Misoprostol for Cervical Priming on Non-Pregnant Uterus

摘要

Introduction Effect of Misoprostol on cervical dilatation and softening in pregnant uterus is well documented now. But the effect on non-pregnant uterus is not well known. Most of the complications in gynaecological procedures requiring cervical dilatation like endometrial biopsy, Hysteroscopy, IUCD insertion, and fractional curettage occur during cervical dilatation.Endometerial biopsy is often performed as outpatient procedure. Difficulty may be encountered in entering cervical os especially in nulliparous women. This may cause, complications, excessive pain and may even hinder performance of the procedure. The same problem may occur during hysteroscopy, dilatation & curettage, chromopertubation, IUCD insertion or fractional curettage. If cervical priming is done by some agent before the procedure, complications may be reduced. Most of the minor gynaecological procedures may be done as outpatient procedures, which may reduce anesthetic complications and decrease hospital stay and hence reduce the cost of the procedure. In addition, occasionally an endometrial biopsy cannot be easily obtained secondary to anatomic cervical stenosis, scarring, or atrophy. These are two areas of concern, and it would be beneficial to our patients if the biopsy could be less painful. This issue is not new and has been approached previously with the use of either paracervical analgesic blocks or oral nonsteroidal anti-inflammatory drugs before biopsy attempt. Secondly, in difficult biopsy cases caused by cervical anatomic changes, it would be worthwhile if there was a way to intrinsically change the cervix to make the biopsy easier. Currently, the mechanical means to overcome anatomic cervical stenosis, scarring, and atrophy during endometrial biopsy is by direct cervical traction with a tenaculum and/or the additional use of a probe, dilator, or spreading clamp. These techniques usually are associated with increased pain and anxiety. They also do not always result in successful biopsies. Misoprostol is known to cause cervical priming in pregnant uterus but its effect in nonpregnant uterus is not well known.We studied the effectiveness of 400 ?g of misoprostol given vaginally for cervical priming before endometrial biopsy, hysteroscopy, D& C, chromopertubation & fractional curettage. Material & Methods The study was conducted at Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun for one year from January 2007 to December 2007. 100 women requiring endometrial biopsy, D&C, Hysteroscopy, fractional curettage or IUCD insertion for various indications were randomized to receive 400 ?g misoprostol or placebo vaginally at night before the procedure. Those who were not admitted in the hospital were advised self administration at home. Women with medical illness like heart disease; hypertension, uncontrolled diabetes, renal disease, asthma, malignancy or other high risk factors were excluded from the study.Detailed history & examination was done. Proforma was filled. Procedure; its indication and Gynaecological examination including consistency and length of cervix will be recorded The resistance to cervical dilatation, mean cervical diameter, pain perceived by the patient, time taken for the procedure, amount of bleeding, any side effects or failure to do the procedure or failure to obtain adequate tissue for biopsy were recorded. The observations were compared between the two groups and results analyzed. Mean cervical dilation achieved before procedure were calculated by passing hegar dilator number 2 to 8 serially. Largest hegar dilator passed without resistance was recorded as mean cervical diameter. Number of women who achieved cervical dilatation more than 5 mm were calculated and compared between two groups. Pain perceived was calculated by visual analogue score and were divided in to three groups ie mild, moderate and severe.All the procedures were done by one consultant to avoid inter observer variation. Acceptability of the procedure