الفهرس 
The Uterine CervixOnly 14 pages are availabe for public view
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Abstract
The National Center for Health Statistics, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) define abortion as pregnancy termination prior to 20 weeks’ gestation or a fetus born weighing less than 500 gm.
Approximately 205 million pregnancies occur worldwide each year and 42 million of these pregnancies end in abortion.
More than 80% of abortion occurs in the first 12 weeks of pregnancy; at least half result from chromosomal anomalies. After the first trimester, both the abortion rate and the incidence of chromosomal anomalies decrease.
Almost 60 percent of induced abortions were performed during the first 8 weeks, and 88 percent during the first 12 weeks of pregnancy.
First trimesteric abortion can be managed expectantly, medically or sugically.
Surgical abortion remains one of the most frequently performed gynecologic procedures, accounting for greater than 99% of all abortions in the United States. EVA is the most commonly used method of early pregnancy termination in the United States.
Surgical termination of pregnancy is associated with complications such as uterine perforation, cervical laceration and incomplete evacuation of the uterus.
The incidence of cervical trauma and uterine perforation is related to the degree of forcible mechanical dilatation required.
Traumatic complications may jeopardize future fertility, and have been associated with increased risk of miscarriage and preterm labour in subsequent pregnancies.
Adequate cervical preparation can help minimize the occurrence of procedure-related complications, such as cervical laceration and uterine perforation.
Misoprostol has been used for decades as preoperative cervical ripeningagent. A dose of 400 mcg per vagina two to three hours prior to the procedure was recommended in a study attempting to determine optimal dosing.
Prostaglandins are effective in cervical ripening, but are associated with several side effects such as abdominal pain, gastrointestinal upset and vaginal bleeding.
Misoprostol is a prostaglandin E1 analogue originally intended for use to prevent non-steroidal anti-inflammatory drugs (NSAID) induced gastric ulcer. However because of its cervical ripening and uterotonic property, misoprostol has become one of the most useful drugs in obstetrics and gynecology.
PGs are associated with a high incidence of side effects, including pain, dizziness, nausea, vomiting, diarrhea, chills.
The human cervix, in contrast to the uterine corpus, is essentially a fibrous connective tissue organ, mainly composed of collagen and proteoglycans.
The cervix is in fact a dynamic structure, the control of which we still do not fully understand. During ripening, marked biochemical changes take place in the cervix, causing it to become soft and dilatable at the time of parturition.
Cervical remodelling during pregnancy and parturition is a single slow progressive process that can be loosely divided into four overlapping phases termed softening, ripening, dilatation during labour and postpartum repair.
The ripening phase is believed to be a catabolic process in which the extracellular matrix components are degraded.
Ripening involves release of proteases that degrade collagen and other extracellular matrix components.
It is thought to be an inflammatory process, and is accelerated by infiltration of leukocytes and release of proinflammatory cytokines Leukocytes such as neutrophils are a rich source of proteases that may contribute to the degradative process. Proinflammatory cytokines such as tumor necrosis factor (TNF)-alpha or interleukin (IL)-8, which induce an inflammatory infiltrate, can induce cervical ripening
The reduced cervical levels of type I collagen in the process of cervical softening suggest at least two possible mechanisms for regulation of the turnover of this collagen.First, the synthesis of type I collagen by cervical stromal cells might be reduced at the gene level in the process of cervical softening, Second, the degradation of cervical type I collagen might be intensified in the process of cervical softening
The effect of acidity on connective tissue remodelling and softening of the cervix needs consideration. It has been shown that acidity enhances bone resorption by decreasing the collagen through suppressing the osteoblastic activity along with stimulating the osteoclastic activity.
Moreover, pH is suggested to play a role in modulating the function of matrix metalloproteinases.
Acidity is important in the modulation of ripening process, and may be active in the connective tissue remodeling. It was reported that the solubility of collagen undergoes a huge increase at full dilatation with no significant change in the water content.
It is known that cervical collagen degradation contributes to the ripening process. Human collagenase (matrix metalloproteinase-1) and other proteolytic enzymes play an essential role in the degradation of collagen fibers and subsequent dissolution of cervical connective tissue. Enhancing vaginal acidification with acetic acid may stimulate the migration and function of neutrophils accumulating in the cervical tissues during ripening, as was previously suggested for hyaluronic acid.
In addition, vaginal acidification may stimulate the synthesis of proteolytic enzymes, including collagenase, by cervical fibroblasts, a role that has also been suggested for hyaluronic acid.
The present study aims to compare the efficacy of vaginal acidity enhancement and misoprostol in cervical ripening in women undergoing surgical termination of first-trimester missed abortion.
A prospective randomized comparative study was conducted at Ain Shams University Maternity Hospital during the period between June 2013 and January 2014. Patients were selected according to preplanned inclusion criteria.
Subjects included in the study were randomized into 2 groups:Group I: Subjects who will be treated with 3% acetic acid acidifying vaginal gel (4 doses) applied every 12 hours, starting 2 days ahead of the planned procedure and group II: Subjects who will be treated with misoprostol (a single vaginal dose of 400 μg) applied every 3 hours before the planned procedure.
Examining the cervix under GA and measuring the vaginal PH then applying the cervical tonometer to the cervix and measuring the peak resistancebefore performing suction evacuation.
Data of the present study showed that preparing the cervix with 3% acetic acid acidifying vaginal gel for 2 days has similar effect as misoprostol on cervical ripening. The force needed to dilate the cervix was similar in both groups. The force needed to dilate the cervix to 3mm, 4mm, 5mm, 6mm, 7mm, 8mm, 9mm&10mm was (0.300±0.651, 0.533±0.681, 1.567±1.305, 2.833±1.859, 5.267±2.703, 7.733±3.118, 11.900±3.527, 16.733±3.383 respectively)in misoprostol group and was (0.167±0.379, 0.633±0.809, 1.667±1.470, 2.967±2.251, 5.167±2.780, 8.500±4.024, 11.600±4.515, 17.500±4.897 respectively) in acetic acid group with P-value of 0.336, 0.606, 0.781, 0.803, 0.888, 0.413, 0.775, 0.484 respectively.
There were no statistical difference in both groups regarding demograohic characters including age, BMI or parity.
Gastrointestinal side effects were more in misoprostol group as there were 4(13.33%) patients complaint of nausea compared to zero patients in acetic acid group(p=0.016*). Lower abdominal pain was more in misoprostol group. There were 25(83.33%) patients complaint of lower abdominal pain compared to 12(40%) in acetic acid group (0.001*). Other side effects were similar in both groups.