Page 17 - WALS Journal

World Journal of Laparoscopic Surgery, May-August 2008;1(2):20-22
Monique Directo Javier
Role of Mechanical Dilatation of Cervix

in Hysteroscopy

Monique Directo Javier
Diplomate of Philippines Obstetrical and Gynecological Society, Cebu, Philippines

Abstract 2.7-5 mm; rigid hysteroscopes, from 1-5 mm; and operative
2,3
Background: Hysteroscopy with sample of the tissue is the gold hysteroscopes can be as large as 8-10 mm. The diameters of
standard in the diagnosing of abnormal uterine bleeding. Operative the telescope prerequisite the dilatation of the cervix to 10-
hysteroscopy can then be performed as a therapeutic procedure in 11mm prior to insertion of the instrument. Ideally, hysteroscopy
patients presenting with intrauterine abnormalities. Cervical dilatation is performed with minimal or no cervical dilation. But this may
3
poses a great challenge particularly in nulligravid, post-menopausal not always be possible because the common complications
women and women with cervical stenosis. Difficulties encountered in encountered during the procedure are reported mainly to be
dilating the cervix poses threat to complications such as cervical tears,
creation of false track, hemorrhage and uterine perforation. related to the difficulty in entering the internal cervical os with
the telescope especially in nulliparous and postmenopausal
Objective: The aim of this study is to review the role of mechanical women. Complications reported are cervical tears, creation of
dilatation in hysteroscopy using oral and vaginal misoprostol and false passages, and uterine perforation. Prevention of cervical
4
laminaria.
injury and uterine perforation during termination of pregnancy
Methods: This study involves a retrospective analytical review and has been demonstrated by pre-operative cervical ripening 5,6
compares the role of oral and vaginal misoprostol and laminaria and may be achieved either mechanically, such as with osmotic
8
application in achieving cervical ripening before hysteroscopy. Its dilators, or biochemically with prostaglandins. Misoprostol
7
effects in cervical dilatation as well as the dosing, advantages and side- is a prostaglandin E1 analogue which is commonly used in
effects were also reviewed. There were twenty articles included in this obstetrics for induction of abortion and labor as well as
study as extracted from electronic databases Cochrane Library, postpartum to control bleeding (Bugaho et al., 1994). Misoprostol
Medscape, Highwire Press and Google. Most of the articles assessed applied before hysteroscopy has reduced the need for cervical
the cervical diameter by the largest number of Hegar dilators that could
be inserted into the cervix without resistance. Subjective assessments dilatation, facilitated hysteroscopic surgery and minimized
of adverse effects and complications were recorded. cervical complications (Preutthipan and Herabutya, 1999). On
the other hand, laminaria tents, made from the stems of Laminaria
Conclusion: Methods of cervical priming before hysteroscopy lessens japomica (brown seaweed), are attractive natural substances
the need of further cervical dilation pre-operatively, lessens the that can cause cervical dilatation with minimal and no systemic
complications associated with the entry of the hysteroscope into the
cervical os and offered acceptable side effects. side effects. They have been shown to be effective in inducing
cervical priming prior to operative hysteroscopy (Ostrzenski,
1994). The aim of this work is to review several studies of the
INTRODUCTION
role of cervical dilatation in hysteroscopy.
Recent advances in fiberoptics, light sources, high resolution
lenses, and endoscopic surgical instrumentation made Methods
hysteroscopy an important diagnostic tool as well as therapeutic There were 19 reported randomized controlled trials that
tool for patients presenting with intrauterine diseases. evaluated the efficacy of misoprostol on cervical ripening in
Hysteroscopy permits direct visualization of the uterine cavity gynecologic patients, after searching medical literature
thus making it the gold standard in diagnosing abnormal uterine databases including Cochrane Library, Medscape, High wire
bleeding. Operative hysteroscopy as well has gained popularity Press and Google. One article evaluated the efficacy of laminaria
as a minimally invasive approach to intrauterine lesions (Siegler tents. The search terms used included “mechanical cervical
and Valle, 1988). However, a systematic review of diagnostic dilation”, “cervical ripening” and “hysteroscopy.” References
hysteroscopy in more than 26,000 women reported a failure rate from identified publications were manually searched and cross-
of 4.2% for ambulatory hysteroscopy and 3.4% for in-patient referenced to identify additional relevant articles. The studies
procedures. Failed procedures were mainly attributed to have shown different cervical responses and outcomes. 9-28
technical problems, including cervical stenosis, anatomic and Most of the studies compared the effect of misoprostol against
1
structural abnormalities and pain and intolerance. Flexible placebo on different groups of women, such a nulliparous women
hysteroscopes used in this procedure range in diameter from and postmenopausal women. Patients received misoprostol
20