The influence of cervical dilatation by laminaria tent and with Hegar dilators on the intrauterine microflora and the rate of postabortal pelvic inflammatory disease

Leukocytosis during cervical preparation with osmotic dilators for dilation and evacuation

Objectives:

To describe leukocytosis trends during cervical preparation with osmotic dilators for second-trimester dilation and evacuation procedures, and to determine whether there is a difference in leukocytosis seen with laminaria versus Dilapan-S.

Methods:

We conducted a retrospective cohort study of 986 women presenting for dilation and evacuation from April 2008 through March 2009 at an outpatient clinic network. We included all procedures at ⩾14 weeks’ gestation where laminaria or Dilapan-S dilators were used for overnight dilation. All women had routine white blood cell testing during the study period.

Results:

There was a median increase of 2.4 × 10³/μL white blood cell count (95% confidence interval 2.2–2.7 × 10³/μL) from beginning of cervical preparation to the day of procedure (95% confidence interval and p value). Women receiving laminaria (n = 805) versus Dilapan-S (n = 181) had a greater increase in white blood cell count from baseline (median increase 2.7 versus 1.2 × 10³/μL, p < 0.001), including when adjusting for age, gestational age, parity, baseline white blood cell count, and number of dilators placed.

Conclusion:

There is increased leukocytosis during the course of cervical preparation with osmotic dilators, and this is increased with use of laminaria versus Dilapan-S. Rates of clinically recognized infection in second-trimester abortion are low regardless of dilator type used.

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.

Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013-4

For a dilation and evacuation (D&E) procedure, the cervix must be dilated sufficiently to allow passage of operative instruments and products of conception without injuring the uterus or cervical canal. Preoperative preparation of the cervix reduces the risk of cervical laceration and uterine perforation. The cervix may be prepared with osmotic dilators, pharmacologic agents or both. Dilapan-S™ and laminaria are the two osmotic dilators currently available in the United States. Laminaria tents, made from dehydrated seaweed, require 12-24 h to achieve maximum dilation. Dilapan-S™, made of synthetic hydrogel, achieves significant dilation within 4 h and is thus preferable for same-day procedures. A single set of one to several dilators is usually adequate for D&E before 20 weeks' gestation. Misoprostol, a prostaglandin E1 analogue, is sometimes used instead of osmotic dilators. It is generally regarded as safe and effective; however, misoprostol achieves less dilation than overnight osmotic tents. The literature supports same-day cervical preparation with misoprostol or Dilapan-S™ up to 18 weeks' gestation. As the evidence regarding alternative regimens increases, highly experienced D&E providers may consider same-day regimens at later gestations utilizing serial doses of misoprostol or a combination of osmotic and pharmacologic agents. Misoprostol use as an adjunct to overnight osmotic dilation is not significantly beneficial before 19 weeks' gestation. Limited data demonstrate the safety of misoprostol before D&E in patients with a prior cesarean delivery. Mifepristone, a progesterone receptor antagonist, is also effective for cervical preparation prior to D&E, although data to support its use are limited. The Society of Family Planning recommends preoperative cervical preparation to decrease the risk of complications when performing a D&E. Since no single protocol has been found to be superior in all situations, clinical judgment is warranted when selecting a method of cervical preparation.

Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation

Roughly 11% of induced abortions in the United States are performed after 14 weeks of gestation, most commonly by dilation and evacuation (D&E). For a D&E procedure, the cervix must be dilated sufficiently to allow passage of operative instruments and products of conception without injuring the uterus or cervical canal. Preoperative preparation of the cervix reduces the risk of cervical laceration and uterine perforation. The cervix may be prepared with osmotic dilators, prostaglandin analogues, or both. Osmotic dilators currently available in the United States include Dilapan-S, Lamicel, and laminaria. Laminaria tents are made from dehydrated seaweed and require 12-24 h to achieve greatest dilation. The synthetic products, Dilapan-S and Lamicel, achieve maximum effect within 6 h. Dilapan-S achieves greater dilation than the others and, thus, requires fewer dilators to be placed but may be more difficult to remove. For same day procedures, Dilapan-S and Lamicel are preferable to laminaria. A single set of one to several dilators is usually adequate for D&E before 20 weeks of gestation. Additional sets over 1-2 days may be needed in challenging cases. Misoprostol, a prostaglandin analogue, is sometimes used instead of osmotic dilators; however, the data to support such use are limited. Misoprostol is inferior to overnight dilation with laminaria for cervical priming prior to D&E. Misoprostol use as an adjunct to overnight osmotic dilation is only marginally beneficial for priming beyond 16 weeks and does not truly demonstrate any benefit before 19 weeks of gestation. Limited data demonstrate the safety of misoprostol prior to D&E in patients with a uterine scar. The Society of Family Planning recommends preoperative cervical preparation to decrease the risk of complications when performing a D&E prior to 20 weeks of gestation. The three currently available osmotic dilators (laminaria, Lamicel, and Dilapan-S) are safe and effective for this use. Since no single protocol has been found to be superior, clinical judgment is warranted when selecting a method of preoperative cervical preparation.

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.

Septic shock after intracervical laminaria insertion

OBJECTIVE

Laminaria placement is seldom thought to be associated with postabortal sepsis.

CASE REPORT

A nulliparous woman presented with high fever, low blood pressure, and signs of infection during artificial legal abortion with laminaria placement for cervical dilatation. Broad-spectrum antibiotics were given. Cultures of blood, placenta, and arterial line all yielded Enterobacter cloacae. The patient responded to antibiotics and supportive care.

CONCLUSION

The use of laminaria still places patients at risk for infection because there is a certain risk of ascending colonization with potentially pathogenic microorganisms from the vaginal and cervical microflora, as in our patient. Surgical disinfection, prophylactic antibiotics, and shortened duration of laminaria placement are helpful to prevent infectious insult. Once signs of infection are noted, physicians should take action as soon as possible, such as initiating broad-spectrum antibiotics and intensive care.

Complications of osmotic dilators

This article reviews safety, efficacy, and complications of intracervical osmotic devices and discusses diagnostic, therapeutic, and preventative measures for managing them. Osmotic dilators have been used to ripen the cervix in gynecologic and obstetric procedures for centuries. Their gradual effect in softening and dilating the cervix reduces the chance of stretch injury or perforation and could enhance completeness of evacuation of the uterine cavity. Natural and synthetic devices are available, each with unique properties. Notwithstanding major advances in prostaglandin analogs as cervical ripeners, these mechanical devices continue to play a vital role in cervical preparation. In the event of an unfavorable cervix, they are adjuncts for accelerating inductions of labor and for safe uterine entry during hysteroscopy and diagnostic dilation and curettage. For inducing pregnancy, they are routinely used as cervical ripeners from the late first trimester onward. The English-language literature was surveyed. The author used citations from a MEDLINE search, 2 unpublished case reports, and personal experience. Laminaria and Dilapan dilators can get trapped and fragment with the potential for serious adverse clinical and legal consequences. Lamicel devices do not share this feature. Serious infection is uncommon and anaphylaxis is rare. Timely, well-selected imaging techniques can aid diagnosis. Preventative measures could reduce the number and severity of osmotic dilator-associated complications. Measures suggested by some include predilating with metal dilators, incorporating laminaria or Lamicel devices with Dilapan, adding misoprostol, and using sonohysterography. However, these measures, singly and in combination, are unlikely to eliminate all complications.

Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis

OBJECTIVE

To determine whether laminaria tents are a safe and effective method of cervical dilatation in patients with a history of cervical stenosis and difficult ET.

DESIGN

Case reports describing two patients.

SETTING

Tertiary care, assisted reproduction practice.

PATIENT(S)

Two patients with cervical stenosis and a history of multiple failed cycles of IVF.

INTERVENTION(S)

Laminaria tents were placed intracervically before ET.

MAIN OUTCOME MEASURE(S)

Presence of a gestational sac and fetal heartbeat on ultrasound.

RESULT(S)

Successful clinical pregnancies occurred in both patients after laminaria placement and ET.

CONCLUSION(S)

Laminaria tent cervical dilatation appears to be a safe and effective option to assist ET in patients with a history of cervical stenosis.

Incidence of pelvic inflammatory disease after first-trimester legal abortion in women with bacterial vaginosis after treatment with metronidazole: a double-blind, randomized study

OBJECTIVE

The purpose of this study was to evaluate the effect of metronidazole treatment on the incidence of postoperative pelvic inflammatory disease after first-trimester abortion in women with bacterial vaginosis.

STUDY DESIGN

A double-blind, randomized, multicenter study was conducted on 231 women undergoing first-trimester legal abortion and fulfilling the criteria for bacterial vaginosis. The women were randomized to either metronidazole 500 mg three times daily for 10 days or placebo. Treatment was started at the outpatient visit the week before the operation.

RESULTS

Among the 174 women who could be evaluated, pelvic inflammatory disease developed in 14 after the abortion. In the treatment group there were three infections (3.8%) compared with 11 (12.2%) in the placebo group (p less than 0.05).

CONCLUSION

These data suggest that patients with bacterial vaginosis should be treated in conjunction with first-trimester abortion because treatment with metronidazole reduces the postoperative infection rate more than three times.