Sublingual versus vaginal misoprostol for cervical ripening before hysteroscopy: a randomized clinical trial

A randomised comparative study of sublingual and vaginal misoprostol for cervical priming before minor gynaecological procedures

This study aimed to compare the effect of misoprostol using vaginal or sublingual routes on the non-pregnant uterine cervix prior to minor gynaecological procedures. One hundred and forty women were randomised 1:1 into two groups: A and B. Group A received misoprostol 400 mcg vaginally and pyridoxine 40 mg sublingually and Group B received misoprostol 400 mcg sublingually and pyridoxine 40 mg vaginally 4 h prior to procedure. The outcomes studied were maximum size of Hegar's dilator that could be inserted into the cervix without any resistance, ease of dilatation, need and time required for further dilatation, side effects and complications. Baseline cervical dilatation was significantly more in Group A than Group B. Need for further dilatation and time required for further dilatation were also significantly less in Group A than Group B. Thus, we conclude that vaginal misoprostol is more effective than sublingual misoprostol in cervical priming before minor gynaecological procedures. Clinical Trial Registration Number: www.ctri.nic.in; CTRI/2018/07/015080 IMPACT STATEMENTWhat is already known on this subject? Cervical priming has been shown to result in shorter operative time, easier mechanical dilatation, reduced incidence of complications and blood loss when used prior to surgical abortion and has been recommended as a standard practice in various national and international guidelines for safe abortion practices. Misoprostol has many advantages over other ripening agents like osmotic dilators, other prostaglandins and mifepristone. Misoprostol can be given through oral, sublingual, vaginal, buccal and rectal routes. Use of misoprostol has been found to improve cervical dilatation, reduce need of further dilatation and ease of dilatation without many complications when compared to placebo for cervical priming of non-pregnant cervix. Studies comparing vaginal and sublingual routes have shown no significant difference for cervical ripening in pregnant women.What the results of this study add? We found that vaginal misoprostol for cervical priming was more effective than sublingual misoprostol in reaching a higher baseline cervical dilatation, with reduced need and time required for further dilatation before minor gynaecological procedures, although the ease of dilatation was similar in both groups. This effect of vaginal misoprostol was more marked in premenopausal women.What the implications are of these findings for clinical practice and/or further research? The results of our study are at variance with other studies done on use of misoprostol via the vaginal or sublingual routes, and hence it is imperative that large multi-center studies be performed to bring about consensus on the topic.

The use of misoprostol for cervical priming prior to hysteroscopy: a systematic review and analysis

The effects of misoprostol use on cervical priming prior to hysteroscopy have been controversial. Therefore, a systematic literature review and meta-analysis of studies were conducted to assess the effect of misoprostol on cervical priming prior to hysteroscopy. All studies published before July 2014 with data related to the use of misoprostol for cervical priming compared with placebo or no medication prior to hysteroscopy, were identified. Twenty-five randomized controlled trials involving 2,203 females were systematically analyzed. The results showed that, compared with placebo or no medication, the use of misoprostol prior to hysteroscopy led to a significant relief of the need for cervical dilatation, resulted in a significantly greater cervical width, had fewer hysteroscopy complications, and mild and insignificant side effects. Subgroup analyses revealed that the regimen of 200 or 400 μg vaginal misoprostol may be a simple and effective method for cervical priming, especially prior to operative hysteroscopy.

Complications of Hysteroscopic and Uterine Resectoscopic Surgery

Adverse events associated with hysteroscopic procedures are generally rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. There exists a spectrum of complications that relate to generic components of procedures, such as patient positioning, anesthesia, and analgesia, to a number that are specific to intraluminal endoscopic surgery that largely comprise perforation and injuries to surrounding structures and blood vessels. Whereas a number of endoscopic procedures require the use of distending media, the response of premenopausal women to excessive absorption of nonionic fluids used for hysteroscopy is somewhat unique, and deserves special attention on the part the surgeon. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar radiofrequency uterine resectoscopes that involve thermal injury to the vulva and vagina. Furthermore, the uterus that has previously undergone hysteroscopic surgery may behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Fortunately, better understanding of the mechanisms involved in these adverse events, as well as the use or development of a number of innovative devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.

Experimental comparison of properties of natural and synthetic osmotic dilators

PURPOSE

The in vitro study compares natural and synthetic osmotic dilators in selected parameters influencing their clinical efficacy.

METHODS

Diameters of Laminaria and synthetic dilators (Dilapan-S and Dilasoft) were measured in dry state, during free swelling in isotonic solution and during swelling against a force. Three aspects were evaluated-diameter increase, speed of action and consistency of action.

RESULTS

The maximum diameter increase of 3 and 4-mm Dilapan-S was 3.6 and 3.3 times, of Dilasoft 3.2 and 3.1 times, respectively. For Laminaria, it was 2.9 and 2.7 times. The difference between synthetic dilators and Laminaria was statistically significant (p < 0.01). Synthetic dilators also swelled faster. Under applied counter force, synthetic dilators increased their diameter more than Laminaria (+3.6 mm for Dilapan-S, +3.8 mm for Dilasoft, +1.2 mm for Laminaria; p < 0.01) and achieved faster expansion. Synthetic dilators also showed significantly higher consistency between samples in all experiments.

CONCLUSIONS

Synthetic dilators compared to Laminaria reached higher maximum diameters, acted faster, were more consistent and were able to expand against force three times more. The results support clinical observations that synthetic dilators are more suitable and preferable for same-day D&E procedure and that fewer synthetic dilators are needed to achieve the same effect.

A Prospective, Randomized Comparison of Intramuscular Phloroglucinol Versus Oral Misoprostol for Cervix Pretreatment Before Diagnostic Hysteroscopy

The aim of this study was to compare the effectiveness and safety of intramuscular phloroglucinol and oral misoprostol for cervix pretreatment before diagnostic hysteroscopy. Several modalities for cervical priming and pain reduction have been adopted to reduce the complications related to cervical dilatation before hysteroscopy. Among them, the prostaglandin analog misoprostol is the most frequently used agent. Phloroglucinol, a spasmolytic, has also been showed to have an effect in inducing cervical dilatation but is rarely used before hysteroscopy. One hundred twenty outpatients undergoing anesthesia-free diagnostic hysteroscopy were randomly assigned to receive 80 mg intramuscular phloroglucinol and 400 mg oral misoprostol before diagnostic hysteroscopy. The main outcome measures were preoperative cervical width, visual analog scales (VAS) for pain, cervical passage time, and adverse reactions. Intramuscular phloroglucinol resulted in a significantly wider cervical width, lower VAS pain score, shorter cervical passage time, and a lower adverse effects rate compared with oral misoprostol. Intramuscular phloroglucinol is more effective and safer than oral misoprostol in inducing proper cervical priming and may be the optimal choice for cervical pretreatment before diagnostic hysteroscopy.

Comparison of nonsteroidal anti-inflammatory drugs and misoprostol for pain relief during and after hysterosalpingography: prospective, randomized, controlled trial

STUDY OBJECTIVE

To assess whether vaginal misoprostol or oral nonsteroidal anti-inflammatory drugs (NSAIDs) reduce pain during and 30 minutes after hysterosalpingography (HSG).

DESIGN

Randomized prospective, controlled, parallel-group study (Canadian Task Force classification I).

SETTING

University teaching hospital.

PATIENTS

One hundred sixty-eight women with primary infertility who underwent HSG for evaluation of infertility.

INTERVENTIONS

Patients were randomly assigned to 1 of 3 groups. Group 1 received 200 μg misoprostol vaginally 6 hours before HSG; group 2, 50 mg diclofenac potassium orally 45 to 60 minutes before HSG; and group 3, no medication. The primary outcome of the study was to evaluate the severity of pain during and 30 minutes after the procedure using a visual analog scale (VAS) ranging from 1 (very favorable) to 10 (very unfavorable). The secondary outcomes were to assess the rate of completion and the vasovagal effects including nausea, vomiting, sweating, weakness, syncope, hypotension, and bradycardia.

MEASUREMENTS AND MAIN RESULTS

There was no statistically significant difference in the median (25%-75%) VAS pain scores between women administered vaginal misoprostol (median, 6.7 cm; range, 4.7-9 cm) and the control group (median, 6.7 cm; range, 4.6-8.8 cm) during the HSG. However, women in the NSAID group (median, 5.5 cm; range, 3-7.6 cm) reported less pain than did those in the misoprostol group (p = .009) and the control group (p = .03). At 30 minutes after HSG, there was no significant difference in the median VAS pain scores between patients administered NSAIDs (median, 2.3 cm; range, 1.4-4.2) or misoprostol (median, 2.3 cm; range, 1.2-4.4) and the control group (median, 2.2 cm; range, 1.3-4.4).

CONCLUSIONS

There is no benefit in terms of pain reduction with the use of misoprostol during HSG or at 30 minutes after the procedure. However, NSAIDs are associated with pain relief during the HSG procedure.