Should we use prostaglandins, tents or progesterone antagonists for cervical ripening before first trimester abortion?

Abstract

Sixty-four women requesting first trimester termination of pregnancy were recruited into a comparative cohort study comparing the cervical ripening properties of a mechanical dilator (Lamicel; n = 17), prostaglandin, antiprogesterone and placebo control (n = 15), gemeprost; n = 17) and mifepristone; n = 15). Compared to the placebo group, all 3 active agents dilated the cervix (p < 0.02) and they significantly reduced the force required to dilate it to 8 mm Hegar (p < 0.001). Although Lamicel insertion resulted in the largest pre-operative cervical dilatation all agents are effective. Therefore the cervical priming agent of choice should be the most convenient to use and the one with least side-effects. The oral antiprogesterone, Mifepristone, is the easiest to administer and has less side effects.

PIP: Obstetrician-gynecologists at St. James's University Hospital in Leeds, England, compared various cervical ripening agents in 64 18-39 year old women presenting for first trimester abortion. The women either received oral administration of a placebo or RU-486 or had a laminaria tent or gemeprost vaginal suppository inserted into the endocervical canal or the posterior fornix, respectively. All cervical ripening agents dilated the cervix better than the placebo (p .02). They also greatly diminished the force needed (50-65%) to dilate the cervix to 8 mm Hegar (p .001). The laminaria tent resulted in greater initial cervical dilatation than gemeprost or RU-486, regardless of parity (p .05), but the total force was not significantly different between the 3 groups. 71% of the women who received the gemeprost vaginal suppository had pelvic pain and regular painful uterine contractions. The pain was so intense in 33.3% of them (20% of all gemeprost patients) that health workers had to inject opiate analgesia intramuscularly. 81% of laminaria tent patients experienced menstrual type pains. A significantly lower percentage of RU-486 patients (33%) suffered mild pelvic discomfort than the gemeprost (p = .03) and laminaria tent groups (p = .001). None of the women in the placebo, laminaria tent, and RU-486 groups received analgesia. 40-41% of women in the 3 treatment groups experienced preoperative vaginal bleeding. Since RU-486 patients suffered minimal side effects and insertion of laminaria tents is inconvenient and potentially damaging (e.g. iatrogenic complications of fistulas, dumb belling, and tent fracture), the physicians concluded that RU-486 is the easiest cervical priming agent to administer and is as effective as the other agents.