Abstract
To investigate the current status of uterine adhesions in patients with residual fetus and analyze the preventive effect of estrogen and progesterone sequential therapy combined with Foley balloon. Eighty-six patients with residual fetus were divided into control group and observation group. On the basis of the treatment plan of the control group, the observation group received estrogen and progesterone sequential therapy combined with Floey balloon treatment. Clinical efficacy, postoperative recovery status (abdominal pain duration, vaginal bleeding duration, vaginal bleeding volume, refluid time), the incidence of intrauterine adhesions, uterine hemodynamics (uterine artery systolic maximum blood flow rate [Vmax], end diastolic blood flow rate [Vmin], resistance index [RI]), and the probability of complications were evaluated. Compared with the control group, the observation group achieved higher curative effect (P < .05); the observation group had shorter duration of abdominal pain, vaginal bleeding and refluid time, and lower vaginal bleeding (P < .05); the probability of intrauterine adhesions is lower (P < .05); before treatment, there is little difference in the levels of Vmax, Vmin, RI, and other indicators between the 2 groups (P > .05). After treatment, compared with the control group, the observation group Vmax, Vmin, and other indicators, the level was significantly lower, and the RI level was significantly higher (P < .05); the observation group had a lower probability of complications (P < .05). The likelihood of uterine adhesions after fetal remains is increased. The use of estrogen and progesterone sequential therapy in conjunction with Foley balloon therapy can improve treatment efficacy, improve uterine adhesion prevention, and promote patient recovery after surgery.
Keywords: estrogen and progesterone sequential therapy, Foley balloon, intrauterine adhesions, residual fetus
1. Introduction
In obstetrics and gynecology, fetal residue is a common occurrence. It refers to a condition in which embryo tissue is not completely discharged from the uterus following a miscarriage or childbirth, resulting in symptoms such as vaginal bleeding and abdominal pain. Intrauterine adhesions and infertility may occur in severe cases. It has a negative impact on reproductive health.[1] Currently, clinical treatment of fetal residue is primarily based on uterine evacuation, in which the surgeon uses a hysteroscope to remove the embryonic tissue remaining in the patient’s uterine cavity, but this causes serious endometrial damage. Following surgery, patients may experience uterine perforation and amenorrhea, increasing the likelihood of uterine adhesions. Therefore, it is of great significance to adopt effective preventive measures for patients.[2,3] Sequential therapy of estrogen and progesterone refers to the treatment method of administering drugs according to the female ovarian secretion cycle, supplementing the patient with exogenous hormones to artificially simulate ovarian secretion, which can effectively promote the regeneration of the endometrium and help the patient restore the normal menstrual cycle. The balloon inserted into the uterus can play a role as a stent and form a biological barrier, which can avoid the occurrence of intrauterine adhesions to a certain extent.[4,5] In order to explore the preventive effect of estrogen and progesterone sequential therapy combined with Foley balloon, this study selected 86 patients with residual fetuses for a comparative test. The report is as follows.
2. Methods
2.1 General information
Eighty-six patients with fetal residue admitted to our hospital from February 2020 to March 2021 were selected and divided into 2 groups using a random number table method. Among the 43 patients in the control group, the oldest was 32 years old and the youngest was 23 years old. The mean value was 27.50 ± 4.50 years; the cause of residual fetus: 14 cases of residual medical abortion, 17 residual patients of spontaneous abortion, and 12 residual patients after childbirth. Among the 43 patients in the observation group, the oldest was 31 years old and the youngest was 22 years old, with an average of 26.50 ± 4.50 years old; the cause of residual fetal matter: 15 cases of residual medical abortion, 17 residual patients of spontaneous abortion, 11 residual patients after childbirth example. The basic information of the 2 groups of patients is not significantly different (P > .05) and can be compared. This study was approved by the Medical Ethics Committee of Jinhua People’s Hospital.
Inclusion conditions: those whose ultrasound examination revealed the existence of fetal remains, whose attending physician determined that uterine evacuation treatment was necessary, and whose informed consent has been signed.
Excluded conditions: patients with insufficient clinical data, patients with surgical contraindications, patients with drug allergies, and patients who disobeyed medical advice or left the study early.
2.2. Method
The control group received uterine evacuation treatment. The patients were treated with bladder lithotomy, and the vulva and vagina were disinfected by medical staff to fix the cervix with cervical forceps. The hysteroscope was inserted into the uterus and the function was explored, and the cervix was expanded with a dilator. The cervix is dilated before inserting the hysteroscope. And use a hysteroscope to suck and scrape the residue (as shown in Fig. 1), with gentle movements to avoid damage to the inner wall of the uterus, until the residue under hysteroscope is cleared to end the operation. We verified its position or the fact that it filled the entire uterine cavity by an ultrasound.
Figure 1.
The operation of uterine cleansing.
On the basis of the treatment plan of the control group, the observation group received estrogen and progesterone sequential therapy combined with Foley balloon treatment, that is, Foley balloon was inserted into the patient’s uterine cavity after the evacuation operation (Fig. 2), using sodium chloride solution The balloon was filled, the sodium chloride solution was released after 2 days, and the balloon was taken out after 1 week. At the same time, the patient was given oral estradiol valerate tablets (manufacturing company: Jenapharm GmbH & Co.KG, Chinese medicine standard: J20171038, specifications: 1 mg), the dose is 2 mg/time, once/d, medroxyprogesterone acetate tablets are added after 10 days (manufacturing company: Southwest Pharmaceutical Co., Ltd, National Medicine Standard: H50020042, specification: 10 mg), the dose is 10 mg/time, 1 time/d, the course of treatment is 3 weeks.
Figure 2.
Foley balloon.
Observation indicators.
Comparing the results obtained after 2 months of treatment between the 2 groups of patients, the results are obvious: the patients did not experience uterine perforation, hemorrhage, etc, menstruation returned to normal, and hysteroscopy showed that the uterine wall was recovered well, and no intrauterine adhesions were seen; effective: the patient did not experience uterine perforation hemorrhage, and the menstruation basically returned to normal. Hysteroscopy showed that the uterine wall was basically restored, and part of the uterine cavity was visible; ineffective: the patient’s menstruation did not improve after the operation, and the hysteroscopy showed that there are obvious intrauterine adhesions. Compare the postoperative recovery of the 2 groups, that is, count the duration of postoperative abdominal pain, the duration of vaginal bleeding, the amount of bleeding, and the time to regain. Compare the probability of uterine adhesions in the 2 groups of patients after surgery, that is, follow up the patients for 2 months, and use hysteroscopy to determine whether they have uterine adhesions. Compare the endometrial conditions of the 2 groups before and after treatment, compare the uterine hemodynamics of the 2 groups before and after treatment, that is, use color Doppler ultrasound diagnostic apparatus (brand: Bells, approved) before treatment and 2 months after treatment Document number: Su Xie Zhun 20182230603, Model: BLS-X1) To detect the maximum blood velocity (Vmax) of the patient’s uterine artery systole, the minimum velocity (Vmin) of the end diastole and the resistance index (RI). Compare the probability of complications of the 2 groups of patients, including hemorrhage, uterine cavity infection, and uterine perforation.
2.3. Statistical methods
SPSS21.0 software was used for analysis of all data, measurement data were expressed by (x ± s), t test; count data were expressed by rate (%), test, and the result was P < .05, indicating that the difference was statistically significant.
3. Results
3.1. Comparison of the clinical efficacy of the 2 groups
Compared with the control group, the observation group achieved higher efficacy (P < .05), see Table 1 for details.
Table 1.
Comparison of clinical efficacy between the 2 groups, n (%).
| Group | Number of cases | Markedly effective | Efficient | Invalid | Always effective |
|---|---|---|---|---|---|
| Control group | 43 | 13 (30.23%) | 19 (44.19%) | 11 (25.58%) | 32 (74.42%) |
| Observation group | 43 | 17 (39.53%) | 22 (51.16%) | 4 (9.30%) | 39 (90.70%) |
| χ2 | 1.904 | 0.974 | 9.204 | 9.204 | |
| P | .168 | .324 | .002 | .002 |
3.2. Comparison of postoperative recovery between the 2 groups
Compared with the control group, the observation group had shorter duration of abdominal pain, vaginal bleeding and remoisture time, and lower vaginal bleeding (P < .05), ee Table 2 for details.
Table 2.
Comparison of postoperative recovery between the 2 groups (x ± s).
| Group | Number of cases | Duration of abdominal pain (d) | Duration of vaginal bleeding (d) | Vaginal bleeding (mL) | Retide time (d) |
|---|---|---|---|---|---|
| Control group | 43 | 2.35 ± 1.04 | 6.51 ± 1.24 | 30.13 ± 7.52 | 26.68 ± 3.22 |
| Observation group | 43 | 1.63 ± 0.91 | 5.03 ± 1.15 | 18.71 ± 6.36 | 20.40 ± 2.31 |
| t | 3.417 | 5.739 | 7.604 | 10.392 | |
| P | .001 | .000 | .000 | .000 |
3.3. Comparison of the incidence of postoperative uterine adhesions between the 2 groups
Compared with the control group, the observation group has a lower probability of intrauterine adhesions (P < .05), see Table 3 for details.
Table 3.
Comparison of the incidence of postoperative intrauterine adhesions between the 2 groups, n (%).
| Group | Number of cases | 1 mo after operation | 2 mo after surgery | Total |
|---|---|---|---|---|
| Control group | 43 | 6 (13.95%) | 4 (9.30%) | 10 (23.26%) |
| Observation group | 43 | 1 (2.33%) | 0 (0.00%) | 1 (2.33%) |
| χ2 | 9.029 | 9.754 | 19.630 | |
| P | .003 | .002 | .000 |
3.4. Comparison of uterine hemodynamics before and after treatment in the 2 groups
Before treatment, there was little difference in the levels of Vmax, Vmin, RI, and other indicators between the 2 groups (P > .05). After 2 months of treatment, both Vmax and Vmin decreased, and RI increased. Compared with the control group, the observation group Vmax The levels of indicators such as, Vmin are significantly lower, and the RI level is significantly higher (P < .05), see Table 4 for details.
Table 4.
Comparison of uterine hemodynamics before and after treatment in the 2 groups (x ± s).
| Group | Number of cases | Vmax (cm/s) | Vmin (cm/s) | RI | |||
|---|---|---|---|---|---|---|---|
| Before therapy | After treatment | Before therapy | After treatment | before therapy | After treatment | ||
| Control group | 43 | 31.06 ± 4.39 | 24.58 ± 3.88* | 15.51 ± 2.22 | 11.53 ± 1.54* | 0.48 ± 0.13 | 0.66 ± 0.20* |
| Observation group | 43 | 30.87 ± 4.56 | 19.92 ± 2.79* | 15.69 ± 2.17 | 8.78 ± 0.74* | 0.49 ± 0.11 | 0.85 ± 0.24* |
| t | 0.197 | 6.394 | 0.380 | 10.554 | 0.385 | 3.988 | |
| P | .844 | .000 | .705 | .000 | .701 | .000 | |
RI = resistance index, Vmax = uterine artery systolic maximum blood flow rate, Vmin = end diastolic blood flow rate.
The comparison with the same group before treatment (P < .05).
3.5. Comparison of the incidence of complications between the 2 groups
Compared with the control group, the observation group has a lower probability of complications (P < .05), see Table 5 for details.
Table 5.
Comparison of the incidence of complications between the 2 groups, n (%).
| Group | Number of cases | Heavy bleeding | Uterine cavity infection | Uterine perforation | Complication |
|---|---|---|---|---|---|
| Control group | 43 | 2 (4.65%) | 3 (6.98%) | 1 (2.33%) | 6 (13.95%) |
| Observation group | 43 | 0 (0.00%) | 1 (2.33%) | 0 (0.00%) | 1 (2.33%) |
| χ2 | 4.761 | 2.436 | 2.358 | 9.029 | |
| P | .029 | .119 | .125 | .003 |
4. Discussion
With policy liberalization and an increase in the rate of induced abortion in recent years, the incidence of residual fetal matter has gradually increased, which can cause vaginal bleeding, etc, increase the risk of uterine adhesions in patients, and seriously affect female reproduction. Patients must receive treatment on time in order to maintain their health and quality of life.[6] For patients with a residual fetus, uterine debridement is the preferred treatment option. The surgeon investigates the position and size of the residue using a hysteroscope, and then uses a hysteroscope to effectively remove the residue and quickly improve the patient’s clinical symptoms.[7,8] However, uterine evacuation can cause damage to the patient’s endometrium, and patients have a higher probability of uterine adhesions after surgery, which is not conducive to postoperative recovery, and more effective treatments need to be sought. Sequential therapy of estrogen and progesterone is a kind of replacement therapy. Replacement therapy means that when the patient lacks a specific hormone, the hormone can be supplemented by drugs to play a replacement role, so as to achieve the purpose of quickly alleviating the disease. It is aimed at patients after fetal residue. The application of estrogen and progesterone sequential therapy can use drugs such as estradiol valerate tablets and medroxyprogesterone acetate tablets to artificially simulate the ovarian secretion cycle, thereby promoting the recovery of the endometrium and improving vaginal bleeding.[9,10] Estradiol valerate tablets contain the estrogen estradiol valerate, which is the human body’s natural estrogen 17β-estradiol precursor, which has the effect of promoting the growth of the endometrium and can supplement patients. The estrogen lacking in the body can be quickly and completely absorbed after taking it and excreted in the urine in the form of ballast acid and glucuronide.[11,12] Medroxyprogesterone acetate tablets are a kind of progesterone drugs, which mainly act on women’s endometrium and promote its proliferation and secretion. It can effectively inhibit luteinizing hormone and estradiol, thereby inhibiting ovulation. After oral administration, it is absorbed through the gastrointestinal tract and degraded in the liver.[13] The Foley balloon has the function of filling the patient’s uterine cavity, covering the wound and forming a biological barrier, avoiding uterine adhesions during the patient’s postoperative recovery process, and is conducive to the repair of endometrial hyperplasia.[14]
According to the results of this study, after receiving different treatment regimens for 2 months, compared with the control group, the observation group achieved higher curative effect, shorter abdominal pain duration, vaginal bleeding duration and refluid time, and lower vaginal bleeding. The probability of uterine adhesions is lower, the levels of indicators such as Vmax and Vmin are significantly lower, the level of RI is significantly higher, and the probability of complications is lower (P < .05). According to the findings, the endometrium of patients with residual fetuses undergoing uterine evacuation is damaged to some extent, and uterine adhesions are more likely to form during postoperative recovery, which is not good for the prognosis. The uterus can be effectively promoted by sequential estrogen and progesterone therapy. Endometrium repair allows patients to quickly alleviate a variety of clinical symptoms. The duration of abdominal pain and vaginal bleeding is reduced, as is the amount of bleeding. Vmax is the maximum blood flow rate during uterine artery systole in the indicators used in this study, and Vmin is the uterus. The resistance encountered by blood flowing in a blood vessel is measured as the arterial end diastolic blood flow rate, or RI. The 3 can be used to represent the patient’s body hemodynamics. The patient’s estrogen and progesterone levels in the body reach perimenopausal levels after taking the medication. Drug-induced amenorrhea, decreased bleeding, lower Vmax and Vmin, and higher RI. The use of a Foley balloon can act as a stent, effectively avoiding endometrium adhesion during the repair process and creating pressure on the inner wall of the uterus. It has improved postoperative hemostasis, hemorrhage prevention, and other situations, which helps to reduce the risk of postoperative complications.
5. Conclusions
To summarize, the likelihood of uterine adhesions after fetal residue is increased. The use of estrogen and progesterone sequential therapy in conjunction with Foley balloon therapy can improve the treatment effect, have a better preventive effect on uterine adhesions, improve uterine hemodynamics, reduce the incidence of complications, and have a high clinical promotion value.
Author contributions
Jie Liu was dedicated to the study concepts and study design; Shanshan Wang carried out the definition of intellectual content, data acquisition, data analysis and statistical analysis; Shanshan Li focused on the clinical studies and manuscript preparation; Xuan Liu was involved in the literature research, experimental studies, manuscript editing and manuscript review.
Abbreviation:
- RI =
- resistance index
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
How to cite this article: Liu J, Wang S, Li S, Liu X. To study the current status of uterine adhesions after fetal residue and the preventive effect of using estrogen and progesterone sequential therapy combined with Foley balloon. Medicine 2022;101:36(e30418).
This study was approved by the Medical Ethics Committee of Jinhua People’s Hospital.
The informed consent has been signed.
The authors declare that they have no competing interest.
The authors have no funding and conflicts of interest to disclose.
Contributor Information
Shanshan Wang, Email: lss18357955578@163.com.
Shanshan Li, Email: lss18357955578@163.com.
Xuan Liu, Email: 15024522619@139.com.
References
- [1].Le Gallee M, Lee S, Spence AR, et al. Association between first-trimester bleeding and retained placenta requiring dilatation and curettage. J Obstet Gynaecol Can. 2021;43:463–8. [DOI] [PubMed] [Google Scholar]
- [2].Guo J, Yu J, Zhang Q, et al. Clinical efficacy and safety of uterine artery embolization (UAE) versus laparoscopic cesarean scar pregnancy debridement surgery (LCSPDS) in treatment of cesarean scar pregnancy. Med Sci Monit. 2018;24:4659–66. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Levin G, Safrai M, Dior UP, et al. Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher rate of complications. J Obstet Gynaecol Can. 2020;42:1080–5. [DOI] [PubMed] [Google Scholar]
- [4].Cirrincione LR, Winston McPherson G, Rongitsch J, et al. Sublingual estradiol is associated with higher estrone concentrations than transdermal or injectable preparations in transgender women and gender nonbinary adults. LGBT Health. 2021;8:125–32. [DOI] [PubMed] [Google Scholar]
- [5].Zheng F, Xin X, He F, et al. Meta-analysis on the use of hyaluronic acid gel to prevent intrauterine adhesion after intrauterine operations. Exp Ther Med. 2020;19:2672–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Jiang J, Wang C, Xue M. High-intensity focused ultrasound versus uterine artery embolization for patients with retained placenta accreta. Eur J Obstet Gynecol Reprod Biol. 2020;252:82–6. [DOI] [PubMed] [Google Scholar]
- [7].Feng Q, Gao B, Zhao X, et al. Establishment of an animal model of intrauterine adhesions after surgical abortion and curettage in pregnant rats. Ann Transl Med. 2020;8:56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Yamamoto E, Nishino K, Niimi K, et al. Evaluation of a routine second curettage for hydatidiform mole: a cohort study. Int J Clin Oncol. 2020;25:1178–86. [DOI] [PubMed] [Google Scholar]
- [9].Escudero C, Giuliani F, Bernedo MM, et al. Allopregnanolone reversion of estrogen and progesterone memory impairment: interplay with serotonin release. J Neural Transm (Vienna). 2019;126:1321–8. [DOI] [PubMed] [Google Scholar]
- [10].Iwamoto T, Fujisawa T, Shien T, et al. The efficacy of sequential second-line endocrine therapies (ETs) in postmenopausal estrogen receptor-positive and HER2-negative metastatic breast cancer patients with lower sensitivity to initial ETs. Breast Cancer. 2020;27:973–81. [DOI] [PubMed] [Google Scholar]
- [11].Ozemek C, Hildreth KL, Blatchford PJ, et al. Effects of resveratrol or estradiol on postexercise endothelial function in estrogen-deficient postmenopausal women. J Appl Physiol (1985). 2020;128:739–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Mitchell CM, Guthrie KA, Larson J, et al. Sexual frequency and pain in a randomized clinical trial of vaginal estradiol tablets, moisturizer, and placebo in postmenopausal women. Menopause. 2019;26:816–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [13].Liu W, Chen Q, Liu Z, et al. Zihuai recipe alleviates cyclophosphamide-induced diminished ovarian reserve via suppressing PI3K/AKT-mediated apoptosis. J Ethnopharmacol. 2021;277:113789. [DOI] [PubMed] [Google Scholar]
- [14].Gallagher LT, Gardner B, Rahman M, et al. Cervical ripening using Foley balloon with or without oxytocin: a systematic review and meta-analysis. Am J Perinatol. 2019;36:406–21. [DOI] [PubMed] [Google Scholar]