I am a family physician and I see a number of nulliparus women requesting and IUD. I understand Misoprostol can be used to decrease discomfort. Can you share specific references? Are there any risks or increased complications (ie perferation)?
I am glad you are using IUDs for some nullips. Misoprostol is used by some clinicians who are inserting IUDs for nulliparous women.
Woman Who Have Not Been Pregnant
Although "nulliparity" is often cited as a relative contraindication to IUD use, the real issue appears to be "nulligravidity," i.e., never having been pregnant before. Uterine enlargement by pregnancy, even one ended through miscarriage or induced abortion, seems to promote successful IUD use. Concerning the risk of upper-genital-tract infection, number of recent sex partners appears to be more important than age or parity per section 56. After its review of the evidence, the World Health Organization listed nulliparity as category 2, meaning that in general; the benefits of IUD use outweigh the potential or known risks. However, the WHO noted that nulliparity is related to an increased risk of expulsion.
Women who have not been pregnant may have a higher rate of mechanical problems with IUDs than other women, related to the small diameter of the cervical canal or size of the endometrial cavity. Several steps can facilitate the insertion and thus minimize the risk of a vasovagal reaction. Cervical priming with misoprostol 400 mcg either a few hours or the night before insertion can open the canal. Similarly, one or more osmotic dilators, such as laminaria, when left in overnight can gently dilate the canal to a small diameter. Prophylaxis with an oral
nonsteroidal anti-inflammatory drug and paracervical or intrauterine anesthesia may help as well. [Intrauterine Devices (IUDs) (Chapter 7 in the 19th edition of Contraceptive Technology; page 128)]
Email to Drs: Carrie Cwiak, Camryn Chrisman and Jeff Peipert: Do you use misoprostol, paracervical block or neither when inserting an IUD for a nullip?
From Dr. Carrie Cwiak: “I agree that the nulliparous patient is usually not the problem. Rather, nulligravid patients may require cervical dilation, and so I prepare the supplies for a paracervical block in case I need it for use prior to dilation. I also currently only use misoprostol if the first attempt does not work as there is little, if any, evidence to support its routine use. I suggest your literature search should start with the SFP guidelines for cervical dilation before first trimester ab (see attached), followed by a search using the terms "misoprostol" and 'IUD" as there is at least one small study regarding its use in this setting.”
Cervical dilation before first-trimester surgical abortion
(b14 weeks' gestation)
Release date 18 April 2007
SFP Guideline 20071
First-trimester surgical abortion is a common, safe procedure with a major complication rate of less than 1%. Cervical dilation before suction aspiration is usually accomplished using tapered mechanical dilators. Risk factors for major complications in the first trimester are increasing gestational age and provider inexperience. Use of laminaria for cervical priming reduces the risk of cervical laceration and, to a lesser extent, uterine perforation. While pharmacological priming agents may potentially have the same effects, no published studies to date have been large enough to assess these outcomes. Given an experienced provider, the risk of these injuries during suction aspiration is very small. Cervical priming can be achieved with osmotic dilators or pharmacological agents. The advantages of osmotic dilators such as laminaria, Dilapan-S™and Lamicel® are their ability to produce wide cervical dilation, and for the synthetic types, their advantages include predictable effects and rapid onset of action. A disadvantage of osmotic dilators is that they require a speculum examination and a trained clinician to perform the insertion. When cervical priming is performed, misoprostol is the prostaglandin analogue most commonly used worldwide.
Compared to laminaria, vaginal misoprostol requires a shorter period of time to achieve the same dilatation, is associated with less discomfort and is preferred by women. The sublingual route appears as effective as vaginal administration and requires less time for priming (2 h), but it is associated with more side effects. Oral administration can produce equivalent dilation to vaginal or sublingual administration, but higher doses and longer treatment periods (8 to 12 h) are required. Buccal administration of misoprostol appears to have a pharmacokinetic and physiologic profile similar to vaginal administration; however, there are no published studies of buccal misoprostol prior to first-trimester suction abortion. While extensive data demonstrate that a variety of agents are safe and effective at causing cervical softening and dilation preoperatively, there are not enough data to conclude that routine cervical priming is necessary to reduce complications of first-trimester surgical abortion. Cervical priming increases preoperative cervical dilation, making the procedure easier and quicker for the physician. However, in order to preoperatively dilate the cervix, the woman must receive the agent at least 3 to 4 h prior to her procedure. Besides the additional waiting, the woman might experience bleeding and cramping prior to the procedure. There are insufficient data evaluating how cervical priming affects women's quality of life in relation to abortion. Based on existing evidence, the Society of Family Planning does not recommend routine cervical priming for suction aspiration procedures. The Society of Family Planning further recommends that providers consider cervical priming only for women who may be at increased risk of complications from cervical dilation, including those late in the first trimester, adolescents and women in whom cervical dilation is expected to be difficult due to either patient factors or provider experience.
© 2007 Elsevier Inc. All rights reserved.
Keywords: Surgical abortion; Cervical dilation; Laminaria; Misoprostol
Induced abortion is one of the most common surgical procedures in the United States. In 2002, 1.3 million
pregnancies were terminated, approximately 90% at less than 14 weeks' gestation . First-trimester surgical abortion is a safe procedure with a mortality rate of 0.7 per 100,000 procedures performed under 13 weeks' gestation and a major complication rate of less than 1% [2,3]. The rate of recognized uterine perforation during first-trimester surgical abortion ranges from 0.1 to 4 per 1000 procedures [3–15]. The rate of cervical injury ranges from 0.1 to 10 per 1000 procedures, with higher rates in adolescents [3–10,12,16,17]. The rate of immediate complications depends on provider experience and gestational age. Within the complication ranges reported above, the higher complication rates come from studies with a large proportion of physicians-in-training performing abortion procedures in a hospital setting. Experienced providers in high-volume outpatient clinics can anticipate lower complication rates . Cervical dilation before suction aspiration can be the most difficult part of the abortion procedure for both the patient.
Contraception 76 (2007) 139–156
0010-7824/$ – see front matter © 2007 Elsevier Inc. All rights reserved.
From Dr. Jeff Peipert: “I use a small amount of lidocaine at 12 o’clock before putting on the tenaculum. I do not typically use a paracervical block, unless the patient is very anxious OR if I must gently dilate the cervix.”
From Dr. Camaryn Chrisman: “I nullips, I routinely infiltrate lidocaine at 12 o’clock and do a paracervical block…I don’t routinely use Cytotec. Once I was unable to insert the IUD in a nullip, I had her place Cytotec the night before her next appointment and I had no issues getting the IUD past the internal os.”
“The question I have is, I know I can easily place IUDs in nullips without Cytotec, but would Cytotec make the procedure more comfortable? I’m not sure…”
Speroff and Darney in their book, A Clinical Guide for Contraception (fourth edition, 2005), make several suggestions:
1. Inject 1 mL of 1% chloroprocaine into the anterior cervical lip if the uterus is anterior and into the posterior cervical lip if the uterus is posterior.
2. Inclusion of atropine 0.4 mg in the anesthetic reduces the risk of a vasovagal reaction
3. After 1 minute grasp the cervical lip with the tenaculum ratcheting it only to the first position SLOWLY.
4. Inject an additional 1 mL on the right at 3 o'clock and another 1 mL on the left at 9 o'clock.
5. WAIT 2-3 MINUTES before proceeding. A common mistake is not to wait long enough for the anesthetic to work.
6. Many women tolerate insertion without a paracervical block particularly at the time of menstruation.
7. If a paracervical block is not performed, have patient cough just as cervix is gently grasped with the tenaculum as this reduces pain and the chance of a vasovagal reaction.
8. An alternative approach is to apply benzocaine 20% gel first at the tenaculum site and then to leave a gel-soaked cotton-tipped applicator in the cervical canal for a minute prior to inserting the IUD.
Carrie Cwiak MD, MPH
Assistant Professor of Gynecology and Obstetrics
Emory University School of Medicine
Jeff F. Peipert, MD, PhD
Director, Family Planning Fellowship
Robert J. Terry Professor of OB/Gyn
Washington University, St. Louis
Camryn Chrisman, MD, MPH
Assistant Professor Department of Obstetrics and Gynecology
University of Michigan Hospitals
Ann Arbor, MI
Key Words: nulliparous women, IUDs, misoprostol, decrease discomfort, references, risks, complications, perforation, cervical dilation, paracervical block, insertion, first trimester, lidocaine, tenaculum, cervix, vasovagal reactions, miscarriage, induced abortion, upper-genital tract infections, World Health Organization, expulsion, pregnant, mechanical problems, cervical canal, osmotic dilators, laminaria, anti-inflammatory drug
Speroff, Darney. A Clinical Guide for Contraception fourth edition, 2005
Grimes DA. Intrauterine devices (IUDs) IN Hatcher RA, Trussell J, Nelson AL. et al Contraceptive Technology 19th edition; page 128: Ardent Media Ind. 2008