目的:为人工流产的实践提供建议。
方法:发布的数据库,已咨询了Cochrane图书馆以及法国和外国Gyn-Obs学会或学院的建议。
结果:人工流产(IA)的数量已经稳定了几十年。当存在计划外怀孕(UPP)时,有很多因素可以解释堕胎的选择。早期开始和选择与女性生活有关的避孕方法与较低的NSP有关。由于其效率(C级),长期作用的可逆避孕药应排在青少年的拳头上。必须鼓励在人工流产前进行超声检查,但在进行IA(专业共识)之前不应是强制性的。一旦胚胎出现超声波,从11周开始,通过测量冠-臀部长度(CRL)或测量双顶径(BIP)来估计妊娠日期(B级).这些参数的可靠性为±5天,如果CRL的测量值分别小于90mm和BIP的测量值分别小于30mm,则可以进行IA(专业共识)。使用200mg米非司酮联合米索前列醇的剂量进行的医学IA在任何胎龄下都是有效的(EL1)。在7周之前,米非司酮在24到48小时之间口服米索前列醇,经颊舌下或最终经阴道,剂量为400ug,可能在3小时后更新(EL1,A级)。超过7周,阴道给予米索前列醇,舌下或经颊的耐受性比口服途径(EL1)更好,副作用更少。建议在器质性流产期间始终使用宫颈准备(专业共识)。米索前列醇是400mcg(A级)剂量的宫颈制剂的一线药物。抽吸疏散优于刮宫(B级)。在器械抽吸过程中穿孔的子宫不应被视为瘢痕子宫(专业共识)。IA与不孕症或异位妊娠(EL2)的后续风险增加无关。堕胎前的医疗咨询不影响,大部分时间,请求IA的决定。的确,在这些咨询中,大多数妇女非常确定自己的选择。当他们能够选择流产方法(B级)时,IA方法的可接受性和满意度似乎更大。精神疾病的增加与IA(EL2)之间没有关系。有精神病史的女性在发生UPP(EL2)后患精神障碍的风险增加。如果是器质性流产,口服雌激素-孕激素避孕药和贴片应从流产之日起开始,在IA(B级)的5天内插入阴道环。如果是药物流产,应在服用米非司酮后一周内插入阴道环,口服雌激素-孕激素避孕药和贴剂应在服用前列腺素(C级)后的同一天或第二天开始使用。如果是器质性流产,避孕植入物可以在流产当天插入(B级)。如果是药物流产,可以在使用米非司酮(C级)的当天插入植入物。铜宫内节育器(IUD)和左炔诺孕酮应优选在器械流产当天插入(A级)。如果是药物流产,在通过超声检查确保没有宫内妊娠(C级)后,可以在米非司酮后10天内插入宫内节育器。
结论:这些指南的实施可能会促进我国要求IA的女性更好,更同质的护理。
OBJECTIVE: Develop recommendations for the practice of induced abortion.
METHODS: The Pubmed database, the Cochrane Library and the recommendations from the French and foreign Gyn-Obs societies or colleges have been consulted.
RESULTS: The number of induced abortions (IA) has been stable for several decades. There are a lot of factors explaining the choice of abortion when there is an unplanned pregnancy (UPP). Early initiation and choice of contraception in connection to the woman\'s life are associated with lower NSP. Reversible contraceptives of long duration of action should be positioned fist in line for the teenager because of its efficiency (grade C). Ultrasound before induced abortion must be encouraged but should not be obligatory before performing IA (Professional
consensus). As soon as the sonographic apparition of the embryo, the estimated date of pregnancy is done by measuring the crown-rump length (CRL) or by measuring the biparietal diameter (BIP) from 11 weeks on (grade B). Reliability of these parameters being±5 days, IA could be done if measurements are respectively less than 90mm for CRL and less than 30mm for BIP (Professional
consensus). A medical IA performed with a dose of 200mg mifepristone combined with misoprostol is effective at any gestational age (EL1). Before 7 weeks, mifepristone followed between 24 and 48hours by taking misoprostol orally, buccally sublingually or eventually vaginally at a dose of 400 ug possibly renewed after 3hours (EL1, grade A). Beyond 7 weeks, misoprostol given vaginally, sublingually or buccally are better tolerated with fewer side effects than oral route (EL1). It is recommended to always use a cervical preparation during an instrumental abortion (Professional
consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 mcg (grade A). Aspiration evacuation is preferable to curettage (grade B). A perforated uterus during an instrumental suction should not be considered as a scarred uterus (Professional
consensus). IA is not associated with increased subsequent risk of infertility or ectopic pregnancy (EL2). The pre-abortion medical consultations does not affect, most of the time, the decision to request an IA. Indeed, a majority of women is quite sure of her choice during these consultations. Acceptability of the method of IA and satisfaction appears to be larger when they are able to choose the abortion method (grade B). There is no relationship between an increase in psychiatric disorders and IA (EL2). Women with psychiatric histories are at increased risk of mental disorders after the occurrence of an UPP (EL2). In case of instrumental abortion, oral estrogen-progestogen contraceptives and the patch should be started from the day of the abortion, the vaginal ring inserted within 5 days of IA (grade B). In case of medical abortion, the vaginal ring should be inserted within a week of taking mifepristone, oral estrogen-progestogen contraceptives and the patch should be initiated on the same day or the day after taking prostaglandins (grade C). In case of instrumental abortion, the contraceptive implant may be inserted on the day of the abortion (grade B). In case of medical abortion, the implant can be inserted on the day of mifepristone (grade C). The copper Intrauterine Device (IUD) and levonorgestrel should be inserted preferably on the day of instrumental abortion (grade A). In case of medical abortion, an IUD can be inserted within 10 days following mifepristone after ensuring by ultrasound of the absence of intrauterine pregnancy (grade C).
CONCLUSIONS: The implementation of these
guidelines may promote a better and more homogenous care for women requesting IA in our country.