03 Jan Surgical Abortions Raise Risk of Future Pre-Term Births and Obstetrical Complications
MedicalResearch.com Interview with:
Gabriele Saccone, MD
Department of Neuroscience
Reproductive Sciences and Dentistry
School of Medicine
University of Naples Federico II Naples, Italy
Vincenzo Berghella, MD
Department of Obstetrics and Gynecology
Division of Maternal-Fetal Medicine
Thomas Jefferson University
Philadelphia, PA 19107, USA
Medical Research: What is the background for this study? What are the main findings?
Dr Saccone: Preterm birth (PTB) is the number one cause of perinatal mortality in many countries, including the US. The annual societal economic burden associated with Preterm birth in the US was at least $26.2 billion in 2006, or about $51,600 per infant born preterm. Defining risk factors for prediction of PTB is an important goal for several reasons.
- First, identifying women at risk allows initiation of risk-specific treatment.
- Second, it may define a population useful for studying particular interventions.
- Finally, it may provide important insights into mechanisms leading to Preterm birth.Prior surgery on the cervix, such as cone biopsy and LEEP procedures, is associated with an increased risk of spontaneous PTB. History of uterine evacuation for abortion, by either induced termination of pregnancy (I-TOP) or treatment of spontaneous abortion (SAB) by suction dilation and curettage (D&C) or by dilation and evacuation (D&E), which may involve mechanical and/or osmotic dilatation of the cervix, has been associated with an increased risk of PTB in some studies, but not in others. Our systematic review and meta-analysis pooled data from 36 studies including 1,047,683 women with prior abortion.
We found that history of surgical abortion is an independent risk factor for Preterm birth and also other obstetric complications including low birth weight and small for gestational age, while prior medical abortion with first-trimester mifepristone or mid-trimester misoprostol was not associated with an increased risk of PTB. The biological plausibility to explain our findings is not completely clear.
However, three main hypotheses can be made.
- The increased risk of Preterm birth could result from the overt or covert infection following surgically uterine evacuation,
- as well as from mechanical trauma to the cervix leading to increased risk of cervical insufficiency.
- Moreover, surgical procedures including curettage during D&E may result in scar tissue that may increase the probability of faulty placental implantation.
Medical Research: What should clinicians and patients take away from your report?
Dr Saccone: Our data warrant caution in the use of standard surgical evacuation for abortion, and should encourage better surgical methods perhaps with cervical ripening before evacuation as well as medical and minimally invasive methods for mechanical cervical dilation such as osmotic dilators). However, patient preference for the type of abortion experience should drive the decision-making but women should be informed realistic and accurate risk of the procedures and the risk in the subsequent pregnancy. So, provided there is no contraindication, medical I-TOP may be the preferred choice for evacuating the uterus in the first trimester, especially for those women without a child and for those who wish to avoid surgery and anaesthesia.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr Saccone: Due to the limitations of the studies included in our meta-analysis it is difficult to definitively recommend that surgical abortion should be avoided and that medical methods should be preferentially offered. To be able to make a definitive statement regarding risk of Preterm birth associated with medical and surgical abortion, more research is needed. Particularly there is a need for randomized controlled trials that investigate if technical interventions (e.g. cervical preparation before uterine evacuation) diminish the risk of PTB associated with surgical uterine evacuation, and for randomized trials comparing surgical and medical evacuation of the uterus.
Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and meta-analysis
Gabriele Saccone MD,1 Vincenzo Berghella MD2
1Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
2Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
Correspondence: Vincenzo Berghella, MD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Thomas Jefferson University, 833 Chestnut Street, Philadelphia, PA 19107, USA
Dr. Gabriele Saccone and Dr. Vincenzo Berghella (2016). Surgical Abortions Raise Risk of Future Pre-Term Births and Obstetrical Complications