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  • Title: Pretreatment of the cervix prior to surgical evacuation of the uterus in the late first and early second trimester of pregnancy.
    Author: Herczeg J.
    Journal: Baillieres Clin Obstet Gynaecol; 1990 Jun; 4(2):307-25. PubMed ID: 2225602.
    Abstract:
    A review of medical and mechanical methods of cervical dilatation for surgical pregnancy termination, is introduced by a description of cervical biomechanics and followed by a summary evaluating the methods. The difficulty with simple cervical dilators is that microscopic or even gross trauma is possible, especially in young primigravidas. If slow mechanical dilators such as laminaria are applied, the cervix dilates by "creep" and then "stress relaxation" through "resistance decay." The initial fast elongation or unwinding of fibers is followed by loss of water from the ground substance, which allows further mobility of the fibers. Nulliparas not only need more cervical dilatation, but suffer more trauma after Hegar 9 mm. Locally applied prostaglandins, especially the analogs, obviate the need for mechanical dilatation. Prolonged treatment is more effective, but risks abortion before returning to the clinic; 3-hour pretreatment is more practical for outpatient management. 2-stage dilatation with vaginal and subsequent intramuscular PGs was tried for wide dilatation: clinical trials revealed excessive cervical tears due to uterine contractions after the 2nd PG injection. Laminaria, now readily available sterilized with ethylene oxide, have received new attention for safe dilatation. They also work best when insertion the previous evening for early 2nd trimester. 3 house is enough for vacuum aspiration. Detailed instructions for numbers of laminaria in different gestational ages and associated medical management are described. Although the cervix dilates because of absorption of water, it also actively dilates during laminaria placement. Synthetic tents made of hydrophilic polymers (Lamicel), or polymers impregnated with magnesium SO4 (Dilapan), also work by absorbing moisture. Dilapan is the most rapid and effective synthetic, but there are reports of breakage. Antiprogestins have also undergone clinical trials. They are indicated for young primigravidas with hyperanteflexed, kinked cervices, who are unable to use PGs or undergo instrumental dilation safely. The advantages of PGs for cervical dilatation are natural cervical softening, and prevention of instrumental perforation and late hemorrhage due to a soft uterus. PGs also preclude the rare risk of coagulopathy that may occur after instrumental dilatation. Intramuscular sulprostone can be used in case of impaction of a dilator.
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