Pregnancy outcomes following routine early provision of intrauterine device after first-trimester induced abortion-A secondary analysis of a randomized controlled trial with a 5-year follow up

INTRODUCTION

Women undergoing an induced abortion are highly fertile and at risk of subsequent unplanned pregnancy. We recently completed a randomized clinical trial showing that routine provision of intrauterine device (IUD) at the time of abortion significantly reduced the risk of subsequent abortion during a 5-year follow up. As the use of highly effective contraception may affect all subsequent pregnancies, we analyzed the rate and distribution of all subsequent pregnancies (deliveries, miscarriages, and abortions), and the risk factors for these various pregnancy outcomes in the above-mentioned randomized clinical trial.

MATERIAL AND METHODS

We enrolled adult women requesting first-trimester induced abortion and candidates for IUD for post-abortion contraception. Women (n = 751) were randomized to receive an IUD (either levonorgestrel-releasing IUD or copper IUD) by the clinic responsible for abortion care vs. routine care of IUD provision in primary health care with oral contraceptives for interval contraception. In the present secondary analysis, we identified all deliveries, miscarriages, and abortions in the intervention (n = 375) and control (n = 373) cohorts during the 5-year follow up using the Finnish national registries. The trial is registered at Clinical Trials (NTC01223521).

RESULTS

The overall delivery, miscarriage, and abortion rates were 42.0, 12.0 and 32.1/1000 years of follow up (yFU). Any new pregnancy occurred in 98 women in the intervention and in 129 women in the control cohort (hazard ratio 0.73, 95% confidence interval 0.56-0.95, p = 0.023). The effect of routine IUD provision in reducing pregnancies was limited to the first 2 yFU. The number of subsequent induced abortions and of women undergoing it were significantly reduced, and time to abortion was prolonged by the intervention. However, the overall number, the number of women with subsequent delivery or miscarriage, and the times to these events were not significantly affected. History of previous pregnancy (delivery or abortion) and smoking were risk factors for subsequent induced abortion, but not for delivery or miscarriage.

CONCLUSIONS

Routine provision of IUD as part of abortion care did not reduce the rates of delivery or miscarriage during the 5-year follow up. The rates of all pregnancies and the need of subsequent induced abortion were reduced by IUD provision during the first 2 yFU.

Fear of childbirth after induced abortion in primiparous women: Population-based register study from Finland

INTRODUCTION

Fear of childbirth (FOC) is a common obstetrical challenge that complicates about every 10th pregnancy. Background factors of FOC are diverse. We evaluated the association of induced abortion (IA) and FOC in subsequent pregnancy.

MATERIAL AND METHODS

Population-based register study based on three Finnish national registers: the Register of Induced Abortions, the Medical Birth Register and the Hospital Discharge Register. The study cases were primigravid women undergoing an IA in 2000-2015 and subsequent pregnancy ending in live singleton birth up to 2017. Each case had three controls, matched by age and residential area, whose first pregnancy ended in a live birth. The main outcome was the incidence of FOC in the subsequent pregnancy. In a secondary analysis, we assessed other risk factors for FOC.

RESULTS

The study cohort consisted of 21 455 women and 63 425 controls. Altogether, 4.2% of women had a diagnosis of FOC. The incidence was higher in women with a history of IA than in controls (5.6% vs 3.7%, P < 0.001). A history of IA was associated with higher odds for FOC: adjusted odds ratio [aOR] 1.20 with 95% confidence interval (CI) 1.11-1.30. In addition, a history of psychiatric diagnosis (aOR 3.48, 95% CI 3.15-3.83), high maternal age, 30-39 years old (aOR 1.55, 95% CI 1.43-1.67; P < 0.001) and ≥40 years old (aOR 3.00, 95% CI 2.37-3.77; P < 0.001) and smoking (aOR 1.20, 95% CI 1.11-1.31; P < 0.001) were associated with increased odds for FOC. Women living in densely populated or rural areas and those with lower socioeconomic class had lower odds for FOC.

CONCLUSIONS

A history of IA is associated with increased odds for FOC in subsequent pregnancy. However, the associations of FOC with a history of psychiatric diagnosis and elevated maternal age (especially ≥40 years old) are more pronounced.

Quality of life and sexual function after tension-free vaginal tape and polyacrylamide hydrogel injection for primary stress urinary incontinence: 3-year follow-up from a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

To assess quality of life (QoL) and sexual function outcomes at 3 years after tension-free vaginal tape (TVT) and polyacrylamide hydrogel injection (PAHG) for stress urinary incontinence (SUI).

METHODS

In this randomized trial comparing TVT (n = 104) and PAHG (n = 108), we assessed changes in QoL and sexuality using the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire, Short Form (IIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and RAND-36 Item Health Survey (RAND-36) at baseline and at 3 years. This is a secondary analysis of a randomized, noninferiority trial comparing patient satisfaction after TVT and PAHG.

RESULTS

In both groups, incontinence-related QoL improved from the baseline (p < 0.00), except for difficulty emptying the bladder and pain/discomfort. Total scores of UDI-6 and IIIQ-7 were lower for TVT compared to PAHG (p < 0.00) indicating better QoL at 3 years. Urinary incontinence with sexual activity or fear of incontinence restricting sexual activity improved in both groups (p < 0.00), with higher scores for physical section subscale in PISQ-12 (p = 0.02) for TVT. Physical and social functioning (RAND-36) improved from the baseline in both groups (p < 0.01) with a better outcome in the TVT group for physical functioning (p = 0.00).

CONCLUSIONS

Both TVT and PAHG improve QoL and sexual function in primary SUI with better incontinence and health-related QoL scores in the TVT group compared to the PAHG group at 3 years.

Pelvic organ prolapse after hysterectomy: A 10-year national follow-up study

INTRODUCTION

Hysterectomy may have an effect on the pelvic floor. Here, we evaluated the rates and risks for pelvic organ prolapse (POP) surgeries and visits among women with a history of hysterectomy for benign indication excluding POP.

MATERIAL AND METHODS

In this retrospective cohort study 3582 women who underwent hysterectomy in 2006 were followed until the end of 2016. The cohort was linked to the Finnish Care Register to catch any prolapse-related diagnoses and operation codes following the hysterectomy. Different hysterectomy approaches were compared according to the risk for a prolapse, including abdominal, laparoscopic, laparoscopic-assisted vaginal and vaginal. The main outcomes were POP surgery and outpatient visit for POP, and Cox regression was used to identify risk factors (hazard ratios [HR]).

RESULTS

During the follow-up, 58 women (1.6%) underwent a POP operation, of which a posterior repair was the most common (n = 39, 1.1%). Outpatient visits for POP symptoms occurred in 92 (2.6%) women of which posterior wall prolapses (n = 58, 1.6%) were the most common. History of laparoscopic-assisted vaginal hysterectomy were associated with risk for POP operation (HR 3.0, p = 0.02), vaginal vault prolapse operation (HR 4.3, p = 0.01) and POP visits (HR 2.2, p < 0.01) as compared to the approach of abdominal hysterectomy. History of vaginal deliveries and concomitant stress urinary continence operation were associated with the risk for a POP operation (HR 4.4 and 11.9) and POP visits (HR 3.9 and 7.2).

CONCLUSIONS

Risk for POP operations and outpatient visits for POP symptoms in hysterectomized women without a preceding POP seems to be small at least 10 years after hysterectomy. History of LAVH, vaginal deliveries and concomitant stress urinary incontinence operations increased the risk for POP operations after hysterectomy. These data can be utilized in counseling women considering hysterectomy for benign indication.

National register data are of value in studies on miscarriage-Validation of the healthcare register data in Finland

INTRODUCTION

Despite the high prevalence of miscarriages, they are not systematically registered and few epidemiological studies have been done. As Finnish health registries are comprehensive and widely used in research, we validated the Finnish register data concerning diagnostics and treatment of miscarriage, and treatment-related adverse events.

MATERIAL AND METHODS

We conducted a validation study regarding miscarriage-related codes of diagnoses and surgical procedures in a Finnish National Hospital Discharge Registry (NHDR) by comparing the information from the NHDR with that of the hospital records. We selected a random sample of 4 months during 1998-2016 from three hospitals, comprising 687 women aged 15-49 experiencing a first miscarriage during follow-up. Women with diagnoses unrelated to miscarriage, or proven to be other than miscarriage, were excluded. The final sample consisted of 643 women with confirmed miscarriage, which was used for analyses regarding the diagnosis, treatment and adverse events of miscarriage treatment.

RESULTS

The majority of miscarriages registered in the NHDR were confirmed by the hospital records (positive predictive value [PPV] = 93.6% [95% confidence interval [CI] 91.8%-95.4%]). Different types of miscarriage were also reliably identified; spontaneous abortion with PPV = 85.6% (95% CI 80.9%-89.2%), missed abortion with PPV = 92.7% (95% CI 88.8%-95.3%) and blighted ovum with PPV = 91.1% (95% CI 84.3%-95.1%). The PPV of surgical treatment (62.2% [95% CI 55.7%-68.3%]) was lower than the PPV of non-surgical treatment (93.3% [95% CI 90.5%-95.3%]). The diagnoses regarding adverse events of miscarriage treatment could be reliably identified. The PPV for clinical infections was 76.0% (95% CI 56.6%-88.5%) and for retained products of conception or/and vaginal bleeding 96.8% (95% CI 83.8%-99.4%).

CONCLUSIONS

The coverage of the NHDR was good concerning identification of miscarriages, different types of miscarriages and non-surgical treatment. Nevertheless, there is a need for clearly defined procedural codes concerning to medical treatment of miscarriage. The register-based data are reliable and practicable for both clinical evaluation and research concerning miscarriage.

Patient-controlled intravenous versus on-demand oral, intramuscular or intravenous administration of oxycodone during medical induced abortion from 64 to 128 days of gestation: a randomized controlled trial

OBJECTIVE

To compare oxycodone administration via intravenous patient-controlled analgesia (IVPCA) vs on-demand administration during late-first- and second-trimester medically induced abortion.

STUDY DESIGN

A prospective randomized controlled study. We enrolled women between 64 to 128 days of gestation in the study between June 2016 and August 2018. Participants were randomized to receive oxycodone either via IVPCA or given on-demand orally, intramuscularly or intravenously. Pain intensity and satisfaction with care were measured using the visual analogue scale (VAS, 0-100mm).

RESULTS

Altogether 99 participants were randomized: 48 in IVPCA group and 51 in on-demand group. Median gestational age was similar between groups (74 days [Interquartile range, IQR 69-81] in the IVPCA group vs 72 [69-80] in the control group, p=0.587). Peak maximal pain was severe in both groups (median pain VAS was 62 [IQR 44-84] and 71 [IQR 56-90], p=0.52). The odds for severe pain (highest pain VAS≥70) were similar between the groups (IVPCA group OR 0.51 [95% Confidence Interval 0.22-1.18], p=0.118). In contrast, the odds for mild or tolerable pain (highest pain VAS≤40) were higher in the IVPCA group (OR 4.06 [95% CI 1.05-16.04], p=0.043). Nevertheless, satisfaction with care was high (VAS 94 [89-100]) in both groups. Of those experiencing severe pain, 94.0% declared pain medication as adequate.

CONCLUSIONS

Women often experience severe pain during medical abortion irrespective of the mode of opiate administration. Oxycodone administration via IVPCA permits women to self-administer analgesics when experiencing pain, raising the odds for mild or tolerable pain during abortion care. Satisfaction with care was high.

Stress urinary incontinence after hysterectomy: a 10-year national follow-up study

Purpose

Hysterectomy has been associated with increased risk for developing stress urinary incontinence (SUI) and having a SUI operation. We examined the long-term rate of SUI operations after hysterectomy and associated risk factors.

Methods

We followed up 5000 women without prior urinary incontinence (UI) who had a hysterectomy in a prospective FINHYST 2006 cohort study until the end of 2016 through a national health register. The main outcome was SUI operations, and secondary outcomes were outpatient visits for UI, and their association of preoperative patient and operation factors.

Results

During the median follow-up time of 10.6 years (IQR 10.3–10.8), 111 (2.2%) women had a SUI operation and 241 (4.8%) had an outpatient visit for UI. The SUI operation rate was higher after vaginal hysterectomy and laparoscopic hysterectomy (n = 71 and 28, 3.3% and 1.8%, respectively) compared to abdominal hysterectomy (n = 11, 0.8%). In a multivariate risk analysis by Cox regression, the association with vaginal hysterectomy and SUI operation remained significant when adjusted for vaginal deliveries, preceding pelvic organ prolapse (POP), uterus size, age and BMI (HR 2.4, 95% CI 1.1–5.3). Preceding POP, three or more deliveries and laparoscopic hysterectomy were significantly associated with UI visits but not with SUI operations.

Conclusion

After hysterectomy, 2.2% of women underwent operative treatment for SUI. The number of SUI operations was more than double after vaginal hysterectomy compared to abdominal hysterectomy, but preceding POP explained this added risk partially. Preceding POP and three or more vaginal deliveries were independently associated with UI visits after hysterectomy.

Association of complicated appendicitis on the risk of later in vitro fertilization treatment requirement and ectopic pregnancy: a nationwide cohort study

INTRODUCTION

A population-based register study utilizing three Finnish National Registers was carried out to determine whether uncomplicated appendicitis, complicated appendicitis and appendectomy without appendicitis are associated with a subsequent risk of requiring in vitro fertilization (IVF) treatment or a risk of ectopic pregnancy among reproductive-age women.

MATERIAL AND METHODS

A total of 23 997 women who underwent appendectomy for uncomplicated or complicated appendicitis or for nonspecific abdominal pain or who had nonspecific abdominal pain without surgical procedures between 2000 and 2012 were included in the study. The later risks of IVF treatment requirement and ectopic pregnancy were assessed after uncomplicated appendicitis, complicated appendicitis and appendectomy without appendicitis. Women with nonspecific abdominal pain without surgical procedures served as the reference group.

RESULTS

The rates of later IVF treatment after uncomplicated appendicitis, complicated appendicitis and appendectomy without appendicitis were low (2.1%, 2.5% and 2.3%, respectively; p = 0.681). Neither appendicitis nor appendectomy was associated with the risk of requiring IVF treatment. The rate of ectopic pregnancy after uncomplicated and complicated appendicitis was very low (0.8%). Women with uncomplicated appendicitis had a significantly lower risk of ectopic pregnancy compared with patients with nonspecific abdominal pain.

CONCLUSIONS

Appendicitis, whether complicated or uncomplicated, and appendectomy without appendicitis does not increase the risk of requiring later IVF treatment or the risk of ectopic pregnancy.

Early provision of intrauterine contraception as part of abortion care-5-year results of a randomised controlled trial

STUDY QUESTION

Can the incidence of subsequent termination of pregnancy (TOP) be reduced by providing intrauterine contraception as part of the abortion service?

SUMMARY ANSWER

Provision of an intrauterine device (IUD) as part of TOP services reduced the need for subsequent TOP but the effect was limited to the first 3 years of the 5-year follow-up.

WHAT IS KNOWN ALREADY

An IUD is highly effective in preventing subsequent TOP. Prompt initiation of IUD use leads to a higher usage rate during follow-up, as compliance with post-TOP IUD insertion visits is low.

STUDY DESIGN, SIZE, DURATION

The objective of this randomised controlled trial was to assess the effect of early comprehensive provision of intrauterine contraception after TOP, with primary outcome being the incidence of subsequent TOP during the 5 years of follow-up after the index abortion. This study was conducted at a tertiary care centre between 18 October 2010 and 21 January 2013. Altogether, 748 women undergoing a first trimester TOP were recruited and randomised into two groups. The intervention group (n = 375) was provided with an IUD during surgical TOP or 1-4 weeks following medical TOP at the hospital providing the abortion care. Women in the control group (n = 373) were advised to contact primary health care for follow-up and IUD insertion. Subsequent TOPs during the 5-year follow-up were identified from the Finnish Register on induced abortions.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The inclusion criteria were age ≥18 years, duration of gestation ≤12 weeks, residence in Helsinki and accepting intrauterine contraception. Women with contraindications to IUD were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

The overall numbers of subsequent TOPs were 50 in the intervention and 72 in the control group (26.7 versus 38.6/1000 years of follow-up, P = 0.027), and those of requested TOPs, including TOPs and early pregnancy failures, were 58 and 76, respectively (30.9 versus 40.8/1000, P = 0.080). Altogether 40 (10.7%) women in the intervention and 63 (16.9%) in the control group underwent one or several subsequent TOPs (hazard ratio 1.67 [95% CI 1.13 to 2.49], P = 0.011). The number of TOPs was reduced by the intervention during years 0-3 (22.2 versus 46.5/1000, P = 0.035), but not during years 4-5 (33.3 versus 26.8/1000, P = 0.631).

LIMITATIONS, REASONS FOR CAUTION

Both medical and surgical TOP were used. This may be seen as a limitation, but it also reflects the contemporary practice of abortion care. The immediate post-TOP care was provided by two different organizations, allowing us to compare two different ways of contraceptive service provision following TOP.

WIDER IMPLICATIONS OF THE FINDINGS

Providing TOP and IUD insertion comprehensively in the same heath care unit leads to significantly higher rates of attendance, IUD use and a significantly lower risk of subsequent TOP.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Helsinki University Central Hospital Research funds and by research grants provided by the Jenny and Antti Wihuri Foundation, the Yrjö Jahnsson Foundation and Finska Läkaresällskapet. E.P. has received a personal research grant from the Finnish Medical Society. The City of Helsinki supported the study by providing the IUDs. The funding organisations had no role in planning or execution of the study, or in analysing the study results.

TRIAL REGISTRATION NUMBER

The trial was registered at clinicaltrials.gov (NCT01223521).

TRIAL REGISTRATION DATE

18 October 2010.

DATE OF FIRST PATIENT’S ENROLMENT

18 October 2010.

Fear of childbirth after medical vs surgical abortion. Population-based register study from Finland

INTRODUCTION

To evaluate the effect of method of induced abortion and other abortion-associated variables on the incidence of fear of childbirth in subsequent pregnancy.

MATERIAL AND METHODS

This population-based register study cohort includes all nulliparous women with their first pregnancy ending in an induced abortion in 2000-2015 and subsequent pregnancy with live singleton delivery between 2000 and 2017 (n = 21 479). Data were derived from three national registers maintained by the Finnish Institute for Health and Welfare. We divided the study population in three cohorts: (a) medical and (b) surgical abortion during first trimester (≤84 days of gestation), and (c) medical abortion during second trimester (85-168 days of gestation). Primary outcome measures were the incidence of registry-identified fear of childbirth and cesarean delivery related to it.

RESULTS

The overall incidence of fear of childbirth was 5.6% (n = 1209). Altogether, 19.2% (n = 4121) of women underwent cesarean delivery. The odds were elevated especially for elective cesarean delivery (odds ratio [OR] 9.30, 95% CI 7.95-10.88, P < .001) in women with fear of childbirth. In multivariable analysis, the odds for fear of childbirth (adjusted OR [aOR] 0.80, 95% CI 0.68-0.94) and cesarean delivery (aOR 0.66, 95% CI 0.84-0.90) were decreased in women with a history of first-trimester medical abortion compared with those with first-trimester surgical abortion. Second-trimester medical abortion had no effect on the odds for fear of childbirth (aOR 1.04, 95% CI 0.71-1.50). Maternal age of 30-39 years and interpregnancy interval over 2 years were additional risk factors for both fear of childbirth and cesarean delivery, but surgical evacuation of uterus after the abortion was not.

CONCLUSIONS

One first- or second-trimester medical abortion does not increase the odds for fear of childbirth, and cesarean delivery related to it in subsequent pregnancy when compared with first-trimester surgical abortion. Older maternal age and longer interpregnancy interval emerged as risk factors for fear of childbirth.

Quality of life and sexual function after TVT surgery versus Bulkamid injection for primary stress urinary incontinence: 1 year results from a randomized clinical trial

Introduction and hypothesis

To assess changes in quality of life (QoL) and sexual function outcomes at 1 year after tension-free vaginal tape (TVT) versus polyacrylamide hydrogel injection (PAHG).

Methods

In a randomized trial comparing TVT (n = 111) and PAHG (n = 113) treatments of stress urinary incontinence (SUI), we compared urinary incontinence and health-related QoL using the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire, Short Form (IIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and RAND-36 Item Health Survey (RAND-36) at baseline and 1 year.

Results

UDI-6 and IIQ-7 showed improved incontinence-related QoL (p = 0.001) from baseline in both groups except for difficulty emptying the bladder and pain/discomfort. At 1 year, TVT patients experienced less urinary symptom-related distress compared to PAHG (p < 0.001). Sexual function improved in both groups (p < 0.001 for TVT and p = 0.01 for PAHG) with higher scores for the physical section subscale (p < 0.001) for TVT. Health-related QoL (RAND-36) improved from baseline in both groups in physical and social functioning (p < 0.001) with better outcome in the TVT group for physical functioning (p < 0.001). Increase in pain from baseline (p = 0.02) was detected for TVT, but not for PAHG. However, there was no difference between the groups (p = 0.78).

Conclusions

In primary SUI, TVT and PAHG treatments both improved QoL and sexual function at 1 year. However, incontinence and health-related QoL scores were better in the TVT group. More pain compared to the baseline was reported after TVT, although there was no difference between groups. Clinical significance needs to be evaluated in long-term follow-up.

Trends in the incidence, rate and treatment of miscarriage-nationwide register-study in Finland, 1998-2016

STUDY QUESTION

What changes have occurred in the incidence of miscarriage, its treatment options, and the profile of the women having miscarriages in Finland between 1998 and 2016?

SUMMARY ANSWER

The annual incidence of registry-identified miscarriage has declined significantly between 1998 and 2016, and non-surgical management has become the dominant treatment.

WHAT IS KNOWN ALREADY

Miscarriage occurs in 8-15% of clinically recognized pregnancies and in ~30% of all pregnancies. Increasing maternal age is associated with an increasing risk of miscarriage. The treatment of miscarriage has evolved significantly in recent years: previously, surgical evacuation of the uterus was the standard of care, but nowadays medical and expectant management are increasingly used.

STUDY DESIGN, SIZE, DURATION

We conducted a nationwide retrospective cohort study of 128 381 women that had experienced a miscarriage that was managed in public healthcare between 1998 and 2016 in Finland.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used the National Hospital Discharge Registry for the data. Women aged 15-49 years that had experienced their first miscarriage during the follow-up period and had miscarriage-related diagnoses during their admission to public hospital were included in the study. Miscarriages were defined by the 10th Revision of the International Statistical Classification of Diseases and related Medical Problems (ICD-10) diagnostic codes O02*, O03* and O08*. Women with ectopic, molar and continuing pregnancies and induced abortions were excluded. Treatment was divided into surgical and non-surgical treatment using the surgical procedure codes.

MAIN RESULTS AND THE ROLE OF CHANCE

The annual incidence of registry-identified miscarriage has declined from 6.8/1000 15-49-year-old women in 1998 to 5.0/1000 in 2016 (P < 0.001). Also, the incidence rate of registry-identified miscarriage (i.e. the proportion of miscarriages of registry-identified pregnancies [i.e. deliveries, induced abortions, and miscarriages]) has declined from 112/1000 15-49-year-old pregnant women in 1998 to 83/1000 in 2016 (P < 0.001). The largest decrease in this proportion occurred among women over 40 years of age, among whom 26.5% of registry-identified pregnancies in 1998 ended in miscarriage compared to that of 16.4% in 2016. The proportion of missed abortion has increased (30.3 to 38.8%, P < 0.001) whereas that of blighted ovum has decreased (25.4 to 12.8%, P < 0.001). The proportion of registry-identified miscarriages seen among nulliparous women has increased from 43.7 to 49.6% (P < 0.001). Mean age at the time of miscarriage remained at 31 years throughout the study. Altogether, 29% of all miscarriages were treated surgically and 71% underwent medical or expectant management. The proportion of surgical management has decreased from 38.0 to 1.6% for spontaneous abortion, from 60.7 to 9.4% for blighted ovum and 70.9 to 11.2% for missed abortion between 1998 and 2016.

LIMITATIONS, REASONS FOR CAUTION

This study includes only women with registry-identified pregnancies, i.e. women who were treated in public hospitals. However, the number of women treated elsewhere is presumed to be small. Neither can this study estimate the number of women having spontaneous miscarriage with no hospital contact.

WIDER IMPLICATIONS OF THE FINDINGS

Both the annual incidence and incidence rate of miscarriage of all registry-identified pregnancies has decreased, and non-surgical management has become the standard of care. These findings are of value when planning allocation of healthcare resources and at individual level considering fertility and miscarriage questions. We speculate that improving ultrasound diagnostics explains the increasing proportion of missed abortion relative to other types of miscarriage. More investigation is needed to examine potential risk factors, complications and morbidity associated with miscarriages.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the research funds of the Helsinki and Uusimaa hospital system, by a personal grant from Viipurin Tuberkuloosisäätiö to R.L. and by a personal grant from The Finnish Cultural Foundation to N.H. The authors have no conflicts of interest to declare.

Induced abortion and future use of IVF treatment; A nationwide register study

OBJECTIVE

In this nationwide study we assessed the use and factors associated with future in vitro fertilization (IVF) treatment after induced abortion.

MATERIALS AND METHODS

The study population was collected by means of record linkage between Finnish national registers. All women who underwent induced abortion between 2000 and 2009 in Finland were identified through the Register of Induced Abortions (n = 88 522). The study group consisted of women who underwent induced abortion and subsequently had an IVF treatment (n = 379); the comparison group were all women who had a spontaneous pregnancy and delivery 12-24 months after the index abortion (n = 7434). Demographic characteristics at the time of index abortion, and factors associated with the abortion (gestational age at abortion, indication and method of abortion, complications after abortion) were compared between the study groups. Logistic regression was used to assess whether some of the demographic characteristics or abortion associated factors increased the use of IVF treatment in the future.

RESULTS

The proportion of women with IVF treatment after induced abortion in the whole cohort was 0.4%. Women needing IVF treatment were older, of a higher socioeconomic status, and had fewer previous induced abortions and deliveries compared to women in the comparison group. No statistically significant differences were observed in the gestational age (≤ 12 weeks or >12 weeks of gestation) at abortion, method or complications of abortion. In multivariable analysis higher age increased, and history of previous deliveries or one or two abortions decreased the use of IVF.

CONCLUSIONS

Infertility necessitating the use of IVF treatment after induced abortion is uncommon. The factors associated with use of IVF after abortion are those generally recognized as risk factors of infertility. Abortion-related outcomes are not associated with an increased need of future IVF-treatment.

Predicting poor compliance with follow-up and intrauterine contraception services after medical termination of pregnancy

BACKGROUND

Attendance at post-abortion follow-up visits is poor, but little is known about factors affecting it.

OBJECTIVE

To assess the factors associated with non-compliance with post-abortion services and to evaluate differences in rates of attendance and intrauterine device (IUD) insertion according to the type of service provision.

METHODS

605 women undergoing a first trimester medical termination of pregnancy (MTOP) and planning to use intrauterine contraception were randomised into two groups. Women in the intervention group (n=306) were booked to have IUD insertion 1-4 weeks after the MTOP at the hospital providing the abortion, while women in the control group (n=299) were advised to contact their primary healthcare (PHC) centre for follow-up and IUD insertion.

RESULTS

In the intervention group, 21 (6.9%) women failed to attend the follow-up visit, whereas in the control group 67 (22.4%) women did not contact the PHC to schedule a follow-up (p<0.001). In both groups, non-attendance was associated with history of previous pregnancy and abortion. Not having an IUD inserted within 3 months was significantly more common in the control group (73.6% (n=220)) than in the intervention group (9.2% (n=28), p<0.001). In the intervention group, predictive factors for not having an IUD inserted were anxiety, history of pregnancy and abortion. However, we identified no significant predictive factors in the control group.

CONCLUSIONS

Factors predicting low compliance with post-MTOP follow-up are few. Comprehensive provision of abortion care and post-abortion services seems beneficial for minimising the loss to follow-up and delay in initiation of effective contraception.

TRIAL REGISTRATION NUMBER

NCT01223521;Results.

Sexual well-being after first trimester termination of pregnancy: Secondary analysis of a randomized contraceptive trial

INTRODUCTION

Although termination of pregnancy is one of the most common procedures conducted worldwide, little is known about sexual well-being after termination of pregnancy. The objective of this study was to assess sexual well-being after termination of pregnancy, and factors affecting it during a 1-year follow up.

MATERIAL AND METHODS

In total, 748 women requesting first trimester termination of pregnancy and participating in a randomized controlled trial on early provision of intrauterine contraception were provided with questionnaires regarding their sexual life, anxiety, quality of life and contraceptive method used at the time of termination of pregnancy, 3 and 12 months after termination of pregnancy. Sexual well-being was measured by the 9-item McCoy Female Sexuality Questionnaire. Anxiety and quality of life were assessed by the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL questionnaire (EQoL).

RESULTS

The McCoy index remained unchanged during the follow up. At all three time-points measured, higher (ie, better) McCoy scores were associated with a lower STAI index (mean difference -2.26 [95% CI -3.23 to -1.29], P < 0.001; -3.76 [95% CI -4.79 to -2.74], P < 0.001; -4.50 [95% CI -5.88 to -3.12], P < 0.001) and being in a relationship (1.16 [95% CI 0.08-2.25], P = 0.023; 1.67 [95% CI 0.43-2.89], P < 0.001; 2.81 [95% CI 1.28-4.34], P < 0.001), and correlated positively with a higher EQoL index (r = 0.20, r = 0.20, r = .27, P < 0.001) and higher frequency of intercourse (r = 0.50, r = 0.46, r = 0.42, P < 0.001). Women using intrauterine contraception had higher McCoy index measurements at 3 months compared with others. There were no significant differences between users of hormonal vs non-hormonal contraceptive methods.

CONCLUSIONS

Sexual well-being does not change significantly after termination of pregnancy. Instead, it is strongly and positively associated with quality of life, relationship status and frequency of intercourse. Anxiety is negatively associated with sexual well-being.

Intrauterine adhesions following an induced termination of pregnancy: a nationwide cohort study

OBJECTIVE

Intrauterine adhesions (IUAs) are a problematic complication after termination of pregnancy, but their incidence is unknown. Our objective was to assess the incidence of IUAs following induced termination of pregnancy and the risk factors for IUAs.

DESIGN

Retrospective cohort study.

SETTING

A nationwide registry study.

SAMPLE

All women undergoing induced termination of pregnancy (n = 80 015) in Finland between 2000 and 2008.

METHODS

The data were retrieved from the Finnish Abortion Registry and the Hospital Discharge Registry. The diagnosis of IUAs or complications was based on the diagnostic codes (International Statistical Classification of Diseases and Related Health Problems 10th Revision, ICD-10) and operative codes according to the Nordic Medico-Statistical Committee (NOMESCO) Classification of Surgical Procedures (NCSP). IUAs were defined as ICD-10 code N85.6 or operative code LCG02. A subanalysis of IUA cases and five matched controls was performed.

MAIN OUTCOME MEASURES

The incidence of and risk factors for IUAs.

RESULTS

A total of 12 (1.5 per 10 000) IUA diagnoses were identified from 79 960 eligible induced terminations of pregnancy. The rate of IUAs was 1.5 and 2.0 cases per 10 000 terminations of pregnancy following medically and surgically induced termination of pregnancy, respectively (P = 0.19). In a subgroup analysis of IUA cases and five matched controls, surgical treatment of the remaining products of conception following termination of pregnancy significantly increased the risk of IUAs (odds ratio, OR 5.50; 95% confidence interval, 95% CI 1.46-20.79; P = 0.012).

CONCLUSION

IUAs that require further treatment are rare after an induced termination of pregnancy. Surgical evacuation following medical or surgical termination of pregnancy was a risk factor for the diagnosis of IUAs. These results suggest that trauma to a recently pregnant uterus is an important risk factor for IUAs.

TWEETABLE ABSTRACT

IUA is rare after induced termination of pregnancy (iTOP), but surgical evacuation is a risk factor for IUAs.

Medical treatment of second-trimester fetal miscarriage; A retrospective analysis

OBJECTIVES

Research on the treatment of second-trimester miscarriages is scarce. We studied the outcomes, and the factors associated with adverse events and need for hospital resources in the medical treatment of second-trimester miscarriage.

MATERIALS AND METHODS

In these retrospective analyses we studied women treated for spontaneous fetal miscarriage with misoprostol-only (n = 24) or mifepristone and misoprostol (n = 177) in duration of gestation 12+1-21+6. Primary outcomes were the risk factors for surgical evacuation and excessive bleeding. Secondary outcomes were total misoprostol dose, time to expulsion and the length of hospital stay.

RESULTS

History of surgical evacuation of the uterus increased the risk of surgical evacuation (p = 0.027). Excessive bleeding was not associated with any of the studied variables. More misoprostol was needed when the duration of gestation exceeded 17+0 weeks (p = 0.036). In multivariate analysis the time to fetal expulsion was shorter in women with history of 1-2 deliveries (hazard ratio [HR] 1.49, 95% confidence interval [CI]; 1.07-2.07), ≥3 deliveries (HR 1.63, 95% CI; 1.11-2.38) and with a two-day interval between mifepristone-misoprostol administration (HR 1.71, 95% CI; 1.05-2.81). Patients with symptoms (i.e. uterine bleeding or pain) at baseline had longer hospital stay (HR 0.66, 95% CI; 0.47-0.92).

CONCLUSIONS

The factors affecting the outcomes of medical treatment of second-trimester fetal miscarriage are similar to those of second-trimester induced abortion. Two-day interval between mifepristone-misoprostol administration might decrease the time to fetal expulsion and the need of hospital resources.

How reliable are health registers? Registration of induced abortions and sterilizations in Finland

Finland's population-based health registers are widely used in health-monitoring and research. We assessed the quality of the Finnish Register on Induced Abortions and Sterilisations and compared it to the Hospital Discharge Register. Ten hospitals out of 67 public hospitals performing induced abortions and sterilizations and three randomly selected months in 2011 were included. This data was compared to the data in the Register on Induced Abortions and Sterilisations. The sample presented 43.1% of all induced abortions and sterilizations during the study months. The coverage on data on induced abortions was excellent: 97.0% of induced abortions were found in the register. Coverage on data on sterilizations was good: 89.4% of sterilizations performed were found in the register. More detailed comparisons of the variable data showed good to very good validity. The coverage of the Hospital Discharge Register was found also to be good. The validity of Finland's Register on Induced Abortions and Sterilisations makes it a good base for research and health-monitoring. The Hospital Discharge Register was a good source in measuring volumes of hospital use as well as the main diagnoses or procedures, but the registration of single diagnoses or procedures may be less ideal for research.

Anxiety and quality of life after first-trimester termination of pregnancy: a prospective study

INTRODUCTION

Possible effects of termination of pregnancy (TOP) on mental health are a matter of debate.

MATERIAL AND METHODS

We assessed anxiety and quality of life during a one-year follow up after first-trimester TOP using the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL Quality of Life Questionnaire (EQ-5D, EQ-VAS) in 742 women participating in a randomized controlled trial on early provision of intrauterine contraception. The measurements were performed before TOP, at 3 months and 1 year after TOP. Inclusion criteria were age ≥18 years, residence in Helsinki, duration of gestation <12 weeks, non-medical indication for TOP, and approval of intrauterine contraception. The trial was registered with Clinical Trials [NCT01223521].

RESULTS

When compared with baseline, the overall anxiety level was significantly lower and quality of life higher at 3 months and at 1 year. Reduction of anxiety and improvement of quality of life was especially evident (p < 0.001) in the 58% of women reporting clinically relevant anxiety at baseline. High levels of anxiety at baseline, history of psychiatric morbidity and smoking predicted significantly greater risk of poorer quality of life and elevated level of anxiety during the follow up.

CONCLUSIONS

TOP is associated with a significant overall reduction of anxiety and an improvement of quality of life among women undergoing it for non-medical indications. High baseline anxiety, history of psychiatric morbidity and smoking are risk factors of persistently high levels of anxiety and poor quality of life after an induced abortion. These data are important when designing and providing post-abortion care.

Complications and long-term follow-up on colorectal resections in the treatment of deep infiltrating endometriosis extending to bowel wall

OBJECTIVE

To evaluate the rate of complications, factors associated with complications and long-term results in colorectal resections for the treatment of deep infiltrating endometriosis of the bowel wall.

DESIGN

Retrospective study.

SETTING

Tertiary center in Finland.

METHODS

Medical charts were reviewed for 164 women undergoing colorectal resections for deep infiltrating endometriosis between June 2004 and December 2012 at the Department of Obstetrics and Gynecology, Helsinki University Central Hospital; in 112 women (68%) bowel resection was performed laparoscopically and in 52 women (32%) laparotomy was needed.

MAIN OUTCOME MEASURES

Complications, re-operations, fertility.

RESULTS

The rate of major complications was 12% for both laparoscopies and laparotomies. However, the rate of complications during laparoscopies decreased from 27% in 2004-06 to 8% between 2010 and 2012. Similarly, the complication rate in laparoscopies fell with increased personal experience of the operating surgeon. A greater size (≥4 cm) of the nodules in the resected bowel was significantly associated with the development of a major complication. During the median follow up of 61 months (range 16-116 months) 7% needed a re-operation due to recurrence. Forty-seven percent of those women who preoperatively desired a pregnancy, subsequently had a child.

CONCLUSIONS

Laparoscopy has become a feasible alternative to laparotomy for performing colorectal resection in cases of deep infiltrating endometriosis of the bowel wall. Moreover, colorectal resections seem to result in good long-term pain relief and fertility. With increasing experience the number of complications was reduced and therefore, the practice of centralizing these operations seems to be well justified.

Is teenage pregnancy an obstetric risk in a welfare society? A population-based study in Finland, from 2006 to 2011

OBJECTIVE

To assess obstetric outcomes in teenage pregnancies in a country with a low teenage delivery rate and comprehensive high-quality prenatal care.

DESIGN

Retrospective population-based register study.

SETTING

Finland.

PARTICIPANTS

All nulliparous teenagers (13-15 years (n=84), 16-17 years (n=1234), 18-19 years (n=5987)) and controls (25-year-old to 29-year-old women (n=51 142)) with singleton deliveries in 2006-2011.

MAIN OUTCOME MEASURES

Risk of adverse obstetric outcomes adjusted for demographic factors and clinically relevant pregnancy complications, with main focus on maternal pregnancy complications.

RESULTS

Teenage mothers were more likely than controls to live in rural areas (16% (n=1168) vs 11.8% (n=6035)), smoke (36.4% (n=2661) vs 7% (n=3580)) and misuse alcohol or drugs (1.1% (n=82) vs 0.2% (n=96); p<0.001 for all). Teenagers made a good mean number of antenatal clinic visits (16.4 vs 16.5), but were more likely to have attended fewer than half of the recommended visits (3% (n=210) vs 1.4% (n=716)). Teenagers faced increased risks of several obstetric complications, for example, anaemia (adjusted OR 1.8, 95% CI 1.6 to 2.1), proteinuria (1.8, 1.2 to 2.6), urinary tract infection (UTI; 2.9, 1.8 to 4.8), pyelonephritis (6.3, 3.8 to 10.4) and eclampsia (3.2, 1.4 to 7.3), the risks increasing with descending age for most outcomes. Elevated risks of pre-eclampsia (3.7, 1.5 to 9.0) and preterm delivery (2.5, 1.2 to 5.3) were also found among 13-year-olds to 15-year-olds. However, teenage mothers were more likely to have vaginal delivery (1.9, 1.7 to 2.0) without complications. Inadequate prenatal care among teenagers was a risk factor of eclampsia (12.6, 2.6 to 62.6), UTI (5.8, 1.7 to 19.7) and adverse neonatal outcomes.

CONCLUSIONS

Pregnant teenagers tended to be socioeconomically disadvantaged versus controls and faced higher risks of various pregnancy complications. Special attention should be paid to enrolling teenagers into adequate prenatal care in early pregnancy.

Trends in teenage termination of pregnancy and its risk factors: a population-based study in Finland, 1987-2009

STUDY QUESTION

What are the current trends in teenage termination of pregnancy (TOP) and its risk factors?

SUMMARY ANSWER

The incidence of teenage TOP fluctuated substantially during the study period and the incidence of repeat TOP among adolescents increased markedly in the 2000s.

WHAT IS KNOWN ALREADY

Teenage pregnancy is associated with difficulties in psychological, sexual and overall health. The proportion of teenage pregnancies resulting in termination varies by country and time, but only few countries have reliable statistics on TOPs.

STUDY DESIGN, SIZE, DURATION

This nationwide retrospective register study included all the TOPs (n= 52 968) and deliveries (n= 58 882) in Finland between 1987 and 2009 among girls <20 years of age at the beginning of pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The cohorts were divided into three subgroups; 13-15- (n= 6087), 16-17- (n= 18 826) and 18-19- (n= 28 055) year-olds.

MAIN RESULTS AND THE ROLE OF CHANCE

After an initial steady decline, the incidence of teenage TOP increased by 44% between 1993 (8.0/1000) and 2003 (11.5/1000), and thereafter declined by 16% until 2009 (9.7/1000). The incidence was higher in older adolescents, but the trends were alike in all age groups. Early TOPs (performed at <56 days of gestation) more than tripled from 11 to 36% during the study period. However, the proportion of second-trimester TOPs remained steady at ≈ 7%. Young age [13-15 years: odds ratio (OR) 1.75 (95% confidence interval (CI) 1.57-1.94), 16-17 years: OR 1.13 (1.05-1.23), 18-19 years: OR 1 (reference category)] and non-use of contraception [(OR 11.16 (10.15-12.27)] were related to a higher risk of second-trimester TOP. The incidence of repeat TOP increased by 95% from 1.9/1000 to 3.7/1000 in 18-19-year-olds and by 120% from 0.5/1000 to 1.1/1000 in 16-17-year-olds between 1993 and 2009. Increasing age [13-15 years: OR 0.16 (95% CI 0.14-0.19), 16-17 years: OR 0.49 (0.45-0.52), 18-19 years 1 (Ref)], living in an urban area [rural: OR 0.62 (0.56-0.67), urban: OR 1 (Ref)] and having undergone a second-trimester TOP [OR 1.46 (1.31-1.63)] were risk factors for repeat TOP. The planned use of intrauterine contraception for post-abortal contraception increased from 2.6 to 6.2% and among girls with repeat TOP from 10 to 19%.

LIMITATIONS

The retrospective nature of the study remains a limitation and the quality of the data is reliant on the accuracy of reporting. We were not able to link repeat TOPs of the same woman in our data set. However, the share of repeat abortions was moderate. WIDER IMPLICATIONS OF THE FINDINGS The rate of teenage TOP seems to rapidly reflect changes in national sexual and reproductive health services and policy. The rising rate of repeat TOP is alarming and may represent a sign of marginalization among these girls. All efforts to maintain a low rate of teenage pregnancy are welcomed.

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 = 27,030) 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 24,006 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.