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Cochrane Database of Systematic Reviews

Maduración preoperatoria del cuello uterino antes de la histeroscopia quirúrgica

Information

DOI:
https://doi.org/10.1002/14651858.CD005998.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 23 April 2015see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Gynaecology and Fertility Group

Copyright:
  1. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Haya Al‐Fozan

    Correspondence to: Obstetrics & Gynaecology/IVF and Reproductive Endoscopic surgery, King Saud bin Abdulaziz University for Health Sciences, College of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia

    [email protected]

  • Belal Firwana

    Department of Medicine, University of Missouri, Columbia, USA

  • Hanan Al Kadri

    Obstetrics & Gynaecology, King Saud bin Abdulaziz University for Health Sciences College of Medicine King Abdulaziz Medical City Riyadh, Riyadh, Saudi Arabia

  • Samar Hassan

    Obstetrics and Gynecology, King Abdulaziz Medical City, National Guard Hospital, Riyadh, Saudi Arabia

  • Togas Tulandi

    Obstetrics and Gynecology, McGill University, Montreal, Canada

Contributions of authors

Haya Al‐Fozan: conceptualised and wrote the initial version of the protocol, updated it in the light of the co‐reviewers' changes and comments, and wrote the final version. Updated the protocol, assessment of trials and quality analysis, data collection, analysis, and wrote the initial draft of the review. Checked literature search, wrote the final version of the review.

Belal Firwana: run in analysis and helped in writing the initial draft of the review.
Samar Hassan: updated and commented on the protocol and review.
Hanan Kadri: updated and commented on the protocol and review.
Togas Tulandi: commented on the protocol, evaluated the review and revised the language.

Sources of support

Internal sources

  • IVF and Reproductive Endocrinology Unit , KAMC,Riyadh AND National and Gulf center for Evidence Based Health Practice(NGCEBHP), Saudi Arabia.

    Free time with free workshops/courses in relation to systematic review and meta analysis

External sources

  • None, Other.

Declarations of interest

None

Acknowledgements

We thank all the women and investigators who were involved in the clinical trials mentioned in this review. We thank the staff of the Cochrane Menstrual Disorders and Subfertility Group Editorial Team for their contribution and excellent collaboration. We appreciate the support of the National and Gulf Center for Evidence Health Care Practice (NGCEBHP). We acknowledge the advice of statisticians M. Hassan Murad, MD, MPH and Zhen Wang, PhD (Mayo Clinic, Rochester, MN, USA) for advice on combining the intervention groups in Fernandez 2004.

Version history

Published

Title

Stage

Authors

Version

2015 Apr 23

Preoperative ripening of the cervix before operative hysteroscopy

Review

Haya Al‐Fozan, Belal Firwana, Hanan Al Kadri, Samar Hassan, Togas Tulandi

https://doi.org/10.1002/14651858.CD005998.pub2

2006 Apr 19

Preoperative ripening of the cervix before operative hysteroscopy

Protocol

Haya M Al‐Fozan, Hanan Al Kadri, Samar Hassan, Togas Tulandi

https://doi.org/10.1002/14651858.CD005998

Differences between protocol and review

Since the protocol was published in 2006 there have been numerous methodological advances. The review now reflects the current methodologies employed by The Cochrane Collaboration.

  • in the primary outcomes the power required to perform procedure was removed.

  • In the full review, we reported the following outcomes in addition to those listed in the protocol.

    • Women requiring cervical dilatation (our primary outcome)

    • Duration of surgery

  • In the protocol our primary outcome was cervical width. After peer review, we decided to use need for mechanical dilatation as our primary effectiveness outcome, as this was deemed more clinically relevant.

  • We will consider expanding eligibility to other intervention agents in future updates.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Misoprostol versus placebo or no treatment, outcome: 1.1 Ease of dilatation: need for mechanical dilatation.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Misoprostol versus placebo or no treatment, outcome: 1.1 Ease of dilatation: need for mechanical dilatation.

Forest plot of comparison: 1 Misoprostol versus placebo or no treatment, outcome: 1.2 Intraoperative complications.
Figures and Tables -
Figure 5

Forest plot of comparison: 1 Misoprostol versus placebo or no treatment, outcome: 1.2 Intraoperative complications.

Funnel plot of comparison: 1 Misoprostol versus placebo or no treatment, outcome: 1.2 Intraoperative complications.
Figures and Tables -
Figure 6

Funnel plot of comparison: 1 Misoprostol versus placebo or no treatment, outcome: 1.2 Intraoperative complications.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 1 Ease of dilatation: need for mechanical dilatation.
Figures and Tables -
Analysis 1.1

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 1 Ease of dilatation: need for mechanical dilatation.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 2 Intraoperative complications.
Figures and Tables -
Analysis 1.2

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 2 Intraoperative complications.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 3 Specific intraoperative complications.
Figures and Tables -
Analysis 1.3

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 3 Specific intraoperative complications.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 4 Time required to dilate the cervix (sec.).
Figures and Tables -
Analysis 1.4

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 4 Time required to dilate the cervix (sec.).

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 5 Preoperative pain score.
Figures and Tables -
Analysis 1.5

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 5 Preoperative pain score.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 6 Cervical width (dilator size in mm).
Figures and Tables -
Analysis 1.6

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 6 Cervical width (dilator size in mm).

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 7 Failure to dilate the cervix.
Figures and Tables -
Analysis 1.7

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 7 Failure to dilate the cervix.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 8 Side effects.
Figures and Tables -
Analysis 1.8

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 8 Side effects.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 9 Types of side effects.
Figures and Tables -
Analysis 1.9

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 9 Types of side effects.

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 10 Duration of operation( min..).
Figures and Tables -
Analysis 1.10

Comparison 1 Misoprostol versus placebo or no treatment, Outcome 10 Duration of operation( min..).

Comparison 2 Misoprostol versus dinoprostone, Outcome 1 Ease of dilatation: need for mechanical dilatation.
Figures and Tables -
Analysis 2.1

Comparison 2 Misoprostol versus dinoprostone, Outcome 1 Ease of dilatation: need for mechanical dilatation.

Comparison 2 Misoprostol versus dinoprostone, Outcome 2 Intraoperative complications.
Figures and Tables -
Analysis 2.2

Comparison 2 Misoprostol versus dinoprostone, Outcome 2 Intraoperative complications.

Comparison 2 Misoprostol versus dinoprostone, Outcome 3 Types of side effects.
Figures and Tables -
Analysis 2.3

Comparison 2 Misoprostol versus dinoprostone, Outcome 3 Types of side effects.

Comparison 2 Misoprostol versus dinoprostone, Outcome 4 Time required to dilate the cervix (sec.).
Figures and Tables -
Analysis 2.4

Comparison 2 Misoprostol versus dinoprostone, Outcome 4 Time required to dilate the cervix (sec.).

Comparison 2 Misoprostol versus dinoprostone, Outcome 5 Cervical width (dilator size in mm).
Figures and Tables -
Analysis 2.5

Comparison 2 Misoprostol versus dinoprostone, Outcome 5 Cervical width (dilator size in mm).

Comparison 2 Misoprostol versus dinoprostone, Outcome 6 Duration of operative hysteroscopy (min.).
Figures and Tables -
Analysis 2.6

Comparison 2 Misoprostol versus dinoprostone, Outcome 6 Duration of operative hysteroscopy (min.).

Comparison 3 Misoprostol versus osmotic dilator, Outcome 1 Ease of dilatation: need for mechanical dilatation.
Figures and Tables -
Analysis 3.1

Comparison 3 Misoprostol versus osmotic dilator, Outcome 1 Ease of dilatation: need for mechanical dilatation.

Comparison 3 Misoprostol versus osmotic dilator, Outcome 2 Intraoperative complications.
Figures and Tables -
Analysis 3.2

Comparison 3 Misoprostol versus osmotic dilator, Outcome 2 Intraoperative complications.

Comparison 3 Misoprostol versus osmotic dilator, Outcome 3 Time required to dilate the cervix (sec.).
Figures and Tables -
Analysis 3.3

Comparison 3 Misoprostol versus osmotic dilator, Outcome 3 Time required to dilate the cervix (sec.).

Comparison 3 Misoprostol versus osmotic dilator, Outcome 4 Cervical width (dilator size in mm).
Figures and Tables -
Analysis 3.4

Comparison 3 Misoprostol versus osmotic dilator, Outcome 4 Cervical width (dilator size in mm).

Summary of findings for the main comparison. Misoprostol compared to placebo or no treatment before operative hysteroscopy

Misoprostol compared to placebo or no treatment for women undergoing hysteroscopy

Population: Pre and post menopausal women
Settings: Operative hysteroscopy
Intervention: Preoperative misoprostol
Comparison: Placebo or no treatment

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo or no treatment

Misoprostol

Ease of dilatation: need for mechanical dilatation

797 per 1000

239 per 1000
(136 to 386)5 to 23 per 1000

OR 0.08
(0.04 to 0.16)

441
(5 RCTs)

⊕⊕⊕⊝
MODERATE 1

Intraoperative complications

29 per 1000

11 per 1000
(5 to 23)

OR 0.37
(0.18 to 0.77)

901
(12 RCTs)

⊕⊕⊕⊝
MODERATE 1

Specific intraoperative complications ‐ Cervical laceration/tear

25 per 1000

6 per 1000
(3 to 14)

OR 0.25
(0.11 to 0.57)

669
(9 RCTs)

⊕⊕⊕⊝
MODERATE 1

Specific intraoperative complications ‐ False track

40 per 1000

14 per 1000
(5 to 39)

OR 0.34
(0.12 to 0.97)

560
(7 RCTs)

⊕⊕⊕⊝
MODERATE 1

Specific intraoperative complications ‐ Uterine perforation

29 per 1000

13 per 1000
(4 to 40)

OR 0.42
(0.13 to 1.38)

455
(7 RCTs)

⊕⊕⊝⊝
LOW 1,2

Specific intraoperative complications ‐ Uterine bleeding

60 per 1000

32 per 1000
(6 to 137)

OR 0.51
(0.10 to 2.49)

340
(4 RCTs)

⊕⊕⊝⊝
LOW 1,2

Side effects

18 per 1000

112 per 1000
(48 to 241)

OR 2.59
(1.15 to 5.79)

272
(4 RCTs)

⊕⊕⊕⊝
MODERATE 1

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Inadequate reporting of methodology by all or most of the studies

2Imprecision: low event rates and wide confidence intervals compatible with no effect or with meaningful benefit from misoprostol

Figures and Tables -
Summary of findings for the main comparison. Misoprostol compared to placebo or no treatment before operative hysteroscopy
Summary of findings 2. Misoprostol compared to dinoprostone before operative hysteroscopy

Misoprostol compared to dinoprostone for health problem or population

Population: Pre and post menopausal women
Settings: Operative hysteroscopy
Intervention: Preoperative misoprostol
Comparison: Preoperative dinoprostone

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Dinoprostone

Misoprostol

Ease of dilatation: need for mechanical dilatation

804 per 1000

704 per 1000
(582 to 801)

OR 0.58

(0.34 to 0.98)

310
(1 RCT)

⊕⊕⊝⊝
LOW 1,2

Intraoperative complications

114 per 1000

40 per 1000
(15 to 96)

OR 0.32
(0.12 to 0.83)

310
(1 RCT)

⊕⊕⊝⊝
LOW 1,2

Side effects

Total side effects not reported. Some specific side effects (abdominal pain, vaginal bleeding, diarrhoea and perception of raised temperature) were more common in the misoprostol group. All side effects were mild.

⊕⊕⊝⊝
LOW 1,3

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Inadequate description of study methods, high risk of attrition bias

2Imprecision: wide confidence intervals compatible with meaningful benefit from misoprostol or with little or no meaningful benefit

3Imprecision: wide confidence intervals compatible with harm from misoprostol or no clinically meaningful effect

Figures and Tables -
Summary of findings 2. Misoprostol compared to dinoprostone before operative hysteroscopy
Summary of findings 3. Misoprostol compared to osmotic dilator before operative hysteroscopy

Misoprostol compared to osmotic dilator for health problem or population

Population: Pre and post menopausal women
Settings: Operative hysteroscopy
Intervention: Preoperative misoprostol
Comparison: Preoperative osmotic dilator

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Osmotic dilator

Misoprostol

Ease of dilatation: need for mechanical dilatation

283 per 1000

702 per 1000
(507 to 843)

OR 5.96

(2.61 to 13.59)

110
(1 RCT)

⊕⊕⊝⊝
LOW 1,2

Intraoperative complications

0 per 1000

0 per 1000
(0 to 0)

OR 5.14
(0.24 to 109.01)

354
(3 RCTs)

⊕⊕⊝⊝
LOW 3,4

Only two events altogether. No events in two RCTs

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Risk of attrition bias unclear; unclear whether outcome assessment was blinded

2Imprecision: single small study with total of 55 events

3One of studies does not adequately describe methods, unclear whether outcome assessment blinded

4Imprecision: only 2 events

Figures and Tables -
Summary of findings 3. Misoprostol compared to osmotic dilator before operative hysteroscopy
Comparison 1. Misoprostol versus placebo or no treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Ease of dilatation: need for mechanical dilatation Show forest plot

5

441

Odds Ratio (M‐H, Fixed, 95% CI)

0.08 [0.04, 0.16]

1.1 Premenopausal women

4

335

Odds Ratio (M‐H, Fixed, 95% CI)

0.10 [0.05, 0.20]

1.2 Postmenopausal women

2

106

Odds Ratio (M‐H, Fixed, 95% CI)

0.04 [0.01, 0.17]

2 Intraoperative complications Show forest plot

12

901

Odds Ratio (M‐H, Fixed, 95% CI)

0.37 [0.18, 0.77]

2.1 Premenopausal women

8

667

Odds Ratio (M‐H, Fixed, 95% CI)

0.27 [0.11, 0.65]

2.2 Postmenopausal women and women pretreated with GnRHa

5

234

Odds Ratio (M‐H, Fixed, 95% CI)

0.97 [0.21, 4.47]

3 Specific intraoperative complications Show forest plot

11

Odds Ratio (IV, Fixed, 95% CI)

Subtotals only

3.1 Cervical laceration/tear

9

669

Odds Ratio (IV, Fixed, 95% CI)

0.25 [0.11, 0.57]

3.2 False track

7

560

Odds Ratio (IV, Fixed, 95% CI)

0.34 [0.12, 0.97]

3.3 Uterine perforation

7

455

Odds Ratio (IV, Fixed, 95% CI)

0.42 [0.13, 1.38]

3.4 Uterine bleeding

4

340

Odds Ratio (IV, Fixed, 95% CI)

0.51 [0.10, 2.49]

4 Time required to dilate the cervix (sec.) Show forest plot

7

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5 Preoperative pain score Show forest plot

4

200

Mean Difference (IV, Fixed, 95% CI)

1.25 [0.77, 1.72]

6 Cervical width (dilator size in mm) Show forest plot

12

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

7 Failure to dilate the cervix Show forest plot

10

690

Odds Ratio (M‐H, Fixed, 95% CI)

0.09 [0.01, 0.82]

8 Side effects Show forest plot

4

272

Odds Ratio (M‐H, Fixed, 95% CI)

2.59 [1.15, 5.79]

9 Types of side effects Show forest plot

7

Odds Ratio (IV, Fixed, 95% CI)

Subtotals only

9.1 Mild abdominal pain

5

548

Odds Ratio (IV, Fixed, 95% CI)

8.48 [3.77, 19.04]

9.2 Vaginal bleeding

6

532

Odds Ratio (IV, Fixed, 95% CI)

7.09 [2.83, 17.78]

9.3 Nausea

5

489

Odds Ratio (IV, Fixed, 95% CI)

2.41 [0.66, 8.75]

9.4 Diarrhoea

5

489

Odds Ratio (IV, Fixed, 95% CI)

5.66 [0.96, 33.16]

9.5 Increased body temperature

2

243

Odds Ratio (IV, Fixed, 95% CI)

5.25 [1.28, 21.44]

9.6 Shivering

2

86

Odds Ratio (IV, Fixed, 95% CI)

0.91 [0.09, 9.18]

10 Duration of operation( min..) Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Figures and Tables -
Comparison 1. Misoprostol versus placebo or no treatment
Comparison 2. Misoprostol versus dinoprostone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Ease of dilatation: need for mechanical dilatation Show forest plot

1

310

Odds Ratio (M‐H, Fixed, 95% CI)

0.58 [0.34, 0.98]

2 Intraoperative complications Show forest plot

1

310

Odds Ratio (M‐H, Fixed, 95% CI)

0.32 [0.12, 0.83]

3 Types of side effects Show forest plot

1

Odds Ratio (IV, Fixed, 95% CI)

Totals not selected

3.1 Mild abdominal pain

1

Odds Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Vaginal bleeding

1

Odds Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.3 Headache

1

Odds Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.4 Nausea

1

Odds Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.5 Vomiting

1

Odds Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.6 Diarrhoea

1

Odds Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.7 Increased body temperature

1

Odds Ratio (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Time required to dilate the cervix (sec.) Show forest plot

1

310

Mean Difference (IV, Fixed, 95% CI)

‐4.60 [‐8.61, ‐0.59]

5 Cervical width (dilator size in mm) Show forest plot

1

310

Mean Difference (IV, Fixed, 95% CI)

0.40 [0.21, 0.59]

6 Duration of operative hysteroscopy (min.) Show forest plot

1

310

Mean Difference (IV, Fixed, 95% CI)

3.20 [1.16, 5.24]

Figures and Tables -
Comparison 2. Misoprostol versus dinoprostone
Comparison 3. Misoprostol versus osmotic dilator

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Ease of dilatation: need for mechanical dilatation Show forest plot

1

110

Odds Ratio (M‐H, Fixed, 95% CI)

5.96 [2.61, 13.59]

1.1 Misoprostol vs natural osmotic dilator

1

110

Odds Ratio (M‐H, Fixed, 95% CI)

5.96 [2.61, 13.59]

2 Intraoperative complications Show forest plot

3

354

Odds Ratio (M‐H, Fixed, 95% CI)

5.14 [0.24, 109.01]

2.1 Misoprostol vs natural osmotic dilator

2

254

Odds Ratio (M‐H, Fixed, 95% CI)

5.14 [0.24, 109.01]

2.2 Misoprostol vs synthetic osmotic dilator

1

100

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Time required to dilate the cervix (sec.) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.1 Misoprostol versus natural osmotic dilator

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Cervical width (dilator size in mm) Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.1 Misoprostol vs natural osmotic dilator

2

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.2 Misoprostol vs synthetic dilator

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 3. Misoprostol versus osmotic dilator