1
|
The Use of Feticidal Agents Before Dilation and Evacuation or Induction of Labor for Later Abortion. Clin Obstet Gynecol 2022; 65:708-716. [PMID: 35293368 DOI: 10.1097/grf.0000000000000702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Abortion is a common medical procedure in the United States that is frequently the target of political and legal restrictions. These restrictions can negatively impact care and interfere with the patient-provider relationship. In this paper, we aim to review the historic context in which feticidal agents became more utilized in later abortion; describe current practices and protocols of using feticidal agents use for later abortion by dilation and evacuation and induction of labor; evaluate patient and provider perspectives on feticidal agent use; and propose areas of further ethical and research inquiry to characterize the use of these agents in later abortion procedures.
Collapse
|
2
|
Effectiveness of intra-cardiac lidocaine and intra-amniotic digoxin at inducing fetal demise before second trimester abortion past 20 weeks at a tertiary Hospital in Ethiopia: A retrospective review. Contracept X 2022; 4:100082. [PMID: 36017486 PMCID: PMC9396292 DOI: 10.1016/j.conx.2022.100082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022] Open
|
3
|
Tufa TH, Prager S, Lavelanet AF, Kim C. Drugs used to induce fetal demise prior to abortion: a systematic review. Contracept X 2020; 2:100046. [PMID: 33294839 PMCID: PMC7689273 DOI: 10.1016/j.conx.2020.100046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/17/2020] [Accepted: 10/19/2020] [Indexed: 11/26/2022] Open
Abstract
Clinicians have used feticidal agents prior to second trimester abortion for many years. Despite the widespread use of various agents to induce fetal demise, a comprehensive or systematic review of the evidence is lacking on the safety, effectiveness, and most effective routes of administration. Objectives To evaluate the existing drugs and routes of administration used in inducing fetal demise prior to abortion, and to determine the safety, effectiveness, and acceptability of these feticidal agents. Methods We searched PubMed, EMBASE, CINAHL, POPLINE, and Global Index Medicus to identify studies describing pharmacologic agents used to induce fetal demise prior to termination of pregnancy. We included randomized controlled trials and observational studies comparing digoxin, potassium chloride (KCL), and lidocaine to induce fetal demise. We included studies that evaluated the primary outcomes of safety and effectiveness, including success in achieving fetal demise, induction to expulsion time for medical abortion, dilation and evacuation time, as well as maternal side effects and complications. Two authors independently screened abstracts and full texts. One reviewer extracted data from the included studies, which was counterchecked by a second reviewer. Results We identified eight studies that met inclusion criteria: three randomized controlled trials, and five observational studies. A total of 4505 women received drugs to induce fetal demise at 17 to 38 weeks' gestation, including digoxin (n = 4174), KCL (n = 324), and lidocaine (n = 7). Intra-fetal digoxin was superior to intra-amniotic digoxin in achieving fetal demise (OR 3.51, 95% CI 1.60, 7.78). Intracardiac KCL 15% 2–3 mL reduced induction to expulsion time by 320 min (p <.006). Similarly, intracardiac KCL 15% 1–3 ml reduced dilation and evacuation time from 16.1 ± 7.9 min to 12.7 ± 5 min (p < 0.001). Intracardiac lidocaine 2% 10 mL was more effective at achieving fetal demise than intracardiac KCL 6 mmol (85.7% vs. 57.9%). Intra-amniotic and intra-fetal digoxin 1 mg, as compared to no feticidal agent, led to greater pre-procedure expulsion, hospital readmission, and the presence of one or more signs of infection. Conclusions Evidence from included cohort studies demonstrates that digoxin, KCL, and lidocaine are all effective in inducing fetal demise. Intra-fetal administration of digoxin is superior to intra-amniotic digoxin administration. Administration of feticide using intracardiac KCL may shorten the abortion experience. Limited data from observational studies also supports an increase in maternal side effects and/or complications related to the administration of digoxin. Implications Intra-fetal administration of digoxin is more effective in achieving fetal demise when compared to intra-amniotic administration. There is a knowledge gap in determining the single best drug for inducing fetal demise prior to abortion. Additional research is needed to compare different feticidal agents in terms of safety and effectiveness.
Collapse
Affiliation(s)
- Tesfaye H Tufa
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.,UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sarah Prager
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.,Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, USA
| | - Antonella F Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Caron Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| |
Collapse
|
4
|
Wingo E, Raifman S, Landau C, Sella S, Grossman D. Mifepristone-misoprostol versus misoprostol-alone regimen for medication abortion at ≥24 weeks' gestation. Contraception 2020; 102:99-103. [PMID: 32407810 DOI: 10.1016/j.contraception.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare time from misoprostol initiation to fetal expulsion for mifepristone-misoprostol versus misoprostol-alone regimens of medication abortion performed at ≥24 weeks' gestation. STUDY DESIGN We conducted a retrospective study of medication abortion performed at ≥24 weeks' gestation between May 2016 and January 2018 at one site, comparing outcomes of patients receiving mifepristone-misoprostol versus misoprostol alone during two periods. All patients received feticidal injection and laminaria; the mifepristone-misoprostol group also received mifepristone 200 mg orally around the time of initial laminaria. Beginning 24-72 h later (depending on cervical assessment), both groups received misoprostol buccally every two hours. RESULTS Analyses included 257 patients in the mifepristone-misoprostol group and 152 patients in the misoprostol-alone group. Median time from misoprostol initiation to fetal expulsion was similar between groups (4.8 h vs. 4.9 h; p = 0.43). Patients in the mifepristone-misoprostol group received less misoprostol overall (median [IQR]: 800 mcg [800-1200 mcg] vs. 1200 mcg [800-1600 mcg]; p < 0.01) and fewer patients received a second round of laminaria (n = 56, 22% vs. n = 58, 33%; p < 0.01) than the misoprostol-alone group. Seven patients (2%) were transferred to a hospital for complications; this proportion did not vary by regimen. CONCLUSIONS Addition of mifepristone was not associated with a reduction in induction interval at ≥24 weeks. However, patients in the mifepristone-misoprostol group received a lower total dose of misoprostol and were less likely to require two days of laminaria. The clinical significance of these differences is unclear, but may have implications for patient experience. Both regimens had low rates of complications. IMPLICATIONS A randomized controlled trial comparing the mifepristone-misoprostol and misoprostol-alone regimens at ≥24 weeks is needed, as is evidence on patient perspectives on these regimens. Given the existing evidence, either regimen is reasonable.
Collapse
Affiliation(s)
- Erin Wingo
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA 94612, USA.
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA 94612, USA
| | - Carmen Landau
- Southwestern Women's Options, 522 Lomas Blvd NE, Albuquerque, NM 87102, USA
| | - Shelley Sella
- Southwestern Women's Options, 522 Lomas Blvd NE, Albuquerque, NM 87102, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA 94612, USA
| |
Collapse
|
5
|
Guilbaud L, Maurice P, Dhombres F, Maisonneuve É, Rigouzzo A, Darras AM, Jouannic JM. [Feticide procedures in second and third trimesters terminations of pregnancy]. ACTA ACUST UNITED AC 2020; 48:687-692. [PMID: 32092488 DOI: 10.1016/j.gofs.2020.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Indexed: 11/19/2022]
Abstract
Performing a feticide as part of termination of late pregnancy is recommended in many countries. Feticide avoids a live birth of a severely affected premature newborn and prevents fetal pain. There are limited data on feticide procedures since only a few countries in the world authorize late termination of pregnancy. The objective of this review was to assess the most appropriate feticide procedure based on published data during the last thirty years. Administration of an initial fetal analgesia followed by a lethal lidocaine injection through the umbilical cord, under ultrasound guidance, appears to be the most effective, safe and ethical way to perform feticide. According to the current knowledge regarding the risk of fetal pain and survival of extremely preterm infants, a feticide should be discussed as early as 20-22 weeks of gestation.
Collapse
Affiliation(s)
- L Guilbaud
- Service de Médecine Fœtale, centre pluridisciplinaire de diagnostic prénatal de l'Est parisien, DMU ORIGYNE, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Netter, 75012 Paris, France.
| | - P Maurice
- Service de Médecine Fœtale, centre pluridisciplinaire de diagnostic prénatal de l'Est parisien, DMU ORIGYNE, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Netter, 75012 Paris, France
| | - F Dhombres
- Service de Médecine Fœtale, centre pluridisciplinaire de diagnostic prénatal de l'Est parisien, DMU ORIGYNE, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Netter, 75012 Paris, France; Médecine Sorbonne Université, 15-21, rue de l'École-de-Médecine, 75006 Paris, France
| | - É Maisonneuve
- Service de Médecine Fœtale, centre pluridisciplinaire de diagnostic prénatal de l'Est parisien, DMU ORIGYNE, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Netter, 75012 Paris, France
| | - A Rigouzzo
- Service d'Anesthésie, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Netter, 75012 Paris, France
| | - A-M Darras
- Service de Médecine Fœtale, centre pluridisciplinaire de diagnostic prénatal de l'Est parisien, DMU ORIGYNE, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Netter, 75012 Paris, France
| | - J-M Jouannic
- Service de Médecine Fœtale, centre pluridisciplinaire de diagnostic prénatal de l'Est parisien, DMU ORIGYNE, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Netter, 75012 Paris, France; Médecine Sorbonne Université, 15-21, rue de l'École-de-Médecine, 75006 Paris, France
| |
Collapse
|
6
|
Costescu D, Guilbert É. No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:750-783. [PMID: 29861084 DOI: 10.1016/j.jogc.2017.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care. INTENDED USERS Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs. TARGET POPULATION Women with an unintended or abnormal first or second trimester pregnancy. EVIDENCE PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched. VALUES The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request. BENEFITS, HARMS, AND/OR COSTS IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.
Collapse
|
7
|
No 360 - Avortement provoqué : avortement chirurgical et méthodes médicales au deuxième trimestre. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:784-821. [DOI: 10.1016/j.jogc.2018.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
8
|
McNamara B, Russo J, Chaiken S, Jacobson J, Kerns J. A qualitative study of digoxin injection before dilation and evacuation. Contraception 2018; 97:515-519. [PMID: 29477630 DOI: 10.1016/j.contraception.2018.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We sought to qualitatively understand patients' experiences with digoxin as a step before dilation and evacuation (D&E). STUDY DESIGN We recruited English-speaking women from one abortion health center where digoxin is routinely used before D&E. We interviewed participants one to three weeks after the D&E about physical and emotional experiences with digoxin and understanding of its purpose. Using grounded theory, we analyzed transcripts iteratively, identifying themes from interviews; we stopped recruitment when we reached thematic saturation. RESULTS We conducted 20 interviews and participants described mixed experiences. Three overarching themes from the qualitative interviews were: (1) physical and emotional discomfort; (2) varied understanding of digoxin's purpose and effects; and (3) reassurance. Most participants described significantly negative experiences with digoxin; however, many participants also described positive aspects of the injection intermingled with those negative experiences. CONCLUSIONS Participants' experiences with digoxin before D&E were both polarized and nuanced. While participants were largely clear about digoxin's action, they were much less clear about the reason for its use. IMPLICATIONS Both the clinical purpose for and patients' experiences with digoxin before D&E are complicated. Providers who continue to use digoxin should consider patient preferences in how they offer digoxin, and consider tools to ensure patient understanding.
Collapse
Affiliation(s)
- Blair McNamara
- Yale University School of Medicine, New Haven, CT 06520, USA.
| | - Jennefer Russo
- Planned Parenthood of Orange and San Bernardino Counties, Orange, CA 92866, USA
| | | | - Janet Jacobson
- Planned Parenthood of Orange and San Bernardino Counties, Orange, CA 92866, USA
| | - Jennifer Kerns
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA 94110, USA
| |
Collapse
|
9
|
Intra-fetal Compared With Intra-amniotic Digoxin Before Dilation and Evacuation: A Randomized Controlled Trial. Obstet Gynecol 2017; 128:1071-1076. [PMID: 27741192 DOI: 10.1097/aog.0000000000001671] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the effectiveness of 1.0 mg intra-fetal or intra-amniotic digoxin to achieve fetal asystole before second-trimester surgical pregnancy termination. METHODS In a randomized trial, women received 1.0 mg transabdominal intra-fetal or intra-amniotic digoxin on the day of laminaria placement before dilation and evacuation between 20 and 24 weeks of gestation. The primary outcome was incidence of fetal asystole, documented immediately before dilation and evacuation. We planned to analyze the primary outcome by original group assignment as well as by as-treated and per-protocol populations. A sample size of 270 was needed to detect an 8% difference in failure rates between groups. Prespecified secondary outcomes included the incidence of adverse events, side effects, and procedural differences. RESULTS Between January 2012 and January 2013, we screened 381 women and randomized 270 women to receive intra-fetal (n=136) or intra-amniotic (n=134) digoxin. Characteristics were similar across groups; the mean gestational age was 21.6 weeks (standard deviation 1.2). The proportion of fetal asystole was higher in the intra-fetal group (128/135 [94.8%]) than the intra-amniotic group (107/130, 82.3%; relative risk of failure to achieve asystole 3.41, 95% confidence interval 1.52-7.68). Results were similar in the as-treated and per-protocol populations. There were no significant differences in adverse events or side effects and no differences in injection duration, operative time, or estimated blood loss. CONCLUSION Administration of intra-fetal injection of digoxin led to a higher proportion of participants achieving fetal asystole within 24 hours than intra-amniotic injection. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov, NCT01047748.
Collapse
|
10
|
Denny CC, Baron MB, Lederle L, Drey EA, Kerns JL. Induction of fetal demise before pregnancy termination: practices of family planning providers. Contraception 2015; 92:241-5. [PMID: 25998938 DOI: 10.1016/j.contraception.2015.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 05/07/2015] [Accepted: 05/09/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Our survey aimed to characterize the practice of inducing fetal demise before pregnancy termination among abortion providers, including its technical aspects and why providers have chosen to adopt it. STUDY DESIGN We conducted a survey of Family Planning Fellowship-trained or Fellowship-affiliated Family Planning (FP) subspecialists about their practice of inducing fetal demise, including questions regarding the circumstances in which they would induce demise, techniques used and rationales for choosing whether to adopt this practice. RESULTS Of the 169 FP subspecialists we surveyed, 105 (62%) responded. About half (52%) of respondents indicated that they routinely induced fetal demise before terminations in the second trimester. Providers' practices varied in the gestations at which they started inducing demise as well as the techniques used. Respondents provided legal, technical and psychological reasons for their decisions to induce demise. CONCLUSION Inducing fetal demise before second-trimester abortions is common among US FP specialists for multiple reasons. The absence of professional guidelines or robust data may contribute to the variance in the current practice patterns of inducing demise. IMPLICATIONS Our study documents the widespread practice of inducing fetal demise before second-trimester abortion and further describes wide variation in providers' methods and rationales for inducing demise. It is important for abortion providers as a professional group to come to a formal consensus on the appropriate use of these techniques and to determine whether such practices should be encouraged, tolerated or even permitted.
Collapse
Affiliation(s)
- Colleen C Denny
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences.
| | | | - Lauren Lederle
- University of California, San Francisco School of Medicine
| | - Eleanor A Drey
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Jennifer L Kerns
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences
| |
Collapse
|
11
|
Umbilical cord transection to induce fetal demise prior to second-trimester D&E abortion. Contraception 2013; 88:712-6. [DOI: 10.1016/j.contraception.2013.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 11/22/2022]
|
12
|
Tocce K, Sheeder JL, Edwards LJ, Teal SB. Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation. Contraception 2013; 88:706-11. [PMID: 24034581 DOI: 10.1016/j.contraception.2013.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study evaluates the feasibility, efficacy and safety of transvaginal digoxin administration to induce fetal demise prior to dilation and evacuation. STUDY DESIGN This descriptive report from a single center involves a large case series of dilations and evacuations (D&Es) ranging from 18 to 22 weeks of gestation. Transvaginal feticidal injection with digoxin was attempted in 1640 cases; intrafetal, intraamniotic and combined (intrafetal and intraamniotic) injections were administered. Digoxin dosage ranged from 0.5 to 3.0 mg, with the majority receiving 1.0 mg. Cases were reviewed to determine feasibility, efficacy and adverse events. RESULTS Successful completion of transvaginal injection occurred in 98.5% (1637/1662) of eligible cases, and 1596 cases were evaluable for fetal demise. Demise occurred by the time of D&E in 99.4% of all cases; 99.7% of intrafetal injections resulted in fetal demise. Doses ≥1 mg were equally effective (98.1%-99.6%) regardless of injection site (intraamniotic, combined intrafetal/intraamniotic or intrafetal). Doses <1.0 mg were less successful at inducing demise if not administered intrafetally (p<.001). Rates of ruptured membranes (4.1%), chorioamnionitis (0.49%) and extramural deliveries (0.12%) were low. Patients who experienced complications were more likely to be of greater gestational age and have had a previous cesarean section. CONCLUSIONS Transvaginal digoxin administration is feasible, effective and safe. IMPLICATION STATEMENT This study demonstrates the feasibility, effectiveness and safety of transvaginal digoxin administration in a large clinical cohort. Future studies will be needed to determine if this method of administration improves patient satisfaction and outcomes when compared to transabdominal feticidal injections.
Collapse
Affiliation(s)
- Kristina Tocce
- University of Colorado Denver School of Medicine, Department of Obstetrics and Gynecology, Mail Stop 198-2 AO1, 12631 E. 17th Avenue, Room 4006, Aurora, CO 80045, USA.
| | | | | | | |
Collapse
|