Lemmers M, Verschoor M A C, Hooker A B, Opmeer B C, Limpens J, Huirne J A F, Ankum W M, Mol B W M
Department of Obstetrics and Gynecology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
Department of Obstetrics and Gynecology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
Hum Reprod. 2016 Jan;31(1):34-45. doi: 10.1093/humrep/dev274. Epub 2015 Nov 2.
Could dilatation and curettage (D&C), used in the treatment of miscarriage and termination of pregnancy, increase the risk of subsequent preterm birth?
A history of curettage in women is associated with an increased risk of preterm birth in a subsequent pregnancy compared with women without such history.
D&C is one of the most frequently performed procedures in obstetrics and gynaecology. Apart from the acknowledged but relatively rare adverse effects, such as cervical tears, bleeding, infection, perforation of the uterus, bowel or bladder, or Asherman syndrome, D&C has been suggested to also lead to an increased risk of preterm birth in the subsequent pregnancy.
STUDY DESIGN, SIZE, DURATION: In the absence of randomized data, we conducted a systematic review and meta-analysis of cohort and case-control studies.
PARTICIPANTS/MATERIALS, SETTING, METHODS: We searched OVID MEDLINE and OVID EMBASE form inception until 21 May 2014. We selected cohort and case-control studies comparing subsequent preterm birth in women who had a D&C for first trimester miscarriage or termination of pregnancy and a control group of women without a history of D&C.
We included 21 studies reporting on 1 853 017 women. In women with a history of D&C compared with those with no such history, the odds ratio (OR) for preterm birth <37 weeks was 1.29 (95% CI 1.17; 1.42), while for very preterm birth the ORs were 1.69 (95% CI 1.20; 2.38) for <32 weeks and 1.68 (95% CI 1.47; 1.92) for <28 weeks. The risk remained increased when the control group was limited to women with a medically managed miscarriage or induced abortion (OR 1.19, 95% CI 1.10; 1.28). For women with a history of multiple D&Cs compared with those with no D&C, the OR for preterm birth (<37 weeks) was 1.74 (95% CI 1.10; 2.76). For spontaneous preterm birth, the OR was 1.44 (95% CI 1.22; 1.69) for a history of D&C compared with no such history.
LIMITATIONS, REASONS FOR CAUTION: There were no randomized controlled trials comparing women with and without a history of D&C and subsequent preterm birth. As a consequence, confounding may be present since the included studies were either cohort or case-control studies, not all of which corrected the results for possible confounding factors.
This meta-analysis shows that D&C is associated with an increased risk of subsequent preterm birth. The increased risk in association with multiple D&Cs indicates a causal relationship. Despite the fact that confounding cannot be excluded, these data warrant caution in the use of D&C for miscarriage and termination of pregnancy, the more so since less invasive options are available.
STUDY FUNDING/COMPETING INTERESTS: This study was funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066.
用于治疗流产和终止妊娠的刮宫术（D&C）会增加后续早产的风险吗？
与无刮宫史的女性相比，有刮宫史的女性在后续妊娠中早产风险增加。
刮宫术是妇产科最常施行的手术之一。除了已公认但相对罕见的不良反应，如宫颈撕裂、出血、感染、子宫、肠道或膀胱穿孔，或阿谢曼综合征外，刮宫术还被认为会增加后续妊娠早产的风险。
研究设计、规模、持续时间：由于缺乏随机数据，我们对队列研究和病例对照研究进行了系统评价和荟萃分析。
研究对象/材料、研究背景、方法：我们检索了OVID MEDLINE和OVID EMBASE数据库，检索时间从建库至2014年5月21日。我们选择了队列研究和病例对照研究，比较因孕早期流产或终止妊娠而行刮宫术的女性与无刮宫史的对照组女性后续的早产情况。
我们纳入了21项研究，共涉及1853017名女性。与无刮宫史的女性相比，有刮宫史的女性早产（<37周）的比值比（OR）为1.29（95%CI 1.17；1.42），而极早产（<32周）的OR为1.69（95%CI 1.20；2.38），<28周的OR为1.68（95%CI 1.47；1.92）。当对照组仅限于药物流产或人工流产的女性时，风险仍然增加（OR 1.19，95%CI 1.10；1.28）。与无刮宫史的女性相比，有多次刮宫史的女性早产（<37周）的OR为1.74（95%CI 1.10；2.76）。对于自发性早产，有刮宫史的女性与无刮宫史的女性相比，OR为1.44（95%CI 1.22；1.69）。
局限性、谨慎原因：没有随机对照试验比较有无刮宫史的女性及后续早产情况。因此，可能存在混杂因素，因为纳入的研究均为队列研究或病例对照研究，并非所有研究都对可能的混杂因素进行了结果校正。
这项荟萃分析表明，刮宫术与后续早产风险增加有关。多次刮宫风险增加表明存在因果关系。尽管不能排除混杂因素，但这些数据警示在使用刮宫术治疗流产和终止妊娠时需谨慎，尤其是因为有侵入性较小的选择。
研究资金/利益冲突：本研究由荷兰卫生研究与发展组织ZonMw资助（项目编号80 - 82310 - 97 - 12066）。
