The use of misoprostol prior to hysteroscopy in postmenopausal women.

BACKGROUND: This study examined whether oral misoprostol exerted a cervical priming effect in postmenopausal women prior to hysteroscopy. METHOD: Thirty-seven patients were randomized to receive either oral misoprostol (400 microg) or placebo (vitamin B(6)) 12 h prior to hysteroscopy. The resistance of the cervix to dilatation was objectively assessed by a cervical tonometer. RESULTS: The mean baseline cervical dilatation (4.2 mm in misoprostol group versus 4.4 mm in placebo group) was similar between the two groups. The mean cumulative force measured (27.7 N in misoprostol group versus 21.8 N in placebo group) was also comparable. None of the patients suffered from any significant side-effects. CONCLUSIONS: These data showed that there were no significant benefits from giving misoprostol pre-operatively in postmenopausal women, and it was concluded that oral misoprostol had no significant cervical priming effect in postmenopausal women.     

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.     

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

Intravaginal misoprostol has been shown to be effective forcervical priming before a surgically induced abortion. The objectivewas to investigate the effectiveness of oral misoprostol incervical dilatation prior to vacuum aspiration between the 6thand 12th weeks of pregnancy. The results showed that in nulliparouspatients, the median cervical dilatation in the treatment group(7.8 mm) was significantly greater than that in the placebogroup (3.7 mm). In multiparous patients, the difference wasalso statistically significant (9.8 versus 6.0 mm). The easeof dilatation, assessed subjectively by the operating surgeons,was significantly improved in the treatment group. There wasalso a significant reduction in the duration of the operationand in the mean blood loss in the treatment group. The side-effectsencountered in the treatment group were mild and well acceptedby the women. Oral misoprostol is an effective and safe methodfor cervical dilatation prior to vacuum aspiration in firsttrimester pregnancy.     

Vaginal misoprostol for cervical ripening before operative hysteroscopy in pre-menopausal women: a double-blind, placebo-controlled trial with three dose regimens

BACKGROUND: To evaluate the effects of vaginal misoprostol on cervical dilatation before operative hysteroscopy in pre-menopausal women. METHODS: Four groups of 12 women were randomly assigned to receive either placebo or vaginal misoprostol in doses of 200, 400 or 800 micro g 4 h before the surgical procedure. The number of patients was calculated with an alpha = 0.01 and beta =0.20 for a difference of 50%. The primary outcome measure was cervical width, assessed by the largest size of Hegar dilator that could be inserted without resistance. The secondary outcomes were subjective assessments of the ease of dilatation and pre-operative pain, as well as adverse effects and complications. RESULTS: There was no difference in the baseline diameter of the cervical opening between the placebo group (6.1 +/- 1.4 cm) and the misoprostol groups (6.3 +/- 2.1 cm). The groups did not differ significantly in the time required for dilatation, ease of dilation, or the number of adverse effects. Pre-operative pain, evaluated by a pain scale, was greater in the treatment groups and was rated at 2.5 +/- 2.3 (P = 0.015), 2.4 +/- 1.2 (P = 0.073) and 2.8 +/- 2.9 (P = 0.012) respectively for each increasing dose group. CONCLUSIONS: Vaginal misoprostol applied 4 h before operative hysteroscopy at three different doses did not reduce the need for cervical dilatation, did not facilitate hysteroscopic surgery, and increased pre-operative pain.     

Oral misoprostol for cervical priming in non-pregnant women

Endometrial biopsy and hysteroscopy are important investigations in women presenting with abnormal vaginal bleeding. Endometrial biopsy is often performed as an outpatient procedure by endometrial aspiration. Difficulty in entering the internal cervical os may be encountered, especially in nulliparous women. The same problem may occur during hysteroscopy or dilatation and curettage. It is well known that use of a cervical priming agent is effective in reducing complications during cervical dilatation in pregnant women. However, its use in non-pregnant women is not well established. We compared oral misoprostol versus placebo for a cervical priming effect in non-pregnant women prior to hysteroscopy. The cumulative force required for cervical dilatation was significantly lower whereas the baseline cervical dilatation was significantly greater in the misoprostol group. We conclude that oral misoprostol is effective for pre-operative cervical dilatation in non- pregnant women.      

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.     

Does an acidic medium enhance the efficacy of vaginal misoprostol for pre-abortion cervical priming?

Absorption pharmacokinetics reveal a relationship between plasma concentrations of misoprostol and its therapeutic effect. To achieve a constant plasma profile and optimal efficacy, it is important to develop a medium that ensures complete dissolution of vaginal misoprostol tablets. Vaginal misoprostol is said to liquefy better in an acidic medium; thus, the aim of this study was to determine whether a 200 microg misoprostol tablet dissolved in acetic acid would be more efficacious than 200 microg misoprostol dissolved in water for pre-abortion cervical priming. A total of 120 healthy nulliparous women requesting legal termination of pregnancy between 6-12 weeks gestation were allocated randomly to either of the study groups. Vacuum aspiration was performed 3-4 h after insertion of the misoprostol tablet. Using Hegar's dilator, the degree of cervical dilatation before operation was measured. Of 60 women, 14 (23%) achieved a cervical dilatation of >/=8 mm when the misoprostol dose was dissolved in acetic acid; 12 (20%) achieved a similar cervical dilatation when the dose was dissolved in water. The mean cervical dilatation for the acid and water media used was 6.3 mm and 6.2 mm respectively; these differences were not statistically significant, neither were pre-operative and intra-operative blood losses statistically different between the two groups. Twenty-four (40%) and four (7%) respectively of women in whom a water medium was used experienced vaginal bleeding and abdominal pain; 20 (33%) and 0 women respectively among those in whom an acetic acid medium was used experienced vaginal bleeding and abdominal pain. These differences in side effects were not statistically significant. Our study shows that the use of acetic acid to dissolve vaginal misoprostol does not improve the efficacy in achieving successful cervical dilatation for pre-abortion cervical priming.     

A randomized, double blind, placebo-controlled study to investigate the use of conscious sedation in conjunction with paracervical block for reducing pain in termination of first trimester pregnancy by suction evacuation

BACKGROUND: This study evaluated the role of conscious sedation in pain relief during termination of first trimester pregnancy by suction evacuation (SE) under local anaesthesia. METHODS: A hundred women undergoing SE before 12 weeks gestation were randomized by computer using the sealed envelope method to receive placebo (saline) or conscious sedation (2 mg midazolam and 25 microg fentanyl) i.v. 5 min before cervical dilatation. Paracervical block was given to all patients, 2 min later. Pain scores during and after SE, post-operative side-effects and satisfaction level were compared. RESULTS: No statistically significant differences in pain scores were found between the two groups. Post-operative side-effects such as dizziness (P = 0.015) and drowsiness (P < 0.001) were significantly more severe in the conscious sedation group. However, patients in the conscious sedation group reported better satisfaction levels than the control group (P = 0.003). CONCLUSION: The use of conscious sedation significantly improved patient satisfaction during termination of first trimester pregnancy by SE under local anaesthesia, despite a lack of improvement in pain relief and the presence of increased severe dizziness/drowsiness in the post-operative period.     

Comparison between the sublingual and oral route of misoprostol for pre-abortion cervical priming in first trimester abortions

BACKGROUND: Misoprostol has been used for achieving cervical priming before suction evacuation (SE) by the oral or vaginal route, although both routes have their shortcomings. We evaluated the efficacy of the sublingual versus oral route of misoprostol for cervical priming before SE. METHODS: A prospective clinical trial was carried out in 100 women with a period of gestation of between 6 and 12 weeks who were sequentially allocated to two groups of 50 each. Both groups received 400 microg of misoprostol 3 h prior to SE by either the sublingual or the oral route. RESULTS: Demographically, both groups were similar. For all periods of gestation, sublingual misoprostol significantly improved cervical dilation (P<0.001) with a reduction in duration of surgery (P=0.024) compared with the oral route. Mean (+/- SD) pain scores for the sublingual and oral groups were similar (2.6 +/- 1.4 versus 3.5 +/- 1.1). No major complications occurred in either of the two groups. CONCLUSION: the sublingual route is an effective alternative to oral administration of misoprostol for cervical dilation. To the best of our knowledge, this is the first study to compare the efficacy of the sublingual versus the oral route of misoprostol for cervical priming before SE.     

Vaginal misoprostol as medical treatment for first trimester spontaneous miscarriage.

BACKGROUND: Misoprostol is effective for cervical priming prior to suction evacuation in first trimester pregnancy termination. This is the first randomized study to compare vaginal misoprostol versus expectant treatment in women presenting with spontaneous miscarriage. METHODS: Sixty women presenting with spontaneous miscarriage were recruited to the study at the Queen Mary Hospital between 1998 and 1999. They were randomized to group 1: misoprostol; and group 2: expectant management. Women in the misoprostol group received vaginal misoprostol 400 microg on days 1, 3 and 5. The expectant group was followed up according to the same schedule. Suction evacuation was performed if there was excessive bleeding or abdominal pain; or if a gestational sac was detected by transvaginal scan on day 15. RESULTS: Fifty-nine women completed the trial. Those who did not require suction evacuation up to the time of return of normal menstruation were considered to be successful. The incidence of side-effects was comparable between the two groups. Three women in the expectant group and one in the misoprostol group underwent emergency suction evacuation because of excessive bleeding. The mean duration of vaginal bleeding was similar for both groups (14.6 days in the misoprostol group versus 15.0 days in the expectant group). The successful rate in the misoprostol group was significantly higher than that of the expectant group (83.3 versus 48.3%, P < 0.05). CONCLUSION: We recommend repeated vaginal misoprostol 400 microg given on days 1, 3 and 5 as a treatment option for women with first trimester spontaneous miscarriage.     

A prospective, randomized, double-blind and placebo-controlled study to assess the efficacy of paracervical block in the pain relief during egg collection in IVF.

The role of paracervical block in the pain relief during egg collection in in-vitro fertilization (IVF) is still not confirmed. In this prospective, double-blind and placebo-controlled study, 135 patients undergoing egg collection in their first IVF cycle were randomized to receive 10 ml of 1.5% lignocaine (group A) or normal saline (group B) in the paracervical block and no local injection (group C). No differences were seen among the groups in the demographic data, the ovarian response, the duration of egg collection, the number of follicles punctured, the pregnancy rates and the pain levels related to blood taking, scanning and insertion of an i.v. cannula. All patients experienced similar pain scores for vaginal puncture but patients in group A experienced significantly less abdominal pain during egg collection, compared with those in group B and group C (P = 0.009 and P = 0.001 respectively; Mann-Whitney U-test). When lignocaine was used, the abdominal pain scores were reduced by 38.9 and 51.4% compared with placebo and no local injection respectively. We recommend that paracervical block with lignocaine should be used in conjunction with i.v. sedation/analgesia during egg collection performed through the transvaginal route under ultrasound guidance (TUGOR) to reduce the pain of the procedure.     

Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol

BACKGROUND: We aimed to compare efficacy of intravaginal misoprostol versus endocervical laminaria tents prior to operative hysteroscopy in selected cases. METHODS: A total of 144 patients with diagnosed intrauterine lesions scheduled for operative hysteroscopy were randomly allocated to two groups according to method of cervical priming prior to the procedure. Misoprostol 200 microg was inserted into the posterior fornix of the vagina for patients in group A (n=72), while laminaria tents were inserted intracervically in group B patients (n=72). RESULTS: Both methods were effective for cervical dilatation with a mean cervical diameter of 7.5+/-1.2 and 7.6+/-1.2 mm respectively. There was no significant difference in the mean cervical diameter or the time required for cervical dilatation (51.6 versus 51.4 s respectively). In contrast, there was a significant difference between the groups with respect to the insertion difficulty and in doctors' and patients' assessments of the procedure. CONCLUSIONS: Both misoprostol and laminaria were equally effective in inducing proper cervical priming prior to operative hysteroscopy with minimal time of cervical dilatation. Nevertheless, misoprostol may be superior due to easy application, reduced cost, and patient convenience and acceptability.     

A randomized study comparing the use of sublingual to vaginal misoprostol for pre-operative cervical priming prior to surgical termination of pregnancy in the first trimester

BACKGROUND: Misoprostol is an effective agent for pre-operative cervical priming before surgical termination of pregnancy in the first trimester. Previous studies have shown that both oral and vaginal routes are equally effective for such a purpose. This study aimed to compare a new route of sublingual administration to the vaginal route of administration for pre-operative cervical priming in first trimester surgical abortion. METHODS: Eighty women with gestational age <12 weeks were randomized by a computer-generated model to receive 400 micro g of misoprostol either sublingually or vaginally 3 h prior to vacuum aspiration. The primary outcome measure was the degree of cervical dilatation, and secondary outcomes included the force required to dilate the cervix from 3 to 8 mm, intra-operative blood loss and incidence of pre-operative side-effects. RESULTS: There was no significant difference in the baseline cervical dilatation (sublingual: 7.6 +/- 1.3 mm; vaginal: 7.7 +/- 0.73 mm), cumulative force required to dilate the cervix from 3 to 8 mm (sublingual: 9.0 +/- 9.8 N; vaginal: 6.6 +/- 5.4 N) and total blood loss (sublingual: 52.1 +/- 20.2 ml; vaginal: 48.3 +/- 12.3 ml). Pre-operative side-effects were also similar. CONCLUSIONS: Both sublingual and vaginal misoprostol are effective in cervical priming before surgical termination of pregnancy in the first trimester. Sublingual misoprostol has the advantage of being more convenient to administer and may be more suitable for day surgery.     

Sublingual misoprostol: A better choice for cervical priming before manual vacuum aspiration

Background: Misoprostol is effective for cervical priming before manual vacuum aspiration (MVA). Aim of study was to determine whether sublingual misoprostol with a shorter interval of 2 hours before MVA would be as effective as its standard vaginal administration. Study Design: This randomized control trial included 82 women randomly assigned to receive 400 mcg of misoprostol, either sublingually or vaginally. MVA was performed 2 hours and 3 hours after in sublingual and vaginal group, respectively. Results: Cervical dilatation of 8 mm was achieved within 2 hours in sublingual group. Mean time taken for procedure (14.4 ± 5.3: sublingual group and 16.2 ± 5.7: vaginal group), and blood loss was comparable (12.2 ± 9.7 ml in sublingual group and 13.7 ± 8.5 ml in vaginal group). Conclusion: 2 hour of cervical priming with 400 mcg of sublingual misoprostol before MVA was as good as 3 hours with vaginal administration of the same dose.     

Effect of lidocaine gel on pain from copper IUD insertion: A randomized double-blind controlled trial

Context: Insertion pain or fear of it may make women hesitate to use the intrauterine device (IUD); a long-term, reversible, highly-effective contraception method. Further study has been recommended on the effects of lidocaine (xylocaine) gel on IUD insertion pain in the recent Cochran review. Aims: To determine the effect of lidocaine gel on pain from TCu-380AIUD insertion. Materials and Methods: At a health center in Tabriz, Iran, 96 women were allocated into 3 groups using block randomization with 6 and 9 block sizes considering allocation concealment. In 1 st group, lidocaine 2% gel and in the 2 nd , lubricant gel was placed in the cervical canal 1 minute before an IUD insertion, and the 3 rd group got no intervention. Immediately after IUD insertion, pain during the insertion was measured using 0-10 cm visual analogue scale. Statistical Analysis Used: Kruskal-Wallis and linear regression in SPSS-13 were used to identify effect of lidocaine gel on the pain. Results: Overall, the mean pain score was 3.5 ± 1.8. In univariate analysis, there was no significant difference in pain scores between the 3 groups. Also, results of linear regression model by controlling effect of the possible confounding showed no significant effect of lidocaine gel on the insertion pain. The mean pain score in the lidocaine group was 0.39 less than the no intervention group, but it was not significant (CI 95% of the difference: -1.3, 0.57). Conclusions: Use of 2% lidocaine gel into the cervical canal has no effect on reducing overall pain during IUD insertion.     

Chemical ripening of the cervix with intracervical application of sodium nitroprusside: a randomized controlled trial

Nitric oxide (NO) has been found to be involved in the processes of cervical ripening. In a randomized, placebo-controlled study, cervical softening by an intracervical application of sodium nitroprusside, one of the most clinically potent and effective NO donor agents, was evaluated. A total of 36 primigravid women undergoing pregnancy termination between 9 and 12.5 weeks were enrolled. In one series, 18 patients were randomized to receive intracervically either placebo or 1% nitroprusside gel (5 mg), followed by uterine evacuation 6 h after treatment. In another series, 18 patients received either placebo or 2% nitroprusside gel (10 mg) into the cervical canal followed by uterine evacuation 3 h later. The cervical resistance, i.e. the force required to dilate the cervix from 3 to 10 mm, was the main outcome variable. It was recorded using a force sensing apparatus (dynamometer). Blood pressure was measured. Adverse events were recorded until 2 h after surgery. Women treated with both doses of nitroprusside gel showed values of cervical resistance significantly lower than those treated with placebo gel, at any tested diameter. No differences were found between subjects treated with the two different doses of nitroprusside. No significant consistent changes in blood pressure were induced by either dose of nitroprusside. No headaches were found in subjects treated with the NO donor. This study demonstrates that sodium nitroprusside applied into the cervical canal induces a rapid and significant softening of the cervix, thus reducing the force required to dilate it, compared with placebo-treated subjects. The chemical ripening of the cervix with sodium nitroprusside intracervical gel is an efficacious procedure in first-trimester pregnancy.     

Cervical priming with sublingual misoprostol prior to insertion of an intrauterine device in nulliparous women: a randomized controlled trial

BACKGROUND: The copper intrauterine device (IUD) is a highly effective andsafe contraceptive method, also in nulliparous women. However,insertion of an IUD through a narrow cervix may be technicallydifficult. Misoprostol has been shown to be effective for cervicalpriming in non-pregnant women prior to hysteroscopy. METHODS: Eighty nulliparous women requesting an IUD were randomly allocatedto receive sublingually 400 µg misoprostol and 100 mgdiclofenac (misoprostol group) or 100 mg diclofenac alone (controlgroup) 1 h prior to IUD insertion. Cervical dilatation was measuredprior to insertion using Hegar pins. Ease of insertion was judgedby the investigator. Pain, bleeding and side effects were recordedat insertion and until follow-up performed one month later. RESULTS: Following treatment with misoprostol, insertion was significantlyeasier than in the control group [P = 0.039, difference 19.36%,confidence interval (CI) –0.013, 39.99]. Pain estimatedon a visual analogue scale (1–10) showed no evidence ofa difference between the groups. The overall distribution ofside effects did not differ. However, shivering was more commonin the misoprostol group (P = 0.0084, difference 23.27%, CI6.64, 39.90). CONCLUSIONS: Misoprostol facilitates insertion of an IUD, and reduces thenumber of difficult and failed attempts of insertions in womenwith a narrow cervical canal. The optimal regimen of misoprostolremains to be defined.     

A prospective randomized study on the measured blood loss in medical termination of early pregnancy by three different misoprostol regimens after pretreatment with mifepristone

BACKGROUND: Prolonged vaginal bleeding is a common complaint after medical abortion. The effect of a 1 week course of daily oral misoprostol after medical abortion with mifepristone and misoprostol on the amount of post-abortal blood loss was studied. METHODS: A total of 150 women (gestation 相似文献   

A randomized controlled trial comparing medical and expectant management of first trimester miscarriage

BACKGROUND: We aimed to determine whether outpatient treatment of miscarriage with vaginal misoprostol is more effective than expectant management in reducing the need for surgical evacuation of retained products of conception (ERPC). METHODS: Of 131 eligible women with first trimester miscarriage, 104 agreed to randomization to either 600 microg misoprostol or placebo intravaginally. They were assessed the following day and administered a second dose of their allocated treatment if miscarriage was not complete. Those not successful after two doses were seen on day 7, and, if miscarriage was not complete, an ERPC was performed. RESULTS: The success rate of medical management was 88.5% (46/52) compared with 44.2% (23/52) for expectant management. There was no significant difference in success rate (100 versus 85.7%) in women treated with an incomplete miscarriage. Women with early pregnancy failure had a success rate of 87% with misoprostol compared with 29% with expectant management [odds ratio (OR) 15.96; 95% confidence interval (CI) 5.26, 48.37]. The complete miscarriage rate was achieved quicker in the medical group than the expectant group by day 1 (32.7 versus 5.8%) and by day 2 (73.1 versus 13.5%) of treatment. There were no differences in side-effects, bleeding duration, analgesia use, pain score and satisfaction with treatment. Women in the expectant group made more outpatient visits (5.06 versus 4.44%; OR = -0.62, 95% CI -1.04, -0.19). More women in the medical group (90.4 versus 73.1%; OR 1.26, 95% CI 1.05, 1.50) would elect the same treatment in the future. CONCLUSIONS: Medical management using 600 microg misoprostol vaginally is more effective than expectant management of early pregnancy failure. Misoprostol did not increase the side-effect profile and patient acceptability was superior to expectant management.     

Mifepristone does not induce cervical softening in non-pregnant women

BACKGROUND: Many techniques have been developed to soften the cervix to reduce complications following surgical dilatation. Progesterone inhibits myometrial contractility and its secretion during pregnancy ensures cervical competence. We used the progesterone antagonist mifepristone as a cervical ripening agent and evaluated its effect prior to office hysteroscopy. METHODS: Fifty-eight healthy non-pregnant women aged 18-50 were studied in a randomized double-blind study. They received mifepristone (200 mg) or placebo 30 h prior to hysteroscopy. A Hegar test was performed prior to drug administration and again before hysteroscopy. A visual analogue pain scale was used to assess pain. RESULTS: Medical history, physical examination and blood tests were similar in both groups, except for serum progesterone which was higher in the study group. Hegar measurement prior to drug ingestion was similar in both groups and after a mean time of 30.3 h increased in both groups. Neither the DeltaHegar measurement nor the pain scale was different in the two groups. There was also no effect of the high progesterone levels. CONCLUSIONS: Unlike its dramatic effect in the pregnant uterus, mifepristone administered 30 h prior to hysteroscopy was not effective in ripening the cervix of non-pregnant women.