***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To compare the efficacy of Laminaria tents with Misoprostol for cervical ripening before surgical process in missed abortion . Method In a prospect i ve study , 70 women with missed abortion were assigned to have either insertion of a 3 mm intracervical Laminaria tent ( n = 35 ) or vaginal Misoprostol 400 μg ( n = 35 ) on the day prior to suction dilation and curettage ( D/C ) . The women were interviewed just prior to the D/C with regard to pain , vaginal bleeding , and cervical dilator preference . Result Cervical dilation was greater in the Laminaria group but not significantly different from that in the Misoprostol group . However , additional cervical dilation before D/C was required in more patients in the Misoprostol group ( 45.7 vs 14.3 % , P = 0.001 ) . Women who received Laminaria reported significantly more pain at the time of insertion ( 62.8 % in Laminaria group vs 22.8 % in Misoprostol group ) compared with women who received Misoprostol . Conversely , Misoprostol was associated with more nausea , vomiting , diarrhea and vaginal bleeding . Conclusions Laminaria tents are more effective cervical dilators than vaginal Misoprostol when inserted the day prior to suction D and C. Vaginal Misoprostol insertion is more comfortable , although it is associated with an increased risk of vaginal bleeding OBJECTIVE To assess the effectiveness of misoprostol in cervical ripening before evacuation of conception in the first trimester missed miscarriages , and to compare between oral and vaginal routes of administration . METHODS A r and omized controlled study was carried out in Baghdad Teaching Hospital , Baghdad , Iraq in 2006 . One hundred and twenty women with first trimester missed miscarriages were divided into 2 study groups , r and omized for oral and vaginal 400 mcg misoprostol priming of cervix , and 2 control groups r and omized for oral and vaginal placebo , before undergoing surgical evacuation of conception after 3 hours . Measured outcomes were : post medication cervical dilatation , time needed to dilate the cervix surgically , blood loss , and development of the side effects of misoprostol .  RESULTS Post medication cervical dilatation was higher in the misoprostol group ( 7.07 + /- 1.36 mm for oral misoprostol , 7.77 + /-1.22 mm for vaginal misoprostol ) , versus the control groups ( 2.43 + /- 0.5 mm ) . Post medication cervical dilatation was significantly higher in the vaginal misoprostol group , compared to the oral group ( p=0.04 ) . The time required to dilate the cervix in the misoprostol group was shorter , compared with placebo . There were no significant differences in the amount of blood loss between oral ( p=0.74 ) , and vaginal misoprostol groups ( p=0.62 ) , and gastrointestinal side effects were significantly more in the oral misoprostol group ( p=0.014 ) . CONCLUSION Misoprostol is an effective cervical priming agent when administered either orally or vaginally before evacuation of conception in the termination of the first trimester missed miscarriage The aim of this study was to evaluate whether a single intracervical application of prostagl and in E2 ( PGE2 ) gel is as effective as a repeated administration with respect to the % of curettage for a missed abortion and to incidence of side effects . 32 consecutive patients with ultrasonographic diagnosis of missed abortion from 6th-13th week of gestation were r and omly allocated to either single ( group A ) or repeated , 2 h apart ( group B ) , intracervical application of PGE2 gel . No differences were observed in cervical dilatation before the administration of the gel between the two groups . In group B , evaluation of cervical dilatation 2 h after the first administration of PGE2 gel and before the second one did not show significant changes as compared to baseline values . The degree of cervical dilatation before surgery was significantly improved as compared to the initial dilatation in both groups ; no significant difference was observed between the two study groups . A single administration of PGE2 gel followed by surgery 5 h later has the same effectiveness on cervical dilatation but fewer side effects than repeated administration of the drug 2 h apart OBJECTIVE To compare the efficacy and safety of vaginal applications of three different principles of cervical priming prior to first trimester curettage , isosorbide mononitrate ( ISMN ) , misoprostol and Dilapan-S , a hygroscopical cervical dilator . STUDY DESIGN Pregnant women with missed abortion between 6 and 12 gestational weeks were included and r and omly assigned to receive either 80 mg ISMN vaginal gel ( group 1 ) or 200 microg of misoprostol vaginal gel ( group 2 ) or Dilapan-S , a hygroscopical cervical dilator ( group 3 ) , for cervical ripening before curettage . Outcome parameters were cervical dilation at the time of operation and maximum dilation reached with Hegar 's dilator and the degree of difficulty in mechanical dilation as well as safety and side effects of the preparations . RESULTS Sixty-five pregnant women with missed abortion were included and assigned to the three study groups ( n=22 for group 1 , n=22 for group 2 , n=21 for group 3 ) . Misoprostol vaginal gel and Dilapan-S were significantly more effective than ISMN vaginal gel in cervical dilation reached with priming ( p<0.005 and p<0.005 ) and in the degree of difficulty in cervical dilation assessed by the surgeon ( p<0.001 and p<0.01 ) . Mild discomfort was indicated by all patients after Dilapan insertion , whereas no patient complained about discomfort after misoprostol or ISMN insertion ( p<0001 ) . Three patients suffered from mild hypotension and headache after ISMN treatment , and two had increased vaginal bleeding due to uterine atony during surgery ( p<0.05 ) . CONCLUSION A vaginal gel of ISMN is less effective for cervical ripening prior to first trimester curettage compared to misoprostol vaginal gel or Dilapan-S. The latter could be an effective and safe alternative to prostagl and in priming avoiding preoperative contractions caused by prostagl and in preparations OBJECTIVE To evaluate the efficacy of isosorbide mononitrate ( IMN ) for cervical ripening  prior to first trimester surgical termination of pregnancy . METHODS A prospect i ve , double-blind , r and omized , placebo-controlled trial . Women scheduled for surgical termination of a nonviable fetus before 12 weeks of gestation from October 2008 to June 2009 were enrolled and r and omly assigned to receive either 20 mg vaginally of IMN ( n=24 ) or a placebo ( n=24 ) 4 hours before suction evacuation . Cervical dilation before evacuation was assessed with 10-mm Hegar dilators followed by smaller sizes that were measured until the instrument passed freely through the internal os . Cervical dilation , adverse effects , termination complications , and patient satisfaction were the main outcomes . RESULTS Mean cervical dilation was not significantly different between the IMN and placebo groups ( 6.29+/-0.99 mm vs 5.71+/-1.04 mm ; P=0.05 ) . Mean operative time did not differ between the groups ( 16+/-0.07 min vs 18+/-0.06 min ; P=0.55 ) , nor did patient satisfaction measured by visual analogue scale ( 7.04+/-1.68 vs 6.54+/-1.22 ; P=0.24 ) . CONCLUSION IMN was comparable to placebo in terms of efficacy and patient satisfaction for cervical priming prior to first-trimester termination of pregnancy Objective : The objective of this study was to compare NO-donor isosorbide mononitrate to misoprostol , both applied as vaginal tablets for cervical ripening prior to first trimester curettage in patients with missed abortion . Material s and methods : Thirty women with missed abortion were assigned after a r and om list to be treated either with 200 μg gemeprost ( Cytotec , Pfizer , Germany ) or with 40 mg isosorbide mononitrate for cervical priming at least 3 h before curettage . Vaginal bleeding or the intracervical presence of products of conception was documented . The largest number of Hegar ’s dilator , which could be introduced without difficulty and the largest number of Hegar ’s dilator at which cervical dilation was performed and the ease of mechanical dilation was assessed . Results : There were no significant differences in cervical ripeness before procedure nor in ease of dilation . In the misoprostol group , the cervical canal was more dilated before any procedure ( median of Hegar ’s dilator 6 vs. 5 ) and after dilation ( median of Hegar ’s dilator 11 vs. 10 ) , although this difference was not significant . Vaginal bleeding occurred in two patients in each group . Products of conception were only found in the cervix of one patient of the misoprostol group . Synopsis : Vaginal application of isosorbidemononitrate in cervical priming prior to curettage abortion is as effective as vaginal application of misoprostol Objective : This study was design ed to determine whether use of prostagl and in E1 ( PGE1 ) is justified to improve the known clinical outcome of prostagl and in E2 ( PGE2 ) gel , because PGE2 gel preparations are more costly than PGE1 tablets in most countries , and data to support the use of the gel in clinical practice is not conclusive . The aim was to compare the safety and efficacy of PGE1 gel when applied in both an in-hospital or ambulatory setting to oxytocin infusion in those women with unfavorable cervical conditions prior to surgical abortion for either medical or obstetrical indications with intrauterine fetal demise . Surgical dilatation of the unripe cervix may result in cervical injury of uterine perforation which could prolong the hospital stay . Methods : We used PGE1 gel prepared from tablets and administered in the ambulatory form ( group 1 ) , the same PGE1 gel administered in the labor room ( group 2 ) and intravenously administered oxytocin in the labor room ( group 3 ) for the induction of abortus in women complicated with intrauterine fetus death and missed abortion . Patients requesting abortion were eligible for inclusion , with > 8 and < 13 weeks of gestation . Eighty-nine women with unfavorable cervices ( Bishop score ≤4 ) were included in this study . Comparisons between the three groups for such variables were done by ANOVA . Results : The statistical test did reveal significant differences in the cervical changes , doses of PGE1 used and maternal labor stay between the three groups . The difference in effect on cervical ripening was seen following PGE1 application in both of these groups , but no difference was seen with the  oxytocin  use . Cervical score changed in 100 % of both groups with the PGE1 gel and 89.6 % of the group with oxytocin use , within 6 days in the latter group . The mean number of days of maternal labor stay were 1.5 , 4.6 and 6.2 respectively . There was no difference regarding the effect on clinical characteristics of the women on the final Bishop score . The number , initial and final Bishop score , vaginal bleeding and other complications were not different . Conclusions : Duration of hospital stay may be decreased by applying PGE1 gel in an ambulatory setting when compared to in-hospital PGE1 gel applications or intravenous oxytocin infusion for cervical ripening . Further research is necessary to determine the safety of PGE1 gel application for preabortion cervical ripening prior to surgical abortion Nitric oxide ( NO ) has been found to be involved in the processes of cervical ripening . In a r and omized , placebo-controlled study , cervical softening by an intracervical application of sodium nitroprusside , one of the most clinical ly potent and effective NO donor agents , was evaluated . A total of 36 primigravid women undergoing pregnancy termination between 9 and 12.5 weeks were enrolled . In one series , 18 patients were r and omized to receive intracervically either placebo or 1 % nitroprusside gel ( 5 mg ) , followed by uterine evacuation 6 h after treatment . In another series , 18 patients received either placebo or 2 % nitroprusside gel ( 10 mg ) into the cervical canal followed by uterine evacuation 3 h later . The cervical resistance , i.e. the force required to dilate the cervix from 3 to 10 mm , was the main outcome variable . It was recorded using a force sensing apparatus ( dynamometer ) . Blood pressure was measured . Adverse events were recorded until 2 h after surgery . Women treated with both doses of nitroprusside gel showed values of cervical resistance significantly lower than those treated with placebo gel , at any tested diameter . No differences were found between subjects treated with the two different doses of nitroprusside . No significant consistent changes in blood pressure were induced by either dose of nitroprusside . No headaches were found in subjects treated with the NO donor . This study demonstrates that sodium nitroprusside applied into the cervical canal induces a rapid and significant softening of the cervix , thus reducing the force required to dilate it , compared with placebo-treated subjects . The chemical ripening of the cervix with sodium nit 
    Output:
    
There was no clear differences between chemical dilation and mechanical dilators for the outcomes : difficulty in cervical dilation , excessive bleeding or adverse effects .
This review found no evidence to evaluate cervical ripening prior to first trimester surgical evacuation for miscarriage for reducing the rate of cervical or uterine injury  , however , this may be because these outcomes are very rare .
Cervical preparation was shown to reduce the need for manual cervical dilatation compared with placebo .
Misoprostol and isosorbide mononitrate and dinitrate were similarly effective in ripening the cervix , however there was more vomiting with misoprostol .
Mechanical ( Dilapan-S hygroscopic ) dilators performed similarly to chemical dilators .