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

A randomized double blinded clinical trial to explore the clinical outcomes of vaginal isonicotinic acid hydrazide (INH) administration six hours prior to T380A intrauterine device insertion in persons delivered only by cesarean delivery

OBJECTIVE

To compare insertion pain and ease of insertion in participants with a prior caesarean delivery having copper intrauterine device (IUD) after pretreatment with isonicotinic acid hydrazide (INH) 900 mg vaginally or placebo.

STUDY DESIGN

From September 2020 to September 2021, we conducted a randomized, double-blind, placebo-controlled experiment at Aswan University Hospital in Egypt with participants who were delivered solely by caesarean delivery and desired copper T380A IUD insertion. The participants were randomly assigned to either vaginal INH or placebo six hours before IUD insertion in a 1:1 ratio. The primary objective of the research was the individuals' self-reported pain during cervical tenaculum placement, sound insertion, IUD insertion, and 5 minutes after the placement, as measured by a 10-cm visual analogue scale (VAS). Our secondary outcomes were ease of insertion, satisfaction, the need for analgesics, and adverse effects. IUD insertion ease was graded from 0 to 10 on a 10-cm VAS scale, with 0 suggesting very easy insertion and 10 denoting extremely difficult insertion.

RESULTS

When compared to the placebo group, the INH group experienced considerably less pain during IUD insertion (2.9±0.85vs.5.11±0.82;p<0.01), lower median ease of insertion score (3(1-4)vs.5(3-6);p<0.01), and better satisfaction (8.17±0.69vs.5.57±0.75). The two groups had comparable side effects.

CONCLUSIONS

Vaginal INH administered before IUD insertion reduce the amount of discomfort participants feel throughout the process in individuals who had previously only been delivered via CD. It also has the potential to make insertion easier.

IMPLICATIONS

In participants who were delivered solely by CD before, vaginal INH given prior to IUD placement reduces the amount of discomfort participants experience throughout the procedure. Furthermore, it could increase the ease of insertion.

Women-specific routes of administration for drugs: A critical overview

The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.

Nitric oxide donors for cervical ripening in first-trimester surgical abortion

BACKGROUND

Cervical priming before first-trimester surgical abortion is recommended in certain groups of women. Nitric oxide (NO) donors induce cervical ripening without uterine contractions, but the efficacy and side effects are of concern.

OBJECTIVES

To evaluate NO donors for cervical ripening before first-trimester surgical abortion, in terms of efficacy, side effects, and reduction of complications.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and POPLINE. We also searched reference lists of retrieved papers. We contacted experts in the field for information on both published and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials comparing NO donors alone or in combination with other methods for cervical ripening in first-trimester surgical abortion.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and extracted the data onto a data extraction form. We processed the data using Review Manager (RevMan 5) software.

MAIN RESULTS

We included 9 studies involving 766 participants. There were no serious complications (infection requiring antibiotic treatment, blood transfusion, complications requiring unintended operation, cervical injury, uterine perforation, death or serious morbidity) in the included trials.NO donors were more effective in cervical ripening when compared with placebo or no treatment. Baseline cervical dilatation before the procedure was higher in NO donors group (mean difference (MD) 0.30, 95% confidence interval (CI) 0.01 to 0.58) The cumulative force required to dilate the cervix to 8 mm (MD -4.29, 95% CI -9.92 to 1.35), headache (risk ratio (RR) 1.73, 95% CI 0.86 to 3.46), abdominal pain (RR 0.87, 95% CI 0.50 to 1.50), or patient satisfaction (RR 0.95, 95% CI 0.84 to 1.07) were not different. More nausea and vomiting occurred in the women who received a NO donor (RR 2.62, 95% CI 1.07 to 6.45).NO donors were inferior to prostaglandins for cervical ripening. The cumulative force required to dilate the cervix to 8 mm to 9 mm was higher (MD 13.12, 95% CI 9.72 to 16.52), and baseline cervical dilatation was less (MD -0.73, 95% CI -1.01 to -0.45) in the NO donor group. However, the probability of dilation greater than 8 mm at three hours was higher in the NO donor group (RR 6.67, 95% CI 2.21 to 20.09). Side effects including headache (RR 5.13, 95% CI 3.29 to 8.00), palpitation (RR 3.43, 95% CI 1.64 to 7.15), dizziness (RR 3.29, 95% CI 1.46 to 7.41), and intraoperative blood loss (MD 33.59 ml, 95% CI 24.50 to 42.67) were also higher. However, abdominal pain (RR 0.33, 95% CI 0.25 to 0.44) and vaginal bleeding (RR 0.14, 95% CI 0.07 to 0.27) were less in the NO donor group. No difference for nausea/vomiting in both groups(RR 1.17, 95% CI 0.94 to 1.46). Patient satisfaction was not different.One trial compared a NO donor with a NO donor plus prostaglandin. The cumulative force required to dilate the cervix to 8 mm was higher (MD 14.50, 95% CI 0.50 to 28.50) in the NO donor group. There was no difference in headache (RR 0.88, 95% CI 0.38 to 2.00), abdominal pain (RR 0.14, 95% CI 0.02 to 1.07), or intraoperative blood loss (MD -50, 95% CI -164.19 to 64.19).

AUTHORS' CONCLUSIONS

NO donors are superior to placebo or no treatment, but inferior to prostaglandins for first-trimester cervical ripening, and associated with more side effects.

Nitric oxide donors for cervical ripening in first-trimester surgical abortion

BACKGROUND

Cervical priming before first-trimester surgical abortion is recommended in certain groups of women. Nitric oxide (NO) donors induce cervical ripening without uterine contractions, but the efficacy and side effects are of concern.

OBJECTIVES

To evaluate efficacy, side effects and complications of NO donors for cervical ripening before first-trimester surgical abortion.

SEARCH METHODS

We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and POPLINE. We also searched reference lists of retrieved papers. We contacted experts in the field for information on both published and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials comparing NO donors alone or in combination with other methods for cervical ripening in first-trimester surgical abortion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected and extracted the data onto a data extraction form. We processed the data using Review Manager (RevMan5) software.

MAIN RESULTS

We included nine studies involving 766 participants. There were no serious complications (infection requiring antibiotic treatment, blood transfusion, complications requiring unintended operation, cervical injury, uterine perforation, death or serious morbidity) in the trials included.NO donors were more effective in cervical ripening comparing with placebo or no treatment. Baseline cervical dilatation before the procedure was higher in NO donors group (mean difference 0.30, 95% CI 0.01, 0.58) The cumulative force required to dilate the cervix to 8 mm (mean difference -4.29, 95% CI -9.92, 1.35), headache (RR 1.73, 95% CI 0.86, 3.46), abdominal pain (RR 0.87, 95% CI 0.50, 1.50) or patient satisfaction (RR 0.95, 95% CI 0.84, 1.07) were not different. More nausea and vomiting occurred in the women who received a NO donor (RR 2.62, 95% CI 1.07, 6.45).NO donors were inferior to prostaglandins for cervical ripening. The cumulative force required to dilate the cervix to 8-9 mm was higher (mean difference 13.12, 95% CI 9.72, 16.52) and baseline cervical dilatation was less (mean difference -0.73, 95% CI -1.01, -0.45) in the NO donor group. Side effects including headache (RR 5.13, 95% CI 3.29, 8.00), palpitation (RR 3.43, 95% CI 1.64, 7.15), dizziness (RR 3.29, 95% CI 1.46, 7.41) and intraoperative blood loss (mean difference 33.59 ml, 95% CI 24.50, 42.67) were also higher. However, abdominal pain (RR 0.33, 95% CI 0.25, 0.44) and vaginal bleeding (RR 0.14, 95% CI 0.07, 0.27) was less in the NO donor group. Patient satisfaction was not different.One trial compared a NO donor with a NO donor plus prostaglandin. The cumulative force required to dilate the cervix to 8 mm was higher (mean difference 14.50, 95% CI 0.50, 28.50) in the NO donor group. There was no difference in headache (RR 0.88, 95% CI 0.38, 2.00), abdominal pain (RR 0.14, 95% CI 0.02, 1.07) or intraoperative blood loss (mean difference -50, 95% CI -164.19, 64.19).

AUTHORS' CONCLUSIONS

NO donors are superior to placebo or no treatment, but inferior to prostaglandins for first-trimester cervical ripening, and associated with more side effects.

Oral misoprostol and vaginal isosorbide mononitrate for labor induction: a randomized controlled trial

OBJECTIVE

To estimate whether vaginal isosorbide mononitrate, added to oral misoprostol for cervical ripening and labor induction, shortens time to vaginal delivery.

METHODS

A prospective, randomized trial was conducted. Women scheduled for labor induction between 32 and 42 weeks and with unfavorable cervices (modified Bishop score 6 or lower) were randomized to receive oral misoprostol every 4 hours, up to four doses, with or without isosorbide mononitrate every 6 hours, up to two doses. A strict protocol was used, including timing of oxytocin use and amniotomy. Side effects were assessed 6 hours after study initiation. One hundred forty-two patients were required to detect a change in time to vaginal delivery of 4 hours (alpha=.05 and beta=.20). Data were analyzed by intent to treat. Student's t, chi square, Fisher's exact, and Mann-Whitney tests were used where appropriate with P< or =.05 deemed significant.

RESULTS

One hundred fifty-six women were randomized; three were excluded after randomization. Seventy-eight women received misoprostol, and 78 received misoprostol with isosorbide mononitrate. Demographic characteristics were similar between groups. The time to vaginal delivery was not reduced when isosorbide mononitrate was added to misoprostol. Cesarean delivery rates and contraction and fetal heart rate abnormalities were similar between groups. Side effects were also similar between groups, except that women given isosorbide mononitrate experienced headaches more often. Neonatal outcomes were similar between groups.

CONCLUSION

The addition of vaginal isosorbide mononitrate to oral misoprostol for cervical ripening and labor induction did not reduce time to vaginal delivery and was associated with a greater incidence of headache.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00374621.

LEVEL OF EVIDENCE

I.

Nitric oxide donors for cervical ripening in first-trimester surgical abortion

BACKGROUND

Cervical priming before first-trimester surgical abortion is recommended in certain groups of women. Nitric oxide (NO) donors induce cervical ripening without uterine contractions, but the efficacy and side effects are of concern.

OBJECTIVES

To evaluate efficacy, side effects and complications of NO donors for cervical ripening before first-trimester surgical abortion.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and Popline. We also searched reference lists of retrieved papers. We contacted experts in the field for information on both published and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials comparing NO donors alone or in combination with other methods for cervical ripening in first-trimester surgical abortion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected and extracted the data onto a data extraction form. We processed the data using Review Manager (RevMan5) software.

MAIN RESULTS

We included eight studies involving 718 participants. There were no serious complications (infection requiring antibiotic treatment, blood transfusion, complications requiring unintended operation, cervical injury, uterine perforation, death or serious morbidity) in the trials included.NO donors were ineffective in cervical ripening comparing with placebo or no treatment. The cumulative force required to dilate the cervix to 8 mm (mean difference -4.29, 95% CI -9.92, 1.35), baseline cervical dilatation before the procedure (mean difference 0.21, 95% CI -0.12, 0.53), headache (RR 1.73, 95% CI 0.86, 3.46), abdominal pain (RR 0.87, 95% CI 0.51, 1.50) or patient satisfaction (RR 0.95, 95% CI 0.84, 1.07) were not different. More nausea and vomiting occurred in the women who received a NO donor (RR 2.62, 95% CI 1.07, 6.75).NO donors were inferior to prostaglandins for cervical ripening. The cumulative force required to dilate the cervix to 8-9 mm was higher (mean difference 13.12, 95% CI 9.72, 16.52) and baseline cervical dilatation was less (mean difference -0.73, 95% CI -1.01, -0. 45) in the NO donor group. Side effects including headache (RR 5.13, 95% CI 3.29, 8.00), palpitation (RR 3.43, 95% CI 1.64, 7.15), dizziness (RR 3.29, 95% CI 1.46, 7.41) and intraoperative blood loss (mean difference 33.59 ml, 95% CI 24.50, 42.67) were also higher. However, abdominal pain (RR 0.33, 95% CI 0.25, 0.44) and vaginal bleeding (RR 0.14, 95% CI 0.07, 0.27) was less in the NO donor group. Patient satisfaction was not different.One trial compared a NO donor with a NO donor plus prostaglandin. The cumulative force required to dilate the cervix to 8 mm was higher (mean difference 14.50, 95% CI 0.50, 28.50) in the NO donor group. There was no difference in headache (RR 0.88, 95% CI 0.38, 2.00), abdominal pain (RR 0.14, 95% CI 0.02, 1.07) or intraoperative blood loss (mean difference -50, 95% CI -164.19, 64.19).

AUTHORS' CONCLUSIONS

NO donors are inferior to prostaglandins for first-trimester cervical ripening, and associated with more side effects. NO donors are comparable to placebo and no treatment for cervical ripening.

Nitric oxide in the human uterine cervix: endogenous ripening factor

The human uterine cervix can produce nitric oxide (NO), a free radical with an ultra-short half-life. The release of NO changes during pregnancy and is increased in early nonviable pregnancies compared to normal uncomplicated pregnancies. This review concentrates on the role of NO release in cervical ripening in pregnant women. Also some suggestions on future aspects are discussed.