Table of Contents    
ORIGINAL ARTICLE
Year : 2015  |  Volume : 6  |  Issue : 3  |  Page : 123-127  

Effect of misoprostol for cervical priming before gynecological procedures on nonpregnant premenopausal women


1 Department of Gynecology and Obstetrics, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
2 Department of Gynecology and Obstetrics, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India
3 Department of Pediatric Medicine, Malda Medical College, Malda, West Bengal, India
4 Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India

Date of Web Publication28-Sep-2015

Correspondence Address:
Dr. Anjan Das
174, Gorakshabashi Road, Royal Plaza Apartment (4th Floor, Flat No-1), Nagerbazar, Kolkata - 700 028, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-9668.166116

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   Abstract 

Background: Misoprostol is very effective in cervical ripening and is used for termination of pregnancy. A similar effect on the nonpregnant uterus will facilitate gynecological operations, and hence we assessed the effect of misoprostol on the nonpregnant uterus of premenopausal women. Materials and Methods: In a prospective double-blinded randomized controlled trial, 280 women were randomly allocated into two groups (12 women did not complete the intervention). Study (A) and control (B) group received 400 μg of misoprostol or 400 mg of metronidazole tablets (as a placebo) respectively in the posterior vaginal wall 6 h prior to gynecological procedures. Results: The mean cervical dilatation was significantly higher (P < 0.0001) in misoprostol compared to placebo group (4.6 ± 0.96 mm vs. 3.6 ± 0.82 mm), benefit were also observed on secondary outcome measures which were need for further dilatation, time taken for further dilatation, ease of dilatation, subjective assessment of pain by visual analog scale. Only 3.61% patients complained of intolerable pain during dilatation in the study group while in control group 48.74% complained of intolerable pain and required anesthesia. Most common side effects of misoprostol were abdominal pain and mild vaginal bleeding. Conclusion: Misoprostol was effective in cervical ripening of nonpregnant premenopausal uterus to facilitate gynecological procedures.

Keywords: Cervical dilatation, misoprostol, nonpregnant


How to cite this article:
Saha M, Chakraborty A, Chattopadhyay S, Saha S, Paul J, Das A. Effect of misoprostol for cervical priming before gynecological procedures on nonpregnant premenopausal women. J Nat Sc Biol Med 2015;6, Suppl S1:123-7

How to cite this URL:
Saha M, Chakraborty A, Chattopadhyay S, Saha S, Paul J, Das A. Effect of misoprostol for cervical priming before gynecological procedures on nonpregnant premenopausal women. J Nat Sc Biol Med [serial online] 2015 [cited 2020 Feb 29];6, Suppl S1:123-7. Available from: http://www.jnsbm.org/text.asp?2015/6/3/123/166116


   Introduction Top


Misoprostol is extensively used in obstetrics and has proved to be very effective cervical softening agent necessary intermination of pregnancy. [1],[2],[3],[4] However, a similar beneficial effect of misoprostol on the nonpregnant uterus, will facilitate gynecological procedures that require cervical dilation such as endometrial biopsy, hysteroscopy, chromotubation, etc. Further the complications related to these procedures such as excessive pain, cervical injury may be reduced. Thus, most of the minor gynecological procedures may be performed without general anesthesia, which will lead to decreased hospital stay and hence reduce the cost of the procedure.

To facilitate cervical dilatation paracervical analgesia block or nonsteroidal anti-inflammatory drugs are commonly used before the procedure. Secondly in a difficult situation caused by cervical anatomic changes it would be worthwhile if there were a way to change intrinsically the cervix to make the dilatation easier. Misoprostol, a synthetic prostaglandin analog is found to be a very useful drug in obstetrics and gynecology. Following the vaginal application peak plasma concentration of misoprostol is reached in 1-2 h. The most common side effects of misoprostol are nausea, vomiting, diarrhea, abdominal cramps and fever, which are, dose-dependent. These side effects are, however, reduced if tablets are given vaginally compared to oral administration. Misoprostol causes strong myometrial contraction and cervical softening and dilatation. [5],[6] Although the beneficial effects of misoprostol can be hypothesized on the nonpregnant uterus as well, only a few studies have tested this. Hence, this study was designed to evaluate the beneficial effects of misoprostol on nonpregnant premenopausal uterine cervix prior to some gynecological procedures that is, to decrease the cervical resistance and facilitate the mechanical cervical dilation, to minimize the cervical or uterine injury and to decrease the pain of dilatation procedure.


   Materials and Methods Top


This randomized controlled trial was conducted from April 2009 to March 2010 in a tertiary care hospital. Following Ethical Committee approval, written and informed consent was obtained from all patients. Patients aged 20-55 years and American Society of Anesthesiologists Physical Status I, II scheduled to have diagnostic D and C or hysteroscopy for different indications, were included in the study. Exclusion criteria included postmenopausal woman, H/O bronchial asthma, allergy to prostaglandin E1, irritable bowel disease, cardiovascular diseases, patient refusal, known allergy or hypersensitivity or contraindication to prostaglandins, impaired liver function (transaminases > twice upper limit), renal dysfunction (creatinine >2.0 mg/dl), uncontrolled chronic diseases, known or suspected history of drug abuse. Proper history regarding chief complains detailed clinical examination, including general and systemic examinations and routine baseline investigations were performed. Preoperative fasting of minimum 6 h was ensured before the operation, and all patients were admitted on the day before the operation in all day care cases. Patients received oral premedication, 10 mg diazepam on the night before surgery and tablet ranitidine 150 mg in the previous night and in the morning of operation with sips of water.

The patients were randomly allocated into two parallel Groups A and B with 135 patients in the study group (Group A) and 133 patients in the control group (Group B) using computer generated randomization protocol. The patients in the study group received 400 μg of misoprostol (two 200 μg misoprostol tablets) while control group received 400 mg of metronidazole (two 200 mg of metronidazole uncoated tablet) 6 h prior to operative procedure. Drugs were administered in all women by on-duty resident doctor without showing the drugs to the patients. Drugs were supplied to the ward as per randomization schedule on the day of admission in the identical sealed envelope mentioning the registration number of the patient.

Normal saline vaginal wash was given in all patients by the on-duty nursing staff to remove any remnant of the drug before sending the patient to the operation theater. There was no discussion regarding the procedure with those persons who had supplied the drug and those resident doctors who had applied the same till completion of the study. The operative procedure was started without using any analgesia or anesthesia. Primary outcome measure was assessed by the largest size Hegar's dilators that could be inserted without resistance at the beginning of the surgical procedure. Secondary outcome were:

  1. Need for further dilatation,
  2. Ease of dilatation,
  3. Subjective assessment of pain during dilatation using visual analog scale (VAS).


They were divided into four groups that are, no discomfort, mild discomfort, mild pain, moderate to severe pain. Those who had moderate to severe pain (VAS 5 or more) received either analgesia or anesthesia during further dilatation (up to Hegar's 8). Development of preoperative side effects such as nausea, vomiting, abdominal cramp, vaginal bleeding, pyrexia of significance, and loose motion was noted. Peroperative complications (cervical injury and uterine perforations) were also recorded.

Statistical analysis

The data were analyzed using Medcalc 11.3.3.0 statistical software (MedCalc Software bvba, Acacialaan22, Ostend, Belgium) (http://www.medcalc.be). Statistical analysis included Chi-square test and t-test to compare the primary and secondary outcome between the study and control group. P < 0.05 were considered statistically significant.


   Results Top


At the beginning of the study, 312 patients were eligible for enrollment. 32 women not meeting the inclusion criteria or refusal to consent were excluded. A total of 280 women were randomized to Group A (study group) and Group B (control group) having 140 patients in each group. During follow-up, 5 in the study group and 7 in the control group were removed for not completing the intervention. 135 in the study group and 133 in the control group completed the study and were analyzed.

Patients in both the group were comparable in relation to age, parity and body mass index [Table 1]. Different operative procedures and indications of hysteroscopy were comparable between the two groups [Table 2]a and b. The primary outcome of misoprostol administration is presented in [Table 3]. Baseline cervical dilatation of 4.6 ± 0.96 mm in the study group was significantly (P < 0.0001) higher than the control group (3.6 ± 0.82 mm). Meantime needed for further cervical dilatation was significantly (P < 0.0001) delayed in the control group (study: 46.6 ± 14.57 s vs. control: 68.6 ± 14.3 s). Pain on cervical dilatation was significantly less in the study group (P < 0.05) [Table 4] and [Figure 1]. Perioperative side effects of which preoperative abdominal cramp and nausea vomiting were significantly higher in study group although these effects did not lead to any prolonged hospital stay [Table 5].
Figure 1: Assessment of pain during cervical dilatation

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Table 1: Patient profile (age, parity, BMI)

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Table 2

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Table 3: Results of misoprostol administration

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Table 4: Subjective assessment of pain during cervical dilatation

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Table 5: Perioperative side effect

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   Discussion Top


Cervical priming prior to gynecological procedures facilitates the operation and decreases the risk of cervical, uterine injury that are often associated with the mechanical dilatation. Various prostaglandin preparations, laminaria tents are commonly used for cervical priming. Cervical injury, uterine perforations, pain due to cervical dilatation despite local anesthesia and precise technique are the major problem associated with these procedures.

The off-label use of misoprostol for gynecological indications has received less attention, despite reports of its effectiveness in inducing cervical dilatation. [7],[8],[9] Indeed oral or vaginal misoprostol application before hysteroscopy resulted in greater cervical dilatation, decreased cervical resistance and less need for further dilatation. [10],[11],[12],[13] In the present study, as well misoprostol treated women had significantly increased baseline cervical dilatation. Resistance to cervical dilatation and mean time taken for dilatation was less in misoprostol group when compared with control group. Which is in contrast to Dan et al. [14] and Perrone et al. [15] reporting no priming effect of misoprostol on premenopausal cervix and rather misoprostol use causing more pain, uterine cramping, and vaginal bleeding. Likewise, Bunnasathiansri et al., [16] Fung et al. [17] also did not observe any significant benefit from applying misoprostol in postmenopausal women. This might however, be due to hypo estrogenic state as pretreatment with estrogen facilitated misoprostol-induced cervical priming in postmenopausal women. [18],[19]

Different studies had used misoprostol in different dose and routes of administration. The dose varied from 100 to 1000 μg and duration of insertion before procedures varied from 2 to 12 h. A single dose 400 μg misoprostol given vaginally 3 h prior to intervention seems to given the best efficacy with least side effects, however this is contradicted by study reporting similar effects achieved by all three routes of misoprostol application (i.e., oral, vaginal and sublingual). [20] In our study, we used 400 μg single dose of misoprostol by vaginal route 6 h prior to the procedures as a cervical priming agent. Our aim was to see the effectiveness of misoprostol by this approach. Though diagnostic hysteroscopy could be done using 4 mm scope without anesthesia in many cases. However, in nulliparous and elderly women introduction of hysteroscope without prior dilatation may cause difficulties. In this study, we have used larger size hysteroscope with an intention to perform minor operative procedures such as removal of Copper T, endometrial biopsy etc., if required, at the same sitting. As vaginal misoprostol was found to be effective as a cervical priming agent in nonpregnant premenopausal women in our study, this approach could be applied before operative hysteroscopy procedures. Moreover, the use of misoprostol as cervical priming agent reduces the requirement of analgesia or anesthesia during the hysteroscopy procedures thereby minimizing the complications and cost associated with treatment. Nevertheless, prior hospitalization was required to apply vaginal misoprostol, and this was the only limitation of this study. Self-vaginal application or sublingual route may be the solution of address this problem, which needs further evaluation. We conclude that misoprostol is effective in increasing cervical dilatation, decreasing both cervical resistance and need for additional dilatation before hysteroscopy in premenopausal women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Hofmeyr GJ, Gülmezoglu AM, Alfirevic Z. Misoprostol for induction of labour: A systematic review. Br J Obstet Gynaecol 1999;106: 798-803.  Back to cited text no. 1
    
2.
Cecatti JG, Tedesco RP, Pires HM, Calderon IM, Faúndes A. Effectiveness and safety of a new vaginal misoprostol product specifically labeled for cervical ripening and labor induction. Acta Obstet Gynecol Scand 2006;85:706-11.  Back to cited text no. 2
    
3.
Sahu L, Chakravertty B. Comparison of prostaglandin E 1 (misoprostol) with prostaglandin E 2 (dinoprostone) for labor induction. J Obstet Gynecol India 2004;54:139-42.  Back to cited text no. 3
    
4.
Sakhare AP, Mahale AR, Kardile GP. Vaginal misoprostol for medical evacuation of missed abortion. J Obstet Gynecol India 2005;55:178-9.  Back to cited text no. 4
    
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Tenore JL. Methods for cervical ripening and induction of labor. Am Fam Physician 2003;67:2123-8.  Back to cited text no. 5
    
6.
Briggs GG, Wan SR. Drug therapy during labor and delivery, part 2. Am J Health Syst Pharm 2006;63:1131-9.  Back to cited text no. 6
    
7.
Ngai SW, Chan YM, Liu KL, Ho PC. Oral misoprostol for cervical priming in non-pregnant women. Hum Reprod 1997;12:2373-5.  Back to cited text no. 7
    
8.
Preutthipan S, Herabutya Y. Vaginal misoprostol for cervical priming before operative hysteroscopy: A randomized controlled trial. Obstet Gynecol 2000;96:890-4.  Back to cited text no. 8
    
9.
Preutthipan S, Herabutya Y. A randomized comparison of vaginal misoprostol and dinoprostone for cervical priming in nulliparous women before operative hysteroscopy. Fertil Steril 2006;86:990-4.  Back to cited text no. 9
    
10.
Oppegaard KS, Nesheim BI, Istre O, Qvigstad E. Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design. BJOG 2007;114:769, e1-12.  Back to cited text no. 10
    
11.
Oppegaard KS, Nesheim BI, Istre O, Qvigstad E. Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design. BJOG 2008;115:663, e1-9.  Back to cited text no. 11
    
12.
Batukan C, Ozgun MT, Ozcelik B, Aygen E, Sahin Y, Turkyilmaz C. Cervical ripening before operative hysteroscopy in premenopausal women: A randomized, double-blind, placebo-controlled comparison of vaginal and oral misoprostol. Fertil Steril 2008;89:966-73.  Back to cited text no. 12
    
13.
Barcaite E, Bartusevicius A, Railaite DR, Nadisauskiene R. Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women. Int J Gynaecol Obstet 2005;91:141-5.  Back to cited text no. 13
    
14.
Dan Yu, Li TC, Xia E, Xiaowu H. A prospective randomized controlled trial comparing vaginal misoprostol and osmotic dilator in achieving cervical ripening before operative hysteroscopy. Gynecol Surg 2006;3:186-9.  Back to cited text no. 14
    
15.
Perrone JF, Caldito G, Mailhes JB, Tucker AN, Ford WR, London SN. Oral misoprostol before office endometrial biopsy. Obstet Gynecol 2002;99:439-44.  Back to cited text no. 15
    
16.
Bunnasathiansri S, Herabutya Y, O-Prasertsawat P. Vaginal misoprostol for cervical priming before dilatation and curettage in postmenopausal women: A randomized controlled trial. J Obstet Gynaecol Res 2004;30:221-5.  Back to cited text no. 16
    
17.
Fung TM, Lam MH, Wong SF, Ho LC. A randomised placebo-controlled trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women. BJOG 2002;109:561-5.  Back to cited text no. 17
    
18.
Oppegaard KS, Lieng M, Berg A, Istre O, Qvigstad E, Nesheim BI. A combination of misoprostol and estradiol for preoperative cervical ripening in postmenopausal women: A randomised controlled trial. BJOG 2010;117:53-61.  Back to cited text no. 18
    
19.
Atmaca R, Kafkasli A, Burak F, Germen AT. Priming effect of misoprostol on estrogen pretreated cervix in postmenopausal women. Tohoku J Exp Med 2005;206:237-41.  Back to cited text no. 19
    
20.
Lee YY, Kim TJ, Kang H, Choi CH, Lee JW, Kim BG, et al. The use of misoprostol before hysteroscopic surgery in non-pregnant premenopausal women: A randomized comparison of sublingual, oral and vaginal administrations. Hum Reprod 2010; 25:1942-8.  Back to cited text no. 20
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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