The use of misoprostol before hysteroscopy in Nulliparous women: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objectives: To assess the value of misoprostol intake before hysteroscopy in nulliparous women.

Search strategy: Databases screening was done from inception to July 2023 using "Misoprostol" AND "Hysteroscopy" AND "Nullipara" and their MeSH terms as keywords.

Selection criteria: Thirteen studies were included in our analysis. Seven studies compared misoprostol to placebo, 3 studies compared it to dinoglandin, 1 study compared it to diclofenac and 4 studies compared different misoprostol doses and routes. These studies were conducted on 1528 participants,958 of them received misoprostol, 221 received dinoglandin, 51 received diclofenac and 308 received placebo.

Data collection and analysis: Extracted data included study place, participants number, inclusion and exclusion criteria, intervention details as dose, route, timing and comparotor, and hysteroscopy details.

Main results: Ease of cervical dilatation was reported in 3 studies (309 participants) and revealed an effect estimate mean difference (MD) of -0.57 [-1.72, 0.58] and a P value of 0.33. The time needed for cervical dilatation was reported in 6 studies (512 participants) and revealed a MD of -22.96 [-43.29, -2.62] and a P value of 0.03. The preoperative cervical width was reported in 4 studies (263 participants) and revealed MD of 1.69 [-0.09, 3.46] and a P value of 0.06. The number of women with failure of cervical dilatation or who needed further dilatation was reported in 4 studies (372 participants) and revealed a MD of 0.40 with [0.13, 1.17] 95% CI and a P value of 0.09. The preoperative pain was reported in 3 studies (351 participants) and revealed a MD of -0.56 [-2.30, 1.18] and a P value of 0.53. Total number of cases who experienced side effects and procedure complications were reported in 2 and 3 studies (249 and 252 participants) respectively and revealed an effect estimate Odd Ratio of 1.99 and 0.42 with [0.27, 14.67] and [0.14,1.32] 95% CI and a P value of 0.50 and 0.14 respectively. In the 3 studies comparing misoprostol to dinoglandin, The ease of cervical dilatation, time needed for cervical dilatation and preoperative cervical width were evaluated in 1,3 and 2 studies with 60, 436 and 376 participants respectively. The estimated MD were not estimated, 0.17 and 0.01; 95% CI were not estimated, [-4.70, 5.05], and [-0.78, 0.79]; P values of 0.94, 0.98 and 0.99 and I₂ of 96%,95% and 74% respectively.

Conclusion: Misoprostol improved the time needed for cervical dilatation without affecting the rate of complications or drug side effects when compared to placebo but has similar outcomes to dinoglandin with higher side effects.

Registration number: CRD42023438432.

Keywords: Hysteroscopy; Misoprostol; Nullipara.

Fig. 1

Prisma flow diagram

Fig. 2

Risk of bias A graph and B summary

Fig. 3

Misoprostol vs placebo ease of dilatation

Fig. 4

Misoprostol vs placebo time of dilatation

Fig. 5

Misoprostol vs placebo preoperative cervical width