Repeated medical abortions and the risk of preterm birth in the subsequent pregnancy

Subsequent placenta accreta after previous mifepristone-induced abortion: A case report

BACKGROUND

Mifepristone-induced abortion (MIA) has been used worldwide to terminate pregnancies. However, the association between placenta accrete (PA) and MIA has seldom been reported.

CASE SUMMARY

A 26-year-old pregnant woman presented with painless vaginal bleeding at 35 wk of gestation. She had a medical abortion (mifepristone followed by misoprostol) 1 year ago at the sixth week of gestation. Her personal history for previous surgery was negative. Abdominal ultrasonography showed a normal foetus with complete placenta previa. The foetal membrane ruptured with massive vaginal bleeding and severe abdominal pain. An emergency Caesarean section was performed, and the newborn was delivered. The placenta failed to expel and manual extraction was carried out. A large defect was noted in the uterine fundus and repair of the uterine rupture was conducted immediately. The postoperative pathology report showed placenta accreta.

CONCLUSION

The evidence suggests a possible etiologic role of MIA in PA, as the incidence of PA after MIA is much higher than general population. Millions of pregnancies are complicated by PA each year, some of which result in fatality. To prevent subsequent placental complications after MIA, hormonal supplementation might be a promising therapeutic options. However, further studies are needed to identify the high-risk factors and to confirm the effectiveness of estrogen supplement therapy.

Incidence and trend of preterm birth in China, 1990-2016: a systematic review and meta-analysis

OBJECTIVES

To update the WHO estimate of preterm birth rate in China in 1990-2016 and to further explore variations by geographic regions and years of occurrence.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Pubmed, Embase, Cochrane Library and Sinomed databases were searched from 1990 to 2018.

ELIGIBILITY CRITERIA

Studies were included if they provided preterm birth data with at least 500 total births. Reviews, case-control studies, intervention studies and studies with insufficient information or published before 1990 were excluded. We estimated pooled incidence of preterm birth by a random effects model, and preterm birth rate in different year, region and by livebirths or all births in subgroup analyses.

RESULTS

Our search identified 3945 records. After the removal of duplicates and screening of titles and abstracts, we reviewed 254 studies in full text and excluded 182, leaving 72 new studies. They were combined with the 82 studies included in the WHO report (154 studies, 187 data sets in total for the meta-analysis), including 24 039 084 births from 1990 to 2016. The pooled incidence of preterm birth in China was 6.09% (95% CI 5.86% to 6.31%) but has been steadily increasing from 5.36% (95% CI 4.89% to 5.84%) in 1990-1994 to 7.04% (95% CI 6.09% to 7.99%) in 2015-2016. The annual rate of increase was about 1.05% (95% CI 0.85% to 1.21%). Northwest China appeared to have the highest preterm birth rate (7.3%, 95% CI 4.92% to 9.68% from 1990 to 2016).

CONCLUSIONS

The incidence of preterm birth in China has been rising gradually in the past three decades. It was 7% in 2016. Preterm birth rate varied by region with the West having the highest occurrence.

Risks of Adverse Perinatal Outcomes after Repeat Terminations of Pregnancy by their Methods: a Nationwide Register-based Cohort Study in Finland 1996-2013

BACKGROUND

Repeat terminations of pregnancy (TOPs) are associated with an increased risk of adverse outcomes in the subsequent birth. The perinatal outcomes after repeat TOPs by their methods have not yet been properly studied. This study aimed to examine perinatal outcomes in subsequent pregnancy among the women with a singleton birth and a history of TOPs.

METHODS

All the first-time mothers (n = 419 879) with a singleton birth during 1996-2013 in Finland were identified from the Medical Birth Register and linked to the Abortion Register. Adjusted multivariable logistic regression analysis was used to estimate risks of adverse perinatal outcomes.

RESULTS

The increased incidence of adverse perinatal outcomes was found with increasing number of surgical TOPs. After adjusting for confounders, the women with one surgical TOP had slightly increased but significant odds of 1.07 (95% CI 1.02, 1.13) for being small for gestational age compared with the women having no TOP. A significantly high risk for extremely preterm birth (OR 1.51, 95% CI 1.03, 2.23) was found among the women having had repeat surgical TOPs when compared to the women with no TOP. Non-significant risks were found for adverse perinatal outcomes after women's repeat surgical TOPs than repeat medical TOPs.

CONCLUSION

Information regarding the consequences of repeat induced TOPs will be significant in sexual health education as well as counselling women after first termination.

Perinatal outcomes after induced termination of pregnancy by methods: A nationwide register-based study of first births in Finland 1996-2013

Background

Women with previous terminations of pregnancy (TOPs) before their first birth have been associated with poorer perinatal outcomes. However, previous studies on the perinatal outcomes by the method in previous TOPs are inconsistent.

Objective

To examine the perinatal outcomes of the first-time mothers with singleton births, by the method of previous TOP (medical and surgical vs no TOP, and surgical vs medical).

Method

This is a nationwide register-based study including 419,879 first-time Finnish mothers with singleton birth during the time period 1996–2013. Mothers having their first birth were identified from the Medical Birth Register and linked to the Abortion Register by their identification numbers. Multinomial logistic regression analysis was performed to examine the risk for preterm birth, low birth weight, small for gestational age and perinatal death by the method in previous TOPs.

Results

Among the first-time mothers, 87.0% had no history of TOPs, 3.2% had a history of medical TOP(s), 9.2% had a history of surgical TOP(s) and 0.6% had a history of both (medical and surgical) TOP(s). No significant differences in perinatal outcomes were found among the women with surgical TOPs, compared to the women with no TOPs. In unadjusted analysis, increased odds for preterm birth and low birth weight were found when comparing women having previous surgical TOPs with medical TOPs. Even after the adjustment of potential confounders, odds for preterm birth < 37 weeks (OR = 1.19, 95% CI = 1.04–1.36) and low birth weight < 2500 g (OR = 1.16, 95% CI = 1.00–1.35) remained significant. After restricting data to the single TOP, the results were similar; OR for both preterm birth and low birth weight was 1.18 (95% CIs = 1.02–1.36 and 1.01–1.38).

Conclusion

Perinatal outcomes did not differ among the mothers with surgical TOPs compared to the mothers with no TOPs, while the outcomes were poorer after surgical TOP(s) than after medical TOP(s).

[Complications of termination of pregnancy]

The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.

Assessment of effects of mifepristone administration to lactating mice on the development and fertility of their progeny

AIM

Mifepristone, a synthetic steroid compound that induces abortion, was recently found to potentially pass into human milk. This study aimed to determine the effects of mifepristone administration to lactating mice on the development and reproduction of their progeny.

METHODS

Lactating mice were gavage fed with mifepristone (8 mg/kg) daily for 4 days either from days 1-4 or from days 7-10 of lactation; controls received only peanut oil. Growth, mortality rate, organ weight to bodyweight ratio, sex hormone at 20, 40 and 60 days, fertility of these F1 progeny and litter size, sex ratio and mortality rate of the second generation were recorded.

RESULTS

No significant differences were observed in the average bodyweight, mortality rate of the female or male pups, and organ coefficient of uterus and ovaries of females in adulthood in comparison with the controls. However, the organ coefficient of testis at day 20 and 40 and testosterone concentration at day 60 were increased in male pups. Moreover, the reproductive capacity of the F1 pups was unaffected by 4 days exposure to mifepristone via their mother's milk: time to birth of F2 pups, litter size, sex ratio and mortality rate were similar to control F1 pups.

CONCLUSION

The study showed that treating lactating mice with 8 mg/kg mifepristone influenced only the organ coefficient of testis at day 40 and the testosterone concentration in male pups at day 60, however, it did not affect the development and fertility of female and male pups.

Cervical stitch (cerclage) for preventing preterm birth in multiple pregnancy

BACKGROUND

Cervical cerclage is a surgical intervention involving placing a stitch around the uterine cervix. The suture material aims to prevent cervical shortening and opening, thereby reducing the risk of preterm birth. The effectiveness and safety of this procedure in multiple gestations remains controversial.

OBJECTIVES

To assess whether the use of a cervical cerclage in multiple gestations, either at high risk of pregnancy loss based on just the multiple gestation (history-indicated cerclage), the ultrasound findings of 'short cervix' (ultrasound-indicated cerclage), or the physical exam changes in the cervix (physical exam-indicated cerclage), improves obstetrical and perinatal outcomes. The primary outcomes assessed were perinatal deaths, serious neonatal morbidity, and perinatal deaths and serious neonatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of cervical cerclage in multiple pregnancies. Quasi-RCTs and RCTs using a cluster-randomised design were eligible for inclusion (but none were identified). Studies using a cross-over design and those presented only as abstracts were not eligible for inclusion.We included studies comparing cervical cerclage with no cervical cerclage in multiple pregnancies.Studies comparing cervical stitch versus any other preventative therapy (e.g. progesterone) in multiple pregnancies, and studies involving comparisons between different cerclage protocols (history-indicated versus ultrasound-indicated versus physical exam-indicated cerclage) were also eligible for inclusion but none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias. Two review authors extracted data. Data were checked for accuracy.

MAIN RESULTS

We included five trials, which in total randomised 1577 women, encompassing both singleton and multiple gestations. After excluding singletons, the final analysis included 128 women, of which 122 women had twin gestations, and six women had triplet gestations. Two trials (n = 73 women) assessed history-indicated cerclage, while three trials (n = 55 women) assessed ultrasound-indicated cerclage. The five trials were judged to be of average to above average quality, with three of the trials at unclear risk regarding selection and detection biases.Concerning the primary outcomes, when outcomes for cerclage were pooled together for all indications and compared with no cerclage, there was no statistically significant differences in perinatal deaths (19.2% versus 9.5%; risk ratio (RR) 1.74, 95% confidence intervals (CI) 0.92 to 3.28, five trials, n = 262), serious neonatal morbidity (15.8% versus 13.6%; average RR 0.96, 95% CI 0.13 to 7.10, three trials, n = 116), or composite perinatal death and neonatal morbidity (40.4% versus 20.3%; average RR 1.54, 95% CI 0.58 to 4.11, three trials, n = 116).Among the secondary outcomes, there were no significant differences between the cerclage and the no cerclage groups. To name a few, there were no significant differences among the following: preterm birth less than 34 weeks (average RR 1.16, 95% CI 0.44 to 3.06, four trials, n = 83), preterm birth less than 35 weeks (average RR 1.11, 95% CI 0.58 to 2.14, four trials, n = 83), low birthweight less than 2500 g (average RR 1.10, 95% CI 0.82 to 1.48, four trials, n = 172), very low birthweight less than 1500 g (average RR 1.42, 95% CI 0.52 to 3.85, four trials, n = 172), and respiratory distress syndrome (average RR 1.70, 95% CI 0.15 to 18.77, three trials, n = 116). There were also no significant differences between the cerclage and no cerclage groups when examining caesarean section (elective and emergency) (RR 1.24, 95% CI 0.65 to 2.35, three trials, n = 77) and maternal side-effects (RR 3.92, 95% CI 0.17 to 88.67, one trial, n = 28).Examining the differences between prespecified subgroups, ultrasound-indicated cerclage was associated with an increased risk of low birthweight (average RR 1.39, 95% CI 1.06 to 1.83, Tau² = 0.01, I² = 15%, three trials, n = 98), very low birthweight (average RR 3.31, 95% CI 1.58 to 6.91, Tau² = 0, I² = 0%, three trials, n = 98), and respiratory distress syndrome (average RR 5.07, 95% CI 1.75 to 14.70, Tau² = 0, I² = 0%, three trials, n = 98). However, given the low number of trials, as well as substantial heterogeneity and subgroup differences, these data must be interpreted cautiously.No trials reported on long-term infant neurodevelopmental outcomes. There were no physical exam-indicated cerclages available for comparison among the studies included.

AUTHORS' CONCLUSIONS

This review is based on limited data from five small studies of average to above average quality. For multiple gestations, there is no evidence that cerclage is an effective intervention for preventing preterm births and reducing perinatal deaths or neonatal morbidity.

Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later

During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.

Reproductive outcomes following induced abortion: a national register-based cohort study in Scotland

OBJECTIVE

To investigate reproductive outcomes in women following induced abortion (IA).

DESIGN

Retrospective cohort study.

SETTING

Hospital admissions between 1981 and 2007 in Scotland.

PARTICIPANTS

Data were extracted on all women who had an IA, a miscarriage or a live birth from the Scottish Morbidity Records. A total of 120 033, 457 477 and 47 355 women with a documented second pregnancy following an IA, live birth and miscarriage, respectively, were identified.

OUTCOMES

Obstetric and perinatal outcomes, especially preterm delivery in a second ongoing pregnancy following an IA, were compared with those in primigravidae, as well as those who had a miscarriage or live birth in their first pregnancy. Outcomes after surgical and medical termination as well as after one or more consecutive IAs were compared.

RESULTS

IA in a first pregnancy increased the risk of spontaneous preterm birth compared with that in primigravidae (adjusted RR (adj. RR) 1.37, 95% CI 1.32 to 1.42) or women with an initial live birth (adj. RR 1.66, 95% CI 1.58 to 1.74) but not in comparison with women with a previous miscarriage (adj. RR 0.85, 95% CI 0.79 to 0.91). Surgical abortion increased the risk of spontaneous preterm birth compared with medical abortion (adj. RR 1.25, 95% CI 1.07 to 1.45). The adjusted RRs (95% CI) for spontaneous preterm delivery following two, three and four consecutive IAs were 0.94 (0.81 to 1.10), 1.06 (0.76 to 1.47) and 0.92 (0.53 to 1.61), respectively.

CONCLUSIONS

The risk of preterm birth after IA is lower than that after miscarriage but higher than that in a first pregnancy or after a previous live birth. This risk is not increased further in women who undergo two or more consecutive IAs. Surgical abortion appears to be associated with an increased risk of spontaneous preterm birth in comparison with medical termination of pregnancy. Medical termination was not associated with an increased risk of preterm delivery compared to primigravidae.