Study Of The Clinical Efficacy Of Three Medical Methods For Second/third Trimester Termination Of Pregnancy And The Management Therapy For Retained Product Of Conception

[Research Background]Mid-trimester termination of pregnancy(TOP)constitutes 10%～15%of all induced abortions worldwide,but is responsible for two-thirds of all major abortion-related complications.In China,there were about 9.85 million abortions in 2015,of which about 5%were in the mid-trimester,regardless of notly higher surgery injury and complication in mid-trimester TOP than in the first trimester TOP.Retained product of conception(RPOC)is estimated to occur approximately 1%for term pregnancies and occur much more frequently after miscarriage or TOP worldwide.High incidence of RPOC varying from 2.3%to 21.3%after second trimester TOP was reported in recent Chinese studies.Curettage has long been the most widely used method to evacuate RPOC.However,excessive using of curettage for RPOC has been questioned by some scholars recently because of potential postoperative complications such as pelvic infection,uterine perforation,cervical laceration,lower abdomen pain,intrauterine adhesions(IUAs)and fertility.It is the high time to query the excessive curettage for RPOC.Part I The analysis of clinical efficacy by three methods for second/third trimester termination of pregnancy[Objectives]To compare the clinical effectiveness of three induction methods for TOP[Materials and methods]We retrospectively analyzed clinical data of 337 patients who underwent second/third trimester TOP at our department between January 2014 and December 2015.According to different induction methods,we divided the subjects into three groups:Group intra-amniotic injection of ethacridine lactate combined with mifepristone(EL group)included 224 patients;Group misoprostol combined with mifepristone(MM group)included 82 patients;Group Foly catheter combined with mifepristone(FC group)included 31 patients.[Results](1)The induction-abortion interval in group EL(38.6±12.9)h was significantly less than group MM((51.5±17.1)h,P<0.001)and group FC((49.6±19.3)h,P=0.012).No significant difference was found in induction-abortion interval between group MM and group FC(P=0.949).(2)The total successful induction rate was 92.6%.The successful induction rate in group EL was significantly higher than that in group MM and in group FC(96.9%VS 82.9%and 87.1%,xχ2=18.499,P<0.001).No difference was found in successful induction rate between group MM and group FC(P>0.05).(3)The average diameter of RPOC in EL group was significantly longer when compared to group MM((38.6±23.5)VS(28.9±16.1)mm,P<0.001),there was no significant difference between MM group and FC group((29.3±20.7)mm,P>0.05)and between EL group and FC group(P>0.05).There was no significant difference in incidence of RPOC among three groups(χ2=1.722,P=0.423).The curettage rate in MM group was significantly higher than group EL and group FC(47.6%VS 32.6%and 32.3%,P<0.05).There was no significant difference in curettage rate between group EL and group FC(P>0.05).(4)There were no significant differences in variation of hemoglobin level,in duration of vaginal bleeding and in menstrual return interval among three groups(P>0.05).[Conclusions]Three induction regimens could finish the second/third trimester TOP successfully.Ethacridine lactate presented a shorter induction-abortion interval.Although the size of RPOC was larger than other two regimens,but the incidence of RPOC and prognosis was similar among three groups,and the curettage rate was highest in group MM.We can’t yet determine which regimen is optimal among three regimens.Part Ⅱ Analysis of curettage rate and its related risk factors after second/third trimester termination of pregnancy[Objectives]To evaluated curettage rate after second/third trimester TOP and elucidated the associated risk factors of curettage.[Materials and methods]Subjects was same as part I.According to the management of RPOC,we divided the subjects into two group,122 patients in curettage group and 215 patients in non-curettage group.[Results](1)The curettage rate in present study was 36.2%.(2)The gestational age in curettage group was significantly lower than non-curettage group((20.3±5.3)VS(23.4±6.5)weeks,t=4.679,P<0.001).The induction-abortion interval in curettage group was significantly longer than that in non-curettage group((44.3±17.7)VS(36.2±12.7)h,t=2.128,P<0.001).There was no significant difference in average diameter of RPOC between the two groups.(3)Gestational age was a protective factor for curettage(OR=0.920,95%Confidence Interval(CI)0.885-0.956,P<0.001).Induction-abortion interval was a risk factor for curettage(OR=1.013,95%CI 1.001-1.026,P=0.036).After adjusted for confounders,gestational age was still a protective factor for curettage(OR=0.932,95%CI 0.888-0.979,P=0.005)and induction-abortion interval was no longer risk factor for curettage(OR=1.006,95%CI 0.991-1.020,P=0.444),while the average diameter of RPOC was a risk factor of curettage(OR=1.012,95%CI 1.000-1.024,P=0.044).[Conclusions]Gestational age,induction-abortion interval and average diameter of RPOC were closely related to curettage in cases of TOP.The curettage rate increased with the decrease of gestational age and the increase of induction-abortion interval and average diameter of RPOC.Part Ⅲ Study in prognosis of curettage versus expectant therapy for retained product of conception and the related risk factors of complications[Objective]To compare the prognosis,subsequent pregnancy outcomes and complications of expectant therapy or curettage for the RPOC,and to investigate the risk factors of complication after treatment of RPOC.[Materials and methods]We retrospectively reviewed the patients’ clinical data of 270 patients who were underwent curettage or expectant therapy after second/third trimester TOP at our department from January 2014 to December 2015.[Results](1)The median of hemoglobin variation level in curettage group was significantly larger when compared to that in expectant therapy group(5 VS 2 g/L,Z=-2.960,P=0.003).The median of duration of vaginal bleeding was significantly larger in expectant therapy group than curettage group(17 VS 14 days,Z=2.824,P=0.005),the incidence of duration of vaginal bleeding beyond 42 days was significantly higher in curettage group than expectant therapy group(6.1%VS 1.3%,P=0.040).No significantly difference was found in menstruation return interval between the two groups(t=0.570,P=0.569),no significantly difference was found in the incidence of a menstruation return interval beyond 60 days between the two groups(χ2 =0.076,P=0.783).(2)The logarithmic value percentage of serum β-hCG within two week of abortion in curettage group was significantly lower than that in expectant management group(χ2 =10.588,P=0.009).There was no significant difference in logarithmic value percentage of serum P-hCG within one week and three week of abortion between two groups(P>0.05).There was no signiffcant difference on time of negative-conversing in serum β-hCG between the two groups(t=2.088,P=0.057).(3)Curettage was a risk factor of complication after TOP(OR=10.60,95%CI 2.36-47.66,P=0.002).After controlled for confounders,curettage was still a risk factor of complications after TOP(ORF=18.26,95%CI 3.57-93.42,P<0.001).(4)There was no significant difference in spontanous re-conception rate,sequent live-birth rate and sequent miscarriage rate between curettage group and expectant therapy group(P>0.05).[Conclusions]Compared to expectant therapy,curettage could not influence the decline speed of β-hCG levels and reduce duration of vaginal bleeding,and could not improve the menstruation return interval and sequent pregnancy outcome,but it would decrease the hemoglobin level and increase the incidence of postoperative complications such as infection,abnormal uterine bleeding.