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UDC 618.39:616-084
COMPLEX REHABILITATION OF WOMEN AFTER LATE ABORTION FOR MEDICAL GROUNDS
1 Omsk State Medical University, Omsk
2 City clinical perinatal center, Omsk
Ye.N. Kravchenko1, Ye.V. Kolombet1, M.V. Naboka2, V.A. Okhlopkov1, I.A.Lavrinenko2, L.V. Kuklina1
The objective was to evaluate the effectiveness of an integrated approach to the rehabilitation of women after late induced abortion. 60 women after interruption of pregnancy in terms of up to 22 weeks with congenital malformations of the fetus, incompatible with life, underwent the rehabilitation. The women were divided into 2 groups: the main group underwent the complex elaborated rehabilitation, in the comparison group the activities were limited by regulatory documents. Delayed complications were observed in 13.3% and 40.0% of women (p = 0.041) respectively, in the study groups (in the main group, complications were 3 times less frequent than in the comparison group); long-term consequences were observed in 10% and in 53.3% respectively (p = 0.000, in the main group 5.3 times less often than in the comparison group). In the complex implementation of rehabilitation measures, the number of late complications was observed 3 times less frequently than with the traditional approach, and the number of delayed sequela - by 5.3 times. The management of patients should not include only standard therapy for the treatment of complications, but also provide for the preventive use of contraceptives, suppression of lactation, a supplementation of folic acid, physiotherapy. Key words: late abortion, rehabilitation, termination of pregnancy.
The topical issue of the reproductive health protection is the minimization of risk of possible complications of medical abortions including late termination of pregnancy for medical grounds by congenital malformations of the fetus incompatible with life. The problem of abortions stays significant due to the possibility of development of early and long-term effect forming in the future a series of pregnancy, delivery complications and gynecological diseases. These circumstances enforce to search the ways of alternative improvement of technologies of pregnancy termination and means of prevention of possible complications [1, 2]. In recent years, there has been conducted numerous researches on the elaboration of various technologies of safe abortion aimed at the reduction of risk of complications [2].
One of the modern means - medically induced abortion at early and late stages by means of pros-taglandins in combination with antiprogestins [35]. The relative risk of complications is, apparently, higher in the II trimester, at the same time, the absolute risk is low, when the interruption of pregnancy is performed by qualified medical personnel [6]. Every year there is improved the quality of medical service by abortions at different stages. According to the Decree of the Ministry of Health of the Russian Federation 572 [7], pregnant women, depending on the term of pregnancy, indications and contra-indications, are exposed to artificial termination of pregnancy using medicamental method on the basis of informed voluntary consent of a woman.
There is also elaborated clinical protocol "Medicated termination of pregnancy in I trimester" considered by international experts as a considerable
reserve in reducing maternal lethality [8]. WHO recommend to make every possible efforts to replace curettage by vacuum aspiration and medicated methods in order to make procedure of abortion more safe [9]. Although, however attenuated the method of abortion is, it still is a serious psychological and physical trauma, hormonal stress and always present risk of serious complications including disorders of menstrual and reproductive functions [10-12].
Recently, the role of rehabilitation in practical medicine becomes more and more significant. The basic principles of rehabilitation include: early start, complexity, phasing, continuity and sequence, individual program, focus on social orientation of measures, control of effectiveness [13-15]. Postabortal rehabilitation implies a complex of measures directed, firstly, at the restoration of reproductive health.
Research objective: to work out and evaluate the effectiveness of complex approach to the rehabilitation of women after late stimulated abortion by congenital malformations of the fetus, incompatible with life.
Materials and methods
60 women after interruption of pregnancy in terms of up to 22 weeks with congenital malformations of the fetus, incompatible with life, underwent the rehabilitation. The women were divided into 2 groups: the main group underwent the complex elaborated rehabilitation, in the comparison group the rehabilitation measures were limited by regulatory documents [7]. The complex approach to the rehabilitation of women after late induced abortion including the following measures:
preparation to abortion, conduction of abortion itself by means of modern attenuated methods, postabortal rehabilitation.
Before late abortion, women were provided with written objective information based on evidences. All women were exposed to artificial termination of pregnancy in terms of up to 21 weeks 6 days in the conditions of the gynecological department of obstetric hospital having the opportunity to provide specialized help.
In accordance with the introduction of regulatory documents into practice [7, 8], artificial pregnancy termination was performed by means of medicated method depending on the term of pregnancy, indications and contra-indications. In this regard, there were used medicinal drugs registered in the territory of the Russian Federation, in accordance with the instructions for medical application of drugs. The control of uterine cavity emptying was maintained by visualization of deleted tissues. On the second day after the abortion, there was performed ultrasound investigation. The decision on the evacuation of the uterus content in case of incomplete abortion was based on clinical symptoms and USI data. By the signs of incomplete abortion and (or) parts of gestation-al sac there was conducted vacuum aspiration. The antibiotic prevention took place at late stages by the following combined method: mifepristone orally in the dose of 200 mg once, in 24 hours luminaria were injected into the cervical canal. If elimination of fetus did not occur, in 3-4 hours - 200-400 mkg of misoprostol [18, 19].
Artificial abortion was accompanied by obligatory anesthesia, women with Rh-negative blood were exposed to the prevention of rhesus immunization, there was prescribed immunoglobulin anti-D injected to unsensitized Rh-D-negative women during 72 hours after the induced abortion.
During the consultation with every woman there were discussed symptoms of complications in case of which she has to immediately contact with the doctor; there were also provided recommendations on the regime, hygienic measures, measures for prevention of abortions and necessity of preservation and carrying of further pregnancy. The control examination by obstetrician-gynecologist by lack of complaints is performed in 9-15 days.
The elaborated complex rehabilitation included the following additional element before the pregnancy termination: the woman was provided with screening for sexually transmitted infections (STIs), all women had the opportunity to be examined for Chlamydial infection and other STIs. By the result of microscopic swab examination of IV purity level, there were additionally excluded the causative agents of basic STIs ((Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium) by means of multiplex kit
produced by the Federal State Budgetary Institution of Science Central Research Institute of Epidemiology, Russian Federal Consumer Rights Protection and Human Health Control Service, Moscow. For the extended characteristics of the state of vaginal flora there were used reactive kits of "Floro-tsenoz" series based on multiplex PCR in real time ("AmpliSens® FloroTsenoz Bacterial vagino-sis-FL"). The results of the mentioned test allowed to quantitatively characterize the content of bacteria and also the content of lactobacillus, G. vaginalis, A. vaginae.
By the diagnosis of "bacterial vaginosis", "nonspecific vaginitis", "vulvovaginal candidiasis", the pregnant women received gel "Metrogil plyus" intravaginally. The recommended dose constituted 5 g (I full applicator) 2 times a day (in the morning and in the evening). The cycle of treatment - 5 days. One gram of gel contains: 10 mg of metronidazole and 20 mg of clotrimazole. By STI verification, there was performed the treatment of infections according to the existing clinical recommendations and international standards [20, 21].
For the group of comparison by the presence of risk factors there was necessary the prescription of broad-spectrum antibiotics. For women not examined for Chlamydial infection - inclusion of 100 mg of doxycycline orally 2 times a day during seven days beginning from the day of abortion, and also 800 mg of metronidazole orally before and during the abortion.
Taking into consideration that the late abortion was conducted for medical grounds, all women were motivated for further realization of their reproductive function, the observation was performed with the transition to preconception preparation with the choice of the optimum pause between pregnancies. The best period for the occurrence of pregnancy after the miscarriage of the previous one are considered the first six months [22, 23]. All women were provided with information on all existing modern contraceptive methods. The discussion and the choice of methods were performed before the procedure. The chosen contraceptive method started to be used right after the abortion. In the early period after the abortion, the implementation of combined oral contraceptives (COCs) assures reduction of intensity (elimination) of bleeding; suppression of proliferative processes; anti-inflammatory and regenerative effect on the level of endometrium; decrease of irritation of pituitary-hypothalamic-ovarian system (PHOS) and reduction of gonadotrophic activity; and, finally, interception [11, 12].
Suppression of lactation after late abortion is a significant component of the rehabilitation of women's reproductive system, as the termination of pregnancy is one of the main causes of mammary gland diseases development. Late abortions are absolute indications for suppression
of lactation, thus, there was prescribed the inhibitor of prolactin secretion (dostinex). To prevent lactation the medication was prescribed in the dose of 1 mg (two pills) once on the first day after the abortion [24].
On account of planning further realization of reproductive function the women received fo-lic acid (daily dose 400-800 mkg) not less than three months before the occurrence of pregnancy and during the whole I trimester (up to 12 weeks of pregnancy) [25].
The complex of rehabilitation including physical factors. Physical factors used for the rehabilitation after abortion has a specific and non-specific effect, cause total and local effect, thus, there were considered contraindications. In the postabortal period, there were used preformed possessing expressed anti-inflammatory, antiedemic, analgetic, uterotonic, desensitizing, immunomodulating and sedative effects aimed at restoration. Influencing receptive fields, functionally active zones, centers of nervous, endocrine and immune regulation, physical conductors of energy restore natural processes of homeostatic regulation of organism functional systems. The success of such regulation is determined by the functional state of organism, correct choice of the factor, regime, localization and parameters of its action.
Physical factors were implied in the early postabortal period for the preventive purpose, in case of complications - with the treatment purpose in complex with antibacterial or other therapy, and in the late period - with the purpose of the menstrual cycle restoration and preservation of the reproductive health. The method of physical therapy was chosen according to the concomitant pathology: intensity of the inflammatory process, presence of myomatous nodules, adhesive process. Upon indications there was implied the combined method - daily amplipulse phoresis with copper sulphate or sodium thiosulfate solution ("Apmlipuls-7", then low intensity laser therapy of the projection of uterus and appendages and lumbosacral spine ("Rik-ta-04", "Milta", "UZOR-A-2K", "Lazmik").
Medical abortion also presents a psycho-traumatic, stressful factor, thus, the course of rehabilitation treatment included also psycho-relaxing methods. The patients subject to such methods were exposed to cranial electrotherapy stimulation or electrosleep therapy, individual sessions with psychologist. Women were directed by the obstetrician-gynaecologist to the room of medical and social help of the women's consultation clinic (Center of medical and social of pregnant women in a difficult situation) for the consultations with psychologist (medical psychologist, when required - social work specialist). The consultation was conducted by a medical worker with higher medical education upon the woman's informed voluntary consent.
Results and discussion
The average age of patients constituted 29,8+3,9 in the main group and 30,1+4,3 in the comparison group. The conducted examination of the vaginal biotope by means of system "Florotsentoz" in the main group showed, that bacterial vaginosis and non-specific vaginitis were observed in 46,6%, in the comparison group disorders of the vaginal biotope were registered only in 26,7%. In terms of research, there were analyzed delayed and long-term consequences. Complications of late abortion developed during the 1st month after the operation were observed in both groups. Endometri-tis in the postabortal period was registered in 1 (3,3%) patient of the main group and in 3 (10%; p=0,605) patients of the comparison group. Subinvolution of uterus was observed in 1 (3,3%) women and in 4 (13,3%; p=0,350) women respectively. Hematometra was diagnosed in 1 (4,0%) patient of the main group and in 2 (6,7%; p=1,0) patients of the comparison group. Inflammatory diseases of appendages or aggravation of chronic inflammatory process were registered in 1patient of the main group and in 3 patients of the comparison group (p=0,605). Totally, delayed complications of late induced abortion were observed in 4 (13,3%) of women and 12 (40,0%; p=0,041) respectively, thus, in the main group complications were met three times rarer than in the group of comparison.
Long-term effects were connected with menstrual cycle disorders, dysfunction of the pitu-itary-hypothalamic-ovarian system (PHOS), psy-chogenic disorders. Disorders of menstrual cycle were observed in 1 (3,3%) patient of the main group and 4 (13,3%; p=0,350) patients of the comparison group. PHOS dysfunction was revealed in 1 (3,3%) woman and 4 (13,3%; p=0,350) women respectively. Mastopathy manifesting itself as mastalgia and galactorrhea was observed only in patients of the comparison group (5 women - 16,7%; p=0,062). Psychogenic disorders are detected in 1 (3,3%) patient of the main group and 3 (10%; p=0,605) patients of the group of comparison. Totally, long-term consequences were registered in 3 (10%) patients of the main group and 16 (53,3%; p=0,000) patients of the comparison group, h.e. in the main group complications were met 5,3 times rare than in the group of comparison.
Conclusion
Supplement to the Decree of the Ministry of Health of the Russia Federation [7] allowed to adjust the regulatory structure in accordance with imperatives within the shortest possible time and introduce modern methods aimed at the improvement of quality of medical service for women by stimulated abortion at late stages. The introduction of clinical protocol "Medicated termination of pregnancy" also allows to efficiently use the experience of foreign countries and specialized
societies of safe abortions in the II trimester upon medical indications.
By the complex conduction of rehabilitation measures the number of delayed complications (endometritis, subinvolution of uterus, he-matometra, inflammatory diseases of appendages or aggravation of chronic inflammatory process) in the main group was registered 3 times rarer than in the group of comparison, the number of long-term complications (menstrual cycle disorders, dysfunction of the pituitary-hypothalamic-ovarian system, mastopathy, psychogenic disorders) - 5,3 times rarer. The tactics of patients' management after artificial termination of pregnancy, especially in late terms, should not include only standard therapy of complications treatment, but also preventive implementation of combined oral contraceptives, suppression of lactation, supplement of folic acid, physiotherapeutic treatment aimed at prevention of negative consequences for woman's health.
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Contacts:
Corresponding author - Kravchenko Yelena Ni-kolayevna, Doctor of Medical Sciences, Professor, Head of the Department of obstetrics and gynecology of further vocational education of Omsk State Medical University, Omsk. 644043, Omsk, Lenina Ulitsa, 12. Tel.: (3812) 230293. Email: kravchenko.en@mail.ru
