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Uterine rupture at 8 weeks' gestation following 600 μg of oral misoprostol for management of delayed miscarriage

1999). A small proportion require inpatient hysteroscopy under general anaesthesia either because of intolerance for removal of large polyps, or because the endocervix cannot be navigated. In our experience, most of the stenosed cervices can be dilated conventionally but a small proportion of women appear to have cervical closure. We have now used this technique on five occasions over 3 years and it has been successful in four and without complication in all. Entry into the cavity is usually signalled by release of brown fluid or mucus. The safety of this technique is unknown. Clearly, there is a risk of haemorrhage and infection, and of damage to surrounding structures. Bleeding and infection have not been an issue so far and we take special care to follow the axis of the cervix, so as to avoid damaging bladder or bowel. This can usually be judged on vaginal examination. The value of the technique is that it avoids the very occasional needed to resort to diagnostic hysterectomy in order to investigate the endometrium. This can be very difficult in women with morbid obesity and our technique appears to reduce the need for that. Of the four women for whom we have undertaken this successfully, three did not have endometrial malignancy and therapeutic hysterectomy was not needed. Some have advocated the use of laminaria tents to overcome cervical stenosis (Glatstein et al. 1997) but that has to be used preoperatively and it is of no value when the endometrial cavity cannot be entered. Preutthipan and Yongyoth (1999) have used preoperative vaginal misoprostol to ease cervical dilatation. This softens the cervix and reduces tissue resistance but it is unlikely to overcome the problem of a blind ending canal.