Cervical priming prior to operative hysteroscopy

Literature Review Article

Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol. Darwish A, Ahmad A, Mohammad A. Human Reproduction 2004;19(10):2391-2394. 

Review
Michelle L. Matthews, M.D. 

The aim of this study was to compare the efficacy of intravaginal misoprostol versus endocervical laminaria for cervical dilation prior to operative hysteroscopy. Patients were randomized to receive either 200 mg misoprostol (72 cases) or a single laminaria inserted into the cervical canal (72 cases) 8 hours prior to surgery. The degree of cervical dilation achieved was assessed by introducing Hegar dilators under general anesthesia. The feasibility of the procedure, complications, physician assessment of the operation and patient impression were all evaluated. 

Difficulties inserting the laminaria were reported for 36% of the patients. However, there were two cervical perforations during hysteroscopic myomectomy in the misoprostol group and none in the laminaria group. Both laminaria and misoprostol were shown to be effective in inducing adequate cervical priming. However, statistically significant differences were found between misoprostol and laminaria with regard to acceptability. Misoprostol was easier to apply (inserted by patient at home), more economical (less cost of medicine and no insertion charge), had improved patient convenience and greater patient acceptability (97.2% acceptability for misoprostol, 76.4% for laminaria). The authors concluded that further studies are needed to compare these cervical priming agents to placebo before recommending them routinely prior to operative hysteroscopy. 

Comments 
Meike L. Uhler, M.D.
Steven R. Lindheim, M.D.
 

Cervical stenosis is one of the biggest challenges to performing operative hysteroscopy, and difficulty with cervical dilation is a frequent reason for uterine perforation. Both intra-vaginal misoprostol and placement of laminaria are good options for cervical priming. The strength of this study is in its design as a randomized controlled trial with adequate and proper power analysis, and this paper adds to the literature to other similar trials using misoprostol (1,2). 
There can be complications associated with osmotic dilators as reviewed by Lichtenberg ES (3), which have been used to ripen the cervix in gynecologic and obstetric procedures for centuries and continue to play a vital role in cervical preparation. Laminaria can get trapped and fragment with the potential for serious adverse clinical consequences, though serious infection is uncommon and anaphylaxis is rare. 

References: 

  1. Barcaite E et al. Int J Gynaecol Obstet. Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women.2005. 

  2. Preuththipan S, Herabuty Y. Vaginal misoprostol forcervical priming before operative hysteroscopy: randomized controlled trial. Obstet Gynecol. Obstet Gynecol. 2000 Dec;96(6):890-4.

  3. Lichtenberg ES. Complications of osmotic dilators. Obstet Gynecol Surv. 2004 Jul;59(7):528-36.

The above review and commentary on this article were written by SRS members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment. Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

 

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