Adjuvant misoprostol not associated with improvement in late second-trimester abortions

Image: PD 

1. Buccal misoprostol plus laminaria for cervical preparation in late second-term dilation and evacuations (D&Es) resulted in only slightly decreased procedure times and no difference in physician satisfaction. 

2. Patients who received adjuvant misoprostol were more likely to report severe pain with the procedure. 

Evidence Rating Level: 1 (Excellent)     

Study Rundown: In this study, researchers found that the addition of adjuvant buccal misoprostol to standard laminaria cervical preparation in late second-term D&Es only decreased procedure time by an average of 1.7 minutes, and was associated with no difference in procedure difficulty. Women who received misoprostol were more likely to report severe pain prior to the procedure than those who received placebo. While prostaglandins are widely used as an adjunct to laminaria for cervical dilation, this is the first study to assess this protocol in later second-trimester abortions.

A strength of this study is the double-blinded, randomized, placebo-controlled design. Limitations include a small sample size, a single study site and lack of power to assess for differences rare complications such as cervical laceration. Additionally, certain findings, such as increased pre-operative dilation with buccal misoprostol (75mm vs. 73mm, p=0.04), while statistically significant, are unlikely to be clinically significant. Future studies might characterize this association in a larger, multi-site cohort, as well as further examine the trend towards increased cervical lacerations after misoprostol use.

Click to read the study in Contraception

Relevant Reading: Clinical guidelines: Cervical preparation for surgical abortion from 20-24 weeks’ gestation

In-Depth [randomized controlled trial]: Researchers randomized 196 women seeking pregnancy termination at 21-23 weeks’ gestation to receive either laminaria with 400 mcg buccal misoprostol (n=98) or laminaria with placebo pills (n=98) for cervical ripening prior to the procedure. The primary outcome was procedure duration. Secondary outcomes included pre-operative dilation, physician-assessed procedure difficulty, side effects, and complications.

The use of adjuvant buccal misoprostol resulted in a slightly shorter mean procedure time (9.6 vs. 11.3 min, p=0.02) compared to laminaria alone. Women in the misoprostol group were more likely to report severe pain (50% vs. 11%, p<0.001). There was no difference in physician-assessed procedure difficulty between the two groups.

By Maren Shapiro and Leah Hawkins, MD, MPH

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