Induced Abortions and the Risk of Preeclampsia Among Nulliparous Women

Diabetic and hypertensive disorders following early pregnancy loss: a systematic review and meta-analysis

Background

Spontaneous and induced abortions are common outcomes of pregnancy. There is inconsistent evidence of an association between early pregnancy loss and subsequent diabetic and hypertensive disorders in women. This systematic review and meta-analysis evaluated evidence on the risk of the subsequent development of pregnancy and non-pregnancy related diabetic and hypertensive disorders in women who experienced an early pregnancy loss.

Methods

Systematic searches were conducted in seven electronic databases (CINAHL Plus, Ovid/EMBASE, Ovid/MEDLINE, ProQuest, PubMed, Scopus, and Web of Science) from inception to 22nd December 2023. Studies were included if they reported an exposure of spontaneous abortion (SAB), induced abortion (IA) or recurrent pregnancy loss (RPL) with an outcome of gestational diabetes mellitus, pre-eclampsia, gestational hypertension, and non-pregnancy related diabetic and hypertensive disorders. Risk of bias was assessed using Risk of Bias Instrument for Non-Randomized Studies of Exposures (ROBINS-E). Random effects meta-analysis was used to pool odds of developing diabetic and hypertensive disorders following an early pregnancy loss. This study is registered with PROSPERO (CRD42022327689).

Findings

Of 20,176 records, 60 unique articles were identified for full-text review and 52 met the inclusion criteria, representing a total population of 4,132,895 women from 22 countries. Thirty-five studies were suitable for meta-analysis, resulting in a pooled odds ratio (OR) of 1.44 (95% confidence interval (CI) 1.23-1.68) for gestational diabetes mellitus following a prior SAB and a pooled OR of 1.06 (95% CI 0.90-1.26) for pre-eclampsia following a prior SAB. RPL increased the odds of developing pre-eclampsia (OR 1.37 95% CI 1.05-1.79). There was no association between IA and diabetic and hypertensive disorders.

Interpretation

A prior SAB was associated with increased odds of gestational diabetes mellitus, but not pre-eclampsia. However, women who experienced RPL had an increased risk of subsequent pre-eclampsia. Future research is required to establish evidence for an association between early pregnancy loss with non-pregnancy related diabetic and hypertensive disorders.

Funding

National Health and Medical Research Council.

The Protective Effect of Abortion on Preeclampsia: An Analysis of Current Research

A review of the current literature on preeclampsia (PE) confirms that this pregnancy complication remains a common cause of maternal mortality. Within the last several decades, obstetric and gynecological researchers worldwide have indicated an association between prior abortions and the development of PE. Different studies have debated whether abortion is a protective or risk factor for PE. However, the most current literature demonstrates a stronger likelihood that a positive history of abortions will offer a protective effect against PE. This association has been supported by advancements in the reproductive immunology literature, which states complex fetal and paternal pathological mechanisms help to build maternal immunological tolerance, thus protecting expectant mothers from pregnancy complications. This literature review will compare studies supporting prior abortions offering a protective effect against PE with those stating prior abortions are a risk factor for the development of PE. Additionally, this critical review will discuss the advancements and current understanding of reproductive immunology and how it pertains to this association between positive abortion history and PE.

Association between previous spontaneous abortion and preeclampsia: a case-control study

Background

The association between previous spontaneous abortion and preeclampsia is not yet fully understood. The current study was conducted to assess the association between previous spontaneous abortion and preeclampsia among pregnant women in Sudan.

Methods

A case–control study (involving 180 women in each study group) was conducted at Saad Abuelela Hospital, Khartoum, Sudan. The cases were pregnant women with preeclampsia, while the control group included healthy pregnant women. The participants’ sociodemographic, obstetric, and clinical characteristics were assessed via a questionnaire.

Results

There was no significant difference in the age, parity, education level, employment status, blood group, body mass index, and hemoglobin level between the patient and control groups. Forty (22.2%) women with preeclampsia and 68 (37.8%) women in the control group had a history of spontaneous abortion (p = 0.001).

Multivariate logistic regression analysis (adjusted) revealed that women with a history of spontaneous abortion had a lower risk of preeclampsia than those without a history of spontaneous abortion [adjusted odds ratio (AOR) = 0.44, 95% confidence interval (CI) = 0.26‒0.73]. However, women with a history of preeclampsia had a higher risk of recurrence of preeclampsia (AOR = 1.92, 95% CI = 1.11‒3.32).

Conclusion

The present study revealed that previous spontaneous abortion reduced the risk of preeclampsia by 59.0%.

Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world

Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.

What has women's reproductive health decision-making capacity and other factors got to do with pregnancy termination in sub-Saharan Africa? evidence from 27 cross-sectional surveys

Introduction

Pregnancy termination is one of the key issues that require urgent attention in achieving the third Sustainable Development Goal (SDG) of ensuring healthy lives and promoting well-being for all at all ages. The reproductive health decision-making (RHDM) capacity of women plays a key role in their reproductive health outcomes, including pregnancy termination. Based on this premise, we examined RHDM capacity and pregnancy termination among women of reproductive age in sub-Saharan Africa (SSA).

Materials and methods

We pooled data from the women’s files of the most recent Demographic and Health Surveys (DHS) of 27 countries in SSA, which are part of the DHS programme. The total sample was 240,489 women aged 15 to 49. We calculated the overall prevalence of pregnancy termination in the 27 countries as well as the prevalence in each individual country. We also examined the association between RHDM capacity, socio-demographic characteristics and pregnancy termination. RHDM was generated from two variables: decision-making on sexual intercourse and decision-making on condom use. Binary logistic regression analysis was conducted and presented as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with their corresponding 95% confidence intervals (CI). Statistical significance was declared p<0.05.

Results

The prevalence of pregnancy termination ranged from 7.5% in Benin to 39.5% in Gabon with an average of 16.5%. Women who were capable of taking reproductive health decisions had higher odds of terminating a pregnancy than those who were incapable (AOR = 1.20, 95% CI = 1.17–1.24). We also found that women aged 45–49 (AOR = 5.54, 95% CI = 5.11–6.01), women with primary level of education (AOR = 1.14, 95% CI = 1.20–1.17), those cohabiting (AOR = 1.08, 95% CI = 1.04–1.11), those in the richest wealth quintile (AOR = 1.06, 95% CI = 1.02–1.11) and women employed in the services sector (AOR = 1.35, 95% CI = 1.27–1.44) were more likely to terminate pregnancies. Relatedly, women who did not intend to use contraceptive (AOR = 1.47, 95% CI = 1.39–1.56), those who knew only folkloric contraceptive method (AOR = 1.25, 95% CI = 1.18–1.32), women who watched television almost every day (AOR = 1.16, 95% CI = 1.20–1.24) and those who listened to radio almost every day (AOR = 1.11, 95% CI = 1.04–1.18) had higher odds of terminating a pregnancy. However, women with four or more children had the lowest odds (AOR = 0.5, 95% CI = 0.54–0.60) of terminating a pregnancy.

Conclusion

We found that women who are capable of taking reproductive health decisions are more likely to terminate pregnancies. Our findings also suggest that age, level of education, contraceptive use and intention, place of residence, and parity are associated with pregnancy termination. Our findings call for the implementation of policies or the strengthening of existing ones to empower women about RHDM capacity. Such empowerment could have a positive impact on their uptake of safe abortions. Achieving this will not only accelerate progress towards the achievement of maternal health-related SDGs but would also immensely reduce the number of women who die as a result of pregnancy termination in SSA.

Association of induced abortion with hypertensive disorders of pregnancy risk among nulliparous women in China: a prospective cohort study

The relationship between induced abortion(IA) and hypertensive disorders of pregnancy(HDP) is inconclusive. Few studies have been conducted in China. In order to clarify the association between previous IA and risk of HDP, including gestational hypertension(GH) and pre-eclampsia(PE), we performed a community-based prospective cohort study enrolling 5191 eligible nulliparous women in selected 2 districts and 11 towns of Liuyang from 2013 to 2015. Multivariable logistic regression was conducted to examine whether IA was associated with HDP, GH and PE. Of the gravidea, 1378(26.5%) had a previous IA and 258(5.0%) diagnosed with HDP, including 141(2.7%) GH and 117(2.3%) PE. The difference in the incidence of GH and PE between gravidae having one versus those with two or more IAs was minimal. After adjustment for maternal age, body mass index at first antenatal visit, education, virus infection and history of medical disorders, previous IA was significantly associated with HDP (OR = 0.67, 95%CI = 0.49 to 0.91) and PE (OR = 0.61, 95%CI = 0.38 to 0.97), but not with GH (OR = 0.73, 95%CI = 0.49 to 1.10). Additional adjustment for occupation, living area, anemia, gestational diabetes mellitus, psychological stress, conception climate and infant sex, multivariable analysis provided similar results. In conclusion, previous IA was associated with a lower risk of PE among nulliparous women.

Human Uterine Decidual NK Cells in Women with a History of Early Pregnancy Enhance Angiogenesis and Trophoblast Invasion

Objective

The present study aimed to identify changes in decidual natural killer (dNK) cells and related cytokines in women who have undergone induced abortions (IAs). The effects of dNK cells on subsequent pregnancies remain unknown. Accordingly, we sought to investigate whether a history of early pregnancy can change dNK cells and facilitate their role in the regulation of angiogenesis and trophoblast invasion. Materials and Methods. dNK cells were obtained from primiparous women who had undergone IA(s) prior to this study and primiparous women who had never been pregnant before this IA (control). Real-time polymerase chain reaction (PCR) was used to measure the mRNA levels of IFN-γ, IP-10, VEGF, and PLGF in dNK cells. The levels of these cytokines were quantified using the enzyme-linked immunosorbent assay. HUVEC and HTR-8/SVneo cells were used to evaluate the angiogenesis, migration, and invasion activities influenced by dNK cells.

Results

In dNK cells, the mRNA level of IFN-γ, IP-10, VEGF, and PLGF in dNK cells. The levels of these cytokines were quantified using the enzyme-linked immunosorbent assay. HUVEC and HTR-8/SVneo cells were used to evaluate the angiogenesis, migration, and invasion activities influenced by dNK cells.

Conclusion

The findings of this study suggest that a history of early pregnancy has an impact on dNK cells. These trained dNK cells can regulate angiogenesis and trophoblast invasion and migration by promoting the production of certain cytokines.

Transient Tachypnea of the Newborn Is Associated With an Increased Risk of Hospitalization Due to Respiratory Syncytial Virus Bronchiolitis

BACKGROUND

Transient tachypnea of the newborn (TTN) is a self-limiting respiratory disorder, resulting from a failure to clear the lungs of perinatal fluid. As similar pathophysiologic features are present in children with respiratory syncytial virus (RSV) bronchiolitis, we hypothesized that these two conditions may be connected.

METHODS

This was a population-based cohort study that included all children born in term (≥37 weeks of gestation) without congenital malformations in Finland between 1996 and 2015. Children diagnosed with TTN (International Statistical Classification of Diseases and Related Health Problems, 10th Revision [ICD-10] code P22.1) after birth and children hospitalized because of RSV bronchiolitis (ICD-10 code J21.0) during first year of life were identified from the Medical Birth Register and National Hospital Discharge Register, respectively, and the data were linked. Logistic regression was used to analyze the association between these two conditions.

RESULTS

Of the 1,042,045 children included in the study cohort, 16,327 (1.57%) were diagnosed with TTN at birth and 12,345 (1.18%) were hospitalized because of RSV bronchiolitis during the first year of life. The rate of RSV hospitalization was higher in children with a history of TTN compared with children without TTN diagnosis [260/16,327 (1.59%) vs. 12,085/1,025,718 (1.18%), respectively; P value <0.0001]. After adjusting for gestational age at birth, mode of delivery, gender, birth weight, multiple births, older siblings and maternal smoking, TTN was associated with increased risk for RSV hospitalization (odds ratio: 1.31, 95% confidence interval: 1.16-1.48).

CONCLUSIONS

TTN diagnosis after birth was associated with increased risk for RSV hospitalization during the first year of life.

[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.

Induced abortion - impact on a subsequent pregnancy in first-time mothers: a registry-based study

Background

To date, several studies concerning the effects of induced abortion (IA) on women’s later psychosocial well-being and future delivery complications have been published. However, the lack of reports on woman’s physical well-being during their first full-term pregnancy occurring after IA is what inspired the current study. Here, we evaluate the physical well-being and use of maternity services of first-time mothers with a history of IA.

Methods

Finnish National Birth Registry data from 2008 to 2010 were linked with the Induced Abortion Registry data from 1983 to 2007. After excluding first-time mothers with a history of miscarriage, ectopic pregnancy or delivery, 57,406 mothers were eligible for the study, with 5,167 (9.0 %) having experienced prior IA. Data from the pregnancy follow-up visits were evaluated and compared between IA mothers and primiparous mothers.

Results

Women with IA had higher rates of smoking after the first trimester and were more likely to be overweight (body mass index >25 kg/m²) than the control group mothers. A higher use of maternity health clinic (MHC) services, thrombosis prophylaxis and participation in a second trimester ultrasound and amniotic fluid sample testing were evident in IA mothers, whereas the likelihood of assisted fertilisation procedure(s) was elevated in the control group. A shorter interpregnancy interval (IPI) seemed to contribute to a late first MHC visit and first trimester serum screening test participation, a higher incidence of placenta samples and an increased presence of preeclampsia and maternal care for poor foetal growth.

Conclusions

IA is associated with being overweight before the subsequent pregnancy and with smoking after the first trimester. More frequent pregnancy follow-up visits in the IA group may be due to greater participation in the placenta sample testing and use of thrombosis prophylaxis. No association between IA and preeclampsia, hypertension, gestational diabetes or preterm premature rupture of membranes was evident in the pregnancy parameters. According to our findings, experiencing IA decreased the need for fertilisation procedures before the next pregnancy when compared to primiparous mothers. Among the IA mothers, the short IPI seemed to contribute to the higher risk for preeclampsia and maternal care for poor foetal growth. However, more research is needed around the IPI before establishing its effect on later pregnancy.

Invited Commentary: Induced Abortion and the Risk of Preeclampsia in a Subsequent Pregnancy

Although it is well established that a having a pregnancy that ends in a birth protects against subsequent preeclampsia, it is unclear whether a pregnancy ending in miscarriage or induced abortion confers any protection. In this issue of the Journal, Parker et al. (Am J Epidemiol. 2015;182(8):663-669) examine whether, in nulliparous women, a history of induced abortion is associated with a lower risk of preeclampsia in a later pregnancy, focusing on the hypothesis that endometrial injury facilitates later implantation. The authors take advantage of data obtained by linking several Finnish population-based registries that include detailed data on induced abortions, although information on miscarriages was of lower quality. Parker et al. found a modest reduction in risk among women with a history of induced abortion. However, there was little evidence that risk differed between women who had medical abortions and those who had surgical abortions (the latter of which is presumably associated with a higher degree of injury). History of miscarriage was not associated with preeclampsia risk. Although the study by Parker et al. adds to the evidence that suggests that women with a history of induced abortion have a lower risk of preeclampsia, it is difficult to evaluate whether the observed association is due to having had a previous pregnancy (however short) versus none, to confounding, or to an actual effect of induced abortion.