Oral misoprostol versus placebo for cervical dilatation before vacuum aspiration in first trimester pregnancy

Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation)

First-trimester surgical abortion is a common, safe procedure with a major complication rate of less than 1%. Cervical dilation before suction abortion is usually accomplished using tapered mechanical dilators. Risk factors for major complications in the first trimester include increasing gestational age and provider inexperience. Cervical priming before first-trimester surgical abortion has been studied using osmotic dilators and pharmacologic agents, most commonly misoprostol. Extensive data demonstrate that a variety of agents are safe and effective at causing preoperative cervical softening and dilation; however, given the small absolute risk of complications, the benefit of routine use of misoprostol or osmotic dilators in first-trimester surgical abortion is unclear. Although cervical priming results in reduced abortion time and improved provider ease, it requires a delay of at least 1 to 3 h and may confer side effects. The Society of Family Planning does not recommend routine cervical priming for first-trimester suction abortion but recommends limiting consideration of cervical priming for women at increased risk of complications from cervical dilation, including those late in the first trimester, adolescents and women in whom cervical dilation is expected to be challenging.

Role of sublingual misoprostol for cervical priming in first trimester medical termination of pregnancy

OBJECTIVE

To evaluate the efficacy and safety of sublingual misoprostol as facilitator in first trimester medical termination of pregnancy (MTP) by surgical method.

MATERIALS AND METHODS

This was a prospective open label study conducted at a tertiary center. A total 150 patients at 6-12 wks gestation requesting for MTP were randomized into two groups. Patients in study group (n=75) received sublingual misoprostol three hours before surgical abortion and in control group (n=75) directly underwent surgical abortion without prior cervical priming with misoprostol. The outcomes of both groups were recorded in terms of baseline cervical dilatation, need of additional cervical dilatation, intraoperative blood loss, operative time and procedure related complications. The results were statistically analyzed using student-t test and chi-square test. p-value of <0.05 and <0.001 were considered significant and highly significant respectively.

RESULTS

The mean baseline cervical dilatation was significantly more in study group compared to control group (8.6±1.3mm versus 5±2.3mm; p <0.001) and the operative time and intraoperative blood loss were also less (p<0.001). Higher incidence of side effects like nausea, vomiting and pyrexia were recorded in sublingual misoprostol group but were well tolerable to the patients.

CONCLUSION

Sublingual misoprostol is an effective and safe drug for cervical priming prior to surgical evacuation and has good patient acceptability.

Oral misoprostol is an effective and acceptable alternative to vaginal administration for cervical priming before first trimester pregnancy termination

BACKGROUND

Cervical priming agents mainly prostaglandins in different doses and routes are used during first trimester vaccum aspiration to prevent cervical injury and shorten the abortion procedure. This study was carried out to assess women's acceptability, the efficacy and side effects of oral versus vaginal administration of misoprostol in facilitating cervical dilatation prior to first trimester vaccum aspiration.

METHODS

A randomised control study where 120 women were divided in oral (51) and vaginal (69) group. Each group received 400 mcg of misoprostol either orally or vaginally 04 h prior to first trimester pregnancy termination. Baseline cervical dilatation, women's acceptability and side effects and complications were noted in both the groups.

RESULTS

There was no difference between the oral and vaginal misoprostol groups with respect to mean cervical dilatation (5.53 mm vs 5.43 mm; p > 0.05). A total of 88% of women in the oral group expressed satisfaction with the route of misoprostol administration as compared to 74% in the vaginal route. The women in the vaginal group were experienced more preoperative vaginal bleeding (43% vs 25%).

CONCLUSION

Oral administration of misoprostol is an effective alternative to vaginal administration in preinduction cervical ripening prior to first trimester pregnancy termination.

Vaginal misoprostol aids in difficult intrauterine contraceptive removal: a report of three cases

BACKGROUND

Intrauterine devices are the most used long-acting reversible contraceptive method worldwide. Under normal circumstances, removal of an intrauterine contraceptive (IUC) is an uncomplicated procedure requiring gentle traction on the string.

STUDY DESIGN

We report three cases of nonvisible IUC strings where, following use of vaginal misoprostol, the IUC strings were visualized and the IUCs were removed intact with gentle traction.

CONCLUSIONS

The uterotonic and uterocontractile effects following vaginal misoprostol facilitated removal in three cases of nonvisible IUC strings. We suggest that clinicians consider including vaginal misoprostol alone or prior to planned repeat office or procedure-clinic interventions for nonvisible IUC strings.

A randomized trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women

OBJECTIVE

To perform hysteroscopy the cervix needs to be dilated and in nullipara and postmenopausal women this is sometimes difficult. Well-known, entry-related complications during hysteroscopy include cervical tear, creation of false tract, bleeding, uterine perforation, scarring, and subsequent anatomical stenosis.

MATERIALS AND METHODS

This study was done to investigate the priming effect of vaginal misoprostol on cervical dilatation in postmenopausal women, before hysteroscopy, to prevent such complications. Two hundred micrograms of misoprostol was inserted into the vagina at least 12 hours before the procedure and the control group did not receive any cervical priming agent. Pre-procedural dilatation, additional dilatation required, and time taken for dilatation was noted in each case.

OBSERVATIONS

The study showed a significant difference between the study group (7.7 ± 1.7 mm) and the control group (4.5 ± 1.8 mm) in terms of pre-procedural cervical width and the number of women requiring a dditional dilatation (7 / 25 versus 22 / 25), and hence, the time required for dilatation (4.7 ± 8 seconds versus 20.6 ± 9.3 seconds).

CONCLUSION

The pre-procedural cervical width was significantly more in the study group as compared to that in the control group. We found significant differences between the study and control groups with respect to the number of women who required cervical dilatation. To conclude, this study helps derive a conclusion that vaginal misoprostol as a cervical priming agent in postmenopausal women appears to be safe, effective, and inexpensive, with mild side effects.

Cervical preparation for first trimester surgical abortion

BACKGROUND

Preparing the cervix prior to surgical abortion is intended to make the procedure both easier and safer. Options for cervical preparation include osmotic dilators and pharmacologic agents. Many formulations and regimens are available, and recommendations from professional organizations vary for the use of preparatory techniques in women of different ages, parity or gestational age of the pregnancy.

OBJECTIVES

To determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred.

SEARCH STRATEGY

We searched Cochrane, Popline, Embase, Medline and Lilacs databases for randomised controlled trials investigating the use of cervical preparatory techniques prior to first trimester surgical abortion. In addition, we hand-searched key references and contacted authors to locate unpublished studies or studies not identified in the database searches.

SELECTION CRITERIA

Randomised controlled trials investigating any pharmacologic or mechanical method of cervical preparation, with the exception of nitric oxide donors (the subject of another Cochrane review), administered prior to first trimester surgical abortion were included. Outcome measures must have included the amount of cervical dilation achieved, the procedure duration or difficulty, side-effects, patient satisfaction or adverse events to be included in this review.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated by considering whether inclusion criteria were met as well as methodologic quality. Fifty-one studies were included, resulting in 24 different cervical preparation comparisons. Results are reported as odds ratios (OR) for dichotomous outcomes and weighted mean differences for continuous data.

MAIN RESULTS

When compared to placebo, misoprostol (400-600 microg given vaginally or sublingually), gemeprost, mifepristone (200 or 600 mg), prostaglandin E and F(2alpha) (2.5 mg administered intracervically) demonstrated larger cervical preparation effects. When misoprostol was compared to gemeprost, misoprostol was more effective in preparing the cervix and was associated with fewer gastrointestinal side-effects. For vaginal administration, administration 2 hours prior was less effective than administration 3 hours prior to the abortion. Compared to oral misoprostol administration, the vaginal route was associated with significantly greater initial cervical dilation and lower rates of side-effects; however, sublingual administration 2-3 hours prior to the procedure demonstrated cervical effects superior to vaginal administration.When misoprostol (600 microg oral or 800 microg vaginal) was compared to mifepristone (200 mg administered 24 hours prior to procedure), misoprostol had inferior cervical preparatory effects. Compared to day-prior laminaria tents, 200 or 400 microg vaginal misoprostol showed no differences in the need for further mechanical dilation or length of the procedure; similarly, the osmotic dilators Lamicel and Dilapan showed no differences in cervical ripening when compared to gemeprost, although gemeprost had cervical effects which were superior to laminaria tents. Older prostaglandin regimens (sulprostone, prostaglandin E(2) andF(2alpha)) were associated with high rates of gastrointestinal side-effects and unplanned pregnancy expulsions. Few studies reported women's satisfaction with cervical preparatory techniques.

AUTHORS' CONCLUSIONS

Modern methods of cervical ripening are generally safe, although efficacy and side-effects between methods vary. Reports of adverse events such as cervical laceration or uterine perforation are uncommon overall in this body of evidence and no published study has investigated whether cervical preparation impacts these rare outcomes. Cervical preparation decreases the length of the abortion procedure; this may become increasingly important with increasing gestational age, as mechanical dilation at later gestational ages takes longer and becomes more difficult. These data do not suggest a gestational age where the benefits of cervical dilation outweigh the side-effects, including pain, that women experience with cervical ripening procedures or the prolongation of the time interval before procedure completion. Mifepristone 200 mg, osmotic dilators and misoprostol, 400microg administered either vaginally or sublingually, are the most effective methods of cervical preparation.

Cervical ripening before operative hysteroscopy in premenopausal women: a randomized, double-blind, placebo-controlled comparison of vaginal and oral misoprostol

OBJECTIVE

To compare the effectiveness of oral and vaginal misoprostol for preoperative cervical ripening in premenopausal women before hysteroscopic surgery.

DESIGN

Placebo-controlled, double blind, randomized trial.

SETTING

University hospital.

PATIENT(S)

Eighty-six premenopausal women eligible for operative hysteroscopy were recruited. Nine women were excluded from the study.

INTERVENTION(S)

Patients were randomly assigned to receive 400 microg of misoprostol orally (n = 39) or vaginally (n = 38), 10-12 hours before operative hysteroscopy.

MAIN OUTCOME MEASURE(S)

Extent of initial cervical width, percentage of patients requiring cervical dilatation, duration of cervical dilatation and surgical procedure, complications during procedure, and associated side effects.

RESULT(S)

Mean cervical widths in the vaginal and oral misoprostol groups after treatment were 7.3 +/- 1.6 mm and 6.0 +/- 1.5 mm, respectively, which was a statistically significant difference. Time required for cervical dilatation (98.6 +/- 88.7 s vs. 49.1 +/- 34.9 s) and duration of surgery (14.5 +/- 6 vs. 7.7 +/- 4.0 min) was statistically significantly shorter in the vaginal misoprostol group. The percentage of women with an initial cervical width of 9 mm was statistically significantly higher in the vaginal misoprostol group (36.8% vs. 5.1%). Uterine perforation occurred in two patients in the oral misoprostol group and in none in the vaginal misoprostol group. Side effects were comparable between the two treatment groups.

CONCLUSION(S)

Vaginal administration of misoprostol is more effective than the oral route for preoperative cervical ripening in premenopausal women.

Misoprostol: pharmacokinetic profiles, effects on the uterus and side-effects

Misoprostol, a synthetic prostaglandin E1 analogue, is commonly used for medical abortion, cervical priming, the management of miscarriage, induction of labor and the management of postpartum hemorrhage. It can be given orally, vaginally, sublingually, buccally or rectally. Studies of misoprostol's pharmacokinetics and effects on uterine activity have demonstrated the properties of the drug after various routes of administration. These studies can help to discover the optimal dose and route of administration of misoprostol for individual clinical applications. Misoprostol is a safe drug but serious complications and teratogenicity can occur with unsupervised use.

A Randomized Trial of Oral Misoprostol in Premenopausal Women Before Hysteroscopy

OBJECTIVE

To determine if the use of oral misoprostol in premenopausal women undergoing diagnostic hysteroscopy produces a clinically important difference in pre-procedural cervical dilatation.

METHODS

At a tertiary care hospital, premenopausal women undergoing diagnostic hysteroscopy were randomized to receive either 400 microg of misoprostol or a vitamin B6 placebo orally 12 hours before the procedure. Patients were stratified on the basis of parity. The primary outcome was the pre-procedural dilatation of the cervix. Secondary outcomes included the need to further dilate the cervix, the time required to further dilate the cervix, and side effects.

RESULTS

Sixty-four women (11 nulliparous and 53 parous) undergoing diagnostic hysteroscopy consented to participate in the study. Thirty-three women received misoprostol and 31 received placebo. Baseline demographics showed no difference in age and parity between the two groups. There were no significant differences in pre-procedural dilatation (5.0 mm vs. 4.7 mm, P = 0.52), need to further dilate the cervix (56.7% vs. 63.0%, P = 0.63), and time required to further dilate the cervix (12.7 seconds vs. 25.7 seconds, P = 0.27). Significantly more women in the misoprostol group experienced menstrual-like cramping (24.2% vs. 3.3%, P = 0.03) and vaginal spotting (21.2% vs. 3.3%, P = 0.05).

CONCLUSION

In premenopausal women, there is no improvement in pre-procedural cervical dilatation with administration of oral misoprostol 12 hours before diagnostic hysteroscopy. Further research is required in both nulliparous and parous premenopausal women to determine whether oral misoprostol improves cervical dilatation and, if so, the ideal dose, route and timing.

Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation). SFP Guideline 20071

First-trimester surgical abortion is a common, safe procedure with a major complication rate of less than 1%. Cervical dilation before suction aspiration is usually accomplished using tapered mechanical dilators. Risk factors for major complications in the first trimester are increasing gestational age and provider inexperience. Use of laminaria for cervical priming reduces the risk of cervical laceration and, to a lesser extent, uterine perforation. While pharmacological priming agents may potentially have the same effects, no published studies to date have been large enough to assess these outcomes. Given an experienced provider, the risk of these injuries during suction aspiration is very small. Cervical priming can be achieved with osmotic dilators or pharmacological agents. The advantages of osmotic dilators such as laminaria, Dilapan-S and Lamicel are their ability to produce wide cervical dilation, and for the synthetic types, their advantages include predictable effects and rapid onset of action. A disadvantage of osmotic dilators is that they require a speculum examination and a trained clinician to perform the insertion. When cervical priming is performed, misoprostol is the prostaglandin analogue most commonly used worldwide. Compared to laminaria, vaginal misoprostol requires a shorter period of time to achieve the same dilatation, is associated with less discomfort and is preferred by women. The sublingual route appears as effective as vaginal administration and requires less time for priming (2 h), but it is associated with more side effects. Oral administration can produce equivalent dilation to vaginal or sublingual administration, but higher doses and longer treatment periods (8 to 12 h) are required. Buccal administration of misoprostol appears to have a pharmacokinetic and physiologic profile similar to vaginal administration; however, there are no published studies of buccal misoprostol prior to first-trimester suction abortion. While extensive data demonstrate that a variety of agents are safe and effective at causing cervical softening and dilation preoperatively, there are not enough data to conclude that routine cervical priming is necessary to reduce complications of first-trimester surgical abortion. Cervical priming increases preoperative cervical dilation, making the procedure easier and quicker for the physician. However, in order to preoperatively dilate the cervix, the woman must receive the agent at least 3 to 4 h prior to her procedure. Besides the additional waiting, the woman might experience bleeding and cramping prior to the procedure. There are insufficient data evaluating how cervical priming affects women's quality of life in relation to abortion. Based on existing evidence, the Society of Family Planning does not recommend routine cervical priming for suction aspiration procedures. The Society of Family Planning further recommends that providers consider cervical priming only for women who may be at increased risk of complications from cervical dilation, including those late in the first trimester, adolescents and women in whom cervical dilation is expected to be difficult due to either patient factors or provider experience.

Clinical applications of mifepristone

Mifepristone is a progesterone antagonist that has been studied for a number of clinical applications. It is a well-known abortifacient that is effective for both first- and second-trimester medical abortion when used with a prostaglandin analog. It is also an effective cervical priming agent that can be used to soften the cervix before surgical evacuation. Its clinical efficacy as an emergency contraception has been proven. Other applications including treatment for fibroids, endometriosis and various cancers have been explored. However, its association with abortion limits the applications of mifepristone in many of these areas.

Misoprostol for cervical ripening in non-pregnant women: a randomized double-blind controlled trial of oral versus vaginal regimens

BACKGROUND

The objective was to compare the efficacy of oral versus vaginal misoprostol for cervical ripening in non-pregnant women.

METHODS

Sixty non-pregnant women scheduled for diagnostic hysteroscopy were randomized by computerized randomization schedule to 400 microg of misoprostol orally (n = 30) or 200 microg vaginally (n = 30) administered 12 h prior to surgery. The diameter of the cervical canal measured with a Hegar dilator, adverse events and any complications were recorded and compared between the two groups.

RESULTS

The mean pre- and post-medication cervical canal diameter and cervical diameter difference were 2.00 +/- 1.93 versus 2.37 +/- 1.83 mm (P = 0.453), 5.10 +/- 1.75 versus 5.60 +/- 1.69 mm (P = 0.265) and 3.10 +/- 1.79 versus 3.23 +/- 1.74 mm (P = 0.771) in the oral and vaginal group, respectively. Seven patients in the oral group and one patient in the vaginal group experienced diarrhoea within 24 h of administration of the misoprostol.

CONCLUSION

Oral misoprostol 400 microg had similar efficacy in cervical ripening to 200 microg of vaginal misoprostol.

Oral versus self-administered vaginal misoprostol at home before surgical termination of pregnancy: a randomised controlled trial

OBJECTIVE

To compare the impact of 400 mug oral versus self-administered vaginal misoprostol at home on pre-operative cervical priming in both primigravid and multigravid women prior to first trimester surgical abortion.

DESIGN

Randomised controlled trial.

SETTING

Norwegian University Teaching Hospital.

SAMPLE

Three hundred and thirty-eight women undergoing surgical abortion between 7 and 12 weeks of gestation.

METHODS

The women were randomised to either 400 microg of oral misoprostol the evening before or 400-microg of self-administered vaginal misoprostol at home the same day as vacuum aspiration. Main outcome measures Pre-operative cervical dilatation, complications and acceptability.

RESULTS

The median cervical dilatation was 6.2 mm (range 0-11 mm) for the women in the 400 mug oral misoprostol and 6.5 mm (range 0-11 mm) in the 400-microg vaginal misoprostol groups. The median pre-operative dilatation was larger in multigravidae (6.4 and 6.7 mm for the oral and vaginal routes, respectively) than in primigravidae (5.8 and 6.0 mm, respectively). In primigravidae, 19% achieved a pre-operative dilatation of > or = 7 mm, with no significant difference between oral and vaginal dosage. In multigravidae, 52% achieved a pre-operative dilatation of > or = 7 mm with vaginal dosage, compared with 36% with oral dosage (P = 0.03). There was no difference between non-immigrant versus immigrant women in pre-operative cervical dilatation. The 400-microg oral dosage group had a higher risk of bleeding, compared with the group receiving 400-microg vaginal misoprostol [odds ratio (OR) = 10.4; confidence interval (CI) 5.2-20.8]. There was no difference between non-immigrant and immigrant women in acceptability of self-administered vaginal misoprostol; almost all women found this administration route acceptable. Complications were minor and were distributed equally between the two dosage groups.

CONCLUSIONS

The vaginal route will result in a satisfactory dilatation in about half of multigravidae but is much less effective in primigravidae. The oral route does not lead to satisfactory dilatation in either group and is associated with a higher occurrence of pre-operative bleeding. Self-administered vaginal misoprostol at home is highly acceptable.

[Pregnancy termination between 12 and 14 weeks gestation: practices and early complications in comparison with termination between 8 and 12 weeks]

OBJECTIVES

To describe and compare practices and complications of induced abortions (IA) between 12 and 14 gestational weeks (GW) with those performed at lower terms (8-10 and 10-12 GW).

PATIENTS AND METHODS

Cohort study enrolled in two IA centers 411 women, 147 of them with 12-14 weeks gestation. Comparisons were made according to pregnancy term (8-10, 10-12 and 12-14 GW).

RESULTS

Pregnancy term influenced the technical conditions of IA. Number and diameter of dilators and suction cannula as well as surgery time increase with gestational age--whether priming agents were used or not. Pain felt during surgery and early complications (within 15 days post IA) did not increase with gestational age.

CONCLUSION

Results of this study show that IA between 12 and 14 GW are as feasible as with lower terms.

Oral versus vaginal misoprostol administered one hour before surgical termination of pregnancy: a randomised controlled trial

OBJECTIVE

To assess the efficacy of oral and vaginal misoprostol as cervical priming agents administered 1 hour before first trimester surgical termination of pregnancy.

DESIGN

A randomised controlled trial.

SETTING

Chelsea and Westminster Hospital, London.

POPULATION

Pregnant women of 10 weeks or less gestation attending the termination of pregnancy clinic.

METHODS

Ninety eligible women were recruited to the study during September 2001 and September 2002. Women were randomised to one of the three groups: misoprostol administered orally (400 microg), misoprostol administered vaginally (800 microg) and standard care (no cervical priming agent) administered prior to surgical termination of pregnancy. Under general anaesthesia, and prior to the operation, a cervical tonometer was used to determine the main outcome measures.

MAIN OUTCOME MEASURES

Baseline cervical dilatation and the cumulative force required to dilate the cervix from 3 to 9 mm.

RESULTS

There was no significant difference in the mean baseline cervical dilation (P= 0.16) or the cumulative force required to dilate the cervix (P= 0.12) between the three randomised groups.

CONCLUSION

No cervical priming effects were detectable with oral or vaginal misoprostol administered 1 hour before first trimester surgical termination of pregnancy.

Intracervical sodium nitroprusside versus vaginal misoprostol in first trimester surgical termination of pregnancy: a randomized double-blinded controlled trial

BACKGROUND

Results from small-scale randomized studies on the effectiveness of different preparations of nitric oxide donors in cervical priming before first trimester termination of pregnancies are not consistent. We compared sodium nitroprusside gel to misoprostol, the standard agent for cervical priming in this randomized double-blinded controlled trial.

METHODS

Two hundred pregnant patients between 8 to 12 weeks admitted for surgical termination of pregnancy were recruited. They were randomized into either 400 microg vaginal misoprostol and intracervical placebo gel, or 10 mg intracervical sodium nitroprusside gel and placebo tablets 3 h before the procedure. The baseline cervical dilatation and cumulative force required to dilate the cervix from 4 to 9 mm were measured with a tonometer. Blood pressure was measured and side effects were assessed.

RESULTS

The cumulative force to dilate the cervix from 4 to 9 mm was significantly higher in the sodium nitroprusside group, and the difference remained when a sub-group analysis was performed according to parity. Baseline cervical dilatation, duration of operation and operative blood loss were all in favour of misoprostol. Transient drop in blood pressure was observed after sodium nitroprusside treatment.

CONCLUSIONS

Intracervical sodium nitroprusside is not as effective as misoprostol in cervical priming.

A randomized comparison of sublingual and vaginal misoprostol for cervical priming before suction termination of first-trimester pregnancy

This randomized trial compares the efficacy and side effects of sublingual and vaginal misoprostol for cervical priming before first-trimester pregnancy termination. One-hundred pregnant women between 6 and 12 weeks of gestation opting for termination of pregnancy by suction evacuation were included in this study. The women were randomly allocated into two groups. Group 1 received 400 microg of sublingual misoprostol and group 2 received 400 microg of vaginal misoprostol 2 h prior to suction evacuation. The abortion was carried out by suction evacuation using a Karman's cannula attached to an electrically operated suction machine under intravenous analgesia. Baseline cervical dilatation, duration of the procedure, operative blood loss, side effects and complications were noted in both groups. There was a significant difference between the sublingual and vaginal misoprostol groups with respect to mean cervical dilatation (8.6 mm vs. 6.8 mm, p < 0.05). However, the duration of the procedure (3.03 min vs. 3.16 min) and the amount of blood loss (29 mL vs. 31.2 mL) were not significantly different between the two groups. The women in the sublingual group experienced significantly more shivering and preoperative vaginal bleeding (68% vs. 56%, p < 0.05). None of the women in the two groups had either uterine perforation or excessive hemorrhage. In our study, sublingual misoprostol (400 microg) was significantly more effective in facilitating cervical dilation prior to surgical abortion than vaginal misoprostol.

Oral misoprostol vs. vaginal gemeprost prior to surgical termination of pregnancy in nulliparae

BACKGROUND

To compare the efficacy and side-effects of intravaginal gemeprost with those of oral misoprostol for cervical ripening prior to first-trimester pregnancy termination in nulliparous women.

METHODS

Retrospective analysis of surgical terminations of pregnancy performed before 90 days of gestation. Intravaginal gemeprost 1 mg or oral misoprostol 800 micro g was administered 2 h before the procedure.

RESULTS

In total, 746 women were enrolled into the study, 84 received intravaginal gemeprost and 662 oral misoprostol. Median baseline cervical dilatation was significantly greater in women who received misoprostol before the operation than in those who received gemeprost (7 mm vs. 3 mm; p < 0.0001). The incidence of fever, vomiting and diarrhea was not different between the two groups. The incidence of abdominal pain with request for pain medication, emergency admission to operating room due to vaginal bleeding, hospital stay longer than 24 h and surgical repair of cervical injury due to Hegar dilatation was significantly higher among the gemeprost group than the misoprostol group.

CONCLUSIONS

In cervical priming prior to first-trimester pregnancy termination in nulliparous women, oral misoprostol is more effective and is associated with fewer side-effects and complications than intravaginal gemeprost.

The use of oral misoprostol for pre-abortion cervical priming: a randomised controlled trial of 400 versus 200 microg in first trimester pregnancies

OBJECTIVE

To compare the impact of 200 and 400 microg oral misoprostol on pre-operative cervical priming in both primi- and multigravidae prior to first trimester termination of pregnancy. Pre-operative cervical dilatation and bleeding were assessed.

DESIGN

Randomised controlled trial.

SETTING

Norwegian university teaching hospital.

SAMPLE

Five hundred and fifty-one women undergoing surgical termination of pregnancy between 7 and 12 weeks of gestation.

METHODS

Patients were randomised to either 200 or 400 microg of oral misoprostol 10-16 hours before vacuum aspiration. The degree of cervical dilatation prior to abortion by vacuum aspiration was measured. Pre-operative bleeding and pain were recorded and vaginal bleeding was measured.

MAIN OUTCOME MEASURES

Degree of pre-operative cervical dilatation and pre-operative bleeding.

RESULTS

The mean cervical dilatation was 5.8 mm (SD 1.7) for the women who received 400 microg misoprostol and 5.4 mm (SD 1.4) for those who received 200 microg (P= 0.004). The pre-operative dilatation was larger in multigravidae than in primigravidae in both dosage groups. The odds ratio (OR) of pre-operative bleeding was 3.3 (95% confidence interval [CI] 2.1-5.0) in the 400 microg dosage group, as compared with the group receiving 200 microg misoprostol. The occurrence of bleeding was dose-dependent. Frequency of bleeding was similar in multigravidae compared with primigravidae in the 400 microg dosage group, whereas the occurrence of bleeding was less in primigravidae than multigravidae in the 200 microg dosage group. Only 89 out of 551 patients bled one or more grams. The volumes measured were not statistically significantly different. Complications were minor, and were distributed equally between the two dosage groups.

CONCLUSIONS

The 200 microg oral misoprostol compared with the 400 microg oral misoprostol given 10-16 hours before first trimester surgical abortions results in less pre-operative vaginal bleeding and in a statistically, although not clinically significant reduction in cervical dilatation.

Induction of labor with 50 and 100μg of misoprostol: comparison of maternal and fetal outcomes

OBJECTIVE

The aim of this randomized controlled study was to compare the efficacy and the safety of different regimens of misoprostol for labor induction. MATERIALS AND METHODS Eligible women received intravaginal 100 microg, every 6 h or 50 microg every 4 h. Treatment continued until: (1) dilatation >3 cm; (2) rupture of membranes (artificial); (3) signs of uterine hyperstimulation; (4) adequate contraction pattern (three contraction/10 min). Managing clinician might use oxytocin during labor. Cesarean section rate was the main outcome that was considered variably. Other outcome measures were neonatal outcome (Apgar scores, meconium staining, and umbilical artery pH) and induction to delivery interval.

RESULTS

A total number of 72 women received either misoprostol 100 microg (n=37), or 50 microg (n=35) randomly. The two groups had similar mean Bishops scores at induction (4.10+/-2.4 versus 4.2+/-2.1; P=0.85), rates of nulliparity, use of epidural anesthesia, and oxytocin augmentation. In two groups the number of doses of misoprostol used was similar (1.6+/-0.5 versus 1.7+/-0.3)

CONCLUSION

There was not any difference between the two groups in the mean+/-S.D. time to delivery (h) and cesarean rate. Likewise, there was not a significance between two groups in the rates of 5 min Apgar score, and of meconium passage.

A randomized controlled comparison of sublingual and vaginal administration of misoprostol for cervical priming before first-trimester surgical abortion

OBJECTIVE

The purpose of this study was to compare the effectiveness of the sublingual and vaginal administration of misoprostol for cervical priming before surgical termination of pregnancy.

STUDY DESIGN

In a randomized controlled trial, 74 primigravid women who were undergoing surgical abortion were assigned randomly to receive misoprostol (400 microg) sublingually or vaginally.

RESULTS

There was no statistically significant difference in the cumulative force that was required to dilate the cervix to 9 mm, for baseline cervical dilatation, for priming to abortion interval, for operating time, or for intraoperative blood loss between the two groups. Women in the sublingual group had more nausea (P=.008), vomiting (P=.01), diarrhea (P=.01), and unpleasant mouth taste (P=.0001) compared with the women in the vaginal group. In the sublingual group, 65% of women were satisfied with the route of misoprostol administration compared with 78% in the vaginal group (P=.11). Most of the staff members (84%) said that they would recommend the sublingual administration of misoprostol (P=.0001).

CONCLUSION

The sublingual administration of misoprostol is an effective alternative to vaginal administration for cervical priming before surgical abortion; despite a higher incidence of side effects, there was high patient and staff acceptability.

A Randomized Trial of Sublingual Misoprostol for Cervical Priming before Hysteroscopy

STUDY OBJECTIVE

To evaluate the effects of sublingual misoprostol on cervical dilatation before hysteroscopy.

DESIGN

Prospective randomized study (Canadian Task Force classification I).

SETTING

University teaching center.

PATIENTS

Forty nulliparous women who received injection of leuprolide acetate 4 weeks before hysteroscopy, of whom 20 were randomized to treatment with misoprostol and 20 to placebo.

INTERVENTION

Sublingual misoprostol 100 mug or placebo administered 12 hours before operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Misoprostol was associated with mild abdominal cramps in four women (20%) and vaginal bleeding in another. No side effects were reported among women in the placebo group. There was no difference in baseline diameter of the cervical opening between the misoprostol group (4.0 +/- 0.1 mm) and the control group (4.2 +/- 0.2 mm). Time to dilate cervix up to 9 mm was also not significantly different (misoprostol 48.4 +/- 9.2 sec, placebo 37.7 +/- 4.1 sec). We found no difference in degree of difficulty dilating the cervix between groups. Cervical tear occurred in one patient in the misoprostol group.

CONCLUSION

Sublingual misoprostol 100 mug does not facilitate cervical dilatation before hysteroscopy. This may be related to leuprolide's hypoestrogenic effect.

Termination of pregnancy for fetal neurological abnormalities

INTRODUCTION

Prenatal screening for fetal abnormalities may identify conditions likely to result in perinatal death or in survival with a risk of handicap, for which termination of pregnancy is legal in many countries.

DISCUSSION

When considering termination of pregnancy, it is crucial that prenatal diagnosis be as accurate as possible and that the prognosis of the condition diagnosed in utero is thoroughly understood by the parents. Our ability to predict postnatal outcome in borderline cases should not be overestimated. Parents should not precipitate their decision, and in some European countries, the absence of a gestational age limit at which a termination may be performed is viewed as a guarantee against hasty terminations. Maternal morbidity potentially associated with termination should be kept as low as possible. This includes maternal analgesia, and avoiding uterine trauma to preserve fertility and to prevent obstetrical complications in subsequent pregnancies. Bereavement should also be taken into account. Tests that could contribute to confirming the diagnosis or to establishing the aetiology of the abnormality, such as fetal karyotype or platelet count, should be implemented when appropriate, since post-termination genetic counselling relies on such data. Post-mortem examination is often crucial for genetic counselling and should include X-rays and gross examination of the fetus as well as brain and spine examination by a neuropathologist with expertise in the field of fetal medicine. Specific post-mortem procedures sometimes need to be planned before termination, for instance, in fetal akinesia sequence. First trimester surgical techniques and second or third trimester medical techniques of termination of pregnancy are reviewed.

Role of sublingual misoprostol for cervical ripening prior to vacuum aspiration in first trimester interruption of pregnancy

This is a prospective randomized clinical trial evaluating, for the first time, the effectiveness of sublingual route of misoprostol for cervical priming prior to vacuum aspiration (VA). The trial included 100 women seeking first trimester abortion who were sequentially randomized into two groups of 50 each. Patients of study group received 400 microg sublingual misoprostol 3 h prior to VA while those of the control group did not receive any premedication for cervical ripening. For all periods of gestation between 6 and 12 weeks, misoprostol significantly reduced pain score, blood loss, time duration and rate of complications without increasing the side effects. Sublingual misoprostol is an effective alternative to mechanical cervical dilatation. It can be self-administered and has a good patient-acceptability rate. As no study has evaluated the role of sublingual route of misoprostol for cervical priming before VA, wider studies should be done to advocate its routine use.

Role of progesterone antagonists and new selective progesterone receptor modulators in reproductive health

Given the importance of progesterone in female reproductive health, it was inevitable that analogues of this molecule would be developed to treat a variety of gynecologic maladies. Such medications, termed progesterone antagonists, act to counteract the effect of progesterone. A newer class of molecules, the selective progesterone receptor modulators (SPRMs), have both agonist and antagonist activities depending upon the site of action. These compounds have been studied for their effect on endometrial growth, endometrial vascular development, the hypothalmic-pituitary-ovarian axis and cervical integrity. Such research has led to a number of potential clinical applications. Progesterone antagonists are well established in their use for termination of pregnancy, although SPRMs seem to have a diminished capacity for induction of abortion. Similarly, antagonists work well to soften and dilate the cervix before surgery, but such efficacy by SPRMs is unlikely. Other applications for progesterone antagonists include induction of labor, the treatment of endometriosis, fibroids and contraception; SPRMs also may prove useful in the treatment of endometriosis and fibroids, as well as for postmenopausal hormone replacement therapy and the treatment of dysfunctional uterine bleeding. Finally, these compounds may aid investigators in unraveling many of the nuances of the role of progesterone in reproductive function.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to describe the receptor action and selective modulation of progesterone, explain the effects of progesterone receptor modulators, and list the potential clinical applications of progesterone antagonists and selective progesterone receptor modulators.

The use of oral misoprostol as a cervical ripening agent in operative hysteroscopy: a double-blind, placebo-controlled trial

OBJECTIVE

The purpose of this study was to assess the effectiveness of oral misoprostol as a cervical ripening agent when used in operative hysteroscopy.

STUDY DESIGN

This was a double-blind, placebo-controlled trial. Any patient undergoing an operative hysteroscopy (with a 9-mm to 10-mm hysteroscope) was considered eligible for the trial. Patients were randomly allocated, by means of computer-generated numbers, to receive either placebo or 400 microg of misoprostol 12 and 24 hours before surgery. The primary outcome measure in this study was the ease of cervical dilatation as measured by the largest-number Hegar dilator that could be inserted into the cervix without resistance. A subjective assessment of the ease of dilatation was also recorded on a Likert scale. Other demographic data including age, menopausal status, parity, and use of gonadotropin-releasing hormone (GnRH) analogues were also recorded. Adverse effects experienced and any other adverse outcomes were also recorded for each group. Logistic regression analysis was used to compare the two groups.

RESULTS

Two hundred four patients were recruited into the study. There were no differences between the two groups in demographic variables. The misoprostol group demonstrated an increased ease of cervical dilatation (odds ratio [OR] 2.6; CI 1.28-5.29; P =.008). This was also demonstrated in the subgroup of patients who were menopausal or who had been pretreated with a gonadotropin-releasing hormone analog (OR 2.49; CI 1.11-5.58; P =.026), as well as in those who were premenopausal (OR 2.15; CI 1.04 4.45; P =.04). There were no differences between the two groups in the time required for dilatation (P =.08) or ease of dilatation (P =.12). Adverse effects were greater in the treatment group: diarrhea (28% vs 4%; P <.001), cramps (27% vs 1%; P <.0001), and bleeding (26% vs 1.3%; P <.001).

CONCLUSIONS

Misoprostol demonstrates a benefit over placebo in the ease of cervical dilatation in premenopausal and postmenopausal women and in those pretreated with a gonadotropin-releasing hormone analog. Adverse effects were more common in the treatment group but did not preclude the patients from taking the medication.

Use of misoprostol in first and second trimester abortion: a review

The use of misoprostol in medical termination of first and second term pregnancies and cervical priming in surgically induced termination of pregnancies has been studied extensively. A survey is given on the available literature (MEDLINE to May 1998) on the usage as a single medication or in combination with mifepristone or methotrexate. A review is given on literature concerning side effects and complications. Misoprostol is a most promising, cheap, and effective agent, which does not need cool storage like other prostaglandins. The use of misoprostol as an abortifacient has, however, not been supported by the manufacturer. This leads to the situation (similar to mifepristone/RU 486) that it is used and researched, but probably will not be officially approved for this specific indication.

The use of misoprostol for pre-operative cervical dilatation prior to vacuum aspiration: a randomized trial

Misoprostol is effective for cervical priming prior to vacuum aspiration for first trimester termination of pregnancy. Previous studies showed that the oral route was more acceptable to patients but there were higher incidences of side-effects when compared with the vaginal route. This study is to determine the optimal dosage and route of administration of misoprostol for pre-operative cervical dilatation. A double-blind, randomized trial was undertaken for 225 nulliparous women with 8-12 weeks amenorrhoea. They were randomly assigned to groups given 0 (placebo), 200 or 400 microg oral or vaginal misoprostol 3 h prior to vacuum aspiration. In misoprostol-treated groups the baseline cervical dilatation was significantly increased when compared with the placebo group; the effect was dose-related in the oral but not in the vaginal group. The cumulative force and blood loss was significantly decreased in the misoprostol-treated groups. The incidences of side-effects were more frequent in misoprostol groups but were not related to the route and dosage of medication. The duration of procedure, incidences of post-operative complications, the duration of post-operative bleeding and the interval to the first period were similar in the five treatment groups. We conclude that a 3 h pre-treatment interval is effective for both oral and vaginal routes. When given orally, 400 microg is more effective than 200 microg. The efficacy was otherwise similar when compared with the vaginal route. We recommend 400 microg oral misoprostol 3 h prior to vacuum aspiration for cervical dilatation.

Vaginal misoprostol for early second-trimester abortion

OBJECTIVES

To demonstrate the effectiveness and safety of misoprostol without the need of postexpulsion systematic curettage in early second-trimester abortions, i.e. at 13-15 weeks' gestation.

METHODS

A group of 151 women, with gestations from 85 to 105 days, received 800 micrograms of vaginal misoprostol every 25 h for a maximum of three doses, without having postexpulsion systematic preventive curettage performed. Outcome measures included successful abortion (complete abortion without requiring a surgical procedure), side-effects, mean expulsion time and mean time of vaginal bleeding.

RESULTS

Complete abortion occurred in 121/151 subjects (80%; 95% confidence interval, 78-87%). The decrease in hemoglobin was statistically significant (p = 0.0001), but without clinical relevance (11.8 mg/dl (SD, 0.9) before treatment and 11.4 mg/dl (SD, 1.0) afterwards. No statistically significant differences were found between the success rate and any of the women's characteristics. Vaginal bleeding lasted 6 +/- 3 days, spotting 6 +/- 3 days, and total bleeding 12 +/- 5 days (median, 11 days; range, 1-29).

CONCLUSIONS

The acceptable expulsion time in 80% of the cases, the fact that postabortion systematic curettage was not needed, the clinically insignificant hemoglobin loss and the abortion rate obtained, show that misoprostol by vaginal administration may be an alternative for interrupting gestation in the early second trimester of pregnancy.

A randomised comparison of oral and vaginal misoprostol for cervical priming before suction termination of pregnancy

OBJECTIVE

To assess the effectiveness and acceptability of oral misoprostol, self-administered 12 h before surgery, as a cervical priming agent prior to day case suction termination of pregnancy.

DESIGN

Randomised trial comparing oral misoprostol with the local standard regimen of vaginal misoprostol.

SUBJECTS

Sixty consecutive women scheduled for day case suction termination in one gynaecology unit.

INTERVENTIONS

Cervical priming with misoprostol 400 mg orally, 12 h prior to surgery or 800 mg vaginally, two to four hours prior to surgery.

MAIN OUTCOME MEASURES

Basal cervical dilatation, cumulative force required to dilate the cervix to 9 mm, operative blood loss and side effects (nausea, vomiting, diarrhoea, abdominal pain and vaginal bleeding).

RESULTS

There were no significant differences between the oral and vaginal treatment groups in relation to basal dilatation, cumulative force to achieve 9 mm dilatation or gastrointestinal side effects. However, those in the oral group experienced more severe pain and heavier pre-operative bleeding. Two patients in the oral group experienced incomplete abortion at home after taking misoprostol and a further patient required early admission because of heavy bleeding.

CONCLUSIONS

Because of the unpredictability of action of oral misoprostol, with incomplete abortion or heavy bleeding occurring prior to admission in three patients, we cannot recommend the dosage schedule evaluated here for routine clinical use.

Oral misoprostol versus mifepristone for cervical dilatation before vacuum aspiration in first trimester nulliparous pregnancy: a double blind prospective randomised study

OBJECTIVE

To compare the effectiveness of oral misoprostol and mifepristone for cervical priming before first trimester termination of nulliparous pregnancy.

DESIGN

Prospective double blind randomised study.

SETTING

Department of Obstetrics and Gynaecology, University of Hong Kong.

PARTICIPANTS

One hundred nulliparous women undergoing termination of pregnancy between 8 and 12 weeks of gestation were recruited for this prospective randomised trial. The women were allocated to either the oral misoprostol or mifepristone group. Subjects in misoprostol group were given placebo and misoprostol 400 micrograms 36 h and 12 h respectively before vacuum aspiration. Subjects in mifepristone group were given 200 mg mifepristone and placebo 36 h and 12 h respectively prior to operation.

MAIN OUTCOME MEASURES

Baseline pre-operative cervical dilatation, the incidence of side-effects, the amount of blood loss and duration of procedure.

RESULTS

There were no significant differences in the baseline cervical dilatation, incidence of side-effects, amount of blood loss and duration of procedure.

CONCLUSIONS

Misoprostol and mifepristone are of similar effectiveness for cervical priming prior to vacuum aspiration in nulliparous women. Misoprostol has additional advantages of being widely available and inexpensive.

Termination of second trimester pregnancy with gemeprost and misoprostol: a randomized double-blind placebo-controlled trial

A prospective randomized double-blind placebo-controlled trial was conducted in 70 subjects to determine whether pre-treatment with misoprostol could facilitate termination of second trimester pregnancy by gemeprost. The women received either 400 micrograms oral misoprostol or placebo tablets 12 hours before the administration of vaginal pessary of gemeprost 1 mg every 3 hours. There were no significant differences in induction-abortion interval and the amount of gemeprost required between the misoprostol and the placebo group. There was no significant difference in the incidence of side effects or analgesic requirement between the two groups. We conclude that oral misoprostol is not useful in facilitating termination of second trimester pregnancy by gemeprost.