Maarit Niinimäki

Immediate Complications After Medical Compared With Surgical Termination of Pregnancy

OBJECTIVE: To estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data. METHODS: All women in Finland undergoing induced abortion from 2000–2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyze the risk of the three main complications (hemorrhage, infection, and incomplete abortion) and surgical (re)evacuation. RESULTS: The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death. CONCLUSION: Both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion. LEVEL OF EVIDENCE: II

Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: population register based study.

Objective To determine the risks of short term adverse events in adolescent and older women undergoing medical abortion. Design Population based retrospective cohort study. Setting Finnish abortion register 2000-6. Participants All women (n=27u2009030) undergoing medical abortion during 2000-6, with only the first induced abortion analysed for each woman. Main outcome measures Incidence of adverse events (haemorrhage, infection, incomplete abortion, surgical evacuation, psychiatric morbidity, injury, thromboembolic disease, and death) among adolescent (<18 years) and older (≥18 years) women through record linkage of Finnish registries and genital Chlamydia trachomatis infections detected concomitantly with abortion and linked with data from the abortion register for 2004-6. Results During 2000-6, 3024 adolescents and 24u2009006 adults underwent at least one medical abortion. The rate of chlamydia infections was higher in the adolescent cohort (5.7% v 3.7%, P<0.001). The incidence of adverse events among adolescents was similar or lower than that among the adults. The risks of haemorrhage (adjusted odds ratio 0.87, 95% confidence interval 0.77 to 0.99), incomplete abortion (0.69, 0.59 to 0.82), and surgical evacuation (0.78, 0.67 to 0.90) were lower in the adolescent cohort. In subgroup analysis of primigravid women, the risks of incomplete abortion (0.68, 0.56 to 0.81) and surgical evacuation (0.75, 0.64 to 0.88) were lower in the adolescent cohort. In logistic regression, duration of gestation was the most important risk factor for infection, incomplete abortion, and surgical evacuation. Conclusions The incidence of adverse events after medical abortion was similar or lower among adolescents than among older women. Thus, medical abortion seems to be at least as safe in adolescents as it is in adults.

Frequency and risk factors for repeat abortions after surgical compared with medical termination of pregnancy.

OBJECTIVE: To compare the frequency and risk factors for repeat abortions after surgical compared with medical termination of pregnancy. METHODS: Frequency of and risk factors for repeat abortions after medical (performed with mifepristone alone, or with a combination of mifepristone and misoprostol or other prostaglandins) compared with surgical (dilation and curettage, or vacuum aspiration) termination of pregnancy were studied using Finnish national health registries. The cohort consisted of 40,360 women undergoing termination of pregnancy between 2000 and 2005 (19,841 medical and 20,519 surgical abortions) with duration of gestation of 63 days or less. Univariable and multivariable association models were used in connection with various factors associated with repeat abortion. The mean (±standard deviation) follow-up times were 3.0 (±1.5) and 4.3 (±1.9) years, respectively. RESULTS: Women choosing surgical and medical abortion differed subtly, but significantly in several respects. The total number of repeat terminations was 37.9 per follow-up year per 1,000 after surgical termination of pregnancy and 40.4 after medical termination of pregnancy (P=.01). However, medical termination of pregnancy was not linked to an increased risk of another abortion when compared with surgical methods (hazard ratio [HR] 0.98, 95% confidence interval [CI] 0.93–1.04). In multivariable analysis, the risk factors for repeat abortion were parity (HR 1.99, 95% CI 1.85–2.14), previous abortion(s) (HR 1.70, 95% CI 1.60–1.82), low socioeconomic status (HR 1.22, 95% CI 1.06–1.39), and being unmarried but cohabiting (HR 1.14, 95% CI 1.03–1.25) or single (HR 1.25, 95% CI 1.15–1.36). The risk of repeat termination of pregnancy decreased with age, among women living in rural areas, and when intrauterine devices or sterilization were planned for future contraception. CONCLUSION: The risk of repeat abortion is associated with various sociodemographic characteristics. The method of abortion used is not a risk factor for repeat termination of pregnancy. LEVEL OF EVIDENCE: II

Interpregnancy Interval After Termination of Pregnancy and the Risks of Adverse Outcomes in Subsequent Birth.

OBJECTIVEnTo assess whether the length of the interpregnancy interval after termination of pregnancy influences the risk of preterm birth, low birth weight, and small-for-gestational-age neonates in a subsequent pregnancy.nnnMETHODSnIn this register-based study, we included all women (N=19,894) who underwent termination of pregnancy between 2000 and 2009 and whose subsequent pregnancy ended in live singleton delivery. The women were divided into five groups depending on the interpregnancy interval between termination of pregnancy and subsequent conception: interpregnancy interval less than 6 months (n=2,956), 6 to less than 12 months (n=3,203), 12 to less than 18 months (n=2,623), 18 to less than 24 months (n=2,076), and 24 months or greater (n=9,036). The incidences and unadjusted and adjusted risks of preterm birth, low birth weight, and small-for-gestational-age neonates were calculated in relation to the different interpregnancy interval lengths, the reference group being that with an interpregnancy interval of 18 to less than 24 months.nnnRESULTSnThere was a significant difference in the rate of preterm birth between the group with the interpregnancy interval less than 6 months and the reference group (5.6% compared with 4.0%, respectively, P=.008). After adjusting for nine background factors, an interpregnancy interval of less than 6 months was associated with an increased risk of preterm birth (adjusted odds ratio 1.35, 95% confidence interval 1.02-1.77). No such association emerged in longer interpregnancy interval groups or regarding other adverse events. The possibility of unmeasured confounding cannot be ruled out.nnnCONCLUSIONnSlightly but significantly increased estimated risk of preterm delivery in subsequent pregnancy was seen when the interpregnancy interval after termination of pregnancy was less than 6 months. These data emphasize the need for prompt initiation of effective contraception after termination and enable counseling the patient for optimal conception interval.

Embryo quality is the main factor affecting cumulative live birth rate after elective single embryo transfer in fresh stimulation cycles.

OBJECTIVEnThe study was aimed to evaluate which factors affect the cumulative live birth rate after elective single embryo transfer in women younger than 36 years. Additionally, number of children in women with more than one delivery per ovum pick-up after fresh elective single embryo transfer and subsequent frozen embryo transfers was assessed.nnnSTUDY DESIGNnRetrospective cohort study analysing data of a university hospitals infertility clinic in 2001-2010. A total of 739 IVF/ICSI cycles with elective single embryo transfer were included. Analyses were made per ovum pick-up including fresh and subsequent frozen embryo transfers. Factors affecting cumulative live birth rates were examined in uni- and multivariate analyses. A secondary endpoint was the number of children born after all treatments.nnnRESULTSnIn the fresh cycles, the live birth rate was 29.2% and the cumulative live birth rate was 51.3%, with a twin rate of 3.4%. In the multivariate analysis, having two (odds ratio (OR) 1.73; 95% confidence interval (CI) 1.12-2.67) or ≥3 top embryos (OR 2.66; 95% CI 1.79-3.95) was associated with higher odds for live birth after fresh and frozen embryo cycles. Age, body mass index, duration of infertility, diagnosis or total gonadotropin dose were not associated with the cumulative live birth rate. In cycles with one top embryo, the cumulative live birth rate was 40.2%, whereas it was 64.1% in those with at least three top embryos. Of women who had a live birth in the fresh cycle, 20.4% had more than one child after all frozen embryo transfers. Among women with three or more top embryos after ovum pick-up, 16.1% gave birth to more than one child.nnnCONCLUSIONnThe cumulative live birth rate in this age group varies from 40% to 64% and is dependent on the quality of embryos. Women with three or more top embryos have good chance of having more than one child per ovum pick-up without elevated risk of multiple pregnancies.

Medical termination of pregnancy during the second versus the first trimester and its effects on subsequent pregnancy

OBJECTIVEnThe objective was to compare the risks of preterm birth, low birth weight, small for gestational age (SGA) infants and placental complications in subsequent pregnancy after second vs. first trimester medical termination of pregnancy (MTOP) in primigravid women.nnnSTUDY DESIGNnA total of 88,522 women who underwent termination of pregnancy during 2000-2009 were identified using Finnish health registers. Of them, primigravid women who underwent MTOP and had subsequent pregnancy ending in live birth up to the end of 2009 (n=3843) were included in the study. The incidences and risks of preterm birth, low birth weight, SGA infants and placental complications after first- (n=3427) vs. second-trimester MTOP (n=416) were compared.nnnRESULTSnDifferences between the study groups in the incidences of preterm birth (3.9% in both groups), low birth weight (3.9% in the second- vs. 3.2% in the first-trimester group), SGA infants (2.4% vs. 2.5%) and placental complications (1.9% vs. 2.6%) were statistically insignificant. Second-trimester MTOP was associated with similar risks of preterm birth, low birth weight, SGA infants and placental complications compared with first-trimester MTOP after adjustment for background characteristics. After second-trimester MTOP, 51.2% of women underwent surgical evacuation, and 4.3% were diagnosed with infection. The differences in the risks of preterm birth, low birth weight, SGA infants and placental complications were statistically insignificant between women with vs. without these complications following second-trimester MTOP.nnnCONCLUSIONSnSecond-trimester MTOP among primigravid women did not increase the risks of preterm birth, low birth weight, SGA infants or placental complications in subsequent pregnancy compared with first-trimester MTOP.nnnIMPLICATIONSnThe present study suggests that medical termination of pregnancy in primigravid women during second vs. first trimester does not increase the risks of adverse outcomes in subsequent pregnancy and delivery. The data are of value when counseling women undergoing second-trimester TOP.

Laparoscopic treatment of profuse bleeding in Cesarean scar pregnancy

A case of profuse bleeding during dilation and curettage due to Cesarean scar pregnancy was treated with emergency laparoscopy. The gestational mass was removed and the perforated uterus was sutured in laparoscopy. The patient had persistent bleeding and 4 months later laparotomy was performed to explore a cystic mass in the isthmic area of the uterus. This necrotic tissue was removed and 6xa0months after the initial operation the patient was fully recovered with healed uterus in hysteroscopy.