Cervical preparation for first trimester surgical abortion: Cochrane systematic review
Assessed as up to date: 2009/10/09
Preparing the cervix prior to surgical abortion is intended to make the procedure both easier and safer. Options for cervical preparation include osmotic dilators and pharmacologic agents. Many formulations and regimens are available, and recommendations from professional organizations vary for the use of preparatory techniques in women of different ages, parity or gestational age of the pregnancy.Objectives
To determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred.Search strategy
We searched Cochrane, Popline, Embase, Medline and Lilacs databases for randomised controlled trials investigating the use of cervical preparatory techniques prior to first trimester surgical abortion. In addition, we hand-searched key references and contacted authors to locate unpublished studies or studies not identified in the database searches.Selection criteria
Randomised controlled trials investigating any pharmacologic or mechanical method of cervical preparation, with the exception of nitric oxide donors (the subject of another Cochrane review), administered prior to first trimester surgical abortion were included. Outcome measures must have included the amount of cervical dilation achieved, the procedure duration or difficulty, side-effects, patient satisfaction or adverse events to be included in this review.Data collection and analysis
Trials under consideration were evaluated by considering whether inclusion criteria were met as well as methodologic quality. Fifty-one studies were included, resulting in 24 different cervical preparation comparisons. Results are reported as odds ratios (OR) for dichotomous outcomes and weighted mean differences for continuous data.Main results
When compared to placebo, misoprostol (400-600 µg given vaginally or sublingually), gemeprost, mifepristone (200 or 600 mg), prostaglandin E and F2α (2.5 mg administered intracervically) demonstrated
larger cervical preparation effects. When misoprostol was compared to gemeprost, misoprostol was more effective in preparing the cervix and was associated with fewer gastrointestinal side-effects. For vaginal administration, administration 2 hours prior was less effective than administration 3 hours prior to the abortion. Compared to oral misoprostol administration, the vaginal route was associated with significantly greater initial cervical dilation and lower rates of side-effects; however, sublingual administration 2-3 hours prior to the procedure demonstrated cervical effects superior to vaginal administration.
When misoprostol (600 µg oral or 800 µg vaginal) was compared to mifepristone (200 mg administered 24 hours prior to procedure), misoprostol had inferior cervical preparatory effects. Compared to day-prior laminaria tents, 200 or 400 µg vaginal misoprostol showed no differences in the need for further mechanical dilation or length of the procedure; similarly, the osmotic dilators Lamicel and Dilapan showed no differences in cervical ripening when compared to gemeprost, although gemeprost had cervical effects which were superior to laminaria tents. Older prostaglandin regimens (sulprostone, prostaglandin E2 and
F2α) were associated with high rates of gastrointestinal side-effects and unplanned pregnancy expulsions. Few studies reported women's satisfaction with cervical preparatory techniques.Authors' conclusions
Modern methods of cervical ripening are generally safe, although efficacy and side-effects between methods vary. Reports of adverse events such as cervical laceration or uterine perforation are uncommon overall in this body of evidence and no published study has investigated whether cervical preparation impacts these rare outcomes. Cervical preparation decreases the length of the abortion procedure; this may become increasingly important with increasing gestational age, as mechanical dilation at later gestational ages takes longer and becomes more difficult. These data do not suggest a gestational age where the benefits of cervical dilation outweigh the side-effects, including pain, that women experience with cervical ripening procedures or the prolongation of the time interval before procedure completion. Mifepristone 200 mg, osmotic dilators and misoprostol, 400µg administered either vaginally or sublingually, are the most effective methods of cervical preparation.
Kapp Nathalie, Lohr Patricia A., Ngo Thoai D, Hayes Jennifer L
Preparing the cervix before first trimester surgical abortion
Preparing the cervix to make it softer and more open before a woman has an abortion may make the procedure easier and safer. There are different techniques for preparing the cervix before abortion, including several types of medications taken either by mouth, injection or placed in the vagina, as well as several types of small rods that can be placed within the cervix. This review found that cervical preparation decreased the length of time necessary for an abortion procedure, but did not seem to decrease rates of uncommon abortion complications. The medication called misoprostol worked better with less side-effects than other similar medications. Misoprostol is most effective with the least side-effects when placed in the vagina, but when placed under the tongue it is equally effective. Another drug called mifepristone worked better than misoprostol; however, it is more expensive to use. All methods of preparation take at least 2-3 hours or more to work. The review could not determine whether women preferred one method best.
Implications for practice
Misoprostol is the preferred prostaglandin for cervical ripening. If misoprostol is used, it should be given adequate time to have maximum effect (3 hours for vaginal administration, 2 hours for sublingual) without extending the time to the point where unplanned expulsions begin to occur (6-8 hours or overnight use). When adequate time elapses between administration and the surgical procedure, lower doses are as effective with lower rates of side-effects. Laminaria have a cervical ripening effect with generally lower rates of gastrointestinal side-effects and greater rates of insertional pain; their use may be limited in women who prefer a same-day procedure. Mifepristone may be superior to misoprostol in terms of cervical preparation, however, its use may be limited by its current high cost and time required for effect (24 hours).
Implications for research
Research should attempt to delineate the gestational age where cervical preparation decreases adverse events and whether there are groups of women where cervical preparation is particularly important (adolescents or nulliparae). Additionally, the use of mifepristone for cervical preparation in the later first trimester should be investigated. Women's preferences for cervical preparatory techniques have been inadequately explored and should be included in future research.Get full text at The Cochrane Library
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