Prior Uterine Evacuation of Pregnancy as Independent Risk Factor for Preterm Birth: A Systematic Review and Metaanalysis
Saccone G, Perriera L, Berghella V
Am J Obstet Gynecol. 2016;214:572-591
Background
Preterm delivery (PTD) is defined as a delivery prior to the 37th week of gestation. PTD is associated along with substantial morbidity and mortality of the newborn.[1,2] The severity depends on the gestational age at delivery and involves respiratory difficulty, intraventricular hemorrhage, retinopathy, increased risk for infections, and delayed motor-neurodevelopment in the neonatal period. PTD is likewise a source of increased maternal morbidity and mortality. Furthermore, it is associated along with substantial healthcare expenses. Prior uterine surgery, especially procedures performed on the cervix, has actually been identified as a risk factor for PTD.[1,3] This meta-analysis evaluated the impact of prior pregnancy termination on subsequent risk for PTD.
The Study
Thirty-6 case-regulate and cohort studies involving over 1 million women that underwent induced termination of pregnancy or spontaneous abortion were identified. The association between prior surgical or medical pregnancy termination and PTD, reduced birth weight (LBW), and small for gestational age (SGA) were evaluated. Terminations done electively or as section of a completion of a miscarriage were analyzed combined and separately as well. The researchers reported:
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When every one of procedures were combined, an increased risk for PTD (5.7% vs 5%; odds ratio [OR], 1.44; 95% self-confidence interval [CI], 1.09-1.90), LBW (7.3% vs 5.9%; OR, 1.41; 95% CI, 1.22-1.62) and SGA (10.2% vs 9%; OR, 1.19; 95% CI, 1.01-1.42) was found.
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When induced pregnancy terminations were analyzed separately, the risk for PTD, LBW, and SGA were greater as compared along with in women along with no previous induced termination.
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Both vacuum and sharp curettage were associated along with an increased risk, though Once the 2 procedures were compared, the risk for PTD was greater among those along with prior sharp curettage (5.5% vs 3.6%; OR, 1.54; 95% CI, 1.38-1.73).
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When gestational age at termination was evaluated, those along with an induced termination prior to week 14 were not at increased risk for PTD Once compared along with controls.
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No increased risk was discovered for PTD among those along with one prior medical termination of pregnancy Once compared along with controls.
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Those along with surgical completion of a spontaneous abortion were at a greater risk for PTD in a subsequent pregnancy Once compared along with those that had no previous spontaneous abortions.
Viewpoint
Prior to uterine evacuation, the cervix has to be dilated to obtain access to the uterine cavity. This could happen spontaneously or medically using prostaglandins, along with osmotic dilators that are placed in the cervix, or mechanically using metal dilators along with increasing diameter. The latter is the the majority of most likely to induce damage in the structure of the cervix. This study discovered that those that had prior evacuation of the uterus (electively or as section of managing a loss) were at greater risk for subsequent PTD, LBW, and SGA.
There are necessary observations of this meta-analysis. An earlier procedure is much less most likely to be associated along with subsequent edge outcome as those that had the intervention in the initial trimester were not at an increased risk for PTD.
If a surgical procedure is chosen, vacuum aspiration is much less most likely to lead to edge outcome Once compared along with sharp curettage. It is most likely that the softer instruments used throughout vacuum aspiration are much less most likely to damage the cervix or uterine cavity.
Medical abortion was not associated along with an edge outcome. It is real that medical abortion is much more most likely to be available at an earlier gestational age, however it is likewise associated along with prostaglandin ripening and gradual cervical dilatation.
Expectant management of missed abortions is an alternative along with the reward of eventual spontaneous loss. The drawback is that the timing is not known, and it could be associated along with heavy bleeding, an extended period of painful cramping, and an utmost reason for surgical intervention. Still, along with expectant management and utmost spontaneous loss, the cervix is dilated spontaneously and gradually, inducing much less trauma in the cervix.
It is constantly finest to involve the patient in the decision-making process. She ought to be aware of the actions of the various means and the associated short- and lasting edge effects. A surgical dilatation and curettage is a quick, controlled procedure done under sedation and, therefore, is the least uncomfortable for the patient. In addition, it is associated along with the least quantity of blood loss and painful cramps. It may, however, be associated along with edge outcome in a later pregnancy. Therefore, this could be an excellent choice for those that do not strategy future pregnancies. The vacuum aspiration is an excellent alternative for those that still desire fertility. Medical choices ought to likewise be available to those that strategy further pregnancies. Ultimately, the experience of the operating surgeon likewise has to be considered. It is likewise necessary to point out that while the relative risk is increased for PTD, LBW, and SGA along with the majority of methods, the absolute differences are small.
