Misoprostol for cervical ripening before diagnostic hysteroscopy in nulliparous women

Abstract

Misoprostol has been used for cervical preparation before diagnostic hysteroscopic procedures, but there is no agreement on the recommended dose, route, or time of administration [1,2]. The aim of the present study was to compare the efficacy of 3 different misoprostol regimens for cervical ripening before diagnostic hysteroscopy in nulliparous women.The present study was conducted at Aretaieio Hospital, Athens, Greece, and LHTO Maternity Hospital, Athens, Greece from March 2005 to November 2010. All participants provided informed consent and the Ethical Committee of Aretaieio Hospital approved the study. Indications for diagnostic hysteroscopy were 3 failed attempts at intrauterine insemination with controlled ovarian stimulation using gonadotropins; at least 1 failed attempt at in vitro fertilization or intracytoplasmic sperm injection; menometrorrhagia; and intrauterine pathology detected by hysterosalpingography or transvaginal ultrasound. Inclusion criteria were nulliparous, premenopausal women who were fit to undergo the procedure. Exclusion criteria were any possible contraindications to the use of prostaglandins; parity; history of previous cervical procedures such as loop excision, cone biopsy, or previous dilatation and curettage; and contraindications to hysteroscopy such as active infection, bleeding, pregnancy, or suspicion of malignancy.Eligible patients were randomly allocated using a computergenerated sequence into 3 groups: group A (n = 39) received 200 μg of misoprostol orally at 12 hours and 6 hours before hysteroscopy; group B (n = 36) received 200 μg of misoprostol vaginally 12 hours before hysteroscopy; and group C (n = 35) received 200 μg of misoprostol vaginally 4 hours before hysteroscopy.Hysteroscopy was performed during the early follicular phase of the cycle. The primary outcome measure was the degree of preoperative cervical dilation required (if the hysteroscope could not be inserted) using Hegar dilators up to size 5 and introduced without force. Secondary outcome measures were time taken to dilation to introduce a Hegar dilator size 5, development of uterine or cervical injury during the procedure, development of intrauterine bands as a result of the procedure, and complications secondary to the use of misoprostol.The characteristics of the patients are shown in Table 1. A significant difference was found in the need for cervical dilation between groups A and C (12.8% vs 74.1%; P b 0.001) and between groups B and C (16.6% vs 74.1%; P b 0.001). In addition, there was a significant difference in the duration of cervical dilation to a size 5 dilator between groups A and C (35.3 ± 18 vs 63.7 ± 23 s; P b 0.001) and between groups B and C (37.5 ± 21 vs 63.7 ± 23 s; P b 0.001) ( Table 2).There were no significant differences in the occurrence of adverse effects between groups A and C, or between groups B and C (P > 0.05) ( Table 3).The group C regimen did not reduce the need for cervical dilation, which supports the findings of Singh et al. [3]. The findings of the present study are in ag...

Comparative study of efficacy and adverse effects of different doses of vaginal misoprostol for cervical ripening 10-12 hours before diagnostic hysteroscopy

“…6 In other study by Bakas P et al in while comparing the effects of 200μg of misoprostol on cervical ripening when it was given orally 12 hours before the before the procedure; vaginally 12 hours before the procedure and vaginally 4 hours before the procedure, found that ease of entry was superior in the vaginal misoprostol group 12 hours before hysteroscopy compared to the other two groups. 10 This observation was very much concordant with our study. From our study and the existing literature it can be concluded that 200μg of misoprostol administered vaginally 10-12 hours before the procedure is superior to 400μg of vaginal dose.…”

“…9 Although fever and shivering with misoprostol are well documented in literature, not many studies comparing the dose response relationship were available. 10 Adverse effects of misoprostol like diarrhoea, fever, nausea, mild abdominal pain and bleeding are significantly increased with increasing dose of misoprostol. However, these side effects are generally minor, transient, and well tolerated by patients.…”

Cervical Priming Before Diagnostic Operative Hysteroscopy in Infertile Women: A Randomized, Double-Blind, Controlled Comparison of 2 Vaginal Misoprostol Doses

“…El-Mazny and Abou-Salem 10 compared 200-mcg vaginal misoprostol with the control group in which placebo was not used; they found that cervical entry was easier, procedure time was shorter, patient acceptability was higher, and pain scoring was lower in the misoprostol group, which is in line with our findings. In a very recent study, Bakas et al 11 administered 200 mcg oral misoprostol to one group (12 hours before), 200 mcg vaginal misoprostol (12 hours before) to another, and 200 mcg vaginal misoprostol (4 hours before) to a third group. Their results support the preoperative use of 200 mcg of vaginal misoprostol 12 hours before the OH, again in line with the findings of the present study.…”