Department of Obstetrics and Gynecology, Assiut University Hospital, Assiut, Egypt
1 To whom correspondence should be addressed at: Gynecologic Endoscopy Unit, Department of Obstetrics & Gynecology, Assiut School of Medicine, Egypt. Email: a_darwish{at}mailcity.com
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Abstract |
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Key words: hysteroscopy/laminaria/misoprostol
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Introduction |
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Misoprostol is a prostaglandin E1 analogue which is commonly used in obstetrics for induction of abortion and labour as well as postpartum to control vaginal bleeding (Bugalho et al., 1994). Its utilization in gynaecology has been limited. It was recently used prior to artificial insemination and operative hysteroscopy. Vaginal misoprostol applied before operative hysteroscopy has reduced the need for cervical dilatation, facilitated hysteroscopic surgery and minimized cervical complications (Preutthipan and Herabutya, 1999
).
On the other hand, laminaria tents, made from the stems of Laminaria japomica or Laminaria digitata (brown sea weed), are attractive natural substances that can cause cervical dilatation with minimal local and no systemic side-effects. They have been shown to be effective in inducing cervical priming prior to operative hysteroscopy (Ostrzenski, 1994). However, there have been no comparative studies of the efficacy of the two methods for cervical priming (Sowter et al., 2003
). The aim of this work was to compare efficacy of intravaginal misoprostol versus endocervical laminaria tents prior to operative hysteroscopy in selected cases.
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Materials and methods |
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Sample size estimation was adequate to detect a difference of 3.2 mm (type I error of 0.01) with a power of 0.99. As a result, 144 cases were included in this study. Randomization was done by means of sealed envelopes. It was a double-blind randomization study in that the evaluator (first author) masked the key from the researcher (third author) to avoid bias. Collected data were revised and coded for computerized data entry. A data entry file was created on EPI Info version 9. After complete data entry, the file was converted to an SPSS file. Analysis was undertaken using SPSS version 11 and expressed as mean±SD. Statistical methods were applied including descriptive statistics (frequency, percentage, mean and SD) and tests of significance [two-tailed Student's t-test, analysis of variance (ANOVA) and 2]. P<0.05 was considered statistically significant.
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Results |
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Discussion |
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Laminaria is a sea-grown plant that swells in the presence of liquid. It has been found to provide a fast and adequate cervical dilatation prior to transcervical removal of submucous leiomyoma (Townsend and Melkonian, 1990) and to reduce significantly the frequency of inadequate cervical dilatation before resectoscopic surgery (Ostrzenski, 1994
).
Laminaria was evaluated in 300 patients before diagnostic or operative hysteroscopy (Townsend and Melkonian, 1990). A 5 mm diagnostic hysteroscopy was performed 23 h after insertion, while a 9 mm operative resectoscope was inserted
24 h after insertion of the laminaria tent. There were no complications with the use of laminaria tents such as infection or bleeding, but some patients complained of mild menstrual-like lower abdominal discomfort. In all cases, laminaria resulted in softening and dilatation of the cervix, which facilitated the passage of the diagnostic and opertive hysteroscopes. In this study, we reported 26 cases of insertion difficulties, explaining a highly significant patient inconvenience with insertion of laminaria (Table V). To determine its efficacy, laminaria were used prior to hysteroscopic adhesiolysis of severe intrauterine synechiae in seven patients with secondary amenorrhoea due to severe uterine synechiae diagnosed by HSG and hysteroscopy (Chen et al., 1997
). The uterine cavity appeared short, narrow and scarred coned or column-shaped. Not only did the women achieve normal menstruation, but also a normal uterine cavity as confirmed by subsequent HSG or hysteroscopy. In addition, three patients became pregnant, two of whom have had successful term deliveries. Misoprostol is a chemical method with a systemic absorption of the drug whereas laminaria tents act by a mechanical dilatation.
We did not find any randomized comparative studies of the two methods of cervical priming. In this study, we found that both were effective in dilating the cervix with a mean cervical width of 7.6±1.2 and 7.5±1.2 mm respectively. There was no significant difference between laminaria and misoprostol with regard to the mean cervical width or the time required for cervical dilatation. In contrast, there was a significant difference between laminaria and misoprostol with regard to insertion difficulty and doctors' and patients' satisfaction with the procedure. The time required for cervical dilation up to Hegar 10 was longer in both groups (51.6 s for misoprostol and 51.4 s for laminaria) compared to previous studies (Ostrzenski, 1994; Preutthipan and Herabutya, 1999
). This may be due to inter-observer variability as we included all cases done by three hysteroscopists in the Unit. A significant difference in cervical injury between misoprostol and placebo was found in a previous study (Preutthipan and Herabutya, 1999
). They reported one (1.4%) cervical tear in the treated group compared with nine patients (11.4%, P=0.018) in the control group, seven of whom required suturing. Recently, three cases of extensive cervical laceration that lead to inability to perform hysteroscopy and two cases of retroperitoneal installation of the distending media due to lateral cervical laceration were reported in one study (Ghazizadeh, 2003
). In our study, two cases of cervical perforation occurred during myomectomy in the misoprostol group, while no case of perforation was encountered in the laminaria group.
From this study, it is concluded that both laminaria and misoprostol were shown to be effective in inducing adequate cervical priming prior to operative hysteroscopy with minimal time of cervical dilatation. Nevertheless, misoprostol is superior as it has the following advantages: easy application (it can be inserted by the patient herself at home), cheaper price (one tablet costs $0.2 versus $5 for each laminaria piece), more economic (eliminates the charge of insertion in the office or the hospital), patient convenience (saves time and the expense of attending clinics or hospital for insertion without requiring time off work), and greater acceptability. More studies are needed to compare misoprostol and laminaria with placebo before recommending routine cervical priming prior to operative hysteroscopy in selected cases. Furthermore, the need for sequential applications of laminaria of increasing diameters rather than a single application requires further study.
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References |
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Chen FP, Soong YK and Hui YL (1997) Successful treatment of severe uterine synechiae with transcervical resectoscopy combined with laminaria tent. Hum Reprod 14, 943947.[CrossRef]
Fung TM, Lam MH, Wong SF and Ho LC (2002) A randomized placebo controlled trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women. Br J Obstet Gynaecol 109, 561565.
Ghazizadeh S (2003) Complications of operative hysteroscopy, report of rare cases. Proceedings of the 12th Annual Congress of the European Society for Gynecologic Endoscopy, Luxemburg, November 2629, p 88, 006.
Goldrath MH (1987) Vaginal removal of the pedunculated submucous myomata. The use of laminaria. Obstet Gynecol 70, 670.[Abstract]
Hald F, Kristoffersen SE and Gregresen E (1988) Prostaglandin vaginal suppositories in nonpregnant women required cervical dilatation prior to hysteroscopy. Acta Obstet Gynecol Scand 67, 219222.[ISI][Medline]
Itzkowic D and Beale M (1999) Uterine perforation associated with endometrial ablation. Aust NZ J Obstet Gynecol 32, 359361.
Ngai SW, Chan YM and Ho PC (2001) The use of misoprostol prior to hysteroscopy in postmenopausal women. Hum Reprod 16, 14861488.
Ngai WN, Chan YM, Liu KL and Ho PC (1997) Oral misoprostol for cervical priming in non pregnant women. Hum Reprod 12, 23732375.[Abstract]
Ostrzenski A (1994) Resectoscopic cervical trauma minimized by inserting laminaria digita preoperatively. Int J Fertil Menopausal Stud 111, 39.
Preutthipan S and Herabutya Y (1999) A randomized controlled trial of vaginal misoprostol for cervical priming before operative hysteroscopy. Obstet Gynecol 94, 427430.
Rath W, Kuhn W and Hilgers R (1985) Facilitation of cervical dilatation by intra cervical application of sulprostone gel prior to hysteroscopy. Endoscopy 17, 191193.[ISI][Medline]
Siegler AM and Valle RF (1988) Therapeutic hysteroscopic procedures. Fertil Steril 50, 685699.[ISI][Medline]
Sowter MC, Lethaby A and Singla AA (2003) Preoperative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding (Cochrane Review). In The Cochrane Library, Issue 2. Update Software, Oxford.
Thomas JA, Leyland Y, Durand N and Windrim RC (2002) The use of oral misoprostol as a cervical priming agent in operative hysteroscopy: a double-blind, placebo-controlled trial. Am J Obstet Gynecol 186, 876879.[CrossRef][ISI][Medline]
Townsend DE and Melkonian R (1990) Laminaria tent for diagnostic and operative hysteroscopy. J Gynecol Surg 6, 271274.[ISI][Medline]
Vilos GA, Vilos EC and King JH (1996) Experience with 800 hysteroscopic endometrial ablations. J Am Assoc Gynecol Laparosc 4, 3338.[ISI][Medline]
Wing DA and Paul RH (1996) A comparison of differing dosing regimens of vaginally administered misoprostol for preinduction cervical ripening and labor induction. Am J Obstet Gynecol 175, 158164.[ISI][Medline]
Submitted on December 8, 2003; resubmitted on January 22, 2004; accepted on June 7, 2004.
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