PREGNANCY SECTION.

8.1 Pregnancy. Risk SummaryCERVIDIL is indicated for the initiation and/or continuation of cervical ripening in pregnant women at or near term in whom there is medical or obstetrical indication for the induction of labor. Fetal, neonatal, and maternal risks are discussed throughout the labeling. Limited available data with CERVIDIL use in pregnant women do not show clear association with adverse developmental outcomes. Relevant animal reproduction data with dinoprostone is not available.. Data. Human DataIn report of 3-year pediatric follow-up study, there were no deleterious effects noted on physical examination or psychomotor evaluation of 51 infants born following maternal treatment with CERVIDIL.. Clinical Considerations. Fetal/Neonatal Adverse ReactionsWhen CERVIDIL was removed for fetal distress, there was return to normal rhythm and there were no neonatal sequelae. Remove CERVIDIL in the event of persistent tachysystole with or without fetal heart rate changes, and follow established institutional protocols in management of patients.

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following adverse reactions are described, or described in greater detail, in other sections:Disseminated Intravascular Coagulation [see Warnings and Precautions (5.2)] Amniotic Fluid Embolism [see Warnings and Precautions (5.3)] Uterine Tachysytole and Uterine Hypersystole/Hypertonicity [see Warnings and Precautions (5.4)] Disseminated Intravascular Coagulation [see Warnings and Precautions (5.2)] Amniotic Fluid Embolism [see Warnings and Precautions (5.3)] Uterine Tachysytole and Uterine Hypersystole/Hypertonicity [see Warnings and Precautions (5.4)] The most common adverse reactions (>= %) are uterine tachysystole without fetal distress, uterine tachysystole with fetal distress, and fetal distress without uterine tachysystole. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact FERRING PHARMACEUTICALS, INC. at 888-FERRING (1-888-337-7464) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.In placebo-controlled trials of 658 pregnant women (320 CERVIDIL-treated women and 338 placebo-treated women), the following treatment related adverse reactions (see Table 1) occurred at an incidence greater than 2% (and greater than that reported in the placebo group) in the CERVIDIL group [see Clinical Studies (14)]. Table 1. Common Adverse Reactions (>= 2%) in Pregnant Patients Near Term Gestation in Trial 1Trial (101-103) and Trial (101-003) evaluated the dinoprostone insert only, without the use of retrieval system, Trial 2, and Trial 3Trial (101-801) evaluated the dinoprostone insert with the retrieval system. Trials 1and 2CERVIDIL (N=320)Placebo (N=338)Uterine tachysystole with fetal distress2.8%0.3%Uterine tachysystole without fetal distress4.7%0%Fetal distress without uterine tachysystole -3.8%1.2%Trial 3CERVIDIL (N=102)Placebo (N=104)Uterine tachysystole with fetal distress2.9%0%Uterine tachysystole -without fetal distress2%0%Fetal distress without uterine tachysystole2.9%1%Drug related fever, nausea, vomiting, diarrhea, and abdominal pain occurred in less than 1% of CERVIDIL-treated patients.In Trial (with the retrieval system) cases of tachysystole uterine hyperstimulation reversed within to 13 minutes of removal of CERVIDIL. Tocolytics were required in one of the five cases.. 6.2 Postmarketing Experience. The following adverse reactions have been identified during postapproval use of CERVIDIL or other dinoprostone products. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure.Blood and lymphatic system disorders: Disseminated Intravascular CoagulationCardiovascular disorders: Myocardial Infarction in women with history of myocardial infarctionImmune system disorders: HypersensitivityNervous system disorders: HeadachePregnancy, puerperium and perinatal conditions: Amniotic fluid embolismReproductive system: reports of uterine rupture have been reported in association with use of CERVIDIL. Some required hysterectomy and others resulted in subsequent fetal or neonatal death. Uterine hypertonusVascular disorders: Hypotension.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Dinoprostone is found in low concentrations in most tissues of the body and functions as local hormone. In pregnancy, dinoprostone is secreted continuously by the fetal membranes and placenta and plays an important role in the final events leading to the initiation of labor including cervical ripening. Dinoprostone stimulates the production of prostaglandin F2 (PGF2), which sensitizes the myometrium to endogenous or exogenously administered oxytocin. Available evidence indicates that dinoprostone, in the concentrations found during the early part of labor, plays an important role in cervical ripening without affecting uterine contractions.In most patients, local effects of CERVIDIL on the cervix include changes in the tissue consistency, dilatation and effacement. Some women experience systemic effects, including uterine tachysystole, and uterine hypersystole/hypertonicity, as result dinoprostone or PGF2 mediated sensitization of the myometrium to oxytocin [see Warnings and Precautions (5.4)].. 12.2 Pharmacodynamics. No specific pharmacodynamic studies were conducted with CERVIDIL.. 12.3 Pharmacokinetics. The delivery rate of dinoprostone from CERVIDIL in vivo is approximately 0.3 mg/per hour over period of 12 hours. Dinoprostone is metabolized in the tissues of synthesis with the half-life estimated to be 2.5 to minutes. The rate limiting step for inactivation is regulated by the enzyme 15-hydroxyprostaglandin dehydrogenase (PGDH). Any dinoprostone that escapes local inactivation is cleared to the extent of 95% on the first pass through the pulmonary circulation.No correlation could be established between the release of dinoprostone from CERVIDIL and plasma concentrations of metabolite of dinoprostone (PGEm). The relative contributions of endogenously and exogenously released dinoprostone to the plasma levels of the metabolite PGEm is not known.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. The effectiveness and safety of CERVIDIL for the induction of cervical ripening was evaluated in 658 pregnant women (320 CERVIDIL-treated women and 338 placebo-treated women) at or near term in three randomized, double-blind, placebo-controlled trials (Trials 1, 2, and 3). Efficacy outcomes included percentage with treatment success (defined as vaginal delivery within 12 hours, Bishop Score >= in the 12-hour observation period, or >= increase in the Bishop score in the 12-hour observation period), time to delivery, and time to onset of labor. Table presents efficacy outcomes from Trials 1, 2, and 3.Table 2: Efficacy Outcomes in Pregnant Women in Trials 1Trial and Trial evaluated the dinoprostone insert only, without the use of retrieval system., 2, and 3Trial evaluated the dinoprostone insert with the retrieval system for CERVIDIL Ripening, Intent-to-Treat PopulationPrimipara/NulliparaMultiparaStudy CERVIDILPlaceboCERVIDILPlaceboP-ValueTreatment SuccessTreatment success was defined as vaginal delivery within 12 hours, Bishop score >= in the 12-hour observation period, or >= increase in the Bishop score in the 12-hour observation period. Trial (N=81)65%(n=26)28%(n=32)87%(n=16)29%(n=7)<0.001Trial (N=371)68%(n=111)24%(n=123)77%(n=65)24%(n=72)<0.001Trial (N=206)72%(n=60)48%(n=63)55%(n=42)41%(n=41)0.003Median Time to Delivery (hours)Trial (N=81)25.7(n=26)34.5(n=32)12.3(n=16)24.6(n=7)0.001Trial (N=206)25.5(n=60)37.2(n=63)20.8(n=42)27.4(n=41)<0.001Median Time to Onset of Labor (hours)Trial (N=81)12(n=26)19.2(n=32)6.9(n=16)18.3(n=7)<0.001.

CLINICAL TRIALS EXPERIENCE SECTION.

6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.In placebo-controlled trials of 658 pregnant women (320 CERVIDIL-treated women and 338 placebo-treated women), the following treatment related adverse reactions (see Table 1) occurred at an incidence greater than 2% (and greater than that reported in the placebo group) in the CERVIDIL group [see Clinical Studies (14)]. Table 1. Common Adverse Reactions (>= 2%) in Pregnant Patients Near Term Gestation in Trial 1Trial (101-103) and Trial (101-003) evaluated the dinoprostone insert only, without the use of retrieval system, Trial 2, and Trial 3Trial (101-801) evaluated the dinoprostone insert with the retrieval system. Trials 1and 2CERVIDIL (N=320)Placebo (N=338)Uterine tachysystole with fetal distress2.8%0.3%Uterine tachysystole without fetal distress4.7%0%Fetal distress without uterine tachysystole -3.8%1.2%Trial 3CERVIDIL (N=102)Placebo (N=104)Uterine tachysystole with fetal distress2.9%0%Uterine tachysystole -without fetal distress2%0%Fetal distress without uterine tachysystole2.9%1%Drug related fever, nausea, vomiting, diarrhea, and abdominal pain occurred in less than 1% of CERVIDIL-treated patients.In Trial (with the retrieval system) cases of tachysystole uterine hyperstimulation reversed within to 13 minutes of removal of CERVIDIL. Tocolytics were required in one of the five cases.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. CERVIDIL is contraindicated in patients with:Known hypersensitivity to prostaglandins [see Adverse Reactions (6.2)] Evidence or clinical suspicion of fetal distress where delivery is not imminentUnexplained vaginal bleeding in the current pregnancyEvidence or clinical suspicion of marked cephalopelvic disproportionConditions for which induction of labor is contraindicatedConditions for which oxytocic drugs are contraindicatedPrevious cesarean section or other uterine surgery expected to affect uterine integrity (such as myomectomy)Conditions under which prolonged contraction of the uterus may be detrimental to fetal safetyConcurrent use with intravenous oxytocic agents [see Warnings and Precautions (5.4) and Drug Interactions (7)] Six or more previous term pregnancies. Known hypersensitivity to prostaglandins [see Adverse Reactions (6.2)] Evidence or clinical suspicion of fetal distress where delivery is not imminent. Unexplained vaginal bleeding in the current pregnancy. Evidence or clinical suspicion of marked cephalopelvic disproportion. Conditions for which induction of labor is contraindicated. Conditions for which oxytocic drugs are contraindicated. Previous cesarean section or other uterine surgery expected to affect uterine integrity (such as myomectomy). Conditions under which prolonged contraction of the uterus may be detrimental to fetal safety. Concurrent use with intravenous oxytocic agents [see Warnings and Precautions (5.4) and Drug Interactions (7)] Six or more previous term pregnancies. CERVIDIL is contraindicated for:Known hypersensitivity to prostaglandins (4)Evidence or clinical suspicion of fetal distress, where delivery is not imminent (4)Unexplained vaginal bleeding in the current pregnancy (4)Evidence or clinical suspicion of marked cephalopelvic disproportion (4)Contraindication to induction of labor (4)Concurrent use with intravenous oxytocic agents (4)History of previous cesarean section or other uterine surgery (such as myomectomy) (4)Conditions under which prolonged contraction of the uterus may be detrimental to fetal safety. (4)Six or more previous term pregnancies (4). Known hypersensitivity to prostaglandins (4). Evidence or clinical suspicion of fetal distress, where delivery is not imminent (4). Unexplained vaginal bleeding in the current pregnancy (4). Evidence or clinical suspicion of marked cephalopelvic disproportion (4). Contraindication to induction of labor (4). Concurrent use with intravenous oxytocic agents (4). History of previous cesarean section or other uterine surgery (such as myomectomy) (4). Conditions under which prolonged contraction of the uterus may be detrimental to fetal safety. (4). Six or more previous term pregnancies (4).

DESCRIPTION SECTION.

11 DESCRIPTION. CERVIDIL (dinoprostone) vaginal insert contains dinoprostone, prostaglandin analog. Each vaginal insert contains 10 mg of dinoprostone in 241 mg of cross-linked polyethylene oxide/urethane polymer (hydrogel polymer) that is semi-opaque, beige colored, flat, rectangular in shape with rounded corners and measuring 29 mm by 9.5 mm by 0.8 mm. The vaginal insert is contained within pouch of an off-white knitted polyester yarn retrieval system. When placed in moist environment, the yarn absorbs water, swells, and releases the enclosed dinoprostone. The knitted polyester retrieval system has long tape-like end that is designed to aid retrieval of CERVIDIL at the end of the dosing interval or earlier if clinically indicated. The finished product is controlled-release formulation that has been found to release dinoprostone in vivo at rate of approximately 0.3 mg per hour.The chemical name for dinoprostone (known as prostaglandin E2 or PGE2) is 11,15S-dihydroxy-9-oxo-prosta-5Z,13E-dien-1-oic acid and the structural formula is represented below:The molecular formula is C20H32O5 and its molecular weight is 352.47. Dinoprostone occurs as white to off-white crystalline powder. It has melting point within the range of 65 to 69C. Dinoprostone is soluble in ethanol and in 25% ethanol in water.. Chemical Structure.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Administer single vaginal insert (10 mg) for up to 12 hours of use (approximately 0.3 mg of dinoprostone is released per hour) (2.1)Remove upon onset of active labor or 12 hours after insertion. (2.1)Carefully monitor for uterine activity, fetal status and the progression of cervical dilatation and effacement. (2.1) CERVIDIL should be administered only by trained obstetrical personnel in hospital setting with appropriate obstetrical care facilities (2.2). See full prescribing information for complete preparation, administration, and removal instructions. (2.2, 2.3). Administer single vaginal insert (10 mg) for up to 12 hours of use (approximately 0.3 mg of dinoprostone is released per hour) (2.1). Remove upon onset of active labor or 12 hours after insertion. (2.1). Carefully monitor for uterine activity, fetal status and the progression of cervical dilatation and effacement. (2.1). CERVIDIL should be administered only by trained obstetrical personnel in hospital setting with appropriate obstetrical care facilities (2.2). See full prescribing information for complete preparation, administration, and removal instructions. (2.2, 2.3). 2.1 Dosage Instructions. Administer one CERVIDIL insert (10 mg) intravaginally for use up to 12 hours (approximately 0.3 mg of dinoprostone is released per hour) [see Dosage and Administration (2.2)]. Monitor uterine activity, fetal status, and the progression of cervical dilatation and effacement with the use of CERVIDIL. Remove CERVIDIL 12 hours after insertion with the onset of active labor, prior to an amniotomy, occurrence of uterine tachysystole, uterine hypersystole/hypertonicity, or fetal distress [see Warnings and Precautions (5.4)]. Remove CERVIDIL at least 30 minutes prior to administering an oxytocic agent [see Warnings and Precautions (5.4) and Drug Interactions (7)].. 2.2 Preparation and Administration Instructions. CERVIDIL should be administered only by trained obstetrical personnel in hospital setting with appropriate obstetrical care facilities. Preparation and Administration InstructionsKeep CERVIDIL frozen until ready for use. Do not warm CERVIDIL prior to vaginal insertion.Tear open the individually-wrapped foil package containing CERVIDIL along the tear mark. Never open the package using scissors or other sharp objects because this may damage the knitted polyester retrieval system. Do not cut the retrieval system and do not use CERVIDIL unless its retrieval system is intact.Immediately after opening the package, insert CERVIDIL transversely, in the posterior fornix of the vagina (see Figure 1). If necessary, use minimal amount of water-miscible lubricant to assist vaginal insertion. Do not permit excess contact or coating with the lubricant, as this could prevent release of dinoprostone from the vaginal insert. Insertion does not require sterile conditions. Figure 1: Placement of CERVIDIL in the Posterior Vaginal Fornix Tuck some of the excess retrieval system into the vagina to avoid movement of CERVIDIL away from the proper position; however, leave small amount of the retrieval system outside the vagina to aid in retrieval. Instruct women to remain in recumbent position during insertion of CERVIDIL and for hours afterward. Women may be ambulatory hours after insertion; however, ensure that the insert remains in place.. Keep CERVIDIL frozen until ready for use. Do not warm CERVIDIL prior to vaginal insertion.. Tear open the individually-wrapped foil package containing CERVIDIL along the tear mark. Never open the package using scissors or other sharp objects because this may damage the knitted polyester retrieval system. Do not cut the retrieval system and do not use CERVIDIL unless its retrieval system is intact.. Immediately after opening the package, insert CERVIDIL transversely, in the posterior fornix of the vagina (see Figure 1). If necessary, use minimal amount of water-miscible lubricant to assist vaginal insertion. Do not permit excess contact or coating with the lubricant, as this could prevent release of dinoprostone from the vaginal insert. Insertion does not require sterile conditions. Figure 1: Placement of CERVIDIL in the Posterior Vaginal Fornix Tuck some of the excess retrieval system into the vagina to avoid movement of CERVIDIL away from the proper position; however, leave small amount of the retrieval system outside the vagina to aid in retrieval. Instruct women to remain in recumbent position during insertion of CERVIDIL and for hours afterward. Women may be ambulatory hours after insertion; however, ensure that the insert remains in place.. Figure 1. 2.3 Removal Instructions. To retrieve, locate the retrieval system and pull it gently until CERVIDIL is fully removed.Upon removal of CERVIDIL, it is essential to perform visual inspection to ensure that the slab has been removed, as it will continue delivering the active ingredient.. To retrieve, locate the retrieval system and pull it gently until CERVIDIL is fully removed.. Upon removal of CERVIDIL, it is essential to perform visual inspection to ensure that the slab has been removed, as it will continue delivering the active ingredient.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. AdministrationAdvise the woman to remain in the recumbent position for hours following CERVIDIL insertion and to inform her health care provider immediately if CERVIDIL does not remain in place [see Dosage and Administration (2.2)].. Disseminated Intravascular CoagulationInform women that the use of CERVIDIL is associated with an increased risk of disseminated intravascular coagulation (DIC) during the postpartum period [see Warnings and Precautions (5.2)]. Amniotic Fluid Embolism SyndromeInform women that the use of CERVIDIL can result in inadvertent disruption and subsequent embolization of antigenic tissue causing the development of Amniotic Fluid Embolism Syndrome, rare and often fatal obstetric condition [see Warnings and Precautions (5.3)]. Frequent or Prolonged Uterine ContractionsInform women that the use of CERVIDIL may cause frequent or prolonged contractions [see Warnings and Precautions (5.4) ]. This might result in disruption of blood flow through the placenta and to the fetus.. GlaucomaInform women that CERVIDIL can lead to raised intraocular pressure and constriction of pupils [see Warnings and Precautions (5.5)].

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Dinoprostone is found in low concentrations in most tissues of the body and functions as local hormone. In pregnancy, dinoprostone is secreted continuously by the fetal membranes and placenta and plays an important role in the final events leading to the initiation of labor including cervical ripening. Dinoprostone stimulates the production of prostaglandin F2 (PGF2), which sensitizes the myometrium to endogenous or exogenously administered oxytocin. Available evidence indicates that dinoprostone, in the concentrations found during the early part of labor, plays an important role in cervical ripening without affecting uterine contractions.In most patients, local effects of CERVIDIL on the cervix include changes in the tissue consistency, dilatation and effacement. Some women experience systemic effects, including uterine tachysystole, and uterine hypersystole/hypertonicity, as result dinoprostone or PGF2 mediated sensitization of the myometrium to oxytocin [see Warnings and Precautions (5.4)].

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Risk SummaryCERVIDIL is indicated for the initiation and/or continuation of cervical ripening in pregnant women at or near term in whom there is medical or obstetrical indication for the induction of labor. Fetal, neonatal, and maternal risks are discussed throughout the labeling. Limited available data with CERVIDIL use in pregnant women do not show clear association with adverse developmental outcomes. Relevant animal reproduction data with dinoprostone is not available.. Data. Human DataIn report of 3-year pediatric follow-up study, there were no deleterious effects noted on physical examination or psychomotor evaluation of 51 infants born following maternal treatment with CERVIDIL.. Clinical Considerations. Fetal/Neonatal Adverse ReactionsWhen CERVIDIL was removed for fetal distress, there was return to normal rhythm and there were no neonatal sequelae. Remove CERVIDIL in the event of persistent tachysystole with or without fetal heart rate changes, and follow established institutional protocols in management of patients.. 8.2 Lactation. Risk SummaryConcomitant administration of CERVIDIL is not indicated in breastfeeding women. There is no information on the effects of maternal CERVIDIL administration on the breastfed child. Insufficient information is available on the effects of maternal CERVIDIL administration on milk production.. 8.4 Pediatric Use. The safety and effectiveness of CERVIDIL have not been established in pregnant girls.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Disseminated Intravascular Coagulation: Assess for evolving fibrinolysis in the immediate post-partum period. (5.2)Amniotic Fluid Embolism Syndrome: Carefully monitor patients for clinical signs of hypotension, hypoxemia and respiratory failure, DIC, coma or seizures. Provide supportive care. (5.3)Uterine Tachysystole and Uterine Hypersystole/Hypertonicity: Monitor uterine activity; remove vaginal insert. (5.4)History of Glaucoma: Consider non-prostaglandin cervical ripening procedures. (5.5). Disseminated Intravascular Coagulation: Assess for evolving fibrinolysis in the immediate post-partum period. (5.2). Amniotic Fluid Embolism Syndrome: Carefully monitor patients for clinical signs of hypotension, hypoxemia and respiratory failure, DIC, coma or seizures. Provide supportive care. (5.3). Uterine Tachysystole and Uterine Hypersystole/Hypertonicity: Monitor uterine activity; remove vaginal insert. (5.4). History of Glaucoma: Consider non-prostaglandin cervical ripening procedures. (5.5). 5.1 For Hospital Use Only. CERVIDIL should be administered in hospital setting with an obstetrical care facility.. 5.2 Disseminated Intravascular Coagulation. CERVIDIL should be used with caution in women at high risk of postpartum disseminated intravascular coagulation (DIC). Physiologic or pharmacologic induction of labor, including the use of CERVIDIL, is associated with an increased risk of DIC during the postpartum period. Women aged 30 years or older, those with complications during pregnancy and those with gestational age over 40 weeks have an increased risk of DIC during the postpartum period. As soon as possible, assess for an evolving fibrinolysis in the immediate post-partum period. Therapy consisting of prompt removal of the source of procoagulant material, replacement of depleted clotting factors and, in some cases, anti-coagulation with heparin should be instituted promptly.. 5.3 Amniotic Fluid Embolism Syndrome. The use of dinoprostone-containing products, including CERVIDIL, can result in inadvertent disruption and subsequent embolization of antigenic tissue causing the development of Amniotic Fluid Embolism Syndrome, rare and often fatal obstetric condition.Carefully monitor patients for clinical signs of Amniotic Fluid Embolism Syndrome including hypotension, hypoxemia and respiratory failure, DIC, coma or seizures and provide supportive care as needed.. 5.4 Uterine Tachysystole and Uterine Hypersystole/Hypertonicity. The use of CERVIDIL may cause uterine tachysystole with or without fetal heart rate changes (see Table 1). While using CERVIDIL, carefully monitor uterine activity, fetal status and the progression of cervical dilatation and effacement. Remove CERVIDIL with any evidence of uterine tachysystole, uterine hypersystole/hypertonicity, fetal distress, or if labor commences. CERVIDIL is contraindicated when prolonged contraction of the uterus is detrimental to fetal safety or uterine integrity, such as previous cesarean section or major uterine surgery, because of the risk of uterine rupture and obstetrical complications (e.g., need for hysterectomy and the occurrence of fetal or neonatal death). Prostaglandins, including CERVIDIL, may potentiate the effect of oxytocin [see Drug Interactions (7)]. Remove CERVIDIL at least 30 minutes before administration of an oxytocic agent is initiated and continue to carefully monitor uterine activity. Remove CERVIDIL prior to amniotomy or following rupture of membranes because the higher vaginal pH that occurs with rupture of membranes may result in higher release rate of dinoprostone.. 5.5 Glaucoma. Prostaglandins, including CERVIDIL, can lead to raised intraocular pressure and constriction of pupils. Consider non-prostaglandin cervical ripening procedures in patients with Glaucoma.