National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK.
Sexual and Reproductive Health Services, NHS Lothian, Edinburgh, UK.
Acta Obstet Gynecol Scand. 2020 Apr;99(4):451-458. doi: 10.1111/aogs.13797. Epub 2020 Jan 22.
Women are increasingly presenting for abortion at very early gestation. However, providers may be reluctant to conduct abortion at this stage as they may be concerned that they cannot exclude an ectopic pregnancy or that they may terminate a non-viable pregnancy, or may be concerned that both medical and surgical methods may be less effective at this stage of gestation. This provider concern may result in delays in the abortion as additional investigations may be required until an intrauterine pregnancy can be confirmed. Additional unnecessary visits may be distressing for women and waste health service resources. The objective of this systematic review was to determine whether it is safe and effective to initiate abortion before there is ultrasound evidence of an intrauterine pregnancy.
We searched Embase Classic, Embase; Ovid MEDLINE® Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily, Ovid MEDLINE®; and Cochrane Library on 25 October 2019. Eligible studies were randomized and non-randomized comparative studies, published in English from 1985, comparing initiation of abortion before there is definitive evidence of an intrauterine pregnancy with initiation afterwards. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were analyzed as risk ratios (RR) and meta-analyzed using the Mantel-Haenszel method. The quality of the evidence was assessed using GRADE.
Two non-randomized studies (n = 3785) showed no differences in "missed ectopic pregnancy" (RR = 0.26, 95% CI 0.03-2.12), "ongoing pregnancy" (RR = 1.06, 95% CI 0.34-3.34), or "complete abortion without surgical intervention" (RR = 1, 95% CI 0.98-1.02) between initiation of medical abortion before or after ultrasound evidence of an intrauterine pregnancy. A third non-randomized study (n = 1530) showed no differences between initiation of surgical abortion before or after ultrasound evidence of an intrauterine pregnancy in "missed ectopic pregnancy" (no events), "ongoing pregnancy" (RR = 0.56, 95% CI 0.03-11.59) or "complete abortion without repeat surgical intervention" (RR = 1, 95% CI 0.99-1.01). The quality of evidence was very low.
Initiation of abortion before there is definitive ultrasound evidence of an intrauterine pregnancy in women without signs or symptoms of an ectopic pregnancy should be considered.
越来越多的女性在非常早期的妊娠阶段就来进行堕胎。然而，由于提供者可能担心无法排除宫外孕，或者担心终止的是不可存活的妊娠，或者担心在这个妊娠阶段，无论是医疗方法还是手术方法都不太有效，因此他们可能不愿意在这个阶段进行堕胎。这种提供者的担忧可能导致堕胎延迟，因为需要进行额外的检查，直到可以确认宫内妊娠。对于女性来说，额外的不必要的就诊可能会带来困扰，并浪费卫生服务资源。本系统评价的目的是确定在没有超声证据表明宫内妊娠的情况下开始堕胎是否安全有效。
我们于 2019 年 10 月 25 日在 Embase Classic、Embase、Ovid MEDLINE® Epub 超前印刷本、处理中及其他非索引引文、Ovid MEDLINE®日报、Ovid MEDLINE®以及 Cochrane 图书馆进行了检索。符合条件的研究为 1985 年以来发表的随机和非随机对照研究，比较了在没有明确宫内妊娠证据的情况下开始堕胎与之后开始堕胎的效果。我们使用纽卡斯尔-渥太华量表评估了偏倚风险。所有结局均分析为风险比（RR），并使用 Mantel-Haenszel 法进行荟萃分析。使用 GRADE 评估证据质量。
两项非随机研究（n=3785）表明，在“漏诊宫外孕”（RR=0.26，95%CI 0.03-2.12）、“持续妊娠”（RR=1.06，95%CI 0.34-3.34）或“无需手术干预即可完全流产”（RR=1，95%CI 0.98-1.02）方面，在有或没有宫内妊娠超声证据的情况下开始药物流产之间没有差异。第三项非随机研究（n=1530）表明，在有或没有宫内妊娠超声证据的情况下开始手术流产之间，“漏诊宫外孕”（无事件）、“持续妊娠”（RR=0.56，95%CI 0.03-11.59）或“无需再次手术干预即可完全流产”（RR=1，95%CI 0.99-1.01）方面也没有差异。证据质量为极低质量。
对于没有宫外孕迹象或症状的女性，在没有明确宫内妊娠超声证据的情况下开始堕胎应予以考虑。
