Ideal Time of Vaginal Misoprostol Administration in Nulliparous Women Undergoing Office Hysteroscopy

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Published on International Journal of Health, Nursing, & Medicine
ISSN: 2193-3715, Volume 1, Issue 2, page 1 – 12
Publication Date: 8 February 2019

Ahmed Abdelmaguid Mohammed, Ismail Talaat Elgarhy, Ahmed Samy Amer & Ashraf Hamdy Mohammed
Obstetrics and Gynecology Department, Faculty of Medicine
Al Azhar University
Cairo, Egypt

Journal Full Text PDF: Ideal Time of Vaginal Misoprostol Administration in Nulliparous Women Undergoing Office Hysteroscopy.

Abstract
Background: hysteroscopy is the process of viewing and operating in the endometrial cavity from a transcervical approach. It is the gold standard procedure for uterine cavity exploration. Objective: to detect ideal time of vaginal misoprostol administration for cervical priming in nulliparous women prior to office hysteroscopy by comparing between giving 400 microgram 3 hours, 6 hours and 12 hours before office hysteroscopy. Patients and Methods: randomized double-blind placebo-controlled study. This study was done on 198 patients to whom office hysteroscopy was done as a part of investigation of (infertility, recurrent miscarriage or abnormal uterine bleeding). those patients divided into three groups each group 66 patients, Group A, received 400μgm vaginal misoprostol 12 hours before office hysteroscopy and placebo 6 hours and 3 hours before office hysteroscopy. Group B received 400μgm vaginal misoprostol 6 hours before office hysteroscopy and placebo 12 hours and 3 hours before office hysteroscopy. Group C received 400 μgm vaginal misoprostol 3 hours before office hysteroscopy and placebo 12 hours and 6 hours before office hysteroscopy. Our main outcome measures were pain score (visual analogue scale), ease of entry (Likert scale), procedural time in minutes, patient acceptability (Likert scale), vaginal bleeding and also to detect side effects of misoprostol and complication of its use. Result: in group A which received 400μgm vaginal misoprostol 12 hours before office hysteroscopy, pain score was lower (2.6 ± 1.3) compared to group B (5.3 ± 1.3) compared to group C (7.3 ± 1.2). Procedural time was shorter in group A (2.7 ± 0.9) compared to group B (5.2 ± 1.2) compared to group C (7.4 ± 1.3), cervical entry was easier in group A (4.2 ± 0.7) compared to group B (3.5 ± 0.5) compared to group C (2.5 ± 0.6), baseline cervical dilatation was greater in group A (5.9 ± 0.8) compared to group B (4.7 ± 1.1) compared to group C (3.9 ± 0.8) vaginal bleeding was least in group A compared to group B compared to group C patient acceptability was higher in group A (4.2 ± 0.7) compared to group B (3.5 ± 0.5) compared to group C (2.5 ± 0.6). No complication detected in both groups. Side effects were minimal and transient. Conclusion: use of 400μgm vaginal misoprostol 12 hours before hysteroscopy is better than using it 6 hours and 3 hours in facilitating cervical ripening with minimal side effects without use of anasthesia.as it decrease pain score, decrease procedure duration, increase ease of cervical entry, higher patient acceptability and with minimal side effects.

Keywords: Office Hysteroscopy, Misoprostol, Cervical Priming.

1. Introduction
Hysteroscopy is the process of viewing and operating in the endometrial cavity from a transcervical approach. It is the gold standard procedure for uterine cavity exploration (1).
In many practices, diagnostic hysteroscopy is the preferred procedure for the diagnosis and treatment of intrauterine pathology and intrauterine anomalies (2).
Hysteroscopy allows direct visualization of the uterine cavity, the endometrium and the cervical canal. The examination may be practiced on an out-patient basis, without anesthesia, using appropriate small-caliber instruments and irrigation with physiological saline (3).
Hysteroscopic examination includes detailed evaluation of the cervical canal, isthmus and uterine cavity. Focused evaluation of the region of the utero-tubal junction and the first few millimeters of the tube with particular reference to the tubal ostia was attempted (4).
Since it allows direct visualization of the endometrium, hysteroscopy has essential role in the evaluation of the uterine causes of infertility as it can detect small lesions that might not otherwise be readily diagnosed by other methods (5).
Hysteroscopy is associated with minimal patient discomfort, excellent visualization and very low complication and failure rates (6).
Over recent years hysteroscopy is being increasingly used in out-patient facilities which alongside the standard advantages of hysteroscopy also provide greater comfort for the patients, since it excludes the need to stay in hospital and decreases the time of treatment, but also the time needed to prepare the patient for further procedures, e.g. medically assisted conception (7).
In post-menopausal women with abnormal uterine bleeding, hysteroscopy with endometrial biopsy shows a high diagnostic accuracy in diagnosing endometrial cancer or hyperplasia (8), whereas premenopausal infertile patients with recurrent IVF failures may experience substantial benefits in terms of increased pregnancy rates (9).
The role of hysteroscopy in infertility investigation is to detect possible intrauterine changes that could interfere with implantation or growth or both of the conceptus (10).
With the invention of miniature hysteroscope, it is possible to perform hysteroscopy in an office setting (Outpatient hysteroscopy; OH), for diagnostic and certain therapeutic intervention (11).
There is a growing consensus towards its use in the primary investigation of infertile women prior to In-Vitro Fertilization (12), as well as in the management of hydrosalpinges in such patients, in place of laparoscopy (13).
Hysterscopy is currently acknowledged as the ‘gold standard’ investigation of the intrauterine abnormalities (14).
However, despite the high efficacy of the procedure in the above mentioned settings, both as a diagnostic or therapeutic tool, hysteroscopy may be associated with certain complications (15).
Although the incidence of these complications is low, 1–1.5% (16), almost 50% of them are related to insertion of the hysteroscope or to the dilatation of the cervical canal (16).
Taking into account that an efficient method to facilitate an easier uncomplicated entry during the hysteroscopic procedure could substantially minimize the risk of complications, several modalities for cervical ripening prior to hysteroscopy have been adopted (17).
Cervical priming prior to diagnostic hysteroscopy softens the cervix and lessens the force needed for dilation (18), thereby potentially reducing the probability of procedural complication such as uterine perforation, cervical laceration, failure to dilate, and creation of a false track that can occur during cervical entry (19).
Cervical ripening is clinically diagnosed by softening, effacement, and dilatation of the uterine cervix (20).
The synthetic analogue of prostaglandin E1, misoprostol, is the agent used most often for cervical preparation prior to hysteroscopy (21).
Consequently, given its high efficacy in dilating the cervix in pregnant women one could hypothesize that misoprostol would also facilitate dilatation in women undergoing hysteroscopy (22) …………