Preoperative Cervical Ripening Research Articles

The results of using the combination of letrozole and misoprostol in comparison with laminaria and misoprostol in preparing the cervix for miscarriages under the second trimester of pregnancy

Background: Therapeutic abortion in the second trimester pregnancy is the choice treatment in cases with severe anomalies or intrauterine fetal death. It can be done by a number of medical (e.g. misoprostol and letrozole) or mechanical methods (e.g. laminaria). The aim of this study was to compare the efficacy of vaginal misoprostol with and without letrozole and combination of misoprostol and laminaria for preoperative cervical ripening among women with under second trimester abortion. Methods: In this interventional study, 80 pregnant women in the second trimester pregnancy (Gestational age under 20 weeks) were randomly divided in two groups (n=40). One group received vaginal misoprostol in combination with laminaria and oral placebo and other group received vaginal misoprostol in combination with letrozole. Patients regularly examined every 4 hours and in the absence of abortion, vaginal misoprostol repeated after 4 hours. No report of products of conception abortion considered as complete abortion and the patient discharged. Data collected in a cheklist and then analyzed by statistical methods in SPSS version 21. Results: Complete abortion was reported in 70 (87.5%) of all patients which in group letrozole+misoprostol in 34 (85%) and in laminaria+misoprostol was reported in 36 (90%). 6 (15%) Curettage was reported in group letrozole+misoprostl and 4 (10%) in laminaria+misoprostol and the difference were not statistically significant. Conclusions: Results showed that both of combination are effective in the abortion but misoprostol in combination with laminaria is recommended for the induction of second trimester therapeutic abortion.

Effect of Intravaginal Isosorbide Mononitrate for First Trimester Preoperative Cervical Ripening

Effect of Intravaginal Isosorbide Mononitrate for First Trimester Preoperative Cervical Ripening

A combination of misoprostol and estradiol for preoperative cervical ripening in postmenopausal women: a randomised controlled trial

ObjectiveTo compare the impact of 1000 μg of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after 2 weeks of pretreatment with estradiol vaginal tablets in postmenopausal women prior to day-care operative hysteroscopy.DesignRandomised, double-blind, placebo-controlled sequential trial.SettingNorwegian university teaching hospital.PopulationSixty-seven postmenopausal women referred for day-care operative hysteroscopy.MethodsThe women were randomised to receive either 1000 μg of self-administered vaginal misoprostol or self-administered vaginal placebo on the evening before day-care operative hysteroscopy. All women had administered a 25-μg vaginal estradiol tablet daily for 14 days prior to the operation.Main outcome measuresPrimary outcome: preoperative cervical dilatation at hysteroscopy. Secondary outcomes: difference in dilatation at recruitment and before hysteroscopy, number of women who achieved a preoperative cervical dilatation of 5 mm or more, acceptability, complications and adverse effects.ResultsThe mean cervical dilatation was 5.7 mm (SD, 1.6 mm) in the misoprostol group and 4.7 mm (SD, 1.5 mm) in the placebo group, the mean difference in cervical dilatation being 1.0 mm (95% CI, 0.2–1.7 mm). Self-administered vaginal misoprostol of 1000 μg at home on the evening before day-care hysteroscopy is safe and highly acceptable, although a small proportion of women experienced lower abdominal pain.ConclusionsOne thousand micrograms of self-administered vaginal misoprostol, 12 hours prior to day-care hysteroscopy, after 14 days of pretreatment with vaginal estradiol, has a significant cervical ripening effect compared with placebo in postmenopausal women.

P496 A combination of misoprostol and estradiol for pre-operative cervical ripening in postmenopausal women: A randomised controlled trial

P496 A combination of misoprostol and estradiol for pre-operative cervical ripening in postmenopausal women: A randomised controlled trial

Comparison of self‐administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design*

ObjectiveTo compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoperative cervical ripening in both premenopausal and postmenopausal women before operative hysteroscopy.DesignTwo separate but identical parallel, randomised, double-blind, placebo-controlled sequential trials, one in premenopausal women and one in postmenopausal women. The boundaries for the sequential trials were calculated on the primary outcomes of a difference of cervical dilatation ≥1 mm, with the assumption of a type 1 error of 0.05 and a power of 0.95.SettingNorwegian university teaching hospital.SampleEighty-six women referred to outpatient operative hysteroscopy.MethodsThe women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before outpatient operative hysteroscopy.Main outcome measuresPreoperative cervical dilatation (primary outcome), number of women who achieve a preoperative cervical dilatation ≥5 mm, acceptability, complications and adverse effects (secondary outcomes).ResultsIn premenopausal women, the mean cervical dilatation was 6.4 mm (SD 2.4) in the misoprostol group and 4.8 mm (SD 2.0) in the placebo group, the mean difference in cervical dilatation being 1.6 mm (95% CI 0.5–2.7). Among the premenopausal women receiving misoprostol, 88% achieved a cervical dilatation of ≥5 mm compared with 65% in the placebo group. Twelve percent of the women who received misoprostol were difficult to dilate compared with 32% who received placebo. Dilatation was also quicker in the misoprostol group. Misoprostol had no effect on cervical ripening in postmenopausal women compared with placebo, and 43% of the women were difficult to dilate. The trials were terminated after analysis of 21 postmenopausal women and 65 premenopausal women after reaching a conclusion on the primary outcome with only 28% of the number of women needed in a fixed sample size trial. Three of 45 women who received misoprostol experienced severe lower abdominal pain, and there was an increased occurrence of light preoperative bleeding in the misoprostol group. Most women did not experience misoprostol-related adverse effects. The majority (83% of premenopausal and 76% of postmenopausal women) found self-administered vaginal misoprostol at home to be acceptable. There were two serious complications in the premenopausal misoprostol group: uterine perforation with subsequent peritonitis and heavy postoperative bleeding requiring blood transfusion, but these were not judged to be misoprostol related. Complications were otherwise comparatively minor and distributed equally between the two dosage groups.ConclusionsOne thousand micrograms of self-administered vaginal misoprostol 12 hours prior to operative hysteroscopy has a significant cervical ripening effect compared with placebo in premenopausal but not in postmenopausal women. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before operative hysteroscopy is safe and highly acceptable, although a small proportion of women experienced severe lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is very cheap and easy to use.Please cite this paper as: Oppegaard K, Nesheim B, Istre O, Qvigstad E. Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design. BJOG 2008;115:663–e9.

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

To compare the effectiveness of oral and vaginal misoprostol for preoperative cervical ripening in premenopausal women before hysteroscopic surgery. Placebo-controlled, double blind, randomized trial. University hospital. Eighty-six premenopausal women eligible for operative hysteroscopy were recruited. Nine women were excluded from the study. Patients were randomly assigned to receive 400 microg of misoprostol orally (n = 39) or vaginally (n = 38), 10-12 hours before operative hysteroscopy. 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. 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. Vaginal administration of misoprostol is more effective than the oral route for preoperative cervical ripening in premenopausal women.

Comparison of self‐administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design*

To compare the impact of 1000-microgram self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoperative cervical ripening in both premenopausal and postmenopausal women prior to outpatient resectoscopy. Randomised, double-blind, placebo-controlled sequential trial. Norwegian university teaching hospital. Premenopausal and postmenopausal women referred to outpatient resectoscopy. The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before outpatient resectoscopy. Preoperative cervical dilatation, acceptability and complications. (a) Intraoperative findings and distribution of cervical dilatation in the two treatment groups. Values are given as median (range) or n (%). (b) Acceptability in the two treatment groups. Values are given as completely acceptable, n (%); fairly acceptable, n (%); fairly unacceptable, n (%) and completely unacceptable, n (%). (c) Pain in the two treatment groups. Pain was measured with a visual analogue scale score, scale ranges from 0 (no pain) to 10 (unbearable pain). Values are given as median (range). (d) Occurrence of adverse effects in the two treatment groups. Values are given as n (%). (e) Complications, given as n (%).

A comparison of isosorbide mononitrate, misoprostol and combination therapy for first trimester pre-operative cervical ripening: a randomised controlled trial

Objective To determine whether a combined therapy with isosorbide mononitrate (40mg) and misoprostol (400μg) for pre-operative cervical ripening in the first trimester would result in improved clinical effectiveness, and fewer side effects compared with each agent used alone. Design Randomised controlled trial. Setting Glasgow Royal Infirmary. Population Sixty-six primigravid women scheduled for suction termination of pregnancy. Methods Women were randomly assigned to receive before surgery, per vaginam, isosorbide mononitrate 40 mg ( n=22), misoprostol 400 μg ( n=22) or both agents together [isosorbide mononitrate 40 mg and misoprostol 400 μg] ( n=22). Main outcome measures 1. To assess the cumulative force required to dilate the cervix to 8 mm; 2. the onset of new symptoms before termination of pregnancy. Results The cervical resistance following combination therapy with isosorbide mononitrate and misoprostol was not significantly different than following misoprostol alone [24.5N vs 18.5N; median difference (95% CI) 19N (-22 to 49)]. Pre-treatment with misoprostol used alone resulted in a lower cervical resistance than isosorbide mononitrate alone (18.5 N vs 39 N, P=0.04, Mann-Whitney U test). There was no difference in the number of women remaining asymptomatic following either isosorbide mononitrate or misoprostol or combination therapy [14/22 (64%) vs 11/21 (52%) vs 11/22 (50%), Fisher's exact test]. Conclusions We have not shown any advantage of combining misoprostol with the nitric oxide donor isosorbide mononitrate compared with misoprostol alone for pre-operative cervical ripening in the first trimester.

Intraoperative blood loss and gestational age at pregnancy termination

Objective: To establish the relationship of measured intraoperative blood loss to gestational age at pregnancy termination, and to determine which factors, if any, affect the risk of bleeding. Methods: A single-operator series of 363 consecutive women undergoing pregnancy termination between 5 and 24 weeks gestational age, as dated by ultrasound, was prospectively evaluated. All pregnancies under 13 weeks gestation were terminated by mechanical dilation and suction curettage without preoperative cervical ripening. All pregnancies between 13 and 24 weeks gestation were terminated by preoperative osmotic cervical dilation with laminaria tents and subsequent uterine evacuation by a combination of suction curettage, sharp curettage, and Bierer forceps extraction. All patients over 12 weeks gestation received a postoperative oxytocin infusion. Whenever possible, amniotic fluid and blood were collected and measured separately. Patients were excluded from the data analysis for pregnancy demise, PPROM, Potter’s syndrome, or inability to separate blood establish their relationship. After adjustment for gestational age, the results were analyzed to determine if blood loss was related to maternal age, smoking history, body habitus, or operative indication. Results: A curvilinear relationship between blood loss and gestational age was observed. Mean blood loss at 24 weeks exceeded 800 mL. After adjustment for gestational age, no factors significantly affected blood loss at dilation and aspiration of first trimester pregnancies. In those patients undergoing dilation and evacuation in the second trimester, both simple and stepwise regression analyses showed obesity (BMI ≥32.3) to be significantly associated with increased blood loss ( P < .05). Neither age, parity, previous cesarean section, nor smoking history were significantly associated with increased blood loss at dilation and evacuation. Conclusions: With advancing gestational age, intraoperative blood loss increases in curvilinear fashion. Termination providers should be advised that, although blood loss is unaffected by many factors, obese patients are at risk for increased bleeding at dilation and evacuation of pregnancies beyond 12 weeks gestation.

İkinci Trimester Missed Abortus Ve İntrauterin Ölü Fetus Olgularında Prostaglandin E2 Ve Oksitosin Kullanımı

The use of oxytocin and PGE2-gel in cases of second trimestr missed abortion and intrauterine fetal death ✓34 women who had missed abortion or intrauterin exitus and required surgical termination of pregnancy from 12-24 weeks of gestation were treated with intracervical PGE2-gel and oxytocin infusion. The patients were divided into two groups. First group were treated with only oxytocin. There was signilicant difference between the two groups according to mean duration of abortion (p<0.05). According to this preliminary experience the intracervical application of the new ready-for use pge2-gel repesents a practicable and efficient method for abortion and preoperative cervical ripening. Intracervical application of gel didn't have any side effects, not induced hypertonic contractions but only locally riped. We didn't confront any complications in the Pge2-gel treated group. ✓ Gebelik haftasi 12-24 hafta arasi olan, missed abortus veya intrauterin eksitus tanilari ile gebeliklerinin cerrahi olarak bosaltilmasi gereken 34 olguda intraservikal PGE2 jel ve oksitosin kullanildi, olgular iki gruba ayrildi. Ilk grupta intraservikal PGE2-Jel ve oksitosin kullanilirken 2.grup olgularda ise sadece oksitosin infuzyonu yapildi. Ortalama dusuk eylemi ,suresi bakimindan gruplar arasindaki farkin onemli oldugu saptandi (0.02<p<0.05).

Antiprogesterone RU 486—a Drug for Non-Surgical Abortion

RU 486 is the first steroidal antiprogesterone in clinical use. It acts by binding to progesterone receptor, thus blocking the effects of progesterone at the uterine level, and provoking endometrial necrosis and shedding. RU 486 can, therefore, be used to interrupt early human pregnancy. In pregnancies of up to 7-8 weeks duration, the rate of complete abortions with RU 486 has ranged from 50% to 90%. The success rate can, however, be augmented up to 95%-100% by combining RU 486 with a low dose prostaglandin. RU 486 induced abortion has been well tolerated by women and highly acceptable to them. The bleeding starts 2-3 days after RU 486 administration lasting for 12-14 days. Possible clinical uses of RU 486 include induction of menstruation, late post-coital contraception, induction of labour after intrauterine fetal death, preoperative cervical ripening and treatment of progesterone receptor positive mammary tumours. When administered in the follicular phase of the cycle, RU 486 inhibits follicular development. In addition, the antiglucocorticoid properties of RU 486 have been used in symptomatic treatment of hypercortisolemia of Cushings disease. The pharmacokinetics of RU 486 are characterised by high micromolar serum concentrations, long half-life of 26-48 hours and substantial metabolism after oral administration. Although effective and well tolerated, RU 486 has aroused great moral controversy, which is currently hampering further testing and distribution of the drug. So far RU 486 has been accepted for termination of pregnancy in France and in the Peoples Republic of China, to be used with prostaglandins and under strict medical surveillance.

Prostaglandins and abortion:Vaginal administration of prostaglandins for induction of first trimester abortion and pre-operative cervical ripening

Prostaglandins and abortion:Vaginal administration of prostaglandins for induction of first trimester abortion and pre-operative cervical ripening