[CG] Cervical priming prior to first trimester surgical evacuation of uterus

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Misoprostol is an E1 prostaglandin analogue.  The advantages of prostaglandin administration prior to surgical evacuation of uterus are well established1 with significant reductions in dilatation force, haemorrhage and uterine/cervical trauma.

Critera

Criteria

 All patients with a non-continuing pregnancy ≤12+0 gestation (CRL 65 mms or less), who wish surgical uterine evacuation and who have no contraindication to misoprostol administration.

Patients with an incomplete miscarriage do not require any cervical preparation as the cervix is already dilated to a degree.


Exclusion criteria

  • Severe asthma not controlled by therapy.2
  • Known hypersensitivity to misoprostol or any component of the product.3

 

Caution

  • Caution required if aged >35yrs and a smoker.5
  • Caution advised in patients with a history cardiovascular disease.4
  • Haemorrhagic conditions or on anticoagulation therapy.3

Management

Practitioners may consider oral or vaginal cervical preparation based on individual patient circumstance, however, misoprostol administered orally via the sublingual route has proven to be effective with high patient acceptability.

Administration for parous women should be a least one hour prior to surgery, and two hours for primigravid women.

Administration

Sublingual administration.

Misoprostol 400 micrograms (2 x 200 micrograms tablets) in a single dose should be placed in the buccal pouch and allowed to dissolve over a 15 minute period. If not dissolved within this timeframe it may be swallowed with small sip of water.

Vaginal administration

 Misoprostol 600 micrograms (3 x 200 micrograms tablets) in a single dose should be placed in the posterior fornix of the cervix and allowed to dissolve. Patient should therefore be advised to lie in semi recumbent position for 30 minutes post administration.

Possible short term side effects6, usually in the several hours following administration

  • Nausea
  • Vomiting, this may affect the efficacy of the drug if it occurs within two hours of administration.
  • Diarrhoea
  • Weakness
  • Transient chills, shivering and fever
  • Dizziness
  • Abdominal cramp
  • PV bleeding

 

Post administration.

Patient observation and assessment to ensure early identification of adverse reaction.

Guidelines will be updated periodically to incorporate results of local audit and published literature.

References

1  Royal College of Obstetrician and Gynaecologists, Green – TOP Guideline No. 25 The Managaement of Early Pregnancy Loss. October 2006; 7:7.4

2 Medical Abortion: A Fact Sheet. Reproduction Health Matters 2005; 13(26): 20

3 Meuleman C, Jourdain P, Bellorini M, et al. Anaphylactic shock and myocytic necrosis after treatment with Artotec. Arch Mal Coeur Vaiss 2002; 95:1230-3.

4  Davey, A. Mifepristone and prostaglandin for termination of pregnancy:  contraindications for use, reasons and rationale. Contraception 2006; 74: 20-4.

 5  Walch L, Labat C, Gascard JP, de Montreville V, Brink C, Norel X. Prostanoid receptors involved in the relaxation of human pulmonary vessels. Br J Pharmacol 1999;126:859-66

 6  Exelgyn SmPC, Excelgyn Laboratories, France. 2006; 6:4.8

Last reviewed: 02 July 2010

Next review: 01 July 2013

Author(s): Dr. C. Taggart, Consultant Obstetrician and Gynaecologist, GGC on behalf of EPAS Group.

Approved By: GONEC Group, A.M. Mathers, Clinical Director

Document Id: 1011