Cervical priming before dilation and evacuation: A randomized controlled trial

In South Africa, termination of pregnancy (TOP) is legal for several indications up to 20 weeks gestation, and approximately 25% of all TOPs take place in the second trimester. Most public sector second-trimester procedures are performed by medical induction with misoprostol alone, although in the Western Cape Province, a team of roving doctors performs dilation and evacuation (D&E). Cervical priming is achieved using sublingual misoprostol, and laminaria tents are not used. Recent research documented that D&E is being performed safely in this setting, and no major complications were observed in a series of 203 procedures. However, 43% of all women undergoing D&E expelled the fetus prior to the procedure, and this was often an unexpected and traumatic experience for women. We performed a randomized controlled trial comparing a modified protocol for cervical priming using buccal misoprostol to one using laminaria. We found that cervical preparation using either laminaria or misoprostol can be safely used before D&E up to at least 19 weeks, though misoprostol requires more mechanical dilation and causes more diarrhea. We hope our results help to improve the quality of second-trimester abortion care in South Africa and inform programs and policies in other similar low-resource settings.