【文章內(nèi)容簡介】 note that if misoprostol is used for cervical ripening, and the woman is unable to undergo surgical abortion as planned, she is at some risk for expelling the pregnancy. Therefore, before receiving misoprostol, all women should give informed consent for the abortion procedure and be adequately screened by appropriately trained personnel.Second TrimesterCervical preparation prior to secondtrimester surgical abortion (dilation and evacuation, Damp。E) is critical to prevent plications from forceful dilation of the ,34 Providers have traditionally used osmotic dilators such as laminaria to slowly dilate the cervix over several hours to days before the Although there are fewer studies than in the first trimester, misoprostol has been evaluated in the second trimester as a substitute for laminaria and as an adjunct to laminaria. The regimens studied for secondtrimester Damp。E vary widely and include 400 181。g of vaginal misoprostol for 3 to 4 hours, 400 181。g and 600 181。g of buccal misoprostol for at least 90 minutes, 600 181。g of buccal misoprostol for 2 to 4 hours, and 800 181。g of buccal misoprostol for at least 20 minutes but not more than 90 minutes –48 As a substitute for laminaria, misoprostol does not achieve the same degree of preoperative cervical dilation and frequently additional mechanical dilation is Although this additional mechanical dilation may be easily achieved in most patients, especially those under 16 weeks of gestation and multiparous women, there is a higher rate of difficult or inadequate dilation when using misoprostol instead of The ideal dosing regimen for secondtrimester procedures is unknown. In terms of safety, a review of more than 6000 surgical abortions between 12 and 16 weeks using 400 181。g of vaginal or buccal misoprostol 90 minutes preprocedure showed a uterine perforation rate of per 1000, parable to historical reports for laminaria Cervical lacerations, however, were not reported. The Society of Family Planning does not remend the use of misoprostol as an alternative to laminaria except by experienced clinicians in the early second trimester (before 16 weeks) in women at low risk for cervical or uterine Misoprostol use as an adjunct to laminaria has been evaluated in a randomized, controlled trial using 400 181。g of misoprostol at least 90 minutes preoperatively in 125 women between 13 and 20 6/7 weeks of Misoprostol improved preoperative dilation in women only at 19 weeks of gestation and above. However, if women needed subsequent mechanical dilation after laminaria had been removed, misoprostol significantly improved the subjective ease of dilation in women at 16 weeks of gestation and above. Given this, the Society of Family Planning does not remend routine use of misoprostol as an adjunct to laminaria under 16 weeks, but it may be considered at later gestational In general, misoprostol may be used for cervical ripening prior to surgical abortion in women with prior cesarean deliveries in the first and second trimesters because uterine rupture rarely occurs in this Cervical Ripening Before Other ProceduresResearchers have studied cervical ripening prior to other gynecologic procedures in nonpregnant women, including hysteroscopy, endometrial biopsy, and intrauterine device (IUD) insertion. Similar to cervical ripening prior to surgical abortion, the aim of misoprostol use in hysteroscopy is to prevent plications of mechanical dilation such as cervical laceration, uterine perforation, and the creation of a false One metaanalysis of 10 studies concluded that misoprostol leads to greater preoperative dilation, decreased need for additional dilation, and reduced rates of cervical laceration in premenopausal The greatest benefits were seen in nulliparous women and with operative hysteroscopy. However, women treated with misoprostol had higher rates of transient vaginal bleeding, cramping, and fever preoperatively. There may also be potential concerns regarding loss of distension from excessive cervical dilation caused by More research is needed to determine the ideal candidate for misoprostol use before hysteroscopy.The optimal dosing regimen for cervical ripening before hysteroscopy is unclear. In premenopausal women, studies have found either 200, 400, or 1000 181。g of vaginal misoprostol or 400 181。g of oral misoprostol given at least 9 to 12 hours preoperatively to be superior to –57 Most of these studies focused on nulliparous women. There are few trials paring routes of administration, doses, and interval to procedure prior to hysteroscopy. One study that pared 400 181。g of oral and vaginal misoprostol given 10 to 12 hours before operative hysteroscopy found vaginal misoprostol to be superior in baseline cervical dilation and time required for cervical Trials evaluating vaginal misoprostol for shorter intervals, 4 to 6 hours preoperatively, have not shown evidence of an ,59 Therefore, it may be that time to adequate cervical ripening is different for pregnant and nonpregnant women. For peri and postmenopausal women and women treated with gonadotropinreleasing hormone agonists, data are conflicting and most studies do not show a benefit from ,60–63 Misoprostol’s actions on th