just briefly and then we'll dive into this brand new AJOG publication here's a question here's a question I'm trying to set up even though it talks about buccal and we don't really do

6:17that so we'll just kind of you know realize and recognize those results tip our hat to that how do you do we'll tip our hat to that but what we really want to do is figure out the vaginal part because that's what people mainly do in the U.S. vaginal cytotectness of prostal for cervical ripening does obesity matter that we're going to take more doses because she's obese do we need higher doses this is a good question to ask as obesity rises in the U.S. so that's where we're going does BMI affect vaginal misoprostal cervical ripening this is a subanalysis of the improved study from the gray journal we'll be right back

7:22oh that quote by buffalo bill in southern to the lambs would get the whole show canceled today yes buffalo bill is not the most PC person around oh my goodness it puts the lotion in the basket all right so all to say is and again that's not mean mean or anything it's just I don't know why producer Michaels thought silence of the lambs which is kind of disturbing I think maybe needs counseling nonetheless get back to what we're talking about before we get canceled they've tried that before all right so let's get back to what we're talking about oh my goodness we're talking about obesity or people living with obesity and how it affects labor induction now this new study coming out that is a release ahead of print in the gray journal specifically was looking at buckel which is not an acogue endorse to method I'll tell you why in a bit versus vaginal however acogue does endorse another route of misoprostal use which is oral okay so we've got two

8:30ways of misoprostal use according to the college for cervical ripening slash labor induction in term singleton intact membrane patients all right so we've got to remember that term singleton intact membrane patients and it says that in this new clinical guidance from the summer of 2025 by the college this is for intact and I've got an episode on how the bishop score doesn't apply if you are ruptured even with pprm okay so if you know nothing wrong with doing a bishop score you can do that but you don't really need to do any cervical ripening if the patient is already ruptured you can go straight to pitocin regardless of bishop score because the data says so now you can give a cervical ripening agent for those who are ruptured is this probably unnecessary there's no real advantage there because they are already are bathed so to speak in terms of their cervical milieu with posseglandins because they are ruptured all right so this new clinical guidance that

9:30just came out in the summer of 2025 from the college reminds us that term singleton intact you can use either pharmacological with oral or vaginal misprostal or mechanical or a combination of the two which is either a cervical balloon with either misprostal or a cervical balloon with oxytocin right now there's very scant data and acutus not recommend the balloon with dino prostone the insert under the combined methods that's recommended for you by the college it's either the balloon with pit or the balloon with citatech okay all to say is that acog in it's again new guidance from july of 2025 does not include buckel or buckle depending on where you are in the country right some say buckels some say buckle all to say is obesity absolutely mispoil it here absolutely affects anything systemic because the volume of distribution

10:32that should be a no-brainer we understand this right so i'm going to give you the data here in a minute so anytime you have to go through the system to get to the uterus you're going to get behind if there's a larger BMI so spoiler alert in this subanalysis of the improved study which was in the gradual in 2019 i'll touch that in a minute yes larger BMI's obviously took more doses to ripen they had longer inductions they needed more pitocin because it was a systemic medication compared to vaginal so vaginal is the way to go however however even though buckel or buckle isn't really endorsed by the college it has implications for oral medication because oral citatech follows the same pattern of distribution as buckel okay in general so higher BMI's even though this study I would be very clear did not include oral it was in the cheek or vaginal but oral follows the

11:35same dynamics okay so oral dosing is definitely affected by BMI with higher maternal BMI correlating with prolonged labor inductions with those with oral medication now this has been looked at oral combined versus vaginal and vaginal always wins regardless of BMI that's why there's an advantage to first uterine or first cervical pass by placing it in the vagina okay so even though this study which is subanalysis of improved trial looked at buckel versus vaginal oral medication oral citatech all follow also follows prolonged dosing compared to non obese patients okay so this is why when you read the acogue guidance and says oh I can do oral or vaginal yes with a caveat that you got to take into account patient characteristics of course never use a prostate landing at the prior section but BMI also can limit oral medication just as it can for buckel medication or buckle

12:37medication okay so as a quick recap in July of 2025 acogue clinical practice update recommended either pharmacological mechanical or combination methods for cervical cervical ripening but it did not include buckel and the reason it didn't include blue buckel was because of what we're talking about right now the original improved study from 2019 is in this 2025 guidance from the college now improve was was a very detailed randomized trial but with an end of 300 so it wasn't like thousands of patients but end of 300 following or comparing vaginal mr. prostal to buckel mr. prostal and they found that vaginal always wins vaginal also had lower rates of C section vaginal had lower rates of C section for feet of heart rate abnormalities so because of the improved study that actually made its way into the July 2020 25 guidance from the college saying a buckel if you want to do that

13:41hey you're on your own but we don't really recommend that because they're safer routes either oral of course with BMI you know characteristics taken to account or vaginal okay so yes the improved study is actually in the July 2025 guidance from the college and that improved study is exactly what this new publication is based upon because this is a subanalysis of that original study which showed that buckel didn't work well vaginal worked better and it was safer but now they're going to take a look at it based on BMI characteristics so it is a secondary analysis of this RCT that was actually triple blinded and placebo controlled for vaginal vices buckel mr. prostal it was amazing okay it was a very well done study so kudos to those physicians and investigators in Indianapolis who put this together okay let me just give you the short of it to have kind of already told you what's going on here vaginal wins okay vaginal wins BMI affects

14:47things that go into the mouth either buculy or orally and the vagina is immune because of the vagina at through cervical placement has a first uterine pass where BMI didn't seem to matter okay now this was roughly about 300 patients that had this secondary review and the primary outcome let me just give it to you here and then we'll start wrapping this up because I just want to tell you again even though we have our quickie episodes and this is definitely not a quickie because going through a lot of data I still want to get this done with an ideally 25 or 30 minutes okay so short of it is in this new subanalysis of improved quote obese and morbidly obese participants required more doses of bucle mr. prostal to achieve active labor compared to non obese that shouldn't be surprising to anyone we get that because of volume of distribution but here's the catch quote however there was no difference in doses between the obese and non obese for those who had

15:52it administered vaginally phenomenal in other words would you place in the vagina of a gentleman hey I don't care I don't care what's going on the outside in terms of BMI because we're working here with an immediate neighbor which is a cervix and the uterus that's why it's called the first uterine pass okay you avoid the volume of distribution through BMI so let me see that again quote however there was no difference in doses necessary for active labor when administered vaginally that's great they want to say quote additionally the mean time to delivery tended to be shorter in the non obese group that received bucle mr. prostal compared to the obese and morbidly obese group and quote again not surprising at all and the last thing quote this difference was not observed in the vaginal dosing group and quote short answer vaginal winds for higher BMI vaginal winds now remember our title here is does BMI affect vaginal miso for cervical ripening slash

16:56labor induction no it doesn't but BMI definitely affects bucle and definitely affects oral because of volume of distribution it's got to go all over the place just to hit the uterus and cervix so this is a nice secondary review of improve kudos again to the authors that put this together to take a look at this because this is super super real world as BMI's increase throughout throughout the country so their tweetable statement in the draft case because this is an officially out their tweetable statement is quote more doses of bucle mr. prostal are required to achieve active labor in obese compared to non obese patients undergoing labor induction no difference in number of dosages was observed for the vaginal route and quote so only in women's health can you say the vagina wins and it makes sense oh I'll guess unless it's a weird

17:59probably inappropriate HR referenced joke that that that gets you sent to HR real quick the vagina always wins so consider that when you're doing cervical ripening if you're doing oral or bucle which is not a cog indoor set the moment consider that in your decision making vagia vagia what the hell vagina always wins and or cervical ripening with a mechanical method either alone or with mr. prostal or oxytocin wow I had some kind of weird words in this one you noticed that Michael what is going on honestly can I can't see what I think it is I it's like midday right now when we're recording this I've typically had like four cups of coffee before that because it helps me concentrate and focus I've only had two and look how it's affecting my speech man I mean I think this is nothing and it's your fault you rush me for I miss my cup of coffee because you were making me come here so all to say there you go this is coming out soon in the gray journal the title is

19:02the impact of body mass index on mr. prostal dosing for labor induction a comparison of vaginal and bucle dosage forms podcast family we care for you we're glad you're part of a podcast community and now that we've done all that I'm going to get my next cup of coffee and we're going to take it home this is Dr. Toppas OBGYN no spin podcast music forget whatever plans you have this weekend because you're staying at home and playing on spin quest and there's never been a better time to sign up then right now new users get $30 coin packs for just $10 all the table games you love with hundreds of slot games and real cash prizes

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