Latta Kristen, Barker Emily, Kendall Paige, Testani Erica, Laursen Laura, McClosky Leanne, York Sloane
Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States.
Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, United States.
Contraception. 2023 Jan;117:55-60. doi: 10.1016/j.contraception.2022.06.011. Epub 2022 Jun 24.
Compare complication rates of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery.
Retrospective cohort study examining induction for abortion or fetal demise for pregnancies from 14w0d to 23w6d gestation at 2 urban academic medical centers from 2009 to 2019. Exclusion criteria included preterm labor or cervical insufficiency, neonatal interventions, or if misoprostol was not the primary induction method. Complication rates were compared between those with no prior, 1 prior, and 2 or more (2+) prior cesarean deliveries. Complications analyzed were retained placenta, failed induction, infection, hemorrhage, blood transfusion, uterine rupture, intensive care unit admission, death, and readmission. Secondary analysis included cumulative misoprostol dosages and complete abortion rate within 24 hours.
Of 520 patients, 411 patients had no prior cesarean delivery, 77 had 1 prior cesarean delivery, and 32 had 2+ prior cesarean deliveries. Eleven patients had a prior vertical uterine incision. About 26.5% of all patients received mifepristone. The 2+ prior cesarean delivery group was significantly older (35 vs 32 vs 32, p < 0.001) and more likely to be induced for fetal demise (62.5 vs 41.56 vs 39.17%, p = 0.04). Both cesarean groups were more likely to be obese (58.62 vs 49.35 vs 34.26%, p = 0.003). Patients with 2+ prior cesarean deliveries were more likely to experience uterine rupture (6.25 vs 0 vs 0%, p = 0.004), and require ICU admission (6.45 vs 1.3 vs 0.49%, p = 0.02). Secondary analysis outcomes were similar. Logistic regression showed patients with 2+ prior cesarean deliveries were more likely to experience a complication than those with 1 prior (adjusted odds ratio [aOR] 2.71, confidence interval [CI] 1.09-6.86, p = 0.03) or 0 prior cesarean deliveries (aOR 3.00, CI 1.30-7.02, p = 0.01). Patients with 1 prior or no prior cesarean deliveries had a similar risk of experiencing a complication (aOR 1.11, CI 0.64-1.89, p = 0.7).
Most patients with prior cesarean deliveries can safely undergo induction in the second trimester for abortion or fetal demise. Patients with 2+ prior cesarean deliveries had a higher rate of at least 1 complication when compared to those with one or no prior cesarean delivery, despite similar misoprostol dosages and rates of complete abortion.
This large 10-year retrospective study examines the impact of prior cesarean delivery on the safety of second trimester induction. While second trimester labor induction abortion remains an option for all patients, specialized counseling for patients with 2 or more prior cesarean deliveries may be warranted.
比较有或无剖宫产史的患者在孕中期引产（用于流产或胎儿死亡）时的并发症发生率。
一项回顾性队列研究，对2009年至2019年期间在2家城市学术医疗中心进行的妊娠14周0天至23周6天的流产或胎儿死亡引产情况进行检查。排除标准包括早产或宫颈机能不全、新生儿干预措施，或米索前列醇不是主要引产方法的情况。比较无既往剖宫产史、有1次既往剖宫产史以及有2次或更多（2+）既往剖宫产史的患者的并发症发生率。分析的并发症包括胎盘残留、引产失败、感染、出血、输血、子宫破裂、入住重症监护病房、死亡和再次入院。二次分析包括米索前列醇累计剂量和24小时内的完全流产率。
在520例患者中，411例患者无既往剖宫产史，77例有1次既往剖宫产史，32例有2次或更多既往剖宫产史。11例患者有既往子宫纵切口。所有患者中约26.5%接受了米非司酮治疗。有2次或更多既往剖宫产史的患者组年龄显著更大（35岁对32岁对32岁，p<0.001），且因胎儿死亡引产的可能性更高（62.5%对41.56%对39.17%，p = 0.04）。两个剖宫产组肥胖的可能性更高（58.62%对49.35%对34.26%，p = 0.003）。有2次或更多既往剖宫产史的患者更有可能发生子宫破裂（6.25%对0对0%，p = 0.004），且需要入住重症监护病房（6.45%对1.3%对0.49%，p = 0.02）。二次分析结果相似。逻辑回归显示，有2次或更多既往剖宫产史的患者比有1次既往剖宫产史的患者（调整后的优势比[aOR] 2.71，置信区间[CI] 1.09 - 6.86，p = 0.03）或无既往剖宫产史的患者（aOR 3.00，CI 1.30 - 7.02，p = 0.01）发生并发症的可能性更高。有1次既往剖宫产史或无既往剖宫产史的患者发生并发症的风险相似（aOR 1.11，CI 0.64 - 1.89，p = 0.7）。
大多数有剖宫产史的患者在孕中期进行流产或胎儿死亡引产时可以安全进行。与有1次或无既往剖宫产史的患者相比，有2次或更多既往剖宫产史的患者至少发生1种并发症的发生率更高，尽管米索前列醇剂量和完全流产率相似。
这项为期10年的大型回顾性研究探讨了既往剖宫产史对孕中期引产安全性的影响。虽然孕中期引产流产对所有患者来说仍是一种选择，但对于有2次或更多既往剖宫产史的患者，可能需要进行专门的咨询。
