Aspiração manual intrauterina versus aspiração elétrica no tratamento da gestação molar

Abstract

Background. Molar pregnancy is the most commom form of gestacional trophoblastic disease (GTD). The clinical importance of molar pregnancy is the risk of progression to gestacional trophoblastic neoplasia (GTN), in addition to the associated clinical complications. In suspected molar pregnancy, the inicial treatment is vacuum uterine evacuation of all trophoblastic content performed by vacuum aspiration: electric or manual. Electric vacuum aspiration is the method currently recommended. Among 38 GTD Reference Centers in Brazil, electric aspiration is used in only 27%, while manual vacuum aspiration is used in 70%. This reflects the legal restrictions on the use of electrical devices associated with elective pregnancy termination in Brazil and Latin America. Studies comparing both techniques are performed in cases of early gestacional loss, where molar pregnancy, due to its rarity, is poorly represented. Objective.To evaluate uterine evacuation of patients with molar pregnancy, comparing manual with electric vacuum aspiration. Methods. This is a retrospective cohort study of patients with molar pregnancy followed at the Rio de Janeiro Trophoblastic Disease Center from January 2007 to December 2016. The individual primary study outcomes were incomplete uterine evacuation, uterine perforation, development of uterine synechia, and development of postmolar gestational trophoblastic neoplasia. Secondary endpoints were other features of the perioperative outcomes (operative time, rate of transfusion, hemoglobin change, length of stay) and the clinical course of neoplasia (Prognostic Risk Score, presence of metastases, time to remission, and need for multiagent chemotherapy). Results. Among 1,727 patients with molar pregnancy, 1,206 underwent electric vacuum aspiration and 521 underwent manual vacuum aspiration. After human chorionic gonadotropin normalization, patients with benign molar pregnancy were followed for 6 months and patients treated for gestational trophoblastic neoplasia were followed for 12 months. Baseline risk factors for gestational trophoblastic neoplasia and demographic features were similar between the treatment groups. Uterine synechia developed less frequently after manual vacuum aspiration than after electric vacuum aspiration, 6 of 521 vs 63 of 1.206 (adjusted odds ratio [OR] 0.21, 95% CI 0.09–0.49), despite no differences in the occurrence of incomplete uterine evacuation, 65 of 521 vs 161 of 1.206 (adjusted OR 0.93, 95% CI 0.69–1.27), development of postmolar gestational trophoblastic neoplasia, 90 of 521 vs 171 of 1,206 (adjusted OR 1.26, 95% CI 0.96–1.67), or the need for multiagent chemotherapy, 22 of 521 vs 41 of 1,206 (adjusted OR 0.81, 95% CI 0.73–1.28). Conclusion. Manual vacuum aspiration appears to be similar to electric vacuum aspiration for treatment of molar pregnancy and may be associated with less development of uterine synechia